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^

BOSTON
MEDICAL LIBRARY

IN THE

Francis A.Countway
Library of Medicine

BOSTON

!E

EDINBURGH

MEDICAL JOURNAL,

THE MONTHLY JOURNAL OP MEDICINE

JLMD

THE EDINBURGH MEDICAL AND SURGICAL JOURNAL.

VOL. X.
JULY 1664 TO JUlf»*M4p.

EDINBURGH:

OLIVER AND BOYD, TWEEDDALE COURT.

LONDON: SIMPKIN, MABSHALL, AND CO.

MDCCCLXY.

1

y

■DOIBUiaH : PBHTBO BT OUTm AMD BOTD, TWBEDDAXA OOUIT.

ALPHABETICAL LIST

CONTRIBUTORS OF ORIGINAL ARTICLES.

Amderbon, Izbtt W., M.D., Kingston, Jftmaica.
. Amnandale, Thomas, F.R.C.S.E., Assistant-Snrgeon to the Royal Infirmary,

Edinboigh.
Babtlbtt, Jobefh, L.R.C.P. Lond., M.R.C.S., London.
Bell, Charles, M.D., F.R.C.F.E., Edinburgh.
Bell, Joseph, M.D., F.R.C.P.E., AssiBtant-Surgeon, Surgical Clinical Wards,

Royal Infirmary, Edinburgh.
BoNNAR, George Lindsay, M.D., Cupar-Fife.
Braidwood, Peter, M.D., Edinburgh.
Browne, J. Crichton, M.D., Newcastle-upon-Tyne.
Buchanan, George, M.D., Surgeon to the Royal Infirmary, Glasgow.
Carmichael, Duncan, M.D., Buckie, Banffshire.
Christie,' John, M.D., F.R.C.S.E., Lecturer on Midwifery, Aberdeen.
CuTHiLL, James, M.D., Denny, Stirlingshire.

Davidson, Andrew, L.R.C.P. & S. Edin., Antananarivo, Madagascar.
Dickinson, W. H., M.D. Cantab., Assistant-Physician to the Hospital for

Sick Children, London.
Dix, John, M.R.C.S., Surgeon to the Hull and Sculcoates Infirmary.
Duncan, J. Matthews, M.D., F.R.C.P.E., Physician and Clinical Lecturer

on Diseases of Women, Royal Infirmary, Edinburgh.
Duncan, John, M.D., F.R.C.S.E., Edinburgh.
Fayrer, Joseph, M.D., F.R.C.S.E., First Surgeon and Professor of Surgery

in the Bengal Medical College, Calcutta.
FiNLAY, Robert, M.D., Edinburgh.
Qamqee, Arthur, M.D., Assistant to the Professor of Medical Jurisprudence

in the University of Edinburgh.
Grbig, David, M.D., F.R.C.S.E., Dundee.
Haldane, D. Rutherford, M.D., F.R.C.P.E., Physician to the Royal

Infirmary, Edinburgh.
Heath, George Y., M.B., M.R.C.S., Surgeon to the Newcastle Infirmary

and Eye Infirmary.
Hewan, Archibald, F.R.C.S.E., Medical Missionary at Old Calabar.
Hjaltblin, John, M.D., Inspecting Medical Officer of Iceland.

IV GONTBIBUTOBS OF ORIGINAL ARTICLES.

Inolis, Andrew, M.D., F.R.C.S.E., Edinburgh.

Keith, Thomas, M.D., F.R.C.S.E., Edinburgh.

Kerr, William, Surgeon, Corresponding Member of the Medical and Physical

Society of Calcutta, and of the Medico-Chirurgical Society of Glasgow.
Ketchem, William, M.D., Suigeon to the Forfar Infirmary.
Laycock, Thomas, M.D., F.R.C.P.E., Professor of the Practice of Medicine

in the University of Edinburgh.
Leslie, David, M.D., Tunbridge, Kent.
Lock WOOD, A. P., Surgeon-Major, 2d Dragoons.
Lyell, John, M.D., Newburgh, Fife.

Macadam, Stevenson, Ph.D., F.R.S.E., Lecturer on Chemistry, Edinburgh.
Maclaoan, Craig, M.D., M.R.C.P.E., Edinburgh.
Maclaqan, Douglas, M.D., F.R.C.P.E., Professor of Medical Jurisprudence

in the University of Edinburgh.
M^Leod, EIenneth, Assistant Medical Officer, Durham County Asylum.
Mitchell, Arthur, M.D., Deputy Commissioner in Lunacy for Scotland.
MuNRO, W. Stuart, M.D., West Hartlepool.
Parker, D. M*N., Halifax, Nova Scotia.
Paterson, George, K. H., L.R.C.P.E., Balbeggie, Perthshire.
Reid, John Watt, M.D., Surgeon, Royal Navy.
Ringer, Sydney, M.D., M.R.C.P., Professor of Materia Medica, University

College, London.
Sanders, William R., M.D., F.R.C.P.E., Physician to the Royal Infirmary,

Edinburgh.
Simpson, Alexander R., M.D., M.R.C.P.E., Glasgow.
Simpson, David James, M.D., Edinburgh.
Skae, Francis, M.D., Edinburgh.
Smith, John, M.D., F.R.C.S.E., Dental Surgeon to the Royal Infirmary,

Edinburgh.
Spence, James, F.R.C.S.E., Professor of Surgery in the University of

Edinburgh.
Stephenson, William, M.D., F.R.C.S.E., Extra Physician to the Royal

Hospital for Sick Children, Edinburgh.
Stewart, T. Grainger, M.D., F.R.C.P.E., Pathologbt to the Royal In-
firmary, Edinburgh.
Thin, George, M.D., formerly of Penicuik.
Thomson, J. B., L.R.C.S.E., Resident Surgeon to the General Prison for

Scotland, Perth.
Tuke, John Batty, M.D., Medical Sapermtendent of Fife and Kinross

Lunatic Asylum.
TURNERy ROBERT, M.D., Keith.
Turner, William, M.B. Lond., F.R.C.S.E., Senior Demonstrator of Anatomy

in the University of Edinburgh.
Veale, Henry, M.D., Assistant Surgeon, Royal ArtiUery.
Watson, James, M.D., Newchang.

■ ? r: y.-. -. Y AM ? i: t a r i u n

THE

EDINBUKGH
MEDICAL JOUBNAL.

$avt jffitnt

ORIGINAL COMMUNICATIONS.

Abticle I.— Surgical Cases. By James Spbnce, F.R.C.S.,
Member of the ^resident's Council, and one of the Examiners
of the Bojal College of Surgeons, Edinburgh ; Surgeon and
Lecturer on Clinical Surgery. Royal Infirmary; Lecturer on
Surgery, Surgeons' HiJl, Edinourgh.

(Bead before the Medico- Chirurgical Society, May 4, 1864.)

1. Successful Case op Pbimart Amputation at the Hip-Joint.

On the 3d of September 1863, Robert Davidson, aged 12 years,
was thrown from a truck which had been suddenly set in motion,
and fell in front of it, both wheels passing obliquely over the upper
part of the left thigh just below the pelvis. The accident happened
at the Melrose station, and the bov was seen almost immediately
by Dr Clarkson, who adjusted the limb, and had him conveyed to
his home at Newstead about a mile distant. About two hours
afterwards, Drs Brown and Smith accompanied Dr Clarkson to see
the case. The boy had recovered in a great measure from the
shock, but his pulse was still very weak. On examination, there
was found a large contused flesh wound at the upper and inner
part of the left thigh, exposing the muscles, which were much torn
and bruised, and allowing the finger to be passed deeply into the
tissues of the limb. The femur at and below the trochanters was
felt to be much shattered. The foot was cold, and pulsation in the
popliteal and tibial arteries extremely weak, but there had been no
great amount of blood lost.

As it appeared to the medical attendants that the boy's only
chance of life was removal of the limb by amputation at the hip-
joint, I was telegraphed for, and arrived at the patient's house about
9 P.M. On examination of the injury, the contused and lacerated

VOL. X.— NO. I. A

2 SUUGICAL CASES BY MR SPENCE. [JULT

state of the soft parts, the shattered condition of the femur, and the
consideration of the great force by which the injury had been
caused, left no doubt as to the practice to be pursued. I at once
coincided in the opinion which his medical attendants had expressed,
although, from the depressed state of the young patient, and the
proximity of the injury to the trunk, the chances of success seemed
very small.

The boy's parents having given their consent, I proceeded to
perform the operation under circumstances not the most favourable.
The room was small, and the only light procurable was from a small
lamp on the mantelpiece, and two small candles held by a non-
pro^sional assistant ; a wax taper I had brought with me was kept
m reserve for exigencies. I had brought Lister's abdominal com-
pressor, but as it could not be applied so as to command thoroughly
the circulation, Dr Smith took cnarge of compressing the common
femoral on the brim of the pelvis, and I instructed one of the
patient's friends how to command the bleeding from the posterior
nap, by grasping it with one hand and pressing a large sponge
upon its surface. Dr Brown took charge of the movements of the
limb, whilst Dr Clarkson administered the chloroform. When the
boy was brought under its influence, I entered my knife between
the trochanter major and the anterior superior spine of the ilium,
and carrying it obliquely across the thigh, brought the point out a
little above the tuberosity of the ischium, cutting a short anterior
flap. Dr Brown then rotated and depressed the limb, with the
view of facilitating disarticulation ; but owing to the shattered state
of the femur, this movement did not produce the desired effect.
Fortunately, however, this caused no great delay, for my knife had
opened the joint in passing' across the limb ; and by grasping the
upper broken fragment of the bone, so as to project the head, I com-
pleted the disarticulation, and cut as large a posterior flap as I
could obtain from the uninjured parts. Some vessels on the poste-
rior flap were first secured, and then the great vessels in the anterior
flap, — the vein beilig included in a ligature. I then removed some
contused and doubtfiil-looking portions of muscle. After all bleed-
ing had been arrested, the flaps were brought tocether with sutures;
and considering the nature of the parts from which the flaps were
formed, they fitted tolerably well. The stump was then oressed,
and the patient placed in bed, hot bottles applied, and some stimulus
given, as he was very weak. He lost very little blood during the
operation, as I ascertained by carefriUy collecting the blood from
the stone floor, when it was found to amount to less than half a
small teacupful ; and altogether, with what was in the sponges, to
about five ounces at most. After waiting till the little patient had
completely rallied from the chloroform, and had got an opiate
administered. I left him in the charge of Dr Smith, who remained
with him all night, and to whom I am indebted for the following
report of the progress of the case : —

1864.] 'surgical CASES BT MB 8FEKCE. 3

Examination of Limb after Removal. — On examination of the
limb after removal, the femur, from the large trochanter downwards
for about two inches, was found to be broken into numerous frag-
ments, the ragged edges of which were embedded in the surround-
ing soft parts. The muscles and other structures were much bruised
and torn, but there was no direct injury to the large vessels or nerves.

4th September. — During the night, patient was very restless and
delirious. Pulse 134, weak. A little brandy and water was
administered at intervals, but was vomited. No reactionary haemop-
rhage of any consequence. Vespere. — Still restless, with delirium.
Pulse 130. To have opiate with a few drops tinct. mur. ferr.

5th. — Restless night Pulse 130, very weak and thready. Sunken
aspect of countenance. Beef-tea, brandy, and milk given in small
quantities frequently.

6^, — ^Bather better. Slept a little. Less delirium. Pulse 108,
stronger. Wound has healthy appearance, except at the bruised
part of the flap, which looks slougny.

7th. — Pulse 108. Sloughing action extending slightly on poste-
rior flap. Foetid sero-purulent discharge. Chloride of soda loticm.
Opiate.

8th. — ^Pulse 90. No delirium. Line of demarcation formed^
showing slouch, rather exceding a square inch in extent. Purulent
discharge copious and less foetid.

9th. — All the stitches removed, and the flaps brought together
as well as possible by strips of plaster. Pulse 100.

12th. — Sloughs separated. An attack of diarrhoea. Slight delirr
ium. Opiate.

14th. — Pulse 108. Diarrhoea less. Stump looking healthy.
Diet for the most part milk, beef-tea, wine, witn a little brandy.

16<A.— Doing well.

20^. — ^Pulse has risen to 120. Had a restless night with delir-
ium. Raw surface of stump covered with patches of whitish semi-
translucent membrane of pretty tough consistence. Copious purulent
discharge. Stimulants given in increased quanti^.^

2l8t. — Pulse 120. Occasional delirium. Wound has same
appearance.

23d. — ^Pttlse 118. Wound has less of its diphtheritic-looking
covering.

27th. — Stump looks hedthy, and is cicatrizing round the edges.
Dressed with sulphate of zinc lotion. Pulse still high, 116. Sleeps
well. Appetite mdifferent.

1st Octoker. — Pulse 110. Doing well.

4^.— Pulse 102.

From this time recovery was slow but uninterrupted. The patient
gained strength gradually, with the aid of tonics, wine, etc. The
femoral ligature did not fall off till 4th November, two months

^ Dr Brown informs me that diphtheria was prevailing in the diBtrict at the tiiue.

y

4 0UBO1CAL CASES BT MB SPENCE. [JULT

after the operatioD, having evidentlj been retained for some time
after its separation from Uie vessel by the granulations surround-
ing it. By the middle of December the stump was healed^ with
the exception of a mere spot. Two or three weeks later this also
had closed, and the patient was able to move about wilh the aid
of crutches.

H&marka. — I have thought this case would be interesting to the
Society, because successful results in cases of amputation at the
hip-iomt are rare, and in primary amputations, exceedingly so. In
the last edition of " Cooper's Surgical Dictionary," it is stated that
there have been six cases of primary amputation at the hip per-
formed in Great Britain since 1838, and all of them proved fatal.
In the Crimea fourteen amputations at the hip-joint were performed
by British surgeons for injury, and not one recovered ; and in the
Punjaub in 1848-49, three cases occurred, with the same unfavour-
abfe result. And, so far as I am aware, the case I have just
detailed is the first successful |>rimary amputation at the hip-joint
in Scotland. But the principal interest which such a case possesses,
seems to me to be the consiaeration of those circumstances or con-
ditions which may have conduced to the successful result, and
which may. influence our practice in similar cases.

The age of the patient may seem to explain the favourable result.
It has been said that in young patients, from the greater remedial
powers of nature, and the smaller surface caused by the operation
in them, the operation is likely to be more successful; but this
is very questionable. The remedial powers in young persons are no
doubt great, when once a certain point has been passed ; but the first
effects of shock either from accident or operation, and especially the
loss of blood, are not well borne by such patients, and these^ together
with the irritability of constitution, which is often marked, in a great
measure, I think, counterbalance the remedial powers observ^ in
them. Then^ as to the less amount of cut surface, though less
absolutely, it is quite as great comparativeljr to the size and vital

Sowers of the patient. Tne amount of mutilation, the consequent
eran^ment of the circulation, and all the risks depending on these
conditions, are at least as ^eat relatively in the boy as in the
adult. From what I have observed in the case of primary amputa-
tions in young children, the patients sometimes sink rapidly and
without any very apparent cause, whilst even the successful cases
are often atten^d at first with as urgent constitutional disturbance
as in adults. Indeed, the state of the patient whose case I have
recorded, shows how great was the constitutional shock during the
first four daj^. and how slowly full reaction set in. The true causes
of success will, I think, be found in the nature of the injury, the
small amount of blood lost, and the comparatively little shock he
was subjected to after the occurrence of the accident.

1^^, As to the character of the injury. Although so excessively

1964.] SUROiCAL CASES BT MR SPENCB. 5

severe as to necessitate amputation, and though in dangerous
pioximi^ to the trunk, the destructive force was limited to the parts
over which the wheels had passed, — there was no laceration ot the
limb below, nor of the abdominal region above, and there was little
bleeding from the contused wound. Then the boy was seen imme-
diately, the limb adjusted, and he was conveyed at once to his own
home, so that he scarcely suffered any secondary shock from removal.
Now, let me contrast these conditions with those of another case
occurring in my hospital practice, and some of the causes which
greatly determine the results will be pretty apparent. A man was
admitted under my care in consequence of an injury inflicted by the
explosion of a large iron flask containing gunpowder. The flask,
the metal of which was about a quarter of an inch thick, had been
in close contact with his body when it exploded, and the wound
was therefore similar to that caused by the bursting of a shell.
The thigh was almost separated from the trunk at the upper and
inner part. ^ The pectinsBus, adductors, and the hamstring muscles,
at their origins from the tuber ischii, were divided and torn into
shreds, whilst the front of the abdomen and lower part of the thorax
were severely scorched by the explosion. The femoral artery,
largely exposed, had escaped injury, but the vein seemed twisted ana
injured, as the blood was coagulated in it. There had been consider-
able bleeding from the arterial branches divided, and slow oozing into
the textures of the limb was going on when the patient was brought
into the hospital. The accident had occurred m Lanarkshire, and
the patient had to be conveyed partly by road, and then by railway
to Edinburgh. In this case also, the only chance of life and relief
from suffering was removal of the limb at the hip ; but after rallying
during the first twenty-four hours, he died on the third day. Here,
in contrast to the case of the boy, we see the disadvantages of a
long and tedious journey, and renewal of shock from time to time,
from the unavoidable movements in being so conveyed to town ;
the slow loss of blood from oozing into the tissues of the limb ;
the extent and severity of the wound, and the scorching of the
abdomen and chest, an injury very dangerous in itself; — such
circumstances are sufficient, I thiiik, to explain the fatal result, —
and from what I have observed in cases of primary amputations, these
are conditions which, according as they are present in greater or
less degree, most materially influence the success of such operations.
Perhaps it may seem that I do not sufficiently appreciate the im-
portance of the patient enjoying the benefits of pure country air,
instead of that of a hospital ward. But whilst it is perfectly true
that there is much need of doing all we can to improve the ventila-
tion of our hospitals, the dwellings of the working-classes in the
country aire not always or even generally models of ventilation. In
the case of the boy. the room he occupied was a small closet, low
in the ceiling, just large enough to contain a small fixed bedstead,
leaving barely room to pass between the bed and the wall, — ^its only

6 SURGICAL CASES BY MB SPENCE. [JULT

means of ventilation a small window and the door opening into the
common room of the family, which also contained beds, so that what-
ever the purity of air in the country round, he did not enjoy much
of it. Without denying the bad effects of vitiated air in hospital
wards, and the necessity of doing all we can to remove that cause
of mischief, I cannot help saying that a good deal of nonsense is
spoken and written about the dangers of operations in hospitals as
compared with those in private practice, as if all depended on nospital
air alone. From some of the discussions of the subject by corre-
spondents in the weekly medical journals, and from recent proposed
methods of ascertaining the results of surgical operations in hospitals,
it would almost seem as if some statisticians had so crammed their
brains with mere figures as to have no room left for a single idea,
or even so small a glimmering of common sense as to make allow-
ance for the nature and class of cases admitted into great hospitals,
or to pay the least attention to the circumstances under which the
patients are when admitted, to say nothine of the surgical treatment.
As to the operation itself, the difficulties were on^r such as must
always more or less present themselves in operatinff in cases of injury,
where the lacerated textures prevent us from obtaining regular naps,
and where the comminution of the bone deprives the operator of the
power of leverage to facilitate disarticulation. There was, however,
comparatively little difficulty here, although the fragment I had to
grasp was small, because I had taken care to pass the knife deeply
so as to open the front of the joint in cutting the anterior flap, and
by doing so the difficulty of disarticulating is much diminished.
There was, however, a condition present which I have seen cause
serious diffictdty in amputation of the thigh for compound com-
minuted fractures, when transfixion was attempted, 1 mean the
dragging up of the lower part of the femur, by the hamstring and
adductor muscles, and the projection of the trochanteric or upper part
by the psoas and iliacus flexing it on the pelvis, so as to project it
towards the skin, and prevent the knife being carried down in cutting
outwards. In this case it was of no consequence, because the soft

Earts in front were so injured that I could not get a long anterior flap ;
ut, supposing the tissues to have been sufficiently sound, the bone
was so tilted forward that I could not have carried the knife onwards.
In such cases I would strongly recommend cutting the flap of integu-
ment and fascia from without, and then transfixing across the joint,
or to cut the flap altogether from without inwards as is now generally
done in primary amputations of the limbs. In regard to the vessels,
it will be observed that in this as in the former successful case of
hip-joint amputation which I communicated to this Society, I put
a ligature on the femoral vein as well as on the artery. In my
former case I did so with great dread of the result, but I have since
done it in some cases of amputation, and as they all did well, I
am sometimes inclined to think that, instead of being hurtftil as I
used to dread, it may possibly be useful as preventing imbibition

1864.] SURQICAL CASES BY MR 8PENCE* 7

or absorption of pamlent or sanions matter from a large woanded
surface ; but I confess I have still so much of lingering prejudice
that I do not like to try or urge the practice generally. I have,
however, no hesitation now in applying a ligature when venous
bleeding is troublesome after amputation.

In regard to the temporary arrestment of haemorrhage during the
operation, that was most efficiently performed by the manual com-
pression of the external iliac on tne brim of the pelvis, and by an
assistant grasping the posterior flap at its base as soon as it was cut,
and pressmg a large sponge firmly on its surface, so that the whole
amount of blood lost certainly did not amount to five ounces. I
believe I was the first to use Lister's abdominal compressor in a
case of amputation at the hip-joint, and then with perfect success,
and I have since applied it several times with advantage in amputa-
tions through or near the trochanters^ but I have also noticed that it
requires great care to prevent it gettmg displaced during an opera-
tion, and becoming inefficient. As to the present case, probably
from the small size of the patient, or other cause, I found that
whilst I could compress the abdominal aorta with the hand, I could
not maintain thorough pressure with the tourniquet, and that the
efforts at vomiting had a constant tendency to displace it, and I
therefore could not trust to it during the operation. I cannot con-
clude without expressing my acknowledgments to the gentlemen
who assisted me at the operation, and especially to Dr Brown and
Dr Smith, on whom the after treatment oi the case devolved, for the
great care and skill thej^ bestowed upon the patient, and to which,
under Providence, I believe his recovery is mainly due.

2. Case op Spontaneous Gangrene op the Lower Extremity,

ACCOMPANIED BT A RARE FORM OP ARTERIAL LeSION.

Mrs Smith, aetat. 79, was admitted into the Eoyal Infirmary
under my care, on the 18th of September 1863, suffering from
spontaneous gangrene of the left leg and foot. The history of her
case, given me by her medical attendant Dr Wilson, was the fol-
lowing : —

" I first saw Mrs S. on the 13th of August last. I found her in
bed, complaining of severe pain in the leg and foot, which pre-
vented her sleeping at night, and this she stated had begun some
time previously. There was at this time no change in the appear-
ance of the limb, and I did not then examine the state of its
circulation. Her pulse at the wrist was rather frequent and feeble.
She had been appljing turpentine as an embrocation to the limb,
which I advised lier to discontinue. I prescribed opium pills, to
allay pain and procure rest The following day, wnen I visited
her. I was informed that the pain had ceased, but that the limb was
cola. On examination this proved to be the case, and no pulsation
could be felt in any of the arteries of the leg. I carefully examined
the state of the heart, but no abnormal murmur could l>e detected ;

8 SURGICAL CASES BT MR BPEKCE. [JULT

but her lips and face were rather blue. The limb was wrapped in
wadding, opiates dven to procure rest, and the patient's general
strength supported. Gradually the limb became discoloured and
shrivelled, and ultimately a line of demarcation formed below the
knee. Under these circumstances, as the foetor was intense, and her
general health not very much sunk, whilst the line of demarcation
seemed tolerably decided, she was sent to the Royal Infirmary, in
the hope that amputation might probably be attempted."

On admission into hospital, I found her exhausted, and she had
an anxious expression ; her tongue was furred, and rather dry in
the centre ; the pulse was slow and felt firm, but this was evidently
due to the atheromatous state of the arteries. The leg, though dry
and shrivelled at the foot, had apparently died more rapidly above,
as it presented more of the appearance of humid gangrene. Im-
mediately below the knee there was a deep line of demarcation
around the limb, presenting a tolerably healthy OTanulating surface,
covered with laudable pus. No pulsation could be felt, however,
either in the femoral or external iliac arteries of that side, and I
observed some slight mottling of the lower part of the thigh as if
from superficial venous congestion, to which I drew attention, that
any increase of it might be watched. At my next visit I found
that the patient had suffered from nausea, and was very restless ;
there was heat of skin over the trunk and arms ; and the pulse was
more frequent and irregular. Her face, though flushed in the
cheeks, had a more sunken appearance, and the tongue was dry.
She was suffering from an accession of irritative fever. The thigh
of the affected limb felt colder ; the mottling from vascular conges-
tion was much more marked; whilst the line of demarcation had
an unhealthy, sloughy look, with purple edges. It was now quite
evident that the gangrene was extending, and that little could be
done beyond allaymg nain, and relieving the patient from the foetor
by applying Condy's nuid and charcoal. The symptoms gradually
became worse, and the patient died on the fourtn day after her
admission into hospital.

Leave having been obtained to examine the body, the arterial
system generally was found to be affected with atheromatous and
earthy degeneration. The vessels of the lower extremities, and the
iliacs and lower part of the abdominal aorta were carefally dissected
out, and reserved for further examination. When this was done
the conditions observable in the preparation now before the Society
presented themselves. The vessels of the leg and thigh affected by
atheromatous disease were found plugged by coagula, as is generally
seen in such cases ; but in the left iliac artery, just at the point of
bifurcation into external and internal, was seen a condition very
rarely met with. At one part its internal and middle coats seemed
to have given way, and the blood had forced itself between them
and the external coat, so as to dissect or separate the tissues for
some distance, coagulating between them, and throwing inwards

I i -

■ f

\(

M»« .OPKN'.'K'.- 'A.SK '/ Am-i

^'\

s

18e4.] SUBGICAL CASES BT MR SPEKCE. 9

the inner coats, so as to arrest the drcnlation at the affected part ;
and, what is still more nnnsoal, the dissection of the coats was in
the opposite duection to the natural current of the blood*

Bemarka. — ^This form of arterial lesion — dissecting aneurism — is
occasionally, though not very firequentlyi met with in the aorta,
but is of extremely rare occurrence in vessels such as the iliacs.
Indeed I am not aware of any preparation showing such a lesion in
any vessel smaller than the aorta, and in all the cases I have seen,
the separation of the coats has been in the direction of the cir-
culation; but in this preparation the separation is towards the
heart; and I think this fact, taken in connexion with the history
of the progress of the disease, will serve to determine what parts
of the morbid appearance stand in relation to the gangrene as
cause or e£kct. Looking at such a very evident source of obstruc-
tion as the peculiar lesion presents, we are apt to conclude that it
was the originating cause of the gangrene. But viewing the mor-
bid appearances, and especially the direction of the sangmneous dis-
section of the coats, in connexion with the progressive symptoms
of the case, I think it much more probable tlutt the onginating
cause was the more common one of coagulation occurring in
atheromatous arteries, and that the lesion of the iliac prolmbly
coincided with the period of the exacerbation of irritative fever
and excited circulation ; that the current of the excited circulation
being obstructed beyond by the previous cessation, caused the
coats of the distended artery to peld at the diseased part, and the
reflux current of the blood to force itself between the tissues of the
artery, thus separating them in the backward direction towards the
heart. If this view be correct, as I believe it to be, then the pre-
paration before the Society has a significance beyond its rarity as a
pathological specimen ; for it will point out a source of danfi^er in
reference to Brasdor's method of operating for aneurism, whidi has
not been adverted to. Hitherto our great dread, in regard to that
method has been the risk of the runture of the sac when the vessel
was tied on its distal side, though that has never yet happened ; but
it is clear that the ligature in such a case would act lixe the spon-
taneous distal obstruction in the case recorded, and a similar lesion
of the artery and a dissecting aneurism might follow.

In conclusion, the case points out the propriety of avoiding
amputation in cases of spontaneous gangrene, if not absolutely, at
least till the line of demarcation has not only almost but altogetner
separated the dead from the living parts down to the bones, and
until the vitality of the limb higher up is secure, as shown by the
vigour of its circulation. In cases of chronic gangrene, resulting
from cold, or after fever, such a line of demarcation as was present
here would have been a perfectly sufficient warrant to operate ; but
the conditions in cases ot spontaneous gangrene, arismg from inde-
finite and probably persistent constitutional causes are very different.

VOL. X.— NO. I. B

10 DR VEALB ON SYPHILIS AND ITS TREATMENT. [JULT

Article II. — Remarks on Syphilis and its Treatment. By Henry
Veale, M.D., Assistant-Surgeon, Royal Artillery.

In the fherapentics of Syphilis, the three following rules may be
regarded as absolute, !««, That every non-indurated chancre should
be thoroughly cauterized if the ulceration be progressive or sta-
tionary ; 2dj That the escharotic employed for the destruction of a
venereal sore should never be of less strength than the faming
nitric acid ; 3rf, That every suspicious excoriation should be treated
as a chancre. It is very seldom that any diflSculty is experienced
in obtaining the cicatrization of venereal sores when they are treated
in this way.

"It has never occurred to me to meet with a true serpiginous
chancre in military life, nor have I ever knowi^ a soldier in whom it
had existed.

Sloughing sores — sloughing phagedsena — are more common, and
are almost invariably associated with a bad habit of body of one
kind or another, and, after cauterization, are best treated by the
tartrate of iron, both locally and internally, as Ricord long ago
pointed out.

Buboes. — It is acknowledged to be useless to attempt the repres-
sion of a specific bubo, and as it is impossible to foretell whether
any given bubo accompanying a venereal sore will prove to be
specifically infected or not, it would seem to be prudent never to
attempt repression at all. The result of such preventive measures
as are usually recommended, viz., leeches, blisters, low diet, anti-
mony, and other similar antiphlogistics, appears to me to be as
unfavourable both to the part and to the system as any that follows
suppuration itself, even when they happen to be successful ; but
when they fail, the strength of the system has been wasted to no
purpose, and a bubo remains, slow in its progress towards recovery,
and, by its exhausting discharge, often developing any lurking
tubercular tendency. As soon as a patient with a primary sore
begins to have jjain and swelling in the groin with other symptoms
indicative of incipient bubo, it will generally be found that the best
practice is to apply hot fomentations and poultices, to enjoin
absolute rest of the part, at the same time to diminish in no respect
our care for his general health, and, if pus forms, to make a small
but dependent ojjening the moment its presence is detected. I am
opposed to waiting until more complete suppuration shall have
occurred, as well as to the practice of " free incision, and coidd
easily adduce cases in support of what I deem to be the more
suitable treatment ; but lallacies are too apt to lurk in such a
method of proof, and I willingly fall back upon the following con-
siderations, which, perhaps, will in themselves be found to be of
sufficient weight.

The main objects in treating a suppurating bubo are to cause it

1864.] DR VEALE ON SYPHILIS AND ITS TREATMENT. 11

to disappear as rapidlj as possible, and to leave the least perceptible
trace of its existence. Now, such a bubo is an abscess, formed
either in a gland or in the connective tissue immediately investing
it, or in both of these structures, and the pus may be either simple
or chancrous. Supposing, then, the pus to be simple and innocuous,
it will be admittea tliat early evacuation by an opening dependent,
and just large enough to admit of the pus escaping reaaily, will
most conduce to rapid recovery with the least deformity. It must
be remembered, however, that one cannot tell beforehand whether a
given bubo in its early stage is simple or specific, or in which of
the structures the pus has been formed; but, granting for tlie
moment that specific buboes require a different treatment from the
simple ones, the question arises, whether it is not advisable to give
the patient the benefit of any doubt in the diagnosis, and in all
cases to act on the most favourable presumption ? An answer in
the affirmative will scarcely be denied. But if the bubo be
specific, why should the opening be delayed or differently per-
formed ? Because, it is said, it is desirable that the structure of
the affected gland may be more completely disorganized, so that,
eventually, wnen the skin gives way over it, the gland may be the
more readily ejected as a siough. Let us observe with attention,
however, the state of the parts when a spontaneous opening occurs,
or when at length an incision is made in such a case, and we shall
invariably find the skin undermined, and the connexions between
the gland and the adjacent connective tissue destroyed by ulcera-
tion everywhere except for a small space at its base. The skin
and fascia overlying the gland are not only detached from it, but
most frequently m a condition quite ready to slough. It is not the
gland that will be found to have suffered by the delay in opening,
so much as the skin and connective tissue. And the reason is
clear ; the gland derives its vascular supply from its base, the only
part by which it is still adherent to the body, but its vitality by
reason of this condition exceeds that of the sxin and fascia, which
receive no such direct supply. Accordingly, if the natural process
is not interfered with, the last-named structures are always more or
less destroyed, whilst the gland remains in what, by a strange
interpretation of the facts, has been usually called an " indolent
condition.'' Now, is it not clear that the ulceration and destruction
of the parts surrounding the gland have been caused by the
chancrous matter which has escaped from the gland and become
infiltrated among them, instead of finding a ready exit from the
body? Such a conclusion would seem scarcely to admit of a
doubt. It is a fallacy, then, to suppose, that delay in opening a
bubo favours disintegration of the affected gland, except in so far
as it likewise favours still more the destruction of parts which it is
highly desirable to preserve.

With respect to the second object of treatment, viz., that of
respecting the natural appearance of the groin, no one can have

12 DR TEALE ON SYPHILIS AND ITS TREATMENT. [JULT

had mttcli practice in venereal diseases without obserrin^ how
exceedingly anxious his patients are npon this point, in all classes,
and nearfy without exception ; and I, therefore, cannot help regard-
ing every line of incision beyond what is required for letting out
the pus. as quite inexcusable. Extensive incisions in this part do
not neai without leaving marks, nor do they heal rapidly at all, as
a general rule ; and for the latter reason alone they ought to be
avoided if possible. For precisely similar reasons the plan so
frequently recommended of cutting away the undermined skm, or of
destroying it by means of powerful caustics, is equally to be con-
demned, for we may be sure that our patients will never have a
very nrateful remembrance of us if we have unnecessarily produced
unsightly and indelible scars upon them.

It may be concluded, then, that the moment pus is detected in a
bubo it ought to be evacuated, and by a small mcision : the latter
being advisable in all cases, first, for the sake of preserving appear-
ances, and, secondly, for the limitation of the extent of surmce to be
infected if the pus should prove of a chancrous quality. This point
may always be determined in the course of a few davs by the ap-
pearance of the opening. If it show a tendency to heal, we may
DC sure that we have not to do with a chancrous bubo, but if it
have a red, irritable, ulcerating aspect, or if its margins become
ash-coloured and sloughy, the case is otherwise, and the part should
be dressed with a strong solution of nitrate of silver, sulphate of
copper, black wash, or some similar application. Injections of the
same snould likewise be made into the interior of the bubo, and this
treatment should be continued until the specific nature of the
ulceration has been eradicated.

But, unfortunateljr, patients frequently avoid applying for assist-
ance until the mischiet has been done, and sometimes also we fail
to detect the presence of pus early enough to enable us to follow
this line of practice. In such cases, when we make the opening
and introduce a probe, we fiind that it passes freely between the
gland and the skin, showing that the subcutaneous tissue has
already, so far, been destroy^, and the best practice then is to
divide the skin by a single or a crucial incision, so as fully to
expose the gland. The skin being then retracted and most care-
fully preserved, the gland should at once be destroyed by the
chloriae of zinc or some other equally powerful escharotic, whilst
nitric acid should be applied to such of the surrounding parts as
may have been infected ; and when the sloughs separate, and the
part again puts on a healing appearance, the skin snould be drawn
over it and union be promoted. It is really surprising, sometimes,
to see with how little deformity a man may thus escape, even
though the incisions at different times may have extended for
several inches, and so many as three or four glands have been
destroyed. It may, perhaps, be objected that sinuses are liable to
follow upon small openings of the kind I have recommended, but.

1864.] DB YEALB ON STPHILIS AND ITS TBBATMENT. 13

without entering into an examination of the process by which
sinuses are formed, which, however, wonld probably suffice to refute
the objection, I may perhaps be permitted to lay some stress on the
&ct. that I have never once observed a sinus in the groin to be so
proauced.

With reference to the general or constitutional treatment of
venereal sores and buboes of the non-infecting kind, my belief is
that measures of depletion are never required or even advisable.
On the contrary, if the patient's health chance to be good, we should
endeavour to keep it so : but if it be already in a bad state, it is
almost needless to add that a tonic methoa of treatment is indis-
pensable.

I shall now proceed to the consideration of the indurated chancre,
and of constitutional syphilis.

Until an indurated chancre has been followed by enlargement of
the lymphatics in the neighbourhood, I am of opinion that it is
both justifiable and expedient to obtain the destruction of the part
affected by it, for which purpose excision is especially applicable
when the sore happens to be seated on any part which, like the
prepuce, admits ot ablation without detriment or disfigurement to
the patient. I make this statement with the utmost possible
deference for those observers who affirm that it is useless to extirpate
an indurated chancre. I do not pretend to deny that most frequentiy,
when the induration has become manifest, the entrance of the poison
into the system is inevitable, and has perhaps already taken place ;
but I think it is an error to conclude that the induration is the result
of the general contamination and a proof of it. For, if it were so,
why should it occur only once? whv should we be unable to repro-
duce it by a subsequent inocidation? why should not every super-
ficial solution of continuity occurring at this period also undergo
the same process? and why should it occur only at the site of
inoculation? It would seem to be more probable that the specific
induration is a strictly local process, dependent, it may be^ upon
the conjunction of several conditions ; of which, however, the lollow-
ing may be regarded as the chief: — First, tne constitution must
have been previously free from syphilitic infection. It must not
have undergone that kind of leucocytosis which the syphilitic virus
produces. Indeed, every leuksemic state seems to be adverse to the
process of induration : for we find that in women, in whom a chloro-
ansmic or leukasmic state is more common than in men, the indura-
tion of chancres is much less frequent ; and it is also observed that
a chloro-ansemic state of the system, however produced, delays the
specific induration even in men. Secondly, a certain degree of
activity or concentration of the virus seems to be necessary j for,
according to several observers, the induration produced by inocular
tion through the medium of the blood, or with the fluid of certain
secondary lesions, is not so well marked as that which results from
the action of the virus implanted directly from a chancre. Thirdly,

14 DB VEALE ON SYPHILIS AND ITS TREATMENT. [JULT

certain purely local conditions seem to be favourable, although by-
no means essential. Thus the process of induration is usually much
more complete on the prepuce and on the lips, for example, than it
is on the trunk, and it may perhaps be owing to a similar special
aptitude or affinity that the lymphatic glands are so constantly and
readily aflPected by it.

It may perhaps be objected, however, that oftentimes when a
chancre has been cauterized or excised, the wound, although made
in parts previously unindurated, has been observed to undergo
induration. But if this be a proof of the action of the virus through
the medium of the blood, or of systemic infection, why is it that
superficial solutions of continuity, happening simultaneously in other
parts, do not also become indurated? Every day's experience
shows that they do not, and yet the same blood and tlie same con-
stitutional state exist for them as for the part that is undergoing
induration. Why again, it may be asked, is a reproduction of
induration in a wound made for excising a true chancre to be re-
garded as a proof of constitutional infection more than the repro-
auction of an epithelial cancer after imperfect extirpation ? The
reproduction of the induration after excision much more probably
proves that the quantity of tissue removed has not been sufficient ;
It perhaps also proves that although the syphilitic virus may have
passed into the blood, the true syphilitic diathesis has not yet been
produced ; finally, it may prove the extremely gradual extension of
the poison from tne primary centre or centres, and may serve as an
argument not against the propagation of the poison through the
medium of the blood, but in favour of a quite different explanation.
If we withdraw our minds from the too exclusive contemplation of
the part played in the animal body by the vessels and tneir con-
tents, we shall perhaps be all the more ready to admit the possibility
of the syphilitic poison extending itself from cell to cell, very mucn
afl^r the manner of cancer. Indeed, in more than one respect, the
analogy between cancer and syphilis is becoming every day more
and more apparent. But, however, that may be, it will perhaps be
allowed that the evidence in favour of the theory which attempts to
account for the extension of the process of induration by reference
to what is vaguely called systemic infection is not clear, whereas
the view that the syphilitic virus disseminates itself through the
contiguous cells, and is carried away by the lymphatics, in the same
way as cancer, becomes more and more tenable the more we examine
it Although, therefore, it is established by clinical observation
that the specific induration of a sore only becomes perceptible to us,
as a rule, after the poison has entered the system, there is nothing
in the mere fact of induration which should cause us to regard the
constitutional infection as either present or inevitable. Such indu-
ration ought rather to be regarded as the direct result of the syphi-
litic poison upon a part suited to undergo the process, and there is
consequently no reason, theoretically, why the excision of a chancre

I86i.] DR YEALE OK 8TPHILI8 AND ITS TBEATVEXT. 15

ahoold not often be as successfal as the excision of its analogue —
cancer; but in order to be so it most be oondacied on the same
principles. It must obviously be a difficalt matter to aflford prac-
tical proof of the truth of this conclusion, because, as yet, we cannot
exactly determine the difference between a specific and an accidental
induration, but it is at least safe for me to say that I have occasion*
ally seen cases in which, after the extirpation of an apparently
specifically indurated sore, there has been no evidence of systemic
infection. But whatever may be the eventual verdict on this point,
it is almost imiversally admitted that when the lymphatics have
once become involved, the treatment of the sore alone is not suflicient.
The poison having entered the system, it must be combated by
constitutional remedies, and this at once opens up the question as
to the use of mercury.

The diversities of opinion which have prevailed concerning the
properties of this drug constitute one of the greatest marvels in the
nistory of medicine. Whilst a large number of medical practitioners
have m successive ages continued to extol to the skies its remedial
powers, others, equally conscientious, and sometimes conspicuous
for their acute powers of observation, have as strenuously denied
them. The question can hardly yet be looked upon as quite settled,
considering that books are still being published in which precisely
opposite opinions may be found concerning it. How can this be
accounted for except on the supposition that certain minds are
unconsciously swayed by preconceived opinions, and thereby become
incapable of observing or interpreting aright the facts which pass
before them ? ^^ Oculoa habent et mm videbuntj aures haberU et nan
attdiebunt.^^

In the following case, on the correctness of the details of which I
am able to place the most implicit reliance, mercury was found to
exert a decidedly curative influence upon the syphilitic constitution,
whilst several other remedies proved almost, if not absolutely inert.

A. B. contracted a venereal sore, which appeared on the third
day after infection, which was slow to heal, and became indurated
somewhere about the fourteenth day, the induration being followed
by enlargement of the inguinal and posterior cervical glands. In
the fifth week a scaly eruption appeared on the skin, and there was
slight soreness of the throat and swelling of the tonsils, but no
idceration.

From the sixth week to the end of the third month he took iodide
of potassium in considerable doses, without any improvement being
perceived. In the fourth month he took arsenic instead, and under-
went a course of warm baths. Slight amelioration of skin affection
ensued, but he became very weak and lost colour, his hair began to
fall out, and, shortly afterwards, he suffered from severe ulceration
of the tonsils. The arsenic was now suspended, nitrate of silver
was applied to the ulcers, and mercury was given internally. Afl»r
about ten days of this treatment the throat was well, and the

16 DR VEALE ON SYPHILIS AND ITS TREATMENT. [JULT

cataneonfl eruption Had almost disappeared. He now discontinned
the mercoiyy because he found its action to interfere with his
occupations.

6^ Month, — Muscular rheumatism after exposure to cold^
relieved in three dajs by iodide of potassium.

%th Month. — ^Fresh eruptions on the skin. Iodide of potassium
internally.

l\ih Month. — Skin affection as before; ulceration of tongue and
throat. Iodide of potassium continued in large doses.

12th Month. — ^The symptoms becoming more severe, and espe«>
ciallv the ulceration of the mouth, the iodide of potassium was ois*
contmued. Mercury was now given in small doses for nearly a
monlhiy during whicn time the various symptoms disappeared, and
the general health also improved.

18th Month. — Health remaining good. A few brownish spots
appeared on the pubis. No treatment.

24:th Month. — ^Eruptions on the skin. Iodide of potassium, in-
ternally, with iron. No improvement.

26th Month. — Cutaneous symptoms as before; general health
failing. The medicine was omitted.

5l8t Month. — ^Ulceration of the throat having set in, he took
mercury and iodide of potassium together, for a fortnight, when the
throat got well, and the treatment was discontinued.

34^ MontL — Cutaneous eruptions ; treated by iodide of potassium,
without benefit.

35th Month. — He took Donovan's solution for about a fortnight
or three weeks, when the skin affection almost disappeared, and his
health improved greatly.

He continued well until the end of the fourth year, when he
again became troubled with repeated ulceration of tne mouth and
tongue. This was treated by the local application of nitrate of
silver and the internal use of iodide of potassium. He suffered
more or less in this way until the §9th month, having also crops of

Eustules constantly coming and going, but never entirely leaving
im. At various times he took quinine, acids, iron, sarsaparilla,
and various other remedies, whilst the local use of nitrate of silver,
chlorate of potash, borax, etc, was frequently had recourse to. His
general health was sometimes good, more frequently indifferent,
and oftentimes it was absolutelv bad.

70th Month. — He suffered from unusually severe ulceration of
the throat, mouth, lips, and marg^ of the anus, as well as from
copious pustular eruption on the skin, for which he submitted to a
month's mercurial course. This had the effect of freeing both the
cutaneous and mucous surfaces from all the manifestations of
syphilis, and his health also underwent a marked improvement.
Wnen 1 last saw him, viz., at the end of the ninth year from the
date of the primarv sore, he was still in good health, and had had
no return oi syphilitic symptoms.

1864.] DR VEALE ON SYPHILIS AND ITS TREATMENT. 17

Notwithstanding that I have omitted, for brevity's sake, many
important details connected with this case, it is yet sufficiently
apparent that the symptoms throughout were those of the secondary
stage, and that of the two systems of treatment — ^the mercurial and
the non-mercurial — each had a tolerably fair trial ; the result being
that iodine, arsenic, iron, warm baths, acids, etc.. proved absolutely
useless as remedies of the syphilitic diathesis ; wnust a rapid disap*
pearance of symptoms, and, in all probability, a diminution of intensity
m the diathesis itself^ invariably followed the use of mercury. And
the result of all that I have seen in military practice equally leads me
to believe that mercury is the most potent of all remedies against the
diathesis of syphilis in its secondary stage, as well as a^inst the
lesions of the skin, mucous membranes, etc., b^ which it may be
manifested. But notwithstanding that mercury is to be regarded as
the most powerful controlling agent that we possess against secondary
syphilis, it canndt be too strongly insisted upon that its use is not
beneficial in every case, or in the same case at all times. The modus
operandi of this drug is still only imperfectly understood. It seems,
however, to be certain that all its preparations exercise, in a greater
or less degree, a specific irritating action upon whatever parts of the
animal economy they happen to reach. Consequently, its eflSacts
may either be direct, indirect, or both. The skin protected by the
epidermis is only capable of being irritated when the preparation
applied to it is a soluble one, as the biniodide or the corrosive
sublimate, or when, if insoluble, its action is promoted by fnction
or prolonged contact. Still, when any effect is produced, it is
invariably that of a special irritant The mucous membranes
being of a more delicate structure are more easily acted upon ; and
accordingly we find that the comparatively insoluble preparations
are capable of irritating them to a considerable degree, whilst the
more soluble ones corrode them, even in small quantities. Thus, five
or ten grains of calomel, given internally, irritate the intestinal
mucous membrane and produce purging, whereas a similar auantitv
of the biniodide or corrosive sublimate would act as a corrosive irri-
tant poison. When absorbed into the blood, its action remains the
same except in degree. It then irritates every part with which it
comes into contact. The mucous membranes, the secreting organs,
the vascular tissues, the nervous matter, all experience its directly
irritant action. But in irritating the Ivmphatic glandular system,
taking this term in its most comprehensive sense, it alters the
quality of the blood, diminishes its red globules, increasing the
white, and rendering the fibrine less plastic. The blood being
altered in this way, the nutrition of every part of the body must
necessarily be mocUfied also. The secretions destined for re-absorp-
tion must likewise be altered in quality ; and thus we arrive at a
tolerably clear notion of what is to be understood by the indirect
action of the drug. Whenever its action through the medium of
the blood is at all prolonged, it is highly probable that the directly

VOL. X. — NO. I. c

18 DR VEALE ON SYPHILIS AND ITS TREATMENT. [JULT

irritant effects are ^atly increased by the altered state of nntrition,
— ^the result of its indirect action, and vice versd. The production
of salivation, and the modified action of the liver, kidneys, and
mucous membranes, as illustrated by altered bile, occasional albu-
minuria, irritation of the urethra, cough, dyspnoea, and hsBmoptysis
on the part of the lungs, and diarrhoea or haemorrhage from the
intestines, are all examples of its directly irritant action, increased
by its indirect effects.

It is surprising what extremely minute quantities are capable of
producing the specifically irritant action. I have often seen the
twenty-fourth part of a grain of calomel given, every half hour, to
produce ptyalism within twenty-four hours ; and although this mode
of administering the drug is seldom had recourse to in this country,
the experiment has been so frequently made as no longer to admit
of a doubt that even smaller quantities may suffice for the develop-
ment of its physiological effects, without there being any special
susceptibility on the part of the patient. The quantity of the
mineral existing in the blood at any given time during its admin-
istration seems to be exceedingly minute, notwithstanding that its
action upon the system may have been long-continued and pushed
to excess. It does not matter in what doses, or by what^ channel,
or for what length of time the drug is given, chemists can never
detect any but the smallest quantities in the blood, and these not
always. It is perhaps for this reason that some have even doubted
whether it was absorbed at all or not ; but perhaps this circumstance
should not be looked upon as being so very remarkable^ seeing that
it may almost be regarded as a general law, that poisons of any
kind, during life, can only exist in the blood in minute quantities
and for short intervals. Whenever a poison has found its way
into the blood, an effort is immediately made by the system to
eliminate it, and so we find it excreted by the intestines, the kidneys,
the lungs, tne skin, etc., according as there happens to be an affimty
between the poison and one or more of these organs ; but some-
times when these channels prove insufficient, the poison is excreted
into the tissues in an insoluble form, as has been frequently observed
in the case of mercury. It seems impossible, in short, for any

Soison or for any foreign substance long to persist in the blood
uring life. It is also to be noted that many poisons during their
elimination irritate by their presence the narts which subserve this
process. Iodine, for example, irritates tne kidneys, the urethra,
and the commencement of the gastro-pulmonary mucous membrane ;
arsenic irritates the mucous membranes and the skin, often causing
eruptions on the latter. Copaiba irritates the mucous membranes,
ana also frequently occasions eruptions on the skin, and so on.
Such of the morbid poisons as may be supposed to have an irritant
action likewise produce similar results. Small-pox, for instance,
irritates the mucous surfaces and the skin, giving rise, on the latter
especially, to its characteristic eruption ; and it is perfectly reason-

1864.] DR VEALE ON STFHILIfl AND ITS TREATMENT. 19

able to conclude that its specific virus is eliminated in this way.
Bat it geneiallj happens that the greater the force with which a
morbid poison ia eliminated the more actively contagions does it
become, and vice versd. In the case of small-pox, the eliminative
force is so intense, that even the insensible exhalations from the
surface probably contain the poison ; and there is reason to believe
that whenever, after the manifest action of a morbid poison upon
the system, no specifically diseased state or diathesis remains, the
whole of the moroid poison has been got rid of; whereas, when such
a diathesis continues, the probability is that it is due to the persist-
ence in the ecpnomy of the morbid poison which first gave rise to it.

These considerations may perhaps facilitate a farther inquiry
into the nature of syphilis. It may fairly be presumed that the
sjrphilitic virus is a specifically irritant morbia poison, harmless
when applied to the dense and resisting skin, but, even if not
powerful enough to act upon the more delicate mucous membranes,
capable of producing its special irritation on any part denuded of
these protecting coverings. One sees the result of its direct and
local action in the indurated sore, and enlarged and indurated state
of the lymphatic glands which it produces. Absorbed into the
blood, it especially irritates the skin and die mucous membranes of
the mouth, throat, and anus, giving rise to various forms of erup-
tion and ulceration, as well as to other modifications of nutrition ;
but it is probable that the quantity so absorbed is extremely small,
or else that it undergoes a change in quality, for if the virus were
as active in the blood as it is at the site of the primary ulceration,
inoculation by means of the blood should be as easy and as certain,
whenever it contains the virus at all, as inoculation by the secretion
of an indurated sore. It has been amply proved, however, that
such is not the case.

There is probably no part of the system which does not experi-
ence the efiects of the irritation of the syphilitic virus ; but owing,
perhaps, to the force of vital resistance being less in certain parts
than m others, or perhaps by reason of the greater degree in which
the skin and mucous membranes are exposed to variations of tem-
perature and other sources of irritation, it is on them chiefly that its
action shows itself. The lymphatic glandular system, however, is
especially subject to the influence of the poison. Not only is there
a direct absorption fi-om the primary sore to infect some of the
lymphatic glanda, but it is probable that they may also be infected
in a more circuitous manner, if there be any truth in the theory
which regards them as organs which, besides contributing to the
formation of the blood, constitute a series of filters, whose ofiice it
is to collect from that fluid, and from the tissues generally, such
foreign and injurious substances as may have found their way into
them. At any rate, whether we accept this explanation or not, the
fact is indubitable, that the lymphatic glandular system is especially
susceptible to the influence of the sjq)hilitic poison, as is clearly

20 DB YEALE ON STPHILIS AND ITS TREATMENT. [JULT

shown bj the induration and enlargement of the inguinal, cervical,
posterior aural, and mesenteric glands, which accompan;^ secondary
syphilis. The proneness of the thymus to ulceration in cases of
inherited syphilis, and the enlar^ment and ulceration of the tonsils
in nearly all the sta^s of the disease, also point in the same direc-
tion ; wnilst if any turther proof wese wanted of the irritant action
of the virus upon the whole glandular system, it would be found in
the diseases of the liver, kidbuey, spleen, testicle, etc., so frequently
observed where its action has be^ of long duration, or favoured
by £Eiulty hygienic or other unhealthy conditions. Lastly, the pro-
duction of the state of chloro-ansemia, or the leucocytotic condition
of the blood, so common in cases of constitutional syphilis, is
more easily explained by admitting the irritant action of the syphi-
litic virus upon the blood-elands than by any other hypothesis ;
and clinical observation will, I think, justify the conclusions, — Ist,
That induration and enlargement of the lymphatic glands is never
absent when secondary symptoms are present ; 2dy That so long
as their specific induration continues, it is an evidence of the per-
sistence of the syphilitic diathesis ; and, Sd. That when the specific
induration and enlargement of these glands disappear, the individual
either entirely recovers or passes into a well-marked tertiary stage,
in which one may presume that atrophy or degeneration of their
structure has resmtCKl firom the long-contmued irritation.

In entertaining the theory that the syphilitic virus is an irritant
poison, it is also necessary to suppose that, as in the case of mercury,
its efiects may be either direct or indirect, or both combined. The
most evident of its direct efiects is induration ; and there is reason to
believe, as I have already stated, that this varies in degree, not
only with the previous state of the system and with the nature of
the part, but likewise in proportion to the quality of the virus
engaged in its production. It is quite consistent with the tendency
of nearly all the most recent observations and reflections on this sub-
ject, to suppose that the virus loses its intensity after a prolonged
residence in the system ^ for it has been sufiiciently provea that the
fluid products of the primary sore furnish a poison which is much
more certainly and easily inoculable than that contained in the
blood or in the secretions of a secondary lesion. It is also believed
by some that the s^ptoms, both primary and secondary, which
result from the action of this presumably modified virus are less
severe than those which ensue upon inoculation from an ordinary
and typical chancre. Still, whibt admitting the possibility of a
change in the nature of the virus, it must not be forgotten that its
indirect efiects, exerted through the lymphatic glandular system
upon the constitution of the blood, and, consequently, upon the
nutrition of every tissue and organ in the body, are probably more
important. It will be admitted that the leucocytotic states produced
by irritation of the lymphatic glands are not always the same in
degree, and it is possible that they may not be the same in kind ;

1864.] DB TEALE ON STPHILIS AND ITS TBEATMEMT. 21

for there is oertablj a very vast difference between the complexions
of cancer^ scrofiilai pregnancy, syphilis, mercurialismy etc. What
the exact changes may ht which correspond with these yarioos states
we are at present unable to determine^ but there is reason to believe
that eveiy such condition necessarily involves a modification of the
nutritive processes and a difference in the mode of reaction of the
economy against the influence of whatever constitutes a stimulus.
At any rate, whether this be true or not, the practical fact remains
that the system becomes so modified by the action of the syphilitic
virus that it soon loses the capability of undergoing the specific
indurating process, no matter in what degree of activity or intensity
thepoison may be employed.

To resume, the primary induration appears to be the result of
the direct action of the virus upon a part previously unaffected by
it, either mediately or immediately ; the secondaiy lesion is probably
a conseauence of the direct action of the poison upon a part already
modified by its indirect effects ; the tertiaiy, on the other hand, is
perhaps either a modification of nutrition caused by the prolonged
duration of the indirect effects, or the result of the direct action of
an altered virus, or, what is more probable still, a combination of
these two conditions.

The sequence of events in syphilis, then, would seem to be nearly
the following : —

Isty Induration of the part inoculated, equivalent to increase of
virus by molecular or cell development.

2d. Absorption and transmission of virus to the contiguous
glands; induration and irritation of these organs; leucocytosis ;
and, consequent thereon, modification of nutrition, owing to which
the capability for induration diminishes, and for the most part
ceases.

3d. Passage of the virus into the blood*; its elimination through
the skii^ and mucous membranes, and, consequently, eruptions and
ulcerations.

4thy Absorption by the lymphatics of the syphilitic virus not
wholly eliminated ; irritation of other glands ; transmission of virus
from one set to another ; further changes in the blood ; lesions of
nutrition ; repeated passage of poison into the blood, followed by
fresh eliminative efforts^ and so on.

5thy Elimination failing ; alteration in quality of virus and its
deposition in certain structures ; profound lesions of nutrition.

Byphilis in fact seems to stand midway between smallpox and
cancer, — the capacity for elimination of their respective morbid
poisons constituting the main difference; and certainly, if we
accept the proposition of Virchow, that ^^ every dyscrasia is depen-
dent upon a permanent supply of noxious ingredients from certain
sources," ana that the blood neither is nor can be its real seat, and
then look to the fact that the lymphatic glands are the only structures
which in secondary syphilis remain permanently indurated^ we are

22 DS VEALE ON SYPHILIS AND ITS TREATMENT. [jULY

almost forced to the conclusion that thej constitute '^ the local
depots from which new quantities of noxious matter are continually
bemg introduced into the blood." This theory is certainly more
tenable than that which supposes the poison always to exist in the
bloody and at certain perioos, viz., at tne outbreak of cutaneous or
mucous manifestations, to undergo a kind of fermentation or zymosis;
but it would occupy too much space to pursue it farther in this
direction for the present.

It has been seen that syphilis produces a leucocjtotic state of the
blood, and that mercury has a similar effect, and it is very remark-
able that the drug in certain cases diminishes and tends to extin-
guish the leucocytotic nisus of the disease instead of increasing and
perpetuating it. But it is equally strange that injections of nitrate
of silver into the urethra will cure an inflammation already existing
there, and yet give rise to it if the membrane be healthy. It may
be said that the antisyphilitic action of mercury resolves itself into
that of a special counter-irritant Still it is to be borne in mind
that nothing more is to be understood by this phrase than is implied
when we say that the salts of zinc, copper, silver, etc., are special
counter-irritants when they subdue an inflammation of the mucous
membrane of the eye or urethra. The counter-irritation established
by mercury in a case of secondary syphilis is, however, probably
more extensive, and consequently more direct than that produced
by any other remedy; ana hence is to be explained, in part at
least, its more lasting impression upon the disease. In a consider-
able number of cases of secondary syphilis the enlargement of the
lymphatic glands will be found to decrease under the use of mercury,
to recur if the drug be prematurely discontinued, and then to be
almost invariably fmlowea by lesions of the skin or mucous mem-
branes. As to the form which the cutaneous eruptions may assume,
it is probable that it depends far more upon the state of health of the
sufferer than upon any aifference in the syphilitic virus. A roseola,
for instance, will be connected with a comparatively good state of
health, whilst rupia will be a tolerably certain indication of a bad
one ; and this state of the constitution may either have been pro-
duced by the syphilitic poison itself, or it may have preceded and
been altogether independent of its action. The diagnosis of the
particular kind of skin affection is therefore of some importance, as
corroborating or guiding our opinion respecting the general consti-
tutional condition of the patient — a point of the utmost importance
with reference to treatment.

This attempt to elucidate the modus operandi of mercury and of
the syphilitic poison will perhaps be considered excusable if it be
remembered that the uncertainty under which we labour, whenever
we prescribe mercury for syphilis, convicts us of ignorance, both of
the essential nature of the disease and of the modus operandi of the
remedy. We know that sometimes, nay, often, mercury will act
like a charm. It is not unusual to hear patients declare that it has

1864.] DR VEALB ON 6YPHTLI8 AND ITB TREATMENT. 23

made them strong, improved their appetite, and restored the desire
for exertion ; whilst we see for ourselves that it has brought back
the colour to their cheeks, and caused the eruption on the skin and
mucous membranes to disappear. But we cannot as jet tell before-
hand whether it will act m this manner in anj given case, or
whether it will add to the Qvil effects of the disease ; and from this
ignorance the practical rule is to be deduced, that mercury should
he administered tentatively in whatever case of syphilis toe employ it
Unless the health undergoes an improvement under its use, and
unless the syphilitic manuestations £sappear, we mav be sure that
it is doing no good, and may perhaps be doing mucn harm. We
must not make an abstraction of the disease — sjphilis, and regard
mercuiy as its antidote. Constitutional syphilis is a morbid state,
the conditions of which, so far as we know them, are extremely
variable, and it is only by patient, intelligent, and unbiassed ob-
servation, that we can expect to attain to a knowledge of the par*
ticular combination of them which admits of the curative action of
mercury.

The manner and form in which the drug is to be administered
are also of importance^ and theonr and practice b(>th imite in
establishing the second practical rule, viz., never to persist in any
method which produces much local irritation. According to my
experience^ the blue pill is the least irritating of the preparations of
mercury which are given internally. The iodide is not only far
inferior to it in this respect, but ukewise much more uncertain.
There seems to be no foundation whatever for the opinion that the
corrosive, sublimate or the biniodide is more suitable than blue
pill in the advanced periods of the disease. When the mineral has
once been absorbed into the blood its action is probably the same,
whatever may have been the form und||jv^hich it was administered.
The advantages of inunction and ftonigation seem chiefly to result
from the little irritation caused by them ; but the disadvantage of
inunction is, that it does not admit of our regulating the amount
of the mercurial action. Fumigation, on the other hand, is incon*
venient: it requires the use of apparatus, and in certain cases in
private life is altogether impossible. Still, each method has some-
thing to recommend it, and should certainly be had recourse to
whenever it is thought necessary to submit the patient for a length-
ened period to the action of the remedy.

In the army it is not the custom to treat syphilis by a six months'
mercurial course. The plan which is generaUy adopted, and which
is probably the best under the circumstances, is to continue the
mercurial treatment only until the disappearance of such lesions of
the cutaneous or mucous surfaces as mav have existed.

A great deal has been written and talked of late respecting
the extent to which venereal diseases exist in the army, and the
sickness and mortality which they cause, but it ought to be remem-
bered that soldiers are taken into hospital for ailments which in

24 DR YEALE ON SYPHILIS AND ITS TREATMENT, [JULT

private life would never be allowed to interfere with a man's
ordinary occupations. There can be no doubt that syphilis pro-
duces a consiaerable per-centage of the inefficiency, ana, perhaps,
of the mortality of our soldiers, and that it behoves us to endeavour
to check it to the utmost of our power ; still, the statements which
have recently been made concerning its ravages have led to
exaggerated, erroneous, and most unjust conclusions. It is rarely
that the soldier of the present day is reduced by syphilis to the
cachectic and diseased condition which has been said to be so
common in the army. Thanks to the intelligence and skill of their
medical officers, the vast majority of our soldiers have, in recent
times, been happily preserved from the evil effects of their venereal
diseases. Fearml indeed would be the mortality and the pecuniary
loss to die country, to put the matter on no higher ground, but for
the solicitude with which an enlightened Government invariably
provides that the treatment of our sick soldiers shall be intrusted
to none but the competent I I do not pretend for a moment to
assert that the treatment of syphilis, as practised in the army, has
the effect of curing the disease entirely, and rendering the patient
safe against relapses. Far from it. 3uch' a happy result seems to
be only very seldom attainable under any kind oi treatment. The
syphihtic disease has a truly wonderful power of persistence, and
the doctrine which teaches that it may be left to itself on the cnance
of its being worn out by time is surely a most pernicious one. I
believe, however, that the plan of combating the syphilitic diathesis
at those periods when it seems to be endowed with special activity,
answers as well in the long run as if the mode of treatment by a
six months' mercurial course were had recourse to.

But it may be asked, what is the danger of leaving the disease to
the effects of time ? In reply it is only necessary to say that constitu-
tional syphilis impairs the health of every individual affected by it,
and that, in its secondary stage at least, it is a communicable disease ;
communicable from the parent to the offspring, and through this
medium from the father to the mother; communicable also from
the child to its nurse, and from the latter again to others, and so on.
With reference also to this subject, I may recall a case in which
syphilis, probably transmitted from the father, persisted unrecog-
nised in nis son for thirty-two years. When 1 saw the latter he
was suffering from languor, debility, bad appetite, dyspepsia, ansamia,
nocturnal headache, sleeplessness, rheumatoid pains in the limbs,
ulceration of the tongue, mucous patches of the throat, ulceration of
the lips, nose, and anus, and a peculiar eruption on the hands and
feet, consisting of indurated swellings, red, but painless, and vary-
ing in size from that of a pea to that of a filbert. There was also
slight enlargement of the glands at the back of the neck and behind
the ears. This patient assured me that he had never contracted
syphilis by any act of his own, that, in fact, he had never exposed
himseU* to a chance of contagion, and the circumstances of the case

1864.] DR TBALE OH 8TPHILI8 AND ITS TREATMENT. 25

were Buch that I have no doubt he spoke the truth. Besides, there
was no trace of any primary lesion, and the hereditary source of
the disease seemed to be rendered still more probable by the fact
that his health had always been indifierent, that some of his teeth
were slightly notched, and that others were peg-shaped and prone
to decay, that his brothers had always had unaccountably bad
health, and, finally, that his father had suffered from syphilis in his
youth. Now this patient had married early in lite, and had
begotten children, and on examination signs of syphilis were found
in them also. The eldest living, a^ed seven, had the two upper
central incisors slightly notched, with enlargement of the tonsils
and of the posterior cervical glands, squamous eruptions on the
scalp, and a lean strumous habit of body. In a younger child the
symptoms were still more decided, whilst the wife, at about the
seventh year after marriage, suffered for the first time from cutaneous
eruptions and ulcerations of the mouth and tongue. Surely, if the
symptoms in either of these cases were due to syphilitic contamina*
tion, it will hardly be contended that we are justified in leaving to
itself a disease which runs on in this way from generation to gener*
ation, imbittering, and probably shortening, the existence of each.
And this is not a solitary case. Indeed, the more one sees of
syphilis the more difficult will it be to avoid the conviction that,
without specific treatment, the diathesis established by it persists
indefinitely, and is capable of being transmitted hereditarily at a
very much later period than is usually believed. The general
opinion seems to be that inherited syphilis almost always shows
itself within a very short period after birth. This may be true,
but only on the supposition that the first symptoms are so slight
that they fail to attract attention, and of such an equivocal kind as
to require confirmation by subsequent and more decidedly syphi-
litic phenomena. It is, perhaps, not easy to avoid falling into error
whenever we try to determine what should be held to be evidence
of syphilis under these circumstances, and what not. Still I think
that enlargement of the lymphatic glands, without any other
apparent cause, deserves to be regarded as the most certain ; but if
with this sign there happen to be frequent eruptions on the body,
on the scalp, behind the ears, at the angles ot the lips, or at the
alsB of the nose, or onyxis, or ulceration of the mucous membrane of
the mouth, the probability is that the disease is syphilitic. We
ought, however, to be especially on our guard against accepting any
one symptom as sufficient or conclusive. The notched or peggra
condition of the teeth, for example, is a highly important symptom
if found in conjtmction with others, but by itself it only indicates
that certain conditions of the teeth and alveoli have existed, which
m^ or may not have been caused by the syphilitic state.

In many of the cases which have come under my observation the
first explosion of manifestly syphilitic symptoms has been as late
as the second year alter birth, and it is a curious fact tliat in many

VOL. X. — ^NO. I. D

26 DS YEALE ON SYPHILIS AND ITS TREATMENT. [JULY

of these cases the lesions of the skin^ mncous membranes and glands^
notwithstanding their late manifestation^ are more easilY cored hj
mercury than bj any other medicinal agent. If we looked merely
to the element of time they would come under the category of
tertiary symptoms, and should deriYe greater benefit from iodine
and its compounds, but such is not the case. NcYcrtheless it must
be admitted that wheneYcr mercury is to be employed for the treat-
ment of late secondaij accidents, it recjuires to be given in extremely
minute doses, and with such precaution as may efiectually prevent
any excessive local irritation. The distinction between the second-
ary and the tertiary stage of syphilis is, as Ricord long ago pointed
out, a purely arbitrary one, and oftentimes the symptoms of the one
will be mingled with those of the other ; still, experience has proved
that when the bones are the parts affectea, when the cutaneous
eruptions assume the tubercular form, when there is a tendency to
the formation of tumours in the muscles and other parts, also when
the fibrous structures appear to be involved, in these and many
similar instances iodine is the sovereign remedy. There is one
point, however, in connexion with the use both of this drug and of
mercury which it is worth while to insist upon, viz., that their
beneficial action seems to be promoted, and their possibly injurious
effects diminished by the simultaneous administration of tonics,
such as iron and quinine, and the adoption of as generous a diet
and regimen as may be suitable to the patients constitution.
Svphilis, it should never be forgotten, is one of the most debilitating
of the dyscrasiae, and it may fairly oe questioned whether the iu
effects which formerly attended the use of mercury were not in
great measure due to the prolonged low diet and rigorous absti-
nence firom tonics and stimulants which were then so constantly
enjoined whenever this drug was given as a remedy for syphilis.

Article in. — Observations on Shoulder PreseniaJtions of the Fcstus.
Bj John Christie, M.D., F.R.C.S. Edin., Lecturer on Mid-
wifeiy and the Diseases of W omen and Children, Aberdeen.

Shoulder presentations are, in certain circumstances, amon^ the
most dangerous occurrences which present themselves in midwifery.
In a woman who has already borne children, in whom the pelvis
is roomy, the membranes unruptured, and the os uteri dilated or
dilatable, or where the membranes have only iust given way, and
the uterus has not yet contracted firmly round the foetus, little or
no difficulty is usually experienced in turning the child, and com-
pleting its extraction in a brief space of time. But it is far other-
wise when the pelvis is narrow, or the liquor amnii has been for a
long time discharged, and the uterus has, consequently, come to be
closely contracted around the body of the foetus, even when the os

1864.] DR GHRUrriE OH SHOULDBB PRESENTATIONS. 27

uteri is ftdlj dilated, or, if not so^ readily gives way to the dilating
force of the operator s hand.

But, setting aside the more common presentations of the shoulder^
and the consideration of the circnmstances which maj complicate
them, and render their treatment difficult, I would direct attention
to a class of cases which do not seem to have been much noticed bj
obstetricians. This is possibly, of late years more especially, due
to the simplicity aimea at in describing shoulder presentations.
Madame La Chapelle and Nsgele were undoubtedly right in limit-
ing malposition of the fdll-grown living foetus to arm and shoulder
presentations. The latter, also. Judiciously divided these mal-
positions, according to the order of their occurrence, into two. viz.,
iikQjirst position of the shoulder, in which the back of the loetus,
compared with its anterior surface, is turned more than twice as
often to the anterior wall of the abdomen of the mother ; and the
secondj in which the same surface is turned towards the posterior
wall.^ In either of these positions^ we are taught that the head
lies towards the one or the other iliac fossa, and the bodv in an
oblique direction over to the other side, the presenting shoulder
forming the most depending part of the foetus, or that with which
the examining finger necessanly first comes in contact.

In the great majority of instances this is true, but there are cases
in which the shoulder is the presenting part, and yet the body of
the foetus does not lie in the transverse direction to anything like
the degree almost universally assumed in regard to shoulder pre-
sentations. Smellie, in this, as in so man^ other points of practice,
seems to have been far more accurately informed than either his
contemporaries or successors. In his " Sett of Anatomical Tables,"
etc (London, 1764), the thirty-second plate represents a shoulder
presentation with the left arm prolapsed, and the uterus closely con-
tracted around the body of the foetus. In this state of matters, the
uterus, with its contained foetus, forms a roundish mass, having its
greater diameter running from the right side somewhat obliquely
up towards the left; and here we can, for the most part, move
^^ the foetus with the hand, so as to turn the head ana shoulders
to the upper part, and the breech and legs downwards." *

But SmeUie shows, farther, that the shoulder may present, and
the foetus nevertheless occupy a very different position in the uterus
than that commonly ascribed to it. To understand this, let us see
under what presentations nature is generally believed to be of
herself able to efiect the expulsion of the foetus. Wherever, accord-
ingly, the long axis of the foetus corresponds to the long axis of
the uterus, no matter whether it be the vertex, the face, the breech,
or the feet which presents, experience has ftilly proved that labour,
as a rule, terminates without any interference on the side of art

1 F. K. NaBgde, Lehrbuch der GeburtshtQfe, etc., Heidelb., 1844, p. 222.
* W. Smellie : a Treatise on the Theory and Practice of Midwifery, vol. 1.,
4th edition, London, 1762, p. 334.

28 DR CHBI8TIE ON SHOULDER PRESENTATIONS. [JULT

With the view of removing obstacles to its due progress. True, Dr
Churchill, with others, still ranges face and breech presentations
under the head of ^'unnatural labours;" but when he tells us of
the former, that ^^ of late years it has been established as a rule,
that assistance is unnecessary merely on account of the mal-
position," and of the latter, that ^^ the less interference the better
for the patient," ^ we at once see his practice is far in advance of
his Iodic Dr Murphy adopts the same arrangement of these pre-
sentations, and is so influenced by it, that, in vie general case, after
the labour has reached a certain stage, he recommends a very
"meddlesome midwifery."* Dr Tyler Smith shies the question of
arrangement, but agrees generally in the views expounded by Dr
Murphy, and unmistakably, therefore^ leans to the idea that pelvic
are preternatural presentations, requiring in the end, as a rule,
rather active interference.'

But, notwithstanding the views of these able and distinguished
men, it is now-a-days, on almost all hands, virtually, if not formally,
admitted, that the correspondence of the long axis, both of the
uterus and foetus, is sufficient to constitute a natural position of the
latter, whether it be its cranial or its pelvic end which is the pre-
senting part ; and that, wherever this happens to be the case, labour
is practicable by the unaided powers of nature. Accordingly, in
the so-called cases of transverse presentations, it is the aim of art
to bring about this correspondence by means ot certain manual pro-
ceedings, and thus reduce the process of labour as near as possible
to one 01 its natural types.

But, even in the worst cases of transverse presentation, nature
may herself overcome the obstacle to labour, as we see in the
examples of spontaneous evolution and expulsion of the fcetus
xecorded by Denman and Douglass, and in those of spontaneous
rectification and turning, by other observers. In all cases of
shoulder presentation, says Braun, in order to make labour possible,
the foetus, whether mature or not, must undergo a change into the
longitudinal position, or be subjected to dismemberment. These
are effected m the following ways: — 1. By rectification of the
foetal position; 2. By spontaneous turning; 3. By spontaneous
evolution; 4. By the technical turning by the head, the breech,
one or both feet, and one or both knees ; and, 5. By the decapita-
tion of the foetus, or bv embryotomy, or its evisceration.* But neither
of these modes incluae all that nature can do in bringing about a
longitudinal position of the foetus in shoulder presentation. Another
means of effecting this has been almost wholly overlooked. Smellie

1 On the Theory and Practice of Midwifery, 4th edit., London, 1860, pp.
412 and 421.

' Lectures on the Principles and Practice of Midwifery, 2d edit., London.
1862, p. 376, et seq.

' A Manual of Obstetrics, London, 1858, p. 347, et seq.

* Lehrbuch der Gebortshttlfe, etc. : Wien, 1857, p. 597.

1864.] DR CHRiqriE ON 8H0ULDEB PRE8ENTATI0N& 29

has^ Indeed, admirably figured the state of things (Tab. zzxiy.)
which may lead, in a shoulder presentation, to the advance of the
fcetns through the pelvis with its long axis in a longitudinal direc-
tion, but he does not appear to have ever witnessed^ or to have even
suspected such a thing to be possible.

In speaking of the difficulties which may be encountered in pre-
sentation of the shoulder, and in contrasting the round form ot the
uterus, contracted close to the foetus in the usual state of things,
with another state of the organ, in which it resembles ^^ a long
sheath," with the child lying in it " lengthways " (vol. i. n. 334).
the head being ^^ reflected over the pubes to the right shoulaer ana
back, and the feet and breech stretched up to the Amdus " (Tab.
xxxiv.), he describes a position of the foetus in which, as will pre-
sently be shown, it may be extruded by the expelling powers alone,
without anything resembling spontaneous evolution, or the other
processes alluded to by Braun, taking place. For example, early
in the morning of the 7th January 1861, 1 was called to Mrs A.,
16 Lon^ Acre, a primipara, who had been in labour from 5 o^clock
A.M. of the preceding day. The os uteri was about two-thirds
dilated, so that the presentation could readily be made out to be
that ot the cranium in the first position. In a few minutes the
membranes burst, and soon after a very small but male living child
was bom. After separating it from die mother, when a vaginal ex-
amination was made for the purpose of ascertaining the position of
the placenta, the membranes of a second foetus were found project-
ing through the os uteri, but the presentation could not be made
out because of its heieht above the inlet of the pelvis. In half an
hour, the pains, which had subsided on the birth of the first child,
returned very actively, and on an examination being made the
presentation was found to be a shoulder one, an arm having already
come down into the vagina. At this moment the infant already
bom, being very feeble, required my attention for a few minutes.
During my absence from the bedside the membranes mptured, with
the escape of a large quantity of liquor amnii. On now making an
examination, the left arm was found to be that prolapsed into the
vagina, the corresponding shoulder being at the brim of the pelvis.
The nature of the case being now quite clear, I passed my right
hand up along the arm till the trunk of the foetus was reached, and
while cautiously but firmly endeavouring to get at the feet, for the
purpose of turning, I found the head of the foetus to lie lorwards
over the horizontal ramus of the left os pubis, while the neck was
so bent that it lay in contact, at the same time, with the right
shoulder. Moreover, the breech and feet were tumed upwards to
the ftmdus uteri ; and the uterus contracted so closely and so power-
ftilly round the body of the foetus, in the form of a " long sheath,"
whenever I attempted to force my hand onwards, that Icould not
pass it so far up as to reach the feet, or even the flexure of a
knee. Attributmg this in some measure to the rather awkward

80 DR CHRISTIE ON SHOULDER PRESENTATIONS. [JULY

position of my hand^^ I tried^ howeyer, before withdrawing it^ to

Sush np the presenting part, with the view of brin^g the head
own to the inlet of the pelvis ; but the very powerfin contractions,
induced by every movement I made, rendered the attempt fruitless.
Accordingly, I withdrew the ri^ht hand, for the purpose of substi-
tuting the left, but on introducm? it into the vagina, I found the
shoulder, neck, and head pushed down into the cavity of the pelvis,
all compressed together, much in the form of the breech, and
advancing so rapidly under the action of yerjr powerful pains, that
I at once determined not to proceed farther in the attempt t was
about to make to turn. In a few minutes the presenting parts
came down to the perineum, and in half an hour swept over it, and
passed through the outlet of the pelvis, with the shoulder jammed
hard against the arch of the pubes, until the upper part of the
trunk, with the head turned over towards the right shoulder, and,
as it were, embedded in the neighbouring parts, was bom, when
the rest of the body followed in the usual manner. The child was
dead, and, considering it was a twin, large, since it weighed fully
6 lbs.

I made a note of the case at the time, and on consulting the
authorities I had at hand, I found no similar one recorded except
by Smellie, with a reference to, and copy of his plate in the excel-
lent work of Dr Lee.^ And although, since the occurrence of
this case. I have had several instances of shoulder presentation to
deal witn, there was nothing in them to remind one of its

Eeculiarities, untiL on the 22a September last, I was requested
y my friend Dr Ferguson of the Cove, to see, in consultation with
him, a case of transverse presentation, in a fisherwoman at the
Downies, a fishing village on the Kincardineshire coast, and who
was in labour with her second child.

. On my arrival at the Downies, at 3 o'clock a.m.^ Dr Ferguson
informed me that his patient had been in labour smce late in the
afternoon of the previous day, and that on his arrival, about 8
o'clock of the evenm^, he found the left shoulder, with the arm and
navel cord prolapsed, presenting, the membranes having been
ruptured some time before he reached the place. As the pains
were not by any means severe or active, and the os uteri was sofb
and well dilated, he proceeded at once to turn the foetus. In this,
however, he was baffled; for although, in one or two attempts
made with the right hand, he could reach one of the legs, he could
not bring it down, in consequence of his hand becoming paralyzed
under the action of the uterus, excited by every attempt to gain his
object. In this position of the case he resolved to have a consulta-
tion, and, as already, stated, I joined him about 3 o'clock of the
morning in the management of it; and, on making a va^nal
examination, I found the state of things exactly as represented by

^ Lectures on the Theory and Practice of Midwifery, etc. : London, 1844,
p. 339.

1864.] DB CHRISTIE ON SHOULDER PRESENTATIONS. 31

Dr FergOBon. The uterus, too, was still acting feebly in the
absence of manual interference ; and but for the alarm natural to
her in such circumstances, the patient was otherwise in a very
favourable state for an attempt to turn being still made. Acting
under this conviction, I accordmglj passed mj right hand up along
the foetus, but by no justifiable torce could I reach the feet, or any
part, indeed, by whicli turning could be effected. This was due
m part to the close contraction of the uterus round the foetus in the
form of " a long sheath," exactly as described by Smellie, in part
to my hand bea>ming numbed under the strong contractions ot the
uterus whenever an attempt was made to carry it up towards the
fundus uteri, and in part to the palmar aspect of the hand not being
readily turned towards the anterior surface of the foetus. For the
latter reason I next tried the left hand, but, although it could be
passed with much greater ease up through the inlet of the pelvis,
and the position of the foetus could be far more readily ascertained,
viz., that " the left shoulder, breast, and neck " were presenting, I
did not consider myself justified in using such an amount of force
as would have enabled me to reach a part by which the pelvic
extremity of the child might be brought down, and so abandoned
the attempt.

On consulting farther with Dr Fer^on, I was inclined to
recommend him to give a full dose of opium, and to wait for a few
hours, when, chloroform having meantime been procured, a new
attempt might be made to turn under its influence, and, in the
event of that failing, recourse might be had to evisceration of the
foetus, or even imm^iately to proceed to that operation rather than
repeat the attempts already made to change its position. My friend,
however, thought that one more attempt should be made to turn,
and I advised him to try the lefl hand, since I had been able to
use my own with so much more freedom than the right. Accord-
ingly, he introduced the left hand, and after some time spent in
cautiously but perseveringly forcing his way towards the lower
extremities of tne foetus, he succeeded in hooking the forefinger
into the flexure of a knee, which afterwards proved to be the ii^t.
With great difficulty, in consequence of the cramped state of his
hand, ne contrived to retain his hold, and while I assisted by
external manipulation, ^e brought the knee so far down that at last
he got a blunt hook passed over the ham. Being quite exhausted,
or rather I should say, his left hand being quite benumbed, he
passed the hook to me, when I proceeded to extract in the following
manner, — Guarding with the forefinger of the left hand the end of
the hook, which otherwise would have come in contact with the
brim of the pelvis about two inches to the right of the symphysis
pubis, I made traction with the right hand in the direction of the
axis of the inlet of the pelvis, Dr Ferguson at the same time so
manipulating the abdominal tumour externally as most efficiently
to aid my effort to bring down the pelvic extremity of the foetus.

82 DR CHRISTIE ON SHOULDER PRESElfTATIONS. [JULT

In a short time this was so fax effected that the right foot passed
through the vulva^ when a loop of tape was thrown round the
ankle^ the blunt hook, of course, being removed whenever the les
came down so as to permit of the escape of the foot. The lett
hand being now set iree, I coiled the end of the tape encircling the
ankle round the fingers, and. with the right hand introduced into
the vagina^ pushed the shoulder upwards, while I at the same time
made traction on the delivered leg, and tnus in a few minutes the
version was ultimately effected. The body and shoulders of the
foetus were next brought down, and after a brief delay, and with
slight difficulty, the head was brought through the pelvis and
delivered. The woman recovered without a bad symptom.

What is remarkable in this and the preceding case is the longi-
tudinal position of the foetus, and the corresponding elongation of
the uterus in the form of "a long sheath." In the first case,
nature clearly overcame the difficulty by compressing the head and
upper part of the foetal trunk into a mass of such dimensions as
permitted it to be forced through the pelvis in accordance with the
mechanism which regulates the transmission through it of the foetus
under ordinary cranial or breech presentations. This was, no
doubt, greatly facilitated by the dilatation of the parts of the
mother consequent on the birth of the first child. But although it
shows how fertile nature is sometimes in overcoming apparently
insuperable obstacles to labour, such a result is no more to be
calculated upon than is spontaneous evolution, and such like, in the
ordinary run of so-Killed transverse presentations. In the second
case, the process had gone no farther than merely bending the head
over into contact with the shoulder ; but had tne expulsive pains
been at all effective, I have no doubt the upper part of the foetal
trunk and the head would have been pressed together as in the first
case, and that they would have come to present at the inlet of the
pelvis condensed, so to speak, into one mass, even if they had
never come to be so modellea or reduced in dimensions by com-
pression as to become enga^d in or to pass through it.

Of the propriety of tummg in either the one or the other case,
there will, I presume, be no question, even although nature in the
first stepped m so unexpectedly to the relief of the patient. To
turn is out to do what she herself indicates, whether by rectifica-
tion of the presentation, spontaneous evolution^ and so on, or by
the process described in the first case, and that is, the substitution
of a directly longitudinal for the transverse, or. to speak more
correctly, oblique position which obtains in shoulder presentations.
In these cases, as Foster well observed^ " considering the size of the
foetus and pelvis in a natural view, it is just to hold cross presenta-
tions absolutely impracticable by tne force of labour alone." ^ Still,
it is of importance to understand how nature proceeds under the
difficulties attending such cases, and to recognise, in the various

^ The Principles and Practice of Midwifery, etc. London 1731, p. 195.

18€i.] DR DATIDSON ON TUBEBGULAR LEPROSY IN MADAGASCAR. 33

modes hj which she sometimes surmounts them^ a single under-
lying principle which seems to direct her in effecting the birth of
the toetus wnen it presents in labour, more or less transrersely, at
the inlet of the pelvis. Her whole energies here seem to be directed
to ultimately bring the foetus into a longitudinal position, and
the obstetrician but imitates this when by art he brings either the
cranial or the pelvic extremity of the foetus to take the place of the
presenting part in a cross presentation.

Article IV. — An Account of Tybercular Lqprosy in the Island of
Madagascar. By Andrew Davidson, L.R.C.r. & S. Edin.

{ConmunuxUed to the MeeHco-Ckirurgical Soddyj AprU 6, 1864.)

Leprosy, which in Europe and America had become well nigh
an historical disease, is again beginning to show itself in various
localities in the old and new worlds. This fact will justify me in
laying before the public a short account of the disease as I have
observed it in the Islaud of Madagascar. The number of cases
treated in the dispensaiy at Antananarivo during the year 1862 was
nearly one hundred, and the following account of the disease is
drawn up £rom the notes of the cases actually observed.

For the sake of clearness of description, the progress of tubercular
leprosy may be divided into three stages or periods, — the firsty
characterized by the appearance of spots ; the second, by tubercles j
and the thircf]^ oy ulceration or falling off of the members. These
three stages may co-exist simultaneously in different parts of the
body : thus, leprous spots may be seen on the trunk, tubercles on
the face, and ulceration may be ^oing on at the extremities. Spots
of changed skin, however, mvanably precede the tubercles, and the
latter are in turn succeeded by ulceration.

Tubercular leprosy is singularly uniform in its symptoms, progress,
and termination in different parts of the world, nor has it suffered
any modification whatever smce it was first described by Aretsaus,
Severfd varieties indeed have been described by authors, as Lepra
ancBsthesiaoa. Lepra tauricaj and some others ; but these varieties are
not founded upon any differences of importance, but upon the
degree in which a common symptom is present, which really
furnishes no sufficient ground for establishing them as distinct
varieties.

The disease usually begins so insidiously that the patient is
unable to state the precise period of its commencement. Some
authors have described it as beginning with the constitutional
symptoms proper to fever or inflammation, as hot skin, full pulse,
ngors, and muscular pains.

Judging from the many cases which have come imder my own
observation, this must be a mistake. Fever may occur in a leprous

VOL. X. — ^NO. I. B

34 DRDAVIDSON ON TUBERCULAR LEPROSY IN MADAGASCAR. [JULY

subject ; — it may eren be an exciting or, speaking more exactly,
determining cause; but it must not on this account be supposed
that the fever was the beginning of the leprosy, or that there was
more than an accidental connexion between the two. Aretseus
remarked justly, " the commencement of the disease gives no great
indication of it ; neither does it appear as if any unusual ailment
had come upon the man. ... In this way the patient's
condition is hopeless, because the physician, from inattention and
ignorance of the patient's ailment, does not apply his art to the
commencement, when the disease is feeble." This could not have
been said of leprosy, if it began with the symptoms of fever or
inflammation.

The patient probably discovers accidentally a small patch of
his skin presenting a tint different from the rest of the body. Such
spot may be seated anywhere, very frequently about the back or
shoulders. The spot of changed skin may be of any shape, but is gen-
erally oval or circular, and varies in size from sixpence to that of the
palm of the hand. At first the change is so slight as to be observ-
able only in some reflections of the light. The colour of these
patches is almost exactly the same in every case, whatever the
original colour of the patient's skin. In all, the first change is to
a li^ht brassy tint, which, as the disease advances, becomes more
distmct. It IS soon observed that the texture as well as the colour
of the skin is affected. It becomes cracked, fissures running across
the spots in all directions. The hairs upon the part become yellow
and stunted, and afler a time fall off*, leaving the hair bulbs empty,
patent, and enlarged. The affected skin acquires a greasy look,
as if it were glazed or varnished, and ceases to be perspirable.
From an early period the spots become thickened, but are not at
first elevated above the surrounding healthy skin. This thickening
depends upon effusion into the subcutaneous cellular tissue. As
the disease advances the true skin becomes the seat of effusion, and
is felt to be slightly elevated to the touch.

In three or four of the cases which I have noted the disease
seemed to be more particularly seated in the cutis vera^ elevating
the skin into large, broad prominences. Sensation is at first
heightened, slight wandering pains, formication or itching may be
felt over the body or in tne affected parts only. After a few
months this hyperesthesia gives place to ansesthesia ; thus it not
nnfrequently happens that one or more of the older spots are
decidedly numb and feelingless, while there is excited sensibility
in the more recent ones. It has been already remarked that some
describe, as a distinct variety, a Lqpra cffUBsmeeiaca^ but ansBSthesia
is present more or less in every instance. In two cases this symptom
was present in a very marked degree. In both the disease had been
remarkably slow in its progress ; the tubercles dilatory in showing
themselves. In neither had the malady reached the stage of
suppuration, although the disease had existed in the one patient

1864.] DR DAVIDSON ON TUBEBCULAR LEPROSY IN MADAGASCAR. 35

for twenty, and in the other for twelve jears. I feel satisfied, firom
carefol observation, that anaesthesia is more decided in the cnronic
form of the disease in patients who live a sober, prudent life,
whose habits seem calculated rather to mitigate than accelerate or
intensify the malady. The hair, as I have stated, falls from the
diseased spots ; but this is not confined to the spots alone, although
it usuallv oegins there. The hair of the eyebrows never escapes,
and I have noticed that it uniformly begins to fall from the
outer angk inwards, I am not aware that this singular fact has
ever been alluded to by writers on leprosy, although it is quite
constant and sufficiently remarkable. The hair of the axilla and
pubes, and the eyelashes fall as the disease advances, but the hair
of the head is never affected. A popular writer on the East, in
describing leprosy, has spoken of baldness as a symptom of the
disease as observea in Syria.^ It may indeed happen that a leper,
like any other man, may be bald, but it is an error to regard the
baldness as a symptom of leprosy. This mistake is not uncommon,
and arises from the writers having in their mind the description
given by Moses of a perfectly different disease. Wherever the
hair falls, the hair follicles become enlarged and patent, especially
in the face, so as to present one of the most diagnostic signs of the
malady. So characteristic is this of leprosy, either as a latent
diathesis or a developKed disease, that I nave never seen a leper
who did not present it ; — more, I have often been able from this
condition of tne hair follicles alone to recognise members of a
leprous family in whom the disease was yet latent

The nakea eyebrows become thickened, rugous, and projecting,
hanging over the hairless eyelids. To render the aspect still
more unsightly, the eye assumes a lurid glare impossible to describe.
Perhaps the word j&rrety is the most appropriate that can be
applied to a change which no words can express.

The second or tubercular stage of leprosy supervenes upon the
first with various degrees of rapidity, sometimes within a few
months, at others after the lapse of years, according to the intensity
of the disease, the constitutional powers of the patient, and other
circumstances to which I shall hereafter refer. The tubercles,
usually of a duskv colour, smooth and distinct, be^n to show
themselves on the iace. The lobes of the ears are thickened and
irregular, and the whole external ear curved forwards toward the
cheeks. The alse of the nose grow heavy, the nostrils dilating
and the nose becoming flattened and studded with tubercles. The
lips swell^ and are livid, the lower one more so than the upper ; and
the chin is lengthened and misshapen ; the whole face bagged or
puffy. The hands are livid as if from cold, the fingers swell, the
arch of the foot becomes flattened by leprous efiusion beneath the
fascia. In fact, tubercles may appear in any part of the body,
although they are most common in the situations mentioned. But
1 Thomson's *' The Land and the Book." New Edition.

36 D& DAVIDSON ON TUBEBCULAR LEPB08T IN MADAQASGAIU [JULY

thej are not confined to the skin alone, they afiect more or less the
mucous surfaces. In the nose thej give rise to difficulty of breathing
and oz88na, in the larynx and trachea to laboured respiration^
husky voice, and occasionally to aphonia. The lining membrane
of the external ear is rarely affected. The cutaneous and pulmonary
exhalations become foetid in the last degree. So peculiarly pene-
trating indeed is the smell of leprosy, that there is no difficulty in
detectmg, by the sense of smell aLonCi the presence of a leper in a
large company.

As these changes are going on, ulceration begins to take place,
commencing generally on the hands or feet. These become livia
*as if half frozen ; the temperature is really lower than that of health.
The nails grow dry, shrivelled, and fall without pain. Tubercles
burst in succession, discharge a thin watery matter, and after a
time dry up. Other ulcers form on the fingers close to the joints, and
deepen until the joints abeady infiltrated by leprous effiiion, their
vitality all but extinguished, drop off. After the part falls away
the ulcer heals over for a time ; thus, member after member dies as
it were on the yet living body, leaving the sufferer as helpless to
himself as he is loathsome to those who have to minister to his
wants.

So much for the outward signs of leprosy in its various stages.
Its efkcta upon the ftmctions, vital and natural, are at first by no
means so evident or uniform. The earlier stages of the disease
may be accompanied by nothing abnormal in the ftmction of any
of the organs. Experience alone informs us of the serious nature
of the complaint, in some patients there is even from the begin-
ning a remarkable torpidity, physical and mental, and this is
observable in the later stages in eveiy case. The patient is unfitted
for active work ; he is rarely irritable, but sluggish. The appetite
is seldom impaired at the commencement, and even towards tne end
it is rather perverted than lost The patient eats almost anything
set before him, but without a relish. Loss of appetite is a most
fatal symptom, and firequently indicates approacning dissolution.
The tongue becomes large, .flabby, and foul, the gums bluish and
roongy, and the bowels irregular or costive. Sooner or later in
the malady indigestion manifests itself, the function of the liver
being imperfectly or inactively performed. The urine, as regards
quantity, specific gravity, constituents and their proportions, does
not differ from the healthy standard. Menstruation in the female is
seldom affected, for I found in twenty-two patients, between the ages
of fifteen and forty, only one in which the menstruation was irregular.

The ftmction of reproduction in the male and female continues
unimpaired for a long series of years. The facts bearing upon this
point were not recorded in many instances ; but I find that I have
notes of nine persons in the second stage of leprosy and sick from
three to six years, who had young children. This shows that
even after the disease has existed several years, and advanced con-

1661.] DB DAVIDSON OK TUBEBCULAB LKrB08T IX MAOAOAIK'AB* 37

siderablj, the function of reproduction may not be mffectrd. It !«,
however, eoually certain that it faiU during the ImX sta^e of the
maladj. I believe that the ^Ubido xnexplthiltMj^ mentioned bj
some authors, is a mere fancjr, — when the poictr ceaat'A, the d€»im
is extinguished*

Bespiration is impeded in two ways, — by thick^ninfr '^f the
^ lar^^eal and tracheal mucous membranes from effusion, and from
* a similar effosion into the substance of the lung itself and into the
minute bronchL The pulmonaij capillaries lose their tone and
become congested. The changes wiiich the blood under^iea in
the lung are imperfectly carried on; the action of the heart Ijcromcs
increasingly feeble with the progress of the disease ; the pulse is
inyariably weak and slow. The fatal termination in Icprofty is
often owing to some affection of the respiratory organs.

In a few instances the blood was examined during the firHt and
second stages of the disease. The coa^um was found occasionally
to be loose : but the sensible qualities of the fluid were normaL
It is probable that there is some materieB morbi in the blood, which
may hereafter be detected, of which we are yet entirely ignorant.

As bloodletting is eyiaently contra-indicated when tlie patient
is reduced by the disease, the blood has seldom been examined
during the last stage.

Organic disease of the heart was not detected in any of the cases
observed. Dr Copland mentions ^ case in which that oi^gan was
found softened : further investigation is required to settle whether
this is a coincidence or a result of leprosy.

That the nervous systems, both organic and cerebro-spinal. are
involved, is evident from what has already been said. The itching
and flying pains, the heightened sensibility and succeeding anaesthe*
sia, the depressed vital power, enfeebled action of the heart, inactive
secretion, depraved appetite, — all evidence the extent to which the
nervous system is implicated. These symptoms become more
prominent as the disease advances.

In conducting my inquiries, I had special regard to the causes,
predisposing and exciting. Several points of great interest and im-
portance were clearly and conclusively established, while others
were left where I found them.

Persons suffering from leprosy have a great reluctance to ac-
knowledge an hereditary taint, in regard to a considerable number
of the patients I was unable to gain any satisfactory information ;
but I succeeded in tracing the disease in other members of the
patients' &mily in the following cases: —

TcAle showing the Hereditary Nature of Leprosy,

FEMALES.

Mamphantana, set. 45; ten years sick; father and sister leprous; several

cmldren alive not leprous.
RafitiiB, set. 40 ; mother and brother leprous.

38 DB DAVIDSON ON TUBERCULAR LEPROSY IN MADAGASCAR. [JULT

Bamananharivo, est. 42; mother and sbter leprous; married, no children;

husband quite well.
RanavOi set. 15 ; father and mother §aid to be healthy ; younger brother leprous.
Ifara, est. 35 ; mother leprous.

Ramatoa, set. 40 ; no account of parents ; two daughters, the youngest leprous.
Raketaha, 8Bt. 25 ; fkther leprous.

Izafy, set. 35 ; brother leprous. No information regarding father and mother.
Renizoma, st. 46 ; three years sick ; younger daughter five years a leper.
Isindra, set. 24 ; brother leprous ; father and mother said to be healthy.
Laizoma, sot. 12 ; father, uncle, and brother leprous ; one brother well.
Izala, 86t. 15 ; father and brother leprous.
Rabako, st. 47 ; fifteen years sick ; brother and sister leprous.
Rafozaehana, set. 40 ; fiither, mother, and one daughter leprous.
Rasoa, est. 41 ; several of the family leprous.
Ramavo, ast. 45 ; husband and child leprous.

HALES.

Samo, 8Bt. 12 ; father leprous.
Bolo, about 11 ; mother leprous.
. Ramanana, est. 36 ; mother leprous.

Kotofotsy, ; one child leprous.

Ramboamavo, ast. 55 ; mother, uther, and one child leprous.

Andramanana, set. 35 ; mother leprous.

Rabeampina ; brother and child leprous.

Ratsilainga, set. 47 ; son leprous.

Mangalahy, set. 10 ; several members of the family leprous.

Manakavana ; sister and grandmother leprous ; father and mother healthy.

Rafara, one daughter leprous ; no account of parents.

Javy, set. 7 ; father leprous.

Ibolo, father and mother both leprooi ; elder brother not leprous.

These facts leave no room for doubt as to the hereditary nature
of leprosy. It often happens that children who have been bom
before the disease has manifested itself in their parents^ either
escape the disease altogether, or at least much longer than the
chilaren bom after the leprosy has developed itself in one or other
of the parents. They also suffer from a milder and slower form of
the malady. It is thus frequently noticed, and there are one or two
instances of it in tlie above table, that the disease first attacks the
younger children^ and then the others inversely according to their agcj
— proving that the more advanced the disease is in the parents,
the sooner will it affect the offspring. We also observe now and
again the disease to break out in the children before it shows itself
in the parent from whom they inherited it. Thus, in the table I
have given, Benizoma, a patient aged 46, had suffered from leprosy
for three years, while her daughter had actually been ill for five
years. The disease thus appearing two years earlier in the child
who inherited it, than in the mother who transmitted it.

Leprosy will occasionally remain latent for at least one gen-
eration, and re-appear in the next, — as in the case of J/ano-
kavana^ whose own parents were healthy, but whose grandmother
and sister were lepers. In all such instances, however, the leprous
diathesis may be recognised in those who escape the ftiliy developed
disease.

1864.] DR DAVIDSON ON TUBERCULAR LEPROSY IN ITADAGASCAR. 89

The signs of this diathesis are^ 1^, Falline of the hair of the
cheeks^ and a patent condition of the hair follicles ; 2dj Loss of
hair from the outer angle of the eyebrows ; 3d. Enlargement of
the lobes of the ears ; 4thj Mental and nhjsical torpitude. The
persons presenting these features often oie from diseases of the
respiratory organs.

Where a liability to the disease exists, exposure, overwork, grief,

Soor or bad diet, cold and damp, imprudence and aebauchery, form
etermining causes ; and when it has taken hold of the system, these
circumstances powerfully tend to aggravate it. As men are more
exposed to the operation of these causes than women, we may
account for the fact that women are less liable to the disease than
men ; and the well-to-do members of society than the poverty-
stricKen ; while sobriety and care will tend to prevent its aevelop-
ment or render its progress slower and milder.

In a very considerable number of the patients, I could not
obtain any reliable information respecting their family history.
I several times found that patients altogether denied the exist-
ence of leprosy in their families, althougn private inquiries «Aer-
wards satisfied me that one or more of their relations were at the
time suffering from the disease. It is looked upon as a disgrace,
and few will admit that it is real leprosy from which they suffer.
Then we all know how readily such circumstances as are thought
to be discreditable are allowed to pass into oblivion. No trouble
is taken to record the fact that an ancestor was a leper. Making
allowances, then, for these considerations, I am inclined to believe
that in the vaat majority — ^nay, in almost every case — careful inquiry
would establish the existence of a hereditary taint.

Yet there is no doubt a very small per-centage where no such
taint can be discovered. In sixteen of tlie cases observed, the most
careful examination and inotuiry failed to make out any history
of leprosy in the patient's family. This leads to the important
(question — Does leprosy originate de now at the present day, or is
it spread by contagion ? We have in the hundrea recorded cases,
three instances of husband and wife being both at once affected.
There was one patient, too, in whom there was no history of leprosy
in the family, but who had lived in the house with a leper. The
question may be asked, are these coincidences, or are they something
more ? At present we have not a sufficient number of facts to
decide this question. It cannot be highly contagious in the
ordinary sense of the word, for we constantly see husbands suffering
from the disease living for years with their wives, without com-
municating it, and vice versa. It certainly deserves notice, that
while the Laws of Madagascar excluded leprous persons from society,
the disease was kept within bounds ; but after this saJutary law
was permitted to fall into disuse, leprosy has spread to an almost
incredible extent There is no doubt that tnis result is partly
owing to lepers being allowed to marry without any hindrance, but

40 DR DAVIDSON ON TDBEBCDLAR LEPBOST IN MADAGASCAR. [jULY

the natives are also stronghr impressed with the conviction that
the disease is inoculable. Unon this point m^ cases cast no light.
It is highljr probable that tne same originatmg causes, which at
first gave rise to leprosj, are still in existence and endemic in cer*
tain localities. It maj spring up now and then under certain
circumstances, de novOy without contagion or hereditary taint.
What the originating causes are is a profound mystery. In the
island of Madagascar there are a number of different races — of all
shades of colour, from the pure Negro to the Hovah, whose com-
plexion is not darker than a native of Spain. These occupy widely
varying climates. The central provinces, from their great elevation,
possess a temperate climate, similar to that of the south of France.
The climate of the plains, on the other hand, is tropical, and towards
the north excessively warm. The circumstances and modes of life
of these races are as varied as their origins, and the nature of the
localities in which they reside. Yet leprosy affects all alike. The
Hovah who lives in European fashion, and in a temperate climate,
is no less exempt from this scourge than the African slave. It is
found amongst the Betsemasarahas who eat pork, and amongst the
Betanmenas who abhor it. It occurs where fish is an article of
food ; but it is also to be seen where no fish is to be had, and where
rice and vegetables satisfy the simple wants of the population. It
exists in town and country, — at the elevation of 7000 feet above the
level of the sea, along the coast line, and through all intermediate
elevations. Kace, geographical situation, and diet, — all seem abso-
lutely unimportant elements in relation to its presence or its spread.
Probably the dirty habits so prevalent in many half- civilized
nations must tend to aggravate it; eating from a common dish
with the fingers ; the custom, very common in Madagascar, of inter-
changing garments, and of all Ij^ing huddled promiscuously together
at night, cannot fail to render it more inveterate, even if they do
nothing in the way of originating it.

It has been a favourite theory with many that leprosy is related
to syphilis or to yaws. But what proof is there to substantiate
this theory ? Syphilis has suffered marked modification in different
ages and amongst different races. Leprosy has remained unchanged
through seventy generations and longer, even in the same country.
We do not see leprosy result from syphilis in England. The
spread of syphilis in the fifteenth and sixteenth centuries was not
followed by an increase of leprosy, but the reverse.

Leprosy seems to be a disease sui generis distinct altogether from
syphilis and yaws ; propagating itself by hereditary transmission
and poeaibly by inoculation. It is probably seldom produced im-
mediately and at once in any constitution from the causes originating
it, but ^aduatty bj the persistence of the causes operating through
successive generations.

In the treatment of this most formidable disease we are still in
the dark. Everything has been tried, and in vain. The utmost

1864.] DR DATIDSON ON TUBERCULAR LEPROSY IK ITADAOASCAR. 41

that can be accomplished in the present state' of our knowledge is
to palliate, not care^ the disease. In a considerable number of the
cases, iodide of potassium in various combinations, according to the
peculiarities of tne case, was given, and often with marked effect in
producing absorption of the tubercles, accompanied, however, bj
loss of appetite and weakness in the patient. I will give two
cases.

Andriamanana, a blacksmith, seven jears unwell. The whole
skin is altered in texture, thickened and glazed. The nose and
lips thickened and tuberculated, the ears irregular and curved for-
wards. The hair of the evebrows and eyelids fallen. Hands and
feet livid, cold, and insensible. Voice rough and husk^, with pain
in lairnx. Tnis patient was put upon iodide of potassium in com-
bination with warm tonics. After a week's treatment some of the
tubercles burst, others were being absorbed, and after a longer
time the skin became much more natural, a few tubercles only
remaining.

Bavao, aet. 40. Two years leprous ; tubercles scattered over the
epreater part of the body ; was ordered iodide of potassium in small
doses three times a-day, with tepid bath, and generous diet. A
manifest improvement took place, most of the tubercles having dis-
appeared. The patient's appetite, however, began to fail, and after
three months the iodide had to be suspended. In these, and in
several other instances, the iodide of potassium really seemed to
produce absorption, to cause the tubercles to disappear, and to render
the skin thinner and softer. The patient Bavao was permanentlv
improved, but in the case of Andriamanana, the weakness increased,
ulceration of the cornea ensued, and death speedily took place. I
cannot help thinking that the fatal result in this instance was
hastened by the treatment.

Arsenic, with attention to the general health, was perseveringly
tried for months in eleven cases. The usual constitutional symp-
toms of arsenic, when administered in medicinal doses, were mani-
fested in several of the patients without any mitigation of the disease.
I noticed, also, in more than one case, an inflammatory condition
of the skin, especially in the face, to result.

Where ulceration existed great temporary benefit was obtained
firom the use of quassia in large^ frequently repeated, doses. I am
indebted to Dr rowell, of Mauntius, for a knowledge of the value
of this remedy in the ulceration of leprosy. Under its use ulcers
heal for a time more readily than under any other treatment.

When a venereal taint was known or susjpected, mercury was
tried. The preparation used was the bichloride in small doses.
No good was observed to result.

A treatment directed to the improvement of the general health,
and the due performance of the various ftmctions, with the use of
tonics and occasionally of cholagogue purgatives, if the liver is
inactive, will be of service. Should the ulceration be troublesome,

VOL. X.— NO. I. p

42 PR DAYID30N ON TUBERCULAR LEPROSY IN MADAGASCAR. [jULY

quassia, alone or in suitable combinationSy will promote the healing
process. Iodide of potassium given at intervals and in small doses,
will help to promote the absorption of the effusion, care bein^ taken
to suspend it if the appetite fail or the health suffer. The tepid bath
will always be useful in promoting the action of the skin and the
comfort of the patient Experience is also in favour of inunction as
an adjunct to other treatment. It is probably more serviceable than
any single remedy. The oil used by me was the best olive oil, and
it was thoroughly rubbed into the skin twice a-day, after the patient
came out of the warm bath.

By the persevering use of ^ these simple means, many of the
patients experienced benefit, although none were entirely cured.
Yet, I am convinced that in the present state of our knowledge,
more good may be hoped from such general treatment than from
any single medicine used empirically.

!Now that the attention of the profession has been directed to this
disease, may we not hope that our knowledge of the therapeutics
and pathology of this fearful scourge of our race may be speedily
advanced.

Article V. — Cose ^ Ccssarean Bection. mth Bwicestrful Bemlts to
both Mother and Cnild. By Izett W. Anderson, M.D., King-
ston, Jamaica.

{Communicated to the Edinburgh Obstetrical SodOy, on 23d December 1863.)

Ann BLACKWOOd, a black girl, was admitted into Lady Barkly's
Lying-in Institution on the 25th of April 1863. As the nurse in
attendance immediately detected something unusual, I was requested
to see the case.

On my arrival, I found her to be a strong healtliy-looking girl,
apparently about twenty-five years of a^, and in active labour.
On inquiring of her mother, who came with her, as to her previous
histoiy, I ascertained that she had always been healthy, had never
met with any accident, and had been about twenty hours in strong
labour. On making an external examination, I was immediately
struck with the very great narrowness of her pelvis. After the

f)atient's recovery, I made careful measurements of the size of the
alse pelvis, with the following results : — The anterior superior
spinous processes of the ilium were at the same level, with only a
distance between them of six and a quarter inches. From each
of these points, round the back, measured fifteen inches. The
mons veneris was unusually prominent, from the approximation
and projection forwards of the horizontal rami of the pubes. It
could be grasped by the fingers, applied laterally, ana proved a
bony projection of at least an inch and a half in height, r rom the
anterior superior spinous processes on either side of the centre of this

1864.] DR ANDSK80N*S CASE OF CiESAREAN SECTION. 43

projection measured three inches. On examination per vaginam, I
found that only the two first fingers could be passed between the
tuberosities of the ischium^ and even then they were in close ap-
position^ and partially overlapping each other. The descending
rami of the pubes were, however, much closer together, as only
one finger could be passed up anteriorly between them, and even
then with some difficulty. Posteriorly, between the ischial tuber-
osities and the coccyx, two finders could only iust be introduced
into the pelvic cavity. On passmg the finger as nigh up as possible
into the pelvis, a small curved projecting sharp bony ridge could
be felt on either side, but more developed on the left. The sacrum,
as far as I could ascertain, was also more prominent than it shoula
be. The os uteri could be felt with difficulty, and appeared dilated
to about the size of a crown piece, though with regard to this I
could not be certain. The presentation could not be made out. A
good bag of waters projected into the vagina. No placental bruit
or foetal heart sound could be made out. The vagina was cool and
moist; skin natural; pulse 84, full and regular; tongue dry,
brown, and furred (probably in consequence of a dose of Dover's
powder, given some hours before I saw her) ; pains strong, regular,
and bearing-down in character.

I requested Drs Bowerbank and Fiddes to see the case with me,
and after most careful and repeated examination, we all agreed that
delivery bv any method " per vias naturalis " was impossible, and
that the Gsesarean section was the only chance of escape for both
mother and child. As we considered that the sooner it was performed
the better, preparations were immediately made for the operation.
Plenty of hot water was procured, with several new well-washed
sponges. Chloroform, with the necessary instruments, were in
readiness, and the trained nurses of the institution were at hand, to
act as assistants if required.

The patient was then placed upon the operating table, and
chloroform administered by Dr Bowerbank. When complete
anaesthesia was produced, this was handed over to one of the
nurses to take charge of, leaving Dr B. at liberty to assist me.
The catheter was then passed, and a small quantity jof urine drawn
off: the rectum was ascertained to be empty. Standing on the
rignt side of the patient, with a strong scalpel, I made an incision a
little to the right of the umbilicus, about ten inches in length, ex-
tending from a little above the umbilicus down to the pubes. I
then at one point gradually deepened the incision, until the peri-
toneum was reached, and cautiously opened. Introducing the two
fore-fingers of the left hand, and usine them as a guard, I slit the
peritoneum, both up and down, with a curved probe -pointed
bistoury, to the same length as the superficial incision. Some of
the intestines then escaped, but were easily returned and kept in
9itu by the edges of the abdominal wound being closely applied to
the uterine walls by Drs Bowerbank and Fiddes on either side.

44 DR Anderson's case of cesarean section. [jult

The nteroB, of a pale pink sbining appearance, with lar^e veins
ramifyine on its surface, was thus iully exposed. An incision,
cutting through about half the thickness of this or^n, was made,
about six inches in length, exactly in its mesian hne. This was
deepened at one point, and the uterine cavity opened. The waters,
of a dirty-greenish colour, rapidly escaped, owing to the strong
contractions of the uterus; and, notwithstanding all the care
exercised, some ran into the abdominal cavity. Introducing the
fingers of the left hand as a guard, with the probe-pointed bistoury
I extended the wound both up and down^ to the extent of the
superficial incision. Passing in the hand, I seized and extracted
the presenting part, which turned out to be the left arm. The
hand being again introduced, the feet were found, and the child
extracted with care. The cord having been tied and divided, the
child was handed over to the care of one of the nurses, who soon
made it cry lustily. The uterus then contracted rapidly, and it
was with a little difficulty that I passed in the hand, found the
placenta adherent to the upper ana posterior part, picked it off,
and removed it. During the delivery but slight haemorrhage took
place, and that only fix)m the lips of the uterine wound. After the
removal of the placenta, the uterus contracted rapidly and firmly
to the size of a foetal head. Smart oozing took place for some
minutes from some of the large venous sinuses at the lower edge of
the uterine wound, but ceased on the application of a spon^
dipped in cold water. The abdominal cavity was then carefully

Songed out with warm water, and a few coagula removed. The
ges of the abdominal wound were approximated, and ten sutures
of silver wire introduced, deeply, though not through the peritoneum.
While this was being done, vomiting came on, repeatedly causing
the escape of nearlv the whole of both large and small intestines,
notwithstanding all our endeavours to prevent it. A little blood
was brought up with the vomited matter. The line of incision
was then dressed with a strip of dry lint, a thick pad placed on
either side to make deep pressure, over this a broad roller, and
finally the binder. The patient was then removed to bed, and ext.
opii. gr.iij., in the form of pill, given as soon as the effects of the
cnloroform had passed off. She presented no appearance of shock,
skin being natural, and pulse 96, full and regular.

9.16 P.M. Pretty well under the influence of opium. Lies quietly
in bed, without making complaint, unless askea if she feels pain,
when she complains of uneasiness in the abdomen, and says that she
cannot breathe freely. Respiration, however, is normal. There
has been no vomiting, though slight hiccough occasionally. Pulse
is good, 112. A small amount of discharge has taken place ^^ per
vaj^nam." Passed the catheter, and drew off about fviii. of clear
urine. Gave directions to the nurse in attendance that the patient
is to be disturbed as little as possible during the night ; no food is
to be given, though small pieces of ice occasionally, if the thirst is

1864.] DB ANDEBSON'B CASE OF CfiftAREAN SECTION.- 45

great If pain is complained of, ext opii. gr.j. may be given every
fliird hour.

26th. — Patient slept well until four this morning, when, being
restless, an opium pill was given, toeether with a little arrow-
root, which she asked for. Soon after, she vomited a large
quantity of watery bilious fluid. In the act of vomiting a large
quantity of bloody serum escaped from the lower part of tne wound
and through the vagina. She now complains of much pain in the
lower part of the abdomen, paroxysmal in character, and due, I
think, to uterine contractions. Only slight tenderness exists, on
pressure being made. The facial expression is good; pulse 96,
and regular ; tongue covered with a white fur, and inclined to dry-
ness ; skin natural ; no nausea or hiccough ; says she feels very
hungry. Passed catheter, and drew off about half a pint of clear
urine. Ordered ice ad libitum^ and thin gruel for diet. Two grains
of ext. opii. at once.

27th. — Since last report patient has taken four grains of opium.
She slept pretty well last night, though at times, the nurse says,
she appeared very weak. The present state is — pulse 120, full and
regular ; tongue moist, but furred in patches ; abdomen tvmpanitic
and painful, though she bears well the pressure of the hand ; lochial
discharge small in quantity, but free from foetor ; large amount of
bloody serum is constantlv oozing from the lower part of the wound,
soaking through the bandage and binder ; breasts flaccid and pain-
less. Lies in bed with tne legs extended, and can move them
freely, without increasing the abdominal pain. The expression of
face is good; she is cheerful, and fond of talking. Ordered to
continue the ice and thin gruel, and to take frequently the essence
of beef in doses of a tablespoonful at a time. Ext. opii. gr.ij.
statim.

9 P.ir. Patient has had a bad day« The pulse has been high
(above 130), with much heat of skin, and an increase of me
abdominal pain and tympanitis. A poultice has been kept
constantly applied to the abdomen, ana opium, to the extent
of three grains, has been given in divided doses. She is now
decidedly worse. The abdomen is enormously tympanitic, and
very tender and painful, particularly in the region of the trans-
verse colon. She has an anxious^ pinched expression of face,
with cold sweat standing on the forehead. The skin is hot —
pulse 144, and very weak — lochial discharge small in quantity —
respiration very rapid — heart's apex can be seen pulsating much
above its ordinary situation. I removed the dressings of the wound,
and found that the greater part of it had united by the first inten-
tion, while the remainder was in a healthy granulating condition.
A large enema of warm water was given, and I tned to pass
O'Bim's long rectum tube, with the intention of relieving the
enormous ^mpanitis, but could not get it beyond the promontory
of the sacrum. The catheter has been passed by the nurse regu-

46 DR ANDEBSON'b case of CJESAREAN section. [JULY

larly erery six hours since the operation, and the urinary secretion
has always been free. Ordered a continuance of the hot poultices
to the abdomen during the night, and one-grain pills of opium
regularly every three hours, whether the patient sleeps or not.
Beef-tea is to be frequently given, and hall an ounce of brandy
every two hours.

28th, 5.45 A.M. — Nurse reports that the patient was pretty quiet
during the night, and took her, medicine, brandy, and beet- tea
regularly. Occasionally, however, she seemed very low. This
morning there is, I think, a little improvement. Her present state
is — pulse 124, and a little stronger; features not so anxious or
pinched; respiration not so rapid; cold perspiration replaced by
warm ; abdomen less tympanitic and painful ; lochial discharge
still small in quantity and toetid. Dressed the wound, which looks
well, with lint dipped in warm water, and over that applied
terebinthinate fomentations to the whole surface of the abdomen.
Continue opium, brandy, and beef-tea.

10 A.M. — Fully under the influence of opium, having taken five
grains of the extract since nine last night. Can be roused, though,
if left alone, sinks into a semi-comatose state, pupils contracted.
Bowels have not been open since operation, and abdomen is still
very much distended. Omit opium. Ordered an enema of a pint
of gruel, with tinct. assafoetidae et ol. terebinthinae aa i&a.

Evening. — Has just passed a large semi-fluid bilious stool.
Effects of opium passing off. The tynapanitis is decidedly less,
and the respiration is not so oppressed. Has passed urine for the
first time, «*a sponte. No vomiting, and only slight hiccough.
Pulse 142, and very weak. Face is covered witn cold perspiration,
though the teinperature of the extremities is natural. Continue
brandy and beef-tea during the night ; and half-drachm doses of the
spir. ammon. aromat. are to be given if there is any appearance of
sinking.

29th. — Nurse states that the patient dozed during the night, but
was at times very weak, and, in consequence, ammonia was. freely
given. In the morning she appeared a little better, pulse 130, and
weak ; abdomen still distendea, though not so much so as yester-
day. The wound, I find, has not united as well as I thought it
had, as, on pressure being made over the abdomen, a dark-coloured
foetid fluid escapes at several points, with bubbles of gas. On
examining the wound I found sometliing projecting at the lower
part, and with a little care I extracted a portion of the foetal mem-
oranes about twelve inches long, black ana intensely foetid. Several
clots and an immense quantity of fluid were discharged after its re-
moval. I cut, but did not remove, the lowest suture, with the intention
of giving free exit to the discharge. Lochial discharge is mode-
rate in quantity, and foetid. Bowels again open, and urine passed
freely. Ordered a grain of opium at once, with a continuance
of brandy, beef-tea, and eggs. In the evening she had altogether

1864.] DR ANDEBSON'S CASK OF CiESAREAN 8E0TI0N. 47

improved in appearance, and said she felt better. Pulse stronger^
124.

30^ — Was restless during tbe night, and the bowels have acted
five timeS; the stools being very yellow and semi-fluid. A grain
of opium was given at eleven last night, and another at three this
morning. Ammonia was also freely given in consequence of great
debility. Free discharge of fluid is taking place n-om the lower

Ejt of the abdominal wound. Pulse 118, and stronger. Slight
ccough occasionally.

Evenina. — ^Bowek have acted three times to-day, though opium
has been nreely given. Complains of much gripingin the abdomen,
though it is softer and much less distended, llemoved another
piece of membrane from the wound, about three inches in length,
roultice to be applied to abdomen, and one grain of opium given
at once, and repeated at three A.M. if necessaiy. Pulse 120.

Isi May. — Though restless during the earlier part of the night,
was easier at three, and, in consequence, the ^ill was not given.
Much troubled by niccough, which ammonia, in small doses fre-
quently given, relieved. Bowels have not acted again. Patient is
now comparatively free from pain ; abdomen is gradually reducing
in size ; clots^ with foetid discharge, pass freely from the wound, and
also per vagmam; pulse 120; tongue moist. Dressed wound,
which looks healthy, with sol. chlor. sodae. Opium, gr.i., statim ;
and brandy and l>eef-tea cid libitum. Asked for, and smoked a
cigar with much pleasure.

Evening. — Very low to-night ; pulse 130 ; feet cold ; voice very
faint; cold perspiration on the face; tongue dry; much thirst.
Drachm doses of spir. ammon. aromat. to be frequently given with
the brandy.

2cL — Passed a very restless night, with much pain in the abdo-
men, cold feet, and frequent hiccough. Was only kept alive by
the continued administration of brandy and ammonia. Says she .
feels much easier, thopgh she is veiy restless and much troubled
with hiccough. (Jovered with profuse perspiration ; pulse 134, and
very weak ; tongue dry ; discharge very foetid. Ordered a mixture
of chloric aetlier and ammonia to be frequently taken.

Evening. — Has vomited twice, being the first time this symptom
has appesured since the day after the operation. Bowels have acted
once. Takes her nourishment and stimulants well. Continue
medicine.

Sd. — ^Another bad night, though the patient seems a little better
this morning. As there was a good deal of pain during the night,
a grain of opium was given. One large wateiy bilious stool nas
been passed. Pulse 122. Discharge from abdomen is paler, not
so foetid, and less in quantity. Tongue moister.

Evening. — Has vomited once to-day, and the bowels have acted
three times. Had a grain of opium at four this afternoon. Pulse
184. Frequent hiccough. Face, neck, and thorax covered with
cold sweat, though the extremities are warm.

48 DR Anderson's case of c^esarean section. [july

4eA. — Frequent doses of ammonia had to be given last nighty as
she was very weak. Bowels have acted three times. Pulse is
stronger this morning, and 130 ; skin warm, and tongue moist^
though red at the tip and edges. Abdominal dischar^ is senn
purulent and firee from foetor. As the patient complaint of much
griping pain in the abdomen, I ordered the following mixture : —
9 Lic^. opii sedat. 3j. ; Spir. ammon. arom. et Spir. Lavand. co.
Si 5ij. ; Mist Cretee. ad §viij. — M. Capiat gj. o. 2 h. Removed
three of the sutures, and apphed strips ot plaster. About one inch
of the lower end of the abdominal wound is unimited, and gapes
widely, and through it can be seen the edges of the uterine wound,
presenting a healthj granulating appearance.

Evening, — Much more cheerful, and complains less of the griping
and hiccough. Bowels have onlj acted once during the daj.
Lochial discharge quite free. Pulse 130.

5th. — ^Doing well, though pulse is high, 134. Dressed wound,
which looks healthj, and removed three more sutures. Medicine
to be continued, as there are still a few tormina.
Evening. — Pulse 144.

6rt. — Morning, prdse 134, evening, 122. Can sit up in bed
without assistance, and seems altogether better. Wound looks
well, and is skinned over in one or two places. Removed another
suture, and re-applied strips of plaster. As the patient complained
of uneasiness in tne throat, I examined it, and found on the soft
palate several patches of white membrane easily removed, and
closely resembhng the diphtheritic exudation. Tongue red and
irritable. Ordered a chlonde-of-soda gargle.

Ith. — Weaker to-dav. Pulse 124. Throat better. Breasts still
flaccid, though the cnild has been frequently applied to them.
Removed another suture, and placed a pad on eitner side of the
abdominal sinus with stnps of plaster, in order, if possible, to bring
the edges together. The profuse purulent discharge from the abdo-
men, though quite healthy and free from foetor, seems to be exciting
a hecticcondition. 9 Potassse chloratis, 3j. ; Qjuins disulph., gr, xij.
— M. Divide in chart, vj. Capiat j. ter in die.

8^. — Throat better, though patches of false membrane have
extended to the inside of the cheeks.

%ik. — Much griping pain in the abdomen during the night. Ten
grains of Dover s powoer were given by the nurse, but were soon
after vomited. Discharge verv nree. rulse 122. Applied a lar^
pad over the whole of the aodomen, and over this a bandage, in
order, if possible, to procure deep-seated adhesions. Tympanitis
has quite passed off.

Evening. — Griping still continues. Ordered one grain of opium
at once, and warm fomentations to the abdomen.

12«A. — Since last report has been going on pretty well, though
very weak. Pulse has ranged between 110 ana 130. Abdominal
discharge is now decidedly less, and appears to be stopping. In

1664.] DR ANDERSON'S CASE OF C.SSAREAN SECTION. 49

consultation with Dr Bowerbank we resolved to close the abdominal
smos^ if possible. The sinus — ^large enough to admit a small wal-
nut— ^gapes widely, and allowsM view of the upper part of the uterus^
and one or two folds of intestine of a pink colour mottled with dark
patches. I passed a silver wire deeply through the abdominal
walls and peritoneum at the middle of tne sinus, and fastened either
end of it to a piece of pencil in the manner of a quilled suture.
Two other sutures were then passed through the skin and muscles
at points equidistant above and between the deep one. The parts
were thus accurately brought in apposition.

Evening. — Skin warm. Has vomited a little. Complains of pain
at the pomts of suture.

13<A. — Doing pretty well. Has had a good deal of bilious vomit-
ing. Pulse 120. Ordered 9 Sodse bicarb., Bismuthi trisnit, afi
5s8, ; MorphisB acet. gr. j. — M. et divide in chart vj. Capiat j. ter
in die.

15«A. — ^Vomiting quite checked. One of the sutures was cut out.
Adhesion has taken place, only to a slight extent, at the upper
part of the sinus, and sero-purulent fluid oozes out between tnose
still remaining. Bowels confined. Ordered a dose of oil. Patient
seems cheerful, and eats and sleeps well.

16<A. — Oil acted well. The nrst stool passed contained a good
deal of clotted blood. Removed the two other sutures, as thej
appeared to be of no use, and applied a strap of plaster. Sinus is
much in the same state as it was before the sutures were introduced.

20<ft. — Getting on well. Sits up in bed for several hours daily.

22df. — ^Was called late to-night to the patient, who I was m-
formed was worse. On seeing her, I founa that she had suffered
from rigors occasionally during the last two days. Has vomited
during the day a large quantity of bilious fluid. Discharge from
abdomen has nearly ceased. Complains of much jDa,in at a point
about two inches below the ribs on the left side. On examination,
I found that at the seat of pain there was an indurated swelling,
about three inches in diameter, very tender on pressure. All other
parts of the abdomen were soft and free of tenderness. The skin
was hot, and pulse 120, of good strength. Ordered a large poultice
over the abdomen, and $ Pulv. opii, gr.iss. ; Bismuthi, Sodas
bicarb., aa gr. x. — M. et fiat chart statim sum.

23df. — Patient is easier this morning, though she vomited fi«-
auently during the night. Skin cool, and pulse not so rapid.
Swelling in abdomen still very hard and tender. As the bowels
have not acted for two days, ordered a dose of magnesia.

24<A. — Going on pretty well. Abdominal swelling not so pain-
ful or tense^ though it has a feeling of deep-seated fluctuation.

26^. — Nurse reports that while patient was turning round in bed
last night, she felt something give way within the abdomen, and
inmiediately a gush of fluid took place through the sinus to the
extent of at least a pint The fluid discharged was sero-purulent,

VOL. X.— NO. I. a

50 DB ANDERSON'S CASE OF CfiSABEAN SECTION. [JULT

jellowish in colour^ and smelled very offensively. This morning
the patient seems much easier, and the vomiting which has so much
distressed her for the last three or four^days has qnite stopped. At
the point of swelling in the abdomen there is a depression of about
two inches in diameter, surrounded by indurated edges, presenting
to the fingers much the same feeling as is noticed in sanguineous
tumours of the scalp resulting &om an injury.

28th. — Doing well. The abdomen is softer, less tympanitic,
and free from pain on nressure. Sinus has much contracted, and the
discharge, though stiu going on, has much diminished. Uterus is
firmly adnerent to the lower part of the abdominal walls^ and is
drawing them in.

4A June. — B^ the request of its relatives^ the child was dis-
charged to-day in good health. Mother is doing well, and able to
take a daily walk in the grounds of the institution.

10th. — I'he abdominal wound is now perfectly cicatrized over,
except where the sinus existed. At this point there is a small
papilla, which on pressure exudes a drop oi serous fluid. Mother
was this day discnarged, at her own request, in a good state of
health.

5th September. — I have to-day seen both mother and child in a
State of robust health. The mother is enabled to pursue her daily
avocations as well as she did before her confinement. The sinus
has completely healed, and union is perfect at all points of the
incision. She has now a plentiful supply of milk, having procured
it by drinking a decoction of the leaves of the cotton-tree {Ghsay-'
piufn Barbadenee)^ in accordance with the advice of some old
woman. This decoction is well known in this island as a galacta*
gogue of great power, far superior to the leaves of the BidnuB
ccnnmunis.

Remarka. — ^In tropical climates^ as is well known, the process of
parturition usually takes place with comparative ease and freedom
from danger. The extreme cases of distortion, requiring instru-
mental interference, so frequently met with in tne mother country,
especially in the manufacturing districts, but rarely occur in this
island ; and the majority of labour cases are in the hands of mid-
wives, who, notwitlistanding the injurious practices they pursue-
both during and bS^ax labour, generally bring them to a successful
termination.

Diseases affecting the bony pelvis, such as rickets and tumours,
are seldom seen ; and the Cesarean section has not been required in
this city, nor, as far as I have been able to ascertain, in the island,
within tne memory of any one living. It was therefore a matter of
some interest to ascertain the origin of the malformation that gave
rise to the necessity for this operation.. This was a matter of some
difficulty, for the mother of the patient was a woman not particu-
larly enaowed with intelligence, and very forgetful of past events.

1864.] Vn AMDEBSON'B case of OCaABEAN 8ECTI0V. 61

I maiMged, however, to ascertain that her daughter had neyer met
with any accident, and had always been healthy, except for a period
of about three months, when she was under a year old. At this
time the child got very thin, and would not nurse well* She was
taken to a medical man, who stated that her ''bones wanted
strengthening," and he gave some medicine, as he said, '' to run
through the bones." Under his treatment the child rapidly
imnroved in health, and from that time to the present has not
haa a day's illness. I suspect that the child had an attack of
rickets, and that then the distortion took place which was the
cause of so much trouble when she became a parturient woman.
But whatever the cause was, when the patient came under my
care in active labour, no doubt could exist as to the only means to
be employed to procure delivenr. The three methods usually
resortea to in cases of contracted pelvis (viz., version, forceps, or
craniotomy) were all utterly out of the question, and the only
chance of escape for both mother and child was in the performance
of this operation. This decision was arrived at after repeated and
careful examination by myself, in conjunction with the two oldest
and most experienced medical practitioners in this city. In accord-
ance with what is generally considered as the principal element of
success in those cases which have resulted favourably, we resolved
that no time should be lost, believing, as we did, that if the opera-
tion was performed whilst the patient's powers were still unim-
paired, she, toother with her child^ would nave a reasonable chance
of life, while, if we resorted to the meffectual trial of other means to
relieve her, much precious time would be lost, and she would have
ultimately to be subjected to the dernier resort of operative mid-
wifery, under circumstances which would give but little promise of
a successM issue. I therefore operated within two hours of my
first visit. The operation was in itself simple enough, only two
circumstances having occurred during its performance which gave
me any concern. One of these was the rapid escape of the liquor
amnii immediately the cavitjr of the uterus was opened, in conse-
quence of the strong contraction of that organ. Notwithstanding
all the care exercised by Drs Bowerbuik and Fiddes in keeping
the edges of the abdominal wound closely applied to the uterus,
much of the fluid escaped into the abdominal cavity. This was^ I
have no doubt, in a great measure the cause of the subsequent in-
flammation and the purulent discharge that went on for so many
weeks after delivery. The other circumstance was the slight thoura
persistent hsdmorrhage that took place from the lower edge of tne
uterine wound after the extraction of the child and secundines.
This, though slight in amount, I was glad to find checked by the
application of a little cold water. The mere loss of such a small
quantity of blood would not in itself have produced any serious
effects, but I was anxious to avoid if possible the formation of any
clots in the abdominid cavity acting as foreign bodies. Small clots

52 DR ANDEBSON'S case of CiESAREAN SECTION. [JULT

came awaj subsequently through the wound, but I am inclined to
think that thej came from the uterine cayitj, as thej followed the
removal of portions of the foetal membranes.

The operation being over, and the patient placed comfortably in
bed, with a good pulse, two great risks were in a measure over, viz.,
shock and haemorrhage ; but many others had to be passed through
before recovery took place, — severe peritonitis, exhaustion occasioned
by long-continued purulent discharge, diarrhoea ; and when con-
valescence appearea to be fairly established, the formation of an
acute abscess which burst into the abdomen. From each of these,
as they successively appeared, I feared a fatal issue, and it was a
matter of surprise to me that the patient got through them all.

The two points most worthy of remark in the after history of the
case, are the long-continued abdominal discharge, and the abdominal
abscess. Discharge of purulent matter went on from the peritoneum,
through a sinus large enough to admit a walnut, for nearly four
weeks after the operation. Through this sinus I could daily
watch the gradual cicatrization and involution of the uterus, and
the peristaltic action of the intestines. It is rare, I believe, for the
contents of the abdomen to exhibit such tolerance of free exposiire
to the air as occurred in this case ; but I have noticed that in this
climate wounds *of serous surfaces, and their free exposure to the air,
are not attended with the same dangers as in England. The
abdominal cavity of my patient seemed converted into a large
chronic abscess, the walls and contents of which were continually
secreting pus. That this pus did not come solely from the uterine
wound was shown by the fact that pressure on any part of the
abdomen . brought it away in a gush. This discharge went on
until the twenty-seventh day after the operation, when an acute
abscess began to form. Three days later this dischar^d a pint of
stinking pus through the sinus, — ^a result which I hardly expected,
for I imagined that its exit would be through the intestines. The
stools were accordingly carefully examined daily, but with a ne^
tive result. After the abscess discharged, convalescence was rapid,
and the patient with her child was dismissed (both in good health)
on the forty-sixth day after the operation.

The medical treatment pursued after the operation was of the
simplest kind. Besides the free administration of opium and
ammonia, but little medicine was given ; believing as I did that if
recovery was to take place it would rather be by carefrd nursing
and attention to all means capable of supporting the strength of the
patient than by anv heroic measures tiiat I could adopt. The
patient was kept by herself in a detached building in th^ institution,
which is favourably situated in the outskirts of the city. Two
carefril and experienced nurses were in constant attendance on her
day and night, and it is to their unremitting care and kindness that
much of the successftil termination of the case is owing. With the
exception of the first two or three 'days, the patient took and

1864.] DB Anderson's case of cjesarean section. 53

digested daily three pounds of beef steamed down into the strongest
essence possible* Eggs and milk were also given, with plenty of
brandj. Of the latter she consumed for some time more than a
pint daily, and its beneficial effects in combination with ammonia
were well marked. Frequently, when she appeared almost " in
articulo mortisy^ with rapid, nearly imperceptible pulse, and cold
sweat standing on th^ face and upper pturt of the body, a good dose
of brandy and ammonia roused her flagging powers, and tided her
on for an hour or two, when it was again repeated with equally
beneficial effect. One favourable sjmptom was present throughout,
and that was her capacity for receiving and digesting any amount
of nourishment that could be given.

If called upon to operate in a similar case, there are two points
in which I would act differently. In the first place, I would
rupture the membranes per vagmam previous to operation. By
doing this all risk of escape of the amniotic fluid into the cavity
of the abdomen would be avoided : a matter, I think, of some
importance. The only objection I see to this method is, that
if the waters were discharged spme minutes previous to opera-
tion, the uterus might be strongly contracted round the child, and
more force be required in its extraction. Experience, however,
only can show whether this objection is well founded or not.
Another point is with regard to the mode of bringing the edges of
the abdominal wound together. If I had another case I would
certainly pass five or six sutures of wire deeply through the peri-
toneum, and instead of tying or twisting them, fasten them on
either side to an elastic bougie, in the manner of the quilled suture,
as used in the perinseum. The substance used instead of the quills,
whether bougie or anything else, should be large — ^to produce deep
pressure on the parts included in the sutures, and elastic — to allow of
the abdominal oistention that must to a greater or less extent take
place after the operation. A portion of a long gum-elastic rectum
Dougie would answer very well. Of course, in f^dition to the deep
sutures, superficial ones should also be inserted.

$art Seconlr.

REVIEWS.

On the Arcu8 Senilis, or Fattu Defeneration of the Cornea. By
Edwin Canton, F.R.C.S., JPresident of the Medical Society of
London, etc., etc. London : Harwicke : 1863.

The frequency and importance of fatty degeneration have only
lately been recognised. A few years ago, all that was known re-

54 MR CANTON ON THE ARCUS SENILIS. [JULT

^ding fat as a manifestation of disease, was connected with its
aeposition in abnormal quantity in the cellnlar tissue, its presence
in the form of layers around mtemal organs, or its existence in
Tarious situations in the shape of distinct tumours. We now
know that the elements of almost all the tissues of the bodj may
be converted into fat, and that fatty degeneration is one of the
most important of the morbid processes ; climacteric disease, there
can be no doubt (as was indeed suggested many years ago by
Sir Henry Holland), depending essentially on the occurrence of
a change of this kind in the heart, the arteries, and various other
organs.

The condition called arcus senilis has been long known ; it con-
sists in the presence of an opaque ring of a whitish or yellowish
colour around the margin of the cornea. Of the cause of this
appearance, however, various explanations were formerly given.
Thus it has been ascribed, as Mr Canton points out^ to an unnatural
dryness of the parts ; to coagulation of the fluids m the substance
of the vessels ; or to the presence of an exudation between the fibres
of the cornea. But we now know that it consists of a fatty de*
generation of the substance of the cornea; and to Mr Canton
belongs much of the credit of having clearly established this fact. In
itself the arcus senilis is not of much importance; in its earlier
stages it may long escape observation ; and, even when fully formed,
it causes no pain, impediment to vision, or other inconvenience.
The condition, however, becomes of much more interest when
looked upon as an index to the state of internal organs. We
cannot in the early stage recognise the fatty heart, or the athero-
matous artery; but a veiy slight change in the tranroarent cornea
will attract the attention of me carefm observer. Some, in our
opinion, attach too much importance to the aicus senilis as a
diagnostic sign, for cases not very unfrequently occur where the arcus
has been well marked, yet where little or no fatty degeneration of
internal organs is found ; or on the other hand, where the cornea
has been transparent, yet the heart and arteries are in a state of
advanced degeneration. This, however, amounts to no more than
saying that tne sign is not infallible, and in the majority of cases it
may, we fully believe, be depended on. The following passage
quoted by Mr Canton firom Mr Paget, expresses, we believe, very
accurately the value of the arcus senilis as a dia^ostic si^n:
^^ The arcus seems to be, on the whole, the best indication which
has yet been found of proneness to an extensive, or general fatty
degeneration of the tissues. It is not, indeed, an infallible sign
thereof: for there are cases in which it exists with clear evidence of
vigour in the nutrition of the rest of the bodv ; and there are others
in which its earlv occurrence is due to defective nutrition conse-

2uent on purely local causes, such as inflammatory affections of the
bopoid, or other parts of the eye ; but, allowing for such exceptions,
it appears to be the surest, as well as the most visible sign and

1864.] MB CANTON ON THB AB0U8 8ENIU& 65

measore of those primary degeneTations which it has been the chief
object of my two last lectnres to describe/*

The volume before us is devoted to an account of this condition,
and of some of the other changes in the economy with which it is
associated. It is interesting, and contains important matter, but it
is certainly too long. Several of the chanters might with ereat
advantage have been shortened, and the Dook would have been
more interesting to the reader, and not less creditable to the writer,
had much of the accessory matter been omitted* We have also to
complain that the correction of the press has been in some places
most carelesslv executed ; one French quotation in particular, on the
two-hundredth and fifteenth pafi;e, literally teems with errors, and
Dr Gairdner's name is persistently misspelt Gaidner. The punctua-
tion, also, is most inaccurate : amon^ other peculiarities a comma is
invariably inserted after a conjunction, so that the appearance of
some of the sentences is most singular. The two following quota-
tions will illustrate our meaning : '^ The coloration of the crystalline
lenses, the gray hairs on the temples, fatty degeneration, and, ossifi-
cation of the laryngeal, and, costal cartilages, interstitial absorption
of the necks of the thigh-bones, atheroma, and, calcification of the
arteries, etc., supply us, also, with instances of this symmetry of
change, gradually, but, surely impressing the body, as years steal
on, and, stamp it with the indelible ma^ of the decline of life."
— '^ The ezuaed material may, however, remain, and, undergoing,
or not, vascularization, becomes converted into new tissue : or, pass-
ing into low forms of fluid, or, solid is, now, to be regaraed as
d^enerate : and, amongst other phases determined in this degenera-
tion, we recognise the^^, and, caloareous.^^

Such carelessness in punctuation, and we may add in composi-
tion, detract veiy materially from the pleasure we might have in
reading the work.

The first chapter of Mr Canton's book contains a minute general
and microscopical description of the arcus senilis. The condition
in question commences as a slight diminution of the transparencnr
of some point of the margin of the cornea, which gradually extendui
so as to assume a semilunar form. Two arches are formed in each
eye, one at the ^per, the other at the lower border of the cornea.
There is some difference of opinion as to which of these arches
forms first, but Mr Canton maintains, and we believe maintains
correctly, that, as a general rule, the first formed arch is that which
occupies the upper se^ent ot the cornea. After a time these
arches meet ana constitute an ellijpse or zone around the cornea,
though a narrow rim of unaffected tissue generally remains external
to the arcus. On microscopic examination, oil-globules are found
in the corneal cells, in their processes, and in the inter-cellular or
inter-lamellar substance. The following is the method which Mr
Canton recommends for demonstrating t£e fatty nature of the arcus
senilis:

56 MB CAKTOK ON THE ARCUS SENILIS. [JULT

*' Haying selected a perfectly fresh eye in which the arches are well-marked,
or, a circle exists, cut, circularly through the sclerotic at the distance of a few
lines from its junction with the cornea, and, detach the two, conjoined, from
the iris, ciliary muscle, etc. The piece removed is to be divided into four
equal parts, by two incisions intersecting at the centre of the cornea. Pin
each triangular portion to a wax tablet, and, let all become dry in a current of
air. After drying, remove, ^carefully, with a sharp knife, a very thin * shaving *
from the edge of the preparation ; place it on a slide, in a orop of water to
which has been addea a little acetic acid, and, having (after a few minutes)
covered the object, proceed to its investigation.

" Examined by tne microscope, first, with a power of 60 diameters, the
specimen shows the mbatarUia propria, at a short distance from the sclerotic, to
be of a very light-brownish hue, and, its fibres appear as though matted, or,
confused together. The depth of this tint is, ordmarily, greatest towards the
anterior, elastic lamina, and thence, declines, more and more, as it approaches
the membrane of Decemet. This is seen to be the case, more especially, if the
arcus, still, retains the bluish, or, bluish-white colour which is characteristic of it
in the earlier stages of its formation, and, when fatty degeneration has not, as
yet, involved the entire thickness of the proper substance of the cornea. In
proportion, however, as this part becomes more invaded, and, the colour is seen
to have changed to that of a dense white, or, ochery white, so will it be found,
under the microscope, that fatty degeneration has extended to the deeper
lamellfiB of the cornea, and, in its whole thickness it, now, presents the lignt-
brownish tint I have already referred to.

" It would, thus, appear that the change, ordmarily, commences in the super-
ficial laminae, and thence, extends, by degrees, through the whole of the sub-
stantia propria at this spot."

On using higher powers the affected tissue will be found fiiU of
fine oil-globules. An interesting observation made by Mr Canton
is^ that the arcus senilis is often associated with fatty degeneration
of the muscles of the eye, atheroma of the ophthalmic arteries and
their branches, as well as with similar changes in distinct but more
important localities.

The second chapter treats of the arcus senilis as influenced by
hereditary predisposition. As a general rule it does not appear till
after fifty years of age ; it may, however, occur sooner, m conse-
quence of great general debility, of disease or injury of the eye, or
tne existence of an hereditary predisposition. An interesting case is
recorded where the arcus senilis was well marked in a lad of
sixteen years of age, where the tendency to its formation was
probably hereditary ; or where we should rather say the lad had
inherited from his parents a feeble and debilitated constitution, one
of the si^s of which was the occurrence of fatty degeneration of
the margm of the cornea.

In the third chapter Mr Canton considers the arcus senilis in
reference to its being occasionally produced by disease or injury of
the eye. Severe choroiditis, when it continues for some time, very
frequently gives rise to it. No doubt, the explanation given by Mr
Canton of this connexion is the correct one, namely, that the
inflamed and swollen choroid presses upon the bloodvessels which
supply the cornea, its nutrition is consequently impaired, and fatty
degeneration takes place.

1864.] MB CA2IT0H ON TH£ ASCUS 8KNIUS. 57

The next chaDter is headed ^^ on the oocasional non-oecurrenoe
of the arcns in old age ;" but though it extends to twenty-six pages^
the result arrived at maj be very briefly stated. It would appear
that though the occurrence of tlie arcus senilis in old people is the
rulci some persons reach a very advanced age without exhibiting
any, or but very slight, traces of it.

The fifth chapter professes to treat of the connexion between the
arcus senilis ana fatty and calcareous degeneration of the costal and
laryngeal cartilages ; but the greater portion is devoted to a minute
description of the anatomical and histological changes which take
place m the cartilages.

The two following chapters treat of the occurrence of the arcus in
the intemperate and the gouty, but they do not seem to call for any
special remark.

The last chapter consists of ^^ general and additional observations
on the arcus, and its disappearance under constitutional treatment.'*
Under this heading the author speaks of the causes and characters
of defective nutrition in general, and illustrates his statements by
cases where patients in this condition were the subjects of the arcus
senilis. We must conclude our notice of Mr Canton's work by the
following extract, which is interesting as showing that while the
existence of the arcus is a sign of a debilitated constitution, its
gradual disappearance ifkay nSord evidence that the system is
regaining part of its former vigour.

"There can be no doubt that much maj be accomplished, in process of time,
by means of medical treatment, where it is ascertained that such conditions are
present as tend towards a general, or, systematic decadence ; and, in which is,
not uncommonly, implied an atrophying state of many, and, diverse t'ssues.
Numerous cases, of tnis description have come under my observation, daring
the last twelve years : and, it is extremely interesting to have had occasion to
notice that, paripassuy with amendment of health has been the disappearance of
the orcitf, in those instances where thiu symptom was present, and, by its
presence had afforded the clue to the peculiar character of the mischief in
progress.

" Being anxious to ascertain whether others had made the same observa-
tion as myself, I applied to Dr R. Quain, who informed me that he, too, had
seen several examples of the disappearance of the arcus ; and, at the same time,
he kindly furnished me with the following case, which, as he observed, will
illustrate many of a similar character : —

" A clergyman, aged 46, came under my notice in March, 1851, as proposing
his life for insurance. He was tall, portly, stout, in proportion to his height,
and, one who, in common talk, woula be described as * a fine, healthy-looking
man.*

" A gknce at his features, placed in a good light, happened to detect a well-
marked, though not broad, arcus senilis. This was tne key to the following
short Imtory. He had been accustomed, until Ifive, or, six years before I saw
him, to active pursuits both in his profession, and. out of it. Then, his wife
became the subject of a painful, ana, protracted disease, which imposed upon
him much anxiety, and, &tigue. From this state he was relieved by her death ;
but, only to be involved in a Chancery suit. He had endured these troubles for
five years before his visit to me. He said that he was not conscious of suffer-
ing from any distsase ; a little inquiry, however, showed that he was no longer
equal to any exertion, a hill or a stair ascent rendered him faint, and, breathless.

VOL. X. — NO. I. H

58 MK CANTON ON THE ARGUS SENILIS. [jULY

His pulse was weak, and, compressible. His functions, generally, seemed toler-
ably well performed, save that the hearths sounds were feeble, and, languid, and,
that his digestion was occasionally somewhat out of order. After a short
interview, he thus summed up his feelings, — * I <io feel that I am wearing out.*
Some suggestions were made to him for his future guidance, and, he came again
under observation in May, 1852 (after a period of 14 months). His Chancery
suit had ended to his satisfaction soon after his last visit ; and, he had since
devoted much of his attention to the restoration of his lost strength, and,
successfully.

" He was now, he said, ' ten years younger, and, equal to any amount of
exertion.' There was much trutn in his observation. He was evidently now
vigorous. His pulse, and, heart's action were stronger. The arcus had fJraost
altogether disappeared, and, would not have been perceived had not a previous
knowledge pointed to its existence. His life was, now, accepted at a moderate
increase of premium.

"This case seems to show: —

" 1^. The value of the arcus as an aid to a diagnosis.

" 2c%. The circumstances which, impairing health, tend to the production of
that premature deca^, or, degeneration recognised as ' fatty. ^

" 3c%. The possibility of arresting, and, removing this condition.*'

A Manual of Minor Surgery. By John H. Packard, M.D.,
Demonstrator of Anatomy in the University of Philadelphia.
Philadelphia : Lippincott and Co. : 1863.

It is a deeply-rooted principle in every well-constituted mind, to
be prepared to cavil at, and object to, anything or anybody which
has been praised or held up as a model for imitation.

The good boy of the stoiy-book, and the justice of Aristides,
become equally wearisome. The scene over which the guide-book

Sies into raptures only gives rise to invidious comnarisons, and this
anual of Minor Sur^ry, on the same principle, mi^ht almost
change the usually placid reviewer into a malignant wielder of the
tomahawk and scalping-knife. For it comes forth to the world
having been sat upon by a board — a board of military surgeons,
and it has received their favourable verdict ; a verdict, too, which
not only pronounces on its absolute merits, but also gives its rela-
tive rank — the board " being satisfied that it is a better text-book
upon the subject than any of the treatises with which the American
market has hitherto been supplied." Really, in its bad grammar,
in its cool assumption, in ks mercantile view of the subject, this
finding of the board mi^ht rouse antagonism in the heart of the
quietest Quaker in Philadelphia.

Were it not for the board and the reminder it gives us of the cool
manner in which the ^^ American market does supply itself ^^ with
books, even by English authors, this inoffensive little work might
escape any hostile criticism. It is a careful enough compilation,
choosing rather to describe all the plans of performance of an^
minor operation, than to point out or describe the beat plan. It is

1864.] DB Packard's manual of mikob suboebt. 50

tempered to the intellectcial level of a hospital orderly, rather than
of even a janior student

The chapter on bandages, includine an analysis of Major's book
on the use of handkerchiefs, is carefiu and intelligible. Fractures
are folly treated of; but taking at random the account of that most
important set of fractures of the shaft of the thigh-bone, we find no
fewer than ten plans described, all very various and complicated in
detail, and all involving the principle of constant counter-extension
bv weights, plasters, bandages, elastic bandages, pulleys, etc., some
01 which ^' require to be changed daily ^ the perinseum to be washed
with whisky, and carefully dried before re-application."

At page 69, and also in a footnote, we fina the grooved director
put to some of its most objectionable uses — to be passed into the
sheath of an artery (in the operation of li^ture), and then to be
bent and passed under the artery, as a guide to the probe carrying
the thread.

In the chapter on sutures, there is an omission of minor import-
ance, and perhaps merely accidental, but still curious in an American
work, — ^there is no notice whatever taken of any shape of needle
suited for conveving metallic sutures, except the old flat curved
needle. Have the needles of Professor Lister or Mr Price not yet
found their wajr to the country to which we owe the great practical
improvement involved in the substitution of metallic for organic
sutures?

The work is ftilly illustrated and very neatly got up, and clearly
printed* With the imprimatur of an army board, we doubt not its
merits as an instructor of dressers and hospital orderlies will be
fully tested in this weary war.

Ten Years of Operative Surgery in the Provinces. By AuGUSTiN
Pbichabd, F.R.C.S., Surgeon to the Bristol Boyal Idirmary,
etc Part 11. London : Kichards : 1863.

This is the second and concluding portion of a work which has
been already noticed in these pages, and it fully bears out the
favourable opinion expressed of the part previously published.

This volume contains autoplastic operations, excisions, tumours,
and amputations. The excisions of joints are too few in number to
avail much as a contribution to statistics. Of three cases of exci-
sion of the knee-joint, all recovered after more or less tedious con-
valescence, with useful limbs. All, however, were well selected
cases in adults, between the 8^s of twenty and thirty-five. Mr
Prichard has been led to pre^r the semilunar to the H-shaped
incision.

In these days, when it is so much the fashion in some circles to
decry the results of operative surgery, it is refreshing to find such

60 MR PBICHARD'S OPERATIVE STJRaEBT IN THE PROVINCES. [jULY

statistics^ contradicted in their own &vonrite field, in so far at least
as Mr Prichard's practice is concerned, for out of eighteen primary
and secondary amputations of the thigh, only two cases proved
fatal, one of which was a child of two and a-half years, who had
been run over by a cart, and also suffered severely rrom whooping-
cou^h.

We cannot go more into detail, but in one particular especially
this little volume, as well as its predecessor, is worthy of all honour ;
we mean the manly honesty which records both the operations
which have proved successful, and those in which mistakes in
diagnosis or treatment may have been made.

There is nothing of a mere manual or compilation about this
work ; it is the honest record of ten years of honest labour, and
modestly conveys many practical hints of great value.

On the JSestarution of a lost Nose by Operation. By John
Hamilton, Surgeon to the Richmond Hospital, etc. London :
John Churchill and Sons : 1864.

When the notary, the hero of Edmond About's grotesque novelette,
was in despair, regretting his lost nose, his rival and conqueror
consoled him with the thought that in Paris there were skilfal
surgeons who had infallible secrets for the restoration of parts
mutilated or destroyed. Ireland, our author tells us, has up to
this time been behind Britain, and far behind the Continent, in
this branch of operative surgery, and the present monograph is a
description of what Mr Hamilton nas done in the special department
of rhinoplastv.

A short historical account is prefixed to the main body of the
work, which consists of a full ctescription, with copious woodcuts,
of ten cases, in which new noses were made to supply various
decrees of deformity. The loss in most of the cases was the result
of lupus, iti two of syphilis, in one of cancer ; and the new features
were obtained from the forehead by the Indian method.

The chief peculiarity of Mr Hamilton's plan, in which it differs
slightlv from others, is, that the central projecting portion of the
flap which is destined to form the septum is small, and ends above
in a point, instead of being either square or rounded. The methods
of fixing the stitches, preparing uie foundation, and stuffing the
nostrils, seem in no essential point to differ from those used, by his
predecessors.

The successftil results, as vouched for by the woodcuts, and by
the testimony of the patients, seem in great measure due to the
very careful preparation of the patients, by systematic and continued
therapeutic and hygienic treatment.

1864.] ANNALS OF MILITABT AND NAVAL SUBGERY. 61

Anncds of AttHtary and Naval Surgery and Troptoal Medicine and
Hygiene: An Annual BetraapecL London: Uhorchill & Sons.
VoLL 1863,

Thb namerons highlj-educated and acoomplished medical officen
in the sister services have vast opportunities of observation, and
jear by year are taking more advantage of these opportunities.

The present volume consists of a selection of extracts or analyses
of the more important of the contributions to medical literature by
the medical officers of the army and navy, and promises to be the
first of a most interesting and valuable series.

A distinct part is devoted to each station of the army and navy ;
and this arrangement, along with a most copious index, ^eatly
facilitates reference, besides showing separately the healtn history
of each command.

Amid so much valuable material, selection is almost invidious ;
but to some of us in Edinburgh, the very able medical journal of
the ^^ Icarus" by Dr Macdonald has a deeper interest than its pro-
fessional one, describing as it does the outbreak of yellow-fever in
which a most promising young graduate and dear friend, Br David
Maclagan, fell a sacrifice to his professional enthusiasm.

The papers on Dysentery by Drs Ewart and Mackav — on Gun-
shot Wounds by llongmore and Niell — on Syphilis by Marston,
would be sufficient alone to stamp the book a valuable one. For
officers on foreign stations, without access to medical libraries or
facilities for transporting many volumes, this series, if continued,
promises to be of extreme value.

In outward appearance like the Abstracts of Banking or Braith-
waite, it comes mto competition with no other work, nils a comer
hitherto unoccupied, and will, we trust, meet with the success it
deserves.

PERISCOPE.

8UR6ERY.

ON THE EMPLOYMENT OF SUBCUTANEOUS INJECTIONS IN OPHTHALMIC SUSGEBV.
BT PBOFESSOB VON ORAEFE.

Professor Von Graefe lately delivered a series of clinical lectures on the
employment of sabcutaneous injections in ophthalmic snigery, of which we pro-
pose to give a brief abstract. His experiments have been only made with the
acetate of morphia and the sulphate of atropine. The most nvonrable situa-
tion for making the injections is the middle of the temporal region, and it is this
which the Professor chooses under all circnmstances, unless there be some

62 PERISCOPE. [JULY

special indication, such as neuralgia or spasmodic phenomena, which makes it
probable that some other point may be preferable. The integument should
DC well raised from the subjacent parts, — the canula should be pushed into
the cellular tbsue, and the skin should be closely applied around the canula,
so as to prevent the return of the liquid injected. Tlie quantity of acetate of
morphia employed in Graefe^s experiments, varied from the tenth of a grain to
half a grain, — a fifth or sixth of a grain being the usual quantity. The solution
contained four grains of the acetate in a drachm of distilled water ; it should
be neuter, or very feebly acid. The physiological action is the same as when
morphia is taken into the stomach, but in general it is better marked, and
consequently the amount injected ought to be smaller by about a third than
the quantity which would be administered internally. The action on the iris is
interesting. Often at the end of a minute, sometimes not for half an hour, the
special contraction of the iris {qpium-myosis) manifests itself. This contraction
is best observed by comparing the dimension of the pupils with a moderate
light. The degree and the duration of the myosis vary remarkably ; in a large
number of cases it remains well marked for several hours, and disappears
slowly. Sometimes in very irritable persons, spasm of the muscle of accommo-
dation of the iris takes place ; when this phenomenon occurs, it is at an
advanced period, at the end of the stage of irritation. The most important
therapeutical indications of subcutaneous injections of morphia are, according
to Graefe, the following : — let. In the case of traumatic injuries which have
involved the eye-ball, soon after their occurrence, and when there is severe
pain ; for instance, after the penetration of foreign bodies, superficial burns or
wounds, the pain is more speedily allayed by the subcutaneous injection of
morphia than by the instillation of solution of atropine between the eyelids.
Professor Graefe is opposed to the application of leeches after the extraction of
foreign bodies, after contusions, and after penetrating wounds ; he looks upon
them as more likely to produce than to prevent inflammation and suppuration.
2df, After operations on the eye, when they are followed within a short time by
intense pain. Mj In the neuralgia of the ciliary nerves which accompanies
iritis, glaucomatous choroiditis, and several forms of inflammation of the
cornea. 4M, As an antidote for poisoning by atropine, an action which was
pointed out by Mr Bexijamin Bell in 1857. 5A, In necualgic affections of the
terminal branches of the fifth pair in the frontal region, not dependent on an
affection of the eye. Qth. In different forms of reflex spasms, such as spasm of
the eyelids in traumatic keratitis, and spasmodic contraction in the course of
the facial nerve.

In the case of injections of atropine, the greatest prudence is necessary. In
some persons the sixtieth of a grain is sufficient to give rise to general
B3rmptoms. In general the first dose injected should not exceed that quantity ;
it may afterwards be gradually increased to the twentieth of a grain. Accord-
mg to Professor Graefe, the occasions for the employment of atropine in injec-
tions are very limited, and to produce the mydriatic effect, the form of instillation
is preferable. Even when a full quantity is injected, the dilatation of the
pupils is moderate, and the power of accommodation of the iris is not superseded,
wMlst the desired effect is obtained by much smaller doses introduced between
the eyelids. In neuralgia, iniections of atropine do no good, in spasmodic
affections their effect is very doubtful ; so that their employment seems to be
limited to cases in which the conjunctiva would not tolerate the presence of
the atropine. — BuUelin GiiUral de TkSrapeutique,

ON ▲ NEW MODE OF APPLYING SOME EXTERNAL AGENTS TO THE EYE.
BY J. F. STREATFIELD, F.E.C.8.

The use of paper as a medium for the anplication of sulphate of atropine and
yarious other soluble salts to the eye, nas been before the public since my
communication on the subject in the " Ophthalmic Hospital Keports,*^ in the
number for January 1862. This medium has been very much approved, and,
I may say, generaUy adopted, owing to its convenience, and more or less also

V

ISM.]

8UBGEBT. 68

owing to its peculiar efficacy in some cases. It has occurred to me that an
improvement might be made if, in the new medium we could secure, along with
the convenience and efficacy pertaining to the paper, some vehicle which
would not need to be removed from the eye after it had been applied, and the
desired result had been ^ined. I have not now time or space even briefly to
relate the advantages arising from, or the way of making the application by,
the paper vehicle. I can only refer to my communication above mentioned,
and to another in the succeeding number of the same loumal. But I may
aUnde to the alarm felt by some patients at any investigation of their eyes,
even if only to remove the scrap of paper that has been introduced, and to the
trouble sometimes found in removing it when it has got up beneath the upper
lid. As the proposed substitute for paper need not be removed, the surgeon
will often be saved a delay of twenty minutes, and will not be obliged to wait
for the desired effect in order to remove the scrap of paper, and therefore, also,
the patient can be trusted to employ the new medium himself, which is not the
case with the old one. In order to obtain what I wanted, I first tried what is
called " wafer paper," but this is brittle when dry, and looses all consistence
when wet, so that it becomes unmanageable as soon as it is moistened ; and,
moreover, the pulpy substance in the eye, if not washed out, might irritate. I
am now employing gelatine, rolled out m sheets of the thickness of thin writing
paper, and imbued with a definite proportion of sulphate of atropine or any
other salt required. This retains the advantages of, and only requires the
same mode of application as, atropine paper, but U need not be removed from the
eye. It is soon aissolved in the tears, and acts in every way well. The dose
employed thus, it appears, is more quickly applied to the eye than when a
similar dose has to be dissolved out of the meshes of tissue paper; and to this
it is that I attribute the pain felt by some of my patients when I have used a
laige square of " gelatine atropine paper." They have not complained of pain
when I have used a smaller bit (or dose), less than a whole square. 1 am
thinking of having a check of small squares printed in green on the gelatine,
to define the doses, and to make the transparent gelatine more readily visible
when about to be uaed^ for it need not be looked for afterwards. It is made by
Mr Squire, chemist to Her Majesty, 277 Oxford Street, London. — British ami
Foreign Medico- Chirurgioal Review y let January 1864.

ON A NEW AGENT FOB PRODUCING CONTRACTION OF THE PUPIL.

We observe in a late number of the Prager Medizinische Wochenechrift^ that
Dr Braidwood, a graduate of Edinburgh University, read before the Medical
Society of Prague, a paper, embodying the results of a series of experiments
upon the action of a new arrow poison from the island of Borneo, called
'* dagakoch," a quantity of which he had obtained through the kindness of
Professor Du Bois-Raymond. This substance acts both upon the heart and
the pupils. Its effect upon the former is that of arresting its action, which
it does by first causing weakness and irregularity in the cardiac contractions.
Mid in a very short time their complete cessation. On post-mortem examina-
tion the ventricles are found to be pale, bloodless, and contracted, while the
auricles and veins are distended with blood. This substance acts upon the
pupil in the same manner, though not so powerfully as the Cahibar bean, givmg
rise to well-marked contraction.

[We have received Dr Braidwood's paper, and shall insert it in the next Damber of this
Jonmal.— Ed. Mbd. Jodbxal.]

64 MEU)ICAL NEWS. [JULT

yort iFottvt|.

MEDICAL NEWS.
MEDICOCraRURGICAL SOCIETY OP EDINBURGH.

8E88ION XLm.— MEETING YD.

Wedfuadayf 4ih May 1864.— Dr Douglas Maclagan, President of the
Society, in the Chair.

I. CIRRHOSIS OF THE LIVER.

Dr Hdldane showed a specimen of cirrhosis of the liver^ which contained
masses of syphilitic deposit. The particulars of the case will be fowid at
p. 1074 of the last number of this Journal.

II. EXOSTOSIS OF THE HUMERUS.

Mr Spence showed the cast of the arm and a tumour which he had recently
removed from the humerus of a boy twelve years of afe. The boy was an
inmate of Ueriot^s Hospital, and was placed under Mr Spencers care by
Dr Andrew Wood. It was stated that the swelling had oxuy been noticed
a fortnight nreviously ; and the father of the patient said that his son had
been carefully examined three months before, and nothing wrong had been
noticed about the arm. From the feeling of the swelling, its hardness and
firmness; from the fact of its having a distinct neck; and from the age
and healthy appearance of the patient, Mr Spence came to the conclusion
that the tumour was not of a malignant character, as from the rapidity of
its growth one might have been led to believe, but that it was either an
enchondroma or an exostosis, consisting partly of cartilage. The rapidity
of the growth might probably be expleiiued by the youth of the patient
and the activity with which all nutritive changes go on at that perioo. Mr
Spence, accordmgly, determined to remove the tumour, reserving to himself
the alternative, in the case that in the course of the operation the growth
should turn out of a worse character than was anticipatea, of amputating the
arm. A free longitudinal incision was made, and the growth was round deeply
seated, partly below the deltoid, partly below the triceps muscle. It was
removed readily enough, though the neck was found to oe broader than is
usual in such cases. From the condition of the bursa over the tumour, as well
as from the appearance of the tumour externally, and after being cut into,
there could be uttle doubt that it was of a simple nature, in fact, an exostosis.
Mr Spence had requested Dr Grainger Stewart to examine it microscopically,
and had received from him the following note of the appearances found : —

** The tumour consisted of a base or centre of spongy bone, with numerous
cartilaginous nodules on its surface. These nodules were of various sices,
and idl were connected with and passed into the bone.

" Microscopically the bone presented its ordinary appearance, with corpuscles,
canaHculi, etc. (fig. 1). The cartilage presented three distinct varieties.

"1. In some parts it presented the ordinary appearance of costal cartilage.

" 2. In some its cells were greatly enlarged, and rapidly proliferating, com-
paratively little intercellular substance remaining, and that presenting a some-
what fibrous character. This form seemed to be most abundant where the
greatest elevations existed, i.e, where there was most rapid growth. (Fig. 2).

*^ 3. In some parts the cartilage was impregnated with calcareous matter, or
was passing into bone. In these parts the cartilage cells was of considerable
size, and contained distinct rounded nuclei, which sent out processes, and

1864.] MEDICO-OHIRUBOICAL SOCIETY OF EDINBURGH. 65

became jagged as they approached the line of OMification — ^they presented the
appearance of bone corpuscles — and it seemed to me that they became trans-
formed into them. The deposit of the salts of lime first appeared in the inter-
cellular substance, and most markedly in the walls of the cartilage cells, and
gradually spread into the cell contents, and defined the bone corpuscles.

^ In the fibrous and muscular tissues connected with the tumour, I found
many of the nuclei enlarged, but not to any extent beyond what might be
accounted for by simple irritation."

Perhaps the most interesting point in this case was the rapidity with which
the tumour had formed ; now, though this might doubtless be in piirt explained
by the youth of the patient, Mr Spence was inclined to believe that the tumour,
for a long time, had been simply overlooked. We knew that this was fre-
quently the case with regard to exostoses of the femur, and that these might
attain a considerable size without the attention of the patient being directed
to them. And as the rapiditj of growth was the only suspicious circumstance
in this case, Mr Spence was mclined to explain it in this way, and would fain
hope that what he had removed was a simple tumour of bone, and that there
was no danger of its recurrence.

III. OVARIAN TUMOURS REMOVED BY OVARIOTOMY.

Dr Thomas Keiih showed six ovarian tumours which he had recently removed
by ovariotomy. With a single exception all of these were examples of the
common multilocular growths ; in the exceptional case the tumour consisted of a
single cyst. Of these patients five had recovered, one died. The case where
death occurred went wrong almost immediately after the operation, fatal
peritonitis bavins set in. The patients were of various ages, from twenty-one
to sixty-eight ; the latter age being, so far as Dr Keith knew, the greatest at
which the operation had been performed; the patient had gone on well.
The last operation had been performed in the case of a woman of twenty-one
on the 29th of April ; the lower part of the tumour was nearly solid, and there
had been great difficulty in the aiagnosis, as it had been almost impossible to
determine the state of the uterus. In the course of the operation the solid
portion of the tumour was found to fill up the pelvic cavity; the patient
had been exceedingly feeble at the time, but had since gone on remarkably
well. In conclusion, Dr Keith might state that he had performed ovario-
tomy fourteen times ; that ten of the patients had recovered, and that four
had died.

IV. DISEASE OF LOWER END OF FEMUR.

Dr Wataon showed the lower part of the femur and the upper part of the
tibia, from a case in which he had recently performed amputation. The dis-
ease had continued for eighteen months, and had been attended by extensive
and copious suppuration. The articulating ends of the bones were completely
honeycombed, tne proximate ends of the shafts much thickened, and the
epiphysis of the femur had been displaced completely inwards and backwards
by the softening process which had affected the bone, more especially at the
junction of the shaft with the epiphysis.

V. FRACTURE OF NECK OF SCAPULA.

Dr WaUon showed a specimen of fracture of the neck of the scapula, com-
plicated by fracture of the neck of the humerus and ribs, with laceration of
the axillary artery. . The injury was the result of direct violence applied to
the shoulaers.

VI. TUMOUR OF HARD PALATE.

Dr Wataon exhibited a tumour occupying and developed from the hard
p^te ui)on the right side, which he had recently removed from a patient of
th Mackie^s of Cupar. The operation was effected through an incision dividing
the centre of the upper lip. The bone was divided in the middle line by bone
pliers, and by a transverse section of the upper jaw by the saw. The palatal

VOL. X.— NO. I. I

66 MEDICAL NEWS. [JULT

Elate and alveolar arch were then easily removed, leaving the palatal bone
ehind soond and intact.

VII. ANNULAR SEQUESTRUM FROM TIBIA.

Dr Watson shoyred a sequestruro from the tibia, in shape like a tailor *8 thimble;
it formed the parietes of a trephine incision, which he had made some months
ago, for the purpose of openmg an abscess cavity in the bone, in order to
extract a small sequestrum.

VIII. SUCCESSFUL PRIMARY AMPUTATION AT THE HIP-JOINT.

Mr Spence read a paper on this subject, which will be found at page 1 of
this number of the Journal.

Professor Miller had listened with much, interest to the details of this case.
He was inclined to attribute the patient's recovery chiefly to two circumstances.
In the first place, the patient nad been treated on the spot, and had con-
sequently been spared a long and painful transit ; in this way, as Mr Spence
had remarked, there was scarcely any secondary shock to be gone through.
In the second place, infinite credit was due to Mr Spence and to his assistants
for the mode in which the operation had been performed ; very little blood had
been lost — a most important point in a young subject. These Mr Miller con-
sidered the two main causes of the successful issue of the case. At the same
time, Mr Miller would not put out of sight the locality where the operation
had been performed, and the after-treatment conducted ; for, circumscribed as
the space of the patient's lodging was, he was at least as fairly situated in this
respect as if he nad been in a hospital. With Mr Spence's conclusions Pro-
fessor Miller quite agreed ; and he must say that he considered that Scottish
surgery was entitled to no little credit for the successful termination of this
case.

IX. GANGRENE FROM OBSTRUCTION OF THE COMMON ILIAC ARTERY.

Mr Spence read a paper containing the particulars of a remarkable case of
plugging of the right common Uiac artery, which will be found at page 7 of
the present number of this Journal.

Professor Simpson had formerly brought before the Society a series of cases
of obstruction of arteries, but no one of them had been exactly of this type ;
in fact, he believed that the case now related by Mr Spence was in some
respects unique. So far, however, as he understood Mr Spence's explanation,
he considered it somewhat forced. It seemed to be this: the artery haa
become obstructed by a coagulum, which had formed in consequence of the
diseased condition of its coats ; the circulation was for a time arrested ; blood,
however, in course of time oozed through, and the interior and perhaps the
middle coat of the artery was dissected from the outer. Mr Spence seemed to
think that the direction of the dissection should have been doumwards — that
is, in the course of the circulation. This, however, in Dr Simpson's opinion,
must depend upon whether there was more facility for the blood to get up or
down ; for, when the blood once got out, the law of fluid pressure came mto
operation, — that is to say, the pressure was equal in all directions, — and if
there was less resistance to pressure upwards than downwards, the blood
would obey that law and spread upward. Dr Simpson believed that dissecting
aneurisms generally were not to be accounted for by the direction of the stream
of blood, but by the facility with which the blood burrowed in one or other
direction. One symptom to which Mr Spence had alluded was the pain
experienced by the patient. Of this Dr Simpson had seen several marked
instances ; in one case, in particular, it had been so intense that the patient on
various occasions required to have chloroform administered for hours together,
as without it her screaming was quite unbearable. The pain in these cases
was a common but not easily explicable symptom.

Profes9or Madagan might mention a case as illustrative of Professor Simp-
son's remarks in r^ard to the frequency of pain as a symptom of obstract^d
arteries. In September last, he saw a gentleman who bad just returned from
country quarters, where he had suffered from what appeared to be sdatka.

1864.] MEDICO-CHIRURQICAL SOCIETY OF EDINBUBOH. 67

aod for wbich he hftd undergone appropriate treatment. When aeen by Dr
Madagan, he was found to be subject to severe paroxysms of pain running
down toe back of the thigh and leg as &r as to the foot. On exammation, there
was found to be a little diminution in the warmth of the foot, and the patient
described it as feeling '* asleep." No pnlse could be felt in the posterior tibial
artery; and Dr Madasan came to the conclusion that the case was one ot
embolism of the femoru artery. Dr George Keith, who also saw the patient
at that time, was of the same opinion. For the next three months the gentle-
man was able to go about ana attend to his business. Three months after-
wards, the patient had an unusually severe paroxysm of pain, which occurred
while getting out of bed ; next day a little gan^p-enous spot was noticed on the
foot Dr liuiclagan altered the treatment which had been hitherto pursued.
The limb was wrapped up in cotton wadding, and antiphlogistic means were
employed. Professor Svme saw the patient, but did not recommend any
further interference. There was an appearance of the formation of a line of
demarcation, but it never came to anytnmg. A slight gangrenous appearance
of the other limb manifested itself, and the patient gradually sank. It should
also be stated that, in the interval between the time when Dr Maclacan first
saw the patient and the occurrence of the gangrene, the patient had a very
slight hemlplegic attack ; there was a little twistmg of the face, and a degree
of thickness of articulation. This attack in all probability depended upon
embolism of one of the cerebral arteries. The heart was frequently examined,
but nothing abnormal was detected.

Mr Spence thought there was very little difference between his own explana-
tion of the formation of the dissecting aneurism and that suggested by Dr
Simpson, so far as the law of fluid pressure was concerned. He had specially
referred to tlie direction of the separation of the arterial coats, as showmg that
the dissecting aneurism was probably not the primary cause of the gangrene,
but resulted from the force of the reflux current of^ blood acting on a weak

S^int of the artery when its usual onward course had been previously obstructed,
e would quote the words of his paper as showing this : — " The current of the
excited circulation being obstructed beyond by the previous coagulation, caused
the coats of the distended artery to yield at the diseased part, and the reflux cur-
rent of the blood to force itself between the tissues of the artery, thus separating
them in the backward direction towards the heart." With regard to the pain
which had been experienced, this was met with in almost all cases of aneurism,
and after the appbcation of a ligature. The usual explanation was, that when
the main artery was obstructed, the collateral vessels became enlarged ; the
•mall veeseb and the neiuilemmal branches shared in this process ; hewse there
was pressure upon the nerve-substance, and this occasioned the pain.

Profeuor ^npiou did not think Mr Spence*s explanation of the cause of
pain m these cases satisfactory. When perchloride of iron was injected into
the sac of an aneurism, and coagulated the blood there and in the afierent
artery, sometimes the pain had proved instantaneous and extreme, occurring
long before any chanse could take place in the collateral vessels. In cases of
obstructed arteries also, the pain often went off for a long time, and again
came on. It was stated that in one of the first cases on record, that extreme
pain was experienced in the lower extremity ; the patient was seen in consulta-
tion by several Parisian doctors, who doubted of what nature it was, whether
rheumatic, neuralgic, etc. Her physician Dr Le^roux, found, however, on
careful examination, that there was no arterial pulsation in the foot and left,
and came to the conclusion that the main artery nad become obstructed, whidi
was corroborated on dissection. The occurrence of pain led to this almost
accidentid discovery of the obstruction.

Mr Spence did not think it surprising that the perchloride of iron should
cause great pain when injected into the sac of an aneurism, for it did so when-
ever it was applied to a raw surface. The perchloride was sometimes injected
in cases of nsevus, and then also it caused great pain.

JDr P, H. Wateon thought it was certainly remarkable that pain in embolism
shoald not merely be on the distal side of the obstruction, but that it should

68 MEDICAL NEWS. [jULY

be felt at the point. Hitherto it had never been supposed that the arterial
tissue was very sensitive, and there must be some unknown cause to account
for the suffering. He quite agreed with Mr Spence that injecting perchloride
of iron into a nsBvus caused severe pain.

Professor Laycock had observed closelv several cases which were somewhat
similar to that which had been described by Dr Maclagan. In particular, he
remembered the case of a gentleman, a solicitor, who had been much engrossed
with writing. In consequence apparently of excessive use of the right hand and
arm, he began to suffer from neuralgic pains in them. The arm and hand got
red ; spots of a redder and deeper colour made their appearance ; finally the
parts became cold, and arterial pulsation was found to have ceased. The
patient went to London and consulted several surgeons, among others the late
Sir Benjamin Brodie. Some diagnosed an aneurism, others, an obstruction of
the artery. A certain amount of gangrene took place, and the patient lost the
tips of his fingers. The patient tonen came under Dr Laycock*s care, and was
under observation for some months. He suffered from repeated paroxysms of
pain, and at these times the arm and hand were studded with deep red spots
which were the seats of such exquisite agony, that large quantities of opium
required to be administered. Dr Laycock was finally led to the conclusion
that the pain did not depend upon obstruction of the vessels, but that it was of
a nervous character, and that it preceded or coincided with the morbid condi-
tion of the vessels. Another important point in the case was, that the patient
had neuralgic pains over the liver, and that when these were present, Bpots
similar to those on the limbs made their appearance in that situation. The
patient recovered a fair state of health, but was unfit for his profession, and
accordingly determined to enter the church. In consequence apparently of
having walked too much, he had an attack of neuralgia of the right leg ; the
nervous system appeared to be exclusively affected ; there was at wnt no
appearance of embolism. In the course of a day or two, however, the artery
became obstructed, and the patient lost two or three of his toes. He recovered
from this attack, and subsequently tried various means for the relief of the
neuralgia which affected his head, scalp, shoulders, and other parts. Finally
there was vomiting of blood ; the spleen was found enlarged ; dropsy super-
vened, and death soon followed. This patient appeared to be powerfully pre-
disposed to disease of the bloodvessels ; his uncle at the age of twenty -two
haa lost a limb from the same cause ; he had overwalked himself; an obstruc-
tion of the artery took place ; gangrene set in, and he died. In neither case
was there any reason to believe that there was any atheroma of the vessels to
predispose to this obstruction. Dr Laycock, indeed, was satisfied that there
was not, but considered that a change in the nervous system preceded the
morbid condition of the artery ; pluggmg occurred, but the neuralgia preceded
or coincided with its occurrence.

Dr Haldane would state what he believed to be the cause of pain in cases of
obstruction of the arteries. In the normal condition, there was no conscious
sensation in the arterial coats. The same was true with regard to the intes-
tinal canal ; in a healthy condition we were not conscious of the presence of
matters in the bowels ; but if the intestines became distended witti air, or if
they were spasmodically contracted, severe pain was the result. The structure
of the arteries was essentially the same as tnat of the intestines ; in each case
the middle coat consisted of involuntary muscular fibre. The external coat of
the arteries was abundantly supplied with nerves ; any abnormal contraction
or dilatation of the middle coat would necessarily irritate these, and under
these unnatural conditions, pain would result. The dilatation might be pro-
duced by the presence of an obstructing clot, or the accumulation of blood
behind it ; while the irritation of the inner coat of the vessel might lead to
spasm and contraction in the neighbourhood, or at more distant points.

Dr Sanders would hazard a suggestion as to the cause of the pain in these
cases. If an artery was obstructed, the coUateral circulation coula not at once
supply the necessary quantity of blood to the parts below. The result was,
that a species of molecular death was going on for a time ; such changes took

1864.] OBSTETRICAL 80CIETT OF EDINBURGH. 69

place in the nerres as would lead to the Mine reault as if the nerre had been
injared. By the molecular disintegration of the particles, the whole fibres were
irritated, and the irritation was applied exactly where it would be most powerful
— that is, at and near the sensory extremities.

Fro/ester Simp&an remarked that there was this difficulty in accepting Dr
Sanders' explanation of the pain in cases of embolism, that severe pain did not
follow the application of a ligature to an artery ; in such a case, tne interrup-
tion of the flow of blood was sudden and complete, and the causes to which Dr
Sanders had aUuded ought to be in full operation. On the whole, Dr Simpson
was inclined to attach a good deal of weight to the explanation suggestea by
Dr Haldane.

PROCEEDINGS OF THE EDINBURGH OBSTETRICAL SOCIETY.

SESSION XXIII.— MEETING Y.

21th January 1864.— Dr Graham Weir, PreMeni, in the Chauri

' I. CASE OF RENAL CALCULUS IN A CHILD.

Dr Graham Weir gave the following history of this case : —

Samuel Johnston, age 3 years, admitted to the Edinburgh Hospital for Sick
Children on the 20th of Februaiy 1862.

History before Admisnan, — ^His father says that when bom he was a stout,
healthy child, and that when six weeks old he became suddenly sick and ill, and
began to swell about the lower part of the abdomen, especially about the
scrotum, which latter increased rapidly, and to such an extent as almost to
entirely conceal the penis. In this condition he remained for upwards of a
week, and then began gradnally^ to recover. About this time his thirst
became, and continued up to within a .short time of his admission to the
hospital, almost insatiable. His urine began to dribble away from him. When
about a year old he was examined by a medical practitioner in attendance
apparently for stone. There was never any blood noticed in the urine, and
though frequently complaining of sickness, and inclined to keep his bed for a
few da^s at such times, he never complained of pain either in kidneys, bladder,
or perns.

Symptanu on Admisdon, — Patient is a thin, emaciated child, with a very
sallow complexion, and looks much older than he is said to be. Complains of
no pain. At times, and esnecially when he is going about the wards, he has
complete control over the bladder, and is able to retam his urine for a consid-
erable time, and pass it in a tolerably full stream ; but when in bed this control
is lost, and his urine dribbles continually from him.

The urine is of a dark, smoky hue, which, on cooling, deposits a thick white
sediment. On the application of heat and nitric acid, albumen is thrown down
in large quantities ; and, on examination by the microscope, this white sediment
is found to be composed entirely of pus-corpuscles. Alter having been in the
hospital for a fortnight his general health improved, and it was frequently
remarked how happy and contented he always was, never complaining of pain
or uneasiness of any kind. In this condition he continued up to Sunday, 30th
March, when he began to complain of sickness, with loss of appetite, a slight
dusky-brown rash at the same time showing itself about the nates. On the
following day, he became feverish, tongue red, dry, and somewhat glazed;
pulse weak, and about 140; considerable swelling externally on each side of
the throat, and a mixed kind of rash was observed over the greater part of the
body. The uvula and tonsils were also inflamed and swollen, but not ulcer-
atea. This rash continued for three or four days, and then disappeared, as did
also the affection of the throat. He never completely rallied from this attack,
but continued to grow weaker until the 23d of April, when he died.

Inspection, — External appearance, that of the last stage of marasmus. The
thoracic and abdominal cavities were alone examined, and, with the exception
of the kidneys, their contents were healthy.

70 MEDICAL NEWS. [jULY

Both kidneys were deeply lobulated, and double the normal size. A section
of the right kidney being made, the pelvis was found greatly enlarged, and
completely filled by the calculus marked 1 in the woodcut. No. 3 was also
found in this kidney, but in a cyst detached from No. 1.

The caloulus marked No. 2 was found m the pelvis of the left kidney.

I am indebted to Dr Arthur Gamgee for the following accurate description
uid carefid chemical analysis of the calculi.

** Calculus No. 1, the largest, consists of a trian^ar body, with four pro-
cesses projecting from its bue. The largest and thickest of these processes ia
situated at one extremity of the base, and is capped by a very white calcareous-
lookine mass. The process at the other extremity of the base is bifurcated.
Tlie calculus as a whole is like an ill-shaped hand with out-spread fingers.

The body of the calculus is of a pale fawn colour ; the processes, especially
ttt their summits, are white.

Weight of calculus, 94-17 grains. Measurements — ^greatest length, 1 inch 6
lines ; length, 1 inch ; breadth, 1 inch 6 lines.

Chemical Composition. — Portions of the body of the calculus and the white
masses were subjected to analysis ; the body of the calculus consists mainly of
the phosphate of magnesia and ammonia (triple phosphate), with a very httle
phosphate of lime, and a considerable quantity of organic matter.

The fawn-coloured superficial layer was specially tested for uric acid and
urate of ammonia, but none was found.

Calculus 2. — ^Thifl calculus ia of a very irregular shape, and is composed of
two masses, of which the convexity of the one fits into the concavity of the
other. These masses were so slightly connected, that in scraping a tew frag-
ments off for chemical examination, they became detached. One of these
portions of the calculus has projecting from it two processes, both of which
are bifurcated, each being capped with masses exactly resembling those of
calculus 1.

Weight of calculus, 37*01 grains. Measurement, greatest length, H lines.
This calculus has very evidently much the same structure as csJculus 1 ; its
colour is, however, different. Some portions of its surface are of a fawB
colour, others are of a bluish purple, and others of a beautiful pink tint. Ab
before stated, the processes of this cmlculus are like those of the first, capped
with white masses. In this case the summit of the masses is finely tinged with
pink colouring matter.

Chemical Composition. — ^The quantity of oolonring matter is so small that
its properties could not have been investigated without altogether destroying
the calculus. By exclusion, however, I think we may safely say that theite
colouring matters must be blue and red colouring matters (uroglaucine and
wihodine) produced by the oxidation of indican in the urine. The tint
exactly resembles these substances.

1864.] 0B8TETB1GAL SOCIETY OF BDINBUBGH. 71

The body of the caleolnfi eonflists of phosphate of lime, mixed with a rwy
small quantity of the triple phosphate and organic matter. The eomposition
of this calculus diifers from that of the first, in as far as in the latter there was
much triple phosphate, with little phosphate of lime; in calculus 2, much
phosphate of lime, with little triple phosphate. In neither case wa« the
mixture such as to confer a fusible cnaracter to the concretions.

The masses situated on the processes were so evidently the same as those
in the same situation in calculus 1, that I did not examine them.

Calculus 3. — ^This calculus is very small, is of an oral shape, and weighs 8'i
grains. Its largest diameter measures 2) lines.

Chemical Composition. — Same as body of calculus 2, and consists chiefly
of phosphate of lime with a little triple phosphate.

Dr Weir remarked that the case was mteresting on account of the large size
and peculiar form of the calculus, as well as the immunity from pain.

Dr Moir had met with a case in an adult where there were numerous calculi ;
yet the patient had never complained of any pain, although his occupation,
that of a dancing-master, might have been expected to have given rise to that
symptom.

Profeuor Sir/yMon explained that the paroxysms of pain caused by a renal
calculus were due to the stone falling down into the ureter, and there acting as
a plug or pea-valve, the fit lasting till it was removed. Acting upon this view,
he had treated some such cases by elevating the pelvis of the patient above
that of the rest of the body, so as to allow the plug to fall back and permit the
urine to pass. He at one time had a patient under his care who suffered
frequently in this manner. One day, havmg received a message that the ladj
was in great agony, and had taken chloroform without relief, he sent his
assistant, with directions to turn her over the back of a sofa with her head
downwards. He soon returned, and with surprise exclaimed, " I have cared
her I What have I done?'* The patient has been several times relieved in
this manner. Pain could not occur in Dr Weirds case, because the calculus was
held too high up to obstruct the flow of urine.

n. INDENTATIONS ON THE UTERINE SURFACE OF THE PLACENTA. '

Frofeuoft Sitnpson showed a preparation, which he had seen some examples
of without knowing its exact pathology. It was a case of placenta prsBvia.
The histonr of it was as follows : —

On the 24th of January last, at half-past four in the morning, Mrs W., on
rising to make water, was seized with oleeding from the vagina. For soma
years past she had lost much blood from piles ; she had bom three childnm.
the labours being easy, with the exception of the first, when the forceps had
to be used, and was now by her computation at the full time in her fourth
pregnancy. At half^past ^ve^ when the first examination was made by Dr
FinJuiy, a comer of the placenta was felt projecting behind the front lip of tiM
OS uteri, and as the bleeding, though it had abated, did not cease, the mem-
branes were raptured at a quarter from seven, when the head of the child was
felt presenting. After this there was no more haemorrhage. Between ten and
eleven in the forenoon slight labour-pains were felt, and recurred at intervals
of half an hour, until two o'clock, when a hand of the child was felt jprojecUng
into the vagina, and the head could be reached by the point of the nnger only
with great difficulty. The pains went on as before, and at half-past five the
ease was seen by Dr Simpson, who, shortly before seven, deliverea by turaing«
the patient having been rendered insensible by the action of chloroform.
The child was dead. No bleeding followed the operation, and Mrs W. passed
a good night under the influence of opium. During the next two days she
felt pretty well, but the pulse never fell below 120. On the third fi(ay sh«
became delirious, the pulse rose to 160, and on the sixth dav she died.

The site of the rupture of the bag shows the position of the placenta to have
been over the os. The peculiarity of the case consisted in several deep indenta-
tions <m the uterine suiace of the organ by clots of blood. The cause why snob

72 MEDICAL NEWS. [jULT

indentations shoold take place in some cases he was unable to explain to his own
satisfaction. Were such indentations not the result of the compression of
the comparatively yielding placental tissue b^ incarcerated and accumulating
clots of blood ? One of the students in his class, to which he had put
the question, supposed it due to the pressure of the head when passing the
placenta. He (Prof. S.) had examined, with Dr Peddie, the body of a patient
who had died in labour with very little bleeding, but where they found on
dissection a large clot of blood lying on the centre of the placenta, which
organ was attached high up in the uterus beyond the reach ot the head, and
showed a very large and very deep depression or indentation at the site of the
clot. Merriman and others relate some cases of the same kind.

Dr Weir had met with such cases.

Dr Moir thought that it occurred in cases of partial separation of the
placenta, but where the blood did not escape on account of tnat organ being
still attached or adherent round its edges.

MEETING VI.

1(WA Fdruary 1864.— Dr Pattison, Vtce-Prendent, in the Chair.

I. ON AMPUTATION OF THE CEKYIX UTEKI IN CASES OF ELONGATION.

Dr Alex, R, Simpson, in the absence of Professor Simpson, showed a draw-
ing of a portion of the anterior lip of the cervix, which had been removed by
the ^craseur. There had lately oeen a patient in the hospital on whom the
same operation had been performed, and whose history was as follows : —

Joan Campbell, aged 29, admitted to the Royal Infirmary, November 26, 1863.

About six and a half years ago, patient began to suffer from bearing^down

Eiins. Six months previously she had eiven birth to a female child. The
hour was difficult and tedious — the shoulder presented, and turning was
resorted to. Ten months after the birth of the child, her doctor discovered
that the cervix of the uterus protruded beyond the vulva. Some kind of
instrument was introduced into the vagina, for the purpose of keeping the
uterus in its position, — it having fallen down somewhat, — ^but was withdrawn
two days subsequentlv in consequence of inflammation attacking the uterus.

During the three following years patient suffered from repeated attacks of a
similar nature. For five weeks after the birth of her child patient had a con-
stant discharge of blood from the womb. Four weeks after tne bleeding ceased
she menstruated, and continued to alter regularly everv month for about the
space of one year. Although she had nursed her child for the ten months
previous to the first inflammatory attack, it is worthy of notice that she men-
struated regularly every month duruig that period. For the last five vears
patient has menstruated every two or three weeks. During this period, and
especially when '* poorly,'* she suffered from considerable pain in the right
groin — so much so at times, that the weight of her clothes was unbearable.

On admission, the general health was good. The uterus was somewhat pro-
lapsed and the cervix elongated.

On December 22, Professor Simpson pulled the cervix outside the labii,
applied the ^craseur to the cervix, and amputated a portion about one inch in
length. There was almost no bleeding.

Patient slept well after the operation, and never had a bad symptom, with
the exception that on the day after the operation she required to have the
catheter passed, to draw off her water. She made a good recovery, and was
dismissed cured on the 12th of January.

The operation in these cases was performed by transfixing the portion to be
removed by one or two long needles, and passing the cham of the ^craseur
over above them. There was no hsemorrhage after the operation.

Dr Thornaa Balfour had a patient under his care where the cervix was con-
siderably enlarged. The patient was only sixteen years of age, and the pro-
minent symptom was great menorrha^a. Under local astringents and general

1864.] 0B8TETBICAJ. 80CIBTT OF EDINBURGH. 73

tODicB the uenorrhagia had greatly decreased, bat the cervix remained in much
the same condition.

U. CASE OF PUERPERAL TETANUS.

The following notes, by />. MaegreggcTy Esq., were commonicated by Dr
M*Cowan:—

Mrs R., SBt. 27, the wife of a boot-closer, and the mother of three childreo,
miscarried when about three months gone with her fourth.

She could assign no particular cause for it, unless it was due to lifting a
heavy tub a day or two before.

On the mommg of the 9th January (1864), she felt slight {^ains in the lower
part of the abdomen — resembling labour pains, — and soon noticed that she was
losinff blood from the vagina.

Thmking that she was again " unwell,** and not pregnant at all, she paid no
attention to the bleeding tmit day. But on the morning of the 10th, the pains,
which were hitherto trifling, became more severe, and the haemorrhage increased,
when several la^ clots, followed by a considerable quantit^r of fluid blood,
were expelled. She now felt much relieved, as the pains diminished in severity
as well as in frequency.

Feeling so much better, she did not think it necessary to call in medical
assistance till late on the night of the 10th, when she was getting faint and
giddy ; for the hemorrhage still coutinned although the piuns had decreased
since the raoniing. I was sent for about 10 p.m., when I found her very psJe
and blanched, rulse very feeble, small and quick, and so weak that she could
hardly turn in bed. Findmg also that she was still losing blood, I immediately
applied cold-water cloths to the lower part of the abdomen, laid her head low,
and got the temperature of the apartment lowered. After continuing the cold
cloths a little time, the hnmorrhage somewhat abated, but did not cease entirely.
I then plumed the vagina, ordered her a little wine at stated intervals, and
perfect quietness; and left her for the night. Next day, the 11th, I saw her
again, removed the plo^, and, the bleeding not recurring, I ordered the con-
tinuance of the wine, with beef-tea. On the 12th, she seemed much better;
no bleeding had recurred; colour was showing in the cheeks and lips. I
ordered fifteen drops of the tinctura fer. mur. thrice daily, with nourishing diet.

She continued to make steady progress till the 16th, and feeling much better
that day, she got out of bed in the evening, — contrary to my advice, however,
as I still thought her too weak to assume the erect posture.

On the morning of the 17th, she felt some stiffness about the neck, but not
sufficient to alarm her. She aeain got out of bed during the day, and remained
up most of the evening. Whue partaking of food she remarked that she had
some difficulty in swaUowing the solid part of it. During that night, however,
she was awakened by diffictdty of breathing and severe spasmodic contractions
of the muscles of the neck and the lower jaw, which compelled her to sit up in
bed and get supported by pillows. About noon on the 18th, I was again sent
for (I did not see her on the 17th), when I found her sitting in bed, bent
forwards (she could not lean back), very alarmed and anxious looking, and her
teeth so firmly clenched that she could not part them. She was quite conscious,
and was able to answer questions put to her. I ordered hot poultices to the
neck and lower jaw, with a mixture of sol. morph. mur., canab. indica, and
chloric eth., internally. After a little time the poultices so far relieved her
that she was able to separate her teeth somewhat : very little, however, —
enough to admit the point of a teaspoon only. I endeavoured to administer a
dose of the medicine as above, and did get it into the mouth ; but as soon as
she attempted to swallow it, a severe spasmodic action of the muscles of the
pharynx and larynx immediately followed, threatening suffocation. She sprang
forwards with an expression of agony and terror, and seized the bedclothes for
support. The suffering was so severe that she would not be persuaded to txy
another drop. The same mixture was then ordered to be given by enema,
with beef-tea and wine. She had tasted no food that day. The enema was

VOL. X.— NO. I. K

74 KEDICAL NEWei [JULT

given, and repeated after a lapse of a couple of hours, with no apparent diminu-
tion of the symptoms. As the poultices at least soothed her, they were
continued that night. On the morning of the 19th, I found her no better ; but
the strength diminished. She was stiU sitting up in bed supported by pillows ;
for although there were no very urgent .symptoms of dyspncea, yet she could
not suffer the recumbent position. The enemata of beer- tea and wine were
continued at intervals, but soon began to be rejected.

I was obliged to leave her then, but soon returned, prepared to give her
chloroform by inhalation. I found, however, that she was sinking very
rapidly, and already so weak, and bathed in cold clammy perspiration that it
would be absurd to attempt it. She died at 6 p.m., two hours after my visit,
without a struggle.

The only thmg I now regret is, not having exhibited chloroform sooner, when
there was a chance of doing good.

Dr PatUson thought, from the account just read, that the abortion had not
been expelled ; and the best treatment under the circumstances would have
been, if possible, to have emptied the uterus, since that organ was evidently
the source of irritation.

III. CASES OF ARRESTED DEVELOPMENT OF THE 17TERUB.

Dr Alex. R, Simpson showed a preparation of an imperfectly developed
uterus, and made a communication, which will appeal in a future number of
the Journal.

MEETING vn.
9iA March, 1864.— Dr Graham Weir, Preddant, in the Chaur.

I. TANGLE-TENTS.

Frofenor Simpson reminded the Society that a variety of substances had
been used as tents, passed into the os and cervix uteri with the view of dilat-
ing the canal, so as to get access to the interior of the uterus for diagnostic
and therapeutic purposes. In olden times they had made use of the dried
gentian root, which was described by Cooke in nis " Marrow of Surgery,** and
by various other writers, as the best substance for this purpose. His friend,
Dr Horatio Storrer of Boston, had a few years a^o proposed tents made of the
bark of the slippery elm. What he (Prof. S.) naa long been in the habit of
using, as they were all aware, was a piece of sponge, which was brought into
the proper shape by dipping it in a solution of gum, compressing it into a
conical form by a piece of wnip-cord wound round it, and then d^ing it in
an oven. Dr Braithwaite had afterwards pointed out to him that the ^um was
unnecessary, for if the sponge were compressed after being simply dipped in
hot water, it retained its form on being dried, and all that was tnen needed
was to dip it in a mixture of wax and lard, to make for it an external coating,
to fiftcilitate its introduction into the uterine cavity. Latterly, Dr Sloan of Ayr
has proposed as a substitute for compressed sponge the driea stems of the sea-
tangle (Laminaria digikUa), which is thrown up in such abundance along all
our coasts. In its dried and collapsed condition it could be cut or filed down
to any shape and size, and when placed in water, or brought into contact with
the fluids of the uterus, it would swell up to such a degree that a piece of tangle
would expand in the course of a few hours to about three times its original
thickness. For some time past he (Prof. Simpson) had used the tan&le-tents,
and had found them to fulfil all the indications of a uterine tent so admirably,
that he believed they would ultimately replace the sponge and other substances
hitherto employed. He had brought with him some specimens of tangle-tents
made by Krohne in London, that the Fellows might have an opportunity of
seeing them ; and also some bougies for the male urethra, and for the
lachrymal ducts, — for its application was not restricted to the uterus, but
might come into play for the dilatation of any kind of constricted canal. The
tangle did not perhaps distend to such an extent as the sponge, but it exerted
much greater power of dilatation ; for whilst a piece of sponge, which on
withdrawal seemed to be of the thickness of the thumb, was found to have

18e4.] 0B8TETBICAL SOCIETY OF EDINBURGH. 75

left a CAoal which would barely admit the little finger, the canal left on the
remoral of a piece of tangle wa« always found to correspond throughout in
measurement with the full size of the expanded tent. The tangle had a
further advantage over the sponge in that it does not absorb — or form rather —
those foetid fluias with which a sponge always seems to get charged when left
long in the genital canals. The tangle-tent, moreover, was more easy of
introduction, because of its greater soudity and stiffness ; and though some-
times he had found a little trouble in introducing it in consequence of its
becoming slippery whenever it got moistened, yet then he had succeeded in
passing it with the aid of a pair of long dressing-forceps, or, better still, of
an old porte-aiguille. Then the greater abundance and consequent cheapness
of the tangle presented an additional advantage ; and if we wanted to be very
economicu, the same tent might be used a second time after being simply
dried, — a process that would be attended with much danger if we had to do
with a piece of sponge that had once been impregnated with deleterious dis-
charges. The tangle did not dilate quite so rapidly, perhaps, as the sponge ;
but tne expansion was effected with sufficient speed for all ordinary purposes.
He showea a tangle-tent expanded to about the thickness of a little nnger,
which he had removed from a patient on his way to the meeting at eight
o^dock, and which had been introduced in the forenoon. In its dry, undilated
condition, it might have been about the thickness of a crow-qudl. On the
whole, he thought that tangle-tents would come to replace the others in use,
because they were, — 1st, cheaper in price; 2d, more easy of introduction;
3(/, more potent as dilators ; and, 4M, cleanlier in their use.

Dr Keuler remarked that he had lately been using the tangle-tents, and had
found them answer the purpose admirably; he felt sure they would soon
supersede the sponge-tents in common use. He found that after drying them
the^.were useful a second time. There was a difficulty in introducmg them,
which he had endeavoured to overcome hj the use ot a pair of long curved
forceps, upon which, however, he was making some improvements, and would
exhibit them at the next meeting of the Society. He had used tangle before
as bougies, but it did not occur to him to dry it for the purpose of re-
expansion.

Lh A. R, Simpson bad found this kind of tents verjr apt to slip out. A

Siece of sponge placed below them held them in position till they began to
ilate, but probably a piece of worsted wound round the point would be suffi-
cient to overcome the difficulty.

Dr Graham Weir thought that one of the greatest advantages of the tangle
over the sponge tents, and which had been referred to by Professor Simpson,
was their equal dilatation.; the sponge, as every one knew, often did not dilate
at the very part it was most required.

Professor Simpson incidentally remarked that the use in Switzerland, durmg
the seventeenth and eighteenth centuries, of sponge and sea-tangle in goitre
had been much ridiculed by some physicians ; but the problem of the utility
was at once solved when, above half a century ago, iodine was found to cure
goitre, and sea-weeds were found to contain iodine. Dr Gillis has recorded
that he had found the natives of South America, far inland, using what were
called goitre-sticks, which were nothing but sea-tangle. It was remarkable
how two nations at so great a distance should thus both discover the use of
iodine in goitre.

n. CASE OF P0LTPU8 UTERI, WITH PREPARATION.

Dr T. A. O. BaXfowr gave the following history of this case : —
The patient had suffered from bad health till menstruation was fully estab-
lished. She afterwards suffered much from menorrhagia, losing at those times
large quantities of clotted blood. She was given tonics and wine ; her health
improved, but the menorrhagia continued. There was in her history an illus-
tration of the effect of mental emotion over the functions of the body. She
turned unwell on the SOth June, but the menses suddenly disappeared on the
2d July — her marriage-day. She continued to suffer from menorrhagia till

76 MEDICAL NEWS. [JULT

the end of January last, when Dr Balfour wan suddenly called to her. He
found her extremely exhausted, and fainting from loss of blood, over which
ergot and other remedies had no effect. On making a vaginal examination,
the polypus, which he showed, was felt protruding through the os. He re-
moved it by the ^craseur, and since that tune there had been no return of the
menorrhagia. He had had occasion again to examine the patient, three weeks
after, and felt the stalk of the polypus still nnabsorbed. There was no history
at any time of the expulsion ot the polypus.

ni. CASE OF SUDDEN DEATH TEN DAYS AFTER LABOUR.

Dr T. A, O. Balfour gave the following history of this case : —
The patient, 26 years of age. was confined of her second child. The labour
was natural, and she did well tor nine days. On the morning of the tenth day
she was getting over the bed, when she seemed to fieiint, and suddenly died. She
was extremely anaemic, and suffered from shortness of breath. At the post-
mortem examination, the liver and heart were found to be fatty. This was the
only cause of death that could be discovered. The wonder was that the death
did not occur during the severe pains of labour.

PtofesBor Simpson was inclined to regard the case as one of embolism. The
history was exactly that of many cases which had been recorded, where a plug
had been discovered in the pulmonary artery. The patient progresses favour-
ably, till, upon some slight exertion, she suddenly falls back, dead. A plug in
one of the large veins of the uterus gets disengaged, and is carried on by the
current of the circulation till arrested in the puunonary artery.

REPORT OF THE TRIAL OP GEORGE BRYCE FOR MURDER,
High Court of Justiciary, Edinburgh, dOiA and 31^ May 1864.
With Remarks by Hugh Cowan, Advocate.
In this trial the defence of insanity, although urged with great ingenuity and
earnestness, was disregarded by the jury, who, after a lengthened trial, returned
a verdict of guilty, coupled with a recommendation to mercy on account of the
low mental organization of the prisoner. The grounds upon which the plea of
insanity was in this case rested appear to me to be of a very inconclusive
nature. The medical witnesses for the defence both founded strongly upon the
opinion they had formed that the prisoner was a person of low mental oigani-
zation, and they based then: opinion of his being at the time of the murder
insane, upon the alleged delusion under which he was said to labour, that the
person whom he murdered had at one time called him a drunken blackguard.
Their opinion, they stated, was confirmed by the circumstance which they held
to be proved that the prisoner had no recollection of his having done the deed.
In regard to the first of these, it was well remarked by the Solicitor-General,
in his speech to the jury, that it was just persons of low mental organisation
that would commit murder, and who required to be restrained from committing
it by the fear of punishment. As to the second, the medical gentlemen were
both obliged to admit that, if it were true that the unfortunate deceased had
called the prisoner a drunken blackguard, there would cease to be any delusion
in the matter. The evidence on this point was conflicting, — it rather appeared
that she had not said so to the prisoner, but it clearly appeared that she enter-
tained this opinion regarding him, and that she had good reason for it. But,
even if she had never said so, it would be a most serious matter for society if
any man who, with or without foundation, conceives that another has miscalled
him, should be allowed with impunity to cut that other's throat, and then say
be had an insane delusion that the other called him a drunken blackguard.
It is an utter mistake to say that this is such a delusion entering into the act

1864.] TBIAL OF G£OKG£ BRTGE FOR UUBDEB. 77

as will excuse a crime. To exempt from the ponishment of crime, the deln-
sion must either be of such a nature that if it were not a delusion, but true, the
man would be justified in acting as he is proved to have acted under the
alleged delusion ; or it must be of such a nature as radically to change the
whole character of the surrounding circumstances. Examples of such delusion
may be found in the cases of Moyatos and Amot quoted below, where the man
believed his own life to be in danger, or where a man believes himself to be a
deity, or that it is a devil or a wild beast that he is attacking. Now« even
admitting that Jeanie Seaton never called the prisoner a drunken blackguardy
it was only a mistaken idea of the prisoner's that she did so. He was conscious
in himself how deserved the appellation was, and it was this that made the
unkind word rankle in his bosom. It was his unhappy hatred of this woman
that wrought the change in the prisoner which was noticed ever after that 10th
of March 1863 when he so behaved himself as to alienate the affections of
Isabella Brown — Jeanie's neighbour. Rightly or wrongly, he took up the idea
that Jeanie had something to do with this, and his heart conceived enmity
against her. But it is only a man of a depraved and wicked moral nature, who
could for so trifling an offence against him, if his idea in regard to her had been
true, have conceived the deadly enmity and hatred which the prisoner did
against Jeanie Seaton. No man whose mind is rightly constituted would have
done the act committed by the prisoner. But what is it that makes the differ*
ence between a murderer and other men ? Is it not just this, that while he
allows the evil and wicked passions of his bad heart to obtain the mastery over
him, and hurry him into crime, theff learn to control these evil passions and to
cast them from them as abhorrent to the better nature which God has planted
within them. A good man, imbued with Christian virtue, learns so far to over-
come these bad feelings as even to love his enemies, and do good to those who
hate him. But there are multitudes of bad men in the world who would
willingly gratify their hatred of others by committing murder if it were not for
a wholesome dread of its punishment. There seems to be only this distinction
between their case and that of Bryce, that he was not deterred from wreaking
his vengeance on his poor victim by this fear. And it will hardly recommend
the plea of bsanity to the &vourable consideration of the uninitiated, if the
only practical difference which insanity makes upon a man is that it frees him
from the dread of punishment. That insanity does not really do so is well
known to those who are engaged in the practical management of asylums, the
inmates of which are capable not only of being deterred from what is against
the rules by the fear of punishment, but of being induced to do what is right
by the hope of reward.

The alleged delusion in Bryce*s case comes then only to be an explanation
of the motive of the crime. It would be curious and interesting to take a
survey of the murders during the past half century and see how many of them
were actuated by similar hatreds taken up from equally absurd grounds. It
has been said that there can be no adequate motive for murder, and in a certain
sense this is true, for whea the motive is adequate the act ceases to be a crime.
We never can justify a murder, but we may often discover the motive which
has impelled the murderer to his crime ; and when a motive to the commission
of the crime is discovered in a case of doubtful evidence, it has hitherto been
supposed only to furnish an explanation of the crime, and to add one to the
other links in the chain of evidence against the prisoner. It was reserved for
the ingenuity of the prisoner's counsel in this case, to turn the discovery of

78 MEDICAL NEWS. [JULT

the actuating motire, where the evidence without it was clear and conclusive,
into a proof of the murderer*s insanity. The last circumstance founded on as
showing the prisoner*s insanity is his total want of recollection of the crime.
The circumstances tending to show that this was pretended are forcibly pointed
out in the speech of the Lord Justice-General. It is difficult to believe that a
man who recollects the minutest circumstances up to the moment of the com-
mission of a crime can be speaking the truth when he says that from that point
his memory is a blank. More especially u this difficult in a case where the
crime is said to be committed under a delusion entering into the act. The
analogy of other cases leads us to expect that the gratification of vengeance for
the supposed wrong would fix the act on the man^s memory; and that it
remained on this man*s memory is shown by the answer which he made to the
policeman who charged him with the murder — She's cheap of what she's got —
an observation which shows a dbtinct recollection of the deed which he had
done. It is understood also that before his execution Bryce confessed that, in
the statement that he had no recollection whatever of the murder, he was not
speaking the truth.

The plea of insanity in bar of trial has lately been stated in two cases— both
trials for murder in the High Court of Justiciary. The one of these was the
trial of Joannb Manolatos or Jean Moyatos, on 6th April last, for the murder,
on board the British barque Pontiac, of Robert Campbell, a sailor dn board
the same ship with him. He was also accused of a murderous assault on
another sailor named George Williams. From the evidence it appeared that
the prisoner laboured under the following insane delusion : — He had sailed from
Liverpool in a vessel called the Atahualpa to Valparaiso, where it was wrecked.
Shipping on board the Pontiac he sailed to Callao, where Campbell and
Williams were shipped, and the Pontiac sailed for Liverpool. The delusion
under which the prisoner laboured was that Campbell and Williams were hired
by the captain of the Atahualpa to throw him overboard. Being possessed
with this idea, which was proved to have no foundation in fact, he attacked
the two sailors with his knife, causing the death of one, and seriously injuring
the other. The other trial was that of Thomas Amot, on 6th June laist, for
the murder of David Paton, a little boy, on the Stirling road, near Alloa. The
prisoner was proved to be labouring under various delusions, the principal of
which was that he was the subject of unremitting persecution on the part of
the Free Church, and that the boy, whom he had never seen before, and against
whom he had no enmity, was an emissary of the church — that he felt himself
impelled to strike an unexpected blow against his enemies, and so killed the
boy as a part of the general system. In this case the Lord Justice-General
intimated that the Court had no difficulty in holding the insanity proved.
Now, in both of these cases there was delusion entering into the act charged.
In the one there was a delusion which might be said to justify the act of the
prisoner. He was in bodily fear. His life was m danger, and he acted in self-
defence. In the other there was a pervading delusion of such a nature as
altered the whole circumstances about him so thoroughly that it is impossible
for a sane man to imagine under what delusive idea at the moment the man
acted. Both cases afford an instructive contrast to the case of Bryce, showing
what the delusions are which the law regards as proof of insanity.

The prisoner George Bryce was placed at the bar charged with the crime of
murder, in so far as on Saturday the 16th day of April 1864, within the house
or yilla, near the village of Ratho, occupied by Robert Tod, mill-master and

1864.] TRIAL OF GEORGE BRTCE FOR MURDER. 79

grain-roerchant, he did, wickedly and feloniously, attack and assault Jane
Watt or Jane Seaton, now deceaaed, then a servant of the said Robert Tod,
and did violently take hold of her and force her down, and get above her, and
press upon her, and seize her by the throat, and did kick her, and otherwise
maltreat and abuse her; and the said Jane Watt or Jane Seaton having fled
from him, he did pursue her, and having overtaken her at a short distance from
the foresaid house or villa, and near an old building called the Old Distillery,
he did there wickedly and feloniously attack and assault the said Jane Watt
or Jane Seaton, and did throw or knock her down, and did with a razor, or
other sharp instrument, cut and wound her severely on or near the neck, by all
which the said Jane Watt or Jane Seaton was mortally wounded and injured,
and in consequence inmiediately or soon thereafter died, and was thus murdered
by him.

The counsel for the Crown were the Solicitor- General (Young) and Mr
Adam Gifford, advocate-depute; the counsel for the prisoner were Messrs
Patrick Eraser and Charles Scott, advocates.

On the motion of the counsel for the prisoner, and of consent of the Crown,
the medical witnesses were allowed to remain in Court to hear the evidence
adduced as to the facts of the case. The pannel pled generally not guilty, and
specially that at the time when the alleged crime was committed he was insane
and labouring under insane delusions.

The general evidence led in support of the charge established the following
circumstances:— On Friday night, the 15th of April, the prisoner, who had
not slept at home the night before, was put to bed by his father, being over-
come either with drink or sleep.^ He rose about six on Saturday morning, and
loitered about the yard at his father's house, which is in the village of Ratho,
for nearly an hour.^ Leaving that about seven he crossed the bridge over the
canal, going along the road past the villa occupied by Mr Tod.' To his uncle,
who met him on the road, and asked where he was going, he replied, *^ To the
station," the road being that which led to the railway station. He said to a
baker's boy, whom he passed on the road, .after passing Mr Tod's gate,
" Fine morning, batchie."' Leaping the wall of the villa he accosted Isabella
Brown, who was at the back door, asking her where was Jeanie.^ Getting no
answer he went in at the back door and found his way to the nursery, where
he found the deceased and immediately attacked her, throwing her down and
struggling with her.' She was rescued by her mistress, who called to her to
run away. She did so but the prisoner followed, leaping the wall which sepa-
rated the villa from the road, and having overtaken her he again threw her
down, placing his knees upon her breast, and with a razor, which he had, cut
her throat.^ The deceased was carried into a neighbouring house and laid on a
mattress on the floor. The wound in her throat was bleeding dreadfully, but
ahe asked for a drink of water ; but, when it was brought, she was unable to
drink it, and she never spoke again, dying almost immediately.^ The prisoner,
on leaving the deceased, endeavoured to make his escape, but was followed

1 John Bryoe, his fkther. > John Weston, his nncle. * Adam Lawrie^ ^ Isabella Brovn.

B Isabella Brown, Mrs Tod, Catherine Binnie, and Margaret Gibson.

* John Yoang, Mrs Henderson, Mrs Binnie.

7 The wonnd is thus described in the medical report prepared b7 Dr Littleiohn and Dr Cr^g :—
There was a deep gash on the left side of the neck, about its middle, of an elliptical shape, measuring
Ihlly five inches in length; its greatest breadth was two inches ; and its depth was, at its maximum,

three inches, but both behind and in fh>nt it became superficial There was an aperture, tally

an inch long, in the external Jugular yein Both sides of the neck were carefml7 dissected,

when it was ascertained that the Jueular vein was the onl7 important vessel wounded, and that the
carotid of the left side, and the oesophagus, and the trachea had escaped ii\)ur7.

80 MEDICAL NEWS. [jULY

and Becuied. In the course of the chace he twice threatened to take his own
life with the nusor, and he tried to nse it against those who followed him.
When apprehended he was told that he had cut a woman's neck, to which he
replied) She's cheap of what she's got ; adding, that "he would rather go to
Edinburgh than Ratho, as he did not like to pass his father's house, and among
the people of his acquaintance. In his judicial declaration, emitted a few hours
after the murder, the prisoner stated that he remembered going to Mr Tod's
house that morning, but that he did not recollect of seeing any person at the
house except Isabella Brown ; that he had no recollection of seeing Jane Seaton,
or of doing anything to her. He recognised his cap, which he had left in the
nursery, when shown him, and also his racor ; but denied having had the razor
with him when he went to Mr Tod's house.^

The only question involved in the case was in regard to the prisoner's
sanity. The following is a full note of those parts of the evidence of each
witness which bore upon this question .- —

Mrs Tod, — I never saw the prisoner do anything or heard him say anything
that led me to suppose he was insane. Croaa-examined bjf Mr Eraser. — ^I have
never had any lengthened conversation with the prisoner. I have often met
him on the road, and almost always nodded to him. He always returned my
nod. I could not say whether he was a shy man or a sulky man. I fonned
the impression that he was either the one or the other from his look and
demeanour. He was always very obliging and was very quiet. About a year
a^o I spoke to Jeanie Seaton about a notion he had got that she had called
hun a arunken blackguard. I said, it seems Qeoree Bryce is very angry at
you for having said he drinks ; you needn't be auaid, for if he says an ill
word to you, you have onlv to tell me, and Mr Tod will put a stop to that.
She gave a little smile ana said. The stranee thing is that I never said such
a thing. When he gazed at me when I had hold of his wrist I cannot say he
recognised me. He had a bold, brutal look.

John Young^ ploughman, and Mrs Hendersoti, both of whom had known the
prisoner, deponed, That thepr had never seen or heard him do or say anything
which led them to regard him as insane or different from other people.

James Mackay^ constable, in cross-examination,— Vtv&oji&c usea to be riotous
at his father's house sometimes, but only riotous so &r as I knew. After some
of these scenes in his &ther's house he used to say when he was sober that he
had no recollection of what had taken place. It appeared to me that there was
a sort of a " want" about him. To the Lord JiLsUce- (general, — He appeared to be
sort of silly, easilv advised and easily led away. He was easily led to go and
drink with comrades. I never saw him doing anything oiUrS when he was sober.

Robert Davidson, blacksmith. — I am about the same age as the prisoner, and
was at school with him. I was pretty intimate with him, both at school and
since. I never saw or heard of anything in his conduct that would have led me
to suppose that he was insane, nor was there any such notion about the place.

Dr James Craig, Ratho. — ^I have known the prisoner all his life. I fre«
quently saw him soing about doing his work ; but I was not aware, till the
month of October last, that he was addicted to drink. I then saw him in the
police-office, where he was violent. I never saw anything in his conduct to
lead me to suppose that he was wrong in his mind, or I would have considered
it my duty to mform his father and the authorities concerning it. At that
time liis father called upon me regarding his son's habits, and the difficulty he
had in managing him when he was the worse of drink. When I saw him in
the police-office last October he was perfectly rational. I gave him advice
about refraining from drink. After that occasion I saw him going about as

1 It iB underatood that before his exeeatfon the prieoner ooci<iBSBed that he had earried the rasor
with him for a fDrtnlght, with the riew of eommittlng the murder; that, haring failed to And an
opportunity at night, he had gone when he knew Mr Tod waa from home; and that be was quite
aware of having committed the murder on that morning.

1664.] TUIAL OF GEOBGE BRTCE FOR MUBDER. 81

Qstud, and I never was consulted professionally since then. I have never seen
anything about him that would lead me to doubt his sanity. In the evidence
to-day 1 have heard nothing that would lead roe to believe he was insane.
Cros^-eoMmined, — I have spoken to the accused only twice. In October, when
I saw him in the police-office, he was perfectly sober, although somewhat
flushed. He said he did not recollect anvthing that had taken place in his
&ther*s house, and I told him ffenerallv wnat had taken place. After [ had
spoken to him of the danger he ran by drinking, and when I spoke of his
mother, he began to cry. 1 saw him next morning m the police-office, when he
still denied afl recollection of what he had done when in drink. I could not,
however, reconcile myself that he was telling truth. After his apprehension I
again saw him in the police-office, when he again exhibited a defect of memory.
I asked him what he nad been about that morning, but he gave me no answer.
I asked him if he had been at Mr Tod*s, but he denied having been there. He
likewise denied having that morning seen either Mrs Tod or Jane Seaton. I
believed that he was not then aware of her death. I then asked him if he
recollected when he had last seen me, when he answered " Yesterday." At
that time I had forgot that I had seen him on the previous day, but this
brought to m^ recollection that I had passed him while driving along the road.
I then asked if he remembered the aa vices I had given him in October last,
and he said he did. I also asked him why he did not follow them, but he save
no answer. I then asked him where he had been all morning, and he told me
he had been in the plantation. His answers were quite rational, and my
onestions were with the view of satisfyine mvself as to his state of mindf.
Re-examined, — I perfectly satisfied myself tnat he was quite sober, and quite
intelligible. I knew Jane Seaton perfectly well.

DrlAtU^ohnj police surgeon. — I saw the prisoner on the day of the murder.
He was quite sooer and rational. I asked him if he was aware that to kill
another was a crime. He said he was. I also asked him if he knew people
were punished for so doin^, and he nodded acquiescence. Mv object in puttmg
these questions was to satisfy the Sheriff as to the state of the prisT)ner^s mind
before ne was examined. I was satisfied that he was in his sound and sober
senses. In the evidence to-day I have heard nothing stated which leads me
to believe otherwise. Crose-examined, — I never saw him before that day, and
I have not seen him since. My conclusion as to his soundness of mind was
from the answers he gave to the questions put to him, and from watching his
demeanour.

WilUam Btfint!0,jun., joiner, Ratho. — Between seven and eight on the morn-
ing on which Jane Seaton was killed, I saw the prisoner near the canal bridge.
He asked me about a house we were erecting in Dr Fowler*s garden, and I gave
him the desired information. He appeared to be ouite sober and rational. I
parted with him to the north side of the bridge, and he went in the direction of
Mr Tod*s villa. I heard of the murder about ten or fifteen minutes afterwards,
when I went to my father^s house, and- 1 saw the dead body. I was present
when the prisoner was brought in to see the body. I yrBB at school with the
prisoner, and have known him ever since. There was nothing in his conduct
when at school, or since, that led me to believe that he was insane. Such a
thought never occurred to me. On the Saturday rooming of the rourder he
had on his light shoes, and did not seem as if he was going to work. Crais-
esoaminedby Mr Scott. — ^When we told him it was a photographic house we were
erecting at Dr Fowler*s, he smiled. He was a man who seldom spoke much.

The following witnesses were examined for the defence : —

Jamee Wight, formerly constable in the Edinburgh Police at Ratho, and now
market officer in Leith. — While at Hat ho I knew the prisoner well. I had
occasion to notice his state of mind on various occasions, and my opinion is
that he had a ** want." It showed itself when I said, ** It's a fine morning,"
when he would reply, " YouVe a funny ane." If you asked him a question, tie
would go on with a few words, and then go off into anotlier subject, as if for-
getting what he had been talking about. His talk was rambling, and in the

VOL. X.— NO. I. L

82 MEDICAL NEWS. [jULY

course of one conversation he would refer to many subjects. On one occasion,
in the back end of 1857, there were two of the late Lord Morton's footmen
and a gamekeeper along with him, when one or other tapped him gently on
the shoulder, and said he was wrong in some particular statement. Bryce
then drew a clasp-knife from his pocket, and said he would stab any man who
said he was wrong. Before that they had all been laughing. When he had
the knife in his hand he seemed to be very wild. I went between the prisoner
and the footmen, ordered him to give the knife to me, and took him home.
He went home quite peaceably. I went with him to his father's house, when
he went to bed without speaking to any one, although his father and mother
were in the kitchen. He was perfectly sober. I told his father that if he did
not keep a watch over him he would do something that he would repent of. I
did not then suggest that he should be taken charge of. I saw the prisoner
next day, and asked him what he meant by drawing a knife to stab anvbody.
He denied all knowledge of it, and said I was " shamming with him," ana " fun-
ning with him." He was sober. At that time I thought he was ** shamming "
with me — that he was pretending not to remember. After that I asked several

Seople about him, and they said he was thoughtless, and did not mind what he
id. I remember one occasion since then having been in his father's house,
when his father was ordering him out of the house, for something he had done.
I left along with him. Two days afterwards, when I was passing, his father
and mother asked me if I had seen or heard an3rthing of him, as thev had no
intelligence of him since he left. I said I had not seen him. We then
searched the straw and hay in the stable, and after turning it over for some
time we found the prisoner lying under it, nearlv exhausted. When lifted up
be said he was only taking a rest to himself. At his side a knife was picked
up. On being asked by a man named Clark what he was going to do with the
knife, he said he was going to cut his throat with it. He then got some food,
was taken into the house, and put to bed. Very frequently he wandered away
from home for days. On these occasions his father and mother came and
asked me about him. He was absent once about nine days. I once saw him
walking to and fro in Norton Wood, when I asked him what he was doing
there. He said he was " taking a walk to himself." I asked him to go home
to his father's with me, which he did. He looked worn-out and fatigued, but
was sober. I never saw him much the worse of drink. In driving his horse
and cart alons the road, if anybody spoke to him he would allow them to go
away along the road by themselves. I have on several occasions heard him
speaking to himself, but I never could make out distinctly what he said.
When ordered by either his father or roe to do anything, he would do it at
once. When stationed at Portobello, in 1861, I met Bryce. Before that, I
received a letter from his father, stating that he had been absent, and asking
me, if I saw him, to send him home. I also got a message from his father,
through the drayman, with a similar request. 1 met Bryce after that, on the
street in Portobello. He came from the direction of Musselburgh, and seemed
fatigued with travelling. I asked him where he had been, and he replied he
had been taking a walk. I took him to my house, and save him dinner, which
he ate ravenously. I afterwards took him to Edinburgh, and saw him off with
the Ratho coach. On that occasion he never referred to his absence from
home. I have heard the boys in Ratho say of him, " Here comes daft Geordie
Bryce." When asked by the voung lads of the village to "stand* treat," he
would take them into a public-house, and spend all his money with them.

On crois-examinathnf the witness admitted that he had left the Edinburgh
Police to avoid being dismissed ; tliat, having afterwards got into the Police
force at Leith, he had been dismissed for giving prisoners drink on their way
to gaol ; that, when stationed at Ratho, he frequently dropped into the prisoner s
father's house, in passine, which was a public-house ; and that when the prisoner
had left their house, and he went to look for him, at the mother's request, it
was usually in a public-house that he found him.

Jamea MeikU, station-master, Gogar. — ^I have known the prisoner for eight
years. He often came about the station, on business for his father. I had

1864.] TRIAL OF QEOBGE BRTCE FOR MURDER. 83

occasion frequently to converse with him. He appeared to have an impedi-
ment in his speech. He did not enter mach into conversation. I have seen
him come into the station, look about him, and leave without speaking. On
other occasions I have seen him come into the station in a fighting attitude —
squaring with his fists. I have seen him come forward, ana pull me by the
whiskers, and say, " Gome along with me ; yon are my prisoner ; what^s this
youVe been about, sir ? " and so on. At times I humoured him ; at other
times I could not afford to be bothered with him ; and sometimes I had to
push him away. On these occasions he went away laughing, and looked half-
witted. He often saluted me in military style, and asked me, " How are
you to-day, Ck>lonel Meikle ? " He generally addressed me as *' Colonel '* or
'* SeiKOftnt." He often asked for my wife, although he knew perfectly well
that I was not married. He often looked unable to find words to express his
thoughts. I would have trusted him with nothing about the railway or the
station. I would not have trusted him with the management of the points. I
gave an express order that he should not be allowed to meddle with them. I
would far sooner have trusted a child of ten vears of age. I always considered
the prisoner " half daft.*' In going about the streets, his mouth was usually
open. I have seen him on the road, about a hundred yards behind his cart,
with his arms crossed, gazing into the air ; and I have come up to within a foot
of him before he observed me. I always found his memory very defective. I
always found that he neglected to execute the orders I gave him for coals.
He was a man of good temper, civil, and obliging. I never saw him under the
influence of drink. There is a weighine-box at tne station, and when I wanted
the prisoner I had only to go there, and I was sure to find him stretched upon
a form — even when there were men about the station with whom he could con-
verse. CroBS-excunined. — ^I do not think that silliness was shown only by him
calline me colonel or sergeant. I thought he made himself too familiar with
me, when, knowing that I was unmarried, he asked kindly for my wife, and
pulled my whiskers. There were other features in his behaviour that con-
vinced me he was not altogether sane — such as sending his horse and cart
round the road by the passenser station — a distance of §00 or 900 yards (the
only way by which they could leave the station) — while he himself went along
the railway line, for a near cut.

John Bryce, father of the prisoner. — The prisoner is one of a family of four-
teen. From his youngest time he was always different from the others. He
made very little progress at school, and I took him away from it. His
peculiarity increased as time went on, but more so within the past few years.
1 noticed a change for the worse upon him about ten years ago, when he joined
the militia. He was enlisted for five years ; and was absent from home at first
for about a year and a-half, and then occasionally for a few weeks at a time.
I set him to drive my carts. He was sometimes at the farm, but very seldom.
1 never tried him at anything else. He was very easily affected by drink ; two
glasses of whisky would have put him mad. When he got the length of three
or four glasses, he generally fell asleep. After this change for the worse came
over him, he continued as before to wander away from home. He was away
often for a week or a fortnight at a time. Sometimes I knew he had no money.
He never told me where he had been ; but I often heard from people who had
seen him wandering about. On these occasions, when he returned he looked
as if he had had nuiny a hungry belly. On Sundays the family took their
meals together in the parlour, but the prisoner preferred to eat by himself in
a comer of the kitchen. About three years ago he appeared to be more
peculiar. He became very restless, both night and day. At that time he
began to drink a good deal ; but a change came over him about a twelvemonth
ago. Since then I think he has been dnnking less, and he has fallen off in his
body. I have often heard him muttering to himself. In October last he had
a fit of drinking, and became very outrageous. I required to get him hand-
cuffed. I asked the policeman to take nim to the station-house, for tofety.
When his hands were shackled, he went to the room, and lifted a razor. It
was taken from him. I went for Dr Craig, and asked him to go and see the

84 MEDICAL NEWS. [JULT

prisoner, because I thought there was something wrong with his mind. I have
Known him leave his horse and cart standing at Ratho Station, and go away,
without returning, for several days. The horse and cart were taken to the
Quarry. I remember of his putting on his black clothes on a Sunday. About
tnree years ago I went with my son-in-law to the stable. My daughter, Mrs
Wilson, told me that Georee had told her he was to do something to himself;
that in ten minutes he would be in eternity. The stable-door was locked. I
assisted Wilson in by the hay-lofl, and he opened the door to me. I saw a
rope in Wilson's hand. We brought away the prisoner, took him home, but
he would not rest, and we tied him to his bed. On one occasion he wished to
ffet into a room for his clothes, to go to Edinburgh, but his mother prevented
him getting them, by lockine the door. He attempted to jump out by the
window, but I seized him and pulled him back. For the past twelve months
his brother William has slept with the prisoner. He was very unwilling to do
so. On the Wednesday night before Jeanie Seaton was killed, the prisoner
did not sleep in my house. On the Thursday morning I found him lying
among some straw in the byre. He did not sleep in my house on the
Thursday night ; but came out of the b^e on the Friday morning. He went
to his work between six and seven on Friday morning. 1 had been from home
on the Friday, but came home between six and seven, and found the prisoner
sitting in the front room. I could not say whether he was sober. He went to
bed l^tween seven and eight o'clock. I rose at two o'clock, and went into his
bedroom. He was lyine with his head towards the foot of the bed. I rose
again at five o'clock, and he was then lying properly. His brother, William,
got up at five, and the prisoner about six o'clock. I saw the prisoner after he
rose, out he said nothing. I did not see him leave the house. Afterwards a
girl, named Isabella Brown, came for me to the house. My wife's maiden
name is Agnes Fraser ; her mother's name was Catherine Nimmo. She had a
brother named John Nimmo, whom I knew. He was not right in his mind.
This John Nimmo's mother's brother's son was a minister, and went to America.
John Nimmo's mother had another brother, who was not right in his mind.

Mt% Bryee^ the mother of the prisoner, deponed to much the same effect.

Mrs WiUcnj examined by Mr Fraeer^ deponed — ^I am a sister of the prisoner.
I remember about three years ago of the prisoner coming into my nouse in
Ratho on Saturday evening. He sat for about half an hour, and when he rose
np to go away, he said that in less than half an hour he would be in eternity.
He then went away, and I went and told my father and mother what he had
said. I told my husband before going to my father, and he went away to my
Other's after I came back.

WUUam WiUon, porter, Ratho Station, deponed — I remember on a Saturday
nighty about three years ago, my wife told me her brother had been at my
house, and said that she was to look for his corpse in half an hour after that.
I went down to the stable below my house. I found the door locked, and I
went in through a hole above the door. I found George Bryce with a rope
round his neck. It was tied to a beam. I took the rope off his neck, and
went for his father, and we took him out by the hole by which I had entered.
We could not get the key. He was in the loft above the stable, and the rope
was tied to the beam ana round his neck. It was just above the hatch-hole.
The rope had a runninc noose upon it. I recollect, about two years i^o, of his
lying two days among hay in the stable-loft. I went to him several times, and
asked him to come into the house. He returned me no answer. He got no
food that I knew of during these two days. Crose-examined by the StwcUor^
General, — I went to the stable because I heard him lock the door. Did it not
sound strange to you that he should tell you to come and look for his body in
half an hour? Yes. It did not look much like an intention to take away his
life? I don't know. You never heard of a suicide giving people notice
to come and look for his body in lialf an hour? No. When you went
to seek him you found him on his legs ? Yes. He was the worse of drink,
but not much. I don't think he had become much addicted to drink by that
time. He got worse afterwards. He was very violent when he got drink.

1864.] TRIAL OF QEOROE BRTCE FOR MURDER. 85

I always noticed him weak in the mind a little. If 70a pat a question to him,
yott never got a right answer from him.

JamiM Dick9on, pointsman, Ratho Station, deponed — I know the prisoner. I
was at school with him, and have known him all his life. I thought he was
deficient in mind. I remember on one occasion that he tamed his horse and
cart right round in the way, when an engine was shunting tracks. He was
deficient in memoiy. His mind appeared to wander. That condition of mind
has grown worse since June 1863. He did not seem to be so tidy about him-
self. He seemed to become more silent. Before that we often walked
together, bat since that rather seldom. He rather shunned my company since
that. Cro89-examined by the SolicUor- General, — I have seen hmi send his horse
away from the station, and did not follow it himself. This was about the
'^daftest** like thing I ever knew him do. He made very many mistakes.
Interrogated, Will you tell us one ? I gave orders to send my trnnk to the
station, and it never came. Who did you tell ? Somebody connected with
the house. Did you speak to the prisoner about it ? Yes, afterwards. Let
us know the biggest mistakes he ever made ? He quarrelled with his father
about putting ^e horse*s bit in its mouth, and although he was wrong he
would not admit it. Will you give us an iuMtance of how he answered one
question by referring to another ? I cannot exactly do that.
, Professor Layeoek, examined by Mr Fraeer, — I am Professor of the Practice
of Medicine in the University of Edinburgh. I have examined the prisoner
twice in prison — on Wednesaay last and ^resterday. I subjected him on both
occasions to minute examinations on a variety of subjects, with a view to ascer-
tain-his mental condition. He has a low type of physical organization. By
the form of the head, the &ce, the jaws, and the mode of articulation, I am able
to tell this. He has a small head, a receding forehead, and superciliary ridges.
His articulation is thick and indistinct, which is often the case among persons
of low organization. I have heard the evidence given to-day, ana I have
examined him, and I do not consider him to be in his sound senses. I do not
think that, on the morning of the murder, he was in his sound senses. [By die
Court. — Does that depend on whether he committed the deed or not ? No.]
I think at the time he was suffering from maniacal excitement. That tit might
come on suddenly and go off suddenly. This is not uncommon in homicidal
mania. It is one of the characteristics of the fit that, after a person comes
out of it, he does not remember what he has done. The prisoner might, at a
subsequent period of the same daj on which he committed the deed, appear
to ordmary observers as quite rational. My conclusion is adduced from the
fiict brought before the Court, that for some years back he has been in a morbid
state, and I conclude that about twelve months ago he began to suffer a further
change of a morbid kind, which we term chronic dementia, and which in similar
cases has been observed to pass into complete dementia. The suddenness of
the attack without any apparent immediate exciting cause also led me to the
conclusion to which I have come. The fact that the symptoms detailed by
the different witnesses indicated that he is of a class to suffer that kind of
madness. The conduct of the man during and after also led me to the same
conclusion, as these cases of homicidal excitement are characterized by the
reckless fury which I found exhibited here. After the deed is done, the
patient has no recollection of it. I think any person in that morbid condition
would be more excited after he had received tne blows on the head from the
umbrella. Homicidal and suicidal mania are very often combined in the same
person. When I saw the prisoner yesterday, he aid not remember that he had
seen me on Wednesday. He did not, I think, pretend he was insane in prison.
I believe he was suffering yesterday from disease of the brain, which impaired
his memory ; and I was quite sure he was not feigning. It is usually held
that a person in whose relations insanity has appeared, is more prone to the
disease than one among whose relations it has not appeared. A very eminent
authority on the subject of insanity says that it is more readily transmitted by
a female than a male relation ; but I will not give an opinion on such a difficult
subject. Oroee'eoKunitted by the SoUdior- General, — ^I assume the fit came upon

86 MEDICAL NEWS. [jULY

the prisoner after he had left his father's house that morning. I assume that
he jumped over the wall and attacked Jeanie. I assume the fit must have
passed off some time between the commission of the deed and when he first
saw Richardson. Assuming that he was running for an hour and a-half, was
the fit on him then ? I am unable to give an opinion. What is the cause of
your inability to give it ? I know of no case similar. Although he had run
for an hour and a- half, I would still think that the fit had gone off about the time
Davidson first saw him. My opinion is, that after he was informed that he had
killed Jeanie, he ran away. I account for his running away through fear, appre-
hension, delusion. I assume there was a delusion on his mind, and that he was,
when the deed was committed, ignorant of having done it. I think the attack
on the girl had to do with his previous enmity, but I do not think the attack
was to gratify the enmity he had against her. He did not know what he was
doing. Is it your opinion that he knew who she was when he was attacking her ?
I have no opinion on that subject. I have no medical opinion to the effect that
he did not know what he was doing. I do not assume that he knew whether
what he was doing was right or wrong. I think he did not know what he was
doing. On previous occasions, when excited, he said he did not know what he
had done, in the whole history of the case, so far as I have heard it, I think
his delusion was that he thought Jeanie called him a drunken fellow. I have
heard of such delusions. I have frequently known cases of insanity with no
jpreater delusion than this. If that was no aelusion, then there was no delusion
in the case at all. He had a delusion, for instance, that his father's horses
were his own. I think he showed that he was an imbecile in memory and
in judgment. He had in some cases no memory at all. What do you mean ?
Can you give us an instance ? I must appeal to the Court. I have been here
since ten o'clock this morning, and I must say that I am perfectly exhausted.
Without referring to the notes which are in the hands of the advocates, it is
impossible for me to give the instances desired, for I took no notes. From the
opmion I have formea of him he was a man liable to brood over a real or sup-
posed wrong. That brooding, and the enmity it would excite, might induce a
fit of maniacal excitement, and a desire to cut his enemy's throat. Ee-exam'
ined by Mr J^Voaer.— The prisoner had a tendency to this fit of maniacal
excitement before he went to Mr Tod's villa on the Saturday morning. His
sleeping in the byre on Thursday evening indicates, I think, a morbid condi-
tion, in forming my opinion to that effect, I have taken into account all the
facts that I have heard proved. It not unfrequently happens that people in
that condition run away and hide themselves. A man may be a lunatic while
ordinary observers think him sane enough — that is very common. It is often
very difficult for experienced men to discover that a man is a lunatic. 220-
craas-examined by this SolicUor- General, — If a lunatic is unconscious of what he
has done, even although that should be wrong, will he attempt to escape ?
No ; he has no reason to escape in that case. And if a lunatic does what he
thinks is quite right, will he still try to make his escape? Did you ever
know of such a case ? I cannot tax my memory at the present moment. You
must remember I have been here for fifteen hours. By the Court.— Ib it a
common thing for a person with suicidal mania to announce beforehand his
intention to kill himself? That is very often the case. There are certain
persons who commit suicide to punish those that offend them ; and where the
affections are wounded that has very often been the case. Do you think that
in the case before us there is anything of that kind? I think so. The
announcing of his intention was an indication of a weak mind. Do you con-
sider that the prisoner is insane now? I think so. He is labouring under
insanity — a form of chronic dementia which will go on increasing ; and I con-
sider the disease incurable.

Dr Robert Ritchie, who, being examined by Mr Eraser, deponed, — I was
formerly resident medical officer at Bethnal House Medical Asylum at London.
I was tnere for three years and seven months. I had on an average about 300
TOtients in that institution. I left it in March 1861, to commence practising in
Edinburgh. I am now physician to the Royal Dispensary, and extra-physician

1864.] TRIAL OF GEORGE BETCE FOR MURDER. 87

to the Sick Chfldren*8 Hospital at Edinburgh. I have examined the prisoner
with the view of examining his state of mind. I saw him three times in jail.
I saw him first on the 18th Ma^, then on 23d May, and then on 25th May. I
have also seen him this mommg. I have also heard the evidence that was
adduced yesterday. I would caU the prisoner a man of low mental organiza-
tion. In my interviews with the prisoner I subjected him to a long examina-
tion. I took him over his whole life so far as I could ascertain from his
description of it. I commenced at his early days, and tried to trace what facts
in his life had made the chief impression on his mind. He gave me to under-
stand that it was his belief that he was sane. [By the Court. — ^I put the ques-
tion. But when I asked whether, when he threatened to commit suicide, he
considered he was sane, he replied that he did not know whether he was then
sane or not.l I could not have come to the conclusion that he was decidedly
insane merely from examining himself with reference to the evidence. I was
particularly struck in the evidence yesterday by the fact that he aopeared to
nave become decidedly worse about three years ago ; and that a further change
had occurred about one year ago. The change that occurred one year ago
was an evidence to my mmd of delusion. His bodily health apparently became
worse about a vear ago, from the evidence yesterday. One great evidence of
that was his sleeplessness ; and I think also his mother stated that he had
evidently become feebler, and there was also an increased restlessness. There
seemed to be a change to the worse. As far as the cerebral state seemed to
be indicated, there seemed to be a change to a melancholy condition, with a
tendency to commit suicide. These symptoms, occurring in the order they
did in this case, I regard as indicative of cerebral disease. I have had occa-
sion to notice this frequently in the patients under my own charee. I would
regard the sleeplessness as an incipient stage of insanity, though it does occur
in all stages. Suicidal mania and homicidal mania are very frequently com-
bined. I would expect the man having a tendency to commit suicide as likely
to have a tendency to commit homicide in many cases, but I would not say
that it is so in every case. Do the insane who are under homicidal mania
frequently show great skill and cunning wherewith to effect the death of some
person they hate, aud patiently wait for an opportunity of effecting their pur-
pose ? They do. Is it also common, after an insane person has committed
nomicide, to make an attempt to escape from punishment ? I cannot answer
that from my own experience ; but it is not uncommon for a lunatic who has
done an act to tr^ to escape punishment for that act. I cannot recall an
instance of a lunatic who has done an act, or who has been told he has done it,
attempting to escape from punishment. It is very common for lunatics to
suppose that they have been slandered by people. It is a fact that medical
men often cannot discover insanity by an examination of a man himself without
reference to his past life. Assumme that the prisoner committed the act with
which he is charged, I do not consider that he was of sound mind when he did
so. In my opinion, he was in a state of maniacal paroxysm when he committed
that deed. He had a tendency to that, I think, before he left his father's
house. I think that when he passed the gate the sight of the place probably
brought the girl to his remembrance, and that brought on the paroxysm.
After such maniacal paroxysms are over, it is common for the person who has
been under them to have no recollection of what he did when under them.
From the evidence given by his mother as to his state in October 1863, when
he was strapped down, I have no doubt that he was then under a paroxysm.
I would have recommended then, had I been called in, that he should be sub-
jected to restraint. I think his pulling out the knife to Ijord Morton^s men is
only one of the many instances I heard in the evidence which indicated his being
of an impulsive tendency. As to the evidence as to absence of mind, abstraction,
gazing at' the stars, and such like indications, I would not infer from any
one of these that he was insane ; but in this case, with the distinct progression
of these indications, I would infer that they indicated that the man was gradu-
ally becoming insane. The disease gradually progressed. There was a change
in June, then there was a paroxysm in October ; and from the evidence and

88 MEDICAL NEWS. [jULY

my own inspection of the man, I would infer that the case would gradually
progress towards dementia. I mean by that that it would end in total loss
of intellect. I think he is now in a quiet state, but that the delusion under
which I consider him to labour stiU exists. I still consider him insane.
Croaa-examined bjf the Solicitor- General. — Do you use the term dementia as
something different from insanity ? I mean to say that dementia is one of
three divisions of insanity — ^mania, monomania, and dementia. Do you consider
the prisoner to have dementia ? No, I consider him to be just now a mono-
maniac? According to the assumption you make of the fact, you were of
opinion that he was a monomaniac on the 16th of April last ? Yes. When
did he become a monomaniac ? About a year ago. So far as I know, the
subject of that monomania has been the same. What is the subject of that
delusion ? A delusion regarding certain statements alleged to have been made
by Jane Seaton — statements which she never had made. That is the only
delusion you have any notion he is labouring under? Yes ; but I have reason
to suspect otherwise, although I could not say positively. Then, if that was
no delusion, which yon mentioned as the only delusion, tnere is no delusion at
all, and he never was a monomaniac ? There is other evidence of progressive
changes in his mind. There was one reason, namely, that of wishing to dine alone
on Sundays, which I think was not sufficiently brought out. Why, because he
had suspicion of his family. Suspicion of what ? I cannot say in what respect,
but to my mind it appears tluit he suspected that they would do something to
him — ^at least that may have been the case. I am merely offering that as my
opinion. As a guess? No; as my opinion founded on other cases. You
think his family had offended him, and he had a dislike to them ? Not exactly
that. SoL' Gen. — It appears to me very much like what I have observed in other
cases of a person havingHeparated himself from his family, in the belief that they
had offended him. Drii, — Another reason I have for considering he had a delu-
sion was that he muttered to himself, and I think he then considered somebody
was speaking to him. The only delusion which influenced you was that which
he had in connexion with Jane Seaton ? Yes. Have you K>rmed your opinion
entirely from what has come out in the proof? I have. If that was no
delusion, was there an^ delusion for your opinion to rest upon ? No. Do
you think that his mind was capable of entertaining, for a Ions time, a
feeling of enmity or ill-wiU against a particular person ? I think it was.
Do you think his mind was capable of entertaining a strong desire to gri^tify
that feeling of ill-will by doine an injury to the person ? The fact of his hav-
ing a delusion would not, I thmk, keep him from gratifying his feeling of ill-
wSl. The delusion may have produced that feeling. Do you think his mind
was competent to understand the full nature of the injury he inflicted on that
eirl ? I cannot say for the time when he committed the act. I understand
urom that that there is no fact in this case that can lead you, as a medical
man, to come to the conclusion tliat he did not know what he was doing when
he committed the deed ? (No answer.) Have you any reason to doubt that
he knew the girl whom he attacked was the girl tnat injured him ? No. Have
you any reason to doubt that he attacked her in consequence of that feeling of
enmity towards her ? I believe he did attack her in consequence of that feel-
ing while labouring under a delusion. You think that the feeling of enmity
proceeded from a aelusion, but that it was the feeling of enmity wnich caused
the attack? That would be somewhat different from what I already said.
Very likely. Have you any reason to doubt that, when he drew the razor
across the girl's throat, his desire was to kill her ? I cannot say that it was
his desire, but it was evidently his intention to kill her. Now, have you any
reason to suppose that he thought it was right and i.ot wrong to kill her? I
cannot say. Have you anything which enables you to form an opinion one
way or other whether he thought it was right or wrong to kill the woman ?
No. I cannot say whether he thought it was right or wrong, as I cannot
entirely enter into his state of mind. Of course not ; you cannot entirely
enter into the state of any man's mind. The Solicitor' General — It comes to this,
then, I think. He knew the girl ; he had a feeling of enmity towards her,

1864.] TRIAL OF QEOBOE BBTC8 FOR MURDER. 89

arising from a ddaBion, fiuic3riiig that she had injured him when she had not.
He hiui a deeire to gratify that f(Mling of enmity, and he kQled the girl. Have
yon any reason to suppose that by so doing he imagined he was doing right ?
2>r JUichi&^lly opinion of the matter is that he was acting under a delusion,
and while under that delusion he had a sudden monomaniacal paroxysm, and
in that paroxysm he committed the murder. Be-txamin&d by Mr Fnuet — ^Is it
common in lunatics to entertain a feeling of enmity and ill-will ? Yes. Is it
not a very prominent characterbtic in cases of aelusion ? It is. Knowing
the person quite well against whom they entertain the ill-will? Homicidal
attacks are caused very often by delusion. I haye had a case of the kind
nsyself, where a patient thought I was writing things against him, and when he
brought large stones into tiie institution with the intention, I have no doubt, of
killing me. This is a danger which the physicians in such establishments run.
If Br^oe committed tho deed under the delusion that he was slandered, was
his mmd capable of understanding the case ? I take this case to be like my
own, where ne was acting under a delusion. [The Lord Pretidmt — But the
question is, Was he capsBle of understanding that he was acting under a delu-
sion ? I do not think he knew he was acting under a delusion.] Mr ProMtr
— ^Before the paroxisms in October and April, were there all the symptoms of
incipient monomania ? There were symptoms a year before. He entertained,
when I spoke to him this morning, the same delusion in regard to the girl
Seaton.

This concluded the case for the prisoner.

The SoUcUor-Qmetal for the Crown, and Mr Fraeer iot the prisoner,
addressed the jurjr.

The Lord jugiic&'Gkneral proceeded to charge the jury. In the course
of his charge, his lordship laid down the law as to insanity in the following
terms : — Insanity, in a general sense, may be of various kinds. It may be
imbecility or fatuity. That is not the case before yon. Or it may be yiolence
— a mama leading to yiolence, which is said to be the case before you. That
may be of various kinds, but what we haye to deal with here is said to be
monomania. It is said that in a paroxysm of that disease the prisoner com-
mitted the offence. The disease is what constitutes the unsounoness, and the
paroxysm Lb only an event in course of the disease. Now, the opinion expressed
in substance by both the medical sentlemen is that he was at the time under an
insane delusion — a delusion which shows that he was insane — ^and that it waa
acting under that delusion that led to the perpetration of the act, and that in
eonse^uence he is to be reabrded as a person not responsible for it. I think it
was said, especially by Br Ritchie, in the concluding part of his evidence, that
the only delusion proved was the delusion he was labouring under in believing
that a man of the name of Peat had told him that Jeanie Seaton had said he
was a drunken blad^nard. I need not tell you it is not every eccentricity
that is a defence against the perpetration of a crime. It is not the mere cir-
cumstances of od£ty that will be a defence against a criminal charge. It is
not that the intellect is more or less weak that can constitute such a defence.
The defence in the present case is that he exhibited an insane delusion, which
insane delusion being acted upon, led him to the perpetration of the offence,
and that therefore he is not responsible. Delusions may be of various kinds.
There are delusions which are dearly indicative of insanity. There are cases
of men and women who have believed themsdves to be some great persons of
antiquity, of men who believed themselves to be constituted of particular
materials, of men who believed themselves to have existed before the flood ;
and there is also the case of a man who believed himself to be the Deity. All
these strange, supernatural ideas, if they are really entertained, are conclusive
evidence of insamty. There is no doubt of that. But there are other kinds
of delusions which are not evidence of insanity. A man labouring under a
mistaken belief respecting himself is not necessarily insane. A man believing
that another has an iU-wul towards him is not therefore insane, however ill-
founded the notion may be. There are various errors of judgment, leading to

VOL. X.— NO. I. M

90 MEDICAL NEWS. [jULY

wrong inferences, deduced from facts observed — strong opinions entertained on
insufficient grounds, leading to erroneous conclusions. These may be called,
more or less, delusions, because there is no good foundation for the opinions
that are entertained. But delusions of that kind are not such as will screen a
person who, on acting upon them, has perpetrated a crime. If you choose to
call that insanity, still it won't do. It is not an insanity of the kind that will
be a defence against the consequences of such an act as this. Now, what is
the nature of the case ? The nature of the case here is this, that this man
believed that Jeanie Seaton had said to Margaret Gibson, who had repeated it
to Peat, that he was a drunken blackguard. Now, Peat says he never told
that to the prisoner, and Margaret Gibson says she never told that to Peat,
and that Jeanie Seaton never told that to her ; so that the chain of communi-
cation, so far as the witnesses go, is broken. But supposing that he is under
the impression that he had heard it from that source, and supposing it was not
true, it does not necessarily follow that he is insane, so as to be irresponsible.
It appears that the opinion was entertained at Mr Tod's villa by some of the
people there, that the prisoner was a person addicted to drinking ; and it does
appear that Mrs Tod had told Jeanie Seaton — had told the servants, all of them
— that if he was a person of that kind, his visits ought to be discouraged. It
does appear — as probably you will be satisfied — that Jeanie Seaton had enter-
tained the opinion that he was a worthless, drunken fellow ; and it is very
likely that she may have said so. It would appear from the evidence that she
had said that to her mother and to her father-m-law ; and it is very probable
that such was her opinion. It may have been true that she influenced the
opinion of Lizzie Brown, to whom he was paying his attentions. That story
may or may not have got circulation so as to come to his ears. He may have
drawn conclusions that this was her view, and that she had been stating it.
He may have been, in believing the delusions, labouring under mistake as to
Peat being the person who told him ; it may have been somebody else that
told him. But is that to make him irresponsible for the act of murdering Jane
Seaton ? If a man has a delusion on any matter, however slight or frivolous, is
that a reason for absolving him from the penalties of the law when he has
incurred them ? We must consider the consequence of absolving persons that
are without restraint, of absolving them from the effects of the law when they
commit acts of violence ; and it is for persons so pleading insanity, to make
out something that is a good answer to the charge. Is it a ^ood answer to say
— << I was under the delusion that Jeanie Seaton had entertamed the opinion of
me that I was a drunken blackguard, and had expressed it to others ; that I
was under the delusion that I heard it from Peat, who got it from Gibson ? "
I am of opinion that that will not do. llie delusion must have reference to
something far more serious and far more warranting and proroptins to the act.
If a man is under the delusion that another is assailing him to take away his
life, then he may be justified in retaliating by taking away the life of the per-
son who he believes is attacking or plotting against his life. But that a person
has merely the idea that some one has said something of him, which he himself
probably is conscious is not unfounded— to hold that as an excuse for taking
away the life of that person is quite out of the question. It nmy be an indica-
tion of insanity taken with other matters, but it is not so standing by itself.
But would you require to have it established beyond all doubt that the delusion,
whatever it was, or the belief, was wholly groundless ? Would you require to
have it established that nothing of the kind took place ? You are asked here
to go into that inquiry, and on doubtful evidence to decide whether she ever
made that statement in regard to him ; and then, on the result of that inquiry,
you are to build this theory of insanity, and on this theory of insanity, in reference
to a matter so trifling, the man is to get impunity who commits murder. Gentle-
men, the question of insanity — of insanity to the effect of relieving a part^ from
responsibility — the question of whether a man is insane or not, is a question for
you to decide. It is a question on the whole facts of the case ; it is not a medical
question. The medical gentlemen have opportunities of observation which make

1864.] TRIAL OF QEOROE BRTCB FOR MURDER. 91

their testimony firequently very important in reference to such matters ; bat the
qaestion is not a medical question ; it is a question of fact whether the insanity
amounted to this, that he was doing a thing which he himself considered, and
had grounds to believe, and respectmg which his beKef was a sincere one, that he
was warranted in doing — whether he really believed that something had occurred
which would be a ground for taking away the life of this unfortunate girl. It
is a question for you whether his state of mind was such as to warrant you in
sustaming this defence. It is no doubt true that, if the result of your inquiry
should be that the prisoner committed this act in a state of insanity, he would
not be let loose on society. The public must be protected against persons who
have uncontrollable passions, but I can by no means endorse the doctrine that
seems to be held, that when a man cannot control his disposition to do an act
he is not responsible for it. Nothing is more common than a person being
unable to control his passions. His passion gets the better of him, and he
becomes for the moment beyond control. But merely because vou call it a
paroxysm of monomania, that is not a reason for holding that such persons are
to be held as out of the pale of the law in regard to answering for the conse-
quences of the crime they commit. But the result would be--if you are of
opinion that he is insane — immediate restraint, and, as Mr Fraser said, possibly
subsequent restoration to society. But no matter for that ; the qaestion you have
to decide is, has it been establbhed or has it not, that this act was perpetrated
through insanity ) — insanity in this sense, that the party was bereft of mind,
that he believed, from grounds that acted upon his imagination, that facts had
occurred which warranted him in committing violence ajsatnst this individual.
The prisoner is said to have no recollection whatever of what happened, and
that want of recollection is said to be a very common sequel to a paroxysm of
mania. It appears that when he left his father^s house he had taken with him
a razor. It appears that he met some people on the road, that he met a baker^s
boy not &r from Mr Tod*s villa, and that when he met him he passed on
beyond the house, and entered the grounds, it is supposed, further up by climb-
ing the wall. Now, it is remarkable that, while he states that he aoes not
recollect what he did to this woman on that morning, he did recollect that he
had gone to Mr Tod^s house. He did recollect that he had seen the cook in
the premises, and that he did recollect he had been in the kitcheu. He knew
that the razor which was exhibited to him was his, and he says he does not
know how he came by it. In short, he pleads want of recollection of the par-
ticular act that he dia in committing the murder, or of the possession of the
particular weapon, but he remembers all the other circumstances of the case.
If he was not m this state of mental aberration when he left his father^s house,
or until he got to the house of Mr Tod, it is strange he should not recollect
how he got the razor. He recollects perfectly well having seen Hunter, and
having been in the kitchen ; and when he had committed the last assault on the
deceased, and cut her throat, he immediately fled. He was pursued, but was
apprehended and taken back ; and when spoken to bv the constable, he remarked
that she was cheap of what she had got, and asked if she was dead. This is
not like evidence of a total want of recollection. The allegation of want of
recollection is one thing, the proof of want of recollection is another. It is
not proof that a man does not remember that he says he does not remember;
and if he remembers things occurring about the time, but abstains from giving
any information as to the particular thing he is charged with, you will judge
how far you are to take that as a total want of recollection on his part. But
this want of recollection is not a very unfrequent thing on the part of persons
accused of crime. I have said that he carried on his ordinary vocation as a
carter, and I think it is also in evidence that he was in the miUtia, and that he
was out on duty for weeks at a time ; and we have no evidence that he was
incapable of performing his duties there — nothing of that kind. There is no

Eroof that he was an imbecile, or that he was not trusted in the work which
e did perform. Sometimes, it is said, he left his cart in jeopardy ; sometimes
he leftnis horse and cart altogether, and did not appear for days. He is a

92 MEDICAL NEWS. [JULT

person, it appears, of erratic dispositioii — and this tendency may account for
all that — ^bat that he did carry on his occupation, and that he was regarded by
those persons who came in contact with him as perfectly competent to do these
things, and not as a man who was exempt from responsibility for the conse-
aaences of his acts. Is it, then, the case that he suddenly becomes insane,
tnat he could no longer be held responsible for his acts ? — ^that is a question
for you to consider. It is not enough that the eyillence shows him to be a man
of unsettled disposition ; that will not exempt htm from being responsible. He
is guilty, unless you hold him to be insane. If you are of opinion that he is
insane now, it is ^rour duty so to find ; it is your duty to say so separately, and
without pronouncing any opinion on the question of guilty or not guilty- If
' [; he IS sane now, but that he was insane on the loth of

you are of opinion that 1

April last — ^insane in the sense of not being responsible — ^you will find that he
is not guilty by reason of the insanity which was on him at the time. If yon
are of opinion that he was not insane at the time, and not insane now, your
verdict in that case will simply be a verdict of guilty.

The jury having retired, returned a verdict of guilty, with a recommendation
to mercy on account of the low mental organization of the prisoner ; in respect
of which verdict the prisoner was sentenced to death.

OBITUART.

THE LATE PROFESSOR MILLER.

The unexpected and premature death of Professor Miller, which took place on
the morning of the 17th June, will be sad news to many an old friend, to many
confiding patients, and to a whole generation of pupQs in every quarter of the
globe. For several years past, Mr Miller's friends have observed with distress
that his fine &ce and manly figure were not as once they were and should
still have been; that his expression was often haggard and exhausted; and
that he was yielding gradually to the continued strain of overwork. Of this
he himself frequently admitted the truth, and he wisely allowed himself longer
periods of summer holiday than had been his wont. During these holidays
he paid repeated visits to Homburg and Schwalbach, and evidently derived
much benefit from the use of the chalybeate. But although he thus far took
proper care of his health, he continued to abnegate the use of stimulants to a
degtw which many of his friends thought prejudicial to him ; he was not an
inflexible teetotaller whom no advice could convert even to the temporary
use of wine for his body's sake ; but he was at the same rime so zealous and
scrupulously honest a nephalist, as he called himself, that he immediately
gave up the use of wine when the distmctness of the need for it became
obscured. He would not consent to become a habitual drinker of wme on any
terms. Whether this was a just decision in the case of a man who had for
the greater part of his life used stimuUnts moderately, and who had far too
much and too anxious occupation of body and mind, we shall not here attempt
to decide. So great also was his devotion to the advancement of religion and
of social ameliorations, that he was undoubtedly, and often not in ignorance,
led to add to his strictly medical engagements a very great amount of business
and hard work, more than any ordinary man can continue to bear. And he
was not a strong man ; he had been treated for pericarditis by Dr Abercrombie ;
he had an almost constant but varying dyspepsia; he had frequent slight
attacks of gout, which he inherited from his father ; and he had some ten years

ISM.] THE LATB PR0FE880B MILLER. 98

before Us death eontracted, hj a prick of his bwtoary, an infoctieD whieh
oould not but add materiidly to his other eonroee of weakness. Latterly, he
became increasingly dyspeptic ; then he grew decidedly hypochondriacal ; from
gay he became gloomy. This state of mind abont a fortnight before his death
greatly deepened ; active disease of the brain showed itself passing on to a
state of imperfect coma, in which he continnad till the last. Only in his last
hours he was able, with a dear mind, to bid his £unily an affectionate adieu.
He died at the age of fifty-two.

Like many of his eminent Scottish compeers, Mr Miller was bom in a manse.
His fiither was the minister of Eassie, in Forfarshire. Possessed of more thaa
ordinary erudition, a man of great energy and of a fine presence, highly and
widely esteemed, the Beyerend Mr Miller fonnd himself surrounded by a large
liunily, in which the subject of our sketch held the place of third son. Jamea
was bom on the 2d April 1812. His next elder brother is the weU-known
Beverend Dr Samuel Miller of Free St Matthew^s, Glasgow, and his yooi^gest
brother is now a surgeon in Her Majesty's Indian Army, The minister of
Bassie brought up his boys under his own eye, and to a great extent under his
own direct tuition. The manse was for a time indeed a small school, for,
besides his own fiye boys, the minister was intrusted with the education of
William and Lauderdale Mauk, sons of his patron Baron Panmure. From this
grammar-school James Miller was sent to the University of St Andrews in
October 1824, where his general education was carried on and completed in
three winter sessions. He here came in contact with Dr Thomas Chalmers,
who was one of his teachers ; and here he made the acquaintance of many who
now lament his death, among whom we may name, Sheriff Jameson, Rev. Dr
Robert Lee, Lord Jerriswoode, and ReT. Dr Lindsay Alexander.

In the summer of 1827, he b^an to prepare for professional education, by
being attached as a pupil to Dr Ramsay of Dundee. Bad health, however, soon
broke up this connexion, and in the same year he went to Edinburgh, and
began the regular career of a medicid student under Mr Mackenzie. In 1832,
he received the license of the Royal Ck)Uege of Sui^eons. During his student
life the chief teachers in the school were, Monro, Knox, Lisars, Christison,
Syme, Graham, Duncan, Home, Hope, Alison, Mackintosh, John Thomson,
Tumer, Russell, Ballingidl, Mackenzie, etc., and it is to them that he owes more
or less directly his primary medical Instraction.

Now a surgeon, he became attached to Listen, whose favourite pupil he had
previously been. Of the nature of this connexion we can say little. Only
Miller was Liston*s assistant ; he was also a devoted friend and admirer. And
he not only did the ordinary duties of surgical lieutenant to Listen, but afforded
him very great aid in the production of his well-known works on Surgery.
Liston went to London in 1834, and wished to draw his young friend after him,
but Miller preferred to cast his lot in the metropolis of his native country.
At the great ovation to Liston, given him by his more distinguished Edinburgh
friends, Mr Miller was, in some sort, named as his successor; and the fact is
that he rapidly fulfilled the expectations formed of him, becoming at once a
fully employed and popular practitioner. About the period of his commencing
practice he was also dosely connected witli Professor Monro, for whom he
executed much literary work in connexion with his book on the Gullet.

On 11th July 1836, he espoused Penelope Garden Campbell Gordon,
daughter of a military officer and of an old and well-known northern fiunily. Of

94 MEDICAL NEWS. [JULT

thifl marriage the issne is Beven children ; — James, now a sargeon in the East ;
Elizabeth, now wife of Dr Patrick Heron Watson ; Alexander, now a medical
student ; and four younger children.

In 1842, the death of Sir Charles Bell produced a Tacancy in the chair of
Surgery in the University. To this important office Mr Miller was appointed,
after a severe struggle with Dr Argyll Robertson and Mr Lizars, his competitors.

In recent times no Scotch medical man has enjoyed a wider reputation or
secured a more lucrative practice. He recruited his patients not only from
these isles, but also from various parts of the four continents. Whoever was
his patient was also his friend, and continued his friend. Mr Miller*s practice
was by no means confined to surgery. Besides his suigical practice, he had
considerable eroplojrment as a general practitioner, and was much consulted
as a physician both in his own house, and in every part of the country, as
well as in England.

Mr Miller was a bold and dexterous surgeon. We are not aware that he had
any special hobby among operations, but he was reputed as specially skilful
in dbeases of the rectum and bladder, in which his experience was very large.
He was always averse to having recourse to the knife without an evident in-
evitable necessity, and in many passages of arms has defended with his lance
what he called conservative surgery against the more zealous men of the craft,
whom he justly believed to be drawn by an inevitable prolixity into an excessive
confidence in the knife. In illustration of this peculiarity, we may mention
the great zeal with which he espoused the modem treatment of tubercular
diseases by constitutional remedies, and the satisfaction he had in saving limbs
for scrofulous patients, who would in his youth have been at once placed on
the operating table as their only source of hope of cure.

Mr Miller is well known to have been a successful teacher. He had always
large and attentive audiences. In his course he used his " System** as a text-
book, but did not adhere to it at all slavishly^ on the contrary, he regularly
made fresh notes for the lecture of every day. His lectures were copiously
illustrated by diagrams, firesh dissections, and preparations from his own and
the other rich collections of the University. In speaking of his teaching, we
cannot omit mention of his extraordinary fluency of English diction. This
valuable talent was but of little service in his didactic occupations; but
when he had occasion for it, and had had time for some preparation, he was
equal to the great orators of the day ; the audience, whether sympathetic or
not, was always delighted with his handsome form, his simple gestures, his
fine voice, hb elegant diction, his abundant wit, his occasional humour. There
can be no doubt that had he been fiivourably situated for the exhibition of his
powers in this way, he might have reached the highest rank among public
speakers.

As we have no desire to encroach on the functions of the biographer, we
shall not enter on the private life of the deceased. Without derogating in
any degree from Mr Miller's high character as a public and a professional man,
we are sure his personal friends wiU join us in asserting that it was in private
life that Mr Miller's beautiful character shone to the greatest advantage. It
was impossible to know him intimately without becoming increasingly fond of
him. His powers as a good companion were unrivalled, and for a great part of
his early life he was much in society, being everywhere courted for his genial
wit and abundant humour, and for every good quality and talent of a host or

1864.] THE LATE PB0FE880B MILLER. 96

of a gneit. After the Dismption of the Church of Scotland he devoted so
miich of his spare time to the interests of religion and of the Church, that he
necessarily greatly contracted the circle of his friends in general society. Bat in
the new sphere he acquired a host of new and zealoos friends and admirers, who
looked ap to him no less as a man of ability and of power, than as one whose
straggle to lead the life of a true Christian demanded their admiration and
imitation. In his latter years he became more and more devout, and of him it
may be truly said that he died in the glorious hope of a joyful resurrection.

Mr Miller had been President of the Medico- Chirurgical and of the Harveian
Societies ; and, at the time of his death, was a Fellow of the Royal Society
ttjid of the Royal College of Surgeons ; Professor of Pictorial Anatomy to the
Royal Academy ; Surgeon in Ordinary to the Queen for Scotland ; Consulting
Sorgeon to the Royal Infirmary ; Surgeon to Chalmers' Hospital for the Sick
and Hurt; Consulting Surgeon to the Royal Hospital for Sick Children.
Besides, he held several honorary diplomas from Continental and American
medical institutions.

The following is a list of Mr Miller's principal published writings : —

1. Probationary Essay on the Dressing of Wounds, as Simplified and Improved

in Modern Surgery. Written when a can^date for admission to the
Fellowship of the Koyal College of Surgeons. 1840.

2. Chapter on the Restoration of Lost Parts. — Listen's Practical Surgery, 1837,

1846.

3. Principles and Practice of Surgery. Two volumes, duodecimo. Also

three editions octavo of the same work.

4. A System of Surgery. 1864. Beine a 5th edition, in one volume, of the

previous work, largely revised by Dr P. H. Watson.
6, On the Treatment of the Hsemorrhagic Diathesis. 1842. London, and
Edinburgh Medical Journal.

6. An Introductory Lecture on Sur^ry. Delivered 4th November 1840.

7. Syllabus of Lectures on the Principles and Practice of Surgery. 1841.

8. Introductorv Lecture on Pictorial Anatomy, delivered to the Students of

the School of Design, and published at the request of the Honourable the
Commissioners of the Board of Trustees for the Encouragement of
Scottish Manufactures. 1842.

9. On a Case of Inguinal Aneurism, in which the Patient committed Suicide

by wound of the Tumour. Edinburgh Monthly Journal of Medical
Science.

10. Statement in Reply to Mr Syme's " Case of Stricture of the Urethra,"

treated by External Incision. Monthly Journal of Medical Science.

11. Ununited Fracture treated by Subcutaneous Puncture. Monthly Journal

of Medical Science. 1848.

12. Address to the Graduates of the University of Edinburgh, 1st August 1856.

Edinburgh Medical Journal.

13. Address to the Medico-Chirurgical Society of Edinburgh, delivered on the

occasion of his taking the Chair of the bociety, 17 th December 1856.

14. Valedictory Address delivered at the Meeting of the Medico-Chirurgical

Society, 15th December 1858.

15. Address on Sureery, read at the Twenty-sixth Annual Meeting of the

British Medical Association held in Edmburgh in July 1858. British
Medical Journal, 28th Aupst 1858.

16. Hora Harveiana. An Address delivered at the Annual Meeting of the

Harveian Society in 1860. Edinburgh Medical Journal.

17. Neuenahr. A New Spa on the Rhine. 1861. Edinburgh Medical Journal,
• and largely reprinted.

96 MEDICAL NEWS. [JULT 1804.

18. On the Progress of Surgery in the isst Thirty Tears. Edinburgh Medical

Journal.

19. Medical Missions. An Address to Students introductory to a Course of

Lectures on this Subject. 1849.

20. Physiology in Harmony with the Bible. 1855. 2d Edition. 5th Thou-

sand.

21. The Day of Rest. Tract for Working Men and their Firesides.

22. Labour Lightened, Not Lost.

23. Abstinence, its Place and Power. A Lecture delivered before the Toung

Men*8 Christian Association in Exeter Hall^ 31 st December 1856.

24. Painless Operations in Surgery. North British Review, May 1847.

25. Prostitution Considered in JRelation to its Cause and Cure. Edinburgh

Medical Journal. 1859.

26. Alcohol, iu Place and Power. 1857. 33d Thousand.

27. Nephalism, the True Temperance of Scripturei Science, and Experience.

28. An Appeal for the Sustentation Fund by Elders of the Free Church of

Scothuid.

29. Speech delivered at a Meeting for the Formation of an Association for

Suppressing Drunkenness in Scotland, May 1850.

30. Surgical Experience of Chloroform.

31. History of Surgery. In the two last Editions of the Encydopssdia Bri-

tannica.

32. Numerous Speeches in Church Courts and elsewhere, on Topics connected

with Religion and Social Improvements.

PUBLICATIONS RECEIVED.

▲rlidge,— The Mortality of Stoke-npon- Heryon, — Practical and PiKihoIogleal Re-

TVent. By J. T. Arlidge, M.B. 1884. Bearches on the varioiu Fonns of Para-

Amott,— Contribntions to Practical He^i- Ivsia. Bf Edward Meiyon, M.D., etc

cine and Surgery. By James Amott, London, 1864.

M.D., etc. London, 1864. Percyt^PhTsioIogical and Medicinal Pro-

Basham, — Croonian Lectures for 1864 : The perties of the Yeratrnm Yiride. By

Significance of Dropev as a Symiitom in Bamoel Percy, M.D., etc Philadelphia,

Renal, Cardiac, and Palmonaiy Diseases. 1864.

By W. R. Bairiiam, M.D., etc London, Pnrsell,~Rheaniatism, Gont, Sciatica, and

1864. Neuralgia : their Rational Pathology and

Chambers,— Lectures: chiefly Clinical By Successful Treatment By John PnneU,

Thomas King Chambers, M.D., etc Lon- M.D., etc. London, 1864.

don, 1864. Raddiife,— Lectures on EpUepsy, Pain, Par

Da Costa,— Medical Diaffnosis, with Special ralysis, etc By C. Bland Raddiffo, M.D.,

Reference to Practical Medicine. By J. etc. London, 1864.

M. Da Costa, M.D., etc Philadelphia, Swan,— Delineations of the Brain in Relation

1864. to Yolnntaiy Motion. By Joseph Swan.

Frits,— Etude dinique sur divers Symp- London, 1864.

tomes spinaux obserr^ dans la Fi^vre Tilt, — A Handbook of Uterine Therapeutics.

typholdc Par le Dr £. Frits. Paris, By Edward J. Tilt, M.D., etc Second

1864. Edition. London, 1864.

QtRYid,— The Essentials of Materia Medioa West,— Lectures on the Diseases of Women.

and Therapeutics. ByA.B.Qanod, M.D., By Charles West, M.D., etc London,

etc Second Edition. London, 1864. 1864.

Jones,— Clinical Obserrations on Functional Wilde,— Ireland, Past and Present By Sir

Nervous Disorders. By C. Handfield W. R. W. WUde. Dublin, 1864.

Jones, M.B., etc London, 1864. Zander,- The Ophthalmoeoope : its Varietiea

Lunacy,— Sixth Atinual Report of the Oen- and its Use Translated m>m the Qerman

eral Board of Commissioners in Lunacy of Dr Adolf Zander. By R. B. Carter,

for Scotland. Edinburgh, 1864. MJK.C.S.E, etc London^ 1864.

)9art Jf^int

ORIGINAL COMMUNICATIONa

Article I. — Further ObservaHana an the Waxy cr Amyloid Form of
Briahia Diaeaee. By T. Grainger Stewart, H.I)., F.R.aP.,
Pathologist to the Koyal Infirniaiy, Lecturer on General Patho-
logy and Morbid Anatomy, Edinburgh,

In February 1861, 1 published in this Journal certain views as to the
symptoms which accompany the waxy or amyloid degeneration of
tne kidney, one of the forms of Bright^s disease : symptoms which
I conceivea to be so distinct and constant as to render it easy for
us to distinguish during life between this and other fonns of renal
affection. In this paper I propose to indicate the results of my
obseiration of that aisease since the period of my former communi-
cation, and the conclusions at which I have anriyed. Mesrhr all the
cases have been observed in the Koyal Infirmary, and I beg to
acknowledge my obligation to the physicians who nave kindly per-
mitted me to publish them.

The description which I then gave was the following : — '^ An
individual who has long* suffered from wasting disease, such as
scrofula, caries^ necrosis, or syphilis^ or who, though without pal-
pable disease, is of a feeble constitution, feels an increasing weak-
ness, and begins to pass large quantities of urine, and to drink
largely. He is, contrary to his usual custom, obliged to rise
repeatedly during the night to make water, and on each occasion
passes a considerable quantity. The amount of urine varies from
50 to upwards of 200 oz. daily, always bearing a relation to the
amount of fluid drunk, generally nearly eaualling it in amount, or
sometimes even exceeding it The feet and ankles become csdema-
tons after a hard day's work, but return to their natural condition
during the night's repose. In many cases there is observed a hard-
ness and swemng in the hepatic and splenic regions, dependent on
an increase of bulk of the liver and 8{)leen. The patient feels a
constant lassitude and unfitness for exertion. His unne gradually
becomes albuminous, and a few waxy or hyaline tubecasts are to
be found in the very scanty sediment which it throws down. It is
of low specific gravity — 1005 to 1015. The blood presents some
peculiarities microscopically: the white corpuscles being somewhat
mcreased in number, and the red presenting a flabby appearance, with
a marked tendency to tail, — that is to say, instead of forming into

VOL. X.— NO. II. *•

98 DR aRAINQEK STEWART ON THE WAXY OR [AUQ.

roaleaux, like healthy corpasclesy thej become stretched out into
long, spindle-shaped bodies. The blood changes I have observed
only when the degeneration affected the lymphatic or blood glands.
The patient may continue in this state for months, or even years —
may, indeed, undergo a temporary improvement — the liver and
spleen becoming diminished in bulk, and the blood resuming a
more healthy character; but, sooner or later, for the most part
ascites or general dropsy gradually supervene, accompanied fre-
quentljT by diarrhoea, which is at times found quite uncontrollable.
The urine, now very albuminous, diminishes in quantity, so as at
times to be almost or altogether suppressed; effusions into the
serous cavities or severe bronchitis ensues ; the patient becomes
exhausted and sinks, or drowsiness comes on, and the disease
terminates amid coma and convulsions."

Further experience has confirmed the opinions then expressed,
and in all cases in which an autopsy revealed the lesion, and in
which I had the opportunity of carefully examining the patients,
I ascertained the existence of the symptoms which I have indi-
cated. In support of my views I adduc^ in my former communi-
cation twenty cases, in nine of which the existence of the lesion
was ascertained by post-mortem inspection. In the present paper
I shall complete the history of three of these, continue that of
another to the present time, and give a summary of sixteen other
cases, in several of which autopsies have been made.

Case I. — ^A. M., shoemaker, »t. 33. His case was minutely described in
the previous paper. Of a syphilitic constitution, he was, about four ^reani
ago, ' . . - - . - -

^th

water, of low specific gravity. From his historv and the unnary ,,- ,

I ventured to anticipate the appearance of albumen in the urme. It was
carefully tested, day oy day, ana, atfler a while, a trace of albumen appeared ;
tliis gradually increased ; and afterwards fine hyaline tubecasts were occasion-
ally seen in the urine. These symptoms had lasted for about nine months at
the date of my former publication, and since that time they have steadily
continued. The following notes were taken at the dates mentioned : —

4ih Fdfruary 1861. — The Hver and spleen have further diminished in size.
His appearance is somewhat less cachectic. For some days he has had a pain
in the neighbourhood of the umbilicus, and along the maivin of the hver,
aggravated on movement or on pressure, and after eating. The stools are of
a dark colour, and contain some bright red blood. He has no piles. The
amount of urine continues high, about 120 oz. daily. It is albuminous.

Sth October 1861. — The patient again presented himself; his cachectic
appearance is increased ; he comolains of a severe pain in the lumbar region,
and along the spermatic cords. His renal symptoms continue unchanged, and
the liver is still distinctly enlarged.

Since that time he has frequently presented himself at the New Town Dispen-
sary and elsewhere ; has repeatedly oeen an inmate of the Royal Infirmary; has
been able occasionally to work at his occupation of shoemakmg, and has of late
acted pretty constantly as cook to the Mid-Lothian Militia stationed at Dalkeith.
The last note I have taken of his case was on 21st March 1864. He continues
to make large quantities of water daily, usually upwards of 120 oz. It is still
albuminous, but no tubecasts have been discoverea for some time. The hepatic
dulness is diminished to about six inches ; the organ is still painful on pressure.

1864.] AMYLOID FOBM OF BRIQUT'B DISEASE. 99

He has no nansea, and liia boweb are regular; but on several occasiona lately
he has had inteniie diarrhoea, sometimes bloody, and has vomited blood-coloured
matters. His complexion is even darker than before, and his eyelids are more
oedematons than I nave ever observed them. From some observations made for
me by Mr Taylor, it appears that his temperature is somewhat lower than natural.
Case II. — £. H., a Washerwoman, set. 43. This case was reported in the

Erevious paper. She had been of intemperate habits, but was not known to
ave had syphilis ; she had long-continued polyuria ; her urine was of low
specific gravity, veijr albuminous, and contained hyaline casts. She had also
a lesion of the aortic and mitral valves. She was dismissed from the Royal
Infinnary in May 1860. In November of that year I found that her symptoms
•Were not materially changed. She continued to make from 180 to 210 ojb. of
urine daily. It was of low specific gravity ; it contained albumen and cast«.
There was slight oedema ; the diarrhoea less intense than formerly ; the cardiac
symptoms unchanged. Throughout the years 1861-62-63 I saw her frequently
in St Cuthbert's Foorhouse, in the Koval Infirmarv, in the dispensary, and
elsewhere. Her renal symptoms were little altered. A distinct aneurismal
dilatation had gradually aeveloued itself; and a certain amount of oedema of the
limbs occasionally appeared. When she was last in the Infirmary I had the
opportunity, by the tmdness of Dr Laycock, of making the following notes : —

20ik April 1864. — ^The skin is pale ; conjunctiva clear, slkrhtly oMematous.
There is a good deal of congestion over the malar bones. The legs are oede-
matons ; the tongue is clean. She has some difficult v in swallowing, particu-
larly solids. Sickness follows eating, and she occasionally vomits. Vertical
hepatic dulness in the right mamillary line measures about ^ve inches. The
bowels are loose. She complains of pain in the left hypochondrium. She has
occasional giddiness, and sleeps badly. Her pupils are equal. There is a double
blowing. murmur at the apex of the nenrt, and at the base of the neck there is
a very distinct aneurism. The urine is copious, exceeding on an average 100
oz. daily. Its specific gravity is about 1008. It is of an acid reaction, contains
much albumen, some phosphates, and epithelium and fpranular casts.

6ih June, — ^Her dyspnoea, dropsy, and general debility gradually increased,
until the 5th of June 1864, when she died.

Auiopsyy 5S hours after death. — ^The body was well nourished. The right
pleural cavity contained about half an ounce of clear serum. The left pleura
was obliterated by old adhesions. Both lunffs were congested and oedematous ;
in several parts there were small dense nodules, whose nature was not deter-
mined. The pericardium contained a little fluid, and some lymph was deposited
on both its layers. The heart was enlarged, weighed 84 ounces; it was
fatty. The margins of the mitral valve were thickened. The aortic valves
incompetent. The aorta was dilated, its coats sclerotic and atheromatous, and
contained some calcareous plates. There were distinct dilatations in the course
of the innominate and subclavian arteries. The liver weighed 3 lbs. 3^ ounces,
was soft and fatty, and presented no reaction with iodine. Spleen weighed 3}
ounces, and was not waxy. The right kidney was small, weiehine 4 ounces ;
the capsule was adherent; the surface granular; the cortical substance was
atrophied. The left weighed 6 ounces, was distinctly waxy and &tty, less
atrophied; the capsule was also adherent. The Malpighian bodies, as well
as the arteries of the cortex and of the cones, were in a state of waxy
degeneration.

Ca0b III. — £. B., a bricklayer's labourer, aged 33. His case was recorded
in the previous paper. Of a syphilitic constitution, he made a large quantity
of water, upwards of one hundred ounces daily, highly albuminous, of low
specific gravity, and containing a few waxy casts. He was dismissed from the
Infirmary on tne 30th of Apnl 1860. The following notes indicate his after
history : —

7th April 1861. — His general appearance is better than it had been last year.
He states that he is quite well, but that the daily amount of urine has not
diminished. It is highly albuminous, of low specific gravity, and contains casts.

100 DR QRAINGEB STEWART ON THE WAXT OR [AUG.

His tongue is clean ; his appetite good ; his bowels are moved twice a-day.
The liyer is much enlarged, measures eight inches vertically, and extends con-
siderably across the epigastrium to the left side. The spleen is also enlarged.
The blood contains an excess of white corpuscles. Expiration is harsh and
prolonged at the apices of both lungs. The heart-sounds are altered in tone,
out not of a blowing character. *

13th Augutt 1862.-'The patient again presented himself. He is more emaci-
ated. States that from increasing debility he has been unable to work for a
month past. He still makes large quantities of urine, which is albuminous,
but not so intensely as before. It deposits a sediment containing hyaline tube-
casts, with oU-grannles here and there arranged in groups, as ifresultinff from
disintegration of cells. There has been no oropsy of late. The liver, Uioug^
still enlarged, is decidedly diminished since last report. He complains much
of his breathing.

22d September 1863. — He complains much of difficulty of breathing, and of
cough and headache when he attempts to stoop; he has also dropsy; and
from all these symptoms feels himself unable to follow his usual work. The
amount of urine is still large. He is obliged to rise three or four times evety
night in order to micturate. The urine is albuminous, and contains casts.
He entered the Infirmary, and under the care of Dr Sanders improved, so as
to be able to go out, and for a time pursue his usual avocations ; but in
November he again presented himself, complaining of a further aggravation
of his symptoms. He died soon after admission, in November 1863, and his
body presented the following post-mortem appearances : —

The body was somewhat emaciated. The neart was enlarged ; its left side
was much hypertrophied. The aortic valves were competent ; but at the base
of one of the segments there was a calcareous mass. The aorta was very
atheromatous. The lun^s were very oedematous ; the bronchi were congested
and full of mucus. The liver was about the natural size. On its surface were
a number of nodules and cicatrices. At the bottom of some of the latter,
nodules of a pale colour were visible. On section, numerous nodules were
found scattered throughout the organ ; they were pale, dense, and had an
appearance exactly resembling bees- wax ; their structure was much denser than
that of the surrounding tissue. In some nodules there were streaks of fibrous
tissue throughout the substance and round the margin, and the greater the
proportion of that tissue the deeper were the cicatrices. In the nodules
elevated above the surface there were no such streaks, or very few. In those
situated at the bottom of deep cicatrices, the fibrous element was abundant, or
even in excess of the glandular. On applying iodine to these masses, the whole
of the waxy-looking material assumed the brownish red colour characteristic
of the amyloid defeneration, but the fibrous streaks simply assumed a yellow
tinge. Microscopically, the masses were found to present exactly the char-
acters of ordinary amyloid hepatic cells. They were composed entirely of these
cells, enlarged, transparent, and finely granular. In some parts the ceUular
elements were broken down, and a finely grannlar material containing some
oil-globules was present. The fibrous tissue in the masses presented the
ordinary characters of connective-tissue ; and where it was most abundant the
cells were most atrophied. Throughout the rest of ~the organ the cells were
little affected with the waxy deeeneration, but some of the small vessels showed
it distinctly. The fibrous bands were seen passing into the tissues round the
cicatrices and nodules. The capsule of Gbsson was thickened in some parts,
and on applying the iodine externally to the cicatrices no reaction was observed.
The spleen contained one cicatrised mass, which presented no reaction with
iodine. The kidneys were somewhat contracted in the cortical substance, and
presented a very well-marked instance of the amyloid degeneration of the
vessels and Malpighian bodies. There was some degree of amyloid degenera-
tion of the villi of the small intestine ; the bowels were otherwise natural.
The prepuce presented traces of the old s;^hilis, and it had been previously
ascertained that there were numerous syphilitic ulcerations in the throat.

1864.] AMYLOID FORM OF BBIOHT's DISEASE. 101

Case IV . — J . M. , brashmaker, aged 83. His case was recorded in the previous
paper. Of a syphilitic constitation, he exhibited distinct traces of the cachexia.
Willie nnder OMervation, he passed from 60 to 80 ounces of urine daily, of low
specific gravity, albuminous, with hyaline tubeca8ts,and containinff here and there
a fistty cell. He was dismissed from the Infirmary about the middle of August
1860, and for a year afterwards I saw him occasionally. He always retained the
cachectic appearance, and continued to make large cj^uantities of urine. Until
the end of October 1861 he was going about attending to his work, but sud-
denly his urine diminished in quantity, and became bl^v, and on the follow-
ing day he was seixed with convulsions. These continued for some da^s. He
was removed to the Infirmary, where he died on 5th November. In the mtervals
of his fits he was conscious, though unable to speak.

On post-mortem examination there was found syphilitic necrosis of the
cranial bones, and other evidences of constitutional syphilb. The liver was
large and distinctly waxy ; the spleen presented the degeneration in a slight
degree ; the kidneys were somewnat contracted, firm, and presented an exqui-
site specimen of the amyloid degeneration of the vessels and Malpighian bodies.

In these four cases we have a continuation of the history of this disease in
cases previously published. The following cases are new.

Case Y. — ^J. M., labourer, aged 18, admitted to the Royal Infirmary, under
the care of Dr Bennett, 13th September 1861. He stated that six weeks pre-
vious to admission he caught cold, had cough, with frothy expectoration, and
soon afterwards that he noticed that he was passing more water than usual.
Had frequently to get up durins the night to empty his bladder. About a
month later his feet began to swell.

On admission, the heart-sounds were normal. There were the ordinary signs
and symptoms of bronchitis. There was no dropsv. The skin was cool and
moist. There was lumbar pain. The urine was pale, very copious ; of specific

Savity 1012; highly albuminous; contained granular and fatty tubecasts.
e had great thurst. The bowels were constipated.

The amount of urine varied between 3d and 15th October from 75 to 122
ounces. Only on three days was it below 100 ounces. Throughout that month
the (quantity continued uirge^ though on some days it was considerably
diminished, and it was almost mvariablv in excess of the fluids drunk. The
pulmonary symptoms rapidly increased in severity. The upper half of one
lung became distinctlv dull, while the bronchial affection increased. There
was some degree of dropsy. The blood contained fully double the natural
proportions of white corpuscles.

During November and December the daily quantity of urine gradually
diminished. The albumen did not diminish. The casts became less fatty.
General dropsy set in. This symptom became so distressing, that, on 10th June,
acupuncture was employed for the relief of the dropsy. At the same time the
pulmonary symptoms steadily increased, and the patient died on 13th January.

On post-mortem examination, there was general dropsv of cellular tissue
and serous cavities. The heart was somewhat hypertropbied. Both pleursB
were adherent. The lungs were oadematous, and contained distinct traces of
tubercle. The kidney capsule was adherent; the surface granukir. The
cortical substance somewhat atrophied. Many of the tubules were filled
with finely granular fatty matter. The spleen was firm ; the intestines were
cedematous. On adding a solution of iodine, many of the arteries and Mal-
piehian bodies assumed a reddish orange colour, and on the fmrther addition of
dilute stdphuric acid became reddish purple. There was slight waxy degenera-
tion of the liver, spleen, and of portions of the intestines.

Case VI.— I. C.^t. 16, a servant, admitted to Ward XT., 27th February 1861,
under the care of br Laycock. She had in the year 1860 been affected with
phthisis pulmonalis, and had somewhat improved. After I had lost sight of
ner she observed that she had occasion to get up several times every night to
make water, and that each time she made a large quantity. About January
she was exposed to cold and wet, and noticed that her feet and ankles swelled,

102 DR GRAINGER RTEWART ON THE WAXT OR [AUG,

and her urine became diminished in quantity. She had also some lumbar
pain and diarrhoea, and on this account entered the Infirmary.

On her admission I had an opportunity of examining her, and found the
signs of phthisis considerably developed. She looked anaemic. Her appetite
was bad. She freauently vomited. Her bowels were very loose. The amount
of her urine coula not be determined on account of the diarrhoea. It was
highly albuminous; specific gravity 1030. Contained hyaline casts. The
liver and spleen were enlarged. The blood contained an unusual number of
white corpuscles. There was considerable general dropsy, and she died a few
days after admission.

AtUopsy. — The lungs were found to contain large quantities of tubercle, and
on the intestines there were numerous irregular tubercular ulcers. The hver,
kidneys, and spleen were found to be large and waxy. The Malpishian bodies
and small arteries of the kidneys assumed a reddish purple colour on the
addition of iodine and sulphuric acid. Many of the hepatic cells and the
Malpighian bodies of the spleen presented the same reaction.

Case YII. — .J. C, set. 21, a miner, was admitted, under the care of Dr
Haldane, into the Royal Infirmary, in January 18G4. He was of stunted
growth. He had worked underground since he was seven years of ase. At
the age of sixteen he had pneumonia, and ever afterwards was breathless and
liable to colds. He used to notice that he had to rise during the night to make
water, and was often interrupted at his work from the same cause. Two
months before admission he was exposed to cold and wet, and became drop-
sical. His urine diminished in quantity ; its specific gravity was 1015, albu-
minous, and contained some casts. He died exhausted, partly by the renal
and partly by pulmonary affection.

Autopsy^ forty-two hours after death. The body was greatly emaciated.
The lungs contained tubercle and carbonaceous matter. There were some
vomicsB towards the apices. The heart was dilated. The liver normal The
spleen presented amyloid degeneration of the Malpighian bodies. The kidneys
were ofgood size ; many of the tubercles filled with fatty granules and exudfa-
tion. Tne small arteries and Malpighian bodies presented a translucent
appearance, and assumed a blue colour on the addition of iodine and sulphuric
acid. The villi of the small intestine also presented this degeneration.

Case VIII.— J. N., at. 32, Ward VII., under the care of Dr Haldane, in the
Royal Infirmary. Examined 25th January 1864.

f^ourteen years ago, when the patient was eighteen years of a^e, he had chancre,
and other signs of constitutional syphilis. These syphilitic symptoms con-
tinued to recur at intervals for a long time. Six years ago, having been
exposed to cold and wet, he had what seems from his description to have been
an attack of acute renal dropsy. From this he recovered. Has since had pains
in the tibia, worst at night ; in the epigastrium, and in the region of the kidneys.
Towards the end of last year he observed that he was obliged to get up several
times every night and make water, and that on each occasion he made a con-
siderable quantity. He estimated the amount to be about 160 ounces. This
has continued to the present time.

On admission, his liver was found enlarged. In the line of the nipple it
measured 7 inches vertically; in the middle line 5i. The spleen was also
enlarged ; measured 41 inches vertically, and 6 inches across. The blood con-
tained an excess of white corpuscles, and the red did not form rouleaux, but
irregular clumps; they had a tendency to tail. The toneue was loaded in
the centre, furred at the edges. The appetite was good, but some sickness
and vomiting followed every meal. The bowels were natural. The heart
sounds were normal. Pulse about 92 per minute. There was some crepi-
tation heard at the bases of both lungs, and at the apex of the right. There
was pain on pressure over the kidneys. The urine varied in amount, from
90 to 130 or 150 oz. ; was pale, of low specific gravity, contained much
albumen, but no tubecasts could be found. There was also enlargement of the
right testicle, and dropsy of the left tunica vaginalis. There were numerous

1864.] AMYLOID FORM OF BRIOHT'S DI8EA8R. 103

muJl periosteal sweUings over both tibue. There was also a tendency to
swelling of the feet in the evening, but not to any great extent. There were
also occasional attacks of epistaxis, and of h»morrhii^e from the bowels, and a
purpuric condition of the skin of the lower extremities. The gums were also
swollen and spongy.

I2lh AprU. — l^der a general tonic treatment, the patient has in so far im-

S roved, bat he continues to present the sjrmptoms characteristic of waxy
exeneration of the kidneys, liver, and spleen, lie was dismissed relieved.

Case IX. — A. M., a seaman, »t. 34, admitted to Patents ward, under the
care of Dr Laycock, 6th February 1864. In his profession of seaman he has
travelled much in foreign countries. Was never an intemperate man, though
he sometimes took a week's debauch on getting ashore. He never had syphilis,
but once, sevwal years ago, had some ulcers m the throat. Four years a^o,
while in India, he was ill of inflammation of the liver, at least an inflammation
at the hejMitic region, unaccompanied by jaundice. Since that time he has
been working on the Bumtislana ferry steamer, and was much exposed to cold
and wet. He noticed that his feet tended to sweU slightly, particularly
towards evening, and about nine months ago (last August) he observed that he
was compelled to leave his bed several times every night in order to micturate,
and that each time he made a considerable quantity. This was before the
dropsy be^an. Last October he caught cold, bad cough and expectoration, and
about Christmas his feet and legs swelled considerably, and he noticed that his
abdomen was remarkably prominent and hard. These symptoms increasing,
he was unable to work, ana was admitted to the Infirmary 6tn February.

On admission, he was a stout-built man, somewhat pale, but Vith numerous
distended capillaries over the maJar bones. He had an incipient arcus senilis.
His breath was short; but the respiratorv and circulatory sounds were normal.
The gastro-mtestinal system was normal ; but the liver was much enlarged,
measuring about eight inches vertically, and extending over on the epigastrium.
The spleen also seemed enlai^ed. The blood contained a slight excess of
white corpuscles, and the red had a somewhat flabby appearance. There was
some degree of ascites. There was no lumbar pain even on pressure. The daily
quantity of urine was about 120 ounces. Its specific gravity was about 1013 ;
its colour pale amber ; its reaction acid ; it contained a good deal of albumen,
and a few finely granular and hyaline tnbecasts.

12th AprU.-— Since he has been under treatment, his general health has im-
proved. The dropsy has for the most part disappeared, but the characters of
the urine have remamed unaltered. He was dismissed relieved.

Casb X.— £. D., set. 35, a bookbinder, first examined 7th March 1861.
This patient had contracted syphilis fifteen years before he came under my
observation. Since that time he has suffered from various const itutiontd
symptoms, eruptions, nodes, tic, etc. At the time he was under my care he
liad a pustular syphilitic eruption on his face. During the year preceding he
had observed that he was obliged to get out of bed several times each night in
order to make water, and that he m^e a considerable quantity on each occa-
sion. At the same time he observed that his feet were swollen at night, but
the swelling had subsided in the morning. The urine varied in amount from
65 to 150 oz. per diem. It was highly albuminous, and contained a few hyaline
casts. This large quantity of urine continued to be passed daily for several
months during which he was under observation. The liver and spleen were
natural.

The patient having left Edinburgh, I lost sight of him ; but the symptoms of
his case were so distinctly those of amyloid degeneration, that I nave no
hesitation in including him in this category.

Case XI. — J. M., et. 36, a labourer, was admitted to the Hoyal Infirmary,
under the care of Dr Haldane, in April 1864. He had led an irregular li&,
had been a soldier, and was believed oy his friends to have been the subject of
syphilis. About two years before admission he was observed to make large
quantities of water, and at a time at which he exhibited no other symptoms of

104 DB GRAINGER STEWART ON THE WAXT OR [AUG.

illneiw, his frequent micturition had become a standing joke in his family
circle. About six months before admission he became dropsical, and exces-
sively intemperate. About the middle of April he was exposed to cold and
wet, and was seized with rigors, following upon which was a severe pneumonia,
from which he died.

AtUcpty. — His body was examined eighteen hours after death. The heart
was normal. The right lung was pneumonic throughout, some portions of
it in a state of gre^ hepatization, otners less advanced. The left lung was
adherent to the diaphragm at the base, and in its lower lobe contained a
cicatrix. The liver weigned 5 lbs. 10 ounces, was waxv and fatty. Spleen
waxy, weighed upwards of 1 lb. The kidnevs were both enlarge^ the ri^ ht
weighed 11 ounces, and the left 9 ounces. Both, of them presented exquisite
examples of the amvloid degeneration of the vessels ana Malpighian tufts.
There was also marked fatty degeneration of the epithelium in the tubules,
and while the whole organs were increased in size, the cortical substance was
relatively diminished. The surface was granular. There was abundance of
fat throughout the bodv, particularly in the omentum and mesentery. The
intestines tore off from tlie mesentery with the greatest ease. Its vessels were
found to be in a state of amyloid degeneration. The villi and minute arteries
of the small intestine presented exquisite examples of the degeneration.
Brain congested. Serous effusion on its surface ana under its membrane.

Case XII. — M. R., set. 44, was admitted to the Roval Infirmary, under the
care of Dr Sanders, 26th May 1864. She was a field-worker, and latterly
a washerwoman ; had generally been healthy, but for two months before admis-
sion had been* out of nealth; her breathing being embarrassed, her appetite
poor, bowels loose, urine copious. A fortnight before admission dropsy had
appeared. The quantity of urine was upwards of 80 ounces daily ; it was pale,
of specific gravity 1011 ; contained albumen, and no tubecasts. In the hospital
these symptoms continued, and she died exhausted on 10th June.

Autopsy^ seventy-two hours after death. The body was well nourished.
The heart was natural. Aortic valves somewhat thickened. Arch of the aorta
was very atheromatous, and contained some calcareous plates. The lungs were
oedematouB. Near the root of the lefl there were some tubercle-like deposits.
Bronchial glands were enlarged, one of them suppurating. The liver was some-
what waxy ; presented some syphilitic cicatrices. The spleen was intensely
waxy, and throughout its substance there were a number of small abscesses. The
pus which they contained was normal, and presented no reaction with iodine.
The abscesses were scattered throughout the substance. The capule was
thickened, but not of dense structure ; it was adherent to neighbounng parts.
The kidneys were atrophied, and intensely waxv, some of the tubes as well as all
the arteries and Malpighian tufts presenting the ordinary reaction with iodine.
Connected with the uterus was a number of fibrous tumours. The ovaries
were fibrous. The intestinal canal was also in a state of waxy or amyloid
degeneration ; its viUi and small vessels presenting the reaction very distinctly.

Case XIII.— A. L., set. 26, admitted 16th May 1864, to the Royal Infirmary,
under the care of Professor Bennett. The patient was a sempstress, un-
married. She stated that she had been quite healthy until two years ago
(May 1862), when she had acute rheumatism, and since then had never been
well. Her feet and legs, and afterwards her abdomen, swelled, and she was
obliged frequently to get up during the niffht to make water. On admission,
the heart and lungs were normal, face swollen, skin pale. The urine was large
in quantitv, varying from 70 to 100 ounces daily, of low specific gravity, and
of pale colour; it contained abundance of albumen, and some tubecasts. She
also had severe diarrhoea, and occasional sickness and vomiting. The dropsy
gradually increased, and she died exhausted on the 29th of June.

AuUipty. — The face and upper parts of the body were very oedematons.
The abdomen was somewhat distended with fluid, and the legs pitted slightly
on pressure. The heart was natural. The left pleural sac was obliterated by
old adhesions, and in the right there was considerable effusion. The lungs

1864.] AMTLOIU FORM OF B11IGHT*8 DI8BA6E. 105

were congested and ^ematous. The liver was connected with neighbourinff
parte by a number of old adhesions, and on its surface there were several
cicatrices. The whole organ was fatty and waxy ; the vessels exhibiting a
distinct reaction with iodine. The cicatrices were composed of fibrous tissue,
with numerous vessels in a state of waxy or amyloid degeneration. The
spleen weighed 8 ounces. Some of its vessels and Malpighian bodies were
waxy. The kidnevs weighed 6| ounces each, were fatty and waxy, granular
on the surface; the cortical substance partially atrophied. Many of the
tubules were filled with granular exudation, and the vessels and Malpighian
bodies presented the appearance of the waxy degeneration and a marked
reaction with iodine. Some of the smaller vessels were also fatty. The intes-
tines were waxy throughout their whole extent, and presented no trace of
ulceration. In the lai^ intestine rings of pigmentary deposit surrounded
many of the solitary folhcles.

Cabb XIV.— a. C, »t. 30, was admitted dOth May 1864, to the Royal
Infirmary, under the care of Dr Sanders. The patient stated that she enjoyed
ffood health till within four weeks of her admission, but for some months
before had observed that she passed a lar^r quantitv of urine than natural.
She was obliged to get up several times during tne uignt in order to micturate.
She had a little dropsy, but it disappeared on the occurrence ot diarrhcea
a few weeks before admission. Her urine was pale, of specific gravity 1010,
contained much albumen ; was always upwards of 60 ounces daily, although
she was affected at the same time with severe diarrhoea. She had frequent
vomiting, and gradually became exhausted and died on 28th June. There was
a distinct history of scrofula in her fiimily. There was no positive evidence
of syphilis, but she had the cachectic appearance, and comphuned much of
pains in her bones.

Autopty, — The body was somewhat emaciated. The heart and lungs were
natural. Bronchi contained much mnco-purulent fluid. The liver was large,
weighed 4 lbs. 6 ounces ; was bound to the diaphragm by numerous old adhe-
sions. It was fatty and waxy throughout ; both the vessels and cells were waxy.
The spleen weighed 1 lb. 1 uunce ; was intensely waxy. It was adherent to the
diaphragm and neighbouring parts. The kidneys were both enlarged, the left
weighme 9 1 ounces, the right 1\ ounces. Both were intensely waxy. The
vessels both in the cortical and conical substance, and the basement membranes
of the tubes, presenting the amyloid reaction. In the right there were some
tubercular-like masses, with corresponding cicatrices on the surface. The
intestines were in a state of waxy degeneration. There was a small super-
numerary spleen, which was also intensely waxv.

Case Xv. — A. F., set. 22, a hawker, resiaing in Fountainbridge. She
came under my care in March 1862, complaining of cough and oedema of
her feet. I found that for three years she had nad a cough, accompanied
with expectoration and shortness of breath. Her chest gave signs of phthisis
pulmonalis, but of a very chronic character. There was comparative dulness
at the right apex; the respiration was indistinct, and accompsnied by fine
crepitation in tne same region. The respiration at the left apex was clear, but
the cardiac sounds were ver^ distinctly propagated. The liver was enlarged,
and extended across the epigastrium. Its vertical dulness in the mamillary
line measured 5 inches. The spleen was not enlarged. The quantity of
water was much above the normal, ranging from 80 to 130 oa. per diem. It
was of a pale amber colour, slightly albuminous. No casts were found. The
skin was dry ; the appetite very fitful.

Since 18^ the patient has l>een under observation, and has sometimes im-
proved in strength under tonic treatment, and at times suffered accessions of
ner disease. She has continued to pass large quantities of urine, which has at
tiroes been albuminous, at others not. She has also had hemoptysis, and her
chest symptoms are increasing in severity.

When sne was lately an inmate of the Royal Infirmary, the following was
her condition :~Skin pale; respiration harsh; slight dulness under right

VOL. X. — NO. u. o

106 DB 6BAIKQEB STEWART ON THE WAXY OR [AUG.

clavicle; appetite irregular; urine about 105 oz. daily, of a pale yellow colour,
ftpectfic gravity ranging from 1005 to 1012, of acid reaction, contained much
albumen, much epithelium, and no sugar ; no tubecasts were found. In thia
condition she continued when last seen.

Case XVL — Mr , a gentleman of independent fortune, had, at about the

affe of 14, an abscess in the rifht side, near the hepatic region, but the source
of which was not ascertained. He after this was healthy, vigorous, a keen
sportsman ; but at the age of 31 he began to complain of gripine pains and
severe diarrhoea. On examination it was found he was passing large quan-
tities of urine. He was frequently obliged to get up during the night, ib
order to micturate. The urine was quite clear, very pale, of specific gravity
1008, containing albumen in considerable quantity. The casts were few, hya-
line, with occasional fatty cells. The appetite was capricious ; the stools were
pale, and of an offensive odour. The liver was not enkirged. His symptoms
gradually increased, and he died about the age of 32.

No autopsy was permitted ; but his symptoms were so distinct as to incline
me decidedly to reckon this a ease of waxy degeneration of the kidney and
intestine.

The following case illustrates the apparent curability of this
degeneration. The patient exhibited all the symptoms of the
degeneration of the organ, but these symptoms gradually disap-
peared:—

Casb XVn. Mr M., a gentleman, sot. 21, resident iu Edinburgh, has been
under my care for some months.

Some years ago he fell into a state of delicate health. His appetite became
poor, and he became subject to occasional hemorrhages, from the nose and
other sources. His liver was greatly enlarged, eitending downwards to the
umbilicus; the quantity of urine mcreased to a marked extent, and was
albuminous ; his bowels were very irr^^r ; and his general health much im-
paired. Under a course of iron, and of iodide of potassium, his general health
improved, the liver diminished in sice, and the urine became free of albumen.
For about a year past no albumen has been observed ; and his strength has
become such as to enable him to resume his ordinary employment, and to
work at it regularly durine the past winter. The liver continues, even now,
somewhat enlarged, and the cachectic appearance continues, but the urinary
symptoms have very markedly improved.

The following case is of interest, as one possibly of amyloid
degeneration of the kidneys, though the disease is not in the mean-
time distinctly defined : —

Case XVIII.— W. L., a brassfounder, set, 53, was admitted to the Royal
Infirmary in March 1864, under the care of Dr Haldane. He states that he
never had any venereal disease, excepting an attack of gonorrhoea, thirty years
ago. He has been tolerably steady, but, while working in London, was
accustomed to consume a good deal of beer. He noticea for some months
past that he has been obliged to rise during the night to make water ; and that
if he was much confined his feet swelled slightly. In the end of February he
vomited some clotted blood, and his stools were black.

On admission, he was anasmic ; the skin and sclerotic slightly icteric ; the
eyelids were distmctly oedematous; the tongue was furred ; the appetite poor ;
the bowels constipated. The liver was of normal size ; the spleen measured
3 inches vertically, and 44 inches across. The red corpuscles of the blood
were pale and flabby, and the white were not increased in number. The
heart and lungs were normal. The urine was, on the day following his
admission, 60 oz., of specific gravity 1015 ; of a straw colour ; acid reaction ;
contained a slight mucous cloud ; otnerwise normal. The following day, how-

1864.] AMYLOID FORM OF BRIOHT'S DISEASE. 107

ever, he made more water, about 100 os., of specific grayity 1010; and he
has continued ever smce to pass that amount at least, every day. Albumen
has not been observed. His general health has somewhat improved; but a
lumbtf pain has appeared, the oedema of the eyelids is undiminished, and his
mrinary symptoms continue. I mentioned in my former paper that I had
anticipated in one case the appearance of the albumen in the urine, judging
from the symptoms that an early stage of amyloid degeneration was present.
It seems not unprobable that in this case also we have the early symptoms,
which may erelong develop themselves into something more important.

Haying thus sketched the cases which I have recently obeervedy
I shall now proceed to speak of each of the symptoms in saccession,
to indicate tneir importance. *

The Quantity of Urme. — It will be observed that in all the cases
I have mentioned, this is a prominent symptom. The increased

Joantity of nrine being marked throughout the whole cooroe of the
isease; a diminution below the natural standard occurring only
towards the end of the case, or under accidental influences. In
many cases I hare found that the patient was not aware of the
increased flow of the urine, and onl^ indicated it when he stated
that he had to get up frequently during the night to make water,
and that at each time he made a natural or excessive quantity ; ana
thus I have found it necessary to ask them, not only whether they
have observed that they made an excessive amount of water, but
whether calls to micturition had disturbed them during the night.

The pathological anatomy of the disease seems to me to account
very well for the changes in the amount of thiB secretion. The
earliest manifestation of the degeneration is commonly in the trans-
verse muscular fibres of the small arteries, and if these fibres are
degenerated, it is reasonable to suppose that they are paralyzed, and
so the regulating influence lost, ana a congestion of the Malpighian
bodies results. Unquestionably, when the defeneration has advanced,
it diminishes the lumen of the arteries, and so must diminish the
supply of blood ; but other parts may act more vigorously, and more
than compensate for the aisadvantage. In the extreme stage a
diminution actually does take place, and this perhaps coincidently,
as I previously suggested, with exudation into the uriniferous tubules,
as well as extreme degeneration of the arteries. This view, which
I maintained on a former occasion, was opposed, on the ground
that, in proportion as the degeneration of the arteries advanced,
their calibre became diminished, and, as a necessary consequence,
a smaller quantity of blood than natural could be transmitted to
the vessels beyond ; and if it were true that the watery part of the
urine was mainly derived from the Malpighian tufts, it seemed very
strange that the secretion should be increased, for it was precisely
in the vessels forming these tufts that the degeneration was found
most advanced ; and it was maintained that the only way in which
the increase of urine could be accounted for was by a reference to
Virchow's and Beale's discoveries as to the circulation in the kidney.
These observers show that a considerable quantity of blood passes

108 DR GRAINaER STEWART ON THE WAXT OR [AUG.

directly irom the branches of the renal artery into the vasa recta of
the medullary portion, and from thence into the capillaries, without
passing into the cortical portion at all. From this it is evident that
not only in the waxy degeneration, but in other forms of disease of
the kidney, where there is an obstruction of the paBsase of blood
through the vessels of the cortical portion, an increased collateral
nressure would be exerted on the vessels oi the medullary portion,
nrom which, in conseauence, an increased flow of watery urine would
take place, and the whole quantity passed might be above, or, at
least, not below the average. But the amount of blood sent directly
to the medullary portion is very much less than that sent to the
cortical substance, and no one can conceive that a shutting off of
the latter from functional activity could be more than compensated
by increased activity in the former. To say that a set of vessels,
not amounting to more than one-fifth of another set, are capable of
performing all their functions, seems to me extremely unsound, and,
especially in this case, untenable, seeing that the vasa recta of the
medullary portion are themselves very often the seat of this degene-
ration, ana ^et the poljniria is present. The explanation seems
quite inapplicable to this form of disease. Besiaes, it is by no
means proved that merelv the amount of blood in a vessel bears
relation to the amount oi fluid transuding through its walls ; the
state of these walls themselves may probably influence these transu-
dations in a manner and to a degree that we by no means under-
stand. I do not wish to commit myself to any theorjr on this point,
but it seems to me that the probabilities are more in favour of my
explanation than of the other. An increase of thirst and of drinking
cannot be regarded as the essential cause of the polyuria, seeing that
in some cases I distinctly ascertained that the amount of urine was
equal to, or even surpassed, the total amount of fluids consumed.

Character of the Urine. — The pale colour, and low specific gravity,
and the presence of albumen, do not require special notice. The
quantity of urea I hope soon to make the subject of special inquiry.
The Tubecasts, — ^In the amyloid degeneration we may meet with
tubecasts of various kinds, the delicate transparent casts, which
were formerly called waxy, and are now better termed hyaline ;
these hyaline casts with occasional epithelial cells in a state of
fatty degeneration enclosed in their substance, others with a larger
number of fatty cells, and occasionally finely or coarsely granular
casts. Occasionally we see casts containing individual cells in a
state of amyloid degeneration, and presenting its peculiar reaction.
The occurrence of casts, such as these last mentioned, and which
may be termed the amyloid casts, would of course establish the
diagnosis of amyloid degeneration of the kidney ; but none of the
others aflbrd any special evidence on one side or other, for they
occur in all forms of Bright's disease. Thus, the hyaline casts con-
stantly occur in the late stages of that degeneration which follows
upon acute nephritis, and are thus evidently derived from uriniferous

18^.] AMYLOID FORM OP BRI0HT*8 DISEASE. 109

tabnles which have been denuded of epithelium. Those which
contain a few cells in a state of fatty degeneration, and derived from
tabtdes whose cells have in so far been destroyed, but in which some
still remain) and those which present the granular appearance^ are
either composed of cells completely broken down, or of exudative
matter in a state of incipient degeneration. If we trace a case
of acute nephritis, we find in succession bloody and epithelial casts,
granular casts, fatty casts, the amount of fatty cells gradually dimin-
ishing, and ultimatelv hyaline casts. In the waxy or amyloid
degeneration we see the same casts, but appearing in the reversed
order. Many varieties of conditions of the tubules exist in these
cases of amyloid degeneration, and consequently we have a corre-
sponding variety of casts. In the gouty kidney we also meet with
the same forms ; so that in no case can we positively conclude, unless
where we have bloody or amyloid casts, as to the nature of the dis-
ease from their indications. It is true, that in the earlv stage of the
amyloid de^neration hyaline casts prevail ; but that, if unsupported
by other evidence, cannot enable us to establish a diagnosis. Casts
are formed by the coagulation of an exudation, or transudation
poured out mm the bloodvessels into tubules. This exudation,
of course, encloses within it the epithelial or other elements which
may be present within the tubes, and when the current of urine
carries away the exudation, it, of course, carries also the enclosed
matters. Thus, if it be poured out into a tubule denuded of
epithelium, hyaline casts result: if into one full of cells, cell
tubecasts result ; if into one witn a few cells, corresponding casts
are formed. It is much to be regretted that the term '^waxy
casts" has so often been applied to the hyaline, for it has led
many to imagine a relationship between these casts and waxy
degeneration. The name is one which can only deceive, and should
be abandoned.

Dropgy. — In some cases this symptom never appears at all ; but,
in the majority of instances, it occurs as a serious concomitant late
in the disease, and in many at earlier stages. The patient com-
plains that towards evening his bo3ts become tight, though they
fitted him comfortably in the morning. This state may continue
for months, and only very gradually increase so as to become
serious. Very commonly it first becomes severe in conseauence of
an intercurrent attack of acute nephritis. I do not think that it
consists with the object of the present paper to enter into the causes
or mechanism of dropsy ; we shall therefore not say more on this topic.

Diarrhaoa. — This is a very common, and frequently veiy serious
symptom in cases of waxy degeneration. It appears to occur in all
cases where the mucous membrane of the intestine has been affected.
In the " Cellular Pathologic," Virchow speaks of the association of
this symptom with the degeneration of the intestine as an estab-
lished fact, and it will be observed that the cases I record confirm
his observation.

Temperature. — ^I am indebted to my friend Mr Herbert Taylor

110 DR QBAIN6EK STEWART ON THE WAXT OR [AUQ.

for a few observationB on the temperature of A. M.^ Case 1, from
which it appears that a constant diminution by a few degrees
exifltedy but much more extensive observation would be required to
enable us to arrive at anj general conclusion on this subject.

The CackeaAa,^ and the &ate of the Liver and the Blood. — ^In many
of the cases it will be observed a peculiar cachexia exists. There
is a pale anssmic appearance^ with occasionally a little dark pig-
mentary deposit in the skin^ particularly about the eyelids, an
air of general debility, and a pasty or waxy complexion. This
would seem to be most commonly associated with the syphilitic
forms. In other cases there is a characteristic appearance of the
face with which I have become familiar, when the surface generally
is pale and clear, but a very distinct conation exists over botn
cheeks. This is not a congestion like a blush, but is seen by the
naked eye to depend upon distention of narrow, small vessels, quite
above the size of capillaries. These appearances, though interest-
ing, do not seem to me important. But in many of the cases we
have a distinct morbid condition of the blood, along with a slight
increase of the colourless corpuscles. We observe that the red
are soft and flabby, tending to tail, and form groups rather than
rouleaux as do healthy corpuscles. This condition seems to depend
upon affection of the spleen and lymphatic &;lands with the amyloid
degeneration. In not a few instances the liver is found enlarged,
sometimes to an immense extent, and whenever we find this con-
dition, as well as those above indicated, we have a certain amount
of evidence corroborative of the other more important symptoms.

The Previous History is often of great value in assistmg us to
arrive at a conclusion on the question of the nature of such cases.
The fact has long been known that the amyloid degeneration is
induced by long-continued wasting diseases, particularly syphilis,
caries, and necrosis, and thus it is obvious that the fact of any of
these having occurred in the previous history is in so far an evi-
dence that the case of Bright's aisease is one of this particular form.
At the same time, it is by no means a constant occurrence that these
^maladies precede the degeneration, and they are therefore not to be
looked for in every case.

The Duration of the Disease is evidently, from some of the instances
recorded, very protracted. One of my cases (A. M.) has been under
observation for upwards of four years, and though it was during
that period that his albuminuria first appeared, we have no positive
proot how long the polyuria had previously existed. The case also
of E. B. was under observation for more than three years and a
half, and when he first attracted my attention he had for some time
been affected. The woman E. H., whose body was examined in
Jiuie, had been under observation for four years, and had
throughout presented the same characteristic symptoins. In many
cases, then, it would appear to be very chronic, and I have not yet
seen a case from the very commencement of the renal symptoms to
its fatal termination. The health of those who are suffering from

18ei.] AMTtOlD FOkM OF BBIGHT's DI8EABE. Ill

the maladjr is never good ; they are weakly, and have a great want
of vital force, and are apparently very liable to other affections.
They are subject to pains, aches, hemorrhage ; but on the whole do
not suffer mach from their degeneration, unless when it happens to
occur in the intestine, when the wasting diarrhoea becomes a dis-
tressing symptom.

I%e Modes of Terminaium ofAe Ca$ei. — A lar^ majority, indeed
almost all, seemed to pass on to a fatal termination ; but from two
cases, Nos. 15 and 17, 1 am inclined to think that it is not invariable.
In both of these instances the albuminuria disappeared from the
urine, and even the quantity of that fluid became diminished under
the influence of tonics and good diet and regimen. In one of them
this has gone on to what seems a complete recovery. In the other,
relapse occurred so soon as she was deprived of the favourable
surroundings in which she had been temporarily placed.

When it terminates fatally it would seem to lead to death in a
variety of ways, most commonly by a disease superadded to the
degeneration, sometimes an inflammatovy affection of the kidneys,
sometimes a disease of the bronchi, and sometimes from the ordinary
concomitants^ such as phthisis pulmonalis. In no case have I seen a
patient die simply of the degeneration or its direct consequences ;
there seems to be always another disease superadded.

TreaknenL — ^The cases which I have recorded render it perfectly
evident that, under judicious treatment, the symptoms of this
degeneration may be greatly ameliorated, and perhaps the degenera-
tion itself cured. The rules which seem to me most important are,
latj To attend to the nutrition of the patient, giving good nutritive
food in the forms best suited to the individual tastes and powers of
digestion ; 2^9 To give such tonic medicines as may improve the
appetite ; 3dy To give such hasmatic medicines as control the ten-
dency to anaemia, and among these pre-eminently the syrup of
the iodide of iron ; 4t&, In all cases in which a syphilitic infection
has been traced, and even in many others, to give the iodide of
potassium in moderate and sustained doses. The effects of these
medicines are often very striking^ and in particular the influence of
iodide of potassium in diminishing the oulk of the liver is most
remarkable. Ag^in and ^ain I have seen the size of the organ
diminish under its use. In many cases all that we can do is of
little or no avail, and the patient becomes worse and worse, and
ultimately sinks.

Let us now fflance at tlie amount of evidence we have collected.
I have recorded in my two papers thirty-four cases, in all of which
a certain series of symptoms was observed, which svmptoms I
associate with the waxy or amyloid degeneration of tne kidney ;
one of the forms of Bright's disease. In nineteen of these cases a
post-mortem examination has been made, and in all of them the
expected lesion has been found. In no case hitherto have I
examined a body expecting the lesion and not found it. This
evidence seems to me to prove that in many cases of the degenera-

112 DR REId's cases of delirium tremens [AUG.

tion the symptoms are such as I describe, and are so distinct as to
enable us positivelj to distinguish it from other forms of renal
affection. But I bj no means assert that I have absolutely esta-
blished my views, and still less that I shall not likely require
to modifjT them. 1 recommend the subject anew to the attention of
the prorcssion, anxious to test my obseryations by the general
experience, and only recommending a very careful sifting both of
the history and symptoms before a diagnosis is attempted.

ARTfCLE II. — Gtues of Delirium Tremens treated with Large Doses
of the Tincture of Digitalis. By John Watt Reid, M.D.,
Surgeon, R.N.

The following cases came under my care whilst I was in charge of
the Royal ifaval Hospital at Halifax, Nova Scotia. As they
appear to me to possess some points of interest to the practitioner,
I now lay them oefore the Profession.

Case I. — J. S., aged 41, boatswain's mate, a large-framed
powerful man, was admitted on the 6th June 1862, with delirium
tremens of 24 hours' standing, said not to be his first attack.
Three half-drachm doses of tincture of opium had been given, and
he had slept about half an hour. When admitted there was much
tremor ; but he was by no means violent, and he did not wander
very much ; the pulse was 92, soft, small, and irregular. Until the
afternoon of the 9th he was treated with opiates and stimulants, the
bowels having been kept open by injections, without any sleep
being obtained. He had become extremely restless, and talked
constantly.

At 3 P.M. on the 9th, the pulse being then 120-132, rather small
and hard, and the pupils much contracted with injected conjunc-
tivae, half an ounce of tincture of digitalis was given. At 8 p.m.,
as he still had not slept, a similar dose was repeated ; and at 11 p.m.
he got two drachms more. The pulse continued regular, and had
fallen 20 beats. He was a good aeal quieter, and looked sleepy.

10^. — After the last dose he lay quiet, only tumine now and
then; and at 4 A.M. he fell asleep. He did not awake until a
quarter to 6 P.M. (indeed I roused him up), when he spoke quite
sensibly and calmly. However, at 7.30 p.m. he suddenly started
up in bed in an excited mannef ; and then, as the pulse was 96,
quite regular and good, another two-drachm dose was given.

llih. — He slept from 10 p.m. until 5 a.m. During the day he
got an aperient aose, and he took an egg, beef-tea, etc. In the
evening, although he had slept at times during the day, and his
manner and appearance were quite quiet and con^sed, two drachms
were given as a sleeping draught. Subsequently he needed nothing
but nourishing diet, with porter, vegetable bitters, a laxative, etc.
In this case the pulse never intermitted, and did not fall below
84-96, although so large a quantity of digitalis was given. I may

16M.] TREATED WITH LAME 00«E8 OP DJOrTALIfl. 113

here remarkj Aai eertamly lAe loH doKy amd, periajm^ oUo tke cm
hefimrey wob ufmecestary.

Case II. — J. B., aged 44, able aeaman, a spare but muscular nan,
was admitted on the moming of the Idth June 18^2. He had \iefn
placed apon the sick-list in his own ship on the l^th, ha%'in);
previously been on shore drinking for five or six day*. The
sjnnptoms at first were much tremor and sleeplessne^^ with vcimit*
ing, for which opiates and stimulants had been given without Unrnt.
On the 14th, be had become delirioos, with occasional violt-TK^
which was said to be increasing. When admitted he w«ii<J«*rfd
much, and was restless and obstinate, bat not violent; the eyes
were oleared and fiery; the tongoe was red and clean, but ni<»i5t ;
the bowels were open ; the poise was 116, fall and forcible. It waA
said that he had slept a very little on the evening of tlie 13th.
Half an ounce A tincture of digitalis was given at 10 A.if . : and at
1 P.M., as he was then in much the same stale, a mmilar do« was
repeated. He fell asleep at 3 p.m.. and slept until 9.30 P.M. On
awaking he vomited a good deal of bile, without any smell of
digitalis.

At 11 P.M., not having again fidlen asleep, and the raise being
96-102, and quite refi;ular, two drachms were given ; oat almost
immediately afterwaraB he vomited. In a few minutes he dozed
off; and he slept the whole nig^t afterwards. Next moming he was
quite rational, and said that he felt well, <mly weak ; the pulse was
60, occasionally intertniuina. Nourishing diet, porter, vepretable
bitters, etc, were afterwards given. In Mtf ooae, oZso, one dose loo
much was given.

Case IU. — ^H. M., set 38, caulker, a stout muscular man, was
admitted on the moming of the 18th June 1862. There had been
no time for treatment, as he was sent to the hospital immediately
upon being taken on board his ship. He wandered much, but there
was no great degree of tremor; the puLae was 96, full and strong ;
the tongue was white and moist Half an ounce of tincture of
digitalis was given at 10 A.M. ; and at 2 p.m., being then cjuieter,
with a softer and still regular pulse, and although he complained of
slight nausea^ a similar dose was repeated.

At 6 P.M. ne had not slept; the pulse was 48, intermitting trery
two or three beats with a thrill, but of good strength. He had
vomited some tea (which had been given against orders), half an
hour before. After taking a little arrow-root he fell asleep ; and he
slept calmly until 7 a.m. next morning.

At 9.30 A.M. (on the 19th), die pulse had not risen above 48,
but it was quite regular and good.

He continued well, and convalesced rapidly.

Case IV. — ^T. A., aged 28, able seaman, a short muscular roan,
was admitted on the moming of the 12th November 1 862. He bad
had half a drachm of tincture of opium when taken to the sick-bay
on board, at 8 A,M. that day, having returned to his ship from

VOL. X. — NO. n. p

114 DR reid's cases of delirium tremens [Aua.

broken leave during the previous night. When admitted there was
great tremor, with frequent rigid spasms ; he was very restless and
alarmed, and would not reply to a question; the pulse was 112-
120, and full.

Half an ounce of tincture of digitalis was given at 10 a.m. In less
than half an hour he was calm and answered reluctantlv and slowly,
but rationally ; and soon afterwards he fell asleep. When he awoke
in the evening he was quite composed and sensible, took some
arrow-root, and slept again. The pulse was 96, regular, and good.
Next day he got some calumba and bismuth, and he speedily was
quite well.

Case V. — A. A., aged 29, private marine, a well-made, strong
man, was admitted on the 6th June 1863. He had had a grain of
morphia the evening before when first seen on board his ship.

On admission he trembled much, and had a wild^taring expres^
sion ; he was only partially sensible, and articulated with consider-
able diflScultv, but lay muttering and mumbling ; the pulse was 96-
108, full and soft ; the tongue was coated and moist.

10 A.M. — Half an ounce of tincture of digitalis was given (as in
the former cases, with the same quantity of water).

1 P.M. — He was much calmer, and spoke more distinctly and
rationally. The pulse was 96, smaller, qmte regular. A similar dose
was repeated ; but at 2 p.m. he vomited matters smelling of digitalis.

6 P.M. — He had taken and kept down some arrow-root, and had
Iain almost quite quietly, but had not slept. The pulse was 72,
oocasionaUy intermtUinff.

11*30 P.M. — He had dozed a little. All tremor had left him.
The pulse was 60-72, and intermitted as before. He complained
of cardiac oppression and slight headache.

7th June. — He slept nearly four hours in the middle^watch. The
pulse was 48-56, intermitting, of fair strength. He was quite
collected, and said that he felt much better ; he had no headache,
but still complained of some degree of uneasiness in the region of
the heart. A bitter infusion was ordered ; and strong beef-tea, with
bread, was given. In the evening the pulse, which had been in-
termitting less and less during the day, was 60, and almost quite
regular. Two drachms of the tincture were given at 9 p.m. as a
sleeping draught, but vomiting occurred about 11 P.M. However
he slept the greater part of the night afterwards. Convalescence
ensued steadily. In this case, as in Cases I. and II, one dose more
than voaa required^ or vxis judicious^ toaa given.

Case YI. — B. S., aged 34, private marine, a middle-sized,
muscular man, was admitted on the 26th June 1863, without any

Erevious treatment. He had broken his leave, and been drinking
ard, and leading a very dissolute life for nearly a week. When
admitted there was moderate tremor ; he wandered but little, and
could be readily made to answer rationally ; he lav with a fixed,
staring, penitent expression ; the pulse was 108, full and soft ; the

1864.] TREATED WITH LABOE D0AE8 OF DIOITALT8. 115

tongue was coated and dry. Half an ounce of tincture of digitalis
was given at 10 a.m.

3 P.M. — There was little or no change, only the pulse was 72,
but quite regular.

5 P.M. — He vomited a good deal of greenish matter, without any
smell of digitalis. The pulse was 60| and still regular. He was
inclined to sleep. Some arrow-root was given, and kept down.

8 P.M. — ^He was dozing. The pulse was 48-52, intermiuing
after twelve or fourteen beats. He had no cardiac uneasiness.

21 ih June. — He slept several hours during the night The pulse
was 68 to 72, intermitting as before. Afterwards nourishing diet
and tonics were given. Convalescence was slow, owing to the weak
state of his stomach, etc., caused by his previous dissipation.

Remarks. — ^I have but a few remarks to add, for the cases, short
as the^ are, speak sufiBciently plainly for themselves. No doubt
the digitalis was pushed ftirther than was necessary or even advis-
able in Cases I., II., and V. ; but in the first, at any rate, I had all
the zeal of a convert who had previously entertained a groundless,
perhaps an unreasonable, dread and disuke to the remedy. I must
own that I commenced the new treatment with apprehension, but
at the time I had little or no hope of the man's recovery j in fact, I
regarded him as a dying man, so I considered myself justified in
the adoption of what 1 then looked Upon as an extreme measure.

I would particularly call attention to the large quantity that was
borne in tne first case, without inducing vomiting, or causing
intermittenoe of the pulse, — ^to the vomiting which occurred in Cases
II. and v. ; (is vomiting an indication of the limit of tolerance?), —
to the almost instantaneous effect of the single dose in Case IV^ —
and to the contrast afforded by Case I. to Cases III., V., and Vl.,
in the impression on the circulation.

It seems to me that this digitalis treatment is more smtable for
hospital patients, either in naval and military or civil life, than for

Erivate practice, unless when the physician can see the case every
our, or oftener, and can have an intelligent and trusty nurse by
the bedside, with assistance at hand if need be. All my patients,
too, were men in the prime of life, who had been previously in
robust health ; and such treatment is perhaps more adapted for
patients in similar circumstances, than for habitual drunkards with
Droken-down constitutions.

The precautions that I took were, to ascertain that no heart-
disease existed, and to prevent the patient leaving his bed for any
Eurpose before he slept, and for at least twenty-four hours after he
ad regained his nervous control. I always saw, also, that he got
a small quantitpr of strong beef-tea (essence of beef), or of arrow-
root, at proper mtervals before sleep.

I have only further to add, that the drug had been in my charge
two and a half years, and had been supplied from the Boyal Naval
Hospital at Plymoutn (originally from Apothecaries* Hall, London).

116 DR PARKER'8 case OF DEATH RESULTING [AUQ.

Article III. — Case of DeaA resulting from the PrcusUce of Arsenic-
Eating. By D. M^N. Parker, M,I)., Halifax, Nova Scotia.

The repeated assertions of travellers, aided hj the occasional
reports of medical men, to the effect, that the inhabitants of Styria
and other parts of the Austrian empire have been accustomed for
years to take increasing quantities of arsenic, with apparent benefit
to their respiratory organs, general appearance^ and health, have
doubtless had the effect of influencing many vam and thoughtless
individuals to practically test the matter on their own persons.
Fatal results have, I believe, been known to follow the habit in
Styria ; but I am not aware that there is a published history of any
such cases. Its novelty, its scientific bearings and interest, as well
as the desire to prevent, if possible, the continuance of such a prac-
tice, wherever it may have oeen adopted, induce me to give early
publicity to the following case, which, unhappily, terminated fatally
while under the professional cnarge of Dr Tupper and myself.

A. C, photographic artist, unmarried, set. 30 ; a strong, muscu-
lar, well-built man, two years since consulted me on account of an
obstinate chronic sy{)hilitic throat. He was a private patient from
November 1860 until May 1861, when, consiaering himself well,
his visits were discontinuea. During this time he was taking one
or other of the following preparations : — Iodide of potassium, iodide
of mercury, bichloride of mercury. Fowler's or Donovan's arsenical
solutions. He frequently complained of my prescriptions producing
abdominal pain and diarrhoea, which symptoms were occasionally
so urgent that I was obliged to discontinue the treatment, and resort
to opiates and astringents.

After May 1861, 1 occasionally met him in the street, apparently
in the enjoyment of vigorous health, but saw nothing of him pro-
fessionally until Thursday the 20th November 1862, when I
received a pressing message to visit him at his lodgings, which I
did at half-past ten o'cIock p.m. I found him in bed, suffering
intense pain in the region of the stomach, which was not materially
increased by pressure. The abdomen was much swollen and tym-

Sanitic, vomiting was incessant, and thirst intense, with a constant
esire for cold water, which, even in the smallest quantities, could
not be retained. His pulse was 110, regular, but soft and weak;
the skin was cool and moist; tongue moist, and coated with a
thin white fur ; urine scanty ; respiration natural ; countenance
anxious ; features contracted, and the face much thinner than when
I had last seen him. His complexion was unnatural, and by gas-
light, was of a dark greenfsh hue ; head free from pain, and intel-
lect clear.

He stated that for three or four weeks past he had suffered from
what he considered dyspeptic symptoms, during which time he
frequently complained of pain after meals, and could use little else

1864.] FROM THE PRACTICE OF ARSENIC-EATING. 117

than oatmeal porridge, or other lieht farinaceous food. On the
Sunday previous (16th November), he walked a distance of twelve
or fourteen miles, and in the evening complained of fatigue. Before
retiring to rest he partook of a hearty tea, with cold meat. The
following evening, contrary to his usual habit, he partook somewhat
freely of brandy and water. That night (Monday^ he rested badly,
and vomited frequently. ^

While engaged in examining the case, and endeavouring to ascer-
tain the exciting cause of so much pain and suffering, he abruptly
said, " Doctor, would the daily use of arsenic, for a long time, pro-
duce this disease ? I have been in the habit of using it for years,
and it has never before injured me ; but the idea has just struck me
that it may be the cause of all the mischief; '* or words to this effect.
I replied that the symptoms were analogous to those of arsenical
poisoning, and then, as briefly as possible, elicited the following
facts from him : — About four years ago, he met with an article in a
newspaper, or magazine, relative to the practice of arsenic-eating in
Styria. Struck with the reported results, he resolved to practically
test the matter on his own person, and at once commenced the use
of arsenious acid. At first he took it in minute doses, measuring
the quantity with the eye, on the point of a penknife. Sometimes
it was taken rolled up in thin paper, at other times it was merely
placed on the back of the tongue and swallowed unprotected.
Having always used it in this loose and careless way, it was im-
possible for him to do more than give an approximate estimate of
the quantity thus daily consumed. Pointing to a one-m'ain pill of
onium made up with a small portion of soap, he said, if the quantity
of arsenic he liad been daily using for the last five months were
rolled up in the form of a pill, it would be as large as the one before
him ; and his impression was that the last few doses were of even
greater bulk — especially that ofJ?uesday the 18th, after which date
no more was taken. He had hoped that by increasing the dose he
would be relieved of painfid dyspeptic symptoms, which had been
unusually troublesome for the two or three preceding weeks. He
had on several occasions discontinued it for a few days, and once
even for three or four weeks, but, fancying that he was not so well
as when under its influence, resumed the practice. He was im-
pressed with the belief that his spirits and general health were
Detter under its use ; but stated most decidedly, that his complexion
instead of being rendered more clear was on the contrary often
made dingy, and anything but improved by it. It produced no
appreciable effect on the respiratory organs, or. as he expressed it,
'^ aid not improve the wind ; " and the muscular system, although
remarkably well developed, did not appear to have gained any
additional stren^h. The genital organs had, he thought, been
stimulated by the arsenic. He had had a metallic taste in his
mouth and throat for some time.

On the previous evening, feeling very much worse than usual, he

118 DR PARKER'S CASE OF DEATH RESULTING [AUQ.

had consulted Dr Tupper, but had made no allusion to his suspicion
of arsenic being the cause of his sufferings, and had indeed com-
plained of symptoms mainly referable to his respiratory organs^ but
nad made no mention of abdominal pain, or irritability of the
stomach. Dr Tupper prescribed for the congestion of the lungs,
under which he was evidently labouring. In Dr Tupper's absence
from the city, I was sent for on the following day, found him in the
state already described, and prescribed trisnitrate of bismuth and
opium, in large and frequently repeated doses. Externally^ mustard
poultices, with hot opiate and turpentine fomentations. For nauriah"
mentj he was ordered barley-water, thin arrowroot, or beef-tea,
whichever could be best retained on the stomach.

2l8t — ^At my morning visit found him easier. The abdominal
pain and vomiting had ceased ; otherwise, his condition was much
the same as on the previous evening. He had slept but little.
Continued the treatment general and local. I careiuUy examined
the eyes, evelids, fauces, and anus, to see if I could detect by day
any morbicl change in these parts, which was not perceptible by gas
light. All were in their normal state, except the mucous membrane
of the anus ; this was red and irritable, as far within the sphincter
as could be discerned. Later in the day the pain and vomiting
returned, when opiate injections, with prussic acid and tincture of
opium by the mouth were substituted for the bismuth and opium.

22d. — ^On visiting him at seven o'clock A.M., found him much
altered for the worse. Had had no sleep. The burning pain of
stomach and vomiting had continued all night. Abdomen more
distended. Countenance more hippocratic and the complexion
darker than on the previous day. Pulse hardly perceptiole; at
times it could not oe felt Respiration 22. Tongue slightly
iurred^ and white, but moist. Skin cold. Neither nourishment nor
medicme could be retained in the stomach. Dr Tupper saw him at
ten o'clock A. M. We agreed to return to the bismuth and solid
opium, to place a large blister over the stomach, and to give him
nutritive and stimulating injections. At midday his symptoms
were . unaltered. The rectum would not retain the nourishment
thus administered. Although pulseless, when exempt from pain,
which was occasionally the case for a few minutes, he said he felt
quite well, and strong enough to walk out in the street. Indeed,
while thus circumstanced, not more than one hour before this visit,
he rose froib bed, and unassisted, descended a flight of stairs to the
duiing-TOom, where he remained for a few minutes, and then
returned to his bedroom. At ten p.m., we could detect no pulsation
in the radial, temporal, or subclavian arteries. The femorals gave
a vexy feeble impulse. The heart's sounds, very indistinct and
confused, could just be detected with the stethoscope, but its pulsa-
tions could not be counted. Respiration 22. No dyspnoea. He
conversed freely in a firm tone ot voice, giving us again a very
intelligent and connected account of his arsenic-eating liabits from

1864.] FBOM THE PRACTICE OF AB8BNIC-EATIN0. 119

the beginning. While we were in the xoom, he ro«e from the bed
anassiated, exhibiting in the act a very considerable amount of
moflcalar strength, and went to the night-chair, but could void
neither faeces nor urine. Tenesmus and strangury were exceedingly
troublesome. The skin and extremities were cold. The {jupifs
rather contracted. Only a few drops of urine had been voided
during the past twentj-tour hours. The intense thirst from which
he had heretofore simered had passed away; the irritability of
stomach was also gone. Ue was directed to taJce milk and barley-
water as often and in as large quantities as could be retained by
the stomach. The opiate treatment by the mouth and rectum to be
continued as circumstances and symptoms demanded.

2Sd. — Half-past eight o'clock A. m. His attendants reported that
he had passed a most distressing night from pain in the region of the
stomach, and from painful but ineffectual attempts to relieve the
rectum and bladder ; not even the smallest quantity of urine bad
been voided. The opiate injections were not retained long enough
to benefit him. He had until the last few hours been able to rise
and visit the night-chair unaided, but now required a bed-pan.
Had had no desire for nourishment, but had taken some beef-tea,
and retained it. Since six o'clock a.m., he had been (ree from
acute suffering, and had dozed a »x)d deal His mind had wandered
much. The pupils were somewhat contracted. Tongue clean and
moist Abdomen very tympanitic Bespiration 20, and not
laboured. The extremities and skin were dry and veir cold. No
pulsation perceptible in any of the arteries. A sliglit confused
action of the heart could with difficulty be detected. On being
roused, he said he '^ feels quite well, and will never be caught in
such a scrape again." After my visit he continued to grow weaker,
and to talk more incoherently, until half-past ten a.m., when be
ceased to breathe.

Post-mcriem Appearancea and Examination. — Sanguineous fluid
commenced to flow from the mouth and nose in large quantities a
few hours after death. When seen twenty-four hours after his
decease, the whole body was enormously swollen and disfigured.
The abdomen was distended to the utmost limits. All the volun-
tary muscles were excessively rigid. Flexing the limbs was per-
formed with difficul^, owinjz to this unusual amount of rigor mortis.
There was great lividity of countenance, and the skin of the face
had a glistening appearance^ owing to emphysematous distention
and excessive venous congestion. Both emphysema and capillary
congestion were general on the surface of tne body, and air could
be freely detected by the touch wherever sought. The penis and
scrotum were black and swollen firom decomposition and gaseous
distention. On puncturing these parts, and making pressure, the
confined air or gas escaped through the venous oozing, in rapidly
succeeding bubbles. The sectio cadaveris was made by Drs Cowie
and Gk>8sip, at eleven o'clock A.H., 24th November.

120 DR Parker's case of death resulting [Aua.

Head. — On removing the scalp, it and the pericranitim were
found exceedingly congested, and the yessels contained air. The
membranes and surface of the cerebrum and cerebellum were in the
same condition. The membranes were firmly adherent to each
other and to the cerebral surface at the point of junction of the two
parietal with the occipital bone, extending continuously down
through the fissure dividing the cebral lobes to the tentorium cere-
belli. On removing the brain, it appeared to the touch unusually
firm and resisting. Its substance, when cut into, was natural in
appearance — not congested, — this condition bein^ confined to the
surface and walls of the ventricles. The ventncles contained a
small additional amount of fluid. The corpus callosum was unusu-
ally soft. The sinuses and vessels of the pia mater contained a
quantity of air, which escaped in bubbles wnen these were opened
or divided. The blood of the brain, as of the whole body, was
black and in a very fluid state.

Thorax. — The deposit of adipose tissue over the thorax and
abdomen was rather lar^e. The pericardium contained two ounces of
fluid. The left ventricle was largely hypertrophied and firmly con-
tracted. Its muscular fibre was much more d!ense and hard to the
touch than is usual in cases of hypertrophy. The left auricle was
also empty and contracted. The walls of the right side of the heart
were attenuated ; the auricle full of very dark liquid blood ; the
ventricle collapsed and empty. The lungs were congested through-
out ; perfectly engorged posteriorly. The oesophagus was not altered
in appearance or structure.

Abdomen. — There were about two quarts of fluid in the peri-
toneal cavity.

The Stomach externally was not much changed; internally it
was but slightly congested over its first or oesophageal half. The
congestion increased as the duodenal end was approached. Its
mucous membrane was softer than natural. Between the mucous
and muscular coats air was freely distributed, and could be moved
from place to place by pressure. Patches of extravasated blood
were also numerous between these two coats. The small intestine
was inflamed or congested throughout. The duodenum was almost
black ; the colour became lighter, and the congestion less, as the
ileo-coecal valve was approached. Many large marks of extrava-
sated blood were observed beneath the difierent coats and on the
mucous surface, the largest being beneath the peritoneal covering of
the Ileum. The large mtestine was lighter in hue, yet considerably
congested, with here and there small patches of extravasated blood
in its walls. The rectum was inflamed firom its commencement,
but most so in the neighbourhood of the sphincter. The liver was
of the natural size, mottled, and of a very peculiar dark greenish-
blue colour throughout its entire substance. It was engorged with
black fluid blood. The gall-bladder was lull of black bile. The
spleen was also loaded with blood, and was of the same colour as

1864.] FBOM THE PSACHCB OF ABSEIflO-XATOIO. 121

the liver. It wbb of the normal sice and oonaiateiiee. The kidoejs
were of the nsnal bicOi but very much congested. The Madder waa
empty and contracted. Its urethral orifice waa congested. Porttona
of the abdominal viBoera and brain were retenred far chemical
examination. These were sabmitted to Professor How of King's
College, Windsor, and Drs Cowie and Clossip, who reported as
follows: —

Knio*B CoLLBGB, WomsoB, NJ., Dm. 88, 1808.

Dear Su*, — ^I have made two very carefol tests for arsenic, bj
Beinsch's method, in the portion of*^ spleen received from 70a on
the 19th inst I employed aboat two-thirds of the whole material,
or rather more perhaps, and in both experiments I obtained an
excessively faint sabumate^ of a white colour, bat I could not
obtain, by careful heating m an oil-bath at a proper tempomtnre,
in either case, the characteristic crystals of atsenious acid; so
that I must conclude that I have &iled to obtain any evidence of
the presence of arsenic As yon probably are aware, the delicacy
and accurac]^^ of this test are such that, according to Tavlor (on
Poisons), if it fails, there is hardly any reliance to be placed oo
Marshes alone.

Trusting that I have met your wishes, I am, dear Sir, yours
truly, HaNBT How.

C. Tapper, M.D., Halifia.

Halifax, Deeember 1B68.

Dear Sir, — We have made two examinations of parts of the viscera
from the man supposed to have died from arsenic In the first
(using the liver omy) slight indications of arsenic were obtained,
by Marshes test, and by ammonio-sulphate of copper. In the test
in which we used the stomach, duodenum, and ulcerated patches
from the jejunum and ileum, not the slightest trace of arsenic could
be discovered by either Marsh's or Beinsch's tests. — ^We remain
yours truly, A. J. CowiB, M.D.

Cha& J. O068IP, M.D.

Dr Parker, Argyle Street, Hslifia.

These chemical investigations demonstrate convincinglv the
rapidity with which arsenic is eliminated from the system wnen it
is taken in small quantities continuously. I had sujyposed that its
chief receptacle — ^tne liver — ^would have detained it, if not in bulk,
certainly in appreciable quantities; but when tested, only very
slight traces ot the poison could be obtained from that organ.

Bemarks. — ^It seems singular that a man of intelligence, whose
daily occupation made him familiar with powerful chemical agents,
should have partaken of arsenic for ^ears, and during all or nearly
all that time, suffered from its use without suspecting the cause. I
have learnt since his decease, from his most intimate friends and
those with whom he lived, that although looking well, and to all
appearance strong and robust, he had been, to use the words of one

VOL, X.— -NO. II. Q

122 DR parkeb's case of death resulting [AUG.

of my infonnants, ^^ a complaining man for the last three or four
years." Indeed^ so frequently did he refer to his pains and dyspeptic
symptoms^ that those to whom he most frequently talked on the
subject were in the habit of thinking and speaKing of his complaints
as ima^nary. I have no doubt myself that the abdominal pains
from which he suffered while under my care in 1860-61, on account
of an affection of the throat, were produced entirely by the poison
he was daily using. The quantity of arsenious acid taken into the
system cannot be definitely stated. Guided by the statements of
the dying man. I have taken eyery care to ascertain it as nearly as
possible, andj m>m the data giyen, conclude that for the last fiye
months of his life his daily dose was not less than two and not
more than three grains. In this connexion I must state that while
the few last doses, and especially that of Tuesday the 18th
Noyember, were larger, he did not by any means lead me to infer
that the increase was yery material.

One thing is certainly taught by the circumstances and symptoms
narrated in connexion with this case, yiz., that habit or continuous
use does not be^t a tolerance of the agent in the animal economy.
This is in accordance with the opinion of Professor Christison, that
while the system may become habituated to the use of some of the
organic poisons, habit does not diminish, but probably rather in-
creases the actiyity of the inorganic poisons which enter the blood.

It may be asked why antidotes were not used immediately on
m^ ascertaining the cause of the patient's illness. I reply that the
poison haying been taken in small quantities, and a period of sixty
nours or thereabouts haying elaps^, after ^e last dose, before i
saw him, during the greater part of which time he had been yomit-
ing and purging freely, I concluded, and I think correctly, that
the arsenic had either been absorbed or ejected from the alimentary
canal, and that it was my duty rather to attack the effects than an
absent cause.

The cause of death in this, as in most cases of arsenical poisoning,
is to be referred mainly and primarily to the state of the intestinal
canal, especially of its upper portion.

In making a few remarxs regarding the symptoms in this case, I
must premise that I had neyer before had under my care a case of
arsenical poisoning, and that, therefore, I had not the adyantaee of
being able from my own experience to compare this with others.
I may, howeyer, briefly allude to the points in which this case
resembled the recorded obseryations of medical men, and those in
which it appeared to present certain peculiarities. The symptoms
of poisoning by arsenic usually obseryed, and which were present
in the case now detailed, were the following :— Contracted features,
and anxious countenance; dark and unnatural complexion; ab-
dominal pain; tympanitis; metallic taste in the mouth; burning
pain of tne stomach ; intense thirst ; tenesmus ; dyspnoea (present
on the 19th, when seen by Dr Tupper, absent from the date of my

1864.] FBOM THE PRACTICE OF AB8ENIC*£ATING. 123

first visit) ; feeble cardiac and srterial action : coldness of surface ;
strangoiy ; diminished quantitj, and eventaal suppression of urine.
The absence of dyspnoea during the last few days of life struck me
as being an anomalous feature of the case. The lungs were
evidently gorged with blood, and there was great abdominal pain :
notwithstanding which, the respirations did not at any time exceed
twenty-two in the minute. Again, the state of the circulation
surprised me: here was a man pulseless for twenty-four hours
before death, with intellect clear and undisturbed, and feeling
during the absence of pain mite weU, and with phvsical strength
sufficient, while in this condition, to rise unassistea from his bed,
to descend and ascend stairs, and to walk with a firm step all over
the house.

The following symptoms, more or less frequently observed in
other cases, were absent in th%8y viz., a congested or cedematous
condition of the eyelids and oonjunctivs ; cutaneous eruption ; a
diseased state of the hair and nails ; yellow vomiting ; salivation ;
discoloured and swelled penis ; cramps and tetanic contractions of
the limbs ; head symptoms ; palsy.

I may here refer to a result of arsenic-eating, not recorded, so far
as I am aware, by previous observers. I refer to its action on the
genital organs. In reply to a question proposed to him, he said
that it was his impression that these organs were stimulated by its
use. I would hesitate to record the circumstance if it were founded
merelv on this statement ; but I have since learned that for a long
time he had been notorious for his amorous propensities.

I have before stated that A. C. gave a negative reply to the
question as to whether his complexion had been improvea by his
arsenic-eating habits. It is but ri^ht to add, that manv of his
friends are equallv positive in asserting the contrary. They sav
that his improved pinkish complexion, as if paint had been used,
had frequently of late attracted attention, and been the subject of
remark among them.

The post-mortem appearances found in this case were such as
have usually been met after poisoning by arsenic. The onlv points
worthv of remark appear to be the unusual rapidity with which
putrefrtction set in at a cold season of the year, and the very emphy-
sematous condition of the cellular tissue.

Abticlb IV.— 7^ FhysiologuxU Actions of Dqfakschy^ an Arrow
Poison^ used in Borneo. By Peter M. Bbaidwood, M.D.

ExPEBiM ENTAL researches as to the action of poisons on the animal
organism present to the physiologist by no means an uninteresting

* While working in his laboratory in Berlin. Professor Du Bois-Reymond
kindly gave me thu poison, dajak»dk^ which he nad received from a doctor who

124 DR BRAIDWOOD ON THE [AUO.

field of inquiry, inasmuch as they either provide him with the only
means of ascertaining certain physiological facts, or enable him to
confirm results reached at by less refined methods of investigation.
A good example of the latter is the working of the poison which
forms the subject of the following paper.

Characters of the Extract. — ^The aried extract has a dark iron-
gray colour ; is firarile. It is dissolved by water, but not so readily
as IS woorara; and, when finely pulverized, it is to a slight extent
soluble in both alcohol and ether. It is not more soluble in hot
than in cold water. Water dissolves it more readily in the presence
of acte&, whereas alkalies do not increase its solubility in water. It
IS insoluble in chloroform. The foregoing solutions give an alkaline
reaction with test paper. The watery solution used for experiment
had a bitter taste, was of a brown colour, and its odour resembled
organic matter decaying in a moist place.^

Otneral Symptoms produced by me Poison, — ^The first noticeable
evidence of the working of this poison, when administered subcu-
taneously, is restlessness, and signs of irritation. These reflex
movements are not those resulting from excessive pain, but resemble
such as are produced by a mild local irritant. This is followed by a
state of languor — ^the animal lying perfectly still, and the respiration
being slow, but not laboured. Its posture, however, does not allow
of the supposition of want of motor power, but only of indisposition
to move. This condition is interrupted by several fits of convulsions,
which increase in intensity firom time to time. By degrees, para-
Ivsis, Bt first of sensation, and then of motion, sets in. The onset of
the paralysis is in some instances not very marked, and in no case
did the general paralysis seem to be an effect of the action of the
poison. This paralytic stage shortly precedes death, and sets in
mnn half an hour to an hour after the cessation of the heart's con-
tractions. Lastly, the respiration is noticed to become heaving and
irregular ; sometimes the respiratory movements are spasmodic, gasp-
ing, and occurring at long intervals. In the case oi warm-blooded
animals, vomiting and the passage of fceces and urine are noticeable
svmptoms, which present themselves soon after the exhibition of
the poison, and continue to a greater or less extent till general
paralysis takes place.

Specific Action of Dajaksch on the Pupil and on the Heart, — On
the application of a couple of drops of a diluted watery solution of

had been in Borneo. It waB in the form of an extract, wound round a small
piece of stick, and dried thereon. It was wrapped up then in paper, and sealed
m a piece of bamboo about three inches long, which bore tne inscription,
<* Dajaksch : Pfeil-eift von Borneo."

> From this simile it is not to be thonsht that the extract used was ahready
too old and had begun to decompose. All those who smelt the watery solution
considered its odour to be quite cnaracteristic ; and though thie comparison is not
perfectly accurate, it is as nearly so as possible. The odour, moreover, does
not increase as the solution is kept longer, and is not very strong, though
marked.

1864.] PHYSIOLOGICAL ACTIONS OF PAJAKSCH. 125

Dajaksch mixed with glycerine, between the eyelids, in the case of
the lower animals the iris was found to contract But this effect
was not nearly so marked as that noticeable on the use of the
Calabar bean; and therefore it is only incidentally noticed here.
In those cases in which death resulted from the use of the poison,
the contraction of the pupil was first obserrable at the commence-
ment of the convulsive stage, and lasted till general paralysis set in.
when the pupil began again to dilate. Though this poison producea
contraction of the pupil in the lower animais, it is not to be con-
cluded that it has the same effect on the pupil of man ; for it has
been repeatedly found that poisons which, to a marked extent,
contract the pupil in the lower animals, do not act on the human
subject.

The Complete CeeeaHon of Cardiac Actiim is, however, the char-
acteristic enect of dajaksch on the animal organism. In the course
of a short time (varying according to the amount and strength of
the solution used), after the subcutaneous administration of the
poison, the hearths pulsations are found to become feeble. Shortly
thereafter the heart contracts irregularly and peristaUically. The
irregular pulsations consist in the auricles contracting twice as often
as the ventricles,— once with the ventricles, and once during the inter-
mediate pause.^ By degrees the ventricles cease to contract, and ex-
hibit only a slight heaving movement of their walls, by the blood
passingthrough them ; and at last they become eimuUaneaualy motion*
less. Some time thereafter (about half an hour when the dose is
small), the auricles are observed to pulsate more and more slowly and
feebly, and at last they also become motionless. General motion and
sensation are as yet unimpaired; so that, if the experiment be
made on a frog, and it be at this stage released from its fastenings,
it jumps about briskly with an immovable he-art. No portion of
the cardiac organ is re-excitable, either by mechanical or electrical
means after it has once become paralyzed. The heart ceases to
contract in systole. The ventricles are observed to be bloodless and
pale, whereas both the auricles contain blood — ^the left auricle and
the veins leading to it being distended with dark-coloured blood.

PoH-mortem Apf^rances. — These are by no means characteristic.
Besides the condition of tha heart which has just been mentioned,
the other or^ns of the thorax and abdomen are sometimes partially
hvpersBmic, but present to the naked eje no other appreciable
alteration. The muscles of the extremities contracted readily in
the case of frogs when excited directly or through their nerves by
a current of electricity ; whereas the experiments made on warm-
blooded animals e;ave this curious result, that a strong electrical
stream produced aliaht contractions' of the voluntary muscles when
they were excited directly, but failed to produce contractions when

^ These irregular and peristaltic contractions of the ventricles are best
observed in the frog. In tnese animals the ventricle «an be distinctly seen to
contract peristaltically (like the intestines) from the apex to the base.

126 DR BRAIDWOOD ON THE [AUG.

passed through their nerves. In both classes of animals the muscles
retracted on being incised. Electricity^ moreover^ had no power
in renewing the contractions of the heart or of the intestines after
death.

This diyersity on the part of the voluntary muscles of frogs may
perhaps be accounted for by the well-known extraordinary con-
tractile vivacity of the muscles of these animals^ as compared with
those of others.

The question now suggests itself, How does this poison — dajaksch
— ^produce the paralysis of the heart ? Exclusive of a direct para-
lysis of the muscular fibres fwhich is not likely to be the case,
seeing the other muscles of tne body remain so long unaffected),
this phenomenon may be produced through any one of the three
nervous sources which supply the cardiac nerves, viz., through the
vagus, through the sympathetic system of nerves, or through the
spinal cord. Experimental research has long ago demonstrated
tnat the cardiac branches of the varas have the function of arrest-
ing the heart's contractions, while those from the sympathetic are
the truly motor nerves, and those from the spinal cord the probable
sensory cardiac nerves. The proof necessary, therefore, to deter-
mine this point requires to be ooth negative and positive.

Commencing, then, with the former, three sets of experiments
were made to exclude the action of this poison through the vagus:
Firstly y The voluntary muscles of a frog having been completely
paralyzed by means of woorara, which did not however m the
slightest degree affect the contractions of the heart; a dose of
dajaksch was next administered to it subcutaneously, and the result
was as follows: — ^The latter poison exhibited its action on the
heart in the same time and in the same way as it had done in frogs
not previously poisoned with woorara. Secondly^ The medulla
oblongata of other frogs was broken up with a needle, so as to
destroy the origin of the vagus, and this in itself produced a
momentary cessation of the cardiac pulsations ; but after these were
renewed, a dose of dajaksch was given, with the result that it acted
on the heart exactly as it had done in the case of normal healthy
frogn9. Lastly y The vagus was divided in its course, and on the
application of the poison the effect on the heart was exactly the
same as in both the previous instances, provinjg that dajaksch does
not paralyze the heart through the vagus. What further confirms
this conclusion is the fact that irritation of the vagus produces only
temporary paralysis of the heart ; whereas, after the use of dajaksch,
the heart cannot by any means, mechanical or electrical, be re-
excited to contraction.

Besides the circumstance that, as the results of experimental
observation, the cardiac branches supplied by the spinal cord seem
to be for the most part sensory nerves, this source is nirther excluded
by the following consideration, — Tnat the paralysis of sensation
and motion do not set in, in the case of poisoning with dajaksch,

1864.] PHT8I0L0GICAL ACnONfi OP DAJAUCH. 127

till long after the heart has been completely paralysed* Moreover^
post-mortem research does not lead ns to suspect paralysis through
the spinal cord* Therefore, nothing now remains to us except to
conclude that the paralysis of the heart results firom the action of
this poison on the sympathetic cardiac ganglia.

Positive proof of the foregoine assumption, and an explanation
of the manner in which the paralysis attacks the several chambus
of the hearty is afforded us by the following fact : — If the heart be
removed from the body immoliately after it is apparently paralysed|
but while the animal possesses general sensation and motion unim*
paired, and Stannius experiment be made on it, we have Ithis
result, — ^that on exciting the ganglion of the smus venosus with a
Btrang stream of electricity, the auricles are observed to contract
twice slightly, but the ventricle not in the slightest degree;
whereas, if the auricles be separated from the ventricle, neither con-
tract on being electrically imtated.

Condudona. — ^We may conclude, then, —

1st, That this arrow-poison, dajaksch, produces death by para-
lyzing the heart ; which is proved further by the frict, that, after
ligature of the heart, death results in the same way and in about
the same time as after poisoning with dajaksch.

2^, That the cessation of the cardiac contractions is brought
about through a paralysis of the cardiac ^nglia of the sympathetic,
exactly as the same is seen on performing Stannius' experiment
In other words, that with this poison we have a much finer means
of performing Stannius' experiment than the knife and forceps
afford us.

3^. Hence, that the ventricle first ceases to contract, because the
ganglia situated between it and the auricles, and which for the
most part sonply the ventricular sympathetic nerves, are first
paralyzed. Then that the auricles become motionless after the
ganglia supplying them (the ganglion of the sinus venosus in
frogs) are paralyzed.

Aihy That the other general phenomena produced by this poison,
as paralysis of general sensation and motion, etc., may be oonsiderea
as the natural results of the paralysis of the heart.

Experimenta made with Daj AKSCH, illuHratwg the prevUnu Remarka.
A. Itbutra&ng the ConstituiUnud Effects of the Poiaon.

1. IN THE CASE OF GOLD-BLOODED ANIMALS.

Experiment 1. — ^AdminiBtered to a frog (which luid been kept at lesat
twenty-four hoars in the laboratory), sabcutaneonsly on the bftck, a dote of a
watery solution of dajaksch. This dose was equal to about twice the common
dose of a similar watery solution of woorara.

Immediately after the exhibition of the poison, the animal moved restlessly
about. In twenty minutes thereafter, it lay quiet. In seventy-two minutes the
ttof was apparently partially paralysed, and dragged its hind-legs when strongly
tmtated. During this time it moved restlessly at intervals, and the paralytic

128 DR BRAIDWOOD ON THE [AUQ.

condition was preceded by convulsions. In eighty -five minutes after the ex-
hibition of the poison, the animal submitted itself to be laid in any position,
and did not evince the slightest signs of the presence of motion or of sensation.
The pupils were noticed to be contracted to half their normal size. Ten
minutes after this no respiratory movements could be distinguished ; the eye-
lids were open, and the animal appeared to be dead.

AtUqm — immediate. — ^The heart was found to be perfectly still, and not at
all excitable on the use of any mechanical irritation. The left auricle was
noticed to be greatly distended with dark-coloured blood. The organs
generally, especially the stomach, lungs, liver, and kidneys, were somewhat
congested, llie intestinal canal did not appear hypenemic. The muscles of
the limbs contracted when irritated by an electricfu stream both directly and
through the main nerve of the limb.

n. IN THE CASE OF WABM-BLOODED ANIMALB.

Experiment 2. — ^Injected subcutaneonsly into the thigh of a well-grown
adult rabbit rather more than a cubic centimetre of a watery solution of
daiaksch. This dose contained a half-grain of the dried extract. Three
minutes after the exhibition of the poison, on being freed, the animal moved
about restlessly. Diarrhoea and urination took place.' The vessels of the ear
were observed to contain less blood than formerly. In seven minutes there-
after the animal lay quite quiet. The vessels of the ear were again refilled.
On being looked at five minutes later, the animal continued to lie in the same
motionless state, and the vessels of the cartilage of the ear again appeared to
be contracted. Twenty minutes after the exhibition of the poison, the rabbit
appeared quite dead. Death was preceded by slight convulsive momements
of the extremities.

Autopsy — ten minutes after death, — ^The heart was motionless. On being
opened the ventricles were found to contain a very little blood. The ri^ht
auricle was devoid of blood ; but the left auricle, as well as the veins leading
into it, were noticed to be distended with dark -coloured blood. The lungs,
liver, kidneys, and whole intestinal canal did not present to the naked eye any
abnormal appearance whatever. When irritated directly by an electrical stream,
the muscles of the extremities contracted very slightly ; but the muscles of the
thorax and abdomen were not at all excitable by electricity. A few minutes
later the muscles of the extremities also gave no contractions with an induced
stream of electricity. None of the voluntary muscles contracted when incised,
or when the chief nerve of the limb was divided, or when excited by an
electrical stream passed through the chief nerve of the limb. The ventricles
were not excitable to contraction by an electrical current ; but the auricles
contracted readily by this means. When tested again, thirty-five minutes after
the death of the animid, the auricles were found to be less excitable by elec-
tricity. Fifteen minutes thereafter slight contractions of the auricles were
produced by electricity. Three minutes later the right auricle could not be
excited any more to contract, and the electrical stream caused contractions
only at the most distant part of the left auricle. Twelve minutes after this,
and sixty-five minutes after death, no part of the left^ auricle was any longer
excitable by electricity.

Experiment 3. — Administered to a young cat subcutaneonsly in the left thifih
a dose of the watery solution, equal to a quarter-grain of the dried extract. In
fifteen minutes after the exhibition of the poison, fseces were passed. This was
followed by vomiting, and the animal shrieked in sreat distress. Between the
paroxysms of sickness, the cat lay crouching in a dark comer of the room quite
■till ; but, on being strongly irritated, it moved, showing voluntary motion to be
unafiected. The paroxysms of vomiting recurred at short intervals, and were

{{receded by loud shrieking. Fifteen minutes later, the cat appeared quite
istless, and allowed itself, without offering any resistance whatever, to be kud
in any position. Sensation seemed to be absent. The heart, on being examined,
from time to time, through the thoracic wall, was noticed to be pulsating more

1864.] PHYSIOLOGICAL ACTION OF DAJAKSCH. 129

and more rapidly and irregularly. Thirty-two minatea after tlia admimatrB-
tion of the poiaon, strong conTuUions of tne whole body occurred. J oat before
theae convulsive paroiysma, the heart could be no longer diatingniahed by
feeline through the thoracic walL Immediately after theae fita paaaed off tfai
animiQ darted into the centre of the room acreaming ; but finain^ a want of
power in ita hinder limbs it could not run further, and ao dragged itcelf alone
for a few inches and fell on ita side. A few seconds thereafter it atmgglea
strongly to recover its former position ; but, being unable to aupport itaelTany
longer, it apread ont its limba and lay on its belly with its head turned to tlw
left side. In a few seconds it gave a loud shriek and died. The pupila were
noticed to be dilated ; the lower jaw was dropped.

Auiapttf^^mmeeUaie. — ^The heart waa motionless and not excitable by me-
chanical irritation. Its cavities presented the aame appearance aa m the
previous experiment. The veins or the thorax and abdomen were found dia-
tended with dark-coloured blood. The stomach contained some frothy mocua,
and waa alightly congested towards its pyloric end. The other organs^ though
examined, presented no abnormal hypersmic condition. The peristaltic move-
ments of the intestines were absent. The muaclea of the extremities contracted
when incised, but were not affected by mechanical irritation of their nerves.

Experiment 4. — Gave an adult sparrow a dose of the solution, equalling
about one-tenth ^in of the dried extract. Three minutes after the adminla-
tration of the poison by the mouth, the bird having been flying about the roof
of the room, suddenly fell down dead.

Autopsy— -immediaU.—The heart was found passive, and its chamber! aeverally
in the same condition aa in the previous expenmenta. The heart's contrmctlona
could not be in the slightest degree excltea by mechanical means. The pupila
were observed to be dilated.

' Experiment 5.— Gave a large adult grey cat subcntaneonsly, in the left thigh,
a dose of a watery solution containing rather more than one -tenth grain of tlie
dried extract. Aoofft ten minutes after the exhibition of the poison the animal
began whining, and was restless. This was continued at intervals. An hour
after the poison had been given, occaaional vomiting and diarrhoea set in.
Motion and sensation were unimpaired. An hour thereafter, the heart's pulsa-
tions were felt through the thoracic wall to be very rapid and irregular. Sen-
sation seemed to be slightly affected. Pupils were of normal sixe. Twenty
minntes later, urine and fteces were observed to be paaaed very often. The
fteces were fluid, yellowish white, and of a strong odour. Voluntary motion
was unimpaired. The cat lay crouching and listless in a dark comer, and,
when moved from its place, purred angrily and strove to eet back to ita comer.
When Again observed, about an hour later, motion and hearing were found to
be unaffected ; but vomiting still recurred at intervals. Half an hour there-
after it continued to lie quietly in the dark comer when undisturbed ; but when
approached it purred angrily, though it would not stir from its place. Vomit-
ing, diarrhoea, and urination had now quite ceased. When the heart was
examined through the thoracic wall it seemed to be pulsating irregularly, but
not BO rapidly as formerly. On being looked at next morning, about twelve
hours after the administration of the poison, the cat was founa languid, but in
other respects it appeared to be in normal health. At first it would not drink
any milk, but in a few hours it began to take ita food as formerly, and seemed
to have quite recovered the effects of the poison. It seemed to have lain in the
same comer all night, and in the same crouching posture.

B. xUustmting the Special Action of the Poieon.

I. IN PRODUCING CONTRACTION OF THE PUPIL IN THE LOWER ANIMALS.

Experiment 1. — Poured a drop of a weak solution into the right eye of a
rabbit. The ri^ht pupil seemed to begin to contract in about two minutes
after the administration of the poison. About an hour later the right pupil

VOL. X.— NO. II. R

130 DR BRAIDWOOD ON THE [AUO.

was observed to be half as large as the left one, and after another half-hoor it
became two- thirds smaller than the left one.

Experiment 2. — A few drops of a weak watery solution were applied with a
brush to the right eyeball of a dog which had very active irides. When looked
at about an hour after the application of the poison the right pupil was found
to be contracted to half its normal size, and tq be more sluggish than the left
one. Besides causing local uneasiness the poison seemed^to have no other
effect. The pupil contracted to about one-third of its normal dimensions ; but
after about three hours the poison appeared no longer to act on the pupil.

U. IN PARALTZIMa THE HEART.

(a) In ihe case of Frogs.

ExPERiiiENT 1. — Exposed the heart in a frog, and found its pulsations to be
46 per minute, regular, and of normal strength ; in five minutes thereafter gave
it Bubcutaneously, in the thigh, a huge dose of a strong solution of dajaksch.
Immediately after the injection of the poison the heart's pulsations were 46 per
minute. In ten minutes after its exhibition the heart's pulsations were found
to be 8 per minute, and feeble, but regular. The fro^ made strong muscular
movements when irritated, but these did not in the shghtest degree affect the
heart's pulsations. In eight minutes later the ventricle ceased pulsating, and
the auricles contracted feebly and at irregular intervds. Four minutes there-
after the auricles ceased to contract, but voluntary motion was found to be
perfect. The paralysis of the heart was followed m seven minutes by inter-
mittent convulsive movements of the extremities. During this convulsive
period, respiration was slow and laboured. Before the ventricles ceased con-
tracting, it pulsated more and more feebly, slowly, and not synchronously with
the auricles. Voluntary motion continued unaffected for nearly three-quarters
of an hour after the heart became motionless, but during this tune several con-
vulsive fits occurred. An hour and seven minutes after the cessation of cardiac
action the animal Uy dead, with its lower limbs stretched out behind. When
an induced electrical current was passed into the muscles of the extremities
directly and through the main nerve of the Umb, it caused contractions an
hour and a quarter after death.

Experiment 2. — On exposing the heart of a frog, its contractions were
found to be 48 per minute, and regular. The poison was exhibited just as in
the last experiment. Three minutes after the administration of the poison,
reflex movements were noticed, but the heart's pulsations were found to be the
same. In thirteen minutes after the commencement of the experiment the
ventricle was quite still, and not re-excitable by mechanical or electrical means.
Before becoming motionless, the ventricle pulsated more and more slowly and
feebly, and then contracted in a peristaltic manner firom its apex to its base.
The auricles pulsated 14 times per minute, but at regular intervals. Five
minutes later the auricular pulsations were found to be 4 per minute, and, of
these, 3 occurred during the first quarter of a minute. Two minutes thereafter
the auricles pulsated 6 times per minute, but irregularly as before. Respira-
tory movements were feebler. Three minutes later the auricles were observed
to contract 5 times per minute, t.«., 4. times in the first twenty seconds, and
then followed a strong contraction at fifty seconds. Sensation and motion
were found unimpaired. When noticed, ten minutes later, the auricular con-
tractions were 7 during twenty seconds, and then none for one and a half
minute, when a strong contraction occurred. In ^^ minutes thereafter slieht
convulsions of the lower extremities seemed to be present. The auricular
pulsations were 2 per minute, and at regular intervals. For twenty-one
minutes after this the auricles continued pmsating, but more and more feebly,
very irre^larly, and at long intervals. Then they suddenly ceased contracting.
The respiratory movements were observed to be laboured, and to occur at long
intervals. Sensation and voluntary motion seemed to be unimpaired. Half
an hour after the paralysis of the auricles the animal was found to have lost
sensation and motion, and appeared dead.

1864.] PHYSIOLOGICAL ACTION OF DAJAK8CH. 131

ExPEKiHENT 8. — On taking a frog and exposing its heart, whose eontrac-
tions were 40 per minote, regular, and of normal strength, I administered to it
a good large dose of dijaksch, snbcataneously as formerly. In nine minutes
thereafter the cardiac pulsations were found to be 18 per minute, and regular,
but feebler than before. In eleven minutes after the administration of the
poison the ventricle was observed to contract non-s^chronousiy and peristaltic-
all^ from apex to base. Six minutes later the auricles were found to contract
twice as often as the ventricle,— once with the ventricle, and once in the interme-
diate interval. But both sets of contractions occurred at regular intervals.
Three minutes after this the ventricle ceased to pulsate, and was not re-excit-
able. In eight minutes after the paralysis of the ventricle, the auricles exhi-
bited very feeble heaving movements, not to be called contractions. General
sensation and motion were at this time found to be unimpaired. Three minutes
later, and half an hour after the exhibition of the poison, the auricles were
found passive. Sensation at this time was somewhat impaired, but not motion,
for the animal jumped about briskly when freed. In rather more than half an
hour after the cessation of the cardiac contractions, general sensation and
motion were found to be absent ; the frog submitted to be laid in an^ position.
At this time the heart was cut out of the body, and Stannius' experiment per-
formed on it, with the following results : — On irritating the ganglion of the smus
venosus with an electrical stream, the auricles contracted each time after being
twice irritated, but not oftener ; whereas the ventricle remained motionless on
being irritated. On separating the auricles from the ventricle, neither contracted
on being irritated. Tnese two slight contractions of the auricles were therefore
the last traces of their contractility. Five minutes after the heart had been
removed, the ftof gasped and died, llie pupils were observed to be of normal
siie. When an mduced current of electricity was passed through the muscles
of the extremities directly, and through the sciatic nerves, it elicited normal
contractions of the muscles.

Experiment 4. — ^To a frog, whose heart had been exposed, and its pulsations
found to be normal, was given subcutaneously a dose of the watery solution,
containing about a grain of the dried extract. In five minutes after the exhi-
bition of the poison the animal was very restless, and exhibited strong reflex
movements. Ten minutes thereafter tne cardiac pulsations were irregular,
much slower than at first, and very feeble ; and two minutes later the ventricle
was observed to be motionless. The auricles ceased to pulsate half an hour
after the ventricle had stopped. A strong electrical stream elicited no con-
tractions after the cardiac chambers became still. Paralysis of motion set in
a quarter of an hour after the auricles had ceased to pulsate. The muscles of
the extremities, an hour after the paralysis of the heart, contracted strongly
when irritated by an electrical cunrent directly or through their nerves.

{b) InihiCtuecf Warmblooded AnknaU.

Experiment 5. — ^After artificial respiration had been established, and the
heart exposed in a young rabbit, about half a grain of the dried extract of
dajaksch, dissolved in half a cubic centimetre of water, was injected through a
small opening in the skin of the left thigh. Before administering the poison,
the cardiac contractions were noticed to be of normal strength, and 100 per
minute. Half an hour later the above dose, seeming not to affect the heart,
but having caused only a ft^quent passage of fteces and urine, and reflex move-
ments of the body, another dose of half a grain was administered. Immedi-
ately after the exliibition of the second dose, the peristaltic motion of the
intestine was marked, and the reflex movements of the limbs were strongly
developed. Ten minutes later the cardiac pulsations were observed to faie
slower and more feeble than at first. They next became irregular, both as to
duration and synchrony, and then the ventricles exhibited vermicular contract
tions, passine from their apex to their base. Twenty-eight minutes after the
second dose nad been given, the cardiac chambers were noticed, all at one and
the same moment, to cease pulsating ; and after a pause the auricles resumed

132 DR BRAIDWOOD ON THE [AUG,

their contractionB, whereas the yentricleB remained motionless and not re-
excitable. The aaricular pulsations were slow, feeble, and at first regular,
but by degrees they became irregular. The auricles ceased to pulsate about
half an hour after the ventricles had stopped. Up to this time sensation and
motion were found unaffected, but by degrees paralysis followed.

On passing a very strong stream of ^ctricity from a ffalvano-electromotor,
about t^ee quarters of an hour after the auricles had ceased to pulsate,
through the muscles of the extremities, they were found to contract (but not
stronffly) when directly irritated ; but they did not contract at all when elec-
trically excited through their nerves. Electricity did not produce the slightest
ventricular contractions, whereas the auricles contracted readily under the same
influence. The auricles continued for half an hour longer to be excitable by
electricity, though to a less and less extent, and then they lost this property.
The intestines could not be excited to peristaltic action by the use of an elec-
trical current. The voluntary muscles of the extremities retracted when iiicised.

Remark, — ^In the above series of experiments an autopsy was made in each
case, with the same results as previously.

C. ExperimerUa promng negatively the Action of the Poison through
the Cardiac Branches of the Sympathetic.

Experiment 1. — Having ligatured the left femoral artery of a frog, I gave
subcutaneously a large dose of the poison, without exposing the heart.

The usual general symptoms of restlessness, reflex movements of the limbs,
contracted pupils, convulsions, and general paralysis were noticed.

On opening the body, the heart was found m the same condition as in previous
experiments. The muscles of both hinder extremities were found to be equaUy
excitable on the application of an electrical stream, directly and through the
sciatic nerves ; as also on being irritated directly and indirectly by mechancial
means — showing that this poison does not act airectly through the circulation
as woorara does.

Experiment 2. — After exposing the heart of a frog, administered to it a
common dose of a watery solution of woorara. Paralysis of the voluntary
muscles having been as usual produced by this poison, but the heart's pulsa-
tions being found to be 36 per minute, regular, and of normal strength, a dose
of dajaksch was next injected subcutaneously into the left thigh.

Fifteen minutes after this latter injection, the ventricles and auricles were
observed to pulsate non-synchronously, and the ventricular contractions to be
peristaltic, passing from apex to base. Four minutes thereafter the auricles
were found contracting twice as often as the ventricle. Three minutes later
the ventricle was not contracting any more, but exhibited a hi aving movement
of its walls. In ten minutes more the ventricle ceased to pulsate. About
half-an-hour after the ventricle became passive, the auricles also ceased to
pulsate. The general symptoms followed the same course as in experiments
on healthy frogs.

Experiment 3. — Having broken up the medulla oblongata of a frog with a
needle, exposed its heart, and found the cardiac pulsations to be 32 per minute,
regular, and of normal strength, a dose of dajaksch was administered subcu-
taneously. Six minutes after the exhibition of the poison the cardiac contrac-
tions were noticed to be irregular and feeble. The auricles contracted twice as
often as the ventricle ; but on gentle irritation both sets of chambers pulsated
synchronously. Five minutes later the ventricle ceased to contract, ana heaved
only ; and in a few minutes thereafter it was motionless. About half an hour after
the exhibition of the poison, and a quarter of an hour after the ventricle had
ceased to pulsate, the auricles became motionless. Then the froe was released,
and jumped briskly about. The general symptoms followed in tne usual order,
and in rather more than an hour after the administration of the poison, the
animal was dead.

Remark, — ^These last two experiments oppose the supposition of the para-
lysis of the heart being produced by the poison acting on the vagus.

1864.] PHT8I0L0QICAL ACTION OF DAJAK8CH. 133

Cwiduding BemarJca. — Owing to the small amount of the poison
which was at mj disposal, the above researches are not so complete
as might be desirable : and a very important element wanting in the
above sketch is a prefatory notice respecting the natural history of
this interesting poison \ but this is not as yet attainable, the poison
being comparatively, if not aoite, new. The peculiar action of
dajaksch on the heart may recall the well-known j ava arrow poisony
Upas Anthiar. But these two poisons, though perhaps allied in
their natural history, differ in other respects from one another.
Upas Anthiar is properly a Java poison, and, if met with in BomeO|
it IS only found and used there to a slight extent ; whereas dajaksch
is the name of a well-known native tribe in Borneo. In chemical
characters these poisons show themselves also not to be one and the
same. Lastly, tnese poisons seem to differ from one another in the
physiological effects they produce on the animal organism. For,
as Professor Eolliker ot Wlirzburg stated, as the result of his
investigations, in a paper read before the Medical Society of
WUrzburg in 1857, Upas Anthiar produces paralysis of the heart by
acting directly on its muscular fibres ; whereas dajaksch produces
cardiac paralysis by acting on the sympathetic ganglia of the heart.

Physiologists have now, seemingly, two separate means of pro-
ducing that wonderful and interesting phenomenon of a living animal
with an immovable heart; but they are required also anew to
unravel this problem, — Wherein consists the death of an animal, or
what is the boundary between life and death ?

I have much pleasure, at this time, in tendering my grateful
thanks to Dr Rosenthal, Professor Du Bois-Beymond's assistant,
for his aid while making the above researches.

Abticle V. — Case of Rupture of the Uterus^ in which Gfaetrotomy
vHu SueceesfuUy Performed, By R. W. Cbiohton, M.D.Edin.

Mrs M.. 8Bt 28, had been three times delivered by the forceps
previously to her present confinement. On all of these occasions the
children had survived birth only a short time, on account of the
strong compression that was necessarily applied to the head to
efiect delivery.

Having attended her during her last confinement, and ascertained
from the great projection of the promontory of the sacrum, that it
was impossible to deliver her of a living child at the full term of
utero-gestation, I advised her in future to have premature labour
brought on between the seventh and eighth months.

Her ordinary medical attendant, Mr Davenport of Hayfield,
finding, during the early part of last winter, that she was again
pregnant, had strongly urged on her the necessity of this proceed-
ing; but, from some cause or another, his intentions were not

134 DR cbighton'b case of bupture of the uterus, [auo.

carried oat. On the 28th of Jannaiy last, about 2 o'clock A.M.,
I received a note from Mr Davenport, requesting me to come as
quickly as possible to Mrs M., as he wished me to applj the long
forceps. I arrived about 4 A.M., and found that rupture of the
uterus had occurred about two hours previously. The patient was
rather flushed, and had an expression of great pain and anxiety ;
pulse 120, of fair strength. As the least pressure caused great
suffering, I could not ascertain the exact position of the child, but
the unequal, nodulated surface of the abdomen, the complete reces-
sion of the presenting part, the free discharge of blood from the
vagina, and the total cessation of labour pains which had previously
been very severe and constant, left no doubt as to the occurrence
of rupture of the uterus, and the escape of the child into the cavity
of the abdomen.

The patient stated that during the last severe pain she had, she
felt something give way with a distinct snap.

Mr Davenport informed me that she haa been in strong labour
since 10 p.m. on the previous day ; and that, before my arrival, he
had made two unsuccessfrd attempts to deliver, first by applying
the forceps, and subsequently by turning. After the last measure
had failed, he gave a liurge opiate, as the pains were very severe,
and it was during one of these that the uterus gave way.

I explained to the patient and her relatives that the only pros-
pect of saving her life was by extracting the child througn an
incision in the abdominal wall ; but, notwithstanding my urg^ing
them as 8tTonel;jr as I could to have it performed at once, I £uled
in obtaining their consent. I left the patient most reluctantlv, and
ordered her half a grain of muriate of morphia every two hoois.
About 2 P.M. I received a note from Mr Davenport stating that the
patient and her friends were anxious to have the operation per-
formed. I arrived about 4 p.m., and found her in great agony, but
with the pulse of wonderiully good strength.

After administering chloroform, Mr Davenport introduced the
catheter, and drew off about a pint of bloody urine. I now care-
frdly examined the abdomen, and found the child lying with its
head downwards, resting on the firmly contracted uterus. Before
operating, I pointed out to Mr Davenport the emphysematous con-
dition of the cellular tissue over the hypogastrium, distinct crepita-
tion being both felt by the hand, and heard through the stethoscope.
I made an incision in the middle line horn below the umbilicus to
within an inch of the pubes through the skin and cellular tissue ;
the peritoneum was opened at the upper part, and the incision
downwards completed with the knife resting on the forefinger of the
left hand. About a pint and a half of dark-coloured bloody fluid
escaped, and the child ^ was at once seen lying in the position above
mentioned. It was removed without any difficulty, and also the
placenta, which was loose under it.

^ The child was afterwards weighed, and found to be 9i lbs.

1864.] IN WHICH GAOTBOTOMT WA8 PERFORMED. 135

The utenifl was seen to be well contracted, the line of rnptnre
being almost directly transverse about the junction of the bodj with
the cervix, and covered bj a layer of coagulated blood.

Several large clots were removed, and some bloody fluid sponsed
out, but much disturbance of the viscera was carefully avoided.
There were no signs of inflammation of the peritoneum except at
one point in the left iliac fossa.

Tne edges of the wound were accuratelv brought together by
twisted sutures on long acupressure needles pasMd through the
peritoneum. Warm-water dressine on pledgets of lint were applied,
and a bandage was passed round the abdomen.

The patient remamed under the influence of chloroform for half
an hour after the extraction of the child, and on awaking, expressed
herself as feeling much relieved.

Pulse 112 ; no sickness ; skin acting fteely. To have one-sixth
of a grain of morphia every second hour, and two minims of
hydrocyanic acid, with a little alkali.

No nutriment was allowed except occasionally a tablespoonftd of
cold toast-water, or arrowroot gruel. I saw her daily for the first
twelve days, along with Mr Davenport (whose intelligent care and
attention were unremitting), and snail give a condensed report of
the progress of the case, as I find it in my note-book.

29/A Jan. — Has slept a great part of the ni^ht, and expresses
herself as feeling very comibrtable. No flushing ; pulse 108, of
eood strength ; has made an effort to vomit ; about half a pint of
dark-coloured urine was drawn off by the catheter ; abdomen not
much distended ; moderate tenderness on pressure. Wound looks
well ; edges in correct apposition, except at one point below, where
bloody fluid escapes on slight pressure. Fresn pledgets of lint
were applied, and the same medicines and diet continued^ with the
addition of a solution of chlorate of potash for drink (gr. iv. to Ji-))
and small portions of ice occasionally to relieve thirst

30t&. — Has had pain during the night in the region of the liver
and right shoulder, for which eight leeches were applied by Mr
Davenport with subsequent relief; urine twice drawn off since last
visit, clearer, about half a pint each time ; pulse 112 ; tongue
covered with white fur ; jaundiced tint of skin and conjunctivae ;
vomited once durine the night some brownish-coloured fluid ; dis*
charge from vagina less ; wound looks well, seems uniting : abdomen
not much distended except at the epigastrium and right nypochon-
drium. Ciontinue water-dressing to wound ; to have an enema of
warm-water immediately, and another in three hours, if first does
not act ; turpentine epithems to be applied to the epigastrium and
right hypochondrium. If the stomach is not irritable, ten minims
of the muriated tincture of iron to be substituted for the hydrocyanic
acid. Continue toasl^water, etc.

31«t — Has passed a good night ; slight sickness once, but only
A small quantity vomited ; urine thrice drawn off since last visit,

136 DR CRIGHTON'S case of rupture op the uterus, [AUG.

lighter coloared and more copious ; abdominal distention not much
increased, except at epi^trium ; jaundiced colour less marked ;
pain in right hypochondnum gone ; tongue moist, cleaner ; respira-
tion nearly natural ; pulse 108, of good strength ; bowels have not
acted, though she had an enema twice. Wound seems firmly
united except at one point below, where the edges are slightly
gaping. Four needles removed ; no opening of line of incision ;
pads applied with warm-water dressing and a banda^. An
enema to be given immediately, another in the evening, if first in-
efiectual; if still no evacuation, gr.v. Hyd. c Cretft, with gr.x.
bismuth. The enemata failing, the powder was given, and soon
afterwards the bowels acted freely ; great sickness, however, soon
followed, bursting open completely the line of wound in its whole
length. Slight haemorrhage occurred from the wound, but not from
the peritoneal cavity. Mr Davenport reintroduced several needles
with twisted suture, and applied straps of adhesive plaster. The
hydrocyanic acid was given more frequently.

Ist Peb.y 8 A.M. — Colour of skin much improved, jaundice nearly
gone ; has slept two hours since the sickness ; tongue cleaner and
moist ; complains of feeling great distention of the aodomen, which,
however, is reported as being less than during the night; pulse
120, firm ; urine drawn off several times since last visit, reported
copious ; plasters partially removed, so as to examine the wound,
which is seen to be without any gaping of its edges, but not so
accurately in apposition as before the vomiting ; has retained the
beef-tea since 11 p.m. To have tincture of iodine painted over the
epigastrium and right hypochondrium, turpentine to be reapplied if
required. Continue prussic acid, with ice, etc. ; beef-tea in small
quantities to be given by the mouth, and, every four hours, a teacup-
ful, with ten minims of the muriated tincture of iron, by the rectum.

2d. — Has passed an uneasy night; vomiting again occurred
about midnight, with pain in the region of the liver, ror which four
leeches were applied, with relief; has not vomited since; bowels
acted well during the night ; has taken about a pint and a half of
beef-tea since yesterday — the greater part by the rectum ; prefers it
now by the mouth ; tongue moist, and nearly clean ; countenance
of natural colour; expression good; pulse 130, of fair strength.
Straps of adhesive plaster removed, and fresh ones applied ; wound
has a tendency to open superficially, but not in its whole depth,
except at one point below, from which dark-coloured fluid escapes ;
abdominal distention less, except at epigastrium ; tenderness on
pressure lessj urine reported paler coloured, and more copious,
drawn off thrice since yesterday. Two long needles substituted for
two shorter ones, and twisted suture applied. Continue warm-
water dressing; painting with tincture of iodine, and the other
medicines. A pint and a half of beef-tea to be given during the
twenty-four hours.

^. — Bowels have acted five or six times during the night ; an

18G4.] IN WHICH GASTBOTOXT WAB PERFORMED. 187

opiate wasriven by Mr D. at 6 A.if. ; ainoe then the diarrhoea haa
ceased. Tongue moist and clean; jaundice quite gone; urine
oopiouB and ciear^ drawn off thrice ; araomen much re£iced in naeu
except at epispastrium; pressure well borne; pulse 112. Wouna
dressed as before ; healing at upper and lower pomts ; edges separ-
ated for about three inches betweoi ; free discharge of dark-coloured
fluid from the cavitj of the peritoneum^ with strong foetor. Ordered
two teaspoonfhla of brandj every two or three hours, with one
quart or beef-tea ner daj. A solution of carbolic add to be
sprinkled on the beo.

4ei. — ^Has passed a good night ; no action of the boweb, except
the frequent passage of flatus per anum; pxdse, 112. soft; wound
dressed as before ; no tendency to unite in the middle ; all the
needles removed ; discharge free and very offensive. Continue the
application of the iodine, and the other medicines, etc.

6^ — ^Has had a restless ni^ht, and slept but little, although two
opiates were given ; has had intense pain in the epigastrium and
left hypochondrium, which was relieved by hot fomentations; at
the same time experienced great pain and difficultjr in swallowing;
pulse rose in the night to 144, and is still 140 ; urine drawn off as
usual ; no action of bowels, except the free passaee of flatus. Haa
taken little by the mouth since yesterday, but nad an enema of
beef-tea, with brandy. The cardiac region was carefully examined,
to ascertain whether the dysphagia mi^t be occasioned by efitision
into the pericardium, but no signs of fluid there were discovered.
To have an enema of beef-tea and brandy every three or four
hours. Wound, dressed as before, is now discharging pus freelv ;
a cloth wet with a solution of caroolic acid to be applied over tne
pubes, and changed frequently; this seemed to destroy the fcetor
very thoroughly.

6th, — Has had a good night ; general symptoms improved ; pulse
120 ; wound, healing above and below, still gapes in the miadle ;
can now take the iron every three hours, ana swallows better.
Continue the beef-tea and brandy, with a little milk occasionally.

7tk. — ^Was much troubled during the night with pain in the left
hypochondrium, which is more distended than yesterday ; bowels
acted freely this morning after an enema ; passes flatus freely per
anum ; complains much of a sore over the sacrum, which has been
dressed regularly for some days past with calamine cerate ; appears
more irritable and desponding than she has done before ; pulse 120 ;
wound discharging healthy-looking pus, is contracting. Continue
iron, etc.

8th. — Vomited once since yesterday, after taking a dose of the
muriated tincture of iron, which was, therefore, discontinued for a
time ; had ai^ opiate twice during the night, and slept well ; ex-
pression much improved ; pulse 120, of better strength ; distention
of epigastrium and left hypochondrium less, and pain there much
lees acute ; pressure over abdomen generally well borne. While

▼OL. X.— NO. n. 8

138 DR cbiohton's case of bufture of the uterus, [auq.

dressing the wound, its edges were rather widely separated about
the middle, and what was considered the lower edge of the trans*
Terse colon was distinctly seen at its upper part ; no tendency to
protrusion of any part ot intestinal canal. Straps of plaster were
reapplied more firmly than before, and the edges brought into exact
apposition with diy lint and a bandage round the abdomen. To
have an occasional dose of hydrocyanic acid and another enema ; the
iron to be tried a^in in doses of five minims ; beef-tea, etc., as
before. After the dressing she expressed herself as feeling very com-
fortable, and for the first time said that she had some hope of recoyery.

9th, — Has had a good night ; no vomiting since yesterday, though
she has felt sick occasionally. Pulse 120 ; tongue drier, slightly
brown; distention of abdomen gradually diminishing. Wound
united for upwards of two inches ; discharges healthy pus ; still a
tendency to open widely at upper part: dressed as before, and
calamine cerate applied to the pubes, as tnere was some eiythema
from the discharge. Has not taken the iron since yesterday ; to
have instead, the prussic acid, with a little soda, m infusion of
calumba ; beef-tea and brandy as before, and bread and milk occa-
sionally, of which she is veiy fond.

11th. — ^Appearance much improved since last visit; pulse 112, of
good strengtn : slept during past night firom 11 P.M. till 5 A.V. ;
no vomiting ; Dowels have acted several times ; has passed water
by the natural efforts ; appetite better ; tongue clean and moist ;
distention of abdomen less; wound contracting, though still open
to the extent of two inches ; erythema over puoes less. Plasters,
etc., reapplied ; has taken the iron regularly yesterday and to-day ;
to have, at her own request, a small mutton-chop.

18^. — Has improved steadily since the date of last report ; sleeps
well ; tongue clean and moist ; bowels opened by occasional
enemeta; pulse about 100, of ffood strengtn; size of abdomen
much reduced, no tenderness. Edges of wound well together under
the plaster ; when this removed but little tendency to gape, except
at tne upper part; is evidently healing kindly; a little healthy
pus at the lower angle. Takes half a grain of quinine several times
a-day ; has had for some days beef-tea and mutton-chop, with a
little fish occasionally. After dressing wound she felt so well as to
express a desire to get up soon; can now pass water regularly
without the catheter.

22dl — Continues to improve; pulse 98; bowels^ opened by
enemata; appetite has failed considerably for past two or three
days, notwithstanding the administration of half a grain of quinine
every four hours; abdomen now quite flat^ no tenderness; on
removing plasters, the wound found quite united ; a free discharge
of pus from the vagina replaces that from the wound ; no foetor.
Ordered the same doses of quinine, dissolved in ten minims of the
muriated tincture of iron ; to have porter fr^uently, up to a pint
a-day, and as much animal food as the stomach will digest.

1864.] IN WHICH GASTBOTOMT WAS PERFORMED. 139

From this date she continued steadily to improve till 3d Marchy
when she had a rigor, with pain in the left iliac fossa ; bnt after free
action of the skin, and the reapplication of the iodine, she began to
imnroTe anin in a few days.

On 24u March the pnlse rose to 120, and slight jaundice
appeared, with increased dolness in the ri^ht hypochondrium.
Tincture of iodine was painted over the dull space, and nitro-
muriatic acid given internally, and in the course of two or three
days she was so much better as to be able to be lifted out of bed to
' the sofa for several hours at a time.

During the first week of April she was strong enough to sit up
daily, and was so well on my visit to her on the 4th of that month,
that 1 discontinued my attendance. She mentioned that the menses
had appeared a day or two previously.

On 2d June, she walked nom HajdSeld to my house, a distance of
four and a^half miles (returning again the same evening on foot),
and assured me that she had not been in better health for years.

BemarlcB. — The careftilly compiled statistics of Dr Trask, of
New York, give great encouragement in undertaking the apparently
hopeless operation of ^trotomy in cases of rupture of the uterus :
yet, since the date of the publication of these (1856), I cannot fina
any successftd case recoraed as having occurred in Great Britain.
I have, during the past thirteen years, seen only' one case in addition to
that recorded above. In that case the practitioner in attendance was
not aware that rupture had occurred, and did not folly sanction my
proposal to perform gastrotomy. The patient was abandoned, and
died undelivered about thirty-six hours after the occurrence of rup-
ture. She was a primipara, and apparently free from pelvic deformity.
Ergot had been given freely dunng the progress oithe labour.

in Mrs M.'s case several points deserve, 1 think, especial notice ;
the long interval that occurred between the rupture and the extrac-
tion of the child — fourteen hours ; the recovery from acute iaundice
occurring in the circumstances; and the apparently good effects
of the application of the tincture of iodine extemsuly in causing
absorption of the products of inflammation affecting the serous
covering of the different abdominal viscera.

Chafel-kn-le-Fritb, June 10, 1864.

Article VI. — Twdve Cases of Ovariotamy. By Thomas Keith,

i .H.C.S.£j.

In July 1863, I read before the Edinburgh Medico-Chimrgical
Society an account of the first successful cases of ovariotomy iper-
formed in Scotland since Mr Lizars' single and partial success in 1825.
The subjects of these operations have remained in perfect health.
One married eight months after the operation, and the others have

140 CA8E8 OF OVARIOTOMY BY DB KEITH. [AUG,

sinoe performed the usaal duties of home life ; while one, twenty-
seven years of age, in whom the weight of the tumour removed,
now a year and a half ago, was upwards of one hundred and twenty
pounds — the largest tumour, by far, ever removed successfully
from the living body — ^is now a strong healthy woman. It is now
proposed to continue an account of all the operations for ovarian
disease which I have since then performed — successful as well as
unsuccessful — in the order in whicn they occurred. And I wish it
to be understood that these cases are fair cases ; for I have not
removed small tumours, and I have invariably declined operation
in cases in which the general health was very good and the disease
the source merely of inconvenience, and not of danger to life. But
I have not felt warranted in declining a single case — however large
the tumour or however much reduced the strength of the patient
— in which there was even a bare probability of success, although
by operating on very large tumours, or in desperate cases, one, of
necessity, risks both the credit of surgery and one's own reputation.
In one case I saw last year, and again a few months ago, interference
with the tumour was not recommended, on account of its extensive
and intimate connexions with the uterus^ bladder, and rectum. I
have lately declined other three cases in which I was asked to
operate; but in all of them the disease had nearly reached its
natural termination. Of these, one died within forty-eight hours,
another within a week, and the third within three weeks after
being first seen. It would have been simple foolhardiness to have
expected, that in such extreme cases nature would give one any
assistance, in sustaining the shock, or repairing the injury necessarily
inflicted by such a severe proceeding as ovariotomy must always
be in large tumours. All of these cases, however, had been most
favourable for removal only a few weeks or months before. With
these exceptions, I have declined no case where the tumour
was capable of being removed. It is only fair to add, that since
I commenced these operations, nearly two years ago, I have de-
clined operating in nine cases, in which the general nealth was not
interfered with, and life not yet threatened by the disease, on the
ground that I was not justified in recommending, and the patient
not warranted in undergoing, such a formidable operation. Oi these,
I regret to say, three at least have died. Two oied in the country,
after a first tapping to facilitate their journey to town; while
another case — ^a very sad one — who came to me first about eighteen
months a^o, I declined, though a most favourable case at that time
for operation, on the ground that the tumour was merely an incon-
venience to her. She was very anxious to have it removed, and I
agreed to do so as soon as her general health became much afiected
or her life in danger. She left disappointed, went home, had the
cyst injected with iodine, suffered a ^at deal of pain for several
days after the injection, returned in a few months, larger than
ever, with her general health much impaired, and asked me now tr

X8e4.] 0A8E8 OP OYARIOTOMT BT l>E KEITH. 141

fidfil m^ promisei and remore the tamoar. Bat I waa now obliged
to decline a second time, on account of the adheaiona that had
fonned in the pelvia after the infection of iodine into the cyst.
These were of such finnneaa that the removal of the tunoor would
have been impossible.

The average weight of the tumoara removed was a little over
42 lbs. ; the average of the fatal cases npwarda of 60 lba.| while
that of the sucoessrul cases was 39 Iba.^ or. excluding the veiy
large tumour, a little upwards of 31 lbs. Adhesions, generally ex*
tensive and often of great firmness, were met with in all tlie cases
except three, and these three recovered without the slightest on*
favourable symptom. And, thoueh equally jhvourable recoveriea
occurred in some cases where adhesion was great, in not a few a
successful result was got with great difficulty, and after a long and
tedious convalescence, with more or lees suppuration in the pelvis.

In the following case an attempt was made, towards the natural
termination of the disease, to save the life ol one of the most re-
markable women I ever met. She had been repeatedly tapped,
and I had in consequence to deal with unhealthy blood, and with a
nervous system enfeebled by long and great suffering, and if the
attempt was a failure, and her life was thereby shortened by a few
months, the unfortunate termination seemed after all to have arisen
from rupture ofj and hsBmorrhage fit>m, the ovary that was left, and
which at the time of the operation was apparently in a healthy state
— one of those accidental and unforeseen circumstances that every
now and then must arise after all capital operations.

Case I. — MuUtlocuJar Ovarian Tumour j weighing nearly 80 lbs.
Ovariotomy. Death on the second day.

In the end of May last. Dr Thomson of Dalkeith asked me to see
a married lady, twenty-tnree years of age, who had just come under
his care. She had made a long railway journey the dav before, and
was in consequence much fatiraed. She was so emaciated, and looked
so exhausted, that the idea of interfering with the tumour in anv way
seemed out of the question. The aUomen was occupied by an
enormous multilocuhu: tumour, and she measured upwards of fifty
inches at the umbilicus.

The disease had been detected when she was seventeen vears of
age, a few months before her marriage. Its progress was slow, her
health continued excellent, and after the nrst tapping no solid
matter was felt, and she was soon able to be about again. The
tappings went on, however, the intervals steadily shortening by
one-half, and now, afl;er each time an increasing mass of solid
matter was felt, and her sixe diminished less and less. Till the
last tapping, three months ago, her general health bad remained
unaffe(Aed ; but since then she had not rallied as she used to do,
and had been quite an invalid. She suffered greatly from neural-
^c face-ache and pain in the right side over the semi-solid part of

142 CASES OP OVARIOTOMY BY DR KEITH. [AUG.

the tamoor. She had lost flesh very much, took little food, and
lived mostly on stimulants.

She required tapping about a week after this. Upwards of 50
lbs. of thick fluid were removed. The tumour consisted of one
enormous cyst, with a large semi-solid mass occupying the right
side, extending under the ribs. The tumour was unattached in
the pelvis, but the large cyst did not subside much. A few days
after this tapping she was seized with phlegmasia dolens of the left
leg. She suffer^ severely, but in three weeks she was able to be
up again. She was put upon full non-stimulating nourishment,
her general condition improved, and she gained flesh ; while the
tapping, which was looked for in six weeks, was delayed for
uj)waras of three months. It became necessarv, however, by the
middle of August, and upwards of 50 lbs. of fluid were again re-
moved. I was not aware at the time of the tapping that the period
had not quite passed over, and she was scarcely laid on her back
when she was seized with an intense pain in the right groin. She
said she was sure something had given way. The pain was most
acute, and for two or three days she was very ill, with all the
symptoms of peritonitis. She had great abdominal tenderness, and
a rapid pulse. In a week, however, she was again up, and then,
for tne first time, she spoke to me of the chances for and against
her after ovariotomy. She knew she could not now have an
average chance, but still there seemed a reasonable prospect of
success.

The tumour was accordingly removed on the 27th of August.
There was slight parietal adhesion in front, and the omentum was
wound around ana adherent to the semi-solid portion of the tumour
over a great extent, but there was no difficulty in securing the
vessels, and but little injury done in its separation. The mass of
semi-solid matter was, however, very large. It extended under
the ribs on the right side, over the upper part of the abdomen, and
across to the left side. Several lar^e cysts were tapped, ana the
mass reduced so that it was easily withdrawn. The mass of secon-
darv cysts and cyst walls weighed nearly 30 lbs., and upwards of
50 lbs. of fluid had been removed from the largest cyst, about ten
days before. Before closing the wound the right ovary was drawn
aside, and some of my friends present remarked what a healthy
ovary it looked. Satisfied with its small size and natural appear-
ance, I did not touch it.

She was put to bed in an excellent state. The night was passed
quietly, and next morning she had an excellent expression, and
quiet pulse. About eleven o'clock she suddenlv vomited, and com-*

f)lained of the same intense acute pain that sne had felt after the
ast tapping, and said surely something had given way. Her pulse
be^^an to rise after this; she became chill, and died thirty-eight
hours after the operation.
The pelvis was nearly ftill of sero-sanguinolent fluid. On the

1864.] CASES OP OYARIOTOMT BT DR KEITH. 143

posterior border of the right ovary were two rapttires — one of some
standing the other quite reoent. In the one was adhering a de-
colorized clot ; and this rupture had probably taken place during the
menstrual period, at the time of the last tapping, ten days before.
In the other the fissure was recent, and a rery large coagulum
was adherent in it.

Case IL — MuUUocular Ovarian Tumour weighing 40 Ibe.
Ovariotomy. Recovery*

An unmarried lady, twenty-three years of a^, who had enjoyed
an average amount of health, had her attention directed by her
friends, about the middle of July last^o an increase of her size.
She was seen early in August by Dr JDrummond of Glasgow, who
found the abdomen occupied by a large ovarian tumour. The for-
midable nature of the affection under which she laboured, and the
only remedy for it were accordingly explained by him to her friends,
but as her life was not then threatened by the disease, no immediate
interference was recommended. She was advised to live quietly,
and go for a time to the country.

A few days after this, when on her way through Edinburgh, she
was seized with severe abdominal pain, and was imable to com-
plete her journey. Her distress was farther aggravated by the
jolting in a cab on her way to a friend's house, and when seen
shortly after by Dr Warburton Begbie, she was suffering from
severe peritonitis. The acute symptoms soon yielded to the
remedies employed, but the tumour enlarged. She suffered so
severely from the distention, she had such weary sleepless nights,
and began to lose flesh so rapidly, that on the 21st it became
necessary to relieve her by tapping, the ^rth at the time being
nearlv 45 inches. This I accordin^lv did at Dr Begbie's request.
Nearly four gallons (40 lbs.) of thick ^reen fluid were removed.
The cyst wwls were felt to be very thick, and were extensively
adherent to the parietes, while a mass of secondary cysts filled up
the left iliac region.

She was much relieved, and in the course of a fortnight was able
to be removed to Avr. Though she gained strength to a certain
extent she was unable to walk, but was moved about in a chair.
The cyst commenced to refill, she increased at the rate of half an
inch a-day, and in little more than a fortnight she was brought
back to town nearly as large as before. On the 27th, tapping was
aeain necessary ; and 35 lbs. of very thick fluid were removed.
Sue did not, however, diminish so much as after the former tapping,
for the mass of secondary cysts had greatly increased.

It was now evident that the disease could no longer be safely
temporized with, and that it would run its course with imusual
rapidity. It accordingly became necessary for me to place before
her in cold statistics, the risks and advantages of the radical cure.
She had to take her choice between the certainty of a short life, —

144 CASES OF OVARIOTOMY BT DR KEITH. [AUG.

and it would have been a very short one, not free from suffering, and
the chance of a long life after ovariotomj. The operation was at
once decided upon, and performed on the 29th of September — two
days after the second tapping. Dr^egbie, Dr Warburton Begbie,
Dr Craig of Ratho, Dr Sidey,

and Dr Keith^ were present. There

were extensive, but recent, parietal adhesions, which gave way
readily to the hand. The peaicle was short and broad, extending
about twelve or fourteen inches along the base of the tumour. The
clamp was applied within an inch of the uterus, and there was con-
sequently a good deal of strain upon the pelvic tissues ; a trouble-
some oozing from some torn adhesions to the false ribs on the right
side delayed the closing of the wound for nearly half an hour;
otherwise nothing unusual occurred.

The cyst walls weighed 5 lbs. 6 oz., and 35 lbs. of fluid had
been removed from the large cyst two days before.

No bad consequences followed ; and since her return to Glasgow,
a month after the operation, she has enjoyed excellent health.

Case III. — Large Semi-aolid Ovarian Tumour. Ovariotomy.

Recovery.

In the end of August, Dr Wm. Brown asked me to see a young
lady only sixteen years of age, in whom an attack of abdominal
pain had led to the detection of an ovarian tumour, about seven
months before. Its increase was rapid, and in July last it was
punctured below the umbilicus, and after passing a sound through
the cannula, and breaking into several cysts, a considerable quantity
of very thick viscid fluid was obtained, without, however, much
diminishing the size or determining at any one point the subsidence
of the tumour. When I saw her six weeks after, she was nearly as
large as before.

This young lady's case is thus described by the author of the
Excursion Chirur^ioale en Angleierrey who was present at the tap-

Sing, ^^ Ainsi, j'ai vu une jeune flUe de 15 k 16 ans, dont je vous ai
4jk parl^, atteinte d'un kyste multiloculaire ^norme k contenu
visqueux, filant, gris verdfttre, dont la ponction, apr^ avoir vid^
diverses poches, ne parvint k determiner le retrait sur aucun point,
de I'^pigastre au pubis et d'un flanc k I'autre. l^videmment il

Jaurait eu imprudence k tenter I'extirpation d'une telle tumeur
ont les adh^rences ^taient si fortes et si ^tendues qu'elles auraient
emp^chd probablement le chirurgien de terminer I'opdration. II est
Evident que, dans ces circonstances, Toperation est contra-indiqu^,
et que la maladie par&it in^vitablement mortelle ; mais c'est un cas
k rapporter aux coutre-iudications naturelles de I'ovariotomie."

The abdomen was entirely occupied by a large irregular semi-
solid mass. There was only one cyst of any size, which occupied
the enigastric space, extending under the sternum. The ribs were
alreaay being pushed outwards, and the ensiform cartilage pointed
slightly upwaras. In the left hypochondrium the tumour bulged

18e4.] CASES OF OVARIOTOMY BY DR KEITH. 145

outwards, and felt verj hard and near the skin, which bore the
marks of former leeching and blistering. She had long suffered
from severe pain in this region, and here firm adhesion was evident.
In the right iliac region the tumour felt also very hard and near the
surface, and here, too, pain had been from time to time complained
oil The pelvis was occupied hy a solid mass coming below the
Inrim, and the uterus, though it could not be moved from off the
tumour, had a sort of rotation upon it, giving the impression that
the pedicle was verj short, rather than tnat adhesion existed
between the two.

She was pale and thin, with a feeble circulation, but her general
health was still good. She took her food well, slept well, and was
able to take carnage exercise without fatigue.

After this she went to the country, and I saw her again on her
return to town in the beginning of November. Her general health
continued good, but the tumour had increased in all directions, —
especially above. The cjst, fiUine the epigastric space, was larger
and more tense and momment. The ensiform cartilage now pointed
directly upwards. The ribs were more bulged outwards, especially
laterally, and the measurement over the lower end of the sternum
was two inches greater than at the umbilicus. My attention was
now directed to the state of the spine, for the whole of the lumbar
and three lower dorsal vertebras were very prominent, rendering
the curvature of the back so great, that with the bulged condition of
the ribs she was quite barrel-shaped.

In hopes of getting some information as to the connexions of the
upper part of the tumour, I tapped the upper cyst at its lower
margin, on the 12th November, midway between the umbilicus
and ensiform cartilage. A large trocar was used, but after a few
ounces of very dutinous fluid escaped, the stream stopped and no
more could be obtained, though on passing in a probe it was evident
the cyst was of considerable size. Soon after, pain came on, and in
the course of an hour I foxmd her with a pale anxious countenance,
thoracic breathing, and a very rapid nulse, suffering from intense
pain and tenderness, with vomiting, all over the upper portion of
the abdomen. Large opiates and fomentations relievea this, but
for some days her condition gave rise to not a little anxiety. All
this time there was a constant oozing, from the puncture, of the same
gelatinous sticky fluid, and it was supposed that altogether more
Sian a gallon made its escape. For two or three days there was
clear sound on percussion, as low as two inches below the ensiform
cartila^, but by the end of a week this had quite disappeared, and
the duTness extended as high as before. It was afterwards found
that the upper cyst had not in the least refilled, but that its posi-
tion had been occupied by the semi-solid portion moulding itself
into its place.

After repeated examinations of the tumour, it seemed to me that
there was no obstacle to its removal, as far at least as its upper

VOL. X. — NO. II. T

146 CASES OF OVARIOTOMY BY DR KEITH. [AUG.

portion was concerned. But the nature of its connexion with the
uterus could not be quite satisfactorily determined, while the now
very great curvature of the spine — rendering it uncertain whether
this arose from disease of the bodies of the vertebrse themselves,
or whether it was simply caused by the direct weight and pressure
of the now almost solid tumour — added greatly to the anxious
doubts and grave responsibilities of the case. But on the other
hand, the patient was but sixteen years of age, of a healthy family,
with young and probably not yet unhealthy blood, and her nervous
s^^stem as yet not much broken down by suffering or sleepless
nights. I, accordingly, felt warranted in recommending to the
patient and her friends, that an attempt should be made to re-
move the tumour, else there was nothing to be looked forward to
but a short and miserable life. And as the recent inflammatory
attack would, in all probability, lead to the formation of extensive
adhesion alon^ the upper part of the tumour, it was evident that
this attempt should not be delayed very long. She had lost flesh
since the tapping, and had not been out of bed. She was not in a
very good state for the operation, for the tongue was big and foul, but
there was very little chance of her ever again getting into a better.
The tumour was accordingly removed on the 2l8t of November.
Dr Brown was present. Dr Keith gave chloroform, and Dr Keiller
and Dr James Sidey gave me their usual invaluable assistance.
The tumour was exposed over a mass of thickened and contracted
cysts, the result apparently of the first tapping. The opening was
enlarged sufficiently to admit the hand, which was pushed through
loose adhesion downwards, and the pelvic cavity examined as tar
as it was possible to do so. It was apparently free of adhesion,
but the uterus could not be reached. 3elow the umbilicus the
adhesions were very loose, and gave way at once to the pressure of
the hand. Above they were much as was anticipated, being nearly
universal. These were all gradually separated by the hand ; but, on
the left side, they were of the utmost firmness, and in breaking them
down the tumour fissured and gave way in all directions. I was,
however, totally unprepared for the great mass of solid substance
that extended under the ribs, for three-fourths of the whole tumour
lay above the umbilicus, and though I had enlarged the incision up
to the ensiform cartilage. I am sure I could not have removed the
tumour entire. A verv large trocar was then pushed here and there
into it, but only a small quantity of very viscid thick matter could
be obtained. 1 next cut deep into the heart of the mass below the
umbilicus, cut wiMi the knife and opened cysts in all directions, and,
passing in my hand, broke down the inside of the tumour. This was
not easily accomplished, for the divisions between the cysts — and they
were all small — were very fibrous and thick, and gave way to the
fingers very unwillingly. Half a pailful of fluid and broken down
cysts was thus obtained, but the vascularity of the interior was so
great, that it was necessary to finish this part of the operation with

1804.] CASES OF OVARIOTOMY BY DR KEITH. 147

the Qtmoflt rapidity and with apparent roughness. I succeeded at
length in dragging through an opening, extending only an inch
above the umbilicus, a mass of solid matter and cyst-walls, weigh-
ing upwards of 20 lbs. As this was withdrawn a firm and thick
band of adhesion arising from the right iliac region came into view.
It formed almost a second pedicle, and contained large vessels. It
was transfixed and tied. The pedicle itself now came into view on
the left side, but the uterus came out with it. The tipper part of the
pedicle which ran along the tumour up to near the false nbs was of
great length, but it gradually shortened and disappeared in the
comer of the uterus which was quite close to the tumour. It was
tied in four or five divisions, for the clamp could not be got under
the tumour and the mass cut away. The clamp was then applied
round the long part of the pedicle, and an attempt made to tie the
vessels singly in the portion which was connected so closely with the
uterus ; but after tying two large vessels, there was so much oozing
that I reluctantly embraced the whole in the clamp, brinring the
uterus in consequence against the abdominal wall. When the
bleeding from the torn adhesions had ceased, the clots were removed
and the pelvis sponged out, and the omentum, which was of very
great size, was carefully spread by the fingers over the intestines,
and especially over the left side where the adhesions had been
strongest, ana where the tendency to ooze was greatest. The wound
was then closed by thirteen deep stitches, placed closely together on
account of the thinness of the abdominal wall. But the elevation
of the ribs was so great that the cavity of the abdomen remained
half-filled with air. The ribs were pushed downwards and the air
pressed out as much as possible alongside the clamp, — a large heavy
compress of wet lint bemg placed over the wouna and a bandage
over the ribs to keep them aown and prevent the re-entrance of air.

She was under cnloroform for an hour and a half. The whole
proceeding had been one of the utmost severity ; and when the
pallid, fra^e, emaciated form was lifted into a warm bed, and left
to nature and an intelligent nurse, it seemed to us all that nature
had been asked to do too much to repair the injury that had of
necessity been inflicted.

But on the sixth day after the operation she felt so well that she
thought she might be allowed to do a little work. That ni^ht she
had a slight chill, which, however, seemed to have passed off by
next day after free perspiration, without doing any harm. The
seventh night was restless, and in the morning for the first time the
pulse was rising. There was some abdominal tlndemess, which
was not relieved by having the bowels moved by enema. By mid-
day the distention was considerable, and as there was some pull
upon the clamp, it was removed. This was followed by relief of
the pain, and to a considerable extent of the distention also. The
pulse continued to rise, and towards afternoon vomiting came on,
and though the sutures had been removed some days before, no

148 CASES OF OVABIOTOMY BY DR KEITH. [AUG.

harm was done to the freshly united wound by the first attacks of
vomiting. Some strips of plaster were, however, put on, not that
they were absolutely necessary, but to give confidence during the
vomiting. The attacks of vomiting went on every half-hour, and
were very severe, the pulse having now risen to 150, and her con-
dition for some hours was most critical The state of the pedicle
was examined after every attack. It had considerably retracted,
and there had been some oozing from it, and during every fit of
retching there was a gush of yellow serum from the abdominal
cavity. About midnight a large vessel was observed bleeding from
the stump of the pedicle ; this was at once secured, and the whole
freely touched with the perchloride of iron. Towards morning
copious serous discharges came from the bowels, and the vomiting
then ceased. In a lew days there was decided fulness of the
recto-vaginal fossa, but as there was now a good deal of discharge
from the lower end of the incision — at first of a serous oily nature,
then dirty serous, and then purulent — it was not interfered with,
but its degree of tenseness careiully watched from day to day. Bj
the end of the third week the discharge from the wound was copi-
ous, and continued more or less for several weeks. During all this
time the pulse continued high, but her recovery — thanks to the
most careful and intelligent ofuursing — was now uninterrupted, and
six weeks after the operation she was thoroughlv convalescent.
She was round-shouldered for some time, and had a considerable
stoop, but this soon wore off when she began to get out, and the
spine quicklv regained its normal curvature ; and in a short time it
was impossible to recognise, in the healthv-lookine blooming girl,
the subject of all the anxious doubts of a tew mon& before.

Case IV. — MuMlocular Ovarian Tumour j weighing impounds.
Ovariotomy. Recovery.

On the 18th of October last, Dr M^Watt of Dunse asked me to
see Mrs J., aged fifty, who had sought his advice four months before
on account of ovarian disease. She was then scarcely able to retain
any food, and had had several attacks of vomiting of blood. Under
treatment the vomiting ceased, and her general health much im-
proved till five weeks before I saw her, when she was obliged to
take to bed on account of severe abdominal pain which had remained
more or less ever since.

She was a very little woman, pale, extremely emaciated, and
verjr feeble. The pulse was small, and generally about 90. She
had restless nights 6rom dyspnoea, and could scarcely take any food.
She measured 41^ inches at the umbilicus. The upper part of the
tumour was fluid, but frx>m the extremely oedematous condition of
the abdominal wall it was impossible to make out the state of the
lower portion. The uterus was central, normal, and movable, but
the roof of the vagina came very low down, especially on the left
side. The general condition of the patient was so unfavourable

1864.] CASES OF OYABXOTOMY BT PR KEITH. 149

that the idea of operation conld not then be entertained ; bat in
hopes of giving her some temporary relief, about two gallons of
fluid were removed from the upper cyst by puncturing it above the
umbilicus. A large semi-solid mass was now felt to occupy the
lower and left side of the abdomen below the umbilicus. After
Bome davs, when the oedema of the wall had somewhat subsided,
Dr M'^ att was able to make a more careful examination, and was
satisfied that the adhesions were both firm and extensive.

Much to our surprise she rallied, and had so fax refined strength
as to be removed to town in the beginning of January. Ihe
tumour had nearly regained its former dimensions, and the oedema^
tons anterior wall hung down over the pubis, forming a tumour
nearly the size of the head.

She got cold on her way into town^ and had an attack of in-
fluenza, which was prevalent at the time. To relieve the bronchial
irritation and dyspnoea, she was again tapped, and the oedema of
the limbs and aodominal wall having somewhat subsided, the
tumour was removed on the 16th of January. Dr M'Watt of
Dunse, Professor Stewart of Kingston, Dr Sidey, and Dr Keith
were present The external incision was extended to two inches
above the umbilicus. The omentum was Ij^ing between the
tumour and wall, adherent to both. As the parietal adhesion was
very firm, I cut through the omentum till the surface of the tumour
was reached : and fin£ng the adhesion of the omentum less firm to
the tumour tnan to the wall, I separated it from the tumour to the
left side till the free edge was reached. It was then freed and
turned to the right side, but all its parietal attachments were not
seiMirated. Very firm parietal adhesion existed between the semi-
solid part of the tumour occupying the left side and iliac region.
Posteriorly the tumour was embedded in a mass of small intestine
and mesentery. These adhesions were easily separable, except a
piece of mesentery, about the size of the palm ot the hand, wnich
was very firmly attached, and contained large vessels. Lower
down its connexions were separated along the brim of the pelvis on
the left side, and a semi-sobd mass was adherent along the side of
the rectum and hollow of the sacrum. This last adhesion was
firm, and part of the serous covering of the tumour was torn off and
remained. Finallv, the mass was turned out after much injury had
been inflicted on the peritoneum. The pedicle was short, and when
the calliper clamp was secured outside, from the thickened state of
the abdominal wall there was a great pull upon the uterus. Part
of the omentum, which was still adherent to tne pedicle and side of
the uterus, was separated, and some vessels secured ; still there was
a good deal of oozing coming up apparently from the torn pelvic
adhesions. This was found at last to come from a fissure m the
pedicle immediately below the clamp. The clamp was accordingly
removed and readjusted, and the bleeding point secured. The
wound was then tightly closed by a number of deep stitches in

150 CASES OF OVARIOTOMY BY DR KEITH* [aUG.

anticipation that the oedematous state of the wall would subside in
a few hours.

There was a good deal of shock. She passed a restless night,
and next morning there was so much distention from flatulence that
the head of the clamp was buried in the wound, and the handles
standing up at nearly a right angle. These unpleasant symptoms
disappeared shortly after giving her some simple food. By the
end of the third day the stitches were lying loose and were removed,
as was also the clamp, the wound bein^ quite united throughout.
On the ninth day she was removed during the day to the nurse's
bed, and was walking through the room by the end of the second
week. She returned to Dunse, a distance of fifty miles, in the
midst of a snow-storm on the twenty-fifth day after the operation.
Since then she has enjoyed the best of health.

Case V. — MultUocular Ovarian Tumour^ toeighin^ 37 lbs.
Ovariotomy. Death, on the sixth day, from Pentonitta.

M. B., aged forty, a tall, thin, sallow-looking woman, unmarried,
was sent to me last autumn by Dr Wilson. She had an ovarian
tumour of five months' growth, which already nearly reached the
ensiform cartilage, but as it had not yet given her much incon-
venience beyond what arose from its bulk, I recommended her to
let it alone* Her girth then was 37 inches.

She returned in four months. She was now 42 inches at the
umbilicus ; the tumour had nearly doubled in size, and she had lost
much flesh. She was now unable to do anything for herself, was
be^nning to have restless nights, and suffered from pain in the
epigastrium, while the lower extremities were distended almost to
bursting. There was also great oedema of the loins and abdominal
wall, as high as the umbilicus ; there was no albuminuria.

She haa lived a very sedentary life, and some years before had
been confined to bed for nearly twelve months with subacute
rheumatism, which had left her hands slightly deformed. She was,
moreover, the only surviving member of her family, all of whom
had died early, mostly of phthisis. Her general condition was
thus not a very favourable one for ovariotomy ; still the case seemed
a fair average one.

She was tapped in the end of January. Twenty-three lbs. of
thick fluid were removed from a large cyst which composed the
lower half of the tumour. The upper portion of the tumour did '
not in the least subside, and a large semi-solid part continued to
occupy the upper half of the abdomen. The oedema of the limbs
soon subsidea, but the cyst began at once to refill.

The tumour was removed on the 7th of February through an
opening just sufficient to admit the hand. The lower cyst was first
tapped, and the upper cysts were emptied through the larger one.
There was parietal adhesion, easily separated by the hand, from a
little above the umbilicus upwarcb over the epigastrium. As the

1864.] CASES OF OVARIOTOMY BY DR KEITH. 151

mass of cyst-walls, weighing upwards of 6 lbs., was being withdrawn
through rather a small opening, one of the cysts gave way, but
none of the contents seemed to get into the abdominal cavity.
There was no bleeding, no exposure of the intestines, and the
operation was completed in a few minutes. There was a slight
pull upon the uterus when the clamf) was secured outside, but not
nearly so much as I had 6ften met with before. The wound was
closed by deep and superficial silk sutures as usual.

She vomited very severely as she came out of the chloroform,
and complained all afternoon of intense sickness, with burning at
the epigastrium. B^ evening she was suffering severeljr fipom
flatulence, which continued all night, preventing sleep. This con-
tinued to a most distressing deeree, with a constant overpowering
feeling of sickness. By the end of the second day, there was some
distention of the upper part of the bowel, which went on increasing.
The pulse also began to rise. The clamp was removed on the
third day. and a good deal of yellow serum followed its removal,
without, nowever, affording relief. I could not satisfy myself that
there was any accumulation in the pelvis from the examination of
the recto-vaginal fossa. She died on the morning of the sixth day.

The small intestines were found all glued together by recent
Ijrmph, pretty well or^nized ; and in the i)elvis, which was com-
pletely shut off from the rest of the abdominal cavity, there was
about half a pint of dirty thin peasoup-looking fluid, with flakes of
lymph, showmj; the low form of abdominal inflammation. The
wound was (][uite healed, and the peritoneal line of incision could
scarcely be distinguished. I had allowed the silk sutures to remain
in all tne time the patient lived. She died on the morning of the
sixth day, and there was no matter lying along their tracks. It
would appear, therefore, that in this case at least^ the silk suture
answered all the purposes that the admirers ot the wire suture
claim for it.

Case VI. — Unilocular Ovarian Tumour. Ovariotomy, Recovery.

In April last. Professor Christison asked me to see a married
lady about fifty years of age, who had laboured under ovarian dis-
ease for upwards of twenty years. The tumour had been of very
slow growth, and had scarcely affected her general health till about
the time I saw her. The abdomen was occupied by a large single
cyst, and the contained fluid felt so thin and so near the surface
that but for the history, it would have been impossible to tell
whether it was ascitic or ovarian. There was slight oedema of the
limbs, and she was thin ; otherwise her health was good.

Three months afterwards the tumour had considerably increased,
there was also greater oedema of the extremities, she was unable to
lie down at night, and the heart was beginning to beat above its
normal level. It was accordingly agreed to remove the cyst ; but,
before doing so, I emptied it, and as the fluid was clear, of low

162 CASES OP OVARIOTOMY BY DR KEITH. [AUG.

specific grayitj, and as there was no solid mass whatever to be felt,
— only a thin-walled cyst, — it seemed more pradent to delay for a
time any farther interference.

She suffered severely for several da^s after the tapping from
abdominal pain, vomiting, and vesical irritation. She was, however,
able to be about again in ten days, and for nearly eight months she
enjoyed excellent health, and no trace of the cyst could be detected.
About the end of Februanr, however, it suddenly began to fill with
great rapidity, she quickly lost flesh, and it was agreed to remove
the tumour as soon as the oddema of the lower extremities should
commence.

This was accordingly done on the 26th of March. Professor
Syme, Dr Dewar of Kirkcaldy, Dr Sidey, and Dr Keith were
present. An incision about three inches in length was made, com-
mencing midway between the umbilicus and pubis ; the peritoneum
opened to half this extent, and a large non-adherent cyst tapped
and drawn out. The cyst arose close from the uterus, the cuimp
was placed round its lower portion, and from the absence of pedicle
and great depth of the pelvis, there was a considerable drag upon
the uterus, which was brought up close to the wound. In conse-
quence of this there was a good deal of dragging pain in the back
complained of for the first forty-eight hours, to relieve which small
opiate enemas were given by the nurse when the pain got trouble-
some ; otherwise no unpleasant symptom appeared, and she did not
suffer nearly as much as she had done after the tapping. She was
in the dininff-room to breakfast by the end of the third week, and
returned to the country twenty-five days after the operation.

This lady is the wife of one of the best known and most sue-
cessftil Scotch provincial surgeons, — a man of unusual sagacity,
but unfortunately long laid aside from active life by great suffering ;
and his experience of ovarian tumours during a long and active
practice of nearly forty years did not encourage him to recommend
any other mode of treatment than the radical cure. And while
he observed the slow but steady progress of the disease, and looked
forward to the time when it would necessarily interfere with
the life of his wife, he keenly watched the history and progress
of ovariotomy in Great Britain, and so far back as ten years ago,
having thought the matter out for himself, he venturea to assure
her, that by the time her tumour should require interference, the
operation of ovariotomy would be as common an operation, and
more successftil in its results, than amputation of the leg. Till
1868, however, the success of the operation in England had not
been very encouraging, and in Scotland and Ireland the results had
been invariably unsuccessftil. Its progress at that time seemed
stationary, or rather it seemed to retrograde ; for the surgical heads
of the profession would not give it a fair trial, while the majority
denied it a place in legitimate surgery. The success which Mr
Lane had met with, was quite unknown to the profession, while the

1 864.] CASn OF OTASIOTOVT BT DB KBTTH. 158

mode of operating adhered to by Mr Claj of Mancheater did not
do much to recommend the operation ; for be continued to force
aingle cysts through the large incision, learing the stomp of the
pedicle to decompose in the abdominal

cavity, and giving reiy
quantities of opium as an essential part of the after-treat-
ment But, in 1858, the operation was taken up in earnest by Mr
Wells. In his hands it was much simplified, and he introauoed
common sense into its after-treatment It became at once evident
that a period of Drosress had begun, and it may be imagined how
eagerly were watcnea the brilliant results that year after year have
followed the operation in Mr WeUs' hands ; for there can. it seems
to me, be not the shadow of a doubt that to Mr Wells belong the
credit of reviving this operation in England, and of establishing
it as one of the most justifiable and often most welcomed operations
in surgery.

The above case, though the simplest I had yet operated on, and
the only one in which I had not met with extensive adhesion, is,
however, a very important one, as showing the confidence with
which tne operation of ovariotomy is being received by the pro-
fession. In this family there were no fewer than four active and
intelligent medical practitioners, who. when the question of ovari-
otomy was brought near them in tne person or a near relativCi
thought the whole matter out for themselves, and recommended the
operation ; and they were all too good surgeons not to recognise the
good surgical principle, that the less broken-down the general health
of the patient the greater would be die probability ofsuccess.

{To be continuecL)

^art Seconlf.

REVIEWS.

JTie EssenJfialB of Materia Medica and ThetapeuHcs. By AlfbBD
BARiKa Garkod, M.D., F.B.S., Professor of Materia Medica
and Therapeutics at King's College, Iiondon, etc., etc Second
Edition, revised and much enlarged. London: Walton and
Maberly: 1864: pp. 891.

The work, the title of which forms the heading of this article^ will
be gladly welcomed both by the medical student and practitioner.
A complete but concise book on Materia Medica and Therapeutics
has been a real desideratum. Most of the text-books of this as of
other subjects are much too long ; the writers seem to endeavour to
lay before their readers not only what will be really useful, but a

VOL. X.— NO. IT. u

154 DR QABROD ON THE ESSENTIALS OF [aUO.

mass of details often calculated to conftise^ if not to mislead. Dr
Garrod has avoided this error, and has brought together in a small
but remarkably neatly got up volume, the facts of Materia Medica
with which it is really necessary to be acquainted. The work
appears with peculiar appropriateness at the present time. The
profession has not yet ^t thoroughlv acquainted with the New
pharmacopoeia, and has, m fact, scarcely made up its mind as to its
merits or defects. Numerous helps have indeed been published ;
but, though useful when taken in connexion with large works, they
are by themselves too small to serve the purpose of works of refer*
ence. Dr Garrod's work is not only an explanation, and^ in some
respects, a commentary on the New Irharmaoopoeia, but it is a com-
plete treatise on Materia Medica.

For the preparation of such a work Dr Garrod possessed peculiar
qualifications. As a lecturer on Materia Medica, as an nospital
physician, as a careful observer of disease, his attention has oeen
for a long time directed in an especial manner to the action and
uses of medicines ; while, as a member of the Pharmacopoeia Com-
mittee, he has had the best opportunities for knowing the grounds
on which alterations in the Materia Medica and in pharmaceutical
processes have been made, and has had abundance of time to make
up his mind as to whether these alterations have been judicious or
the reverse. It has not, however, been Dr Garrod's object to enter
upon the consideration of controversial points; the information
regarding the therapeutical action of medicines is confined '^ to the
facts really ascertamed as to the action of each drug, and the
purposes for which it has been advantageously employed."

The work commences with an introduction which treats of weights
and measures, and of the different kinds of pharmaceutical prepara-
tions ; though exten£ng to only ten pages it contains all the infor-
mation on these subjects, which is really essential to the practitioner.

The plan on which the Materia Medica is considered is the same
as that followed by Pareira. Inorganic substances are first treated
of, arranged under a scientific division ; then come drugs derived
from the vegetable, finally, those from the animal kingdom ; an^
inconvenience attending this arrangement, when speedy reference is
required, is obviated by a verv full and accurate index. In treating
of the separate articles of the Materia Medica, Dr Garrod commences
with a description of the crude drug ; this is followed by a state-
ment of its properties, composition, and officinal preparations ; then
comes an account of its physiological and therapeutical actions, and
the doses in which it is to be employed ; finally, we have, where
necessary, a descs^tion of the tests by which the article is to be
recognised, and an account of the chief adulterations to which it is
liable. Tnough much in the book is the same as is met with in the
British Pharmacopoeia, and the officinal preparations are of course
extracted from it, Dr Garrod follows that standard by no means
slavishly ; he gives, indeed, every preparation contained in it, but

1864.] MATERIA UEDICA AKD THEBAPEITTICS. 165

he retains several old drugs which it has abandoned^ and admits
several new ones which the national work has not recognised.

The most interesting and most original portion of the work is
that devoted to the actions and uses of medicines, and we are dad
to see that Dr Garrod proposes to follow this volume with another,
which shall embrace the whole subject of Therapeutics, and treat of
it in a more exhaustive manner than was possiole within the com-
paratively narrow limits of the work before us. At present, there-
fore, we shall select almost at random a few of Eh: Uarrod's state-
ments regarding particular medicines, rather to show how the
subjects are treated of, than with a view to an^ formal criticism.

Arnica, our readers are aware, has been admitted into the British
Pharmacopoeia ; but considering that this drug has been principallj
employed Dj the homoeopathists, the existing testimony in its favour
is not of a strong character. Dr Garrod seems to distrust it alto-
gether. Begarcung its therapeutical properties he says, — " Given
internally, arnica acts as a stimulant and irritant : it has been sup-
posed to influence the spinal cord ; its action upon the system has
not, however, been satisfiictorily made out It is chiefly employed
as an external application for the discussion of tumours, and for
sprains and bruises. The author has leasons for questioning the
virtues of arnica as a remedy in these cases." Our own experience
is quite in accordance with Dr Garrod's; we have employed it
occasionallv in cases of sprains and contusions, but have not noticed
it to be followed by anjr better effects than mignt have been expected
to follow any other spirituous application.

In Lithium, Dr Garrod has a personal interest, the salts of that
metal having been introduced by himself for the treatment of uric-
acid gravel, and chronic gouty conditions. The advantage which
lithia and its carbonate possess over the corresponding compounds
of sodium and potassium is, that they possess great neutralizing pro-
perties, and that the urate of lithia is much more soluble in water
than any other known urate. Regarding the therapeutic actions of
the salts of lithia, Dr Qtmrod says in the wcwk before us, — " From
the small amount of lithia sufiicient to form a salt with uric acid,
and the much greater solubility of the salt, it follows that unless
other circumstances interfere with their aaministration, the lithia
salts must be valuable remedies when it is desirable to keep uric
acid in solution during its transit through the urinary organs, or
prevent its deposition in the structures of the body. The carbonate
of litliia acts as a diuretic, and in the same dose has a more powerful
influence in rendering the urine alkaline than the corresponding
salt of soda or potash. It may be given with great advantage in
certain states ot the system in which urate of soda is liable to be
deposited in the tissues, as in gout, etc. Dose. Of the carbonate,
3 er. to 6 gr. The carbonate may be given in aerated water ; free
dilution aids its diuretic action."

To the preparations of Cerium, however, Dr Garrod does not seem

156 DR QABROD ON THE ESSENTIALS OF [AUQ.

to have devoted any special attention. About ten years ago.
Professor Simpson recommended the oxalate and the nitrate in
those classes ot cases where a combined tonic and sedative action
was required. He found them useful in cases of irritable dys-
pepsia, gastrodynia, and particularly in the vomiting of pregnancy*
Otner observers have met with similar results, and although tne
salts of cerium are not to be looked upon as specific, tbey are
undoubtedly useful in many cases. Disappointment was therefore
experienced in man^ quarters that cerium and its compounds had
not been admitted into the British Pharmacopoeia, as some other
substances had been admitted on — to say the most — no stronger
grounds, while their admission might have given an impetus to their
employment, and their real properties would therefore have been
soon settled. Dr Garrod mentions cerium, indeed, but his notice of
it is very brief. ^^ Some of the salts of cerium, a metal which exists
in a few rare minerals, as cerite, have been maaeuse of in medicine.
The oxide and the oxalate of cerium have been most frequently
used, and occasionally the nitrate has been ^ven. The cerium
salts have been chiefly emploved to allay vomiting, especially that
which occurs in pregnancy, also in the vomiting of pnthisis ; and
in some cases of epilepsy accompanied with gastric disturbance.
The dose of the preparations of cenum may be nom 3 to 5 grs."

We shall give one more quotation from Dr GaiTod's work,
selecting the passage treating of^the therapeutical action of digitalis,
both as affording a better specimen of Dr Garrod's style than the
preceding short extracts have enabled us to do, and because con-*
siderable difference of opinion prevails in the present day regarding
the sedative action of the drug. The opinion long entertained was
that digitalis acts as a direct and powerftil sedative of the heart's
action ; recently, however, some have maintained that it stimulates
the muscular substance of the hearty and augments the contractilitnp' of
the capillaries, and that when it kills, it does so, not by producing
paralysis, but by giving rise to contraction and spasm of that organ!^
Dr Garrod, it wiu be seen, adheres to the old view, although it
will be noticed that he alludes to a difference in its action on the
capillaries when compared with that of other sedatives.

" When taken internally, the most marked effect produced by the drug is
the weakening of the heart's power, accompanied by a diminished rate of the
pulse ; some observers assert, that the heart's action is primarily auickened.
If the dose be increased, or continued after a certain amount of caraiac weak-
ness has been induced, symptoms of an alarming character may arise, such as
nausea, vomiting, faintness. and syncope ! this is especially apt to occur when
the patient attempts to make any exertion, or even to sit or stand up ; in fact,
patients under the full influence of the drug, which is sometimes purposely
induced, are only in safety when in a horizontal position. Although dijgitaha
acts BO powerfufly ujjon the heart, yet its influence over the capillary circula-
tion, when in a morbid condition, is by no means so powerfully exercised as in
the case of antimonial and mercurial preparations. Digitalis oAen produces
copious diuresis, more especially when the deficiency of the urinary secretion

» See Fuller on Diseases of the Chest," p. 592.

1M4.] MATBftU MSOICA AKB THKRAPEUTICB. 157

depend* on cardiac diteaiM ; it also occaaionaOj indocea ileep, or acta aa a
aeoatiTe and soporific, bat onlj when the reatleaeneas ta due to an over-eidled
state of the heart. Digitalis u administered as a cardiac sedatire in almost all
cases where there is eialted action, whether sympathetic in nature, or depend-
ing on organic disease of that organ, or of the mat Tessels, as In hypertrophr,
^nriam, or valTalar disease, etc ; it ahoolo, howtrer, alwajrs ne borne m
mindf that increased action of the heart is not always an indication of bcreased
strength. Digitalis may be given also in hsemorrhages of an actire charaeteri
and as a diuretic in dropsies depending on the above-named cardiac diseases,
and sometimes in other forms. 8ome practitioners hare proposed the nae ai
digitidis in inflammatory affections, bat in these cases its efficacy has not been
wdl established. It has also been employed in phthisis, bat witlioat permanent
benefit; for althongh it often in these cases diminishes the rapidity of the
pulse, it exerts no influence on the progress of the tubercular disease. l)igitalia
IS generally asserted to be a drug the action of which is cumulative in character :
the explanation of this pecoliaritv appears to the author to be as follows, tib.,
that considerable weakening of the neart*s action may occur without any rery
OTident symptom being produced ; but if this is increased aboTe a certain point,
so as to interfere with the efllciency of the circulation, then all the symptoms
are rapidly and dangerously manifested.**

For fuller detaila, bowever, regarding the tlierai>eatic action of
this and many other drags, we shall looc forward with intereat to
tbejpromiaed volome.

We most not omit to notice a verj naefol feature in Dr Garrod's
work, in the shape of a poBological table, in which may be seen at a
glance the appropriate dose of all the articles of the Materia Medica.

In taking leave of Dr Garrod for the present, we have to repeat
our recommendation of ^' the Essentials of Materia Medica and
Therapeutics^' as an admirable work in itself, and as an indis-
pensable companion for the student or practitioner to the British
Phannacoposia,

TranBoctians qf the Odxmiological Society^ 1861-1863. Vol. IIL
Published by the Society.

The Teeth in Health and Dieease. By Robert Thomas Hulme,
F.L.S., etc H. Bailli^: London: 1864.

Enobmous as is the progress in every department of medicine and
surgery within the last half century, in none has the improvement
been more marked than in the diagnosis and treatment of the lesions
of the teeth. The itinerant charlatan, with his harlequin and
chariot, his mullets, forceps, and keys, and the infallible specific for
toothache, has been superseded by a thoroughly educated medical
gentleman, who must be anatomist, chemist, physiologist, and
mechanician, if he means to rise above mediocrity. And this pro-
^resB is one which has this element both of stability and growth
m it, that it has begun at the right end. From scientific experi-
ments and researches, anatomical and microscopic, it has gone on
to improvements in praotice; from the labours of Nasmyth and

158 TRANSACTIONS OF THE ODONTOLOGICAL SOCIETY, ETC. [AUG.

Groodsir, Tomes and De Morgan, to improvements in manipulative
dexteri^ and mechanical appliances.

The Transactions of the Odontological Society for 1861-63 con-
tain several papers of very hi^h character.

Among these is a remarkaUe and original prize essay, by Mr W.
K Bridgeman, on the Pathology of Dental Caries, which^ based on
researches of Davy, Faraday, and others, and extended into much
ingenious experiment and reasoning, tends to the belief that the
^' progressive decomposition of the enamel and dentine are due to
local electro-voltaic action." From the remarkable concentration
of the writer's style, and from the arrangement of the paper in a
serious of propositions, any attempt at abridgment is futile ; but as
a most suggestive and danng inroad into a comparatively untrodden
field, it will repay a most careful perusal.

The papers oy Mr Coleman on " Dental Caries ;" by Mr Spence
Bate on " The Treatment of Inflamed Dental Pulp ;" by Mr
Bridgeman on " Caries and its Treatment," are important contribu-
tions to dental pathology and therapeutics ; while the two papers by
Mr Truman " On the Necessity of Plasticity in Mechanical Den-
tistry," and " On the Manufacture of Mineral Teeth," indicate the
^at progress which has been made, and is still making in mechan-
ical dentistry.

Luxuriously printed, profuseljr and beautifully illustrated, these
transactions speak well for the vigour of the society which publishes
them.

Mr Hulme's book is a plain, short, and pleasantly written account
of the anatomy and diseases of the teeth. The advice concerning
the mana^ment, both of dentition and of the perfectly finished
dental arch, show that it is intended more for the public than the
professional reader. Its perfect freedom from all professional tech-
nicalities renders it fit for the perusal of the public, while its sensible
directions as regards cleanliness, care, and an early visit to the dentist,
render it a much more useful and safe work to place in nonprofes-
sional hands than many otiiers which aim at making every man his
own physician.

Phthisis wnd Ae Stethoscope ; or the Physical Signs of Consumption.
By Richard Payne Cotton, M.D., Physician to the Hospital
for Consumption and Diseases of the Chest, Brompton. liiird
Edition. London: Churchill: 1864. Pp. 104.

Some years ago,* on the publication of the second edition of this
little work, we strongly recommended it to our readers as containing
a brief, but accurate and thoroughly practical account of the signs
of phthisis. The present edition has been carefrilly revised, more

> See this Journal for December 1859.

1864.] DR COTTON ON PHTHISIS AND THE STETHOSCOPE. 159

than twen^ P^^S^ ^^^^ ^^^" added to it, and it will be found even
more valuable Uian its predecessor.

The principal changes in the present edition consist in the addition
of a chapter on '^ the classification and nomenclature of the physical
signs ; " and of another which treats of the ^^ physical signs indi-
cative of arrest or improvement of the polmonary disease in the
several stages of phthisis.'' Of the former of these we have nothing
particular to remark ; while not entering into unnecessary refine*
ments, it explains the more common sounds, and gives a vocabula^
of the physical signs which are useful in the diagnosis of the disease.
The chapter whicn treats of the physical signs indicative of arrest
or improvement in the pulmonary disease contains interesting
matter, and will fill up a blank which the readers of larger ana
more pretentious treatises must have often experienced. It is of
great consequence to bear in mind, that in order to arrive at a
rational prognosis in a case of phthisis, a single examination is
seldom sufiicient; a knowledge of the existing condition of the
lungs is not enough, and the physician must satisiy himself, bv
frequent examination, whether the disease be advancing, retrograd-
ing, or remaining stationary. In connexion with this point, the
beginner would do well to bear in mind the following statement of
Dr Cotton, as showing that the mere presence of abnormal physical
Sims is not sufficient to justify the inference of advancing disease : —
"With the exception of the improved respiratory murmurs, and
the diminution or absence of secretion sounds, other morbid condi-
tions may possibly remain unchanged, although, perhaps, the pul-
monary mischief may be arrested. The dulness mav possibly still
continue, owing either to thickening or adhesion of ttie pleura^
which is generally a permanent condition, or else to quiescent
tubercle, or secondary pneumonic condensation — ^which may be
equally permanent. For like reasons, the same may be said of
morbid alterations in the form and movement of the chest walls,
and of vocal and tussive resonance. The nearer the approach to
healthy condition in these respects, of course, the better ; but it
should be borne in mind that their continued deviation firom*the
healthy standard is no proof that the patient is not progressing
satisfEbctorily, or that his disease is not arrested."

On Diabetes and its Suecew/ul TreatmenL Bv John M. Campxin.
M.D. Third Edition. Eevised, with Additional Notes ana
Observations, by James Gret Gloveb, M.D. London : Church-
hiU: 1864.

A PAKTICULAR interest attaches to the work of Dr Camplin as
having been written bv a physician who was suffering from the
disease which he described, and who, by careful management, was

160 DR CAHPUN ON DIABETES. [AUG.

able in a great degree to overcome it, so as to be able to enjoy a
great degree of comfort, and to fulfil the duties of a laborious pro-
^ssion without any very great restrictions as to diet. Dr Camplin
died somewhat suadenly while engaged in preparing a third edition
of his book, and the task of following out his intentions devolved
upon Dr Glover. The moral both of Dr Camplin's and of Dr
GHover's statements is that, while in most cases of diabetes much
may be done to promote the comfort and to {)rolong the life of the
sufferer, no remedy is known possessing specific power in the cure
of this disease. Still the subject is a hopeful one, and we may
quote from Dr Glover's preface the following sensible observations :
— ^^ The present position of the subject of diabetes is fnll of interest
and promise. .6ur advancing knowledge tends wonderftilly to
fasten upon certain parts of the body the origination of the abnormal

Sroduction of sugar in the system which chiefly characterizes the
isease. Though no specific remedy has been discovered for it,
great progress has been made in defining the treatment by which it
IS most effectually controlled. And, by the way, let it be said, that
this is a good illustration of the progress of therapeutics in general.
Our control over disease seems to be advanced not by the discovery
of single remedies, but by discovering the importance of, and pre-
scribing regard to, a number of physiological considerations, and
the judicious use of helpful, but not specific, medicines. At the
same time, it may be remarked, that the case of diabetes is one so
peculiarly chemical in its character, that it is not unreasonable to
hope for the discovery of a chemical remedy for it. Meantime it is
satisfactory to be able greatly to command the disease, to mitigate
the distress which it occasions, and to enable a great number of
diabetic patients to follow their callings with comfort and efficiencyi
even to an advanced age."

We have only to state in conclusion, that Dr Camplin's book is
well worth V of the attention of medical men, as being ot a thoroughly
practical character, almost every statement in it having been sub-
mitted to the test of an intelligent experience.

An Elementary Text-Book of the Microscope : including a Deacrwtion
of the Methods of Prepariruf and Mounting Objects^ etc. ny J.
W. Griffith, M.D., F.LiS. With Twelve Coloured Plates.
London : Van Voorst : 1864.

The microscope is no longer exclusively reserved for the man of
science. It is now in the hands of every one who cultivates, no
matter how superficially, any branch of natural history, and its em-*
ployment has opened up new fields of instruction and enjoyment
Under these circumstances, it is very important that beginners
should have a text-book which, while strictly accurate, should be

1864.] DR GRIFFITH ON THE MICROBCOPE. 161

as free as possible from technicalities^ and should not presuppose
any pieyioos knowledge of the subject. Such a text-lK>ok it has
been Dr Griffith's obiect to fiupplj, and the result has been in the
highest decree satisfactory. Ihe descriptions are clear and intel-
ligible, while they have been supplemented in a most important
manner by the introduction of twelve beautiftilly coloured plates,
containing between four and five hundred figures. The figures are
thorough^' true to nature, are remarkably well executed, and refer-
ence to tnem will be of the greatest possible assistance to the
beginner. On the whole, we consider this as undoubtedly the best
text-book of the microscope for the general student.

part ^ivn.

PERISCOPE.
PRACTICE OP MEDICINE.

ON THE SLIGHT FORM OF SCABLATINA AMD SCARLATINAL DROPSY. BY DR ROGER.

There have been lately (in the HdpUal dea Enfimts Makuka) a great many cases
of what Dr Roger calls scarlatinettes. They were cases of scarlatma extremely
slight, or so lugacions, that the characters of scarlatina passed unobservea.
Nevertheless, the disease, of which the external manifestations were so slight,
was still present, and if the patients, apparently in good health, and recovered
from a seemingly trivial eruption were exposed to cold, haemataria or dropsy,
sometimes fatal, made their appearance. In one case, an impression of fear
appeared to play the part of exposure to cold, and producea anasarca in a
little ^1 four jeara old, who, ner parents declared, had escaped from the
scarlatina her sister had had, bat who really had had the disease so slightly,
that even maternal solicitude had not detected its existence. At other times
there are anomalous eruptions which have features in common both with
measles and scarlatina, without, however, belonging to either ; such are the
eruptions which have received from different modem authors the names of
erythema scarlatiniforme, roseola sestivalis, roseola miliaris, rosalia, rubeoloid,
riitheln, and rash. According to M. Almeras, who has written a very interest-
ing work on the scarlatiniform exanthemata confounded with scarlatina, it is
at first impossible to give a certain diagnosis. It is only at the second stage
that the disease assumes the following characters, — eruption of a rosy colour,
diffuse, punctuated ; slight angina, but without marked redness of the throat
or tumefaction of the tonsils, nor cheesy concretions ; tongue not characterized
by the intense redness and the prominent papilbs characteristic of scarlatina;
no grave general symptoms ; nothing remarkable with regard to the pulse. At
the third stage desquamation is absent, or when it exists it occurs in a branny
form, not as large scales ; the urine is normal ; there is no anasarca. But we
repeat, if there are pretty well marked differences between scarlatina and the
scarlatiniform exantnemata, the points of resemblance between them are numer-
ous, and, as in times of epidemic it is very difficult to distinguish them, it is
prudeftt when any doubt exists to act as if the disease were scarlatina, and to
make children keep to their bedroom for at least a fortnight if they have pre-
sented any trace of an equivocal eruption. Accordingly, if there are cases of
Bcarhitina well characterized from the first, and where there is no room for
doubt, there are others much less marked, and which may be confounded with
exanthemata of quite a different nature. Still these little characterized forms
VOL. X.— NO. II. X

162 PERISCOPE, [AUG.

merit serious attention, because they are as much if not more likely than the
others of beins followed hj one of the most formidable accidents of scarlatina,
—dropsy, with albuminuria. \

It is from the fifth to the tenth or twelfth day of the eruption that the
albuminuria supervenes. If the albumen is very abundant in the urine, dropsy
follows. According to Roger, dropsy occurs about once in seven cases, and it
usually appears from the tenth to the twentieth day. But as experience shows
that in the immense majority of cases it is exposure to cold which leads to
anasarca, this practical deduction follows that every child affected with scarlatina
should keep its bed a fortnight, and its room at least three weeks. After three
weeks anasarca is not to be dreaded, or at least its occurrence is improbable.
Dr Roger, in fact, does not admit that anasarca may occur during the whole period
of desquamation ; he thinks that the patients who have been attacked witn it at
a later period than that indicated above, had a chronic Bright^s disease con-
nected with a peristent scarlatinal albuminuria, or an acute Bright's disease
independent of scarlatina, which is not very rare in children.

Among the precursors of anasarca, vomiting should be noted. If between
the tenth and twentieth days of scarlatina a child becomes a little feverish and
vomits, we may apprehend anasarca ; the latter generally appears the next or the
following day, and is characterized by a deceitful appearance of stoutness. In
general the urine assumes a red colour, and presents corpuscles analogous to
the grounds of coffee, which enable us to detect the presence of blood without
having recourse to the microscope. In half the cases the dropsy remains ex-
ternal, in the other half you have internal effusions. So long as there is only
abdominal dropsy, matters are not very serious, but it is different when serum
accumulates in the pleura, for as the effusion is generally double, and the
pulmonary substance is infiltrated, extreme embarrassment of breathing is the
result. To this dropsy, oedema of the glottis is sometimes added, for which it
IS necessary to perform tracheotomy. But of all effusions the most dangerous
is the encephalic, which may assume the comatose, the paralytic, or the convul-
sive form. With regard to the convulsions which occur under these circum-
stances, Dr Roger says, that though the prognosis is venr grave, the patients
who manifest them recover in the proportion of one-third.

The preventive treatment of scarlatinal dropsy consists, as has been said, in
keeping the child carefully from exposure to cold. The curative treatment
wiU vary according to the form of dropsy. If it is febrile, active, if the tissues
affected be of a rosy colour, if the skin be hot, sanguineous emissions are indicated.
This is still more the case if there is oedema of the lungs. Bleeding then gives
manifest relief; bleeding from the arm is preferable to leeches or cupping,
which may produce erythema or erysipelas ; it has this disadvantage that it is
pften difficult of performance, but if^ possible recourse should be had to it ;
blood should be arawn to from three to six ounces ; this may be repeated if
necessary, but in general one bleeding is sufficient. We must then endeavoitf
to find means of exit for the serum, although we must respect the kidneys and
treat the intestines with reserve. It is on the skin that we must act by means
of stimulants and diuretics. Dr Roger prefers dry to moist frictions. Flannel
impregnated with the vapour.of benzoin or of juniper may be employed for
this purpose. At the end of two or three days recourse may be had to vapour
baths aoministered ever^r day or every two days. At the same time, acetate of
ammonia may be administered internally, in the dose of half a drachm to a
drachm in two or three cups of infusion of elder. This treatment is suitable
for the acute cases. In the chronic form, unless in the presence of complica-
tions which require bleeding, we trust to diuretics, drastic purgatives, and
repeated blistering over the chest. If there are cerebral symptoms we may
apply leeches to the mastoid processed, and blisters to the thi^ or nape of
the neck ; then we administer hydragogues, and give nitre in doses of from
half a drachm to two drachms in the twenty-four nours. In simple cases Dr
Roger prescribes, along with vapour or sulpnurous baths, dry cupping over the
loins, mtric acid lemonade, and a mixture containing from eight to fifteen grains
of tannin.— Journal de Midedne et de ChirurgU pratiques.

1864.] PRACTICE OF MEDICINE. 163

ON THE INFLUENCE OF PLEURISY IN THE DBTELOPMEMT OF PHTHIB18.
BT DR BEAU.

bf the Hospital of La Charity is a patient whose case, thoujgh apparently of
little importance, has given Dr Beau the opportunity of pointing out the influ-
ence which pleurisy seems to exert on the development of phthisis. Between
these diseases there is a very close connexion ; often j^leurisy merely supervenes
upon phthisis ; hut it is not uncommon to see a pleurisy occur in a subject who,
tul then, has presented no rational sign of phthisis, and to see it followed by the
development of that disease. This was the opinion of Broussais, who attri-
buted to inflammation the formation of tubercles, and Dr Beau has met with
many fiicts which have led him to the same conclusion. Thus, in the case of
the patient in question nothing indicated a year ago that he was tubercular.
This winter he took a pleurisy, perhaps two ; when admitted into La Chants
there was still a little effusion into the left side, which remained persistent, and
was accompanied with a little febrile excitement towards evening. A bUster
removed the effusion, but did not lead to the disappearance of the fever ; the
patient was then carefully auscultated, and the presence of tubercle was recog-
nised in the left inferior scapular re^on. Cases of the kind are not uncommon.
Dr Beau had for his house phvsician a young man who contracted pleurisy ;
two ^ears later he died tubercular. At this very time he has under treatment
a patient whom two years ago he treated for pleurisy, and who is now tuber-
cular. Many other examples could be quoted of tubercle supervening upon
pleurisy. Is this any reason for treating these patients according to the system
of Broussais ? By no means ; a very spare diet is bad because it debilitates,
and an enfeebled state of the organism opens the door to all the diseases which
afflict humanity. — Jowmal de Midecme ei de Chirurgie pratiques.

ON TUOEACENTEBIg IN PLEURITIC EFFUSION. BY DR BEHIEE.

A LONG discussion on thoracentesis has occupied the Medical Society of the
hospitals of Paris ; and as the debates were not free from a certain degree of
confusion, Dr Behier has made a critical review of them, the conclusions of which
may be thus briefly stated.

Thoracentesis is indicated and ought to be performed : In all cases where the
effusion is in large quantity, and does not diminish rapidly under the ordinary
means, and still more if it goes on increasing ; in all cases where the patient
appears too delicate, too w^kk to bear up against the long process of resorp-
tion of an effusion which occupies completely or nearly completely one side of
the chest ; in all cases where, although the effusion is not very copious, we find
the opposite lung impeded in the performance of its function, as by bronchitis, a
certam degree of oedema, etc. ; in all cases where we believe we have to do with
a patient predisposed to pulmonary phthisis, whether we are unable to make
out its existence, or whetner we have the proof of it in the side occupied by the
effusion, or in the other lung. The last case we willingly allow \& by no means
fiivourable.

Before practising the operation, we wait, if possible, until the inflammatory
phenomena have abated ; it is generally between the ninth and the eleventn
days that we expect to see this iA>atement. At the same time, it must be borne
in mind, that inflammatory symptoms may be altogether absent, or at least very
little marked in a large nmnber of cases of copious effusions, and that it is pre-
cisely in these cases that sudden deaths are most frequent, as they are also those
which recover best after thoracentesis. To refuse the operation in such cir-
cumstances on account of the slight apparent ^vity of the disease, and because
we observe neither violent dyspnoea nor immment asphyxia, would be, in our
opinion, a grave fault on the part of the physician. These cases frequently
occur in persons of little vital energy ; their very passiveness is often an obstacle
to their cure by ordinary means. Little capable of undergoing the process of
absorption^ we ought to aid such patients in the process, and thoracentesis
affords this indispensable assistance.— Jotima/ de Midecme et de CIdrurgie
pratiques.

164 PERISCOPE. [auo.

ON THE EMPLOYMENT OF APIOL IN AMENORRHCEA AND DYSMENORRnCEA.
BY DR CORLIEU.

tions suggested by my own practice. I have now employed apiol for eight
years, sometimes successfully, sometimes not. I shall endeavour to point out
the cases where it may be expected to prove useful.

A. In all cases where the menstrual disorder dei>ends upon the derangement
of a vital element, where there is plethora or anssmia, apiol should not be used,
for, being a nervous tonic, it will only aggravate the condition of the patient.
But if the condition of chlorosis be removed, apiol may be prescribed with a
ffood prospect of success. The following case will illustrate this : — A kdy^
wirty-eight years of age, of a lymphatic and nervous temperament, had suffered
for three months from amenorrhoea, complicated with extreme chlorosis. Dr
Gkdligo at first ordered apiol, but without success. At a later period he com-
bined it with chidybeates, which had previously done no good. The combined
use of iron and apiol effected a cure. Dr Marrote relates the following case :—
Miss C, eighteen years old, was of a lymphatic temperament. In childhood
she had had measles, hooping-cough, and modified smallpox. Her skin was of
a dead white, her face somewlmt swelled ; the gums were swelled and discoloured ;
she had very little appetite, and often vomited her food. She menstruated
first when fourteen years old ; for several months the discharge was white,
afterwards it became of a reddish colour, but was accompanied by such severe
uterine pains, that she was obliged to keep her bed. As she was to menstruate
on the l8th of October, I ordered her two capsules of apiol on the 15th, two on
the 16th, and two on the 17th. On the 18th, the menses appeared, though still
in small quantity, but unaccompanied by colics or uterine pains ; they only
lasted two days, and the blood was still very pale. On the Slst, I ordered a
chalybeate which was continued till the 18th of November, when she resumed
the apiol for three dftys. The menstruation was unaccompanied by nains ; it
continued three days, and the dUcharge was more coloured and more abundant.

B. When the menstrual disorder depends upon a diathetic condition (dartres,
scrofiila, etc.), we must, by means of a specific treatment, such as bitters, cod
liver oil, preparations of iodine, sulphur, or arsenic, attack the principal malady.
Apiol is of no use at first in these cases ; but when the cure of the morbid
diathesis has been effected, it may be employed with advantage in stimulating
the torpid menstrual function.

C. tfut it is chiefly in disorders which are under the influence of the
nervous system that apiol is a heroic remedy, leaving far behind it all the
emmenaeogues hitherto employed. As a neurotonic it supplies to the nervous
system the energy it has lost. Change of life, of habits, or of climate, often
determine amenorrhcea. This is a fact which must not be forgotten, and
which is well known to the physicians of boarding-schools and religious houses.
This menstrual suppression is transitory ; it lasts some months, and sometimes
only gives rise to slight nervous disorders, or a slight oddity of character. In
these cases, two, four, or at most six capsules of apiol will restore the menstrual
flux. The following case was observed by Dr Marrote : —

Miss L. J., seventeen years of age, bom in London, arrived for the first time
in Paris in October 1861. She was a tall, handsome girl, of a good constitu-
tion and plethoric temperament ; she had never had any serious illness. She
menstruated for the first time at thirteen, but was very irregular up to fifteen.
Although she never suffered from colics, or lumbar or inguinal pains, her
periods were often delayed for a fortnight or three weeks ; the blooa, contain-
ing fibrin, was pretty abundant. From fifteen to seventeen years, menstruation
was quite regular. She then came to Paris to complete her education. From
the date of her arrival until the month of March of the following year, her
menstruation was completely absent. Nevertheless, no change had been

1864.] PRACTICE OP MEDICINE. 165

observed in her eenend health, thongh I was informed that at times she became
daller, more m&ncholy, and more irritable than usual, and that this state
continued for a short time. Taking this 'as an indication, I administered apiol
in the dose of one capsule night and morning in a spoonful of water, beginnlnff
on the 11th of March, which seemed to be indicated as a menstrual period.
She thus took six capsules in three dajs. On the 14th of March, the menses
appeared without pam, and lasted four days. The lady of the establishment,
accustorned to see apiol almost always succeed under these circumstances, did not
repeat it the followmg month. On the 14th of April, the menses returned, and
lasted four days. On the 17th of May, the 16th of June, and the 2 1 st July, the
same occurrea. Miss L. J. returned to her family in London in perfect health
and quite regular.

The sudden application of cold during a menstrual period may suppress the
discharge abruptly, and give rise to amenorrhoea, which may last for aii indefinite
time. In the month of January 1861, 1 saw a young lady, seventeen years of age,
who had menstrated for two years, but in whom, in consequence of a chill during
menstruation, the flow was suppressed. The belly became considerably enlarged ;
there was, in fact, an ascites, which could only be explained by the amenorrhoea.
There was no albumen in the urine. I employed, without success, purgatives,
Budorifics, chalybeates, and the ordinary emmenagORues. There was consider-
able pain at wnat should have been the menstrual periods. This state con-
tinuea until the end of April. In May, capsules of apiol given night and
morning restored the discharge, though at first it was piue and serous. Iron
was continued, and from that time the abdomen diminished in size. The cure
was complete.

It would be easy to bring forward more cases, but the above may suffice.
The point I wish to establish is, that apiol is the best emmenagogue with
which we are ac(|uainted in all cases wnere amenorrhoea or dysmenorrhoea
faAve their origin in a disturbance of the nervous element. The principal con-
dition for success in the use of apiol is in the choice of the proper moment for
its administration. In almost all cases of amenorrhoea or dysmenorrhoea
which depend upon an organic cause, the use of apiol is contra- indicated. This
IB not the place to lay down the differential diagnosis of these conditions. If
apiol has succeeded in some cases of plethora, it has been because the plethora
was not very considerable. **In order," says Dr Marrote, *4hat apiol may
succeed, it is an essential condition that the pain which accompanies menstrua-
tion depend upon dysraenorrhoea, properly so called, that is, on the vaso-motor
innervation of the womb. It has never succeeded in calming nervous pains,
dull or acute, which were seated in branches of the lumbo-sacral nerves, and
especially in the uterus, pains which appear or become exaggerated at the
menstrual period, and may at first sight simulate d^smenorrhoea proper."
Another condition for success in the use of apiol consists in choosing a time
for its administration corresponding to a menstrual period. If the woman has
not properly calculated the period, we may be enabled to discover it by no-
ticing the sympathetic denmgements which occur under these circumstances. —
Oagette dee Hdpkaiuao,

ON THE TBEATMEMT OF PRURIGO. BY DR DUCHESME-DUPARC.

Prurigo is not a disease which directly compromises the existence, but its
obstinacy, its tendency to relapse, and the insupportable annoyance which it
occasions, render it one which often causes much trouble and anxiety to the
practitioner. Prurigo especially affects the nervous and the sufferm^. It
has been supposed to be contagions, but this is certainly not the case ; it may
be complicated with itch, but when simple, no acarus or any other animalcule
18 present. ^ What distinguishes the two diseases farther is, that the anatomical
character of prurigo is the papule ; of itch, the vesicle. Sometimes, no doubt,
the diagnosis may be different. Thus, in chronic prurigo, some papules may
present at their summit a small vesicle, and on the other hand, the vesicles of
the itch may rest upon a papuliform induration ; but even here the doubt

166 PERISCOPE. [Aua.

should not be frequent, and should not last long, both because such cases are
rare, and besides the papules of prurigo occupy the back of the limbs and the
posterior surface of the trunk, just tne contrary of what is noticed in itch.
The pruritus again affords light to the practitioner who is in doubt. This is
the essential symptom of prurigo, and is much more marked and persistent
than that which is met with in itch. Besides, the small lamellated crusts which
follow the vesicles of scabies, could not be confounded with the black concre-
tions formed in prurigo by drops of dried-up blood. The violent itching of
prurigo may- be simulated around the anus by ascarides in the rectum, by
h»morrhoi&, by slight inflammation of the rectum ; and, in the case of the
genital organs, by pediculi pubis, or eczema of the scrotum or vulva.

In a practical pomt of view there are only three forms of prurigo — ^the recent,
the chronic, and that which was called by Alibert the latent, where papules
cannot be seen with the naked eye. At present we only speak of the treat-
ment of this disease.

If prurigo is recent, the antiphlogistic treatment affords the best results. If
the subject is young, sanguine, and plethoric, and if the eruption occupies large
surfaces, Dr Duchesne-Duparc commences by bleedine at tne arm, or applying
leeches to the anus ; he then prescribes a milk and vegetable diet, cooling
drinks, especially lemonade, prepared with nitric or sulphuric acid, and sweet-
ened with syrup. He lays mucn stress upon bran baths, prepared by boiling
four pounds of bran for half an hour in a suflSciency of water, and mixing it with
the water of the bath. Frequent lotions are made from time to time upon the
affected parts with decoction of lettuce, dulcamara, or poppy ; or the lotions
are replaced by prolonged inunctions made with oil of nyo8c;^amus, opiate
cerate, or the following preparation : — chloroform 75 grains, dycerine 300 grains.
This treatment, combmed with mild purgatives, often leads to a sudden and
complete cure.

But if the prurigo be, as is usuall^r the case, of old standing, we must trust
chiefly to external agents, thoush still insisting upon a suitable regimen and
the use of acid drinks. The alkalies here form excellent topical applications ;
the salts of potash and soda, in sufficiently diluted solutions, both favour the
resolution of the papules and calm the itching. With the same object we may
have recourse to simple or aromatic fumigations, vapour baths, sometimes even
to corrosive sublimate. But the topical application to which Dr Duchesne-
Duparc gives the preference is tar, in suspension or incorporated with lard and
united with opium. Lotions and baths of tar- water should be frequently
renewed. The following formula gives excellent results : — tar 60 grains, gummy
extract of opium 15 ^ins, lard 1 ounce. In the case of baths and lotions it
is well to add a gelatmous substance (such as 2 pounds of glue to 200 quarts
of water), because the papillse parts are the most sensitive of the skin. Dr
Duchesne-Duparc has found that sulphurous preparations are onl^ moderately
useful in prungo. They only do good when it is complicated with pityriasis
or psoriasis. The most useful of the mineral waters are those which are
alkaline, and contain a thick vegetable principle, such as the waters of Neris.

In prurigo pudendi, and in prurigo podicis, we must often have recourse to
the application of prussic acia^ sulphate or muriate of morphia, chloroform,
etc. Tn some patients benefit is derived by the occasional use of astringents
and antispasmodics ; in others, slight and altogether superficial cauterizations
do good. Nevertheless, though topical applications are very important, the
necessity for internal remedies must not be overlooked, especially when the
disease is of old standing. It is here that aconite is ver^ useful. Many years
ago, M. Cazenave derived great benefit from the use of this substance in papular
cutaneous affections, and. especially in prurigo. Considering prurigo as a neu-
ralgia of the papillae of the skin, having as an accessory character the appear-
ance of papules, M. Cazenave had recourse to the simultaneous employment of
alkaline baths, and the use of the following pills :— alcoholic extract of aconite,
extract of taraxacum, of each 15 grains. This to be divided into 40 pills, of
which the patient took one or two night and morning. Dr Duchesne-Duparc

1864.] PRACTICE OF MEDICINE. 167

has made use of similar pills, bat generally prefers the tincture to the extract
of aconite ; where the case is very obstinate the use of the arseniate of iron
and emollient baths are often useful. The prolonged use of the bath is especially
important. Dr Duchesne-Duparc often directs them to be of two or three
hours* duration, and to be repeated daily. If, while the patients are under-
going them, friction of the afllected parts of the skin, or, still better, an intelli-
gent shampooing, be practised, a ver^ beneficial modification of the skin will
be brought about.-~*/otima^ de MideAne et de Ckinirgie praUquei,

TREATMENT OP ITCH AT THE HOSPITAL ST LOUIS.

Dr Hardy's treatment consists in having the patient rubbed for half an hour
with black soap over the whole body except the head, and the friction is con-
tinued by the patient in a tepid bath of an nour's duration. On coming out of
the bath, a rapid and general friction is made with the following parasiticide
pommade : — ^hog's lard z ounces and 60 grains, sulphur 300 grains, sub- carbonate
of potash and water, of each 120 grains. After the friction, the patient dresses
without rubbing off the ointment, the contact of which with the skin is
necessary for some hours, in order to finish the destruction of the acari, and
to reach those which may have remained in the clothes.

fVom 1852 to 1862, 37,429 persons have been submitted to this treatment.
Of this number 535 have required to be treated a second time, and the success
has thus been 69 cases out of 70 persons treated. — GaeeUe dea HdpUauz,

MEDICAL JURISPRUDENCE.

POISONING FROM CAUTERIZATION WITH THE ACID NITBATE OF MERCURY.

BY DR YIDAL.

Cauterizations witli the acid nitrate of mercury are made daily and without
any particular precautions. We are apt to forget that this substance not only
acts locally as a caustic, like sulphuric acid, \ ienna paste, etc., but that, like
arsenical pastes, it is liable to be absorbed, and that, as the result of a too exten-
sive cauterization, mercurial poisoning may occur. Facts of this kind are too
important to be passed over m silence. Dr Vidal brought before the Society
of Biology a fact of this nature. The patient was a woman twenty-six vears
of age, of'^weak constitution, chloro-ansemic, who was admitted into the notel-
Dieu, suffering from most severe pain, the result of a large and deep cauterisa-
tion. By an inconceivable carelessness, the person who attended her had made
a mistake as to the bottle, and, instead of tne liniment ordered, had employed
in frictions part of the contents of a bottle of the acid nitrate of mercuir. The
frictions had been made with a piece of linen saturated with the liquid, and in
spite of the patient's cries of pain, had been persisted in for five or six minutes,
when the patient was brought to the hospital there was found on the left
side of the chest, and in a space of the size of two hands, a large eschar of a
brownish red colour, swelled, and projecting above the healthy parts. Behind,
and on a level with the left scapula, was a second eschar about the size of the
hand ; the skin, acutely inflamea, was of a bright red colour, had an ecchyroosed
appearance, and scattered over it were yellow brown patches ; from this down-
wurds towards the right haunch proceeded a similar tract about half an inch
broad, occasioned bv a portion of the liquid having flowed down below the
limit of the part rubbed. The patient was in a state of prostration and extreme
anxiety; during the night she had several attacks of bilious vomiting. Dr
Vidal found her next morning in a most dangerous state ; her skin was cold,
her features contracted, her eyes sunk, her &ce pale and livid, her voice feeble
and almost suppressed. The patient had extreme epigastric pain, and suffered
almost constantly from nausea without vomiting ; she frequently fiiinted. The
pulse was small, frequent, thready. There was constipation ; the urine was sup-
pressed. The patient had administered to her a mixture containing rum and
tincture of musk, as well as warm stimulating drinks. The following morning

168 PERISOOPE. [AUG.

she had vomiting of bUiouB matter streaked with blood, and the extremities
continued cold and cyanosed. The gums were swollen and bleeding ; the buccal
mucous membrane was red and tumefied, and after visit a very characteristic
blackish line formed on the free border of the gums, which was very well
marked around the insertion of the incisor and canme teeth of the lower jaw,
but was less marked around the molars. The belly was flaccid; consti-
pation continued. The patient made no water ; the bladder was empty. Vo-
mitins continued in spite of the use of ice and Seltzer water. On the fourth
day after the poisoning, the eschars, sun-ounded bpran inflammatory border, began
to be detached. The matters vomited were glairy and tenacious, but vomiting
was rather less frequent than before. On the sixth day vomiting had ceased,
but diarrhoea was severe and accompanied with colic. The patient complained
of extreme weakness, dizsiness, ana ringing in the ears. The coldness of the
surface persisted, the pulse was 140, small and thready. Durine the following
day the weakness increased ; the voice was almost suppressed, the patient onl^
answered by signs when attempts were made to rouse her from the semi-
comatose state in which she lay. She died quietly on the ninth dav after the
accident, at three o*clock in the afternoon. On post-mortem exammation, the
mucous membrane of the stomach had an arborescent red appearance, studded
with ecchymotic patches. The same ecchymoses were round throughout
nearly the whole intestinal canal and in the urinary bladder. The blood was
black and fluid. On microscopical examination, the renal parenchyma was
found much injected, especially in the neighbourhood of the Malpighian bodies ;
the epithelial cells were irregular in shape, granular, and partially destroyed.
M. Flandrin, who undertook the chemical analysis, found a sensible quantity of
mercury in the liver, but no trace of it in any of the other organs.

The above observation is interesting for several reasons. It is a very re-
markable example of poisoning by the external application of a caustic salt of
mercury. It is one of the cases of mixed poisoning, where the substance em-
ployed, consisting of a salt of mercury and an irritant and corrosive acid, nves
rise at once to irritant and specific symptoms. Special attention should be
directed to the existence of ecchymoses in the intestinal and vesical mucous
membranes, and to the change in the kidney, which was evidently produced by
the elimination of the toxic agent. The epitheliel cells, granular and altered
in shape, obstructed the tubes and prevented urinary excretion. This granular
fatty condition of the renal epithelium is analogous to the lesion regarded as
characteristic of poisoning b^ phosphorus. M. Potain has also found it in a
case of poisoning by ammonui. We must then be carefulmot to speak of this
lesion as characierigtic of poisoning by phosphorus. No doubt^ fatty degeneration
of the liver and kidneys takes place very readily in poisoning bv phosphorus,
but other forms of acute poisoning may give rise to the same lesion. This,
then, is a lesion which is to be attributed not. to a particular kind cf poison,
but to a form of poisoning. When corrosive substances which have been ab-
sorbed are eliminated more or less slowly by the kidneys, the liver, the glands,
etc., they produce an anatomical alteration of the elements of the organs which
they traverse, and fatty degeneration b the most frequent of the lesions so
produced. — GtuteUe dee Hopitaux,

POISONING BY DiaiTALIS. DEATH ON THE FIFTH DAY. BY DR MAZEL.

ViCTOiRE Z., servant with an apothecary, generally of good health, sent for
me on the l(Hh of March 1863, about five in the afternoon. She compUuned
of lassitude, violent headache, and pain in the pit of the stomach. She had
had a cough for about a week, and said that a cold had taken away her appetite.
Since the previous evening she had vomited a great deal, and felt herself much
worse. She attributed her uneasiness and the vomiting to indigestion, occa-
sioned by having eaten some chestnuts the previous day. I found the skin cold,
the pulse 52, of fair strength, but irregular, and with frequent intermissions.
The face was pale, the pupils dilated. The tongue was slightly coated, the
thirst considerable, tbe epigastric pain was increased by pressure. The belly

1864.] MEDICAL JURISPRUDENCE. 169

was patnleM, there wm no diarrhoM. There was a little cough, but on aasciil-
tation and percuBsion there was no sifn of a pulmonary lesion. I considered
the case a very serioas one, but could not make a precise diagnosis ; while
waiting till further observation should enlighten me, 1 endeavoured to combat
the existing symptoms and the deficiency of reaction by sinapisms applied to
the lower extromities and infusions of lime-fiowerii. On Wednesday the 1 1th of
March, the third day of her illness, I found that the patient had not slept at all
during the night. The Yomiting had recurred as often as she had taken any-
thing. The pulse was 52, and presented the same characters as before. The
temperature of the skin in those parts exposed to the air was lower than natural.
The pupils were still dilated. She was ordered lemonade, and a mixture con-
taining ether and laudanum. Strong mustard pKOultices were directed to be
i4>plioa frequently to the lower limlM ; those which had been applied on the
previous eyening had been scarcely felt. On returning in the course of the
morning, Mr X., the apothecary, exclaimed, *' The cause of her illness has been
discovered, the unfortunate eirl has been poisoned with infusion of digitalis.**
He then informed me how the discoyery liad been made. The house porter,
while putting the kitchen in order, had round two pots, each containing several
large leaves, which he thought resembled di^talis ; without attaching any^ im-
portance to the ctrcamstance he mentioned it to the apothecary, merely with a
view to know whether he might clean the vessels. Mr X., who had had no
preparation of the kind to make, had the leaves brought to him, recognised
them as digitalis, and immediately saw the connexion which existed between
the infusion and the illness of his servant. On seeing them I also recognised
the leaves in each yessel as digitalis, and by weighing an equal number of dry
leaves I found that about fifty grains had been used to prepare each infusion.
From this moment all was explained, the slowness, irregularity, and inter-
mittence of the pulse, the coldness of the skin, the headache, tne epigastric
pain, the constant vomiting, and the muscular debility. I went immediately to
the patient and asked her if she had taken nothing which could have caused
her illness. She told me that on Monday she had prepared two infusions of
borrage for her cold, and that she had drank the firat at eight, the second at
nine o*clock in the morning. On asking where she had got the leaves, she
indicated in the most natural manner the box containing digitalis. I informed
her that she had made a mistake, and that her impruoence was the cause of
her illness. I have since heard that in spite of the strict and repeated injunc-
tions of her master, she had, on several former occasions, taken articles out of
the shop. According to the patient's statement the following was the history
of the case : — Up to twelve o'clock she experienced no uneasiness, and after
having served tne dinner she ate some chestnuts. A little afterwards she
felt uneasy, and had an inclination to vomit. She went up to her room,
meaning to lie down, but 'almost immediately vomiting came on, at first
of alimentary matter, then liquid, finally of a greenish-yellow colour. She felt
cold all over, had vertigo and dimness of sight to such a degree that she could
not come downstairs the whole evening. She had not urinated, and there had
been no movement of the bowels firora the time that she had lain down. She
felt bruised all over ; felt as if drunk, and vision was still indistinct. There
was no ringing in the ears. There was a soft blowing murmur with the first
sound of tne heart. I continued the previous treatment, which seemed to
ftilfil aU indications. In the eyening she was in the same state. On Thursday,
the fourth day of her illness, I found that the patient had made water about
eleven o'clock on the previous night, and also towards morning ; the bowels
had not been opened. Tlie yomitmg continued ; her pulse was slower, being
only 41 or 42 in the minute. The respiration was embarrassed ; its frequency
was 16. The patient had still vertigo, and felt as if drunk and fatigued. She
was ordered vinegar and water, frictions of yolatile camphor liniment, sinapisms,
and the mixture as before, an enema with an ounce of sulphate of soda. In
the evening the pulse was 46, stronger. The vomiting was less frequent. She
was ordered a tablespoonful of soup, with wine every two hours. On Friday
VOL. X.— NO. n. V

170 PERISCOPE. [AUG.

the 13th of March, the fifth day of her illness, the pulse was 58, less irregular.
Nevertheless, her face had a heavy expression, and the patient, when questioned,
said she was in the same state as the evening before. The vomiting was less
frequent. Urination was performed freely. She was ordered another purga*
live enema. Since the previous evening Y ictoire Z. had complained of lumbar
pains, and she stated that she was at a menstrual period. Menstruation came on
m the course of the afternoon. The pulse was now 60, and was neither irregular
nor intermittent. The wine and soup had generally been retained. The first part
of the night was passed very comfortably ; at two o'clock in the morning the
patient got up alone to make water ; on returning to bed she suddenly fainted.
The persons in attendance rushed to her, but found that she gave no sign of
life. I was sent for immediately, and although death appear^ to me to be
real, I Imd ene^etic frictions practised over the region of the heart and the
extremities. Everything proved unavailing. A post-mortem examination
was not obtained.

The above case seems to me important in several respects. In the first
place, the value of vomiting, as a diagnostic sign of poisoning, should be noted.
When, in addition to vomiting, there is pallor of the face, coldness of the skin,
muscidar feebleness, and derangement of^ vision, doubt is no longer permissible ;
we may be sure that we have to do with a case of poisoning. If I had
attached to this symptom the importance it deserved I should probably not
have misunderstood the phenomejia I observed at my first and second visits.
The idea having once occurred to me, I would have minutely questioned the
patient, and I have no doubt that she would have given -me the informa-
tion which accident at last afforded, and which her own statements con-
firmed. Still, it is singular that she had not suspected the cause of her illness,
and that she did not mention the pretended intusions of borrage. The time
which elapsed between the swallowing of the second cup and the occurrence of
the vomitme probably deceived her, and caused her to attribute all her suffer*
ings to indigestion. What I have said regarding the diagnostic value of
vomiting is especially true with regard to poisoning by di^taUs and its active
principle. The above observation is a typical case of poisoning by this sub-
stance. I have mentioned, with regard to the nervous symptoms, general
feeling of coldness, prostration of strength, persistent feeling of drunkenness,
headache, vertigo, confusion of sight, dilatation of the pupik, ansesthesia. In
regard to the digestive system, there was constant vomiting, constipation, sup-
pression of urine. In connexion with the circulation, there was pallor of the
tkce, coldness of the skin, slowness, irregularity, and intermittence of the
pulse, a blowing murmur with the first sound of the heart. Most of these
symptoms are mentioned in works on toxicology. But there is one which, so
far as I know, has not been noted, and on which it seems proper to fix the
attention of observers — I mean the suppression of urine. In the case under
consideration this lasted for fifty hours. It seems singukr that digitalis, the
diuretic effect of which is so well marked, should, when given in a poisonous
dose, suppress the function which in a medicinal dose it stimulates. This
suspension of the urinary function is at once the consequence and the measure
of tne profound perturbation exercised on the system by the absorption of the
poison. The same symptom is observed in severe cases of cholera, and its
persistence is a very bad sign.

The death of Yictoire Z. did not take place till the fifth day. At my last
visit there was a marked amelioration ; the pulse had risen from 41 to 60 ; its
irregularity and intermittence had disappeared ; menstruation had come on ;
the vomiting was much less frequent ; urination was copious ; and finally, for
twenty-four hours the patient had been taking soup and wine. Death occurred
suddenly at two o'clock in the morning. To what cause was it to be ascribed ?
Was it the direct result of the poisoning, or was it due to syncope ? I believe
that the latter explanation is correct. No doubt, digitalis, from its special action
upon the heart, has a special tendency to produce syncope, and it is on account
or the therapeutical deduction that I make the distinction. In similar cases

1864.] MEDICAL JURISPRUDENCE. 171

our endeavour should be to obviate the tendency to syncope, which is to a
certain extent in our power. If such a case occurred to me again, I should
direct the horizontal position to be strictly maintained until convalescence was
perfectly established.— GaaeUe des H&piiaux.

POISONINQ BY DIOITALINE. BY DR LEFORT.

Db Jules Lefort brought before the Imperial Academy of Medicine a paper,
entitled ^* Chemical and Tozological Researches on Digitaline," of which the
following are the conclusions : —

1. In France two kinds of digitaline are employed in medicine, which possess
very different physical and chemical properties. The one is called German, or
soluble ; the other French, or uisoluble.

2. Soluble di^taline is coloured green more slowly and less strongly by
hydrochloric acid than the insoluble form.

3. Hydrochloric gas colours insoluble digitaline of a deep green, the soluble
of a dark brown.

4. The same gas develops with insoluble digitaline the special odour of the
powder or alcoholic tincture of digitalis ; with soluble digitaline the character
IS less appreciable.

5. Under the microscope, in the case of soluble digitaline, we see traces uf
crystals without a determmate form ; in the case of insoluble digitaline we see
an opaque magma representing a mixture of at least two substances.

6. Soluble mgitaline appears to be a purer and better defined substance than
the insoluble.

7. The principle which Is coloured green by hvdrochloric acid appears to be
independent of the digitalme itself, whether soluble or insoluble ; it is no doubt
volatile, and the same which communicates to digitaline its peculiar odour.

8. The two kinds of digitaline dissolved in water and in alcohol pass through
colloidal membranes, and may be separated by the dialytic process from biu>-
stances which contain them naturally or accidentally.

9. The bitterness of digitaline, soluble or insoluble, its coloration by
hydrochloric acid, the odour of digitalis elicited by hydrochloric gas, are cha-
racters which permit us to affirm its presence in substances which contain &
moderate quantity of it. — Eeoue de TMrapeuHque Midtco- ChtrurgicdU,

CHRONIC POISONING BY TOBACCO. BY DR LE BRIERT.

On the 7th February 1864, 1 was sent for to see a woman, the wife of a miller,
forty-six years of age. She had originally been of sound constitution, had been
married twice, and had had ^wt children. She had suffered much from anxiety
for a long time, but four years ago she had additional grief from the loss of a
daughter eleven years old, to whom she was devotedly attached. From that
time she had no peace of mind. She sought every means of distraction, drank
to excess, and from a singular depravation of taste, took to eatins tobacco of
every kind, to the amount of about two francs* worth a- week. Wnen I arrived
the patient was almost speechless *, her voice was hoarse, and she could only
murmur some inarticulate sounds. The respiration was difficult, sighing ; the
pulse was weak and slow. The heart scarcelv beat. The pupil was diUted
and insensible to light ; the eye had a haggard appearance, ana blindness was
almost complete. Deafness was not complete, but nearing was very dull. The
face was emaciated, pale, and stupid- looking; the tongue was tremulous, red,
and dry. Swallowing was very painful, owine to spasms of the throat. The
belly was retracted. The £»ces, resembling the excrements of sheep, had for
long only been passed after the use of enemata and purgatives ; at first, on the
contrary, purging had been present, and she had often vomited. Soon, how-
ever, her appetite had failed, the gastro-intestinal walls had been, so to speak,
affected with stupor, like all the rest of the body, and the period of prostration
arrived. The urine was passed involuntarily. There was weakness, cold
sweat, sleeplessness. Under these circumstances I could do nothing ; I merely
ordered soup, coffee, and acid drinks. Wlien I saw the patient two days after-

172 PERISCOPE. [AUG.

wards, her voice was suppressed like that of a cholera patient, deglutition was
impossible ; the chest scarcely moved ; the respiratory murmur and the move-
ments of the heart were almost inaudible. All the organs were in a manner
stunned by the influence of the tobacco. Death occurred a few hours after-
wards.— wzeUe dea H6pijtaux,

POISONING BY TOBACCO LEAVES. BT DR NAMIA8.

Some time ago, M. Decaisne laid before the Academy of Sciences a memoir
on '* the intermittence of the heart and pulse occasioned by excessive tobacco
smoking," in which he arrived at the conclusion, that the abuse can produce in
certain persons a condition which may be called narcotism of the heart, and
which manifests itself by intermittence in the beating of the heart, and in the
pulsations of the radial artery. The importance of bringing forward facts in
connexion with this theory, induces me to record the following case. A smuggler
some months ago covered tne whole of his naked body with tobacco leaves, with a
view to defrauding the revenue of the amount of the duty. The tobacco, moistened
by perspiration, produced through the skin a real poisoning, which, however,
was cured by means of alcoholic stimulants and laudanum. The extreme
feebleness of the pulse, its smallness, the cold sweats, the fainting occasioned
by the tobacco applied to the whole surface of the body, present numerous
analogies with the condition called by Decaisne narcotism of the heart, and
which he noticed to disappear entirely or to diminish when the use of tobacco
was suspended or diminished. So far as I know, no other case of poisoning
by tobacco applied to the skin has been recorded. The treatment successfully
employed does not, however, lead to any general conclusions. In ordinary
poisoning, the first thing is to eliminate or neutralize the poison. We must
then direct attention to the condition produced b)r it, and this condition
depends not only on the nature and quantity of the poison, but on the previous
condition of the individual. We cannot thus treat poisoning by the same
poison in different individuals in the same manner, because the same morbific
causes do not always produce the same consecutive malady. Electric currents,
which in other conditions excite hyperomia and inflammation, only exhaust
and use up directly the vital forces when they act with too great violence. I
have made a similar observation as to the efiect of alcoholic stimulants, which
must be combated according to the different symptoms presented by the
patients, that is to say, according to the different diseases which are the con-
sequence of their abuse. — Oasette de$ HSpitaux.

ON THE DELETERIOUS EFFECTS OF ANILINE ON THE WORKERS WHO PREPARE IT.
BY DR KREUSER OP STUTTGART.

The author observed in the Catherine Hospital of Stuttgart several cases of
intense bronchitis, characterized b^ a violent dry spasmodic cough, accom-
panied by ulcerations, situated especially on the scrotum and lower extremities,
of a rounded form, with borders sharply cut, often callous, covered with thick
black crusts, under which was a base of a dirty grey colour, the surrounding
parts being swollen and painful. All this yielded readily to a simple treatment
so soon as the workmen were removed from the manufiictory where the colour
was prepared. If care were taken to protect the skin by suitable clothing, by
raakinff the workmen wash frequently, and by improving the ventilation, these
bad efrects might be avoided. The existence of this peculiar affection haa been
also observed by MM. Stadler at Marbourg, and Stoerig at Wildnngen. —
Eeme de ThfyxtpeuHque MicUoO'Chirurgicale.

^ 1864.] MEDICO-CHIRUBaiCAL 80CIETT OF EDINBURGH. 173

MEDICAL NEWS.

MEDICO-CHIRURGICAL SOCIETY OF EDINBURGH.

SESSION XLIU.— MEETING Vin.

lit June 1864.~Dr Douglas Maclagan, President of the Society, in the Chair.

I. AMPUTATION AFTER EXCISION OF WRIST- JOINT.

Mr 8pmc€ showed a specimen from a man in whoin amputation of the fore-
arm haa been performed. He had, about the beginning of winter, excised the
wrist-joint by means of two lateral incisions, with a view to leave the tendons
untouched. At the time of the operation there was no disease of the radius
or ulna, the caries being confined to the carpal bones. For a time everything
went on well, and the patient was sent to the Convalescent House. After a
time, however, the ends of the bones of the fore-arm were found to be bare.
Mr ^pence hoped that there would only be thin exfoliations, and that when
these came away the patient might still have a useful hand. Unfortunately,
necrosis extended up the shafts of the bones, hssmorrhage in consequence of
ulceration of vessels took place, and amputation was required. Mr Spence
stated that though the result in this case had been unfavourable, it would not
deter him from repeating the excision in a proper case. The man at the time
of the operation was not in a very favourable state for it, being weak and
amsmic. Since the amputation all had gone on well.

U. REMOVAL OP WHOLE SHAFT OF TIBIA.

Mr Edwards showed a tibia which he had removed about a month ago, while
taking charge of Dr Gillespie's wards in* the Royal Infirmary. The patient was
a man forty years. of age, and had su£fered from ulceration of the tibia for many
years ; at times there had been much pain, and diseased portions had been
gouged out again and again. The diHease, in fact, seemed mcurable, and Mr
Edwards 4iad accordingly performed an experiment which, if successful, would
turn out to be important. He had removed the whole bone, leaving only the
periosteum as entire and as thick as possible. This had been done more easily
than might have been anticipated. The wound was now nearly healed. 'Hit
Edwards hoped that the fibula would become h^ertrophied, and that bone
would be deposited (as after compound fracture) m the interosseous membrane
and from the periosteum ; so that if there was not a new tibia, there might at
least be a firm bony rod of some description, which would allow the man to
retain his l^, and be better than a wooden one. Since the operation the man
had been quite free from the old pain.

III. MALIGNANT DISEASE OF THE FEMUR.

Dr Brtioe showed a specimen of malignant disease of the thigh bone, re-
moved a few days ago from the body of a man sixty-three years of age. For
about a year the patient had complained of failing health. There haA been
obscure symptoms simulating neuralgia, but not yielding to treatment. A few
da^s before death a swelling made its appearance in the anterior aspect of the
thigh ; it seemed to be a tu.aour arising from the bone. It continued in much
the same stat6 for a week or tfo, when the femur broke while the patient was
being carefully removed to bed. Dr Bruce saw him at this time, and found
the symptoms of fracture evident. The patient became weaker and weaker,
and at length sank. On post-mortem examination, a mass of malignant disease
was found growing from about the middle of the femur. The bone seemed to
have been very much destroyed.

174 MEDICAL NEWS. [AUO.

IV. CYSTICERGUS CELLULOSES IN BACON.

Dr R. Peel RUcMe showed a specimen of measly bacon. A friend in London
had noticed that some bacon which he had got for family use had an anhealthj
appearance. He sent a little bit of it to Dr Ritchie, who, on microscopic
examination, detected numerous booklets of the cysticercus. Dr Ritchie
accordingly wrote up that the meat was unhealthy, and requested to be supplied
with a larger specimen of it. The portion now exhibited was accordingly sent
down, and in it could be at once recognised numerous cysts of the parasite.
Although there was not much danger to be apprehended, as an^ of the bacon
which had been eaten had been thoroughly cooked, Dr Ritchie had thought
it advisable to recommend the three members of the family who had partaken
of the bacon to have a dose of the male shield-fern. Only one, however, had
taken it. A second took an aperient pill ; whilst the third declined taking any
medicine. None of the family had suffered any bad effects. Thb Dr Ritchie
attributed partly to the bacon being cooked, but chiefly to its being well
cured.

y. TRACHEOTOMY IN DIPHTHERIA.

Dr Joiqph Be2/ showed the air passages in a case of diphtheria in which he had
performed tracheotomy. At the time of the operation the respiration was much
embarrassed, but after its ]3erformance the breathing was much relieved, and
continued so until death, which took place on the third day, not by asphyxia but
by asthenia. On examination, a great deal of false membrane was found in the
tiachea and extending beyond its bifurcation into the bronchi. The case on
the whole, was rather calculated to encourage the performance of the operation,
as showing that relief was afforded even when false membrane was deposited
below the opening in the windpipe. On post-mortem examination the cause
of weakness was discovered in deep and extensive sloughing of the tonsils.
This condition also expUmed the sort of pyemic odour which was felt soon after •
the operation.

yL DISEASE OF DECIDUA.

Dr Gamgee exhibited a specimen illustrative of extensive disease of the
maternal and foetal portions of the ovum. Mr A. Miller had been sent for,
three weeks ago, to see the inmate of a brothel who had had sb'ght uterine
pains for twenty-four hours, and was then suffering from haemorrhage. Shortly
after Mr Millers arrival the mass now exhibited to the Society was expelled.
Its shape was pyriform, and resembled a rather enlarged uterus. The woman,
it should be mentioned, considered herself four months gone. On incising the
mass, Dr Gamgee at first failed to detect any trace of an embryo ; he merely
saw a cavity lined with a sort of serous membrane. On very carefltl examina-
tion, an embryo at a very early stage, presenting the characters of the third
or fourth week, was discovered. The head, upper and lower extremities, could
be distinguished, and black spots for the eyes could just be distinguished. The
length of the embryo was about three or four lines. The mass consisted bf
a number of little cysts; the outer surface seemed covered with muscular
tissue, but no true muscular fibres could be detected, and the appearance was
probably caused by the peculiar cells of the decidua. In this case there had
no doubt been hypertrophy of the decidua, with cystic degeneration. It was
very probable that impregnation had taken place four months before the
expulsion of the mass, but the disease of the decidua had arrested the develop-
ment of the embryo at an early period.

VU. DILATATION OF THE (BSOPHAOUS.

Dr Alexander Wood exhibited a very remarkable preparation illustrative of
dilatation of the CBSophagus, the particulars of which will be given in a future
number of this Journal.

1864.] 06STETBICAL SOCtETT OF EDINBURGH. 175

PROCEEDINGS OF THE EDINBURGH OBSTETRICAL SOCIETY

SESSION XXIII. — MEETIKO YUI.

I3th April 1864.— Dr Pattison, Vioe-Prtrident, in the Chair.

I. ON SOME INSTBUMENTS TO FACILITATE THE INTRODUCTION OF TENTS AMD
DILATATION OF THE 08. BY DR KEILLER.

In exhibiting these instrnment^, Dr KnUer remarked, that at the previous
meeting he had referred to the difficulty which was experienced in introducing
tents, and that he had devised an instrument to facihtate their introduction.
Since then he had been working at the matter, and had now obtamed instru-
ments which would not only be serviceable for that purpose, but which would
also be of use in aiding the dilatation of the os. Tne first instrument was a
pair of curved forceps, fashioned after the form of a sound, and marked like
that instrument, so tnat it might be used for similar purposes in ascertaining
the position and size of the uterus. As a pair of forceps, you could grasp a
tent with it, and by this means much more easily introduce it. He might here
remark al^o, that he had found it of great benefit to give the tangle-tent a
slight curve. It not only facilitated its introduction, but kept it much better
in position when introduced. For using the instrument for the purpose of
dilating the os, by opening the blades when once introduced within the os, he
had put a flattened point upon one of the handles, against which you could
press with the thumb, and in that way exercise a much greater lever power.
The second instrument was a grooved probe-pointed curved director. In using
it, yon first introduce the point into the os, and then, by passing the tent along
the groove, it readily enters within the cervix. The groove, he found,
answered best when placed on the convex surface. This instrument was also of
great service in cases where the os was very high up and far back. In ex-
amining such cases there was often very great difficulty, but with this instrument
von could draw the cervix well down and forwards. It might also be of use in
bringing the os into view when using the speculum, by first introducing the
instrument and then passine the speculum over it. For the purpose of
using the instrument as a dilator also, he had made a sound to correspond
with the curve, and to fit in the groove. The points of both director and
sound having been introduced within the os, you could dilate by separating
them in the manner of a paur of forceps, and when the handles came in contact
you could still further increase the distance between the points by virtue of the
curve in the instrument, by pushing the director further along the groove.
The disadvantage of these instruments in dilatation was that their dilating

Sower was in the antero-posterior diameter, but by changing their position
uring their introduction lateral dilatation could also be accomplished. Dr K.
was lulling an instrument made after the plan of a glove-stretcher, by which
you could dilate in any direction.

Dr Alex, R, Simpion having had no experience in the method proposed by
Dr Keiller, of forcibly dilating the os, was unwilling to express an opinion on
the use of the instruments for that purpose. Thev seemed to be very mgenions
and practical, but it appeared to him that all that was wished to be attained
by them was attainable by the slower, and — he could not but think— safer,
method of using the tents. Gradual dilatation seemed to him, a priori, better.
The fancy for rapid dilatation of the os uteri by means of instruments, how-
ever, seemed to be becoming general; for Dr Priestley, in London, and an
Australian physician, Dr Wilkie, of Melbourne, had lately proposed instruments
for that purpose. In reference to the speculum, he mi^t mention that the
most serviceable form was that of the bivalve, made so as to dilate the vagina
in the antero-posterior diameter.

Dr Myrtle thoiu^ht that as there was often great pain in the use of the tents,
there would be stul greater in the method proposed by Dr Keiller.

176 MEDICAL NEWS. [AUO.

Dr Bum asked what object Dr Keiller wished to obtain by the forcible
dilatation of the os which could not be attained by the tent ?

Dr KeSier explsined that the principal object ne had in view by the ase of
his instruments, was to facilitate the introduction of the tents. Also, in the
examination of the uterus, to enable one to draw down the os in cases where
it was high up and inclined very far backwards. With his director he was
able to ^braw it well down and forwards. Their use for the forcible dilatation
of the OS he only proposed in cases where you wished to spare time. He by
no means intenaea by it to supersede the use of tents where you had time at
your disposal. Another advantage was that the patient did not require to be
confined to bed, as she frequently did in the use of the tents. The ^eat object,
however, was to facilitate the introduction of tents, and, by making the one
instrument serviceable for other purposes, increase their use by simplicity of
structure.

n. CASE OF PUERPERAL SCARLET FEVER.

Dr Bruce read the following histoiy of the case : — Mrs C. was confined on
the 22d February last, the labour bemg of an ordinary character, and every-
thing going on well until the 26tb, when she felt not so easy, and complained
of headache, and at night became very feverish and restless. On seemg her
next day I found that there was a scarlet eruption comibg out all over the
body; the pulse was 150. Next day, the 28th, the eruption was well out,
pulse still l50, and there was a tendency to delirium. z9tA, There is now
much delirium; pulse 160, and weak; she cannot speak well; eruption keeps
out. Ammonia, beef-tea, wine and brandy given to combat the weakness,
which is becoming very marked. March 1</, pulse 160. There was much
delirium through the night. Patient lies in a kind of stupor, but still appears
to be so far sensible ; at night the pulse rose to 166. The stimulants continue
to be given very freely, but without much effect, and she died early in the
morning of the 2d.

Dr Cappie stated he had met with one case where the patient recovered
from the fever, but sunk afterwards, from the complications of post-scarlatinal
albuminuria.

Drs Ziegler and Stqthenson had both had cases which recovered.

m. MOTE ON THE MANAGEMENT OF THE THIRD 8TAOE OF LABOUR. BY HR
ALFRED M. WATSON.

Dr Alexander R. Simpean beeged to remind the Society, that in debating the
history of a case of complex labour at a recent meeting, ne had taken occasion
to speak of the practice that had been coming into vogue in Germany, of effect-
ing the immediate expulsion of the placenta by external compression of the
uterus. It was nothing new to British practitioners to manipulate the uterus
frpm above the pubes, with a view to expedite the extrusion of the after-birth,
and the results of this practice in the hands of such men as Dr Lawrence, of
Montrose (see this Journal for March 1863), showed the importance of hav-
ing recourse to it very speedily after the birth of the child. But, so far as
he was aware, few or none had been in the habit of effecting the delivery of
the placenta toithoui inierfering toith the cord, with the exception of Dr Newman,
of Stamford ; and, as Mr Alfred Watson, a talented pupil of that gentleman,
bad kindly made a note for him of the results in 200 cases treated in this way,
perhaps the Society would allow him to read them : — " The plan,^* says Mr
Watson, " which I have followed in the followinff cases is founded upon the
method described by Dr Newman, in the British Medical JoumaL But I do
not follow his plan entirely. He contents himself with merely extruding the
placenta and membranes into the vagina, and then extracting the mass
from the vagina by erasping the edge of the placenta and withdrawing it,
I endeavour to extruae the whole mass from the vagina as well as from the
uterus, by continued grasping and occasionally compressine the uterine
tumour, and in this I usually succeed. In order to accomplish this it is

1864.] OBSTETRICAL SOCTBTT OF EDINBURGH. 177

neoesaary that the nteniB should be grasped in the hand and kept firmly
compressed very shortly after the removal of the child. The pressure should
be oontinaed, and the nterine tmnonr manipulated through the abdominal
walls. It causes very little inconvenience to the patient, is done without
at all exposing her person, and need not be very ]^inful. It is worthy of
remark here, that the larger the hand of the practitioner, and the firmer and
more complete the grasp of the uterine tumour, the sooner is the expulsion.
There need not urdinarilv be any difficulty in finding the tumour, if the hand
has been employed in fouowmg the descent of the diild during its expulsion.
It is almost alwa;^s in the right iliac fossa, just beneath the margin of the hip.

'* It only remains for me to state, that by following this procedure I have
saved myself much trouble, and have usually succeedra in expelling from the
uterus and vagina the placenta and membranes, without the necessity of
making any traction on tne cord ; indeed, after the ligature has been applied I
find myself in a position to ignore altogether the existence of that appendaoe.

** Further, let me state tmit I have attended considerably over a hundred
cases of midwifery, where I was obliged to follow the old rule of treating the
expulsion of placenta with unaided uterine effort ; and I feel convinced of the
superiority of the method which I have endeavoured to describe.

*' The nature of the cases wUl be best shown by the following statement : —
*' Presentation, — Cranial, in 183 cases ; breech, in 5 ; footling, in 5 ; placenta
pnevia, in 1 ; premature labour, in 4; not noted, in 1 ; hand and funis, 1.-^
Total, 200.

<* Metllod of delivery, — Bv natural efforts in 194 cases ; by forceps, 3 ; by
turning, 2 ; by craniotomy, 1. — ^Total, 200.

" RanUi9. — Post-partum hssmorrhage in 1 case. Adherent placenta, requiring
the introduction of the hand to peel it off, occurred in 1 case. I have not
had a single case of ' hour-glass contraction.*

'* The case in which post-partum hemorrhage occurred was that of a woman
who was the subiect ot oiganic disease of the heart (aortic insufficiency), and
who had suffered from alarming hemorrhage in her two previous labours.

^ The usual duration of the tnlrd stage in these cases was from Jifteen to twmty
Mtnutea, Occasionallv it was prolonged over half an hour, but very rarely.
In the 200 cases it oiuy occurred to me to be detained over an hour, owing to
the placenta, in 4 cases (besides the hemorrhage case), — one of these being that
in which the placenta was adherent.

" In the 200 cases I lost 2 cases ; these patients resided in the same street in a
small town, they were confined on the same day, and they died within a few
hours of each other of puerperal fever, which was then epiaemic, and causing
a mortality among lying-in women.

" Except the 2 version cases, 1 forceps case, and the craniotomy, I conducted
the labour. In all, I had charge of the third stage.

" Some of these cases occurred in Lincolnshire, some in Sussex, and a few in
Dublin."

Dr Bum stated that he had tried the method mentioned in the paper in
eight or ten cases, but had never succeeded in ejecting the placenta oy it.
In the last case he found that a larse portion of the membranes was retained.

Dr Bryoe remarked that t]tie methoa he had for some time adopted was usinff
only one ligature, and allowing the placenta to empty itself of blood. He had
found it very serviceable in facilitatmg the expulsion of the pUcenta.

MEBTINO IX.

27^ AprU 1864.— Dr Pattison, Vke-l^reMaU, in the Chair.

I. CASE OF PUERPERAL CONVULSIONS.

Dr Keillor read the following notes of a case, by Dr Gordon of Juniper
Green : — On the 5th of February last, about nine in the morning, I was called
to attend a young unmarried woman in labour, — first child. She had been
ailing all night, but not very iU. On my arrival, I found her in bed, having

VOL. X,— NO. II. as

178 MEDICAL NEWS. [aUO.

occasional pains, bnt not strong. On examination, I found the os uteri dilated
to about the size of half-a-crown, head presenting. I did not deem it necessary
to wait. I made some visits, and returned in about two hours. During my
absence, pains had become more severe, and her mother told me that she had
had " a queer turn of the nerves," she thoi^ht. This amounted to a little
incoherent talk, and a little staring at the roof of the bed. I remained a little ;
during that time she had a pkin or two, and after one of them a fit of convul-
sions (epileptic). By this tune the os had dilated to the size of a five-shilline
piece. After a few more pains she had another fit. I then bled. This seemed
to have settled both labour pains and fits for an hour or two. Her pains
began again. As they increased the fits became more frequent and more
Revere. Finding her pains not strong enough to deliver the child, although
now the os was fully dilated, I detennmed to use the forceps, which I applied
verv easily, and delivered without any difficulty. The child was a full grown
healthy-looking female child. This I hoped would have terminated the con-
vulsions ; but they continued, and perhaps increased in severity, and never
abated, in spite of another bleeding, a purge of colocynth and jalap, together
with a tartar emetic mixture, till the foUowin^ morning about eight o*clock,
when she died. She was delivered about six m the evening of the 5th. I
regret I had no opportunity of examining the urine.

The case is made more interesting to me in consequence of the child having
begun to take fits the following day, and continued to do so more or less till it
died ; it lived about twelve days.

The young woman was aged 21, strong and health;^. She had been promised
marriage, but the young roan failed to fulfil his promise, which was said to have
made her dull, listless, and sleepless, for some time previous to her confinement.
Could this be the cause of the mother's convulsions, or what might be the
cause? and what connexion between the mother's and the child's? and if any,
how does the former afifect the latter ?

Dr PaUiBon concurred with the remark of Dr Gordon, and thought that
mental anxiety might act aiT a cause of convulsions.

Profes9or Strnmon said there were, however, many cases of convulsions with-
out such mental cause. Albuminuria was probably the cause in the present
case; and he had published some cases where the child was found to suffer
from albuminuria at the same time as the mother. He might take this oppor-
tunity of mentioning a case he had lately seen with Dr T. Balfour. The
patient, very near her full time, suffered from oedema of the whole body, to a
greater extent than he had ever seen before. Her mind was wandering. All
aiuretics, etc., had failed ; and her stomach was so irritable that it was impos-
sible to administer medicine in the ordinary way. Premature labour could
not be induced on account of the excessive oedema of the labia. He recom-
mended the inhalation of the oil of juniper. A profuse flow of urine soon
followed, and the enormous oedema rapidly subsided. The medicine had soon
to be stopped, to prevent too great irritation of the bladder. The patient was
shortly after delivered of a dead child, and made a good recovery.

Mr Pridis had observed three cases of albuminuria, complicated with con-
vulsions, in which there was a great loss of memory, and inquired whether the
members had observed the same symptom. The treatment followed was
bleeding, and large doses of acetate of potass ; in two of the cases chloroform
was given. All the three cases recovered, but the loss of memory was per-
sistent for a considerable time ; in one of the cases partial recovery had only
been attained.

Profes9or Swipatm said, that French authors mentioned loss of memory and
amaurosis as a fre(}uent result of albuminuria. He ^Prof. S.) had frequently
met with it, and in very various degrees. Sometimes a slight degree of
amaurosis was one of the very first symptoms complained of, earlier even than
the oedema. Sometimes it occurred late, and remained after all other symptoms
had disappeared.

Dr Rudde had seen great benefit derived from injections of salt and water

1864.] OBSTETRICAL SOCIETY OF EDINBURGH. 179

in some cases of epileptic conytdsions. They might be repeated when neces-
sary at the interral of an hoar or an hour and a hiaf.

IL A CASE OF COMTBACTED PELTIg AND ITS CONSEQUENCES.

Dr Bryoi (of Dalkeith) related the following case :-—

At 10 P.M. of the 5th January 1862, I was requested to visit Mrs C, a
primipara. On my arrival I learned from the midwife in attendance that Hhe
had been sent for on the morning of the dd,— that she had visited her patient
at intervals during the three previous days, — ^that the labour during these days
appeared to her to be going on^ though slowly, but that she had never been
aole to make out any presentation, and that the pains had entirely ceased on
the evening of the 4th.

On makmg a vaginal examination I found the uterus very high up, the os
pretty well dilated, and the cervix hanging loosely in front of the festal head,
which was resting on the brim of the pelvis, the occiput on, and projecting
considerably over the pubis, and the frontal bone on the projecting promontory
of the sacrum.

The whole pelvis was found to be an unusually small one in all its diameters
but chiefly in the antero-posterior, which measured not more than two and
a-half inches.

A soft tumour about the sise of a pigeon's egg was felt under the right
ramus of the pubis, which entirely disappeared on the introduction of a catheter
into the bladder, and was, in fact, a pouch of the bladder pinched between the
head and pubis in front, and the heaa and sacrum behind.

As the patient was hot and restless, with pungent heat of the passages, and
a frequent pulse, I prescribed some soothins measures, explaining to the friends
that craniotomy or the csesarean section, I feared, would be necessary, but that
I should wait for a few hours till the feverish condition was subdued, when
she would be in a better condition for interfering. I saw her again at 3 a.m.
next morning, the 6th, — ^found that she had had some sleep, and was much im-

f roved in her general condition, but no alteration on the progress of the labour.
saw her again at 7 a.m., when I found that she had enjoyed some more inter-
vab of sleep— that the fever was subdued and the passages quite cool, but still
no return of the pains. Considering her now in a very favourable condition
for instrumental interference, I requested the advice and assistance of Dr
Lucas, who advised further delay, as there was nothing in the condition of the
patient to call urgently for immediate delivery, and as he thought there was
still some prospect of the natural eflbrts — ^if the uterus could be again induced
to take on action — ^bringing the hcAd into a more manageable position, although
they might not be able to complete the labour. We accordingly waited till
1 A.M. on the 7th, when we again saw her together; and as there was even then
no appearance of the return of uterine action, and no change whatever in the
condition of t])e case, we decided on at once opening the head ; but the removal
of the brain and the greater part of the skull producing no appreciable improve-
ment on the progress of the case after three hours of oft-repeated and fruitless
attempts at extraction with the crotchet, we requested the assistance of Pro-
fessor Simpson, who saw our patient at twenty minutes past nine the same morn-
ing, and delivered her at twenty minutes to ten of a female child, with Scanzoni*s
kephalotribe. Notwithstandmg the un&vonrable position of the head — ^not
only above the brim, but thrown a good deal forward by the projection of the
lower part of the spinal column — Dr Simpson applied the instrument with the
greatest facility to the base of the skull, the bones of which it speedily crushed
and so effectually compressed, that the portion of the head still remaining was
soon brought down into the pelvis and aelivered. The shoulders got as nrmly
impacted at the brim as the head had been, but the difficulty was soon over-
come by Dr Simpson hooking down one arm with the large end of the crotchet.
The uterus contracted well, and in a few minutes the placenta was removed.

When I saw the patient in the evening, there was some fever, but no
abdominal tenderness. Next morning, however, she was attacked with pelvic
cellulitis, and at my visit then there was high fever and delirium, with great

180 MEDICAL NEWS. [aUG.

pain and tenderness in the hypogastric redon. On the third day a tumour
about the sijse of an orange appeared in the right iliac fossa, and on the fifth
or sixth day violent diarrhoea set in; after which, the tumour rapidly dis-
appeared.

At my visit on the ninth day, I found her sitting by the fire, and on the
eleventh day I discontinued my attendance as she was then quite well.

Mrs C. again became pregnant in the end of January or early in February
1863. Professor Simnson saw her the following August, and advised the in-
duction of premature labour at the end of seven months and a week. I accord-
ingly induced labour on the 10th of September by dilatine the os and separating
the membranes. Slight grinding pains came on the following day, and on the
12th labour was progressing, though slowly. At 8 a.m. on the 13th, I found
the OS dilated to about the size' of a crown piece, but when I saw her again in
the afternoon, I learned from the midwife that tne pains had ceased for some
hours, and, on making a vaginal examination, I found matters in exactly the
same condition as when I was called to see her in her former labour. In
order to save the child, I decided on delivering with as little delay as possible ;
returned at half-past eight, and assisted by Dr Maclaren, I appli^ Simp-
son*s forceps, and delivered her of a vigorous little girl at twenty minutes past
nine. The uterus contracted firmly, and in a few minutes expelled the placenta.
She recovered without a single bad symptom, and was going about agam on the
third or fourth day.

On examination of the child^s head, we could discover no trace of forceps
marks ; but in the scalp, about the middle of the left half of the occipital bone
was found a small circular ulcer, at the bottom of which the bone was seen
completely denuded of pericranium, and having exactly the appearance of a
hole made by a saddler^s punch. At first I supposed that this ulcer must have
been caused by pressure on some process or exostosis of the pelvic bones, but
have twice searched in vain for such. The patient has also been carefully
examined bv Dr Alexander Simpson, with a like result.

The child nursed vigorously from the first, and was apparently perfectly well
till the evening of the twelfth day after its birth, when it suddenly uttered a
piercing cry, which was often repeated throughout the night till the next fore-
noon, when it died. Twenty-four hours after death I examined the body, and
on removing the calvarium I found evidences of pretty extensive inflammatory
action ; the dura mater was adherent to the occipital bone, and opposite to the
external ulcer above described there was a small denuded point on the internal
surfiMM of the bone. An abscess also had burst in the same locality, probably
at the time of the first piercing cry. The viscera of the abdomen and thorax
were in a normal condition, with the exception of the lungSi both of which were
studded here and there with dark spots, which on section were found to be
gangrenous abscesses, the results of pulmonary embolism.

Profesaor Simpson exhibited a number of kephalotribes which were used on
the Continent, one of which he used in Dr Bryce*s case. They were aU, how-
ever, very heavy and clumsy. He had endeavoured to improve upon them,
and had got an mstrument made, which he also showed, of a similar construc-
tion, but of much smaller dimensions, being only the length of an ordioary pair
of forceps. He had not as yet, however, h&d an opportuity of testing it m the
delivery of a child, but was able to thoroughly break up tne base of the skull
of a newly-born dead infant.

Dr Moir said, in many cases where premature labour was induced, he would
rather apply the forceps even when it was possible than turn. He considered
it safer to tne child.

Profesaor Simpson remarked that either means could be adopted in many
cases, but there were some where the only choice lay between turning and
craniotomy.

ra.* ON THE USE OF BROMIDE OF AMMONIUM IN PERTUSSIS.

Dr E. P. EikMe read a paper on this subject, which appeared in the June
number of this Journal, p. 1095.

1864.] TRIAL OF THOMAS ABNOT FOR MURDER. 181

REPORT OF THE TRIAL OF THOMAS ARNOT FOR MURDER,

High Court of Justiciary, Gth June 1864.

By Hugh Cowan, Advocate.

The prieoner Thomas Amot was placed at the bar charged with the crime of
murder, in 00 far as on Tuesday the 15tli March 1864, on or near the turnpike
road, leading from Alloa to Stirling, and at a part thereof situated about 300
or 400 yards to the westward of the bridge over the river Devon, called Tulli-
body Bridge, he did wickedly and feloniously attack and assault the now
deceased David Paton, farm-servant, then residing with Oeorge Henderson,
farmer, Haugh of Black Grange, parish of Logic, and shire of Clackmannan,
and did with a shovel or spade, or some other weapon to the prosecutor
unknown, strike him several or one or more severe blows on or about the head
and shoulders and other parts of his person, and did otherwise maltreat and
abuse him ; by all which or part thereof the said David Paton was mortally
injured, and died on 16th March 1864, and was thus murdered by the prisoner.

For the Crown the Solicitor - General (Tonng) and Mr J. A. Crichton,
advocate-depute ; for the prisoner Messrs J. Guthrie Smith and R. V. Campbell,
advocates.

Mr Crvthrie Smith stated that he had to inform the Court that the prisoner
was of unsound mind and not a fit object for trial.

The following witnesses were then examined : —

John Gregory Wallace, writer, AUoa. — ^I was consulted by the prisoner's
wife as to hu defence about the end of April last. The following day I saw
the prisoner Amot. I told him my name. He said he had heard of me before.
I told him the object of my visit, saying that I had seen his wife the day
previous, and she had wishea me to see him as to the charge tu^inst him. I
explained to him the nature of the charge. He said that if I was to act for
him as agent I must take steps to brins in the Free Church and the Govern-
ment for trial along with him. I told nim that this could not be done. He
said that he was not the responsible person, but that the Free Church was, because
he had been persecuted by them beyond what any man could bear for the last
eighteen years, that they had published articles during thatperiod against him
in the Alloa newspapers, and, indeed, in all newspapers. Tney had concealed
his name, but he knew quite well that he was meant. He instanced the Car-
dross case, and said that he was McMillan. I understood him to mean that the
FVee Church put in Mr McMillan's name, but he was the party meant. He
said that Mr Goldie of Tullibody was his minister, and that he had preached
against him for a number of years. On one occasion Mr Goldie made refer-
ence to a man with a blue coat and a brown bible — that though there might be
other men with brown bibles he was the only man in the church with a blue
coat, and Mr Goldie had meant him. He said that Mr Mowbray, distiller, Cambus,
was at the bottom of the conspiracy against him — that he influenced Mr Goldie
to preach against him. I asked him what was the object of all this. He said
that the Free Church wished to excommunicate hun, and if they succeeded in
doing so the Government would then lay hold of him and transport him to the
Channel Islands, where he would have to choose between the whites and the
blacks, and that as he had been so long persecuted by the Christians here he
'tronld be obliged to join the blacks, which was all the Government wanted. I
asked him what all this had to do with the case. He said that he had been so
long persecuted by the church that he wanted to bring the church to its trial, and
must therefore strike a blow at one of its instruments, and the boy was one. He
said that the Free Church had used its influence with the Government for the
purpose of bringing in the millennium. He said that that would never do,

182 MEDICAL NEWS. [AUQ.

although it might take place soon. I was with the priaoner about three-
quarters of an hour. The conTersation was very unconnected. He seemed to
be quite serious. I called for Dr Brotherston, and requested him to visit the

Srisoner, and report as to the state of his mind. I saw the prisoner again ten
ays after. I put some questions to him about the witnesses, and could
scarcely get any answers from him. I saw him again on 26th May, and could

get no mformation from him then. He just went over what he told me on the
rst occasion. On none of these occasions did the prisoner express any
regret. I do not think he was able to give instructions for his defence.
Cross-examined. — I had no idea that the prisoner was feigning. He seemed in
very eood spirits, and said he was very comfortable. The second time I saw
him ^e prisoner was engaged at his dinner. He took from a little box in his
cell the indictment, and gave it to me, and then resumed his dinner, and made
no answer to the questions I put to him. On 26th May the prisoner was in
much the same state as on the 10th. He would harmy speak, but when I
pressed him, he @ve much the same account as at the first.

Rev. WUUam F, GoldU, Minister of the Free Church at Tullibody.— The
prisoner had been a member of my congregation previous to 1857, when I
oecame minister, but I don^t think that he communicated after that. On the
afternoon of Tuesday, 15th March, the prisoner's daughter came to me in my
house, and said that her father had come home in great distress, saying that he
had killed a boy. I said to her not to believe her father till the statement
was confirmed, as he laboured under peculiar fancies. I knew he did so. My
first idea of this was caused by what occurred at my communion in June 1860.
Each member when he applies for a token writes his name on a slip of paper,
which he hands in. The prisoner waited till all the other applicants had USt,
and then himded in a paper with his name, and under it these words, — "If any
one have a charge to ormg against me, I am here to answer for myself.*' I
asked him what charge. He said I knew all about it. I stated there was no
charge that ever I knew of. He said that I had been preaching against him,
and that I had been preaching heresy. I said that was a matter for the pres-
bytery, and not for the kirk-session. He left without receiving a token. I
can't say whether he was offered one. My recollection is not distinct, except
that he didn't get a token, and that the impression he was labouring under was
entirely without foundation. Shortly after this — a few weeks probably — ^I had
an interview with him on the Sturline road. He was working as a surfaceman.
He stated that I was actmg under Mr Mowbray of Cambus, and had been paid
by him to preach against him. I met him again on the Stirling road. Pris-
oner was eating his dinner on the opposite side of the road from that on which
I was. He crossed the road and came in before me, having in his hand a
clasped knife open, with which he had been cutting bread. On the other arm
he had a bottle of milk. He had a peculiar startled look. I felt in danger.
He said that if I as a Christian minister would give him my word that I wasn't
acting under Mr Mowbray's instructions, he would believe me. I tried to turn
the matter off by using tne proverbial expression — the man's head's in a creel,
saying that Mr Mowbray was the last person in the world to give any such
instructions, and that I was about the last man to receive them from any one.
I told him there was no chaixe against him whatever, and that if he attended
church I knew no reason why he shouldn't receive a token at our next com-
munion. He said nothing to that, but left me. He attended the church fw
some Sabbaths af^er this, and, what was not very common for persons in his
position, came to a prayer-meeting on Wednesday evening. I spoke to him at
the close, and shook hands with him. After attending for a few Sabbaths, he
disappeared from the church again. I saw him after tnis, on the Stirling road
occasionally, though I rather avoided that road, being afraid of him. He had
a very peculiar appearance, which I cannot well descrioe. I sometimes thought
he looked like two men — ^the one face behind the other. The one face had a
look of injury, and the other of beine superior to all his enemies. On 1 5th March
I went to the prisoner's house, havmg first made inquiry as to the truth of the

1864.] TRIAL OF THOMAS ARNOT FOR MURDER. 183

report. I foand hii wife and dftoghter in ^reat difitress. I said that the general
impreMion was that the boy had been injured by a cartwheel going over him.
Thu was in presence of the prisoner. He said, '* Who told you that ? '* I said
I had gathered it from information in the district. He said, '* Some person has
done it, and you don't know the party.** I said it didn't matter as to that — I
was only stating the general impression. He then drew himself up and said,
" Well, sir, whoever told you that told you a lie ; for I did it." I said, "Well,
Thomas, aren't yon sorry?" He said most emphatically, "Not a bit for the
deed— I'm sorry for my wife and fiunily.*^ He added, " Them that have got the
spirit may take the body also." He told me that the boy had been sent, and
tnat this matter had been going on for twenty years, as I very well knew ; that
the provocation he had received during all that time was such that no man
could bear it. He said that the boy wasn't to blame, and that he had no ill
will to the boy. I saw him next day in his own house. He again stated that
the boy had l)een sent bv other parties ; that they should have employed some
person of ereater mentaf capacity to do their work. He^ began to speak very
mcoherenUy about mental force and manual labour force in connexion with the
reformation of the world ; but that they could not accomplish it in that way, as
the time wasn't yet come. He said that he was a poor man ; that he had never
learnt a lesson of grammar in his life ; and it seemed very strange that there
should be such conspiracies over the whole world against him. I think he
said that I knew the whole matter. He said, What would they do with him ?
This was in connexion with the reformation of the world. He asked, " If a
man did a deed, and confessed it, would they make him insane ? " I declined
to say. He folded his arms across his breast and said, I should think not. I
understood the they meant his persecutors. He seemed to have no remorse ;
but rather to think he had done something meritorious, — as if he had inflicted a
severe blow upon his enemies unexpectedly. The prisoner was nol communi-
cative about his delusions. I understood he was a sooer man. I never preached
against him, nor about a man in a blue coat and with a brown bible.

Alexander McGregor j rector of the academy at Tillicoultry, and formerly
teacher at Tullibod^r, and an elder in Mr Goldie's congregation, proved a letter
to be in the handwriting of the prisoner, which he had received, and in which
the prisoner referred to a confederation against him, and certain alleged pro-
ceedmgs of the kirk-session.

Robert Mowbray^ distiller, Gambus. I attend the Free Church at Tullibody.
I had no acquaintance with the prisoner. Only once spoke to him that I re-
member of. I never gave instructions to the Kev. Mr Goldie, or to any one
else, to annoy him. I never spoke of him to Mr Goldie that I can remember.

Andrew Stalker j surfaceman. I work on the same road as the prisoner. My
section of the road adjoins that on which he was employed. 1 have known
him for about four years. He used to complain of people persecuting him.
Mr Mowbray was one of them. He complained of the minister preaching
against him, and that the persecutions followed him wherever he went. He
said he had been obliged to leave home on account of these persecutions, and
had gone to the west country. He said they had followed him there ; that
there were paragraphs in the newspapers about him when he was away, under
fictitious names. He gave no reason for this. He said they wanted to make
a settlement with him, but he wouldn't take double the money. I had some
talk with him about the Telverton case about four years ago when it was
eoin^ on in Ireland. He asked me about it. I said it was Captain Yelverton
denying his marriage. Says he, I'm Yelverton. That's the way they always
do, they never mention my name. Another time we had some conversation
about the Cardross case. He asked me about it, and then he said, I'm
M'Millan ; and that's the way they always do. The prisoner was quite serious.
He seemed to believe that he was the party in both of these causes. About a
month before the murder, I had some conversation with him. I asked him
how he was getting on with his work. He said, not very well, and that he was
working away among mud and stones. I said we were all doing that, and what

184 MEDICAL NEWS. [AUG.

WAS much worse, we got little pay for our work. He said it was the Govern-
ment did that. The Government had that in their own hands, and did what they
liked with us. He said he could turn the Government with one hand, and he
would make me confess that he could. He said that was a nothing, it was
quite common. Instead of one there should be two, and instead of three, four,
and that would break the Government. I said I believed he was <juite ri^ht.
He said he knew he would make me confess it. He was speaking m a serious
manner. He was a sober man. I never saw him under the influence of drink.
I never heard of his being persecuted by any one except from himself. I
didn't think he was right in his mind.

Eev, ThamoB Murray, prison chaplain, deponed to several conversations he
had with prisoner after his apprehension. On 7th May I had a long conversa-
tion with him, fully an hour. I asked him if Mr Groldie hia minister had been
calling for him. He answered, No. They wouldn't come near him ; It was of
no use. He explained that he meant the Free Church. I asked what were
the pounds of this ? He said he had been under trial for eighteen years. He
had been employed by the Alloa Coal Company about eighteen years before ;
that at that time the carters and others on the road had begun to annoy him
in various ways ; hiding stones with steel in them, removing metals, etc., that
these parties were under the leadership of Mr Lawrence Drvsdale, farmer in
the neighbourhood. That on inquir^, he had found that Drysdale and Mr
Hill, coal grieve, were iu communication with the Kirk Session of Tullibody,
and that the object the Free Church had in view was to brine in the millennium.
By this he meant a general religion in the world. He asked about a recent
movement for general education, and said that this was just the Free Church
movement in another form. I asked him why the Free Church should trouble
him. He said that they had a fault with him, as his wife was not a member
of the Free Church. He had ascertained this on seeking baptism for his
child — but his wife had not been a member before she was married to him.
The child was baptized, but he said the trial still went on. He told me that
Mr Goldie was in the habit of preaching at him ; then followed conversa-
tion as to ideas detailed by previous witnesses. The prisoner said his case
had been before the Presbytery and the Assembly. I expressed surprise at
this. He assured me it was quite true. I asked what all this had to do with
the murder. He said that the boy formed part of the general system ; that
what the boy did was a small thing, but it was his connexion with the whole
persecutions he had suffered. He said the Free Church would now be on its
trial, and there would be a fine' breach between it and the Government. He
said that Scripture aUowed that he should be tried in faith, and that it also said
that we should not be tried beyond what we could bear ; but he had been tried
beyond what he could bear. I saw him again on 8th May. He said he under-
stood the Free Church intended to charge him with insanity, in order that they
themselves might escape ; that he was persecuted by the free Church for seven
years, and that this was their plan, — if at the end of seven years he continued
a member, he was then taken before the Presbytery — then tnere ensued a year
of public trial, in which the Free Church was assisted by the whole community,
and this he called the reginum donum. He said that he left the church about
the middle of this year of public trial, but the trials were then continued to
brinff him back to the church. I didn't think he was feigning in all this. I
concluded he was in a state of monomania.

Profes9or Douglas Madagan, — I have heard the evidence in this case. I
have also seen the prisoner twice in jail, along with Dr Arthur Mitchell, on
Wednesday and Saturday last. The result of my own observation was to con-
sider that man as being insane. My object was to ascertain the state of his
mind. I don't think he is fit to give instructions for his defence. Is his delu-
sion thorough and pervasive ? Very. Affecting his views of everything that
happens? xes; apparently so. And unfits him for taking a correct view of his
position ? Certainly. Is that opinion confirmed by what you have heard to-
day? Yes. His delusions are of the character described? Yes. To Um

1864.] TRIAL OF THOMAS ARNOT FOR MURDER. 185

(kmrt. The delusions which 70a found correspond with those described by
the witnesses ? Tes. Examination continued, — ^And on the whole matter have
yon any doubt of his being insane? Not the least. To the Court. — Are von
satisfied that he is not feigning ? No, my lord ; certainly not. Have you asked
him anything about the act ? Yes ; I spoke about the indictment, and he
speedily got mto the delusion about the boy being an agent of the Free Church,
and the story of his persecutions. The substance of it was, that his object was
not to punish the boy but the Free Church. To Mr Smith, — ^Is the disease

Eroperly described as monomania? No; I would not call it so. I say he
kbours under mania, not monomania.

Dr Arihur MikheU of Trinity,'—! visited the prisoner along with Dr Mac-
lagan on two occasions, Wednesday and Saturday of last week. I came to the
conclusion that the prisoner was msane. His delusion was general and pervad-
ing, indicating general unsoundness of mind. He is quite unable to give
Instructions for his defence. This opinion is strengthened by the evidence
to-day.

There was no evidence led on the part of the Crown to contradict this
evidence.

The ]x>rd Justice-General, after consultation with the other Judges (Lords
Cowan and Deas), intimated that the^ considered this evidence sufficient to
show that the prisoner is at present m a state of insanity,— adding fhat this
was the judgment of the Court without any hesitation.
The usual interlocutor was then pronounced.

ROYAL MEDICAL AND CHIRURGICAL SOCIETY.

ABSTRACT OF THE REPORT OF THE COMMITTEE ON CHLOROFORM.

In laving their report before the Council of the Medical and Chirurgical Society,
the Cfommittee on Chloroform desire to state that they have made comparatively
little reference to the medical portion of the subject. This is not due to their
thmking the medical uses of chloroform of little importance, but to the fact that
but few replies to their inquiries upon this point have been received.

In view of the great extent of the subject submitted to their consideration,
the committee directed their attention to such points as appeared to them of
chief practical importance. Thus, their observations respecting the action of
chloroform on the nervous system, and their remarks on some other points, are
less full than would have oeen desirable had the committee regarded such
details as of equal importance with those specially elected for investigation —
such as its influence on the action of the heart and on respiration.

The committee have chiefly confined their physiological report to observa-
tions which they have themselves made. Without overlooking or neglecting
the labours of former investigators, they have endeavoured rather to furnish
an accurate account of experiments which they have observed carefully and
together, and to compare the results thus obtained and agreed upon with the
phenomena of cases m which death or peril of life has arisen from the inhala-
tion of chloroform in the human subject.

Ph^tkHogical Condunans. — ^The sequence of the phenomena produced by
chloroform inhalation in animals is similao to that observed in man, and if the
Mime percentage of the agent be administered, the results produced are nearly
uniform. The first effect of chloroform vapour is to increase the force of the
heart's action ; but this effect is slight ana transient, for when complete an-
SBSthesia is produced, the heart in all cases acts with less than its natural force.
The stron^st doses of chloroform vapour, when admitted freely into the lungs,
destroy animal life by arresting the action of the heart ; whilst by moderate
doses the heart's action is much weakened for some time before death
ensues, respiration generally, but not invariably, ceasing before the action

VOL. X.— NO. 11. 2 A

186 MEDICAL NEWS. [AUG.

of the heart, death being dae both to the failure of the heart's action and to that
of the respiratory ftinction. The danger attending the use of chloroform
increases with the degree of stnpor it induces ; the apparent irregularities in the
action of the an»sthetic mainly depending on the varying strength of the vapour
employed, on the Quality of the chloroform, and on the constitution oi the
patient. In order that it may be administered with comparative safety, it is
necessary that the proportion of vapour should not exceed three and a half
per cent. ; that its enects should be carefully watched, and the inhalation sus-
pended when the required anaesthesia is induced.

In many respects the action of ether is similar to that of dilute chloroform.
At first its vapour increases the force of the hearths action — an effect which is
both greater and of loneer duration than that observed with chloroform. The
stimulation is followed by a depression of the force of the heart's action, but at
the same degree of insensibility ether does not depress the action of the heart
to the same extent as chloroform. Eventually, ether kills partly by enfeebling
the action of the heart, but chiefly by arresting the movements of respiration.
Thus the energy with which chloroform acts, and the extent to which it
depresses the force of the heart's action, render it necessary to exercise great
caution in its administration, and suegest the expediency of searching for other
less objectionable annsthetics. Ether is slow and uncertain in its action,
thoi^h it is capable of producing the requisite insensibility, and is less danger-
ous in its operation than chloroform. On the whole, however, the committee
concur in the general opinion which in this country has led to the disuse of
ether as an inconvenient anaesthetic.

A mixture of ether and chloroform is as effective as pure chloroform, and a
safer agent when deep and prolonged ansesthesia is to be induced ; though slow
in its action, it is sufficiently rapid in its operation to be convenient for general
use. A mixture composed of three parts of ether, two parts of chloroform, and
one part of alcohol (by measure), is to be preferred on account of the uniform
blending of the ether and chloroform when combined with alcohol, and the
equable escape of the constituents in vapour ; and the committee suggest that
it should be more extensively tried than it has hitherto been in this country.

Effects of Chloroform on the Fauces, — The sudden administration by the mouth
of concentrated chloroform vapour induces a spasm of the fauces which lasts
for some seconds ; afterwards, when the animal has inspired, the phenomena of
asphyxia are for a time associated with those of chloroform poisoning, and
death is finally induced as by dilute chloroform. If, however, partial insensi-
bility is first induced b^ weaker chloroform, no spasm of the fauces ensues upon
the sudden administration of the concentrated form of the agent.

Post-mortem Appectrances. — Judging from the observations on animals,— the
appearances in the human subject having been noticed in but few cases, and
bemg insufficient for yielding satisfactory conclusions, — it appears that though
there may in certain cases be an impediment to the free circulation of the blood
through the lungs, yet the appearances are very different after death has been
caused by chloroform from tnose observed when life has been destroyed by
asphyxia. In death from chloroform, all the cavities of the heart are distended,
and the cases are only exceptional in which the left side is empty. The rule,
however, is alike in both : that the cavities of the right side contam more blood
than those of the left.

BesuscittUion.-~-The most certain means of restoring life after poisoning with
anaesthetics is by artificial respiration. By this means resuscitation may
generally be accomplished after natural respiration has ceased, provided the
heart continues to act, and it may sometimes be effected even after the cessation
of the heart's action ; but this result is exceptional. Galvanism resuscitates
within the same limits as artificial respiration ; it is, however, fkr less to be
relied on than artificial respiration in equal cases. With either remedy it is
found that animals quickly rendered insensible by a strong dose are more
easily recovered than those which have been gradually narcotized even by a
•mall percentage of the anaesthetic.

1864.J REPORT ON THE ACTIONS OF CHLOROFORM. 187

Rules rdaUng to Ae AdnUmgiratum of Chhroform.

The anaofithetic should on no accoant be given carelessly, or by the inex-
perienced; and when complete insensibility is desired, the attention of its
administrator should be exclusively confinea to the duty he has undertaken.

Under no circumstances is it desirable for a person to give chloroform to
himself.

It is not advisable to ^ve an anesthetic after a long fast, or soon after a
meal ; the best time for its administration being three or four hours after food
has been taken.

If the patient is much depressed, there is no objection to his taking a small
quantity of brandy, wine, or ammonia, before commencing the inhalation.

Provision for the free admission of air during the patient*s narcotism is abso-
lutely necessary.

The recumbent position of the patient is preferable ; the prone position is
inconvenient to the administrator, but entails no extra danger. In tne erect or
sitting posture there is danser from syncope. Sudden elevation or turning of
the body should be avoided.

An apparatus is not essential to safety if due care be taken in giving the
chloroform. Free admixture of air with the anesthetic is of the first importance,
and, guaranteeing this, any apparatus may be employed. If lint, or a handker-
chief, or a napkin Lb used, it should be folded as an open cone, or held an inch
or an inch and a half from the face.

The anaesthetic should invariably be given slowly. Sudden increase of the
strength of the anaesthetic is most dangerous. TKree and a half per cent, is
the average amount, and four and a halfper cent, with ninety-five and a half of
atmospheric air is the maximum of the anaesthetic which can be required.
Given cautiously at first, the ^uantit^, within this limit, should be slowly
increased accordmg to the necessities of'^tiie case, the administrator being guided
more by it^ effect on the patient than by the amount exhibited.

The administrator should watch the respiration of his patient, and should
keep one hand free for careful observation of the pulse.

The patient who appears likely to vomit whilst beginning to inhale the an-
SBSthetic should be at once brought fully under its influence, and the tendency
to sickness will then cease.

The occurrence during the administration of an ansesthetic of sudden pallor
or of sudden lividity of the patient^s countenance, or sudden failure or flicker-
ing of the pulse, or feeble or shallow respirations, indicates danger, and neces-
sitates immediate withdrawal of the anaesthetic until such symptoms have
disappeared. On the occurrence of these symptoms, and especially if they
should become so urgent as to threaten death from failure of respiration, of
heart-action, or of both together, the following rules of treatment are to be
observed : — Allow free access of fresh air ; puU forward the tongue, and clear
the month and fauces ; keep or place the patient recumbent ; dMh cold water
on the face and chest, and aid the respiratory movements by rhy^thmical com-
pression of the thorax. In the more threatening cases artificial respiration
must be commenced instantly ; and this rule applies equally in all cases, whether
the respiration has failed alone, or the pulse and respiration together. Gal-
vanism may be used in addition to artificial respiration, but the artificial
respiration is on no account to be delayed or suspended in order that galvanism
may be tried.

Few if any persons are unsusceptible of the influence of chloroform, from two
to ten minutes being required to induce anaesthesia. The time, however, varies
with age, temperament, and habits.

The mixture of chloroform, ether, and alcohol should be given in the same
way as chloroform alone ; care being taken, when lint or a handkerchief is used,
to prevent the too free escape of the vapour.

Use of Chloroform in Surgical OperatUme.
With heart disease the anaesthetic may be given in any case which requires

188 MEDICAL NEWS. [AUG.

an operation, although when there iseyidence of a fatty, weak, or dilated heart,
great caution is demanded. Valvular disease is of less importance.

In phthisis, when an operation is unavoidable, the anaesthetic may be given
with impunity.

For all operations upon the jaws and teeth, the lips, cheeks, and tongue, the
anaesthetic may be inhaled with ordinary safety. By care and good manage-
ment the patient may be kept under its influence to the completion of the
operation. In these cases, mood, as it escapes, if not voided by the mouth,
passes into the pharynx. If any small quantity finds its way through the
urynx, it is readily expelled by coughing. In operations upon the soft palate,
fauces, pharynx, and posterior nares, if sudden or severe hsemorrhage is likely
to occur, it IS not advisable to induce deep insensibility.

In cases requiring laryngotomy and tracheotomy the ansssthetic may be em-
ployed with safety and advanta^.

For operations upon the e}re, involving the contents of the ^lobe, the use of
annsthetics is open to objection on account of the damage which the eye ma^
sustain from muscular straining or vomiting. If employed, profound insensi-
bility should be mduced.

In operations for hernia, and in the application of the taxb, the ansesthetic
acts most beneficially. For most operations about the anus profound anaesthesia
is positively demanded.

In the condition of shock, or of great depression, aa after haemorrhage, care-
ful administration of the anaesthetic diminishes the risk of an operation.

In all cases, other than those specially referred to, it is sufficient to state, so
far as a mere surgical operation is concerned, that an anaesthetic may invariably
be administered.

The continuous vomiting occasionally induced by and foUowin^ upon the
inhalation of anaesthetics, may be injurious by consequent exhaustion, as well
as by mechanically disturbing the repair of a wound. With this reservation,
they do not appear to interfere with the recovery of patients from surgical
operations.

Statigtie8,—'The results of 2586 capital operations performed before, and of
1860 performed since, the introduction of anaesthetics, collected from aXL
authentic available sources,^ prove that anaesthetics have in no degree increased
the rate of mortality.

Use of ChJorofarm in ObsUtric PtacUce.

(a) In Natural Labour, — ^The careful administration of chloroform during
labour is not attended with special danger, there beins, either in this country
or abroad, so far as is known to this committee, no well-authenticated instance
of sudden death where it has been given by a medical practitioner ; but the
occasional occurrence of un&vourable symptoms demands the exercise of cau-
tion during its employment. Administered in a moderate degree, it does not,
as a rule, weaken the expulsive powers, and is decidedly beneficiad in promoting
dilatation of the maternal passa^. It does not predispose to puerperal con-
vulsions or other like complications. The balance of opinion is nearly equal as
to whether it predisposes to imperfect contraction of the uterus after delivery.
As a rule, it in no way retards the convalescence of the mother ; nor has it any
tendency to interfere iinuriously with the function of hictation ; nor has it any
injurious influence on the child.

{b) In Abnormal Labour, — ^The anaesthetic may be employed with advantage
in various obstetrical operations — as forceps, turning, craniotomy, and extrac-
tion of retained placenta, — unless the patient is much enfeebled by haemorrhage ;
when, if given, it ought to be accompanied by the use of stimulants. It may
also be employed advantageously to check the paroxysms in puerperal con-
vulsions.

(c) At to the prtference of ether. Ruka relating to the administration of

1 Appendix D Co the Beport, p. 148.

1864.] BEPOBT ON THE ACTIONS OF CHLOROFORM. 189

cyor^/brm.— There are no reasons for giving preference to ether over chloro-
form, the latter being much more desirable in obstetrical practice generally,
the only exceptions being those in which chloroform notably disagrees.
In addition to those given for its administration in ordinary cases, it is

gmerally desirable to observe the following rules during its administration in
bour, subject to modifications at the discretion of the practitioner: — In
natural labour, b^in to give it generally at or after the termination of the first
stage ; but it may he given earlier if the first stage is unduly painful, or if the os
uteri resists dilatation. Give it only during the pains, and withdraw it in the
intervals. When the foetal head bears on the perineum, give it more freely to
promote relaxation and relieve the increased pain. Withdraw the chlorou>rm
unmediately after the child is ex^lled. If the patient is depressed or the
pains are sluggish during its admmistration, an occasional stimulant mav be
adroinbtered. In cases where it seems to interfere with the progress of laoour
it may be necessary to suspend its use for a time, and reappljr it after an
interval, or even to withdraw it altogether. In turning and instrumental
deliveries deep anaesthesia must be induced, as in surgical operations, and the
administration should then be intrusted to a competent person, whose sole
duty should be to attend to it. In midwifery a special inhsier for its adminis-
tration Lb not generally necessarv or desirable, a handkerchief or towel, so
folded as to prevent blistering of tne face and to allow free acimixture of atmos-
pheric air, being sufficient for the purpose.

(d) Uae of Chhrqfarm in Diaeatea of Women and Children, — ^In the treatment
of diseases of women, chloroform may be employed to facilitate and lessen the
pam of certain examinations. In cases of spurious pregnancy and phantom
tumours, by relaxing the abdominal parietes, it may assist in demonstrating
their true characters ; and, acting in the same wa^r, it may help the practitioner
to define more accurately the character and relations of other abdominal and
pelvic tumours, or to detect feigned disease.

As a therapeutic agent, its inhalation and external application in the form of
a liniment, may be usefiUly employed to allay pain in some cases of severe
dysmenorrhoea, neuralgia, and the like.

There is accumulated testimony in favour of cliloroform inhalation proving
serviceable in various spasmodic diseases of women and children ; as whooping-
cough complicated with convulsions, spasmodic croup, epileptic seizures, and
some other forms of convulsion in children ; hysterical convulsions, epilepsy,
and various muscular contractions in women.

The President expressed in warm terms the obligations the Society were
under to the committee for their able and laborious report.

Mr CurUng regretted that so much time had elapsed since the committee
had been formed. But, as would appear when the paper and the appendix
were published, much more work had been done than would be thought from
the part of the abstract which had been read. There had been a division of
labour into three chief departments : physiological, surgical, and obstetricaL
But the most work had been done by the first section — ^the physiological.
This section had had seventy meetings, and had performed very many careful
experiments. When all this was taken into consideration, the Fellows would
not be surprised that the report had been delayed. The committee wished to
acknowledge the support afforded by many Fellows of the Society and bv the
profession generally. Mr Curling said that he must allude more pointedly to
the labours of the reporters, Mr Sibley and Mr Callender. These gentlemen
had attended all the meetings of the committee, and it was, after hearing the
report, scarcely necessary to express any opinion as to the great zeal, devotion,
and intelligence they had displayed.

Dr Kicld said a great debt of gratitude was due to Mr Curling and the
Physiological Committee for their incessant labours ; yet he could not help
thinking the great chloroform question at present was, as to its safety or
use, a question of practical or empirical observation in hospitals rather than a
question of physiology. Nobody denied that very laige doses killed animals.

190 MEDICAL NEWS. [AUO

We had similar experiments in vast number in books, but the deaths in
practice in the human subject are from idiosyncrac^ (from which the lower
animals are free), from errors of administration, emotion, fright, in the convul-
sive or preliminary stage before deep anaesthesia at all, deaths from spasm of
the glottis, apnoea, almost always m trivial operations, like tooth-orawing,
rather than in the half-hour's deep narcotism of large operations. Physiolo-
gical experiments, such as dropping chloroform on the heart of a frog, or
throwing it into the peritoneum, are fallacious ; the experiment kills, but not the
cMoroform. Then, as to " mixtures " of anaesthetics, they have been used exten-
sivelv in Austria and France, even bv order of Government. The ether was
founa to be first inhaled, then the chloroform, and the spirit of wine remains
behind and has to be squeezed out : they tend towards mystery and are cum-
bersome. The best part of the report is as to the value of electro-magnetism
in resuscitation ; but it is an error that the little magnet-box is not accessible
in hospitals. It is equivalent to saying saving life is not important. The mid-
wifery portion of the report does not offer much that is new, and so of the
general sur^rv part ; but both are good. But as to the use of chloroform in
medicine it is aencient, as this agent is most valuable in asthma, pain of gall-
stones, tetanus, convulsions of children, whooping-cough, and a dozen other
affections. There is at surgical operations now less arterial but more vexlons
blood than formerly : even vomiting will fill a wound with blood (secondary).
Chloroform is safe m what is termed shock or collapse. This is the *' law of
tolerance " so well described bv Miller ; but sur^ons do not read of empirical
rules so much as physiological experiments. The speaker fully agreed as to
the CTeat value of artificial respiration in accidents, out that was best set up
by the electro-magnetism box, as now extensively tried. It is true also that
resuscitation is more difficult in ether accident cases than from chloroform.

Dr Hyde Salter said a point had been overlooked, but on which it was not
possible for the committee to have investigated in so short a time as they had
taken for their report. It was as to the effect on the human constitution of
chloroform administered for months or for vears. He offered this as a sugges-
tion for further investigation. Dr Salter then related the case of a gentleman
who for three years had taken chloroform nearly every night. The effects
were somewhat like those of alcohol : general loss of nervous power, insomnia,
and vomiting in the morning. The chloroform was taken for asthma, and
sometimes as much as three ounces were inhaled in one night. The effect waa
most distressing. The patient lost appetite, became morose, and was unable
to sleep. He tor one month was able to avoid it, and the improvement was
most marked. He got to sleep earlier and earlier every night. This, however,
the patient ascribed to Indian hemp which he took at the time; but on taking
the chloroform a^in, he again haa insomnia, and Indian hemp failed to help
him. The vomitmg in the morning was like that of drunkards. Dr Salter
considered that in other respects the effects would be found to resemble those
of alcohol.

Mr Savory asked under what circumstances and to what extent, in collapse
from injuries or from hsemorrha^, chloroform might be administered. It was
true that it would tend to diminish shock ; but it would, on the other hand, be
likely to render the pulse almost imperceptible. It was a point of great
interest that chloroform tended to reduce the temperature, even, as some
experiments showed, seven or eight degrees. In collapse, too, the temperature
was diminished ; and hence, if chloroform were given, there would be two con-
ditions tending to the same result.

Dr C, J. B. Williams said there could be but one opinion as to the great
debt the Societv owed to the committee— a debt which the Society was
scarcely able fully to appreciate until the publication of the report. One
important point was, however, settled : that chloroform depressed the action of
the heart. This was an important result, as it had been much disputed. It
accorded with the results of experiments he himself had performeo ; and the
histories of cases of death from chloroform all converged to the same point. This

1864.] REPORT ON THE ACTIONS OF CHLOROFORM. 191

in itself helped to suggest methods of coantemcting the effect of too Uirge a
dose. One obvious method was to add ether and alcohol to the chloroform.
Bat there was no reason why alcohol, ammonia, or any other stimulant, should
not be given by the mouth. O^gen had been su^ested, and had, it was said,
been xk^d in America with success : and it was not miprobable that chloroform
and oxygen might form a useful and safe combination. One class of anaes-
thetics Uid not been alluded to— namely, nitrous oxide. From his own obser-
▼ations some years ago, it appeared to be not so depressing, and it was safe. But
there were dmculties in procuring it, and in applying it. Dr Williams then
aJAuded to the effect of chloroform on the blood, and asked what researches the
committee had made in this part of the subject.

Dr Kidd observed that two deaths were published this year from nitrous
oxide used as an anesthetic, so that it is not nree from accident, as Dr Williams
might have supposed. As to the use of a little brandy or ammonia before
administration, the plan was a good one, and always adopted by himself. Then
as to the blood, it was perfectly known, from hundreds of experiments, that
chloroform does not disturb its character at all. But it was not so with ether ;
here the corpuscles are destroyed, and the ether was so dissolved in the blood
tliat it had l^en distilled over and over again from the blood of an animal
deeply narcotized by it. Crystals were of less moment in blood long drawn.
Forty-one deaths from ether had been publbhed in America, and nineteen by
Trousseau in France. It seemed paradoxical that chloroform administered in
small doses should be daneerous. But it was small doses which produced con-
vulsive vomiting ; and so death in hospitals began as a sort of spasm or con-
vulsive irritation of the fauces and glottis, while the patient was half conscious,
not in deep coma ; with a sort of reflex or tetanic rigidity of the respiratory
muscles ; the heart still beating actively, till overpowered or engorgea at the
right side. Hence the great value of artificial respiration. The breathing, in
fact, stopped ; and yet the patient did not inhale the large percentages given
to animals, the chloroform at boiling-point in balloons, etc. It seemed para-
doxical to deny physiological experiments, but we did not prevent glaucoma or
ague by physiology, but rather hy empirical rules ; so was it with regard to
chloroform and prevention of accidents. Oxypen, too, had been tried, but
found wanting: the blood was not deoxygenized, at least by chloroform.
Anesthesia was like hvbernation. The blood would not ti^e up pure oxygen.
In a case at a borough hospital where oxygen was accurately tried it proved
useless. There was a fear that students trusted too much to a complex appa-
ratus. They did not detect the danger early enough. To them " mixtures "
like those of the new Pharmacopoeia would be a sort of mitigation of danger, —
a kind of drag to the wheel of antesthetic progress. Nor did the heart first
stand still, as supposed by some ; it was a popmar error. While as to nitrous
oxide, and even ether, they were both now given up in America, where they
had been extensively administered.

Dr Wynn WiUiams recommended that in collapse from chloroform warm
port-wuie should be injected by an 0*Beime*s tuoe. He had tried this in
collapses from other causes, and had found it to act energetically. It seemed,
he thought, by increasing the warmth, and by giving a stimulant at the same
time, to meet Mr Savory"s remarks.

Dr Ballard objected to that part of the report in which the use of chloro-
form in the convulsion of children was recommended. He was satisfied that
it had no beneficial effect, and asked if its use had been recommended after a
trial in cases.

Mr Curling said it was not recommended that chloroform should be given
until reaction set in after injuries, but then it acted beneficially in the operation
by diminishing shock. In reply to Dr Ballard he said that the recommenda-
tions of the committee were based on a series of facts, and after a krge
experience.

Dr Barley said the action of chloroform on the corpuscles was but slight,
but if ether were added, it dissolved the walls of the corpuscles. It had been

192 MEDICAL NEWS. [aUG.

lone observed by Dr Jackson of New York, that chloroform produced formic
add in the ii;^stem ; but it was impossible to trace the changes. If blood were
shaken up with ether it would sometimes crystallize. Diseased blood would
also sometimes crystallize spontaneously, while blood after slow death from
chloroform, when shaken up with ether, always became like a mass of crystals.

(Dr UatUy then introduced to the notice of the Society an inhaler sent to
him by Dr Skinner of Liverpool, and also an ingenious apparatus, invented by
Dr Squire, for measuring accurately the percentage of chloroform.)

Dr Pearwn said he was surprised to hnd that chloroform was more feared
here than in Edinbursh, where it was invented. In Edinburgh apparatus was
altogether disregarded. He felt certain that it was safer to give chloroform
without an inhaler than with one.

Dr Hyde Salter said that chloroform mieht be given so as to prevent pain
and yet not produce insensibility ; for this he could vouch, as he had experi-
enced it himself. If, then, it could be discovered how to do this, it wouldT not
only lessen the risk, but would diminish the fear of the use of the drug.

Jjr Wright said that the inhaler had been used a year in Mr Spencer Wells*
ovariotomy operations, but it was liable to the objection that a good deal of the
chloroform escaped, and thus affected the bystanders.

Mr BirkeUy one of the honorary secretaries, said that it had been impossible
for him to read the whole of the ^stract, but he had only omitted those parts
which the reporters had agreed should be omitted. — The Lancet.

NOTE ON A CASE OP POISONING BY THE CALABAR BEAN

{Phywstigma Venenaaum).

By David Young, Medical Missionary Dispensary, Edinburgh.

Although the following case does not add much to what is already known
regarding the action of this poisonous bean, still, considering the limited num-
ber of cases that have been recorded touching its influence upon the natives of
this and other European countries, it may not be without interest. The facts
of the case are the following :— -

In the month of April last, a few of the beans came into the possession of a
cabinetmaker, who supposed them to be a peculiar kind of nuts. On the 13th
of June, three or four of them fell into the hands of two children, named David
Wales, aged six years, and James Greig, aged three years. At seven o'clock on
the evening of that day, both the children were observed by their parents to
be amusing themselves with the " nuts." About twenty minutes past seven
the children disappeared, and in twenty minutes from that time they both re-
turned to their respective homes, complaining of sickness. The mother of
James Greig sUtes, that at a quarter before eight o'clock her child entered the
house, his head drooping listlessly, his eyes sleepy-like, and his hands power-
less. On entering the room, he staggered against the door, and was scarcely
able to walk towards her. She took him upon her knee, and questioned him
as to the cause of his peculiar appearance. Her attention had been previously
drawn to the " nuts," which she suspected were poisonous ; and on asking the
child if he had eaten any of them, he confessed that he had. He complained
of severe pain in the epigastric region, made ineilectual efforts to vomit, and
begged that he might be laid upon his bed. He requested also to be allowed
to sleep, and drew up his legs, as if to relieve pain. When ho had been in the
house about fifteen minutes, half a pint of milk was given to him, which
he drank eagerly. In from five to ten minutes after the milk was swallowed,

186i.] NOTB OF A CASE OF POISONINQ BT THE CALABAB BEAK. 183

free vomiting enaoed, the vomited matter appearing to conaiat entirely of
curdled milk. The mother did not observe any pieces of the ** not^** hot she
did not examine carefully. The vomited matter was removed and thrown out.
Immediately after this the child was taken out of the house, for the benefit of
fresh air, but he cried to bo taken back to bed. At a quarter before nine, the
mother came to the Dispensary. A small dose of ipecacuan wine was ad-
ministered, which was repeated in fifteen minutes. In about ten minutes after
this the case was fint seen by me.

I found the child lying in bed, his pnpils were slightly contracted, his pulse
feeble and slow, and he appeared to be totally prostrated. As he had not
vomited after the administration of the ipecacuan wine, and as there was a
supply of this emetic at hand, I immediately gave him a small dessertspoonful
in Inke-warm water. This was followed, in fifteen minutes, by copious vomiting.
I carefully examined the vomited matters, and found four pieces of the *' nut "
which the child had eaten.

David Wales returned home at the same time as Greig. His father stated
that his eyes were " working,^* or, as his mother said, " as if the nerves were
upon him.^* He complained of severe pain in the umbilical region ; he looked
sleepy, Ustless, and depressed, and begged to be put to bed. In a few minutes
after he was Uid upon the bed, copious vomiting ensued. He was so feeble
as to be unable completely to eject the vomited matter, and a neighbour, on
putting her finger into his mouth, removed four or five pieces of the '* nut.'*
He then requested to be taken to the closetf but he could neither stand nor
walk, and when carried by his father and placed upon the seat, he required the
constant support of his arm. He was freely purged. At this stage I saw the
child, whose face was pale, his eyes heavy, and his pupils and pulse natural.

On the following day the children complained of sickness, and declined their
food. On the third day they were quite well.

Wales, when subsequently questioned, admitted that he had broken two of
the nuts by means of a poker; that each nut was broken into about five pieces ;
and that Greig and he had each eaten the broken fragments of one nut. He
did not chew the pieces, but swallowed them whole. When shown seven
similar mOs, and asked to select one of about the size of those he had broken,
he pointed to one an inch in length and half an inch in thickness, weighing
65 grains.

I secured a few of the beans, which, on being shown to Dr Burns Thomson
and other competent judges, were declared to be true specimens of the
Physostigroa venenosum or Calabar Bean.

The reason why the symptoms in these cases were not more fully developed,
and that they did not end fatally, considering the quantity of the poison taken,
is so be found in the circumstance that the beans were not finely divided, and
that they were ejected before they had been fully operated upon by the gastric
juice.

MEDICAL PRACTITIONERS IN MELBOURNE.

The Medical Register for 1864 is at last published, just five months after date.
It contains the names of those who, in answer to a circular issued by the Medical
Board, forwarded their names, addresseb, and qualifications. Of these there are
407 qualified, 6 transferred from the old register, and 7 certificated by the board,
as practising under sufferance. It therefore appears that, taking the population
of this colony at 500,000, there is one medical adviser t6 every 12M) persons.
VOL. X.— NO. II. 2 B

194

PUBLICATIONS AND PERIODICALS RECEIVED. [AUG. 1864.

In England there is one to every 1712 personn, a high numerical difference,
for or againdt this colony, as it may be considered. Many, however, have not
registered, thinking the act a failure, as it certainly in many ways is. It is,
however, most liberal, including all sorts of universities and pseudo-universities,
homoeo-quackish colleges, unqualified men, and men showing no stated qualifi-
cation, making the possession of a legal status one of very dubious honour.
There are also severau men registered, residents of neighbouring colonies, an un-
warranted stretch of the act. Of the class of qualifications it may be observed
that there is not one single M.D. of either London, Cambridge, Oxford, or
Dublin, holders of that degree invariably hailing from universities not granting
the de^ee of M.B. This proves what has often been affirmed relative to the
little likelihood of M.B.V returning for the full degree except when remaining
in practice in the immediate vicinity of their alma maier. In reckoning the
number of medical men those pests, counter prescribers, are not included, yet
most of them have nearly as much right to be there as many who have had
the privilege extended to them, and their pernicious influence perhaps not
greater. — Melbourne Medical and Surgical Review,

PUBLICATIONS RECEIVED.

Bell, — Practical Observations on Diphtheria

and Erysipelas. By Charles Bell, M.D.

London, 1864.
Braithwaite,— The Retrospect of Medicine.

By W. & J. Braithwaite, M.D. January

to Jane 1864. London.
Bimifitead,— The Pathology and Treatment

of Venereal DiHeases. By Freeman J.

Bamstead. New Edition. Philadelphia,

1864.
Comer, — Treatment of (Consumption. By

Matthew Corner, M.D. London, 1864.
Duncan, — V'ariations of the Fertility and

Fecundity of Women according to Age.

By J. Matthews Duncan, M.D. Edinburgh,

1864.
Hicks,— Combined External and Internal

Version. By J. B. Hicks, M.D., etc.

London, 1864.
Hodge, — The Principles and Practice of Ob-
stetrics. By Hugh L. Hodge, M.D. Phila-
delphia, 1864.
Jago, — Entoptics, with its uses in Physiology

and Medicine. By James Jago, M.D.

London, 1864.
Medical Officers of the Army, the Case of,

fairly stated. London, 1864.

M^decine et de Chirurgie pratif^nes, Nouveau
Dictionnaire de. Tome Premier : premi^
partie. Paris, 1864.

Peet, — The Principles and Practice of Medi-
cine, designed chiefly for Students of Indian
Medical Colleges, hy John Peet, M.D.
London and Bombay, 1864.

Pereira, — Selections rrom Physicians* Pre-
scriptions. By Jonatlian Pereira, M.D.
Fourteenth Edition. London, 1864.

Puraell,— Exanthematous Diseases : their
Rational Pathology and Successful Treat-
ment By John Pursell, M.D., etc. Lon-
don, 1864.

Ranking and Radcliffe,— Half- Yearly Ab-
stract of the Medical Sciences. Edited by
W. H. Ranking, M.D., and C. B. Radcliffe,
M.D. January to June 1864. London.

Sonnenkalb, — Anilin und Anilinfarben in
toxikologischer und medicinal polizeilioher
Beziehung. Yon ProC Dr Sonnenkalb.
l^ipzig, 1864.

Weekly Return of Births and Deaths in the
City of Dublin in 1864.

Williamsoo,— Thoughts on Insanity and its
Causes. By W. Wil.iamson. Second
Edition. London, 1864.

PERIODICALS RECEIVED.

American Journal of the Medical Sciences, —
April. PhiUideluhia, 1864.

Births, Deaths, ana Marriages, Monthly Re-
turns of, for May and June 1864.

British and Foreign Medico-Chirurgical Re-
view,— July. London, 1864.

British Medical Journal, — June 4, 11, 18,
25; July 2, 9, 16,23, 1864.

Bulletin (J^n^rale de Th^peutique, — June
15, 30, 1864.

Dublin Medical Press,— June 1, 8, 15, 22,
29; July 6, 13,20, 1864.

Gazette des Hopitanx,— Nos. 61 to 83. Paris,
1864.

Gazette Hebdomadaire de M^decine, etc. —
June 3, 10, 17, 24 ; J uly 1, 8, 15, 22. Paris,

" 1864.

Gazette M<Cdicale d'Orient, — April, May.
Constantinople, 1864.

Gazette M^dicale de Paris,— Nos. 22 to 30,

1864.
Glasgow Medical Jouma],~Jnly 1864.
Journal de M^ecine et de Chirurgie, —

June and July 1864.
Journal ftir Kinderkrankheiten,>-March and

April. Erlangen, 1864.
Journal of Mental Science,— J uly 1864.
Medical Times and Gazette,— June 4, 11, 18,

25; July 2, 9, 16, 23, 1864.
Ophthalmic Review,— No. 2. July 1864.
Revue de Th^rapeutique Mrdico-Chirur|^i-

cale, — June 1, 15: July 1, 15. Paris,

1864.
Vierteljahrschrift fiir die praktische Heil-

kunde,— Vol. 2. Prague, 1864.
Virchow's Arch iv,— Vol. 29. Berlin, 1864.
W Urzburger Medicinsche Zeitschrift, — Vol.

5: PartL 1864.

^avt iFtv0t

ORIGINAL COMMUNICATIONS.

Abticle I. — On the Treatment of AUmminuria in Children. By
Wm. H. Dickinson, M.D. Cantab., Asaistant-Physician to the
Hospital for Sick Children. London, and Curator of the Patho-
logical Museum, St George s Hospital.

Only one of the forms of disease which are known as the source of
albuminuria ever occurs in childhood.

The granular kidney is almost unknown before the age of twenty.
The only state of disease to which the substance of the kidney is
liable during childhood, is that which gives increase of bulk, with
a smooth mottled exterior. I need not repeat what has been else*
where urged, that the fundamental change in all such cases is an
inflammatory state of the tubules, in consequence of which they
become choked up by ap excess of their own epithelial growth.
The accumulation is favoured by the contortion of tne tubes. When
these channels are enabled to discharge their contents, the disease
will soon be at an end.

The mechanical obstruction of the tubes is the only event to be
feared. If the complaint proves fatal, it is in consequence of this
occurrence. It is this which interferes with the formation of urine,
occasions the accumulation of its components in the blood, and is
the source of all the evils to which ttie victims of the disease are
liable. It must be the aim of treatment to keep the tubes clear ;
this done^ the disorder will right itself. The increased vascularity
will subside when free secretion is possible ; and, if nothing is done
to keep up the irritation of the gland, the catarrh will soon be at
an end.

We must seek then to increase the quantity of fluid which washes
the tubes, without doing anything which can produce local irritation.
In short, we must pass as much toater as possible through the
organ. This fluid is necessarily devoid of irritating qualities. It
probably makes no demand upon the true secreting power of the
gland, but passes b^ filtration m>m the Malpighian bodies.

I have aaopted^ since the year 1860, a plan of treatment founded
upon these principles : and when appliecl to children, the results
have been such tnat 1 have determined to bring them before the
Profession.

VOL. X.— no. in. 2 c

196 DR DICKINSON ON THE TREATMENT OF [SEPT,

The tendency of medical observers to find success in methods of
treatment devised by themselves, is an influence probably more
constant in its operation than any remedy to which suffering
humanity is subjected. The consciousness of this source of error
has made me very cautious in drawing conclusions upon this ques-
tion, and has induced me to resort to what means I could of testing
the results.

The treatment of the disease in grown persons does not enter into
consideration here. The tardiness with which the adult kidneys
respond to stimuli, makes a modification of the svstem necessary.

With children the method has been mainly hydropathic. The
way it has been carried out, and the results which have been
attained, will appear from the following details.

Every case of albuminuria in children which I have had to treat
since October 1860, has been subjected to the same regimen,
though in some cases the dropsy was so great as to seem to prohibit
fluids. Notes have been kept of twenty-six cases, most of which
were severe. Many others, of less import, have come and gone
amonff out-patients, and left no record. All have been restricted to
a fluid diet, which nas been of a nutritious character. Besides this,
a certain quantity of spring water, varying firom two to four pints,
has been administered in the twenty-four hours. In three of the
cases no other remedy was used. In the remainder the action of
the water has been seconded by small doses of infusion of digitalis,
or more rarely of acetate of potass. Lastly, when the active
svmptoms have disappeared, iron has been given, either as sesqui-
chloride or acetate.

The results may be stated generally. Of the twenty-six cases
thus treated, twenty-two were known to have recovered and to have

fot rid of every trace of albumen. Three improved greatly, and
ad little evidence of disease excepting slightly albuminous urine,
when they ceased to attend the nospital and were lost sight of.
The remaining case ceased to be my patient, and, as I learned,
eventually died. Thus, out of twenty-six cases twenty-five are
believed to have recovered, which result is known to have been
completed in twenty-two. Many of the cases were of the greatest
severity, such that before the adoption of this system of treatment
no expectation would have been held of their recovery.

These results do not suffer by comparison with those attained by
other methods of treatment.

In the Hospital for Sick Children, I have been able to collect the
particulars of thirty-nine cases which were admitted as in-patients
oetween the years 1852 and 1861. Of these, twenty are known to
have recovered. Eleven died, while eight were more or less relieved.
The remedies for the most part were aperients and diaphoretics, the
latter including vapour baths and antimony. It must oe considered,
however, that from the inadequate size of this institution, none but
very severe cases can be admitted ; and, therefore, no equal com-

1864.] ALBUMINURIA IN CHILDREN. 197

pariBon can be made between these results and those derived from
more mixed cases.

Dr Miller, in his work on scarlatinal dropsy, states, that of
sixty-nine cases afforded by dispensary practice, eight died. His
treatment was that in vogne ten or fifteen years ago, by bleeding,
purging, and sweating.

It was fomid that with the cases under consideration the number
of days under treatment, before the patient was restored to apparent
health, varied from ninety-seven to four j the average of the whole
numb^ of cases being thirty. A certam time was then required
to get rid of the last traces of albumen. The recovery was thus
delayed to between 179 and seven days, giving an average of forty-
five days from the commencement of treatment to the total disap**
pearance of the albumen.

It was found that the use of the water when given under the
circumstances stated, never increased the dropsy, but the contrary.
It was usuid, however, when the oedema was excessive, to let the
digitalis set up a certain amount of diuresis before the full (]^uantity
of water was ordered. Many children take it eagerly, particularly
in the early stages of the disease. The urine was often observed to
undergo a notable increase in the quantity of renal epithelium which
it deposited, and the albumen usually quickly lessened in greater
proportion than fovld be explained by the increase in the quantity
of the urine.

It was supposed, in one or two cases, not under my own care,
that the treatment had a tendency to encoura^ haematuria ; and
although I have not observed this myself, yet it must be ailmitted
that such an occurrence is not unlikely. If the kidney be con-
gested the escape of blood is a natural means of relief. This
cannot take place if the tubules are obstructed through which the
blood must come. When, therefore, the plugs are washed out
it is conceivable that an evacuation should take place which before
was hindered.

The general use of iron during convalescence may be held to
weaken the argument in favour of the other measures adopted. It
may, however, be fairly presumed that it does not influence the
original disorder, though it corrects the anssmia which results from
it. As my object has been rather to benefit my patients than to make
neat experiments, I have departed from simplicity in this respect.

Brief notes of one or two cases may be given as examples.

Case I. — Eliza 8., fifteen years of age, was admitted into St
George's Hospital under the care of Dr Bence Jones, 10th Oct. 1860.
A fortnight previously she had caught cold from dabbling about a
street pump. The face and all the limbs swelled, and were much so
when she came under observation. The complexion was pallid.
She sat upright, with the shoulders supported by the arms : and it
appeared from auscultation that two thirds of each pleural cavity
were frill of fluid. The breathing was rapid. She coughed a good

198 DR DICKINSON ON THE TREATMENT OF [SEPT.

deal, and spat np broncliial mucus. She complained of pain in the
loins, and micturition was frequent The urine was bloody and
highly albuminous. Specific gravity 1019. The use of the
microscope showed that it contained abundant pus cells, but no
casts. The only treatment adopted was the admmistration of four
pints of distilled water daily. By the 4th of November the albumen
was reduced to a mere trace, and the colour of the urine was natural,
excepting that it was less bright than usual. All the superficial
dropsy had gone, and the pleural cavities gave evidence of dimin-
ished distention. But two days later she was unwisely permitted
to go into the garden, and blood re-appeared in the urine. Coarse
granular casts were now discovered, which consisted of broken-down
epithelium. The relapse, however, was temporary, and by the
end of the month she was practically well. The albumen was so
diminished that its existence became a question. On the 10th of
December, she was in perfect health. The face was rosy, the pleursB
fully resonant, the appetite great, and the urine absolutely natural.
She now left the hospital, but returned to show herself occasionally.
She remained in perfect nealth.

Case II. — George T., three years of age, had an attack of scarlet
fever which was followed within three weeks by swelling of the
face, legs, scrotum, and belly. Diarrhoea came on, and the swelling
subsided. The bowels remained loose after the swelling had
entirely disappeared. He then had vomiting, which was frequent
through the whole of one night, and in the morning three well-
markedepileptic fits occurred in succession. He was now brought
to the Hospital for Sick Children, and came under my care as an
out-patient. He was visited at his own home. He was extremely
pallid, but there was no trace of dropsv. The head was hot, the
tongue coated, the pulse rapid — 160. The urine was scanty, it was
the colour of dark sherry, and when boiled the clot of albumen
occupied half the bulk of the fluid. He was ordered to live entirely
on slops, to drink two pints of spring water in the day. and to take
as medicine a drachm of the infosion of digitalis, with naif a minim
of laudanum three times a-day. He had no more fits. The urine
increased in quantity, and gave a copious deposit of epithelium and
epithelial casts. Three days later all chance of head symptoms
appeared to have passed away, and the tincture of sesquichlonde of
iron was ordered in the place of the opium. Next day the albumen
was reduced to a hardly perceptible trace, and on no subsequent
examination could any be discovered. Within a fortnight of his
coming to the hospital he was in perfect health.

This example iUustrates the treatment adopted on the occurrence
of cerebral complications. Cupping, purging, and blistering are
believed to have disastrous effects. An ans&mic state of brain,
of which dilatation of the pupil is a sign, is constantly founa
after death from anssmic convulsions ; and such measures as these
appear likely to increase the condition. Opium, on the other hand.

1864.] ALBUMINUEIA IN CHILDREK. 199

is its direct antagonist. It fills, instead of empMng, the cerebral
vessels. It here seems to have been used saocessnilly as an adjunct
to means more directly bearing upon the renal affection. Experience
shows that convulsive attacks are peculiarly a|)t to come on after
the exhaustion of diarrhoea or vomiting, by which the cerebral and
other vessels are drained of their contents.

The same measures which succeeded in this case have been used
in others with the same result

Case 111. — Edward L., six years of age, became an in-patient at
the Children's Hospital, 11th September 1862. In the absence of
Dr Hillier he fell to mv charge. A month previously he had had
the rash of scarlatina, but the disease was slight, and in eight days
he was going about as usual. Four days before his admission his
face swelled slightly, and his urine was observed to be scanty.
When seen the oedema was excessive over the whole surface, and
the skin had a transparent waxy appearance. The albumen was
not large in amount, but the urine was very scanty. The child was
depressed, the tongue coated, and the case apparently one of great
severity. He was ordered to be fed upon fluios, including plenty of
broth, to drink three pints of water in the day, and to take a drachm
of the infusion of digitalis eveiy four hours. Next day he was
attacked with pain in the side, and a friction sound was heard over
the lower part of the left pleura. No change, however, was made
in the treatment, except that two leeches were put upon the place.
The pleurisy passed away without the effusion of fluid, the urine
became more copious, and the dropsy slowly diminished. On the
17th, it was necessary to stop the digitalis in consequence of faint*
ness. The oedema now was scarcety perceptible. A mixture of
the acetates of iron and potass, in the proportion of two grains to
ten, was given three times a-daj, and under its use all the remains
of oedema disappeared, the child's aspect became ruddy, and all
traces of albumen vanished. When he left the hospital, on the 17th
of October, he was in perfect health, and could not nave been recog-
nised as the same child who had been admitted a few weeks before.

This case is brought forward in conseq^uence of the intercurrence
of an acute inflammatory attack, and its subsidence under local
measures, the treatment of the urinary disorder going on at the
same time.

In conclusion, I must express my thanks to Dr Bence Jones, Dr
Pa^, and Dr Fuller, who have allowed me to test upon some of
their patients in St George's Hospital the principles which I have
here advocated;^ and I must also thank my colleagues at the
Children's Hospital for allowing me unrestrained use of their clini-
cal note-books.

200 DE C. MACLAGAN ON THE ABSENIC-EATEB8 OF STYBIA. [SEPT.

Article IL — On the Arsemo-EcUers of Styrta. By Cbaiq Mac-
LAQAK, M.D., Edinburgh.

{Bead before the Medico- ChinargicaL Sockty, ^ July 1864.)

In tbe Bpring of this year, at the conclusion of a short residence in
Vienna, I resolved to visit Italy, and finding that my route led me
through Styria, I thought it might be interesting to endeavour, by
personal inquiry, to gain some information as to the reputed arsenic-
eaters of that country ; and as my travelling companion, Dr Joseph
Butter of London, was also professionally interested in the question
of their existence, we determined to make a short stay at Gratz,
the capital of the duchy, and thence to make any excursions into
the country, which the knowledge I might acquire should point
out as necessary.

My object in the present paper is succinctly to narrate what I
learned by actual observation ; but before doing so I may be per-
mitted to glance rapidly at the existing condition of our information
on the subject.

Althougn medico-legal observations on this practice had already
been made so early as between 1817 and 1820 (Professor Schall-
gruber, MedidfinJahrlmch dea Oestreich. StaateSj 1822) in Gratz,
the first time that any great interest was manifested in Britain on
the subject seems to have been when a paper by Dr Von Tschudi.
which had originally been published in one of the Viennese medical
journals {Wiener Medicinische Wochenschrijij October 11, 1851),
appeared in an English dress, and found its way into many of the
popular as well as scientific publications of the time, including
Chambers's Journal, and the late Professor Johnston of Durham's
Chemistry of Common Life.

The embellishments which Von Tschudi's narrative received from
other writers, as well as the apparently incredible natiire of the
original statement, caused it to become a subject of much discussion.
The general opinion of scientific men in this country was, that the
statements of Von Tschudi were not worthy of beliei, and this view
of the subject was specially maintained by Mr Kesteven of London,
in a series of papers which appeared in the Association Medical
Journal for 1856, in which he quotes the opinions of the most
celebrated toxicologists of the time, in confirmation of his own dis-
belief in the practice.

Careful inquiry, however, was set on foot by other scientific men,
both British and Austrian. Mr Heisch, of the Middlesex Hospital,
having put himself in communication with persons living in the
districts where the practice existed, was enabled to quote several
very interesting cases, which were very thoroughly authenticated
{Pharmaceiitical Journal^ 1859-60, p. 656), and Dr Von Vest, the
Landesmedicinalrath for Styria, residing in Gratz, having issued a

1864.] DB C. MACLAGAN ON THE ABSENIC-EATEBS OF 8TTKIA. 201

circular to the medical men in bifi diBtrict, asking for information
on the subject, was enabled also to arrive at tolerably satisfactory
proof of the existence of the custom. The most interesting example
of it was communicated to him by Dr Knappe, then residing at
Oberzeiring, in Upper Styria, who had persuaded an ^^ arsenikophar
gite" to come ana uve imder his observation for a few days, and who
not only was thus enabled to see the man take his dose, but was
enabled to transmit to Dr Schafer, a practical chemist in the Styriau
capital, a specimen of the urine passed after the ingestion of the
Srag. and which was proved to contain it.

The facts ascertained by Knappe were made known in Britain,
by a paper by Dr Roscoe, read to the Manchester Philosophical
Society, and published in the Mechanics' Magazine ; and the ex-
istence of the practice has been admitted by some scientific men
who have written since the date of Boscoe's paper. Dr Guy
{Foreimc Medicine^ 2d Edit, p. 368) admits that Roscoe has
brought forward "conclusive evidence" of the fact: but from its
being denounced as incredible in most of our standara works which
have occasion to treat of the subject, such as those of Taylor and
Pereira, and from its havixig been strongly denied in some important
criminal trials, as by Dr Christison in the case of Wooler (Edifin
burgh Monthly Journal^ 1855-56, pp. 709, 710) ; whilst Boscoe's
valuable paper appears not to be sufficiently known, it seems to be
the general belief in this country that there is no foundation in
fact for the alleged arsenic-eating in S^rria.

What seemed to result from the inquiries of Von Tschudi, Knappe^
and Heisch, was this : —

I. That in various parts of Styria and the adjoining countries
oertain individuals were in the habit of swallowing daily, or twice or
thrice a-week, or at longer intervals, a certain quantity of a mineral
substance, called " HiUtereich^''^ for various purposes, such as the
improvement of the appearance, the rendering more easy the res*
piration during mountam climbing, as a condiment, as a tonic and
stimulant, as a prophylactic against disease, and as a preservative
of health ; and tbat this so called Hiittereich yras arsenic

II. That these individuals became, through custom, capable of
taking doses of arsenic vaiying from one grain to several grains
daily.

IIL That its more immediate effect on the system was to make
them lively, combative, and of strong sexual desire. This latter
physiological effect may perhaps be held to be indirectly proved by
the inordinate number of illegitimate children in some of these
places, the proportion sometimes rising nearly as high as 60 per
cent, of the total births.

1 I use the spelling adopted by Dr Macher in his Medizinisch-statistische
Topografie Steiermarks. Althongh the pronunciation of the Styrians makes it
Htttrach, it is obvious that the word really is Htltten-rauch, — ^literally, Fomace
smoke or vapour.

202 DR 0. MACLAGAN ON THE ARSENIO-EATERS OF STYEIA. [SEPT.

Against all this was to be placed —

I. The experience of medical men in other countries, who have
found that by the continued use of arsenic as a drug, even in frac-
tional parts of a grain, certain consequences arose directly contrary
to those experienced by the partakers of it in Styria.

II. The want of proof by analysis that the substance said to be
taken was really arsenic ; the absence of any chemical examination
of the excretions of an arsenic-eater, so as to prove that arsenic
really had been swallowed : the want of any account of its effects
when first begun to be used ; or of any information as to the origin
of the custom.

Most of these objections, however^ have been removed by the
investigations of Drs Knappe and Heisch, to the former of whom I
am indebted for much interesting information on the subject.

It is not at all surprising that in other countries there should be
a prevalent impression of the non-existence of this practice in Styria,
seeing that in Austria itself those who have not made special
inquiries on the subject are generally sceptical as to it. Any one,
therefore, passing through Austria and making casual inquiries,
would most likely be told that the practice of arsenic-eating was
not generallv known or believed in. It is not difficult to account
for this. Tne people who e^t arsenic have the idea that it is re-
garded as a bad habit, and therefore one to be concealed as much
as possible, just like opium-eating in this country ; and they have
the additional reason for concealing the practice, that from the
strictness of the laws regarding the sale of poisons, they cannot get
the arsenic by open purchase, as the opium-eater in this country
can get his laudanum, and therefore they are generally obliged to
purchase it from illicit dealers.

I now proceed to narrate what I have myself ascertained by per-
sonal observation. Though without an introduction to him, I
called on the Medicinalrath, Dr Von Vest, who, on learning the
object of mv visit, with ^at courtesy put at my command any
papers that his office contamed, and, in addition, supplied me with
mtroductions to Drs JKjiappe, Macher, and Tingler, the two former
of whom I was fortimate enough to see, but I was unable to spare
time to see Dr Tingler.

Dr Macher, now resident at Stainz, who is thoroughly acquainted
with all the medical matters of Styria, and whose experience during
a long period of active professional work there, makes his opinion
of no small value, informed me, that, although cognizant of the ex-
istence of the practice, he had little personal experience in the
matter. He related to me^ however, one case, in which a woman,
who had been tried for poisoning her husband with arsenic, had
been acquitted, from " want of evidence," the plea for the defence
being that the man had been an arsenic-eater. Though this
defence was generally believed to be false, it shows, at all events,
that the practice has in a court of justice been admitted to exist.

1864.] DR C. MACLAQAN ON THE ABSENIC-EATERS OF STTRIA, 203

and has served; in at least one instance, as a successful ground of
defence.

Dr Enappe of Lie^t, in Middle Styria, an hour's journey from
Gratz, was mj next informant ; and when I first spoke with him of
the case of J. W., already alluded to as the subject of experiment,
and whose urine had been examined by Dr Schafer, he described
him as a small, strongly-built man. with a great muscular develop-
ment, a woodcutter by trade, who nad taken the drug for a period
of twelve years. Dr Knappe further stated to me that while per-
sonally ignorant of the actual existence of an arsenic-eater in the
neighbourhood, he could go with me to Upper Styria, and show
me the above man, but he suggested that we should first make
inquiiy in the village, whether or not any of those persons described
to nim as indulging in the habit could not be got to take a portion
of it before me. I accordingly slept in Liegist that night, and next
morning I had the satisfaction, in presence of Dr Knappe and my
companion Dr Butter, of having my first interview with an arsenic-
eater.

Case I. — ^Mathias Schober, a healthy-looking, firesh-complexioned,
fairly muscular young man of the ag^ of 26 years, and about 5 feet
9 inches in height, a native of Liegist, and employed as a house-
servant there, said he had taken hiittereich for about a year and a
half, not, however, white arsenic, but the yellow arsenic or orpiment,
of which he took a specimen from his pocket and showed it me.
Of this I retained a piece for chemical investigation. He informed
me that he took the arsenic in order to keep strong, though he had
never suffered from ill health. He said he never had experienced
any bad efiects even when he first began usin^ it, that he had at
first taken rather less than a grain every fortnignt, that he now took
it twice a-week, and that on omitting to take it for any longer
period, he experienced a longing for it, which was relieved by a
repetition of tne usual dose. His reason for taking the orpiment
instead of the white arsenic was, that it was more easily procured ;
but having professed himself quite indifferent whether it were
arsenious acia or the sulphuret, Dr Knappe produced a paper con-
taining the former (of which I also kept a sample), and having
asked him to choose out a piece such as he was in the habit of
taking, it was weighed and found to be nearly five grains ; we had
no finer weight than one grain, but the piece of arsenic was much
over four, though less than five. Dr Knappe having carefully
ground this to powder on a clean piece of paper, it was transferred
to a small piece of plain white bread, about as large as a man's
thumbnail, and this the doctor put into his mouth ; Schober chewed
it and swallowed it, and then swallowed another portion of bread
the same size immediately after. This was at 9*30 a.m. He
stayed with us a few minutes, but he had to return to his work,
promising, however, to come back in a short while. This he did at
11*30, two hours after, and made water in my presence to the amount
VOL. X.— NO. m. 2d

204 DE C. MACLAQAN ON THE ABSENIC-EATEE8 OF STYRIA. [SEPT.

of what I estimated at twenty-eight ounces, into a vessel previously
carefiiUy cleaned, and the urine was put into bottles thoroughly
washed by myself. Unfortunately, in the hurry of my departure,
in trying to pack these bottles into my hat-box, I broke one, and
thus lost part of the urine. Since my arrival in this country, I
subjected the contents of the two remaining bottles to chemical
analysis, adopting the distillation process of Dr Taylor as the most
convenient way of separating arsenic from the organic matters of the
urine. For this purpose the urine was carefully evaporated to dry-
ness in a clean retort; the nearly dry residue was covered with
strong hydrochloric acid, and distilled into a well-cooled receiver.
The product, amounting to about half an ounce, was a clear, feeblv
pinkish fluid, thirty minmis of which, when treated both by Beinsch a
and Marsh's process, gave very characteristic arsenical deposits.

Schober also came the following dav to see me, having taken no
more arsenic since the dose which he had swallowed before me
twenty-six hours previously. I again secured some urine which he
passed in my presence, and this, when chemically examined as
above, also yielded arsenic freely.

Case II. — Joseph Flecker, at. 46, a muscular, healthy-looking,
dear-complexioned man, a tailor by occupation, told us tnat he hs^
taken hiittereich, generally the orpiment, for a period of fifteen
years. He first began to do so, on tne occasion of tne inhabitants of
a house, in the neighbourhood where he lived, being attacked with
fever; and when fourteen people had died in it, ana no one would
enter the premises, he determined to do so, and took, as a pro*
phylactic, about one grain of arsenic daily for three successive days,
while going to the infected house, and though he said he had not
felt quite well at the time, he was unable now to describe specially
what had ailed him ; but on being asked if he had ever suffeim from
vomiting or irritation in the stomach, he said he never had.

The day before my interview with him, he twice, viz., at 10*30
and 3 o'clock, had, in the presence of several of the villagers of
Liegist, and on one of those occasions in presence of the bur^r-
meister, who informed me that he had seen nim do it, taken a piece
of the sulphuret of arsenic from his pocket, and scraped ofi* a certain
quantity of it on a piece of bread and eaten it. He brought with
him a small bottle of^his urine, which he stated to have been passed
eighteen hours after the last oi the two doses, and in which 1 have
since found a considerable quantity of arsenic. The reason which
he assigned for this public exhibition of his arsenic-eating capacities
was, that it had become the subject of conversation in tne village,
that two strangers had come a very considerable distance to witness
an example of arsenic-eating, and inquire into the practice, and that
he wished to make open demonstration of his assertion that he waa
capable of tolerating a considerable dose of arsenic. When he first
came to me, he seemed somewhat unwilling to take a dose that day,
owing to his previous performance, and seemed to fancy it possible

1864.] DR C. MACLAQAN ON THE ABSEKIO-EATERfl OF STYRIA. 205

that he might have some slight irritation of the stomach, such as a ^
feeling of warmth accompanied bj thirst He did not appear to BST*
able to give any reason tor anticipating this result ; perhaps he il^4-
tended it as a sentle hint that the thirst might require assuaging ;
at all events, having been informed that he shoiud not want the
wherewithal to quench it — (he confessed to being by no means
abstemious in the matter of alcoholic potations), he, to satisfy our
curiosity, picked out a piece of arsenious acid, from the same parcel
that had been shown to Schober, and which, on being weighed,
was found to be as nearly as possible six ^ains. This he placed
entire on a small piece of bread, and tuing it into his mouth,
crunched it up audibly, and in about two minutes after swallowed
six or seven oimces of cold water, stating that he liked to drink
immediately after swallowing a dose, ana on such occasions pre-
ferred water. I then made him open his mouth and inspected it
narrowly, but found it quite clear of bread crumbs or anything else,
thus assuring myself that no jugglery could have been practised.
Aftier having swallowed the arsenic four minutes, he enictated
slightly, but till he left us, a Quarter of an hour after, he had no
symptoms of any bad effect. The six grains were taken at 11*30,
and at 12'15 he returned, and passed a small quantity of light-
coloured urine. Nearly the whole of this was bottled for exporta-
tion, and the twelve ounces thus secured were treated by the
process of distillation above described, and also yielded a charac-
teristic deposit of arsenic

Flecker gave me the following account of his use of arsenic. He
stated that he generally takes about the quantity we saw him
swallow once a-week, but with variations in the intervals, there
being sometimes four days only, sometimes eight days between the,
doses. That when he has a distance to walk to his work, he takes
a larger dose, and is then in good spirits for about eight da;^s.
That if he, however, intermits it for fourteen davs, he feels stiff
in the feet, with general lassitude and a craving ror another dose.
If his victuals are hard of digestion, he takes a dose to assist the
stomach, and if he takes a rather ftiU dose, he brings a good
deal of wind off his stomach, but never vomits. He stated that his
father had taken arsenic beiore him, and in considerable quantity,
and that .in the immediate neighbourhood of Liegist numbers use it.
several taking it daily, and many in larger doses than he. He said
that all who take it are healthy, — that he never knew of any one
vomiting from its use, and he believed that, like the use of tobacco,
if the dose is veiy gradually diminished, an arsenic-eater can break
himself of the habit. *

One of the objections which has been made to the acknowledg-
ment of the reality of arsenic-eating is, that the substance swallowed
has not been ascertained by chemical examination really to be
arsenic. This link in the chain of evidence, I am able to supply.
The white substance which I saw Schober and Flecker swallow,

206 DR C. MACLAQAN ON THE ARSENIC-EATERS OF STYRIA. [SEPT.

fart of which I have now in my possession, is pure arsenious acid,
t sublimes into octohedral crystals, and leaves no appreciable
residue. The yellow substance which Schober used is a fair sample
of the orpiment of commerce, and contains, as that substance usually
does, a considerable proportion of free arsenious acid.

I am, of course, not m a position to give any opinion as to the
extent to which arsenic-eating prevails in Styria, — my time would
not have permitted me to enter upon such an inquiry, nor would it
be easy to get satisfactory information as to a practice which is
generally kept secret ; confirmation of the fact of its existence is
more interestmg to us scientifically than its extent ; and that it is a
fact, my personal observation enables me confidently to affirm.
That arsenic-eating is in Styria a universal habit, or one indulged
in by even a majority of the male peasantry, I do not for a moment
suppose ; but the averment " that the story of the Styrian arsenic-
eaters is not only unsupported by adequate testimony, but is
inconsistent, improbable, and utterly incredible " (Kesteven, Asn.
Med. Journal^ 1856, p. 811) ; or that these are " absurd and ex-
aggerated statements, utterly inconsistent with all that is known
concerning the action of arsenic in this or other countries, and but
for the fact that they for a time received the literary support of
Professor Johnston, and were diflused by him in an amusing book,
they would not have required any serious reftitation " (Taylor, On
Poisons, 2d Ed., p. 92) ; or that it is a " mess of absurdity," " a
pure fable," (Christison, JEdtn. Med. Journal^ 1855-56, pp. 709, 710),
are, although justified by the state of knowledge at the time they
were made, no longer tenable ; but, on the contrary, we can no
longer doubt, to use nearly the words of Boscoe, " that decisive
evidence has been brought forward not only to prove that arsenic is
well known and widely distributed in Styria, but that it is likewise
regularly eaten in quantities usually considered sufficient to cause
immediate death."

It is probable that many of the physiological actions attributed to
it are fanciful, and that its use is mixed up with a good deal of
superstition, as, for example, in the case of tne poacher who takes
it to give him courage to pursue his depredations on ground that is
new to him, or that of the ostler who, m giving it to his horses to
improve their coats, thinks that it will have no beneficial efiect
unless he partakes of it at the same time.

It is evident that the confirmation of the existence of the practice
of arsenic-eating must lead us to modify some of the opinions that
are entertained with regard to the influence of habit on the action
of poisons. It has long been notorious, that by habit the human
boay may be brought to bear with impunity doses of organic poisons,
such as opium, which, to those unaccustomed to them, would
certainly prove fatal; but "it has hitherto been considered by
toxicologists that, except within very narrow limits, habit appears
to exercise no influence on the action of mineral poisons" (Taylor^

1864.] DR G. MACLAGAN ON THE ABS£NIC*EAT£B8 OF 8TYKIA. 207

On Poisons^ p. 89). Though the experiments of M. Flandin. by
which he proved that he could brin^ dogs to bear doses of fifteen
grains of arsenious acid in powder m twentj-four hours without
injury to their appetite or health; and the practice of administering
arsenic to horses, nave long been known as pointing rather in the
contrary direction, this has been supposed to be due to some
peculiarity in the constitution of the lower animals. The facts
which have been ascertained with regard to the Styrian arsenic-
eaters, and which the above observations confirm, entitle us to
maintain that the modifying effect of habit is not confined to organic
poisons, but extends to those of mineral nature, at all events to
arsenic.

28 Heriot Row, Edimbubgh, T^th June 1864.

Article III. — On the Wire Compress as a Substitute jor the
Ligature. By John Dix, M.K.C.S., L.S.A., Surgeon to the
Hull and Sculcoates Dispensary, etc., late Assistant-Surgeon
British Civil Hospital, Benkioi.

About five years ago, Dr Simpson of Edinburgh proposed to the
surgical world the use of needles instead of ligatures, as a means of
arresting the bleeding firom wounded arteries; which method he
called "acupressure.'^ Coming from such a source, it naturally
attracted some attention, and was soon pretty extensively tested by
various surgeons — mostly provincials. It was found to be prac-
ticable, effectual, and safe, and bv some it was supposed to possess
considerable advantages. By others, chiefly, I believe, those who
had not tried it, it was sneered at ana almost abused.

It cannot be said to have made much way in the world. A few
surgeons still continue to employ it — some have given it up. A large
majority have never tested it at all, especially in London, where,
so lar as I know, scarcely any operator of note has adopted it.

It does not clearly appear in what respect acupressure has disap-
pointed those who have used it — there are as jtt no published
opinions on the point, — ^but it is a noticeable, and rather encourag-
ing circumstance, that at a debate at the Medico-Chirurgical Society
of Edinburgh, where the subject was lately introduced by Dr
Handyside, the opposition consisted altogether and entirely of non-
experts, whilst all who had tried it spoke in its praise.

For myself, I early made trial of the needles. My case — an
amputation of the arm — is published in detail in the Medical Times
and Gazette of 2d June 1860. As there related, I was to a certain
extent pleased with the process ; but I also observed in it certain
inherent disadvantages.

208 MB DIX ON THE WIRE G0MPRE8S [SEFT.

Most, or all of these, as it seemed to me, might be obviated by
the use of a fine iron or silver wire instead of the steel needles, the
principle of action being the same, and the mode of application not
dissimilar.

So soon as opportunity offered, I put this idea to the proof. The
results are the subject-matter of this paper.

Having satisfied myself of its feasibility by some experiments on
the dead, I first used the wire on a living subject in a case of
amputation of a finger, in September 1860.

The patient was a woman, aged 50 years, affected with consti-
tutional syphilis, the second finger of whose right hand required
removal on account of caries. The head of the metacarpal bone
was covered over by a single flap, taken from the internal lateral
aspect of the finger. Two arteries were secured by compression — a
fine silver wire being used for that purpose. These wires were
removed on the third day. There was no bleeding, and the wound
healed readily, though not absolutely without suppuration.

Encouraged by this success, and convinced of its safety, I next
used the " wire compress " — ^as I proDose to designate this method
— ^in the same patient, upon whom Cfhopart's amputation was per-
formed (April 26, 1861), for extensive disease of the cuneiform and
adjoining metatarsal bones.

The operation was done in the usual way — a long flap beinff cut
firom the sole of the foot. Five bleeding arteries were secured by
silver wire, in the way about to be described. The flap was care-
fully adjusted, with many sutures of iron wire, and from the ap-
pearance of tne stump, the universal verdict of bystanders was,
" that seems a great improvement on the needles."

On the 28th, viz., forty-eight hours after, four of the wires were
withdrawn without diflSculty and without bleeding; and on the
30th, or fourth day, the remaining wire, which commanded the
posterior tibial artery, was in like manner removed. It was found
that the wire was easily applied, as easily taken away, and entirely
effectual for the purpose it was intended to serve, viz., the arrest
of the bleeding firom the cut vessels.

The patient, as I have before explained, was the subject of con-
stitutional disease, and the case did badly fi*om the first. There
was sloughing-of the entire surface of the wound, and this process
gradually involved the substance of the flap, which was ultimately
almost entirely destroyed.

This was an unfortunate thin^ for the patient, and not very
satisfactory to the surgeon ; but it was certainly advantageous to
science, inasmuch as it put this method of secunng arteries to the
severest possible test, and also gave me an opportunity of observing
the process and its effects more closely and accurately than would
otherwise have been possible.

So soon as the sloughing action set in, the sutures were removed,
and the flap opened out, and thoroughly cleaned by gentle washing.

18e4.] AS A SUBSTITUTE FOR THE LIGATURE. 209

Thus it happens that I am in a position to speak positively about
the action of the wire compress upon the arteries so treated. It
was found then that the continuity of the vessel was not destroyed
where it was compressed by the wire ; it was not divided, nor was
its terminal portion cut through as by the ligature. The patulous
end was securely sealed and closed, instead of sloughing away, as
necessarily happened when a silken thread was &stened there-
upon, which could only be got rid of by destruction of the tissue
upon which it was fixed.

Nor can anything more clearly prove the firmness and security
of the adhesion, which this process excites in the vessel itself.
Eveiy surgeon knows how common is secondary hsemorrhage in a
sloughing stump, and understands the reason why. I certainly
expected it in this case. I think I have observed before, in cases
of hospital and other forms of gangrene, that an artery is by no
means the first tissue to slough, its tough and well-nourished
coats often resist the destructive process longer than surrounding
textures, and the length of time required for a ligature to become
detached firom a lar^ artery, confirms this view.

But however this may be, it is certain that in this case the
divided ends of the arteries exhibited healthy granulation, whilst
other tissues were sloughing around. I shall have occasion to
refer to this highly important and interesting observation again by
and by.

This patient progressed from bad to worse; unhealthy suppura-
tion ana sloughing extended up the ankle in the sheaths 6f the
tendons, and erelong pyaemia set in — of which she died on 9th
May, being thirteen days after the amputation.

1 related these cases at a meeting of the East York and North
Lincoln Branch of the British Medical Association, on 22d May
1861.

The third and last case in which I have used this method was
an amputation of the thigh, of which the following is a brief
histoiy : —

A. W., aged 20 years, had suffered from disease of the right
knee-joint for 11 years, by which he was so dwarfed and emaciated
that his appearance was that of a child of 14. There were sixteen
discharging sinuses, and his weight was three and a-half stones.

2l8t Sqptemher 1861. — ^Amputation was performed according to
Mr Luke's plan, viz., the posterior flap was first made bv trans-
fixion, and the anterior, of exactly similar size, by cutting from the
surface down to the bone. The bone was sawn at the junction of
the middle and lower thirds. Five wires were applied upon as
many arteries, and with the femoral artery the femoral vem was
intentionally included. Two small arterial branches were treated
by torsion. The flaps, which fitted well, were accurately adapted
by means of wire sutures, pads of lint, and strips of plaster.

The case went on favourably in every respect ; there was very

210 MR DTX ON THE WIRE COMPRESS [SEPT.

little bleeding at the operation, and none afterwards. The lad
immediately ate and slept well, and was evidently much relieved
by the removal of the offending member.

On the 24th, being seventy-two hours after the operation, four of
the presse-artfere wires were withdrawn with perfect ease and with-
out bleeding. The wire upon the femoral artery remained till the
26th, that is, five days altogether, when it too was removed, without
any difficulty and without a trace of blood. At this time consider-
able union had taken place between the flaps, but there was slight
suppuration about the deeper parts ; so that when I related this case
at a medical meeting on October 9th, being the eighteenth day
after operation, I spoEe of it as a forward stump, and hoped for an
early cure. In this I was disappointed ; for although the lad im-
proved in health and appearance, and was soon walking stoutly on
crutches, still the stump did not heal. Three or four sinuses
remained, discharging pus of a thin unhealthy character; the
granulations were feeble and flabby, with occasional outbursts of
more acute suppuration.

The explanation of all this was subsequently found in a necrosis
of the sawn end of the thigh bone. A considerable ring of this
was gradually loosened, and cast off in the usual way ; and when
found to be detached was removed by an incision made into the
face of the stump. In a few days after this the whole was soundly
healed. It has continued so ever since ; the lad walks particularly
well on a common wooden peg leg, and is now ripening mto a man,
and earning his own livelihood as a railway clerk.

What then do these cases prove with regard to the method
employed for securing the vessels ? Simply this, that it is prac-
ticable, efficient, safe, and manageable, nothing more. As yet I
can show no positive results better than iiiight have been obtained
by the use of ligatures in the usual way. The great desideratum,
primary union, has not as yet been arrived at. Any advantages
then that may be claimed for this procedure at present rest chief y
on theoretical grounds ; not aUogether so either. Surely it has some
superiority, indisputable and d^emonstrable, over the ligature, as I
now propose to show. In pursuance of which object it will be
convenient, first, to consider the effect, action^ and results of the
ligature.

It will probably be conceded by most surgeons, that a ligature is
at best a necessary evil. It is a great nuisance in a wound, and
the chief obstacle to primary union in many operations, and espe-
cially in amputations. Union by adhesion, after a large amputa-
tion, is an occurrence of extreme rarity. The recollections of a long
surgical experience fiimish but here and there an isolated case.
Many men will say they have seen it once (I have met with no one
;who has seen it more than once), whilst many do not believe in it
at all, and even doubt its possibility.

But how constantly does one read, in reports of surgery, such a

1864.] AS A SUBSTITUTE FOB THE LIOATURE. 211

sentence as this : ^' fifth daj, complete onion eascept in the track of
the ligatures^ Such cases eveiy one has seen ; thej are common
enough. Surely then the inference is not far-fetched or illogical,
that, but for the ligatures^ suppuration might often be altogether
avoided. What; indeed^ is a thread of silk or hemp between the
flaps but a miniature seton I The whole number or ligatures col*
lectivelj would form one of considerable size, and are a necessarj
and certain exciter of suppuration : such a seton being, in fact, the
yeiy means we use when we wisn to set up or to maintain this
process.

Again, how is a ligature detached from the vessel to which it has
been applied? Why, bj ulceration I another unhealthy and objec-
tionable process. The part of the artery encircled by the thread
dies by strangulation, whilst a further portion, which has been
drawn out and detached from its sheath for the application of the
ligature actually sloughs away.

This drawing out of the artery hy the forceps is of itself bad, as
it breaks up the vascular and nutritive connexions of the vessel, and
BO retards those vital and physiological processes bv which the
closure and permanent sealing up of the cut tube is effected. How
frequently, too, is this disturbance of the vessel itself, and of the
reparative action going on around and within it, renewed by traction
made on a ligature, supposed to be detached when it is not really
so. In this way also it occasionally happens that a considerable
piece of the artery above the site of the ligature is plucked away, —
fully half an inch I have seen ere now.

The suffering occasioned by this experimental traction, be it
futile or successftd, is horribly familiar to every patient, and dreaded
by every humane dresser. The pain of dressing a stump is over
when once the ligatures are all out.

The knot of a ligature (often deeply buried between the flaps)
cannot be withdrawn without breaking up whatever adhesion has
taken place between the site of the artery and the edges of the
integument Hence, will occur bleeding from torn granulations,
and manifest derangement of the healing process.

Again, a ligature once applied, the surgeon is at its mercy (so to
speak), and the patient too. Who can say when it will be thrown
off? I know a gentleman who carried one in his arm eleven
months afler amputation. I remember another, who, having had
his testicle excised, had two ligatures remaining in the imhealed
wound to the day of his death, which happened several weeks after
the operation. It is obvious that so long as a thread remains a
complete cicatrization is impossible.

But I must push this argument a little further. I need scarcely
dilate on the advantages of primary union could it be obtained.
Time is an important element in most cases. A cure by adhesion
is the work of but five or six days, the secondary processes require
nearly as many weeks ; but there are other considerations far more

VOL. X.— NO. ni. 2 E

212 MR DIX ON THE WIRE COMPRESS [SEPT*

important than this. For instance, what are the chief sources of
danger from amputation ?

First and foremost, the much dreaded pyaemia ; which, it is said,
kills half those who die after amputation.

And the parent of pyaemia is suppuration. So soon as the secre-
tion of pus commences so soon is tnere danger of purulent infection,
which occurs not at all during healthy adhesive repair. Who "will

Sinsay the intimate relation between suppuration and the ligatures?
ave we not seen that they are almost inseparably connected, and
that the ligature may be, and indeed often is, an active source of
pus formation.

The next most fatal accident is secondary haemorrha^, which
arises chiefly or altogether from the ulceration or sloughing of an
unsealed artery. And have we not proof that this very ulcerative
process is set up in the vessels themselves by the ligatures? It is a
necessity of the case, part and parcel of the natural action of the
thread, which cannot in any other way be got rid of. On the other
hand, it is not very clear why, except for this necessity of casting
oflf the foreign body, ulceration of an artery should ever occur, at
least in a healthy stump. Yet it happens not imfrequently that
bleeding occurs, even when reparation is well advanced, and every-
thing appears to be going on ravourablv.

Surely these are striking and remar&able facts, and demand our
most serious attention. Here are two unhealthy processes, the
grand sources of the most fatal sequelae of amputation, shown to be
intimately mixed up with or actually inaugurated by the very
means we use to stop the bleeding. I said that a ligature is at best
a nuisance. I hope to show that it is no lon^r a necessity.

Yet I am prepared to hear, as I have heard before in discussions
on this subject, that some surgeons are content with the results of
the ligature.

Such I would ask to call to remembrance their cases of pyaemia
and secondary haemorrhage following operations, and to remember
that in their ligatures they have, to say the least of it, a possible in-
cerUive to both these dangers.

I entreat them to ponder over the following formula : —

Pyaemia is the offspring of purulent formation, of which the
ligatures are an efficient and probable cause.

Bleeding arises solely from ulceration of a bloodvessel, of which
the primum mobile is again the ligature.

Cfontrast with the fcregoing statement (unexaggerated and un-

frejudiced, as I believe), the effects and action of the wire compress,
unhesitatingly assert that, from one and all of these objections to
the ligature, it is almost or altogether free.

Thus, it has not to be detached by ulceration, neither does it
give rise to this unhealthy and undesirable action. On this point I
speak positively from absolute proof, as related in Case II.

It has little or no tendency to excite suppuration, and certainly

1864.] AS A SUBSTITUTE FOR THE LIGATURE. 213

does not necessarilyi or even usually^ occasion it. This is in
accordance with the well-known jpatnological law, that metallic
snhetanceSy from not absorbing fluids, and perhaps from other
causes not so well understood, are freely tolerated in the living
body, and often remain therein embedded with perfect impunity for
an^ length of time, not causing suppuration, ulceration, nor even
imtation. Frequent experience of metallic sutures has proved this
to the satisfaction of most surgeons, and it needs not to be further
dwelt on here. It is an accepted fact in surgical pathology.

Again, the wire compress is applied without oisturbance of the
natural relations and vital connexions of the vessel. It is removed
at any time according to the will and judgment of the surgeon,
without any interference with the adhesive repair which may have
taken place in the artery, and in the rest of the stump, almost without
pain to the patient, and entirel^p- without those torturing attempts and
uncertain trials wnich appertain to the withdrawal of the ligatures.
To which, I may add, tnat the wire once properly applied, is not
liable to loose its hold, or become detached too soon, as not unfre-
quently happens when a thread is tied upon a brittle diseased
artery, or upon a bleeding vessel in a slouching wound, as, for
example, in secondary haemorrhage from hospital grangrene, — that
twigs of nerve, if accidentally included in the embrace of the wire,
are not injured and excited as by the tight strangulation of a
ligature. Hence there will be but little or no twitching and
jumping of the stump, which was an observed fact in the cases here
narrated.

And, lastly, it is quite easy to compress the adjacent veins along
with the arteries if it be deemed desirable. It is certainly well to
do this if the veins show a tendency to bleed, as thereby all oozing
and formation of coagula between the flaps — than which there is
no greater obstacle to primary union — is entirely prevented. Even
those who fear to tie a vein need not dread any ill results from the
simple compression of it.

Surely all these collectively form an aggregate of no mean or
trivial advantage as compared with the ligature.

It may be thought that the few cases in which this plan has been
tried, are but a small experience on which to speak so confidently,
and almost didactically. It is right, therefore, to state, that what is
here advanc^ is deduced not from these cases alone, but also from
the recorded results of acupressure, which has been successfully
used in numerous instances, and which offers man^ of the advan-
tages, and confirms most of the conclusions on which is based this
advocacy of the " wire compress." This is in reality but a modifi-
cation of acupressure, from which it differs in detail rather than in
principle or modus operandi. Hence it is that I lay no stress on
originality in the matter ; this merit, so far as I know, belongs to
Dr Simpson alone. Yet, I believe the substitution of the wire
for the needles to be a decided and important improvement,

214 HB DIX ON THE WIRE COMPRESS [SEFT.

as i< is free from most of, or I may say all, the shortcomings of
^^ Simpson^s skewers," as the acupressure needles have been irre'*
verently called.

The following may be mentioned as the chief defects of the
needles : — ^When several of them are required, the stump resents as
it were being thus pierced through and through in many places
and in various directions. From this cause, and from the obstruct
tion to the capillary circulation caused by the pressure of the un-
yielding steel, we nnd much tension, oedematous swelling, and in
some cases very great pain. The pain especially has proved a very
serious evil, so much so as to lead one surgeon to my knowledge
to abandon the use of the needles entirely. Again, their projecting
ends, and the puckering they cause in the substance of the flaps,
interferes very much with that accurate adjustment of the cut sur-
faces and edges, which so greatly aids the chances of union bv
adhesion. None of these objections apply to the " wire compress.

The first point is with regard to the mode of application of the
wire, which may be best .done in the following manner : take a
piece of surgical wire, 6 or 8 inches long, and thread each of its
ends upon a straight needle.

Seize the bleeaing mouth of the arteiy with forceps, and pass one
of the aforesaid needles close on each side of the artery, about a line
above the points of the forceps, directly down through the substance
of the flap, so that they emerge at the cuticular sunace, about half
an inch aistant from each other. Draw them both through together,
till the curve of the wire compresses the vessel on the face of the
flap. Now, get rid of the needles by clipping through the wire close
above their eves, also detach the artery forceps. Place a piece of
cork cut for the occasion upon the skin between the points of exit
of the wire, and over this twist the wire tighter and tighter till the
bleeding is arrested. Lastly, cut off the superfluous wire. All
which is done much quicker than described. Eepeat this process
upon as many vessels as require it.

Two arteries Ij^ing near together majr be embraced by one wire ;
and, as I have said, the veins may be included or excluded at will.

The wire should be either silver, or, what is much cheaper and
equally manageable, the finest and softest passive iron. The
generality of tne iron wire used for sutures is too hard and stiff.
That which I have employed was supplied by Mr W. B. Hilliard,
surreal-instrument maker^ Glasgow, who also furnished the needles,
which are about 3 inches m length, straight, and three-edged, with
an eye adapted for carrying wire.

Special care is necessarv in threading the wire, that it be kept
perfectly firee from all kinking or twisting. The forceps are used,
not to draw out the artery, as when a ligature has to be applied —
this, indeed, is to be particularly avoided — ^but merely as a guide to
mark the exact position and course of the vessel. The cork is
necessary to protect the skin from the pressure of the wire. The

UB64.] AS A SUBSTITUTB FOB THE LIGATUBE. 215

stnmp will now be dressed accordiBg to the fashion of the opera*
tion.

Of course, objections will be raised to this scheme. The onlj one
to which I need reply by anticipation, is that which natiurallj
occurs to any one looking at the tninff for the first time. How it
that wire to be toiihdratm t This, at first sight, appears an insuper-
able difficulty. Let any one who entertains that idea try the
experiment on the dead subject, and he will probably be surprised,
asl was, to find how easily and certainly it is efiectod. To which
he may add, my eapertmentum cruets^ that it is equally eas^ and
certain in the living body. Here, I ought to mention, that it was
fi*om Mr Hilliard I first learnt that the abrupt bending of the wire
is not an impediment to its removal. He also suggested to me the
use of two needles in the way just described, by which the wire is
applied much more expeditiously and exactly than by using a single
eedle. The only conceivable obstacle to its withdrawal would ne
a kink or hitch in the wire^ which might cause much inconvenience.
Hence the stress I have laid on the necessity of carefully avoiding
this mischance in threading and fixing the wire. Its removal, no
doubt, requires to be cautiously conaucted. Thus, clip the wire
close to the ed^ of the piece of cork, and straighten out the curve
it has necessanly formed at its exit from the skin. Remove the
cork, and apply instead the tip of one finger, with which press
firmly upon the flap, making traction, gently and gradually, upon
the other end of the wire. In this way it comes out with great
facility ; but if this were roughly and harshly done, it might break
up the adhesion which we suppose has taken place between the
surfaces of the flaps, and it is quite possible that a kink in the wire
might lacerate the artery in passing over it.

^Dut it is certain that none of these evils need happen with ordi-
nary care and tact.

As to the period of withdrawal, farther observations are desir*
able ; but it has been shown, in numerous cases of acupressure, that
for small vessels a few hours of compression is sufficient ; and for
the largest arteries a much less time than might, a priori^ have
been supposed. However, as a general rule, it is not desirable to
disturb a wound in any way for from twenty-four to forty-eight
hours, at the end of which time all wires commanding the secondary
branches may be safely removed, and probably also from the large
arteries ; but, as a matter of prudence, one would at present prefer
to keep a check upon such an one as the femoral for three or four
days at least Better it should remain needlessly long than be
prematurely removed, for, as has been said repeatedly before, the
presence of the wire is almost innocuous.

Hitherto I have spoken of this method of securing arteries only
in reference to amputation of limbs. It is equally applicable to
many other operations. Thus, supposing the testicle to be excised,
how easily and nicely the vessels of the cord may be compressed by

216 MB DIX ON THE WIBE COMPRESS [SEPT.

a wire; safely removable in. a few hours. In a case of this kind,
operated on a year ago, two ligatures were applied. One of these
did not come away for nineteen days, during which time, of course,
many attempts had been made to withdraw it, amid the grimaces
and exclamations of the patient. Moreover^ most of the wound
healed by first intention, and I am firmly oi opinion that but for
the li^ture there would naye been no suppuration.

This method would also be particularly suitable in a case of
popliteal aneurism. I would ask special attention to this, for in no
case are its advantages more obvious and decided. Surely such a
wound as that made during the operation, a single clean incision
on healthy tissue, might reasonably be expected to heal at once,
were it not for the foreign body, the ligature or seton, which keeps
it open. Moreover, the ligature remains some eight or ten days,
long after it has ceased to be necessary or useful ; and above all
things in the way of objection, it seta up vJceraMon^ by which it has
to cut its way through the vessel before it can be detached, whereby
the blood channel is opened, and hemorrhage may and sometimes
does result

Suppose such a case treated by the wire compress. The wire
would be passed under the artery by means of a tubular aneurism-
needle made for the purpose, then brought through the integument
at a convenient situation, by threading each end upon a common
needle, and twisted upon a cork in the usual way. And now,
mark the contrast. I have shown that in amputation of the thigh,
the severed femoral is securely closed in three or four days by the
action of metallic pressure, and there seems to be no reason why
the same thing should not happen here ; from which it follows that
the wire might be safely removed in four days. Whilst there, it
would be innocuous, not exciting suppuration ; and in the end
the coats of the artery would remain intact, and bleeding would be
impossible.

Surely these are great and manifest advantages ; as yet theoretical,
I grant, but nevertheless self-evident, and based on sound reason-
ing and very exact analogy.

It will probably be found that the pedicle in ovariotomy may be
conveniently dealt with by this method, the arteries being secured
individually, and the entire stump also fixed to the abdominal wall
by another wire. This idea has been already promulgated by my
firiend Mr Spencer Wells.

To some wounds the wire compress is inapplicable. Thus, in
the removal of a breast, it is usual to have bleeaing firom the twigs
of the intercostal vessels which pass upwards through the muscles.
Upon these the wire could not be applied ; and the same difficulty
might arise in the removal of any deep-seated tumour.

In these cases the short needles of JDr Simpson have been found
to act well ; but I have elsewhere ^ven reasons why the wire is
preferable where it can be used. Neither should I expect to find it

1864.] AB A SUBgTITUTE FOR THE LIGATUBE. 217

easy to apply the wire upon the vessels of a flat-faced stomp made
by the ciicmar incision. But this is merely an additional reason,
if such were needed, for preferring a flap operation.

It is scarcely necessaiy to allude to the idea, recently put forth
as a novelty, of using vnre as a Itffature, by tying it upon the
arteries. It is neither new nor good, for it is evident that ity like
any other ligature, can only be cast off by ulceration, which pro-
cess, as we have seen, the metallic substance does not readily excite,
and therefore it would probably be more difficult to cet rid of than
even the old-fashioned thread. Nor, I suppose, wiU any stress be
laid upon the now exploded doctrine, that lor the safe closure of an
artery it is necessaiy that its inner coats should be divided. The
results of acupressure have sufficiently shown the non-necessity of
this. It is certain that the needle passing over an artery can
effect nothing of this kind, and yet, by its use, secure and firm
obliteration does take place, and that readily and speedily ; from
which it is evident, that if such a necessity existed about the
beginning of this century, when the doctrine was first invented by
Jones, it is no longer needful at present. Nowadays it is sufficient
that the current of blood shoula be arrested for a few hours by
siinple pressure.*

I take it for granted, that some who read this paper will, ere-
long, be making trial of this contrivance. I woula warn such
against disappointment which might arise, from anticipating too
much, and also at the same time protect myself from suspicion of
exaggeration and extravagance. Therefore, let it be borne m mind,
that entire union by adheswn in large wounos is not to be expected
as a firequent event, neither will pysemia and secondaiy haemorrhage
be utterly abolished. But it cannot be denied, that ligatures are
an impediment to healing, and that the absence of these impedi-
ments increases the probabilities of union ; that the presence of a
ligature in a suj^purating wound increases the suppuration and pro-
longs its duration ; and that the longer the period of purulent
formation, the longer the danger of pysemia exists, and the greater
are the chances of the occurrence of this bane of surgery.

And if my statements should appear in some degree sanguine and
enthusiastic, this arises solely from the implicit confidence I feel in

^ It is more than likely that this laceration of the internal coats of an
artery, so far from being essential to its repair, is in reality detrimental.

An artery is a living stractare, endowed with the same vital properties as
other tissues, and is healed by similar processes. It is clear that the ligature
inflicts an additional injury on the wounded vessel, by tearing and bruismg it,
converting " a simple incised wound ^^ into " a contused and lacerated wound."
This we are told acts beneficially by exciting " adhesive inflammation.'^ Is not
this altogether a fallacy? Improved pathology teaches that there is not
merely a distinction, but an actual antagonism between inflammation and
adhesion, and that the grand essential of repair is "physiological rest.*^
'What makes an artery a solitary exception to this law of nature? Why
should it alone of all structures be subjected to those very curious and
•eccentric aids to healing — contusion and laceration ?

218

ME DIX ON THE WIRE COMPRESS

[SEFT,

the intrinsic merits of the little device just propounded. I have
met with no difficulties or drawbacks that have not been frankly
narrated, nor am I acquainted with any dangers that can be alleged
against it ; and, for myself, I should as soon think of stuffing a
wound with charpie, or of searing a stump with a red-hot iron, as
of using a ligature where the wire could be applied.

Allow me, then, in conclusion, to give in few words, a tabular
resum^ of the points of contrast between the ligature and the wire
compress.

The main distinctions are these : —

The ligature consists of organic
material. It absorbs fluids of
the wound — is itself liable to
decomposition, and is very ob-
noxious to the living structures.

The ligature is nxed to, and
fastened upon, the artery itself.
It lacerates its structure, and
puckers up and corrugates the
tube.

The wire being a metallic sub-
stance is non-absorbent — non-
irritant, and almost innocuous to
the tissues.

The wire is not attached to
the vessel, nor indeed to any-
thing else ; it does not tear the
coats of the artery, but closes it
in a smooth and even manner,
by gently pressing together its
internal surfaces.

Which of these, it may be asked, is the more favourable condi-
tion for healthy adhesive repair, quoad the artery ?

The ligature excites, promotes,
and prolongs suppuration.

The ligature, necessarily causes
ulceration of the artery, and
death of the part on whidi it is
tied.

The ligature remains for an
indefinite time, and on the other
hand, from a brittle or slough-
ing artery, it may be cast off too
soon.

The ligatures project between
the edges of the integument, pre-
senting a mechanical impediment
to their union.

In the application of the liga-
ture, the vital connexions of the
artery are damaged, and its vasa
vasorum broken up.

The wire has no tendency of
this kind, hence will there be less
danger of pvsemia, and a greater
chance of adhesion of the wound.

The wire has no such effect ;
hence, secondary hemorrhage
will be less likely to occur.

The wire is removable at will,
and at the same time it cannot be
spontaneously dislodged. An-
other safeguard against bleeding.

The wire does not interfere
with the edges of the wound, nor
with the adjustment of flaps ;
hence, union by adhesion will be
more probable.

The wire is applied without any
disturbance of the artery itself,
which, therefore, is probably
earlier and more securely closed.

1864.] AS A SUBSTITUTE FOR THE LIOATUBE. 219

The removal of the ligature is The wire is withdrawn at

nncertain ; ineffectual attempts once^ and certainly without any

are common, very painful, and futile, painful, premature trao*

injurious to reparative action ; tions^ or disturbtmce of parts, or

and the knot especially, in its any mterruption to the healing

withdrawal, tears through granu- process,
lations and breaks up c^esion.

Of these advantages, some appertain equal! v to the needles, long
or short, but the wire alone combines them all. It is, at the same
time, free from the chief defects of acupressure, and in most cases
will be found by far the most simple, manageable, effectual, and
satisfactorv method of applying the principle of metallic compree^
eionj any form of which is preferable to a ligature.

P. 8. — Since the above paper was written, I have used the wire
compress in two other cases, viz., excision of a testicle, and exci-
sion of a breast.

The testicle was veiy large from sero-cystic disease, the scrotum
being also greatly distended by hydrocele, so that the wound was
fiilly eight inches long. Two arteries in the cord-^which was
healthy — were secured by two separate wires, fixed, one on each
side of the incision. They were not disturbed till tne fourth day,
because the pieces of cork seem to assist in keeping the edges of
the wound in apposition. The case did well ; the suppuration was
slight, and the liealing rapid.

The breast was affected with cancer. A cut had been made into
it a few weeks before I saw it, in search of pus. From this wound
a fungous growth was sprouting exuberantly. The incision for its
removal was six inches long. Three artenes bled ; none of these
were deep-seated, and they were readily secured by the wires.
These were all removed in twenty-four hours. For some days
there was a considerable oozing of the liquefied fat ; but the sup-
puration was very trivial, and in ten days the cicatrix was firm and
the cure complete.

Article IV. — On some Cuatoms of the People of Old Calabar
relative to Pregnancy and Parturition. By Archibald Hew AN,
L.B.C.S.E., Medical Missionary at Old Calabar.

(Bead he/are the OhMrical Society, 8^ June 1864.)
The paper that I have before me refers to some of the customs of

theOld , . .. . vM.._.._^ ,_.. ^.r.

ceeding

the Old'Calabar people relative to childbearing ; but, before pro-
ding to the reading of the paper, I should mention how it is

VOL. X.— HO. in. 2 P

220 MR HEWAN ON SOME PECULIAB CUSTOMS OF [SEPT.

that I have the honour to stand here before you this evening. In
a communication that I had from Professor Simpson lately while
in Old Calabar, containing instructions regarding a patient of his
out there, he requested to know something of the customs of that
people in pregnancy and |)arturition. I made a few notes, there-
fore, and handed them to him the other day; but, instead of taking
them, he suggested that I should come here and read them to your
meeting this evening. To that proposal I hesitated to consent, as
the notes were so few that it seemed to me like making game of
the Society to stand up to read them ; but as Dr Simpson urged
the matter, I could not resist him.

On thinking over the matter since, it occurred to me that it
might not be uninteresting, nor perhaps altogether out of place, to
add a few notes, by way of enlajrgement, relative to the customs of
the women before pregnancy, and the treatment of their children for
some time after birth.

The betrothal of a Calabar female (among the upper classes) takes
place for the most part very earlv, sometimes so soon as within a
few days after its birth, — ^and this betrothal is not necessarily to a
young man of a corresponding age, but rather, and very commonly,
to a man who is abeady a father of a family, and a husband of
many wives ; and by no means unfrequently is it to a greyheaded
grandfather. I have thus seen a strapping man, in the prime and
vigour of life, dandling on his knees and kissing a baby some two
or three weeks old that he expects to become his wife, and mother
of his children, some fifteen or twenty years after. Pointing to her,
he says, " You see my new wife." The poor little thing is thus,
willingly or not, made over to him — "diwAerf" to him, as he says.
He in turn '^ dashes " it many little things, comes now and then and
nurses it, is entertained by its prattle, watches over it, and fulfils
in great measure the part of a guardian. The child gets to know
him, and perhaps to tove him (they learn early to know each other^s
temper), and when she grows up and becomes his wife, she calls
him Fciher. The iexm jaiher is the common one given by Calabar
wives to their husbands. The presents which the guardian-husband
makes to the child-wife constitute in a great degree a part of the
marriage-contract, so to speak, which the father and the mother
dare not break without being liable to Egbo law, — paying back
every item of present that may have been given, and a great deal
more ; which is sure to be demanded by the bereaved husband.

At about the seventh or eighth year, the process of fattening for
marriage begins. For this there are at least two periods, and some-
times three. The little girl is taken away fix)m the town to a
plantation or farm. There she is placed under the care of some
experienced woman, whose pride and anxiety it is to give her new
charge a development and form creditable among her sex. She now
dwells in a darx apartment, and is daubed fix)m head to foot with a
thin paste made of clay, or marl and water. This chokes up the

1664.] THE PEOPLE OF OLD CALABAR. 221

poresy and aa she is not permitted to exert herself in any way. she
never perspires. It is said, moreorer, that the clay keeps the ooiy
cooL For foody she has placed before her constantly a large
supply of yam and plantain oeaten soft like mashed potatoes ; and
as sne has nothing else to do, she amuses herself by making out of
this mass balU of a conyenient size for swallowing. This she does
between the palms of her hands, dips them into a kind of soup in
which palm-oil predominates, swallows them one by one, never
chewing, but bolting them as one would do a pill. After she has
taken a number of them, she takes a few mouthfuls of water, which
helps to fill up the interstices. A certain q^uantity of food must be
taken every day, or she is punished. Having reached the desired
dimensions, she is washed, and decorated with beads and a thick
roll of worsted around her loins, and is taken to call on her husband
and her friends, who congratulate, her on her development and
beauty. The roll of worsted alluded to is her only covering. It
extends all round the loins, is from two to three inches in diameter,
and is made out of Kilmarnock night-caps of various colours teasea
down and twisted. They make the different colours harmonize
very beautiftdly, and viewed abstractly, one would say it was a
very pretfrf dress.

This being over, she is allowed to go freely about again for a few
years, living now mainly among the wives of her future husband.
She soon loses all her lately acquired ftilness and bloated appear-
ance, and becomes quite mmble and healthy-looking again. But
now comes approacning womanhood. The mammae be^n to en-
large, and the catamenia appear. This ftmction being fairly estab-
liahed, she is brought under an operation — a surgical one — namely,
amputation of the clitoris. The instrument used is a common
razor, and the operator is a woman. Here I may state, by way of
explanation, that no man except the husband dares touch or come
near a betrothed or married woman, not even to shake hands, — ^a
thing not known between the sexes. Hence the women are the
chief surgeons ; they practise the art freely upon either sex. whereas
the man can onl^ practise it upon his own. As to tne modus
operandi of removmg the clitoris, I am sorry that I am unable to say
anything, never having been fortunate enough to see the operation

Grformed. For the most part it is done out of the town. Once I
d what I thought a good opportunity of seeing it, but the young
lady heard that we were to come, and her native modesty rebelled ;
80 that ere a medical friend and 1 arrived it was all over. All that
we were permitted to see was the instrument — the razor — flying
beside her.

Heomorrhage does not, so far as I am aware, frequently attend
the operation. I know only of one case. I was called out of
church one Sunday by a guardian-husband to ffo and check the
bleeding which haa resulted from an operation of this kind. The
operation had been performed in the morning, and the oozbg had

222 MB HEWAN ON SOME PECULIAR CUSTOMS OP [SEPT.

continued all day at an unusual rate ; but, unfortunately for me, ere I
arrived, they had applied some powerful styptic, and the bleeding
was stopped. I was not permitted to see it, but they consoled me
by saying they would send for me if it gave way again.

This process of cutting off the clitoris is common to all young
women, whether betrothed or not. If not done, it is looked upon
as a great disgrace ; and she loses caste among her sex. So also
is the want of circumcision regarded among males. And separation
of husband and wife has taken place when, after marriage, tne want
of the corresponding operation was discovered in the one or the
other.

After this operation the great and final period of fattening com-
mences that is to usher in the nuptials. The young woman is
again taken out to the farm, and there she goes through a course
similar to the first one, somewhat more severe and of longer dura-
tion. She is again covered over with the chalky paste, and she
eats and drinks incessantly. If the development of the mammsB
has not taken place sufficiently by this time, it is assisted by means
of the cupping gourd. She now soon begins to fatten and to bulge
out: her abdomen enlarges; about the loins and waist are seen
thick convoluted folds ; and the eyes begin to disappear under the
enlargement of the cheeks. But matters do not always go on thus
smootiily. It sometimes happens that the constitution gives way
and breaks down under this rigorous and unnatural treatment, and
the patient dies suddenly, or what is almost as bad, becomes feeble,
hysterical, and sickly, ana she is looked upon as spoiled.

Passing over the ceremonies connected with the marriage, let us
look at some of their customs in pregnancy.

The principal signs of pregnancy noticed by them are the suspen-
sion of the menses, the darkening of the areola around the nipple,
and a blanched asn-coloured appearance of the face and upper part
of the breast, with yellowish spots scattered over them. The
areolar sign is a well known one, and is considered pathognomonic.
So much so, and so important a sign is it deemed, that one of the
main objections urged by the men to the women wearing clothes,
which we try to introduce among them, is that this valuable sign
would be in a great de^e lost to the public — the common covering
of a Calabar woman being merely a strip of cloth half a yard broad
around her loins.

During the catamenial flow the woman never leaves the house if
she can help it. She sits during the day on a night-stool with a
vessel underneath. The usual period is firom three to five days.
They date the commencement of pregnancy from the suspension of
the catamenia, and count by lunar months, from one full moon to
another.

At the third month they administer medicines, to prove^ as they
say, the value of the conception. They regard three kinds of con-
ceptions as disastrous : 1^^, Conception of twins ; 2cf, Conception of

1864.] THE PEOPLE OF OLD CALABAR. 223

an embiTO that will die before birth ; and, 3dy Conception of one
that will die soon after birth ; and so for the purpose of voiding
these at as esxly a period as thej think that the conception has
fully taken place, they administer medicines.

These medicines are administered by the mouth, per anum, and
per vaginam. By way of the mouth, and bjr enemata, first. If a
oloody discharge from the vagina follows, it is assisted by an appli-
cation direct to the oa uteri. For this purpose they employ one of
three herbs, one a euphorbia, another a leguminosa. and another an
amomum. The steminal end of the leaf-stalk of the euphorbia,
with its exuding juice, is pushed up the vagina. On the same part
of the leguminous one is placed a small quantity of guinea pepper,
chewed into a mass with the saliva. This guinea pq^per is a species
of the amomums. In the course of a few days the abortion may
take place. But it is not abortion pure and simple that is desired ;
it is conditional, as I have already said. It is only to procure it in
the case of one of three conceptions, either of which being, in
their estimation, unnatural, they consider to have little or no nold
upon the uterus. But it not imfirequently happens that the measures
employed are too severe: serious constitutional disturbance and
or^nic lesions take place, and death ensues.

The seventh montn is regarded by them as a bad one. Many
abortions are said to take place then.

As pregnancy advances the woman is generally sent away to a
farm where she can live quietly and free nrom the excitements and
bustle of the town ; and more than that, to be out of the reach of
witchcraft. Barren women, and women who abort, commonly
attribute their misfortune to the evil eye of some neighoour.

With reference to parturition: — ^While in labour the patient
moves about, or if she sits, it is on a low stool or log of wood. The
midwife squatting before ner with hands oiled, uses steady gentle

i)ressure on the parietes of the abdomen from above downwards and
brwards, helping, they say, the child to find its way down. While
the child is being bom no assistance is given ; it passes out, and is
allowed to lie between the thighs of the mother till the placenta
comes away, however long that may be. The funis is then cut
with a razor, and the child is removed. The mother, very soon
after, has a large potftd of chop placed before her, which her
husl)and had b^n Dusy preparing ror her during her labour, and
she is expected to take a large quantity of it. Around her abdomen
is tied wnat is meant for a bandage. It is simply a handkerchief
twisted so as to make something more like a cincture than a bandage,
and it is placed right over the hard contracting womb.

The child being removed, is rubbed over with fine sand, after which
it is washed with soap and warm water. The juice of the fruit of one
of the amomums, pretty acid, is then squeezed into its mouth, after
which it gets a supply of tepid water. It is not allowed to suck
for two or three days, during which time it gets nothing but water.

224 SOME PECULIAR CUSTOMS AT OLD CALABAB. [SEPT.

Indeed, water seems to fonn one of the principal portions of its
support for some time to come. The mother's breast is generally
redundant with milk, dropping out not unfrequently, and the child
quite able to suck largely, yet a large quantity of water is given it
once at least every i&y. Eveiy morning while the child is being
washed, water is occasionally tnrown into its mouth. This is con-
tinued for several minutes, during which the child gasps and
struggles. It is done, they say, to distend the abdomen, and make
it capacious for afterwards takmg plenty of milk and food to accele-*
rate its growth. Should the motner be absent any day for a few
hours, the child is kept quiet by filling its stomach with this cheap
liquid. They acknowledge its ^reat use in this respect. It is
a remarkable fact in connexion with the lar^ amount of cold water
forced into the stomach of their infants that enlargement of the
spleen is very common among them — ^far more common among the
infants and children than among those of greater age.

The period of suckling continues till within a few months of the
next parturition. This does not generally take place for two or
three years after the last ; the husband not cohabiting with his wife
for eighteen months or two years. Sometimes, when no subsequent
pregnancy takes place, the child is allowed to suck on at his own
pleasure till he choose to give it up.

Fruitful wives are reckoned the favourites. Those who do not
bear give their maidservants to bear for them, and count the ofispring
as their own.

In the middle of the doorway of a house, where there has been a
birth, may be seen a bundle of green leaves suspended by a string.
This is the way they take to advertise a birth.

Twins are looked upon as monsters, and are destroyed: the mother
herself taking the initiative in their destruction. An earthen vessel,
such as they use for carrying water, is brought to her. She then
lifts them up one after uie other, and places them in the vessel
An attendant then carries them out to the woods, and there they
axe left to perish from exposure, or to be devoured by wild beasts.
More frequently the voracious ants that go about in large colonies
find them out, and eat them up in a few minutes.

Should the mother die in childbed the living infant is buried
along with her.

Such are some of the customs of the old Calabar people : very
curious and very cruel they are ; but I am glad to be able to add
that they are now being considerably modified and abolished under
the teaching and influence of the missionaries.

1864.] RECENT IMPBOVElf ENTS IN OPERATIVE MIDWIFERY. 225

Article V. — On the BesuUa of Recent ImprovemmU in OpmiHve
Midmfery in cUminuhing the Number of Caeea requiring jEmbry*
oUmy. By Andrew Inqlis, M.D., F.B.C.S.£din.

{Bead htfare the Edinburgh Obstetrical Society, 11th May 1864.)

In thifl paper I propose to state the efiects which the more recent
improTements in the method of effecting deliverir in cases of con-
tracted pelvis, must have had on the proportion between the favour-
able ana unfavourable results of craniotomy, and then, by reference
to the previous statistics of the operation, to indicate what its value
now appears to be.

The three changes which seem to act most powerfullv in produc-
ing such an alteration are, — ^the use of chloroform, the improve-
ments in the form and in the manner of application of forceps, and
the employment of podalic version.

The effects of the use of chloroform in increasing the death-rate
of craniotomy must be considerable, for though it renders the opera-
tion somewhat easier, and perhaps even safer, still this is not the
case to such an extent as can materially affect the statistics of the
operation ; while, on the other hand, its exhibition, by permitting
tne substitution, in the milder cases of contraction, of a less severe
method of treatment, deprives craniotomy of a number of the very
cases which formerly furnished the greater part of its recoveries.
For in many cases where, without chloroform, craniotomy would
have been resorted to, the use of that agent, by procuring an early
dilatation of the soft parts, gives an opportunity for delivery by
forceps, or, by bringing about the same relaxation, accompanied by
the suspension of uterine action, enables us to extract by turning.

While chloroform has thus been doing much to facihtate the use
of the forceps, great improvements have also been made in their
form and in the manner of using them. This has not been suddenly
effected; but the profession has, in course of time, gradually
become better acquainted with liie shape of the pelvis, and with
many other points connected with their use, which has not only
enabled them to use the old form of instruments more efficiently,
but has also occasioned successive changes in their shape. Tne
result of these improvements has been not only to increase the
safety of the operation in the cases to which their use was formerly
confined, but, in addition, to extend their application to many of the
less severe cases of contraction then considered to require crani-
otomy, thus again tending to diminish the favourable results of
craniotomy in those cases to which its application is thereby chiefly
confined.

Podalic version, which has long been employed for other purposes,
and even suggested at an earlier period in the cases now under
consideration, has only comparatively recently been much used in
labour rendered difficult by pelvic distortion. Not only is it, how-

226 DR ANDREW INGLIS ON RECENT [SEPT.

ever, now used in many cases in which forceps would otherwise
have been employed, but it has been performed with success as
regards both mother « and child, in cases where the deformity was
too great to admit of their use.

It was some time affo shown very clearly by Dr Simpson, that in
many cases of pelvic distortion the child was bom alive when the
lower extremities presented, while in the other labours of the same
patients none were saved when the head presented, — delivery
through the natural passages havine been founa impossible without
craniotomy. He therefore proposed in such cases always to turn
and extract by the feet, and the value of this method of practice
has been fully established by its results; and even when the
child cannot be extracted alive by this operation, but dies in the
course of it, or in consequence of additional operative procedure
being found requisite, the danger to the mother is inconsiderable
compared with that entailed by instrumental delivery in the natural
position of the child.

That the use of version has therefore, in the same way as the
improvements relating to forceps, and to an even greater extent,
lowered our estimate of the value of craniotomy, will be at once
admitted ; though at the same time it may be remarked, that if it
were prefaced, when possible, by turning, much might be done to
diminish the mortality in the cases where it is still performed.

But, in estimating the effect of all these improvements in reduc-
ing the number of cases formerly held to require craniotomy, we
must especially take into account that it is only to the milder cases of
pelvic distortion they are applicable ; and, as the occurrence of the
more formidable cases of contraction becomes rarer in a ratio which
increases very rapidly with its increase in degree, a proportionally
rapid diminution of the number of cases still requiring craniotomy
must be a necessary consequence ; while the unfavourable circum-
stances under which it has to be performed must be accompanied
by a corresponding increase in the^ ratio of mortality attendant
upon it.

To enable us to determine precisely the present value of the
operation of craniotomy, accurate statistics would be required ; but
as these do not exist, I must instead attempt an approximation to
the present death-rate by inferring from previously existing statistics
the probable results of what has now been stated. The previous
statistics are well known, and the mortality deducible therefrom is
1 in 4 or 1 in 5 ; therefore, if what I have already stated as to the
effects of improvement in practice be correct, it will be quite safe
to assume the present mortab'ty to be very considerably greater than
1 tn 4 or 5 ; or probably 1 in 3 would not be a rash assumption.

The next step towards the attainment of a proper appreciation of
the merits of the operation seems to be the comparison of its results
with those of other operations applicable to the same class of cases.
As craniotomy is now confined by the best authorities to cases in

1864.] IMPBOVEUEKTS IN OPERATIVE MIDWIFERY. 227

which deliveiy cannot be effected hy means of forceps or turning
alone^ and as the mortality of these operations is hardly appreciable,
it is evident that a compNarison between them and craniotomy may
be left out of consideration, as affording no criterion for such an
estimate as that at which we wish to arrive ; but with Canarean
section the case is different, for although at present it is true that
that operation (in consequence apparently of reliance on old statis-
tics) is considered justifiable only where craniotomy cannot be per-
formed with success as regards extraction, the aifferenoe in the
mortally is, I believe, by no means certainly in favour of
craniotomy.

With regard to the CaBsarean operation, we are now in a much
better position to obtain success than we were a few years ago ;
and I believe there is a paper by M. Dufeillv on the operation, in
which he has collected the statistics of all the cases performed
since 1858, and shows that, where the operation has been nerformed
with or^nary care, at the proper time for interference, ttie results
have been about 75 per cent, of recoveries, that is to say, 1 death in 4.
being not much more than the result of craniotomy as performea
under the old regime, and consequently in all probability more
favourable than those of the same operation, limited in its applica^
tion, as it may now be said to be, to a small number of cases of a
very unfavourable description. There is another point also to be
noticed in favour of Csesarean section. In this country we have
improved rapidly of late in the performance of ovariotomy, — ^an
operation very similar in many respects, but having adaitional
complications of a serious character; and, if we can produce
by it such &vourable results as one death in four, where, by
enormous incisions and dissections, we remove from the abdomen
a part of the frame itself, and are under the necessity of leaving
benind much that must separate by suppuration, how much
more success oueht we to expect, in removing from the same
cavi^ a foreign body, without oeing obliged to make such exten-
sive wounds, and not necessarily having to leave behind any-
thing to slough away. Besides, if we examine the individual
reports of cases of Cesarean section, we shall find, on the one hand,
that in many of the fatal ones, setting aside the question how long
the patient had been in labour, the operation had been so ill done
that death could not fail to ensue ; and, on the other hand, that
among the recoveries there were some where it had been so badlv
done, as almost to put a favourable result out of the question, leaa-
ing us to infer that on both these accounts, if due care haa been
taken, a much higher success might have been attained.

Since writing the above, I have heard that Dr Tyler Smith has
written a paper advocating the abolition of craniotomy, but I am
sorry I have not yet had an opportunity of perusing it so as to con-
sider his objections, many ot which must be the same as those
now brought forward ; but I am glad to hear that I do not stand

VOL. X.— NO. m. 2 Q

228 DB ANDBEW INGLTS ON REGENT [SEFT.

alone in questioning the correctness of the value at present iisually
put upon the operation.

From the foregoing it will be apparent, that unless something
considerable can be done to render craniotomy a less fatal operar
tion than it is at present, Cassarean section must prove, at least, a
formidable rival. I have already stated my belief that a good deal
might be done in this direction for a certain class of the cases held
to require craniotomy, by the use of turning as a preliminary to the
operation ; but as, after deducting these, there would still be left a
great many cases, with a mortality certainly even greater in propor-
tion than that of the whole number in which craniotomy is at present
performed, it would become only the more incumbent on us to see
if we should really be justified m preferring it to Cadsarean section
for the cases where turning cannot be e&cted <m account of the
narrowness of the pelvis alone.

The best form m which I can express my views as to the value
to be assigned to craniotomy, seems to be the suggestion of rules
for its employment ; but before attempting this, it may be as well to
consider tne nature of the rules at present generally accepted.

At present we have a tolerably sufficient knowledge of the indi-
cations demanding interference of some kind, but the limits beyond
which the different operations ought not to be attempted are so
variously laid down, as to give rise to much confusion. The
principal ^de given for the treatment of such cases is the minimum
number of inches in the different diameters of the pelvis through
which a full-sized child can be extracted, — in one case by means
not necessarily destructive to it, and, in another, by means in prin-
ciple involving its destruction. This guide is obviously unsatis-
factory, for it IS hardly possible to get any two men to agree as to
the measurement in inches of the brim of the pelvis in a patient ;
and, moreover, there are great differences of opinion as to the exact
measurement required to decide which operation ought to be
attempted in any given case. Then these measurements are laid
down without reference to the probable size of the child, which, as
we know, may vary in weight from six to twelve, or even fourteen
pounds, at the full time. Besides, its consistency may also alter
the prospect of the case most seriously. We have also another
source of dissatisfaction in dealing with this operation, viz., the
possibility, if the result be successful, of a doubt remaining as to
whether a milder method of interference might not have been at
least as safe ; and we never can be so sure after such a success,
as we are in most otlier surgical operations, that we have adopted
the best possible means.

I shall now merely, in conclusion, give the rules to which I
have been led by personal observation of cases of labour rendered
difficult by contraction of the pelvis, combined with the study of
published reports of individual cases of the kind.

Istj In all cases where the indications for interjerence are suffidenJt^

18Gi.] IMPBOTEMBMTB IN OPEBATITE MIDWIFERT. 229

the forceps should be applied, provided there is a reasonable chance
of their being Buccessfm without injuir to the mother*

2d, Shaulaforcq>8 be Jbund unsuiUwlej recourse should be had to
veision. even though the extraction of the head with instruments be
afterwards it^quiied.

3df Should the pelvis admit cf turning, but be too small to allow
the extraction of the body, we ought seriously to consider the ad-
yisabililT of Cossarean section.

4th, ahauld the pelvis he too small to admit of turning, the argu-
ments in favour of Caesarean section must be still stronger.

I have divided the cases included in the last two rules into two
sets, one where turning is possible^ and the other where it is impos-
sible, because, I believe, that such a means of distinction is better
than the old rule by measurement in inches; and I have not
insisted on Csesarean section in the former of these cases where
turning was found possible, because I have heard of the head having
been re-turned ana craniotomy having been performed on it " in
situ," but with a fatal result, and it is possible (though improbable)
that some successful precedent may nave given nse to such a
method of practice.

The whole of these remarks on craniotomy have been made with
reference to the size of the pelvis alone, and though I have said
much in disparagement of the operation, still I admit that there
are exceptional cases, where, from the state of the uterus or some
other cause, it appears to be inevitable.

There is another point I have not taken notice of, viz., the value
of the life of the child. I have not done so because, though I
think it might be an additional reason in favour of Ceesarean section,
still it cannot at amr time be compared with that of the mother, so
as te materially influence our decision, where there is a more rea-
sonable hope of preserving the latter by adopting other means ; but
wherever m any individual case we come to toe conclusion that
CsBsarean section gives to the mother a chance of recovery equal to
that afibrded by any other means that can be adopted, then the
additional chance of saving the child becomes an important element
in determining our choice.

Article YL.— Cosmic Sensibility. By David Leslie, M.D.,
Tunbridge, Kent.

''SensibiUty is the nonl of the world.''

From the vibration of the magnetic needle to the perturbation of a
planet, it is sensibility that acts, producing phenomena and generat-
ing forms. Sensibility is physical and vital.^ Vital sensibility
naturally divides itsetf into organic and conscious. But at what

230 DR LESLIE ON COSMIC SENSIBILITY.. [SEJPT,

period physical sensibility became vital, or on what link in the
chain of nature the Promethean fire of life first fell, is as yet un-
known. At what point in the animal scale of bein^ consciousness
first began, is equally involved in mystery. Neither can we dis-
cover exactly when consciousness commences in the period of indi-
vidual development, for no one pretends that consciousness is
possessed by the earliest forms of life even in the highest order of
inteUectual beings? At what period then does it begin? When
did conscious sensibility first exist ? Physical sensibility is chemical
and dynamic Chemical sensibility is manifested only on contact,
by phenomenal manifestations called behaviour, thus using a moral
idea to express a physical fact. However mysterious chemical
attraction may be, and however inexplicable the preference some
elements show for others, with a fidelity that never changes, the
fact that matter is sensible of the presence of matter at immense
distances is still more wonderful. Matter manifests consciousness
of the presence of matter from the insensible distance that measures
the range of chemical affinity to the almost incalculable distances
of fixed stars, producing a uniformity of phenomenal successions
called laws. Matter is nowhere inert, never in repose. It is
always sensible of the existence of other portions of matter, although
at the opposite extremes of the visible universe. Matter manifests
sensibility to the presence of matter from the closest proximity
to the most remote regions of space ; from our solar centre to the
uttermost verge of the known universe, to the very threshold of
infinity.

That matter should be sensible of the existence of matter althouj^h
millions of miles apart is quite inexplicable. Can this sensibility
manifest itself although the subjects be separated by an absolute
void? What is that power that traverses a void, the space so
traversed being still a void? Yet, such seems to be attraction.
Can that be called a void which contains something? for something
must pass from one planet or star to another to make them mutually
sensible of their existence. What is this messenger? Can it pass
through a void, and the space traversed remain a void ? If nothing
pass from planet to planet, or from star to star, how is their sensi-
fcility excited? Whatever this medium of intelligence from star to
star may be, it is always imiform in its action. Matter behaves
with matter {se comporte) invariably in the same manner under the
same conditions. It obeys laws which never change, which are
called physical. It is to the permanent and unchangeable nature
of these laws that we owe physics, t.€., natural philosophy. In fact,
natural philosophy is nothing more than the record of the imchange-
able and fixed laws of the material universe, which is the foundation
of every thing implied in the word science. Laws being nothing
more than uniformity of succession, if that succession was liable to
interruptions or changes, we coula no longer calculate on the cer-
tainty of physical events ; science would cease to exist, and man

1864.] PB LE8UE OH COBMIC SEMSIBILITT. 231

must inevitablj perish. The words skill, cantiony foresi^ht^ etc«|
would then have no existence. Faith in tne invariable unifonnitVi
in the order of phenomenal successions, is almost a religion with the
philosopher (the high-priest of nature) , for it admits of no scepti-
cism, ifature never deceives ua. Our errors can only exist in
words, for the order of phenomenal succession, that is, natural law,
never changes ; if it did, science could exist no longer. Sensibilitj
admits of being divided into two kinds, phvsical and vital. Phy-
sical sensibility is displayed in gravity, electricity, and chemical
affinity. Vital sensibility is manifested in idl the phenomena of
organic and moral existences. This classification, nowever, like
most others, is merely arbitrary, for the transition from material to
vital phenomena is so imperceptible as to be as yet unascertained.
On what link in the great cham of existences the Promethean fire
of life first fell is as yet a secret to naturalists. Where is the point
in the scale of nature where vitality commences, and what is this
new property called life which thus seems to be added to matter?
Spontaneous generation is still only a theory, and whether matter
of itself possess the powers under certain conditions of assuming
organic and vital forms, or whether vitality be a specific creative
addition to matter, is a question as yet undecided. Matter itself is
the unknown cause of the union of Qualities. That vitality should
be a quality, united to matter, manifested only under certain condi-
tions, is no greater mysterv than gravity or chemical attraction.
'^ Sensibility is the soul of the world." It may be used in this
universal sense with propriety. In fact, the expression can scarcely
be called figurative.

Sensibilitjr causes motion. There may be change of place, that
is, motion, without change of form, but change of form cannot occur
without change of place. Physical sensibility generates automorphic
forms which never change under the same conditions. '' Such as
creation's dawn beheld," we see them now. Common salt always
crystallizes in cubes, quartz in six-sided prisms, etc. One part of
hydrogen combines always with eight of oxygen, sixteen of sulphur,
etc., etc. These are essential elective and morphic characters that
never change.

Vital sensibility is geneomorphic, not automorphic, as physical
sensibility is. If vital sensibility be automorphic, then the doctrine
of spontaneous generation is true.

Vital sensibiUty produces geneomorphic forms. It is divided
into two kinds, organic or unconscious, and moral or conscious sensi-
bility. Firsty We nave physical sensibility, such as ^vity, chemical
affinity, and electricity. Second^ Vital, which is divided into organic
and moral.

Organic sensibility exists in the yital world up to the unknown
point where consciousness begins. But at what link in the chain
of animated beings consciousness begins, we know not. From man
to the amoeba, where is the point wnere the consciousness of entity

232 DE LESLIE ON COSMIC SENSIBILITY. [SEPT.

ceases^ where the / am exists no longer? In erowth development,
from the zoosperm to mftn^ &t what exact perioa does the conscioua*
ness of entity bejgin? This particular point in the progressive
scale of physiological development is quite unknown. Is there a
hiatus, a chasm, between organic and moral sensibility, that is,
between unconscious and conscious vitality? No such breach in
the chain of organic development has been discovered ; hence the
difficulty of classification wnich can only represent distance in the
scale of life, but not difference.

Physical sensibility produces automorphism. Particles of matter
possess in themselves that mysterious morphic power which moulds
and shapes the superficial aggregation of atoms, giving them de-
finite forms that never change. It is to this inherent power pos-
sessed by matter that I apply the term automorphic.

Vital sensibility determines organic and moral forms, which are
not automorphic. They are generated by a power called vital;
hence the term geneomorphic, m opposition to automorphic. The
one purely physical, never changing; the other vital, always
changing. Moral forms are the results of volition determined by
the excitement of emotionary sensibilities, such as a chair, or a
watch. A crystal, a flower, and a house, represent physical, organic,
and moral morphisms. Moral selections, moral causation, depend
on the emotionary susceptibilities. They are the resultants of the
several emotionary attractions, the unity of which is choice.

Emotionary. that is, moral causation depending on such varied
moral susceptibilities, must produce varied and different effects,
manifested by different volitions, and, therefore, resulting in different
acts. Hence the same external or internal moral cause will produce
different effects when acting on different emotionary susceptibilities.
An innocent act from certain training and education of the emotionary
susceptibilities may be thought highly criminal, such as eating
pork, etc., etc. From the same causes, what to one would appear
a justifiable death, would be by another murder. The moral or the
voluntary act is the effect of natural causes like a physical pheno-
menon. It is the resultant of emotionary and reflex moral powers
of which the agent is the emotionary cause^ called volition.

The emotion that decides the vobtion is mdependent of the moral
being, uncreated by him, an essential property of his entity, and as
necessary to his specific identity as attraction to matter or form to
a crystal; the cause being purely cosmic, and not individual in
either case, and therefore only a link in the great chain of universal
causation.

Sensibility is the generative cause of all phenomena. It is a
name for an unknown agent seen only by its effects. Our planets
would manifest strong emotion at the presence of a stranger in their
system. Even their changes of place give rise to what are called
perturbations, the result of cosmic sensibility. Potassium is greatly
excited by the presence of oxygen, for even when thrown on water

1864.] DR LESLIE OV CO0MIC 6EN8IBILITT. 233

it ignit»L The needle manifesto great sensibility to the presence
of me magnet

Organic tissues manifest great sensibility to the presence and
contact of certain substances which it seems is quite independent of
dynamic or physical action. A grain of tartar-emetic produces a
greater physiological and dynamic effect on the animal system than
an ounce of cha&. No reasoning h priori would have foreseen this
result, so ignorant are we of vital and physiological laws. Certain
poisons act on one class of nerves^ otners on a different class of
nerves. So remarkable is this fact, that one pupil can be con-
tracted and the other dilated at the same time by different toxic
agents, as by belladonna, and the Calabar bean. 1 had once under
my care a case of aneurism of the arteria innominata^ accompanied
with mydriasis of one eye. The mydriasis was evidently in this
case produced by excitement of the cervical sym^thetic from pres-
sure of the aneurismal swelling. By thus irritating the gangbonic
extremities of the nerves that supply the radiating fibres of the iris,
the harmony of the physiological antagonism between the third ana
sympathetic nerves was deranged ; the circular fibres supplied by
the third pair of nerves yielded to the increased power of the
radiating nbres supplied by the sympathetic, and thus dilation of
the pupil was produced. This was a very remarkable case of
patholo^cal organic and unconscious sensibility. Certain organs
are sensible only to the action of particular substances. The salivaiy
glands are extremely sensible to the presence of mercury, the kid^
neys to alkalis, the conjunctiva to ars^c. The vapour of tur^n-
tine, even its odour, gives to urine the perfume of violets ; cantharides
acts on the urinary organs, etc., etc In the scale of what is called
progress or development, we pass from physical to organic sensibility,
and then to conscious or moral sensibility. At what period in the
scale of vitality, emotionary sensibility, or consciousness commences,
we know not. This is a ^eat mystery, nor is it possible we can
ever know what that conscious entity is, the I, of the I am, for then
the I would be both the subject and the object at the same time*
We have then physical sensibility generating automorphisms, as a
crystal; organic sensibility proaucing vital forms, as a flower;
emotionary, that is, moral sensibility, giving rise to moral acte and
constructive or rational forms, as a watch, or a house.

Moral morphisms and moral acto are tne results of reflex action,
from external or internal causes, acting on the vital and conscious
organization. The morphic creations of man, and his moral acts,
are the effects of causes mdependent of him, as much as the growth
of a plant, or the form of a crystal, is not the effect or act of any
volition in the plant or crystal. Moral power cannot create, it obeys
the laws of cause and effect, like physicBil power. Vital sensibility
produces phenomena inexplicable by dynamic laws; that is, the
uniformity of the succession of vital phenomena is not in accordance
with the uniformity of succession of dynamic or physical phenomena.

234 DR JAMES WATSON^S CASE OF ALOPECIA AREATA [SEPT.

Physical forms are automorphic : the crystal never changes. Vital
forms are geneomorphic : the result of conjugation, even in the
elementary cell. But at what point automorphism passes into

Seneomorphism, it is impossible to tell. When unconscious sensi-
ility passes into conscious sensibility, is equally a mystery. Is
then volition reflex, automatic, without consciousness? The voli-
tion by which the amoeba protrudes its gelatinous processes, is it the
same as that which guided the pencil of Raphael, or the pen of
Laplace? If it differs, at what period in the scale of vital progress
dia this difference begin? We can find no hiatus, no point of
differential volition, except in degree, throughout the whole chain
of animated beings.

Article VII. — Notes of a Case of Alopecia Areata treated by
Carbolic Acid. By James Watson, M.D., Edinburgh.

In a former number of this Journal,^ I drew attention to some
experiments and observations I had made with several new drugs.
One of these was carbolic acid. Since publishing the paper referred
to, I have used carbolic acid for several purposes, and with apparent
advantage. The success which attendea the treatment of favus, by
carbolic acid, in one of Professor Bennett's Wards, and which I
recorded, has now been attained by other medical men in this city,
who have since tried it in the same disease ; and there seems every
reason to believe that it will act as a powerful agent in destroying
parasites in other skin affections. I am not aware that carbolic
acid has been tried in the treatment of psoriasis ; but think, where
the local application of pitch ointment has been so successful,
carbolic acia, one of its essential ingredients, will in all likelihood
be found equally useftil. Should this be so, the application will be
more easily used, less disagreeable to the patient and the patient's
friends, and well adapted for private practice.

Before recording the case of which I am about to give the notes,
I wish to draw attention to a use, to which, from some trials I have
made with carbolic acid, I think it might with advantage be put.
For a long time creasote has been used by medical men, dentists,
and the public generally, to allay toothache, with more or less
success. Dentists now use it principally, I believe, for cleaning
out the carious cavity of a bad tooth. It is for this latter purpose
I would suggest the substitution of carbolic acid. The two sub-
stances are very nearly allied ; but while pure creasote is difficult to
prepare, and rarely to be obtained, pure carbolic acid can be got
from any respectable chemist. From a good many experiments I
have made with the two agents — creasote and carbolic acid — I am
strongly inclined to think the latter the more useful application in
^ January 1864 : Observations on some New Medicines.

1864.] TREATED BT CARBOLIC ACID. 235

destroying and causing the separation of the carions matter in the
cavity of the tooth. In my own experience I never found creasote
allay toothache. I have now repeatedly found carbolic acid do so.

With these preliminary remarks I shall now give the notes of a
case of alopecia areata treated by carbolic acid.

In the first week of January 1864, M. H., set. 28, came to Ward
12, Boyal Infirmary, to consult Professor Simpson about a uterine
disease under which she was labouring. At this time patient
looked weak, under-nourished, and was intensely nervous. After
attention haa been paid to the more immediate object of her visit,
it was noticed that patient's head was completely bald, with the
exception of a few stray, long, dark hairs scattered over it. On
more careful examination she was found to be suffering from incip-
ient phthisis. On making inquiry as to her antecedents, we made
out tne following —

ERstory. — ^Until M. H. got married, ten years ago, she had alwavs
enjoyed good health and strength (unless at her monthly periods,
when she suffered from dysmenorrhoea), and was in the habit of
attending to all the household duties of a &mily of eight brothers,
without experiencing fatigue. About three months after her
marriage she witnessed a wrestling match between two of her
brothers on the green. The elder of the two was the stronger, and,
as patient says, easily excited. Fearing that he was losing temper,
ana that he might hurt the younger brother, she rushed between
the two, in order to separate the combatants. In so doing she fell
and brought down the two wrestlers on the top of her, and was
crushed in the lower part of the abdomen. That night patient,
who was about three months pregnant, aborted, with severe flood-
ing, which untoward circumstance she attributed to the fright and
injury she sustained in the scuffle. From this date, although
patient continued to menstruate regularly, the catamenial flow was
less than formerly, although it had always been scanty. This state
of matters continued till the month of August 1862, when patient
ceased to menstruate altogether ; since which date she has suffered
from amenorrhcea.

Last December (1868), patient suffered from a severe attack of tic
douloureux in the crown of the head. Synchronously with this
attack a small patch of the scalp became bald. Dr Alex. Simpson,
who saw patient in her own house at this time, painted the bala
portion 01 the head with Smith's blistering fluid, m the hope that
this treatment would both relieve the pain and limit the baldness.
But although the tic douloureux was relieved, the baldness extended
and became complete in spite of the repeated applications of the
blistering fluid.

It was at this time (beginning of January 1864) and in this con-
dition, the head bald from ear to ear, and from the brow to the
back of the neck (with the exception of the few dark hairs already
mentioned, which seemed to indicate the points where the several

VOL. X.— NO. m. 2 H

236 DR JAMES WATSON'S CASE OP AfiOPECIA AREATA [SEPT.

round bald patches coalesced) .that patient came to the hospital to
consult Proiessor Simpson. The scalp was well nigh covered with
a yellow favus-like crust, caused by the use of the blistering fluid.
Professor Simpson having prescribed for the uterine affection under
which patient was labouring, I asked his permission to try the
effect ot carbolic acid in the affection of the scalp. He at once and
very kindly acceded to my request.

The treatment indicated was both constitutional and local.

Constitutional Treatment. — As patient's constitution was feeble
and oppressed I ordered her citrate of iron and quinine, dissolved
in infusion of calumba, cod-liver oil,^ wine, and good nourishing
diet.

Local Treatment. — As the scalp was nearly covered with a crust,
the result of the free use of blistering fluid, I got the head poulticed
for two or three days. When the crust was removed the head had
a somewhat oedematous look, otherwise it had all the appearance of
a head bald from age. There were several patches of the scalp
slightly reddened. I now began the application of carbolic acid
dissolved in glycerine, in the proportion of one drachm of the acid to
three ounces of glycerine. The lotion was applied night and morn-
ing ; and, to prevent it evaporating, a cap made of oil-silk was con-
stantly worn. The head was washed morning and evening, before
the lotion was applied, with black soap and water.

Besult of Treatment. — Under the constitutional treatment patient
soon began to improve in appearance, and her general aspect
assumed a healthier and happier character. The cheeks, which
were formerly sunk, became full and nlump, and the lips, once
white and blanched, red and life like. This change, however, was
not immediate, but the result of eight or ten weeks^ treatment

The local treatment by carbolic acid was conmienced about the
12th day of January. The first result observed was the disappear-
ance of the oedema of the scalp, and a freedom from the uneasiness
in the head, which succeeded tne tic douloureux, and continued to
annoy patient till the lotion had been used for about two weeks.
It was next noticed that the slightly crimson patches of scalp
became pale, and the whole scalp white. The few hairs scattered
over the scalp had now fallen out; and from ear to ear, and
from the brow to the posterior aspect of the neck, there was not
a single hair on the head. For a month after the lotion was
used there was a slight frirfuraceous desquamation of the scalp.
At the end of six weeks from the commencement of the local treat-
ment, the head was still quite bare, and it was only by the aid of a
magnifying glass that it was possible to recognise openings in the

^ Patient could not take the cod-liver oil supplied to the hospital, as it
deranged her stomach, and made her generally vomit her food. In this case,
as in several others, I prescribed, instead of the ordinarjr oil, a preparation
called " Furley's cod-liver oil cream," which patient took without inducing any
disagreeable symptoms, and with decided advantage.

1864.] TREATED BT CABBOLIC ACID. 237

skin which commimicated with the fine canals leading to the hair
bnlbs, and distinguiBhed this head iirom the baldness due to age.
At the end of February, a crop of very fine, silken, white hair
made its appearance over the wnole scalp. It was perfectly free
firom pigment, resemblinj?, yet differing from the hair of new-bom
children. At the end of March, the hair was about an inch long
over many parts of the head, the white character of which gave to
the otherwise young appearance of jthe patient a most peculiar
aspect. The lotion was continued morning and evening till the end
of June, since which date the local treatment has consisted solely
in washing the head, night and morning, with black soap and water,
and the free use of a brush to the surface of the head three or four
times in the course of the day.

Patient left the hospital on the 3d day of August 1864, with the
scalp in perfect health, and with a covering of fine, glossy, silken
hair, now very slightly tinged yellow, and measuring firom one and
a half to two inches long.

Bemarks. — ^This case is interesting, inasmuch as it is, I believe,
the first treated by carbolic acid. It is worthy of note that while the
hair, which was very plentiful, fell out, and in the course of fourteen
days left the scalp entirely bare, the patient had not suffered, as
eenerally occurs in these cases, at or about the time firom any acute
rever or inflammatory attack. The alopecia areata, although so
complete as far as the head was concerned, was confined to the
scalp; the eyebrows, eyelashes, hair over the pubes and axillsd
remained intact. Although in this case I dissolved the carbolic
acid in glycerine, it may be sometimes preferable to dissolve it in
acetic acid; and when glycerine is used as the solvent, it may
occasionally be wise to make the lotion considerably stronger.

Article VIIL — Fourteen Cases of Ovariotomy. By Thomas
Keith, F.II.C.S.E.

{Continued Jrom p. 153.)

Case VII. — Cystic and Adenoid Ovarian Tumour. Ovariotomy.

Recovery.

In March last, Dr Drummond of Glasgow asked me to see a lady
who had come under his care two months before, on account of
ovarian disease. She had enjoyed good health till the autumn of
1861, when she suffered from attaciS of diarrhoea. During 1862,
she had violent and repeated attacks, and was then put upon a diet
consisting chiefly of iHsef juice, and upon this she has since con-
tinued principally to live. In January 1863, the lower extremities
began to swell, and for the first time she felt her dresses tight upon

238 CABEa OP OVARIOTOMY BY DB KEITH. [BEPT.

her. She again had diarrhoea in the autumn of that year, and in
September had an attack of menorrhagia, which continued ten
days, with some violence, but which did not recur. In November
she was seized with sudden acute pain in the left iliac region,
recurring from time to time, and of great severity. When Dr
Drummond saw her, two months ago, he found a tumour in the left
and lower part of the abdomen, pushing down into the pelvis, and
there was aistinct ascitic effusion. She was very much emaciated
and feeble, with oedema of the lower limbs, and altogether she
looked very ill. The question at that time with Dr Drummond
was, whether it was a case of malignant disease or of multilocular
ovarian tumour complicated with ascites.

She was placed on a full diet, with a liberal allowance of wine,
and sent for change of air to the country. She returned to Dr
Drummond in six weeks, with her general health greatly improved,
bat with the abdominal swelling immensely increased, and ita
ovarian nature now undoubted.

I found a vigorous old lady, just entering on her sixty-eighth
year, nearly blind, moreover, from double cataract. She was very
sallow, ana extremely thin, with a dry, red, irritable tongue, but
with a heart beating so quietly and firmly, that one's first imprea*
sion waa, that with fair play such a constitution was good for many
years to come. She complained mostly of flatulence, from which
she had sufiered all her life, and attributed to it attacks of
dyspnoea, which came on generally towards morning, and which
were sometimes prolonged and severe. She still had diarrhoea
from time to time.

There was oedema of the lower extremities, and to a slight extent
also of the abdominal wall. The tumour was veiy prominent, and
extended up to the ribs on either side, the upper part of the abdomen
being very much distended from flatulence. Immediately above
the pubis was a projecting solid elastic mass, about the size of a
child's head — the rest of the tumour was cvstic, but its upper
mar^n was very ill defined, and it had a peculiar boggy feeling —
leaving upon me the impression that some soft substance, such as
the omentum or a mass of intestine, lay between the tumour and
abdominal wall. In the pelvis it was entirely solid, an elastic

{iece of it, coming very low down, filled up the recto-vaginal fossa,
n front of the uterus, which was barely movable, it felt very hard
and solid, and was continuous with the mass above the pubis. At
first view this state of matters looked suspicious either ot malignant
disease or of great pelvic adhesion. But after repeated examination
I was satisfiea that the base of the tumour was free from attachment
either to the rectum, uterus, or bladder. The tumour certainly had
a peculiarly elastic feeling which I had not met with before, but it
was just as likely to be adenoid as malignant, and this it turned
out to be.
About a week after I first saw her, she had a severe peritonitic

1864.] CASES OF OTARIOTOMT BT DH KEITH, 289

attack, occasioned hy being jolted in a cab. This was followed hj
a large accumulation of ascitic fluid, which disappeared in a few
days, almost as suddenly as it came, after some diarrhoea. Its pre-
sence, however, completely cleared up the diagnosis of the pelvic
portion of the tumour, but the upper part still retained the same
ill*defined character that it had always presented; and at the
umbilicus there was generally a small extent of clear sound over
the tumour, as if at that point there was adhesion of the intestine.
She remained under observation for a month, the tumour steadily
increasing in all directions. She had occasional feverish attacki^
with abdominal tenderness, followed by ascitic accumulation, which
came and went very rapidly. She was fast losing flesh and strength ;
the dry red tongue still continued ; the disturbance from flatulence
became more distressing, and the attacks of dyspnoea more frequent
and severe. It was after seeing her in one of these attacks, which
more resembled a paroxysm of angina, that I resolved to remove
the tumour, for it was evident that her life was not now safe from
one dav to another. Considering the great age of the patient, her
great feebleness, her blindness, and the doubt as to the relations
of the upper part of the tumour, this determination was arrived at
with not a little difliculty.

On the 21st April, 1 opened the abdomen very carefiilly, im-
mediately below toe umbilicus. The wall was very thin, and a
few touches of the knife exposed the surface of an ovarian cyst*
This was emptied through a small trocar, and another upper cj^st
then came into view* This was quite flaccid and half-empty, with
part of the small intestine and mesentery adhering to it, and frilly
explained the feeling communicated to the hand by external exam-
ination. The omentum was very large, but was nowhere adherent.
The intestine was then carefully separated, but its muscular coat
was slightly exposed. Several small vessels in it and its mesentery
were tied with silk — ^the ends cut short and left behind. The solid
mass was then turned out of the pelvis without difficulty. The
uterus came out with it, but there was plenty of room to secure the
pedicle outside in the usual way. The whole weighed about four-
teen pounds.

For several days after the operation there was very great disten-
tion of the abdomen, and there was a fear for a time that some low
abdominal inflammation was going on, there being for some days
considerable frilness of the recto-va^al fossa. On the fifth day
there was some swelling of the parotia, which gave rise to great pain
and constitutional disturbance, and went on to suppuration. After
this, her recovery was unimpeded, and she returned to Ayrshire
six weeks after the removal of the tumour. The tongue by that
time had become pale and moist She had no more attacks of
diarrhoea, and felt better than she had done for years. The last
time I heard of her, she said she was ^^ as good as new.''

240 CASES OF OYARIOTOMT BY DR KEITH^ [SEFT.

Case VIII. — Semi-solid Ovarian Tanumvy weighing 24 Iha,
Ovariotomy. Death on the ninth day.

J. M., aged 21^ a domestic servant, called on me in March last,
on account of a semi-solid ovarian tumour^ extending nearly to the
ensiform cartilage — her girth at the umbilicus being forty inches.
She stated that nine months ago she came up from Golspie, a
strong healthy woman; that for the last six months, since she
became aware of the presence of the tumour, she had felt feeble,
and unable to do almost any work ; that she rarely passed a da^
without sickness and pain ; that her nights were restless and wean-
some ; and that for the last week she had been mostly inched. She
was much depressed in spirits, and very anxious to have the tumour
removed.

A few days after this visit, she was obliged to take to bed, with
severe abdominal pain, and almost incessant vomiting. This state
of irritation continued, with short intervals of relief, for the next
month. She was never able to be out of bed. and wnen she sat up
she had a peculiar tendency to faintness, which was remarkable and
unusual. In the middle of April she was removed to a suitable
lodging, where for a short time ner general health improved. The
vomiting ceased, she enjoyed her food, and slept well. She was
then in a fair state for operation, and it would have been performed
on the 21st had not the monthly period come on with ^eat violence,
accompanied by such severe gastric irritation, vomiting, and pain,
and such prostration of strength, that for some days she was in a
most critical state, and it seemed as if she would never again get
into a condition for operation. She rallied, however, and the tumour
was removed on the 29th of April. Dr Benjamin Bell, Dr Traill of
Dunfermline, Dr Carruthers of Cramond, and other friends were
present. There was no parietal adhesion, but part of the omentum
was firmly attached to the upper portion of tne tumour, — several
vessels were tied with silk, and the ends of the ligatures cut
off short and left. A piece of omentum, from which there was a
good deal of oozing, was transfixed and tied, the threads being
likewise cut short and returned. The pedicle was of good length,
and was secured bv the clamp without any strain upon the uterus.
Some ascitic fluid m the pelvis was then sponged out, and she was
put to bed in a very good state.

For the two days following the operation she remained in a very
feeble and depressed condition, the pulse ranging from 120 to 150.
There was, however, no pain, no vomiting, and no distention. On
the third day the pulse had fallen to 100 ; and by the end of the
first week her recovery was looked upon as undoubted. The abdo-
men had remained quite flat ; the wound was perfectly united ; the
stitches were all removed; the bowels had acted after the fourth day of
themselves ; she had fair nights ; and took her food remarkably well,
and was cheerful at the prospect of her early return to health ana

1864.] CASES OF OYARIOTOVT BT DR KEITH. 241

independence. But on seeing her on the morning of the ninth dfty,
I was startled by her appearance, which reminded me of a case of
typhus. She had had a restless night ; the pulse was up to 115 ;
were was slight subsultus, and she was covered with a bright
papular eruption. On calling in the evening, I found she had died
rather suddenly about half an hour before. There was no post-
mortem examination, but that blood-poisoning was the cause of
death I have no doubt

Case IX. — Unilocular Ovarian Tumour, Ovariotofny, Beeavery,

M. C, 35 years of age, had been under the. observation of Pro-
fessor Buchanan of Olasgow since the tumour was first detected
about three years ago. Latterly its growth has been very rapid ;
and as soon as she began to lose flesh, and her general health to be
threatened by the disease, he recommended tne removal of the
tumour.

This I did at Glasgow, on the 6th of May, at Professor
Buchanan's request. Dr Drummond of Glasgow, Dr George
Buchanan, and other friends were present. The cyst was easily
removed through an incision three inches in length, and a long
slender pedicle secured by the clamp ; the whole proceeding being
of the simplest kind possible.

I saw her a week afterwards, and removed the clamp, and she
made an excellent recovery.

Case X. — Semi-solid Ovarian Tumour ^ toetghing 35 lbs.
Ovariotomy. Recovery.

In April last an unmarried lady, forty-seven years of age, the
daughter of a medical man, was recommended to me by Dr Cumming,
and Dr Grigor of Nairn, as a fit subject for ovariotomy. The
tumotir had been detected about six months before, and had been
of very rapid growth. All along there had been a great deal of
pain ; while for the last three months the general uneasiness had
Deen so extreme, that she had been unable to sit or lie in any
position, by day or by night, for any length of time. Before the
commencement of her illness she had been very plethoric, but she
was now losing flesh very rapidly.

Three weeks before I saw ner, she had been tapped by Dr Grigor
below the umbilicus, and about fourteen pints of fluid removed.
She had little relief, liowever, from this, for the upper part of the
tumour did not subside, and it had again nearly regained its former
dimensions. The largest cyst that could now be detected was
above the umbilicus, and the cyst formerly emptied did not appear
to have refilled. The greatest ffirth was forty-three inches.

On meeting, on the 10th of May, with Dr Arthur Mitchell and
Dr Cumming, for the purpose of removing the tumour, her general
condition was so unfavourable, that it was agreed to postpone the
operation, and simply to tap the upper cyst, in hopes of giving

242 OASES OF OYABIOTOHT BY DR KEITH. [SEPT.

some relief. This cjst was found to contain about fourteen pounds
of fluid^ and she felt so much more comfortable after the tapping^
and had such good nights, that we felt warranted on going on witn
the operation, on the 20th of May, ten days after the tapping.
The tumour was semi-solid, and there were extensive but easily
broken down adhesions in all directions. These were separated, as
hi as the hand could reach. The tumour was then cut into and
broken up. When its size was much reduced, the hand was again
passed in, and some adhesion to the small intestine and extensive
adhesion to the stomach separated ; and I was then able to with-
draw the whole without extending the incision above the umbilicus.
The pedicle was of fair length, and was secured as usual hy the
clamp, and the wound closed by silver sutures.

It would occupy too much space to go into the details of the
tedious convalescence which followed, — the longest by far I have
yet met with after ovariotomy. Violent peritonitis, nearly proving
fatal, set in on the third day. This was followed towards the end
of the first week, by effusion into the left pleura ; and to this again
succeeded a second attack of general pentonitLs of great severity.
The wound, which seemed at first to have united, towards the end of
the second week, took on unhealthy action, and opened up through its
whole extent. Great sloughing of the cellular tissue of the abdo-
minal wall followed, and the tracks of the wire sutures became con-
verted into so many different sinuses, which went on discharging
for weeks, the wound itself slowly healing by granulation. She
had also bed sores, and lay for many weeks in a state of great
feebleness on a water bed ; and it was not till two months after the
operation that she was able to make the lon^ railway journey to
[Nairn. She is now quite well, and becommg a strong woman
again.

Case XI. — Multilocular Ovarian Tumour weighing upwards of
65 lbs. Omriotomy, Death from Exhaustion.

•Mrs W., «t. 29, but looking twenty years older, came to me
with a verv large ovarian tumour. She had been seen, for the first
time, the day before, by Dr Lum^air of Largo, who, though recog-
nising the advanced state at which the disease had amved, still
thought the case might be one for ovariotomy, as the patient had,
till the detection of the disease eighteen months before, been
remarkably healthy, and she was of a vigorous and healthy
family.

She had already been tapped three times, and had taken a great
deal of medicine of various kinds. Till two months before 1 saw
her she had not suffered much firom her complaint, and had not lost
much flesh, and was generally able to look after her household affairs.
She then imderwent a prolonged mercurial course, which she said
completelv took the flesh off her bones. Since then she has been
very feeble.

1864.] CASES OF OYASIOTOMT BY DR KEITH. 248

She was exceedingljr emaciated, and presented in a well-marked
degree the weary, miserable, faaggara appearance of advanced
ovarian disease. The tnmonr was very large^ measuring upwards
of forty-nine inches a little above the umbilicns. Between the
anterior spine of the right ilium and the umbilicus the measure-
ment was seventeen inches ; between the spine of the left ilium and
the umbilicus she measured twenty-one inches; and the space
between the ensiform cartilage and pubis was thirty inches. The
abdominal wall was, over a large extent, thickened, brawny, and
oedematous. The tumour was mostly composed of one very large
cyst, but there was a considerable amount ot solid matter on the left
side low down* The uterus was central, normal, and very movable.

She was a woman of great resolution, and though she was well
aware that her case was an unfavourable one, she wished to take
her chance of the operation, in the hopes of being restored to her
husband and children.

She was tapped the day after I saw her, and upwards of sixtv
pints of very thick ovarian fluid were removed. She was mucn
relieved. Sue was put upon a ftiU diet, and slept better than she
had done for months. The usual monthly period, after being
delayed for a week, continued for ten days. Nearly tnree precious
weeks were thus lost, the cyst was filling with great rapidity, and
her strength had greatly diminished.

The tumour was removed on the 23d of Mav. Professor Syme,
Professor Lister, Dr Lumgair of Largo, and other friends were

? resent. The girth had already increased to forty-three inches,
^he cyst was wounded in opening the peritoneum, and the contents
were allowed to escape. There were extensive parietal and omental
adhesions, and more bleeding than usual from the torn vessels, as
I have always observed is the case when the abdominal wall is
much thickened. Several vessels in the omentum and wall were
tied with fine silk, the ends cut off and returned. A long thin
pedicle was secured by the clamp as usuaL Owing to a free oozing
from the torn adhesions, the operation was prolonged, and there was
much more sponging and handling of the parts than usual.

She had a quiet night, and required but one small opiate enema.
The urine was copious, and perspiration moderate ; and she took
from time to time some beef-tea and other simple nourishment, with
an occasional small quantity of stimulant. She complained all
along of feeling very tired, and though she promised well next
forenoon, her pulse, though not frequent, was very feeble ; and she
died in forty-six hours, as one dies from the ishock of a great injury.

Case XII. — Ovarian Tumour nearly Unilocular. Ovariotomy.

Recovery.

An unmarried lady, now twenty-seven years of age, was seen in
November 1861, by Mr Wells, who diagnosed an ovarian cyst,
unattached anteriorly, with a secondary cyst or cysts in the wall

VOL. X.— NO. III. 2 1

244 CASES OF OVABIOTOHT BT DB KEITH. [SEPT.

a little below the umbilicns. Her health was then good, and he
recommended her to wait. Some time after this, on her return
home, she was for many weeks confined to bed from supposed
cjst inflammation^ and her general health was for long veiy mdif-
ferent. I first saw her towards the end of last year. She was
then in good healthy but thin, and measured forty-one inches at
the umbilicus. The cyst was still apparently unattached, and the
secondary cyst felt by Mr Wells three years before had not in-
creased, though its position was now more upwards — ^sometimes
to the left of the umbilicus, and sometimes near the edges of the
false ribs. Delay was still recommended.

I saw her again with Dr Dunsmure in May last. The tumour
was steadily increasing. She was losing flesh and was getting
anxious to be relieved of her burden, and we agreed to remove it,
believing that it was safer to do so than to tap so large a cyst

This was done on the 30th of May. Dr Dunsmure and Dr
Gordon of Old Aberdeen were present. The large cyst,* contain-
ing forty pints of fluid, was emptied, and together with a sin&rle
secondary cyst, was easily withorawn through an opening in ttie
peritoneum about two inches in length. As 1 was aoout to applj
the clamp, a small cyst in the broad ligament was observed. Tnis
led to a more careful examination of the attachment of the cyst, and
no fewer than seven small cysts, about the size of beans, were dis-
covered, some of them near the uterus. The ovary itself, diseased
and slightly enlarged, was close to the uterus, and quite sessile. A
double ligature was placed under it, but it could not be got into the
clamp, which was applied almost close to the uterus. From the
thickness of parts embraced in the clamp, a single stitch sufficed to
close the wound. Before tightening the stitch, the strangulated
ovary was brought out alongside the clamp and secured to it
Owing to the great laxit]^ of the abdominal wall, there was not
much strain upon the pelvic tissues, though the uterus was brought
up close to the wound.

On the second day the monthly period came on with great
violence, and there was for two days a copious discharge of men-
strual-like fluid from the incision. The clamp was removed at
the end of a week, but the ligatures round the strangulated ovary
did not separate for five weeks after the operation. Her recovery
was uninterrupted*

Case XIII. — Semisolid Ovarian Tumour umghing Thirtysix
Pounds. Ovariotomy. Recovery.

Miss W., aged thirty, recommended to me by Dr Haldane of Avr.
on account of a large semi-solid ovarian tumour of about six months
growth. When I saw her in the beginning of June, her greatest
^irth was thirty-eight inches ; there was one cyst of considerable
size above the umbilicus, the rest of the tumour was semi-solid.
She was in pretty good health, but wasgetting very thin about the

1864.] CASES OF OVABIOTOMT BT DB KEITH. 245

arms and shonlden. She cotdd walk bat a very short distance, and
her nights were bad.

By the Ist of July her girth had increased to forty-two inches
and a half, and there was some oedema of the limbs. To relieve
this and to give her some good nights before the operation, I
emptied the upper cyst, which contained about eight pounds of
fluid. I removed the tnmpur on the 8th of July. Dr M^Lan-
naghan of Daliymple was present. Some ovarian fluid^ mixed
with large flakes of lymph, escaped on opening the pentoneum.
I then cut into the tumour, passed in my hand and broke it up. and
with some difficulty was able to withoraw the whole througn an
incision not exten£ng above the umbilicus. There was a great
deal of sponging necessary. The pedicle was of fair length, and
was secured by a clamp, and the wound was closed by six deep
and three superficial silk sutures in the usual way.

She got very sick with the chloroform, and vomited bile for the
next twenty-four hours, but her pulse never rose above 70, and her
recovery was unusually rapid. The sutures were removed on the
fourth oay, except one close to the clamp which had escaped notice,
which was removed on the eighth day. There was not a sinrie
drop of matter along the track of any. By the middle of the
third week she was going about quite well, and she went to her
home, near Ayr, four weeks after the operation.

Case XTV. — Large Cyst containing Fifty-five Paunch ofMuicL

y. itecovery.

Miss B., a^ed thirty-five, a patient of Dr Halliday Douglas, had
been aware of the existence of an ovarian tumour for about twelve
years. I saw her first six years ago. At that time it filled up the
whole abdomen; was unilocular, and unattached. It steadily
increased, and now she measures forty-four inches at the umbilicus,
twenty-nine between the ensiform cartilage and pubis, and twenty-
eiG;ht inches between the one anterior spine of the ilium and the
other. There is great elevation of the nbs. and great displacement
of the heart, for its impulse is felt below tne third rib two inches
firom the mesial line. She has latterly become very nervous and
thin, and has bad nights.

On the 25th of July, I opened the peritoneum to the extent of
two inches and a half^ tapped, and drew out the cyst, which con-
tained between five and six gallons of fluid. The cyst was almost
sessile, and the clamp was placed roxmd its base, the uterus being
brougnt up nearly to the abdominal wall. One deep silk suture
was sufficient to close the wound.

For several days after the operation she suffered from severe
cardiac pain, apparently of a neuralgic nature, with a frequent ten-
den<rfr to syncope. There were no abdominal symptoms whatever,
and her recovery was rapid and uninterrupted.

The following table contains an account of all the operations for

246

CASES OF OVARIOTOMY BY DR KEITH.

[sept.

oyarian tumour^ which I have up to this time performed. Of twenty
cases in all, six patients died after the operation, and fourteen
recovered perfectly, and are now in good health.

Table of Twenty Cases of Ovariotomy.

No.

Dftt&

<

Conditlt^a.

1862.

1

Sept.

49

Married,

S

Jan.

66

Married,

8

Feb.

24

Married,

4

March.

27

Married,

6

May.

22

Unmarried,

6

July.

62

Married,

7

Aug.

28

Married,

8

Sept

23

Unmarried,

9

Oct.
1864

16

Unmarried,

10

Jan.

66

Married,

11

Feb.

40

Unmarried,

12

March.

60

Married,

18

April.

68

Married,

14

May.

23

Unmarried,

15

May.

86

Unmarried,

16

May.

29

Married,

17

May.

47

Unmarried,

18

May.

27

Unmarried,

19

July.

80

Unmarried,

20

July.

88

Unmarried,

History, etc.

Result

Multilocnlar; 251b. ; sarronnded by ascitio fluid;

Multilocnlar; 46 Ih ;

Multilocnlar; 681b.; tapped once;

Mnltilocular ; upw. of 120 lb. ; tapped 4 times ;

Multilocnlar; 88 lb.; since married ;

Fibro-sarcomatous, and cystic ;

Mnltilocular; nearly 80 lb.; tapped 7 times;

Multilocnlar; 401b.; tapped twice;

Semi-solid; rerylarige; tapped oooe;.

Seml-solld; 231b.; tapped twice;

Mnltilocular; 37 lb. ; tapped once;

Large single cyst;

Cystic and adenoid;

Semi-solid: 24 lb.;

Large single cyst;

Mnltilocular ; 66 lb. ; tapped 4 times;

Semi-solid; 861b.; tapp«d twice;

Mnltilocular; 86 lb.;

Semi-solid; 861b.;

Very large single cyst, containing 66 lb. of fluid ;

Remains welL

Remains welL
Died 28 hours after.
Remains welL
Remains well.
Died 6th day.
Died 88 hours after.
Remains well.
Remains well.

Remains well.
Died 6th day.
Remains well.
Remains welL
Died 0th day.
Remains welL
Died 46 hours after.
Remains well.
Remains well.
Remains well.
Remains well.

I^art Secontr.

REVIEWS.

A Treatise an Hygiene with Special Reference to the Military Service.
By William A. Hammond, M.D., Surgeon-General U. S.
Army. Philadelphia : Lippincott. 8vo, pp. 604.

This is a work written by a military surgeon of exalted rank,
during a war of unparalleled dimensions, and with special reference
to the military service. But it does not treat exclusively of military
hygiene. It contains much that applies equally to the civilian and
the soldier. It is, in truth, an epitome of the copious literature of
sanitary science, placing before the reader, in a volume of moderate
size, all that is practically worth knowing in the science and art of
prevention.

The book has been written to supply an acknowledged want;
the author believing that " a great necessity existed for a treatise
upon some of the pnncipal subjects of hygiene." Whilst professing
a lively faith in the actions of magistral remedies, Dr Hammond
maintains that the influence of hygienic measures has been too

18e4.] DB HAMMOND'S TBEATI8E ON HTOIENE. 247

much overlooked ; and that dmes, the traditional actions of which
have been positively disproved by physiological and chemical
researches, as well as by the soundest pathological deductions, are
too fireqnentlj administered through tne constant pursuit of that
routine practice which at once hinders the development of medical
science, and cramps the powers of those who labour for its advance-
ment. He thereiore endeavours to take a broad view of his subject^
to the intent that his book may be generally useful. But Dr
Hammond had a stronger motive than that of supplying the pro-
fession with general knowledge, when he undertook, m addition to
his already onerous labours, tne preparation of the present volume.
From the lon^-continued and profound sleep of peace, his country
awoke to the horrors of a gigantic civil war. An army had to be
made, which, when marched mto the field, consisted of officers and
men alike unversed in their duties. To protect the Federal army
from the effects of the numerous external causes of disease which
cling so tenaciously to the camp, was the duty of the medical
officers. But they were inexperienced men, who had not so much
as witnessed a Cobham or an Aldershot. Dr Hammond made to
himself the following proposition, which is demonstrated in the
book before us : — " In me military service," he says, " more than
any other, a knowledge of tUb means of preventing disease, and of
facilitating recovery by methods other than the mere administration
of drugs, is necessary. Armies are often so situated that their
salvation depends upon the knowledge which the medical officers
mav possess, and it never happens that some important application
of hygienic principles cannot be made to them by those who are
charged with their medical superintendence."

Dr Hammond's book is not a mere compilation ; it consists, in
part, of the results of his own personal investigations, which, having
accumulated through manv years of active and responsible practice —
formerly as Professor of Anatomy and Lecturer on Clinical Surgery,
and recently as a Surgeon-General in the army — are entitled to
respectful consideration.

The book is divided into forty-one chapters, some of which are
very short, and their subjects insufficientlv treated — shortcomings
not unlikely to occur in a work written at high pressure, but which
mav be atoned for in a fdture edition.

We shall not undertake a criticism of Dr Hammond's work ; it
is written for the information of those who run, not for those who
have leisure to examine the various paths by which the author
reached his conclusions. Nor can we do more than briefly advert
to one or two topics which the author conceives to be of paramount
importance.

The opening section treats of the qualifications and disqualifica-
tions of recruits. The Federal armv is now numerically larger than
that of any other country in the world ; but that does not of necessity
imply that its aggregate physical strength surpasses thatof aEuropean

248 DR HAMHOKD^S TRISATISE ON HTGIENE. [$EFT.

army of half its size. Tailors, shoemakers, and bricklayers cannot be
made soldiers in a day ; they may don the uniform and shoolder the
rifle, but th^ are soldiers only in name until they haye passed through
the ordeal of a regular and severe course of training. W hen the author
speaks of the ill condition of the earlier drafts of men, he oyerlooks
the fact that the Federal Government had no choice when it allowed
" incapables " to enter the army at the outset of the campaign*
Beady-made soldiers were not forthcoming in sufficient numbers,
and when the first shot was fired, hundreds of thousands of hearts
quivered, for they knew not the meaning of war. If any of the
first-drawn men remain, they are veterans now, and- have learned
the lesson of war by a protracted exposure to its horrors and its
hardships, and by the witness of human butchery, such as civilized
nations nad deemed impossible. The experience afforded by the
present American war shows truly the importance of a carefol in-
spection of recruits ; but it teaches a wiser lesson than that — it tells
us the necessity of preserving our veteran troops, by all the
machinery of efficient sanitary reflations, if we would avoid the
dilemma of sending cripples to the front. The early condition of
the Federal army — ^judging from the author's remarks — ^must have
been deplorable in the extreme.

^^ The present rebellion has opened our eyes to the evils flowing
from the mdiscriminate enrolment of men imnt, by reason of physicsu
infirmities, to undergo the hardships incident to a soldier's life.
Thousands of incapacitated men were in the early stages of the war
allowed to enter the army, to be discharged after a few weeks'
service, most of which had been passed in the hospital. Many did
not march five miles before breaking down, and not a few never
shouldered a musket during the whole term of their service. In a
hospital under my charge, containing six hundred beds, I discovered
at one time, on inspection, fifty-two cases of inguinal hernia in men
who had undergone but an insignificant amount of exposure to
hardship. Cases of chronic ulcers, varicose veins, epilepsy, and
other conditions unfitting men for a military life, came frequently
under my notice. The recruits were either not inspected at all by
a medical officer, or else the examination was so loosely conducted
as to amount to a farce. I know of several regiments in which the
medical inspection was performed by the surgeon walking down the
line and looking at the men as they stood in the ranks. Not long
since a case was reported to me by an intelligent surgeon, in which
the colonel of the regiment to be inspected refused to allow the men
to be stripped in order to undergo examination. Matters, however,
are better arranged now than at the commencement of the rebellion ;
but there is every reason to believe that sufficient care is yet by no
means taken to prevent the entrance of men into the service who
are rather subiects for the hospital than soldiers fit for the field."

The first chapter is confined to the circumstances which in a
general way affect the aptitude of a man for military service, in-

i8Gi.] DR Hammond's tbeatise om hygiene. 249

dading age, statnre, etc. The second chapter treats of the niecial
qnalifieationB and disqualifications, and the sabject is oonsiderea from
an anatomical point of view, the development and diseases of the
different regions of the body being discussed in their order. Thia
completes the first section of the work. The second section is
divided into ten chapters, and discusses the agents inherent in
the organism which affect the hygienic condition of man. This
section is of a more general character, including the subjects of race,
temperaments, idiosyncrasies, age, sex, hereditary tendencies, habits,
and constitutions. The third section consists of twenty-nine cnapters^
in which the subjects of climate, in its several aspects, the sanitary
reg^ulations of hospitals, barracks, camps, diet, dress, clothing, and
others are considered.

The chapters relating to the construction, ventilation, lighting,
heating, etc., of hospitals, barracks, and camps, are full ot valuable
information. Several drawings are made use of to illustrate this
part of the work, and examples of the excellencies and evils of such
Dtdldings are drawn from those existing in various parts of the
world. One of the oldest forms of hospital, that in which three or
four sides of a square are built upon, is particularly condemned.
Ourfs Ho»piudj Necker^ BicStre^ acJpetrih'ey Saint LauiSy and the
Maiaon Muntcipale de SanU of Paris, the Oapitale Maggiori di
MilanOj and the Military Hospital in Algiers j are all built upon the
general principle of the closea court or hollow square, and are alike
disapproved. The principles which Dr Hammond enlarges upon in
the construction and administration of a hospital are : —

1. That it is capable of being well ventilated.

2. That it is sufficiently capacious for the number of inmates it is
to contain.

3. That it admits of good drainage.

4. That it is provided with a sufficient number of windows.

5. That the kitchen, laundry, and other offices of administration
axe well arranged and of ample size.

6. That efficient water-closet, ablution, and bathing accommoda-
tions are provided.

7. That it is amply supplied with water, and gas, or other means
of illumination.

8. That the fomiture, of all kinds, is of suitable quality.

9. That the officers and attendants have their proper respective
duties assigned to them, and that they are in number sufficient for
the wants of the sick.

10. That proper rules are established for the government of the
hospital, for the diet of the inmates, and for preserving order, and
an efficient state of police.

The concluding nine chapters on diet and clothing also abound
With useful information. They contain much of the author's per-
gonal knowledge acquired by actual observation and scientific inves-
tigation, as well as the results of laborious research. This subject

260 DR Hammond's tbeatise on hygiene. [sept.

id not new to Dr Hammond ; he has previously written on it in his
Physiological Memoirs^ and in his prize essay On ike NtUridve
Value and Physiological Effects ofAUmmen^ Starchy and Qvmy when
singly and exclusively used as Food, published in 1856. The relative
value of the different articles of diet is estimated, and the diet tables
of the U. S. Army are given in full. Dr Hammond's book is
worthy of the careful attention of military medical officers, and
cannot fail to be most useful to his brethren at present engaged in
the American struggle.

Lectures: Chiefly Climcal. By Thomas King Chambers, M.D.,
Physician to St Mary's and the Lock Hospital. London :
Churchills: 1864.

The volume before us is a new and much enlarged edition of a
work to which we some little time ago directed the attention of our
readers.^ At that time it bore the title " The Renewal of Life ; "
but as that designation was pretty generally objected to, Dr
Chambers has changed it to that which it now bears. In our
former notice we stated that^ in Dr Chambers' opinion, disease con-
sisted in all cases in a deficiency of vital action, and that it was the
object of rational medicine to " renew life ; " in other words, that
the treatment of the scientific physician should be mainly restora-
tive. With the importance of these principles Dr Chambers is
" more than ever impressed," and the present volume contains faller
illustrations of these than the preceding. For our own part, we
have to repeat what we formerly stated, that while in general we
agree with the plans of treatment of disease recommended by Dr
Chambers, we consider his system of pathology as too exclusive.

The first new subject treated of in this volume is " The forma-
tion of mucus and pus ; " the three chapters in which it is considered
having formed the Lumleian Lectures delivered before the College
of Physicians in 1863. A ereat part of them is to a considerable
degree out of place in a work on Clinical Medicine, but we allude
to them for the same reason on account of which, no doubt, Dr
Chambers introduced them, because they constitute good examples
of his peculiar pathology. Dr Chambers maintains that, in the
healthy state, mucous membranes do not secrete mucus, but that
they are merely moistened by a watery exhalation which contains
no morphological elements except a little effete epithelium. When
disease sets in, and the vitality of the part is mminished, mucous
globules make their appearance^ and this mucus is to be regarded
as a parasite, its globules retainmg no higher function of life than
a reproductive force. In a still higher degree of deficient vitality
the fluid becomes purulent, the pus globules, according to ui
^ See this Joamal for November 1863, p. 454.

1864.] DR chambers' CLINICAL LECTURES. 251

Chambers, being ^' parasites inside the epithelial cells, capable of
increase by propagation within the tissue, just as on the sur&ce the
mucous globules were shown as parasites capable of increase by
propagation without the tissue. And they grow quite independent
of tne true nucleus of the cell, and are not derived from it."

Into the histological arguments by which Dr Chambers attempts
to establish these positions we hare neither space nor inclination to
follow him, particularly as we do not exactly understand his state-
ments regarding the mode of development of mucous and pus
corpuscles, when he endeavours to reconcile and work into a single
system the observations and conclusions of men who differ widely
from one another, such as Henle, Virchow, Beale, Fdrster, Buhl,
and others. The following passage contains statements with which
very few modem histologists will agree : —

** In solid stmctureB this effusion is followed by an endosmotic current of
the watery part back again into the circulation, leaving behind it the more
solid and coagulable constituents. On free surfaces, covered only by soft open
epithelium, the water and salts therein dissolved escape, forming the fluid of
tne mucus. The elements of new tissue, being there very copious to supply
the constant demand for growth, ooze out copiously with the serum, and
constitute the mucous globules. They are wasted elements of new growth,
not themselves a new creation, or evidences of superadded life.

*^ How do these matters get tlirough the coats of the capillaries ? There
cannot be holes for their escape, or else the blood-discs, which are the smaller
of the two, would escape also. Doubtless this is one of the great riddles of phy-
siology. But the art of drawing is in a certain d^ee responsible for some
of the difficulty which it presents to our minds. When we have no means
of correcting by our other senses impressions made on the eye, we are too apt
to consider everything with an outline as equally solid. The necessarily hard
outlines of the engraver express to us forms which may, for all the paper
shows, be spheres of cast iron, whereas in truth they are as delicate as aerial
clouds. Why may the^ not pass through tissues, mutually dissolving and
dissolved by the matenals of those tissues? Just as we see a stratum of
fleecy cloud among mountains, or in Turner's pictures, disappear when it
comes to a stratum of warm air, and reappear in the same form when it
emerges on the other side. To get just ideas of nature, we must look upon
solidity as a comparative, not as an absolute, quality.**

For OTir own part we cannot look upon increased, even if some-
what altered^ secretion, as bj any means invariably a sign of
diminished vitality. If a gram of sand be lodged in the conjunc-
tiva, the effect is a greatly increased flow of tears, by which, very
probably, the offending body will be washed away. There is
nothing morbid up to this point ; it is an example of how the tissues
can take on increased activity ; no doubt, if goinff too far or con-
tinuing too long, it would verge into disease, but if restrained
within due limits it is really physiolo^cal. Or, it may be said to
constitute an example of that nutritive irritaoility, by virtue of
which tissues can assume to themselves a larger amount of nutritive
irritability, although if it exceed certain limits a diseased condition
is the result.

With the therapeutical statements with which the third of these

VOL. X.— NO. III. 2 K

252 BR CHAMBERS*^ CLINICAL LECTURES. [SEPT.

chapters concludes, we genendly agree. A certain degree of cold,
and a firee supply of oxjgen, in the form of atmospheric air, are to
healthy surfaces invigorating and Ibeneficial ; if, however, their
vitality be lowered, the agents, instead of being salubrious, become
deleterious. Hence, no doubt, it is that a layer of healthy pus is
the best covering for a raw surface; and for this reason Dr
Chambers would not encourage too free expectoration in the early
stages of pulmonaiy afiections, because the mucus thrown out forms
the best covering for the inflamed membrane. Afiter having
spoken of the effects of warmth and moisture, the chapter concludes
with the following passage, the statements in which we believe to
be in the main true, though opposed to the views at present fiuhion*
able with regard to the all-importance of ventilation : —

"The recognised benefit of moist warmth may, I think, suggest to as
something more. When an animal submits to the periodical latency of the
higher functions which takes place during sleep, it inatinctiTely seeks the
warmest birth it can find; it is instinctively careless about the supply of
oxygen so that it can get heat. Beasts hide themsdres in unventilatea dens
and burrows ; man surrounds himself with blankets and curtains in a close
bedroom, and not all the questionable aimiments of busy philanthropists can

Sersuade him to open his window at nignt. I suppose that instinct is here*
itary experience transmitted by generation from sire to son, and continuously
increased through countless ages. It is not surprising, therefore, that its
silent voice should beat out of the fidd the voice of argument, however loqua-
cious. But I doubt if we physicians listen for it carefully enough. In that
state of deficient vitality wnich constitutes disease, we are ndly apt to leave
to accident the duty of cherishing the weak life by warmth, in every hos-
pital I enter, the wards are a great deal too cold. Because their foremthers
tried to keep the sick warm by unwise methods, the public in the present
day zealously oppose the better means of healthy warmth which new inven-
tions provide. Can we be surprised at rheumatic patients fiillin^ into peri-
carditis, at fever patients havmg pneumonia, when house- visiters, vigorous and
well fed, walk in from the park, and finding the wards smell of mutton-
broth and poultices, order the windows open without compunction ? Such
things are ; but they might be prevented if physicians would first convince
themselves, and then the public, that an atmosphere and a temperature whick
is sCTeeable and wholesome to the healthy, need not be either agreeable or
wholesome to the sick."

The only other chapter we can notice is headed " Atrophy of
Muscles." Before, however, speaking of the special subject of it,
we have to make a remark on Dr Chambers' views on hypertrophy,
as therein expressed. Dr Chambers says, —

" You may be tempted to inijuire, if over-use of voluntary muscle causes
atrophy, and under-use also, whilst moderate use leaves our frames well-pro-
portioned, what sort of use it is which induces hypertrophy. I confess that
in spite of the dedei rtpetiia statements of physiologists, who have been copy-
ing one another from the time of Glalen, I ao not know that any kind of use
at all does so, in the sense of making the substance of the muscle larger
when measured in a state of rest. Doubtless an actively employed iHceps or
gastrocnemius will more readily be acted upon by the voluntary nerves, will
contract more strongly, and be harder and more prominent when contracted ;
but I cannot find that it grows at all bigger. I do not absolutely deny the

1864.] DB CHAMBERS^ GUNICAL L£GTURK& 258

existence of the physiological hypertrophy of miucle ; I only My tbiU al all
events it is very rare, for I cannot find any instance of it.

" The most notable example of muscular hypertrophy ought to l»e an active,
well-made, one-legged, or lame man ; seeing he oses one leg instead of two,
it ought surely to be enlaiged. Yet in meaauring in several instances the
remaining leg in a state of rest, I cannot find tliat the proportion which it
bears to the arm is at all different from the proportion in ordinary persons of
the same build. And I cannot find that as a rule blacksmtth*s arms are out
of proportion to their legs. Both are muscnUff ; for none but a muscular man
can work at such a tn^e, and when excited, the brachial muscles contract
firmer than those of the lower extremity, and are more marked ; but they
are not disproportionately large when relaxed."

This statement agrees with the rest of Dr Chambers' pathology,
the idea appearing to be, that as hypertrophy of muscle implies
increased action or vitality, it does not exist, or is extremely rare.
With this opinion we ao not agree. We have undoubted and
frequent examples of physiological hypertroph}r of muscle in the
case of the heart Take a case of moderate aortic constriction ; in
consequence of the diminished size of the orifice the ventricle can
no longer supply the system with a full supply of blood ; but a
want is experienced by the tissues, and in order to supply it the
ventricle is called upon for increased exertion ; this increased exer*
tion calls for additional nutritive energy, and in no long time the
ventricle becomes hypertrophied. If the increased bulk of muscu-
lar fibre retain its healthy structure, and if no dilatation of the
cavity take place, the hypertrophy may be regarded as physiologi-
cal, because compensating to a certain degree lor the obstruction to
the circulation occasioneaby the contracted orifice. Neither do we
attach much importance to Dr Chambers' illustration of the one-
legged man ; for though he uses one leg instead of two, the one
leg does not do the work of two ; as progression is effected not by
the single leg, but by it aided by the muscles of the back and
arms applied through the medium of crutches or other means of
profession.

Dt Chambers' observations on the atrophy of muscles we con-
sider exceedingly good. He describes several cases of muscular
atrophy in which the disease appeared due to over-exertion of the
muscles, and then makes the following remarks : —

** You may easily recognise in all these cases the same evil in action under
corresponding circumstances — atrophy produced by local overwork of volun-
tary muscle. And if yon think, and examine closely the relations of the
muscle to the rest of the organism, yon will see that this overworked tissue is
in a position not very, different from the underworked tissue, whose degenera-
tion IS so generally made the subject of remark by physiologists. The defect
is in both mstances a want of renewal. In underwork no demand is made for
renewal, and in overwork the demand is made, but is not efficiently supplied.
In the one the nerve-force, which should guide and govern the metamorphosis,
is let lie asleep, and in the other has been so used up by unwonted toil, that it
is exhausted, and for a time does not exist. So that the last effect on the mus-
cular fibre is the same. No new store of muscular subetance is laid in, and the
old degenerates into inelastic fibre, and finally into a pale fatty tissue of still
lower vitality.'*

264 . DR CHAMBEBS' CLINICAL LECTURES. [SEPT.

The same principle is applied, we think, correctly to the explana-
tion of the palsy occasioned by poisoning with lead : —

" I am disposed to explain a great part of the pathology of painter^s dropped
hand on the same principle which I stated to yon on a former occasion apropos
of simple muscular atrophy. The white lead is slowly absorbed by its gradual
and sparing solution in the fluids of the bod^r, which are rendered capable of
dissolving it by their saturation with carbonic acid. In the blood it destroys
the red globules, and carried to the muscles removes their red colour also,
and renders them incapable of contracting except under extraordinary nervous
influence. This paralyzing effect is most commonly shown on the involuntary
fibres of the intestines, producing the well-known painters' colic. There are
two reasons why it should be exhibited soonest on these intestinal fibres;
first, they are the nearest to the usual portal by which the poison enters,
the path of the food ; secondly, they are weak muscles, and yet have constant,
almost unintermitting work to do, so that they can have but little repose
during which recovery from exhaustion might be possible. Hence colic and
constipation from arrested vitality in the mtestines is the commonest result
of lead poisoning.

To the muscles of voluntary motion in the trunk and limbs the same prin-
ciples apply, and most especially the latter. Those muscles become most
paralytic which are most exhausted by the peculiar employment of the indi-
vidual. 1 had a patient a few years ago whose work lay in a sheet-lead ware-
house, and consisted of moving very heavy masses of that weighty metal. He
became gradually paralytic in the right forearm, and weak in the loins, parts
extraordmarily exhausted by his labour." '

In conclusion, we have only to say, that while on various points
we do not agree with Dr Chambers, we consider that his book,
especially in its present form, contains much valuable matter, and that
it is calculated to prove a trustworthy guide to the practitioner.

Treatment of Diseases of the Skin. By Dr William Frazer, Lec-
turer on Materia Medica. Dublin : Fannin and Co. : 1864.

This little work does not treat of the whole subject of skin diseases,
but, as its name implies, is principally devoted to their treatment.
It is divided into cnapters, each treating of a group of remedies,
under which their therapeutic actions in the different skin diseases
is considered. Thus we have chapters on Mercurials, Arsenic,
Chalybeates, Desiccants, Baths, and so on. This plan, of course,
presupposes a knowledge of the classification and principal forms of
skin diseases, and to the reader who has such a knowledge the
arrangement is in some respects convenient. Still it has the dis-
advantage, that the information as to the treatment of particular
diseases is often scattered over many chapters ; and were this dis-
advantage not to a considerable degree made up for by a carefully-
prepared index, its utility would be seriously impaired.

Without containing much that is new, Dr Frazer's book lays
before the reader, in a very accessible form, a large amount of
usefcd matter ; and a formulary at the end of the volume contains

1864.] ' DR WILLIAM PRAZEB ON DISEASES OF THE SKIN. 255

the prescriptions referred to in the body of the work. He has, how-
ever, committed a great mistake in not having been more careful as
to the nomenclature of the drugs he adopted. We should not have
quarrelled with him for not having in all cases adopted the terms
of the British Pharmacopoeia, but in the case of such a substance as
corrosive sublimate he was bound to do so. This Dr Frazer almost
invariably calls the chloride of mercury, by which the reader would,
of course, luiderstand calomel, were it not that what is stated as to
the doses and properties of the remedy shows that he means cor-
rosive sublimate.

Dr Frazer is led at times to say something as to the symptoms
and pathology of skin diseases. His remarks are generally judi-
cious, but on the subject of scabies we cannot but look upon him as
heterodoxical. He says, —

" From a protracted series of inyestigations upon the subject of scabies, I am
disposed to doubt that the acarus which so generally accompanies it is the real
■cause of the eruption. These acari are a numerous family, ana abound on cheese,
flour, raw sugar, and several other vegetable and animal substances ; and as it
seems reasonable to conclude that there must be some common cause for their
presence in every case, I feel convinced it will be found in their instincts leading
them to settle upon the most appropriate feeding-grounds ; they require nitro-
genous elements for then: support, for they never occur in pure sugar or other
non-nitrogenous substances; and hence, in the cheese, the flour, and the scabby
skin alike, they may well abound and multiply, for all offer suitable habitations
for them, and ample means of living. That itch acari can communicate the
eruption is no more than might be expected ; living upon the morbid secretion,
theu: rough bodies and wrinkled limbs are well suited to transfer it to a fresh
victim: vet it is certain that all persons are not equally susceptible of the con-
tagion 01 scabies, which it appears to me must follow it these acari are admitted
to be its only exciting cause ; and then itch would become as universal in its
diffusion as other insect plagues, and possibly much worse, from the microscopic
minuteness of the insect. There is another interesting fact in the history of
itch, that the parasite is not always the same : in Norway a different creature
of the &mily of mites has been discovered, though both there and in this country
the eruption is found to present an identicafly similar appearance. I have
further ascertained that the majority at least of those persons who have never
been infected with itch are intensely susceptible of acquiring it ; whilst they
who have passed through the unpleasant stages of an attack, and been thoroughly
cured, show a comparative, it might almost be said an absolute, immunity from
future infection. In making researches in this matter, it is alwavs necessary
to discriminate between other pruriginous affections and that which b pre-emi-
nently entitled to the term of itch, as there are no such limits to the reappear-
ance of the former. The strange tendency which this disease shows to relapses,
when insufficiently treated, and its indennite duration if neglected, are both
true ; we cannot offer explanations of those circumstances, or of its rare occur-
rence on the face, another problem of interest as yet unexplained ; thus it will
recur again and a^ain from using clothes soiled by the patient himself; and, as
an instance of this self-reinfection, I have seen severe pustular itch return more
than once in a young child, until a pair of boots were destroyed to which the
virus was persistently adhering.'*

We conclude with an extract in which the therapeutic applica-
tions of glycerine are clearly stated.

" Glycerine has become largely employed of late years as a domestic remedy
to heal superficial bums, excoriations, and erythematous affections, and /or

256 DB WILLIAM FRAZCB ON DISEASES OF THE SKIN. [SEFT.

applying to chapped and tender surfaces. Itisasedas^a therapeutic agent
with two distinct objects ; primarily as an emollient, and still more usefully as
a solvent and vehicle for different active substances. Its bland and unirritating
properties render it a decided favourite ; it is used in several ways in treating
cutaneous diseases ; undiluted it is gently rubbed over the affected part, or kept
in close apposition with it by means of pledgets of moistened lint, or added to
poultices to prevent them from becomm^ too hard and dry ; there is also a
plasma or glycerole made resembling thick arrowroot jelly, by combining it
with amylaceous substances, to prepare which a drachm or more of dry potato
starch or arrowroot is blended with a little water, two ounces of glycerine added,
and all triturated well together, and gently wanned until it oecomes a soft
translucent mass : this plasma is found to relieve the heat and itching of many
eruptive affections ; it adheres to the skin, keeps it always moistened, and
preserves the surface clean and free from scabs or purulent incrustations ; it can
also be applied as an efficient and cleanly poultice to delicate parts. The spe-
cial advantages which glycerine plasma appears to have over ointments are its
freedom from unpleasant odour, its being readily miscible with water, and easy
to wash off, producing none of those stains and discolorations of the linen
which greasy applications will do, but it is difficult to keep and liable to become
mouldy. . . .

" As a vehicle for more active medical substances, glycerine becomes of
special service in practice ; and such are its remarkable solvent effects upon
cnemical and vegetable bodies, that it is difficult at present to assign limits to
its possible applications. When added to washes and lotions it will prevent
their rapid desiccation ; and though it exerts little direct influence oeyond
aiding in excluding the air and keeping the affected part constantly moistened,
this itself proves of advantage, and will often heal simple fissures of the lips
and chapped and tender nipples; in the latter case, when more energetic
local treatment is considered necessary, the glycerine is medicated by dis-
solving alum or tannin in it, or by the addition of an equal amount of
brand]^. The fixed oils or greasy unguents are not properly miscible with
glycerine, which after a time gradually separates from them like drops of
water. This is more than compensated for by its dissolving the metallic
salts, much in the same manner, and nearly to the same extent, as distilled
water is capable of doing ; thus, for example, it freely takes up borax, and
the solution, diluted to any requisite strength, is useful in those affections
where alkaline lotions are of service, as for eczematous and impetiginous
attacks, as an occasional wash, or applied constantly to the excoriated sur-
face upon lint. Solutions containing iodine and iodide of potassium are
prepared in every proportion, in glycerine similar to spirit of wine, and are
preferable in many cases for external use, the absorption of the iodine being
favoured by the persistent moisture of the glycerine. The great solubility of
red iodide of mercury in this fluid enables us to employ it of any desired
degree of concentration ; when dilute acting as a gentle local stimulant, or
if strong as a powerful irritant and caustic. Glycerine is capable of taking up
one fifth its weight of arsenious acid, or one half of chloride of zinc, forming
energetic destructive compounds, likely to be of service in lupoid ulcers, etc.
Preparations containing the salts of morphia, aconitine, and other alkaloids
have already been employed with beneficial results in general practice, and are
well suited for external use in treating cutaneous disease, as they can be
prepared of definite strength, and are clean and manageable. Kreosote,
carbolic acid, and tar are all soluble in glycerine, and mix thoroughly with the
plasma of starch ; they are recommended in cases of psoriasis and inveterate
lichen in the same manner as tar ointment ; this plasma also constitutes a con-
venient vehicle for almost all these numerous substances ordinarily added to our
ointments. M. Demarquay claims for pure glycerine the property of diminish-
ing the amount of purulent secretion from ulcers, and of modifying the unhealthy
character of many secreting surfaces, which, if established, would prove of
great value in therapeutics. A few alone of its principal applications in skin

1B64.] DB WILLIAM FRAZER ON DIBBA8E8 OF THE SKIN. 257

diReases need be briefly mentioned ; in ery%ipehm it is AdTtsed to all«r the
•malting ]>ain and Barnine sensations which attend the eruption, ana alao
during the eraptive stage of snudl-pox, and whilst the pustules are becoming
filled; for herpetic attacks, particnUriy herpes coster and circtnatus; to
loosen the desquamations in the scaly affections, and relieve the distressing
irritation of prurigo and lichen. For lupoid, strumous, rupic and similar
ulcerations, where scabs and incrustations readily form, elycerine is recom-
mended for softening and removing the purulent crusts, and uter their removal
keeps the surface moist and healthy, it is applied on pledgets of lint, after
the manner of water dressing, and covered over with gutta pereha paper or a

layer of dry lint, to prevent it from soiling the dress, though the stains it {

are easily removed by washing."

l&nvt ^ivn.

PERISCOPE.

SURGERY.

ON THE TBEATMENT OF ACUTE ORCniTIB BY PUNCTDRINO THE TESTICLE.
BY HENBY SMITH.

In July 1863, a young man presented himself amongst the out-patients at
King*8 College Hospital with gonorrhceal orchitis in a very acute form. The
pain was unusually severe ; and, on examining the organ, it appeared to me
that suppuration Kad taken place, the sense of fluctuation bcuig, as I thought,
distinct. With a view of evacuating the pus, I took a bistoury, and made a
free and deep incision into the supposed abscess ; but, to my astonishment and
dismay, not a drop of matter escaped — only a little serum and blood. The
Cubes, however, of the testicle shot out, as it were, from the wound, forming a
protrusicm the size of a nut. Some pressure was applied by means of strips of
plaster, and the patient was sent away.

Two days afterwards the man presented himself, but in a very different eon-
dition. He was quite free from pain, all the redness and most of the swelling
bad disappeared, and on taking off the strapping it was foOnd that the protru-
sion of the tubes of the testis no longer existed.

This ease, which was somewhat annoying to me at the time, suggested some
aerious reflections in reference to the speedy relief which had resulted from a
practice which in reality was the effect of an error of diagnosis on my part.
Was the sudden relief here a mere accident? or, if not, to what could it be
due? The quantity of serum and blood abstracted was so small that the ces-
sation of pain and diminution of swelling could hardly be due to this cause ;
but it struck me forcibly that the free division of the fibrous tissue enveloping
the body of the testis, and the consequent removal of tension from the organ,
was the secret of the success, provided it was not a mere accident.

Influenced by this reasoning, and by the result of this case, 1 determined to
try the effect of puncturing the testis in similar cases ; and in the next case of
acute orchitis which presented, I made a deep and free incision with a sharp
marrow bistoury, emitting about half a teaspoonful of serum and several drachms
•of blood; and no other treatment beyond a little of the common aperient
mixture was supplied. The result here was as successful as in the K>nDer ;
and as cases presented themselvea, I adopted the same plan of treatment,

258 PERISCOPE. [sept. ,

reaerying it, however, especially^to those instancea where the swelling and
pain were verv great. After the*trial in a few cases, it was found that the
success attending this practice was such as to lead me to adopt it as the usual
treatment of acute orchitis ; and during the last twelve months I have probably
treated in this way upwards of twenty cases, with such results as have astonished
both myself and those numerous pupils who have witnessed the practice.

In nearly every case so treated — and I have purposely selected the most
acute — the patient has experienced the most striking relief before he has left
the out-patients' room ; and on the next visit, forty-eight hours afterwards, the
contrast presented is so remarkable that the superiority of this plan over the
old-fashioned modes of treatment is at once impressed forcibly upon the minds
of those even who would naturally be prejudiced against so apparently heroic
a treatment. The speedy subsidence of all the acute symptoms is due entirely
to the puncture of the swollen and inflamed organ, for t have taken especial
care not to prescribe anything else except a little of the common white mixture,
or perhaps the use of tne ordinary lead lotion, and this chiefly to please the
patient.

We all know what a terrible ordeal of violent remedies a patient with acute
inflammation of the testicle has to undergo. In the first place, he is obliged
to lie in bed for several days ; a large number of leeches or the constant appli-
cation of ice are necessary to relieve the pain ; and at the same time the unfor-
tunate wretch is compelled to undergo the process of severe purging and
continued nausea, by repeated doses of salts and tartar emetic, before any
decided mitigation of his symptoms ensues ; and two or three days mostly
elapse before he recovers from the depressing influences of these several
remedies. Lastly, the unfortunate organ has to be submitted to the tender
mercies of a dresser, who, however skilful he may be, cannot help putting the
owner of it to severe and prolonged torture whilst he is obeying the injunctions
of his superior to *' strap testicle."

Now for all this I venture to submit the plan now proposed, and one which
I should call a '^new" one; but it is venturing on dangerous ground to call
anything new nowadays. Moreover, my old assistant and our present house-
surgeon, Mr Richmond, informs me that when he was in Paris two years ago
he saw the same method of treatment adopted there ; but I never heard of it
before I resorted to it, and the practice in my hands was entirely due to the
accident I have related above.

Of course several of my friends and pupils have ureed objections against this
plan of treatment, and su^ested serious results, in the form of suppuration of
the organ, impairment of its function, hernia testis, and fistulous sinuses ; but
none of these have I witnessed. It is very natural and proper to make these
objections, for we have always carefully avoided the possibility of a puncture
of the testicle when using a trocar for paracentesis of the tunica vaginalis, and,
indeed, I have witnessed violent suppuration of the testis speedily ensue from
this accident ; but it must be borne m mind that wounding of a healthy testicle
with a large and blunt instrument like a trocar is a totally different thins from
a careful incision made into the highly inflamed organ by a thin sharp buide.

The only inconvenient result I have witnessed from this treatment was the
following : — ^/Vn incision was made into the testicle of a middle-aged man, with
the usual relief, but in a few days the scrotum began to swell, great pain was
experienced, and the man was taken into the hospital. The objectors to the
mode of treatment suggested all sorts of disasters, in the shape of suppuration
of the testicle, etc., but on careful examination it was ascertained that the
swelling consisted of a large and rapid effusion of fluid into the tunica vaginalis,
which was at once evacuated, with speedy relief to the patient. In another
instance I made the incision much deeper than was necessary, carrying the

Eoint of the knife nearly to the back of the organ. As much as ten ounces of
lood were lost ; but the testis was violently i^amedand swollen, and the only
effect of the accident was to make the patient somewhat faint, but at the same
time to give more speedy and effectual relief than usual.

18e4.] SUBQERT. 259

Thi8 circamBtance may lead one to the belief that the relief i« dae solely to
the escape of blood from the pancture ; bat this view is inconsictent with the
fact that great relief is given when only a few drachms of blood, miied with
serum, are discharged. JDoubtless the direct withdrawal of blood from the
highly mflamed testicle is of service, but my own view of the matter is, that
the relief is in a great measure due to the withdrawal of the tension from the
body of the testis by free division of the tunica albuginea.

Whatever may be the precise manner in which the good results are pro-
duced, there is no doubt of the fact, and I would earnestly suggest to surgeons,
especially to my colleagues, the assistant-surgeons of the hospitals, who treat
the majority of cases of orchitis, to adopt the plan proposed, rather than be
aubmitting their patients in a routine war to all the horrors of the middle
passage, from tartar emetic to strapping of the testis.

F,a, — Since the above was written I have seen one of my old pupQs who
has been spending the last six months in the Paris hospitals, and ne informs
me that the ordinary practice at the Udpital de Midi in cases of acute orchitis
is to make a puncture in several places with a lancet ; the instrument is not
carried into tne body of the testicle, but simply through the tunica albuginea.
He describes the plan of treatment as most successful. — The Laneei.

PBRMANQAMATE OF POTASH IK GONORRB(EA.

For the last two years I have frequently employed the permanganate of

Sotash as an ii^ection in the treatment of gonorrhoea, and the constant success
erived from its use has been extremely satisfactory. My usual method had
previously been to administer, first, a hydragogue cathartic, then to give a
mixture of cubebs, copaiva, nitre, etc., with injections of sulphate of zinc,
tannic acid, etc. But since employing the permanganate my treatment has
been much more circumscribed, for with this remedy alone I have frequently
cured very bad cases in forty-eight hours, and this too without its bein^
followed by any evil effect from the sudden arrest of the discharge. My usuiu
mode of treatment, however, is as follows : — Jjt Potassse bitart. V)j. ; podophyllin,
gr. j. M. In chartulas quatuor dividendus. S. One every two hours until
free catharsis is produced. After which : — 9 Potassse permangan. gr. vj. ; aqusa
fontan, J^. M. S. To be used as an injection three times a-day. I direct
at the same time the free employment of mucilaginous drinks, as althaea, ulmus,
acacia, etc., and put the patient upon a non-stimulating regimen.

Out of sixty-four registered cases this course of treatment has failed in but
two instances. And I find that recent attacks usually become arrested by it
after from three to six injections. I have found it advisable to continue the
demulcents for at least a week after the cessation of the discharge. In none
of all these cases was the injection continued after the fourth day. When
accompanied by chordee, I usually employ the following : — 9 Lupulin, 3jss. ;

Sttlv. camphorae, ^j ; micse panis, q.s. M. Ft. mass in pilulas, xvi, dividenda.
. Two, three, or four on going to bed. I think that the permanganate of
potash is a remedy deserving of more notice than physicians have hitherto
given it, and I hope that my experience may produce for it a more extended
trial in cases of gonorrhoea. — Dr J, G. Eich in Canada Lancet.

CASE OF EXTREME SQUINT CUBED, WITHOUT OPERATION, BY THE USE OF
PRISMS ; WITH CLINICAL REMARKS. BY MR ERNEST HART.

The following case is one of interest, as belonging to a class of instances of
aquiut in which, by a careful distinction of causes, the deformity may be treated
npon a scientific basis, and radically cured by a simple adaptation of optical
means without any operation. Mr Hart observed m reference to it, that a
careful study of the origin and nature of various forms of squint shows that the
treatment must, to do justice to the patient, be almost as much optical as
purely surgical ; and there is a large proportion of cases in which merely
optical means succeed perfectly, either in averting the formation of a perma-
VOL. X.— NO. m. ' 2 L

260 PERISCOPE. [sept.

nent squint, in caring it when the proper glass is applied early, or in prevent-
ing relapse after operation.

J. C, aged twenty-seven, a sailor, of good general health, and had always
possessed excellent sight. In May 1863, he had a severe attack of rheumatic
fever ; various joints were attacked in succession, and he lav for nearly two
months helpless in bed . Towards the end of the attack the eyes became affected :
the light became painful to them ; the eyeballs he describes as havmg become
blood red, and acutely painful, the pain being severe over the brow, and dart-
ing through the head from the frontal region. The face was blistered by the
abundant and acrid lachrymation. Thus there seems to have been an acute
rheumatic ophthalmitis. He recovered well, and is not aware that there were
any immediate traces left of the disease. He went a voyage to the Cape, and
came home in satisfactory health ; but in the subsequent voyage, in December
1863, he became aware of a certain dimness and confusion in looking at
objects, -a difficulty in measuring dbtances, and in defining the outlines of
thmgs and persons before him. This came on, he thinks, quite suddenly; and
in the course of the day he found that he had a decided convergent squint of
the right eye, and that he had lost control over the movements of that eye.
He consulted Mr Hart in the middle of January last.

Mr Hart found then a convergent squint, monolateral, of the right eye, per-
manent, and due to paralysb of the external rectus. The visual powers of the
two eyes, tested separately, were very nearly equal. There was no dilatation
or semi- dilatation of the right pupil ; no drooping of the lid. The latitude of
accommodation was equal to that of the left eye. The patient suffered greatly
by the constant confusion arising from the double set of images which the
incongruous eyes received. He was frequently unable to distinguish between
the true image and its ghost, and, besides the giddiness and confusion thus
occasioned, felt himself in danger in walking the streets.

Mr Hart called the attention of the class especially to the case as one in
which, from the positive and negative data above mentioned, the cause of the
squint might be accurately determined. He referred it to insufficiency (paresis)
of the right external rectus. The normal action of the other muscles of the
eye and eyelid and of the iris, excluded cerebral causes; while the absence of
far-sightedness or short-sightedness in any marked degree, and the healthy
appearance of the internal fundus of the eye revealed by the ophthalmoscope,
excluded dioptric or retinal disorder from the etiology of the case. The cause
being thus determined, it remained to decide on the remedy. Mr Hart pointed
out that in this case the cause of the double images which occasioned so much
distress was that incon^uous portions of the two retinse were, by virtue of the
displacement of the axis of the strabismic eye, impressed with the respective
images of each object seen. This might be remedied, then, by the use of a
prismatically ground spectacle-dass, with the base turned in the direction
opposite to that of the squint ; for such a glass has the power of causing a
deviation of rays of light incident on its base, which may thus be used to
deflect the rays proceeding from objects looked at, so that they may, in the
case of the squinting eye, be made to fall upon a part of the retma couctuous
to that which receives them in the normal eye, and thus binocular vision be
restored. In fact, a prism may be used thus to fuse and destroy double
images, just as, conversely, with healthy e3res, it is sometimes used in sport to
produce them. Taking a series of prismatic glasses ground to scale, Mr Hart
then essayed them with this patient before the class. A glass ground to an
angle of twelve degrees placed before the deviating eye so lutered the direction
of the images which it received as to fuse the double images into one. This,
however, would only have removed the visual uiconvenience without curing
the squint. By now selecting a glass of ten degrees the images could be nearly
fused, but not quite ; and then the horror of double images, which is instinctive,
caused an involuntair effort of the semi-paralytic and enfeebled rectus extemus,
which just succeeded in drawing the eye so iar further outward as to compen-
sate for the diminished angle of the prism, and fuse the double image. This,

1864.J SURGERT. 261

then, was the gUus selected for the pfttient to wear ; for by the aid of this
glaas the enfeebled miude was, as it were, gymnasticalJy eiercised and
strengthened. The fusion uf images was not effected without an effort some-
what painful, and which could not long be sustained. Mr Hart therefore
directed the patient to employ the glass at intervals only during the day,
gradually lengthening the period of eiercise. In the course of seven days he
had made considerable proeress, could wear the glasses much longer at a time,
and fuse the images more thoroughly and with less effort. He was then very
anxious to rejoin his ship. Mr Hart therefore fum ished him wit h glassetc of eight,
six, and four degrees respectively, so that as the muscle became stronger a
corresponding^ly greater effort might be required of it ; the glasHCs fulfilling a
true gymnastic as well as optical function, and acting just as dumb-bells of
graduated weight, with appropriate exercise, may be made to act, in dealine
with enfeebled muscles in other parts of the body. The patient was desired
to communicate the result, or to show himself on his return. Recently the
man presented himself quite cured. This cure was effected in the course of
eight weeks. And in June he wrote to say that his eyes are now as good as
ever, that the movements of the two are synchronous, and vision normal.

In another patient, now under treatment, in whom the squint was also mono-
lateral and permanent, and on whom this method of treatment wUl be employed,
the paresis of the abducens has followed on extreme debility after menorrhagia
and lactation. Mr Hart observed that it was essential to the good repute of
this method of treatment that it should be employed with discrimination, and
as the result of a careful diagnosis. It would be useless to attempt to cure by
this means an alternating concomitant squint with hypermetropia, or a stra-
bismus from active organic cerebral disease. But in every case of squint, the
divergence of the eye must be regarded as a symptom, to be treated differently
according to the nature of the various causes from which it arises. Sometimes
a squint was the first indication of insidious meningitis in a chUd, of which he
cited a remarkable case that he had Litely seen in conjunction with Mr Paul
Jackson : then the ophthalmoscopic indications are of the highest value for
the purposes of general treatment, and the squint must be disregarded. Yerf
frequently a slight squint or confused image, due to insufficiency of the S3mergic
action of the ocular muscles, was the first symptom of an impending acute or
chronic cerebral disorder, and the ophthalmic surgeon had to yield place to the
physician. In either of such cases to operate would be useless cruelty.
Another set of cases were those of which the above-quoted is a fair type.
Then came the large class, so admirably investigated by Donders and Von
Graefe, in which squint is due to hypermetropia of the eve leading to excessive
contraction of the internal rectus : in such cases, the degree of squint being
measured, the division of the tendon, carefully adjusted, was followed by the
best results. But to make strabotomy yield the almost uniformly successful
results which might now be obtained from it, it was necessary to exclude all
the cases which might be cured by other means, and also those which were
incurable by any means. The apphcation of a prismatic spectacle glass in the
class of cases above defined was most successful, if carefully carried out and
used for fit cases. — The Lancet.

M. CHABBAIGNAC'B drainage TUBEg.

The greatest and simplest and most generally useful of M. Chassaignac*s special
modes of treatment is the draining tuhe^ and we doubt whether the professional
mmd on this side the Channel is yet sufficiently alive to its merits. Most of
our readers have heard of it— a little india-rubber tube perforated with holes,
and introduced into suppurating cavities, in order to provide for the gradual,
constant, and immediate discharge of all secretion without admission of air.
Any one who follows M. Chassaignac for a few mornings, and hears him order
unpen de drainage will see the class of cases to which the method is applicable ;
and if he shares our good fortune, he will see some of the results, and hear a
clear exposition of the very simple principles on which it is based. As the

262 P£BISCX)PE. [SEPT.

visiter follows from bed to bed amongst the chronic snrffical citses attended
with suppuration, he will see here a thigh, there the back or the breast, or
possibly a tarsus swelled into that too-familiar lump indicative of scrofulous
caries, and in each case one, two, or perhaps half a dozen of the tiny black tubes
passing right through the diseased part ; in fact (in the case of a diseased
tarsus, for example), wherever there is, or threatens to be, a sinuous opening,
there M. Chassaignac orders un peu de drainage. As he passes round in hii
visit, the tubes are examined to see if they flow freely, and the edges of the
aperture are just touched with a solution of lunar caustic, to supply which, the
clinical clerk follows with a bottle of the solution, and a hanaiuf of wooden
'skewers armed with a little piece of cotton wool, which are rapidly used and
thrown aside. This protects the orifices from ulcerative action, and from
possible contamination from without. The principle of the drainage system
18 clear enough. A bone is carious ; particles of the tissue in a state of decay
are cast off, and mingled with the exudations of the surrounding. parts, they
form a petty swelling. This cannot be absorbed in most cases ; and it acts
as a source of irritation to the neighbouring tissues, and tends to spread the
morbid action of which it is the result. In ordinary practice, when it has
accumulated in quantity to form an abacesSy it is discharged by incision, if need
be. But fresh collections form, and discharge themselves in other tracks, till
the whole member is riddled with unhealthy sinuses. Here drainage does
well what the best efforts of Nature point to, but accomplish ill. It provides
at once an exit for discharge and necrosed particles, through a tracK which
the surgeon chooses, and which does not add to the severity of the original
disease, for the hole made by the fine trocar, which introduces the tube, is a
very slight injury. But this slight wound accomplishes all that can be done
by A free incision. Again, instead of waiting till extensive disease has resulted
in large abscesses or in a heroic operation of excision, or of gouging, these
little tubes do the work of the gouge piecemeal and incessantly. We do not
say that English surgeons are unacquainted with the tubes, but they do not
know enough of their preventive functions. Surgical books contain cuts of
gouges, and of oetecftritea for cutting or grinding away carious bone, when the
case has become a matter of life or limb ; but they do not tell us to bore a
tarsus with the little tube, which shall stop the mischief at its outset. As to
the results, we saw at the clinical lecture patients presented cured, who had
suffered from lumbar abscess following vertebral caries, and from various other
scrofulous diseases of bone. The exposition of the method and of the result
was admirably given, showins immense shrewdness and ingenuity, together
with that thoroughly practical seeking for remUe^ which we are apt, in these
isUnds, to think peculiarly our own. — Medical Timee and Gazette,

MIDWIFERY.

ON PLACENTA PRiSyiA. BY ROBERT GREENHALGH, M.D.

At a meeting of the Obstetrical Society of London, held on the 6th of July,
Dr Greenhalgh read a paper on the subject of placenta prssvia.

The author first alluaed to the large mortality both to mothers and children
(one in four and a quarter of the former, and about two-thirds of the latter),
which he attributed mainly to the severe and repeated losses of blood, to the
delay in effecting the delivery, and the method of turning usually had recourse
to in these ca^es. He then gave the details of twenty-four cases which had
occurred in his own private and consulting practice between the years 1842
and 1864. He placed before the Society several statistical tables, chiefly
taken from Dr Read^s work, to show, in addition to other facts, that the ex-
pulsion of the child generally takes place before the full period of utero-gesta-
tion, — premature labour being the rule and not the exception ; that nature,
unaided, frequently terminates the delivery with safety both to mother and
child ; that complete and partial artificial separation of the placenta before the

1864.] MTDWIFERT. 263

birth of the child haa failed in namerons cases to arrest the hsemorrhage ; and
that these methods and turning had proved most nnsatisfactory in their results.
Having dwelt at some length upon these several points, he strongly advocated
a close observance of the way in which nature terminates these cases with
safety to mother and child. Having specified the result of his observations on
that head, he confidently recommended the following plan of treatment, which
had proved, as far as the limited number of cases could prove, in his hands and
in those of others, far more successful both to mothers and children than any
other method hitherto devised. It was as follows: — Isty That in case of
haemorrhage, whether profuse or otherwise, occurring after the commence*
ment of the seventh month of utero-gestation, ascertained to be due to
placenta prsevia, artificial premature labour should be induced at once, or as
soon as the condition of tne patient will admit of it. 2cKy, That in order to
effect that end without loss of blood, an air-ball, covered with spongio-piline.
be passed, collapsed, into the vagina, and then inflated so as effectually to fill
that canal, while a bandage is placed firmly round the abdomen ; at the same
time the ergot of rye and borax are to be administered in repeated doses.
He further recommended as aids, stimulating enemata, with tincture of nuz
vomica, galvanism, and friction over the abdomen. The author concluded by
condemning, in the strongest terms, the use of general hygienic means and
hemostatic remedies over days and weeks in these cases, wnich course, he was
firmly convinced, was the cause of many valuable lives being lost.

Dr Bamea observed that, agreeing senerally in the principle that labour
should be brought on in cases of severe hsBmorrhage from placenta prsevia, — a
principle, he believed, commonly acted upon in liOndon, — be could not assent
to much of Dr Greenhalgh*s reasoning, or concur in approving his plug. His
statistical reasoning was open to criticism. He assumed two postulates ; first,
that the mortality of placenta prasvia was 1 in 4i ; secondly, tnat the mortality
from inducing premature labour was 1 in 53 ; and he drew the extraordinary
conclusion that by always inducing labour we might substitute the low mor-
tality of premature labour induced under selected circumstances for the
assumed heavy mortality of 1 in 4^. Now both the postulates were false, and
the conclusion was manifestly illosical. The mortality of 1 in 4} drawn from
Pr Read^s tables was a most unfair representation of the results of modem
obstetricv. He (Dr Barnes) had analyzed his own cases. Since the publica-
tion of his Lettsomian Lectures, 59 cases had come under his own observation ;
and he drew 24 from other sources, roost of these last being treated upon his
(Dr Barneses) principles. The deaths were 6 only, or 1 in 14. And if he were
to follow Dr (ireenhalgh in striking out the fatal cases on the ground that
treatment was too late, he might show statistical results very mr superior.
He should have, not 10 successful cases, but 77. Two of his cases aied of
pysemia, having been treated by forced delivery, — ^that is, in direct opposition
to his principles ; 2 were moribund when seen, and 2 were hopelessly anemic.
He haa taken all cases as they occurred in his books without selection or
arrangement, yet 26 cases fell as an uninterrupted series of recoveries, which
he might fairly place against Dr Greenhalgh^s selected 10. Then as to the
mortality in premature labour. Premature labour was induced under selected
circumstances to avoid dangerous complications. Such cases were not to be
compared with labours forced upon us by the flooding of placenta previa.
This Dr Greenhalgh disregarded. But surely placenta previa went for some-
thing. Then the children. Dr Greenhalgh had been fortunate. In his small
series of 10 cases he had 8 living children. He (Dr Barnes) ventured to say
that a larger experience would modify this result. Many dangers surrounded
the child m placenta previa : cross births, funis presentations, immaturity, and
asphyxia in utero *, some were bom putrid. His (Dr Barnes's) plan was emi-
nently adapted to secure the child. But his mortality was '63. The very
method of Dr Greenhalgh of bringing on premature labour must of itself often
destroy the child, for the floodings would come on at six and seven months. And
in some cases flooding did not occur until the end of gestation. These were often
the most dangerous. Yet here Dr Greenhalgh's plan was not available. And

264 PERISCOPE. [sept.

what was Dr Greenlialgh's plan? The use of a fxiginnl plug, not differing
essentially from the colpearynter of Braan. It acted like all other yaginal
plugs, by exciting uterine contraction, if the uterus was excitable. But unfor*
tunately in the worst cases the uterus was paralyzed. In these, where art
was most necessary, the plu^ was useless. He was surprised to hear Dr
Greenhalgh underralue rupturmg the membranes. This simple method was in
many cases quite sufficient, and no method was long serviceable without it.
If in combination with rupturing the membranes, the placenta was detached
from the cervical zone, so freeing the cervix, the cervix then artificially
expanded by his cervical dilators, and the bimanual method of turning resorted
to, he was confident, from large experience, that a greater measure of success
would be obtained than by any other especial method. He took that oppor*
tunity of stating that the first published case of the use of the intra-uterine
dilator in placenta prsevia which attracted his attention belonged to Mr Jardine
Murray of Brighton.

Dr HaU Davis remarked that he had little faith in statistics of placenta
prsevia representing a mortality of 1 in 3 or 4 from that complication,
knowing that former statistics to that effect had included cases originally pub-
lished, not to show the average mortality, but as selected instances for the
most part hopeless when first brought under medical observation, and intended
to prove the fatal tendency of this complication of pregnancy if not timely seen
to. He would also observe that we are not left without authority, laid down
in lectures and works of reputation, to convince us of the dangers of delay in
placenta prssvia, and guide us to efficient treatment. He might refer, for
example, to the lectures of the late Dr D. D. Davis at University College from
1828 to 1841, and to his esteemed System of Obstetric Medicine, which taught
no temporizing treatment, but, on the contrary, the necessity of early and
active mterference, while at the same time pointing out the hazards of a
forced delivery through a rigid os uteri. As to his own experience, he might
state that in tne Royal Maternity Charity alone he had had, from 1842 to 1862,
as physician of the western district, 24 cases of placenta prsevia. In that
number twenty-two mothers were saved, and the two deaths would have been
averted had the injunctions given been observed. His treatment had varied
with the case. Thus in partial placenta prsBvia he had found the simple dis-
charge of the waters usually sufficient. When the flooding has not been thus
arrested, and delivery has been impracticable by reason of the small size of
the uterine orifice, he has plugged the vagina impactedly with sponge, or with
a sufficient quantity of other suitable material at hand. He has then waited
in security for the first opportunity of acting if necessary. In many cases, on
withdrawing the plu^ tlie head was found descending, and the birth was
quickly completed without further aid. In cases of entire placenta pnevia,
when the os uteri would not admit of delivery, he also resorted to the plug,
and of similar materials as before, believing such a plug, from its solidity, when
efficiently applied, to be far superior to any elastic dilator. After from two to
six hours he was generally enaoled to remove the plug and deliver by turning.
In this operation ne preferred to pass his fingers in b3r the side of the placenta,
where it might already be detached, to perforating its centre, as some have
recommendea, as this fatter mode necessitates a more considerable injury of
the placental vessels and further hsemorrhage. In the operation of turning,
it had been his usual practice to fix the uterus by the right hand applied
externally on the abdomen while turning with his left hand. To Dr BJcks,
however (Obstet. Trans., vol. v.), were we indebted for a definitely combined
mode of external and iiUemal version by acting on the opposite poles of the
child, the breech above being depressed by the external hand, while at the
same time the presenting head is pressed upwards and to its own side. Then
the feet are lowered to the os uteri, and one or both brought through ; the
risk, so especially great in flooding, of passing the hand into the cavity of the
uterus being in this way avoided. In conclusion, he might say that, while he
differed from the author on the points to which he had referred, he fully con-

1864.] MIDWIFERY. 265

curred with him, as all jadicioiu practitionera mint do, that to delay efficient
interference in this complication is most hazardous.

Dr J. Braxton Hick$ quite agreed with Dr Greenhalgh as to the necessity of
inducing labour in placenta nravia as soon as arrangements could be made,
which he believed to be the plan adopted by all who saw much midwifery in
this city ; it was the practice he had always adopted. With regard to the
statutics quoted from Dr Read's work, he quite agreed with Dr Barnes as to their
want of value. All large ^oups of statistics were utterly useless as a guide of
any particular practice. It was absolutely essential that the details of the
cases should be known. In the tables presented to the Society it was impos-
sible to say what were the surroundings of the patients ; whether, in fact, they
had died from the operation, from the hssroorrhage, or from the subsequent
calamities to which it was known cases of placenta nrevia were eiposed.
How, therefore, could we tell the value of any particular plan of treatment
without this information ? He considered that when it was said the death-
rate was 1 in 4^, there must be some mistake as regards present practice. In
the Guy*s Hospital Charity it was for nine years at 1 in 74. He also was
obliged to differ from the assertion that the life of the child was not influenced
by placenta prsevia. That it was so he had no doubt ; for in half of the cases
he had seen where it was made out clearly, the child was known to be dead
before any operation was attempted. He hoped the author would have alluded
to the plan which he (Dr Hicks) had recommended in his recent paper on
** Combined Version,'* because he felt sure that it was a very useful one, and
not difficult to any one who would take the trouble to learn it He had known
at least nineteen cases, many of them very severe, in which it had been used,
with only one death, and tbiat arising from extreme haemorrhage before seen,
and which could not be put down to version. In all his cases there had been
immediate cessation of bleeding as soon as the breech was in the os, and he
had found that almost in every case labour pains expelled the child within two
or three hours from the commencement of the operation. This point it was
important to know in order that we mi^ht make our arrangements accordingly.
The child was a most efficient plug, and it could be brought down as soon as
the OS would adniit a linger or two. With regard to the small size of the os
preventing turning in the above-mentioned mode, he could say it must occur
Dut seldom ; when it did so, the detachment of placenta romid by one finger
generally liberated it considerably, enough at least to introduce two fingers ; if
not, the elastic bags could be used with much advantage. We must judffe of
treatment by its practical application : our hands we have always with us,
whereas if called to a case at a distance from home, or in great hurry, it would
be impossible sometimes to obtain the plug now shown. The effect of version
upon the life of the child he could not compute. Doubtless, cephalic was the
best presentation ; but he had not found in his cases any ereat mortality. The
important point was not to hurry the case after the breech was in the oh. The
child was generally destroyed by drawing it down before the os uteri was open
sufficiently. When the breech was in the oSj the case in almost every instance
might be left to nature, adopting the rule as m breech cases.

Dr Graily HewiU considered the principle enunciated in the paper now read,
of the necessity of interference in cases of placenta previa, to oe one of great
value. This principle had never been sufficiently insisted on, and although
admitted by men of experience, it had not been laid down as a principle in the
obstetric text-books. He might mention that two years ago a gentleman in
practice in Yorkshire had, in conversation with him, alluded to this very
subject, having lost a patient from a suddenly recurring hsBmorrhage due to
placenta prsevia. The gentleman in question had hesitated, on the occurrence
of the first haemorrhage, to induce premature labour, not finding such practice
sanctioned by the text-books, and the patient, living at some distance, had
perished when the haemorrhage recurred two or three weeks later, before
assistance could reach her. Doubtless there were cases of this kind occurring
from time to time, and which would have been saved by interference. He

266 PERISCOPE. [sept.

considered, therefore, that the expression of the opinion of the Society on this
subject would have a most beneficial influence, and that patients known to
have placenta preevia would not be left liable to perixh at any moment from
haamorrhage. With reference to the particular plan of treatment advocated by
Dr Greeuhalgh, which was a moditication of the " plugging " system, he had
some remarks to make. It was to be recollected that m cases of placenta prsevia
we have two lives to consider — ^that of the mother and that of the child.
What is best for the one is not always the best — ^nay, it is frequently the worst
for the child. The safety of the child lay in speedy delivery ; the safety of
the mother in preventing haemorrhage. Plugging the vagma, artificial or
partial separation of the placenta, were measures calculated to stop haemorrhage ;
Dut such treatment, unless accompanied with speedy delivery, was prejudi-
cial to the child, whose vitality was necessarily destroyed by separation of the
placenta to any considerable extent, with or without concurrent external loss
of blood. On referring to Dr Greenhalgh's statistics, it would be seen that
although the mortality to the mother was, on his system of treatment, low,
yet that the percentage of stUl-births was high, and the plan in question was,
therefore, open to this serious objection. He (Dr Hewitt) was quite aware
that it was impossible to legislate equally well for all cases, the circumstances
of each case being, to a great extent, peculiar ; but any generally accepted
system of treatment must have in view the preservation of the lives of both
mother and child. Rapid natural delivery best fulfilled all the indications, and
this should be the object sought to be attained in the treatment of these
dangerous cases. In a certain number of instances rapid natural delivery was
not possible, and under these circumstances the operation of turning offered
the best alternative. The extraction of the child should not be performed too
soon after the version, unless the bleeding still continued ; for until the os was
tolerably dilated, the neck of the child was likely to be so tightly caught by
the OS as to prevent extraction. When the foetal heart was b«atin^ very
slowly, rapid extraction of course afforded the only chance of preserving its life.
In conclusion, he considered the Society under obligation to Dr Greenhalgh
for his very practical and able paper.

Dr Beatty (of Dublin) in reply to an invitation from the President to address
the Society on the subject, said that he addressed the Society under very
senous difficulty ; for not having had the advantage of hearing the paper now
under discussion read at the former meeting, he did not well understand its
bearings ; but as well as he could collect from the speakers who had preceded
him, he inferred that there were two points particularly dwelt upon by the
author. The first was the time at which we should mterfere in cases of
placenta prtevia ; and the second, the kind of assistance most proper to be
given. It appeared to him (Dr Beatty) that the author of the paper recom-
mends delivery as soon as possible after the case was fully made out. In this
respect there was not much difference between his and the practice very usual
in Dublin. We wish to finish the case as soon as possible ; but it must be
recollected that in many cases speedy delivery was impossible, for occurring
as the haemorrhage most usually does for the first time in the eighth month, or
even earlier, when the os uteri was little disposed to relax, it not unfrequently
happened that the os uteri was so rigid that delivery could not be attempted.
We must then temporize, and by means of position, plug, cold, etc., endeavour
to gain time, and save the patient from loss of blood as much as possible. He
had spoken now of cases in which there was complete covermg of the os
uteri by the placenta; but in cases of partial covering, where we could
feel any portion of the transparent membranes, the practice was to rupture
them at once, and discharge the liquor amnii. When this could be accom-

Slished, we feel pretty easy about the case. The head of the child comes
own, and by pressure on the placenta, prevents any further loss of blood.
If the uterus was not disposed to act vigorously, its action was quickened by
the ergot of rye. He always depended upon the infusion of the powder made
on the spot. It was a meaicine that required great care for its safe preser-

1864.] MIDWIFEBT. 267

▼atioD. He never went out without a drachm of the powder in his pocket-
case. It was pat up in metallic paper, so as to prevent the absorption of the
oil by ordinary paper. It shoula not be kept more than two months in the
case. I£ not used before then it should oe replaced by another drachm.
When used it was infused in four ounces of boiling water, and half of it,
powder and all, given at once, and the other half in a quarter of an hour.
When treated in this way the medicine had never failed him. If the case was
one of complete covering of the os uteri, we watch the earliest moment at
which the os uteri was dilatable, and then proceed to deliver the patient by
turning the child. From these few hurried observations it appeared that the
practice in Dublin does not much differ from that laid down by the speakers
who had preceded him (Dr Beatty) in this debate.

Dr Woodman mentioned some cases in which he had observed the good
effects of the treatment recommended by Dr Barnes.

Dr Gervis remarked that the observations of Dr Beatty relative to the
firequent necessity of " temporizing " in cases of hflsmorrhj^^e from placenta
prsBvia, where there existed a rigid condition of the os and cervix, illustrated
the main point at issue between Dr Greenhal^h and Dr Barnes. Dr Green-
haleh in such cases advised the use of the vagmal plug, an abdominal bandap^e
with which to maintain pressure on the uterus externally, and the adminis-
tration of ergot; while Dr Barnes maintained that his cervical dilators by
themselves sufficiently superseded the use of the plug, the bandage, and
the ergot, inasmuch as wniie they were dilating the os and cervix, thej
simultaneously prevented hsemorrhage and excited uterine action. In this
estimate of their utility Dr Gervis entirely concurred. Instead of temporizing
in any manner, or trusting for the accession of labour to the use of ergot, by
these bags you obtained full control of the case from beginning to end ; and
after adequate dilatation of the os, you could either separate the placenta
from the orificial zone, rupture the membranes, and then, if that sufficed to
check the haemorrhage, leave the case to nature, or by the bimanual method of
version, complete it at will. It was not, of course, meant that the dilators
were always needed ; but their particular value appeared in those cases where
but for their use mere temporary measures had to oe adopted until the os had
sufficiently dilated to permit of operative procedure, and so possibly lead to a
delay that might prove fatal.

Zir Oldham also agreed that it was important to take steps at once in any
case of placenta prsBvia to accomplish delivery — a plan, he thought, admitted
by most practitioners in London, and one upon which he had uways acted.
However, to effect this object, he believed that nothing was more easy or
MiisfactOTY than to turn b^ the plan recommended bv Dr Braiton Hicks, and
to bring oown the child mto the os. He (Dr Oldham) had only the night
before a case where its application was most satisfactory. He considered the
plug, which had been recommended for many years, might be used where the
cervix was very rigid, and preventing the introduction of the finder ; but its
chief advantage was as a provocative of labour, and he doubted if it would be
equal to stop nsemorrhage.

Dr Qreenkaigh stated in reply, that he was very pleased to learn from the
several speakers that in these cases they had, one and all, adopted the plan of
earlv delivery advocated in his paper, and mostly with satisfactorf results to the
mothers, which he maintained was not the course recommended m the standard
treatises on midwifery or pursued by practitioners in general. He believed
that the great success to the children in his cases was mainly due to not sepa-
rating either a part or the whole of the placenta from the uterus, to retaining
the membranes intact until dilatation of the parts had been effected by the
pains and plug, and by avoiding version in cases of head presentation, which
entailed more or less risk upon mother and child. He was quite convinced
that with these precautions a premature child, whose head was small and easily
compressible, stood as good, if not a better chance of being bom alive than a
child at term. In allusion to the plug, he stated that some years ago, as

VOL. X.— NO. ui. 2 m

268 PBBISCOFE. [S£PT.

ntentioned in hie paper, he had used on inflated india-rubber bag, bat had
found it inefiiBctual in arrestiag the flow of blood from the vagina, which be
had never failed to control, no matter how levere, with the spongio-piline plug.
He conndered the effects of the ping to be as follows : — 1st, To prevent the
escape of blood from the vagina ; 23, To fiivoor its coM^tion in the npper
part of that canal ; Sd, To excite uterine action ; andj 4t^, To dilate the
passages. The author approved and adopted the practice of rapturing the
membranes in 8lip;ht cases of pifrtial placental presentation, and of taming
m certain mal-positions of the child ; but he said that he had not alluded to
this class of cases in his paper. Dr Barnes having stated that the statistics
of Dr Read were not trostworthy, and that the author of the paper had
estimated the mortality to the mothers too high, Dr Greenhalgh urged in
confirmation the results of the practice of the Dublin Lying-in Hospital, and
of his own early experience in cases of placenta previa. In conclusion, he
trusted that after the expression of opinion of so many eminent accoucheurs, there
could be no doubt whatever as to the propriety of early delivery in these cases,
upon which the ultimate safety of the mother mainly depends. — The Lamed,

CASE or CESAREAN SECTION — ^BISTU OBSTRUCTED BY ENORMOUS HYDATID
CYST OF LIVER. BY DR MICHAEL THOMAS SADLER.

On the evening of 26th April 186d, I was reouested by Mr BUckbum of
Eamsley (who was confined to his bed by severe ulness) to see Mrs S., residing
about two and a-half miles from Bamsley, and who had been for some days in
lingering labour under the charge of his assistant.

The patient was twenty-one years of a^e, about nine months pregnant with
her first chUd ; she was a little under the average height, and had from an
early age a remarkably protubcmnt abdomen. 1 found that there had been
an escape of liquor amnii on the morning of the 19th, and ever since that time
there had been from time to time violent pains for brief periods followed by
long intervals of repose. On examininj^ per vaginam, I found that I could

Sit reach the ob uteri by passing my finger up a narrow passage between a
rd prominence in front of the sacrum and the pubes ; the os was undilated,
nndilatable, and flattened, and the head could be just reached within it. The
pulse was about 80, and there were no signs of approaching exhaustion, and
as a medical friend, who had seen the case before, thought that there had
been some little progress, we determined to wait until morning, and then to
have a further consultation, leaving her in the meantime in charge of an
assistant.

Next morning, finding that there was no improvement, I got two medical
friends to see her with me. Bv this time her strength was fli^^ng, the pulse
had risen to 150 and was smaU, an offensive discharge was begmning to flow
from the vagina, and the parts felt hot and unhealthy. They agreed with me
that it was (juite necessary to deliver the woman at once, and, at the same
time, that delivery by the natural passages was impossible, as only two fingers
could be passed between the pubes and promontory of the sacrum, and even if
we had succeeded in perforatmg the cranium of the foetus, it would have been
impossible to have got the fragments through the brim of the pelvis. The
obstructing protuberance was excessively hs?d, and had all the characters of
a large exostosis of the sacrum. The space between it and the pubes was
about an inch and a quarter. After much anxious deliberation it was decided
to perform the Csesarean section, which I accordingly did with the assistance of
Mr Stawman, Mr Harrison, and Mr F. Churchill. Having emptied the bladder
and rectum, I made an incision from a little below die umbilicus along the
linea alba to the pubes, and cautiously opened the abdomen, when a large mass
of apparently mesenteric disease came into view above the uterus, and which,
through the integuments, had felt remarkably like the head and limbs of a
child. The uterus was opened rather to the left, to avoid risk of injuring the
bladder, a quantitv of thick yellow liquor amnii was carefully sponged out, and
a dead child of fuU sice removed, and after that the placenta and a quantity of

16C4.] MIDWIFBRT. 269

meconinm. Having Mcertained thai the vtamii wai perfsctlT empty, and
iMviiig felt from abore the narrow antero-poeterior diameter of the bnm of the
pelvis, the ateras beinff well contracted and all blood and elots remored, wa
closed the wound with silver wire sutures and broad straps of plaster, and
applied a bandage roond abdomen. At 7.46 p.m. the patient was sensible,
me from nam, and desired to sleep.

2Stk, 9.30 A.M.— Has slept well, and is free from pain. Has vomited twice
since last evening. Pnlse 130, feeble. Moderate discharge from vagina. A
few drops of urine were drawn off by the catheter. Stimulants, beef-tea, etc,
were taken during the da^, and at 8 p.m. there was not much change. She
died, however, ab^t midnight, still sensible and free from pain.

With great difficulty, permission was obtained from the friends to re-open
the wound and examme the body as far as possible without enlarging tha
aperture, but nothing more was to be done. The first thing that attracted
attention on opening the abdomen was the appearance of a semi-transparent
round body about the size of a krge mu-Ue, roIUnK about among the intestines ;
these rapidly mnUiplied, and we soon found that tne cause of aU our difficulties
had been an enormous cyst filled with these hydatids, occupying the whole
upper part of the abdomen in the region of the liver, and extending downwards
au)ng the spine to the pelvis, and so compressed by the pressure of the uterus
from above a^ to assume a degree of hardness simulatiog that of a bony growth
from the promontory of the sacrum.

Of course it is easy to see now that the best course would have been to have

gassed a trocar into the supposed bony obstruction, for though no quantity of
nid could have escaped by the canula, yet the non-bony nature of the growth
would have been demonstrated, and we might possibly have been able, bv as
incision through the VHgin&j to have let out a siuBcient quantity of the hyaatid
growth to have allowed the child to have passed through the pelvis, and so
might have given the poor woman a very slightly better chance of her life than
was afforded by the dreadful iJtemative of the Cswurean section. I have thought
it my duty, however, to publish the case, as it is, as far as I know, unique, and
may not be the less useful to my fellow practitioners for being unfortunate for
the patient and unsatisfactory to myself. — Medical IHmes and Gaaette,

THE TEEATMENT OF LAGERATIOM OF THE PERIN JSUM INTO THE RECTUM
DURINQ PARTURITION. BY DB T. ROBINSON.

In the Medical Times and GaaeUe^ August, 1861, 1 drew attention to the suc-
cessful treatment of severe laceration of the perinteum and^ rectum by simple
means, adapted to retain the parts in undisturbed approximation, and allow
union by first intention. Subjoined is another instance of the success of this
plan. In this case the rectum and vagina were made one large opening, the
rent, two days after the accident, being several inches in length.

The subject was a primipara, aged 30 years, with a vagina so small that the
conjugal rite could not be consummated until artificial means to dilate it had
been resorted to. At the full period of gestation labour came on, and after
twenty hours of steady natural uterine action a lacge dead child was bora*
The vasnna preserved its integrity during the passage of the head, which was
very soft and pliable, and of low temperature. Death had occurred probably
a few days before. The shoulders were delayed some time on the fourchette,
and at length suddenly expelled by a violent uterine effort, laying open the
vagina into the rectum to a most formidable extent. On the second day,
observing that fsecal matter had passed through this recto-vaginal opening, I
cleared out the intestines by an aperient, and afterwards gave opium, and
adopted a limited diet containing very tittle solid matter — so that the descent
of faeces into the rectum might be retarded,— and having washed the parts free
from flJl excrementitious matter, I bound the knees together, and desired the
patient strictly to avoid all movement of the lower half of the person, to main-
tain the psrts undisturbed. This plan was pursued during eignt days, when a
general union was apparent ; an enema to unload the bowd was given, and the

270 PERISCOPE. [sept.

patient allowed to get oat of bed. From this time she might be considered
recovered ; the parts have continued sound and whole to the present date — a
period of two months.

That laceration of perin»um, short of implicating the rectum, is a common
accident, and may be left entirely to nature with wfety, is an axiom in mid-
vdfery, substantiated by daily experience; and I wish to impress that very
extensiye injuries opening up the rectum may be cured by adopting means to
prevent the torn surfaces bemg disturbed, and to induce healing by first inten-
tion. The means for attaining this object are, first, keeping the patient for
several days on food containing very little solid matter, which in its descent
into the rectum would disturb heabng; secondly, opium daily to constipate
the bowels ; thirdly, by preventing movement of the lower limbs as mncn as
possible. At first the knees should be bound together. Patients become very
weary of this after two or three days, and it may be discontinued, as was done
in the above and other cases I have had — it bemg forcibly impressed on them
that they must not separate the thighs, — cautious flexion is not hurtful.

Should these means hily we can then have recourse to " paring and stitching,"
with the usual chance of success. — Medical Times and Gazette.

ON IODIDE OF POTASSIUM AS AN ANTELACTESCENT. BT FREDEBIC H. MORRIS.

It was in consequence of the unsatisfactory results obtained from the external
application of belladonna, in. arresting the secretion of milk, that I was induced
to try the internal administration of iodide of potassium, first recommended, I
believe, by M. Roussel, of Bordeaux.

I have resorted to its use in upwards of a dozen cases, during the last ^VQ
years, where it has been advisable to arrest the secretion — e.g. where the child
has been still-bom, or has died a few days after birth ; where, from sore nipples,
injury to the breast from prior abscess, or from some accidental cause, conges-
tion of the breast has been set up, and lacteal abscess threatened, — ^and in no
instance have I been disappointed, even when belladonna has failed to afibrd
relief.

The following case may serve as an illustration : —

Mrs R. was confined of her first child on the 25th of December 1863. The
child, a weakly infant, died a few days afterwards from atelectasis puhnonum.
The breasts of the mother became tumid and painful. Extract of belladonna
mixed with glycerine was applied round the areola for two days, when the
pupils became dilated, without, however, any relief to the breasts. The patient
was feverish and restless ; the breasts were tumid and painful, and exhibited
every appearance of speedjr suppuration. Three grains of iodide of potassium
in a saline draught was given every four hours, and five grains of Dover's

Eowder at bedtime. Next day the breasts were less swollen, and she expressed
erself as feeling much better. In the course of three days all tumefaction had
subsided, and she discontinued the medicine.

The plan I adopt is to give three gnuns of the iodide in an ordinary saline
dratu^ht every three or four hours. In from twenty-four to thirty-six hours
the fever ana engorgement have ceased, and in from two to three days all
tumefaction has suDsided, even where abscess seemed unavoidable. — The
Lancet.

1864.] HEDIGO-CHIRUBaiCAL SOCIETY OF EDINBURGH. 271

$art iFottrtl.

MEDICAL NEWS.
MEDICO-CHIRURGICAL SOCIETY OF EDINBURGH.

8E8BION XLin.—UEBTIMa IX.

Gth July 1864.— Professor Douglas Maclaqan, President of the Society,

in the Chair.

I. CASES OF DISEASE OF THE TRICUSPID VALVE.

Dr Haldane exhibited two hearts, in both of which there was a morbid state
of the tricuspid valve.

The first specimen was obtained from the body of a woman, thirty*eight
years of age, who was admitted into the Royal Infirmary about the middle of
March, in a state of great oppression, and suffering much from difficulty of
breathing. The face was oedematous and of a dingy colour, the conjunctiva
had a yeUowish tinge, and there was considerable general anasarca. The sur-
face was cold, and the pulse scarcely perceptible. Having been somewhat
revived by the application of heat and the administration of stimulants, she
stated that she had never been very strong since she was fifteen years of affe,
when she had measles, followed by rheumatic fever ; of the latter disease she
had had two subsequent attacks, and for many years had been unable to make
any unusual exertion without suffering from ayspnoea. She was, however,
able to go about until about six weeks ago, when, in consequence of the
severity of the cough and increasing weakness, she had been obliged to take
to her oed. On examination of the chest the respiration was found harsh, the
expiration prolonged, and coarse crepitation mixed with bronchitic rftles was
almost everywhere audible. The cardiac sounds were feeble and very rapid ;
the only murmur distinctly audible was a whiff with the first sound, of a super-
ficial and somewhat musical character, heard close to the left border of the
lower part of the sternum, and inaudible either at the apex or at the base of
the heart. The veins at the root of the neck were distended, but there was
no distinct pulsation. The patient remained in a very weak state, and died
three days after admission. On post-mortem examination the lungs were
found highly OBdematous and congested, and the bronchi contained much
tough muco-purulent matter. The heart was somewhat enlarged ; the right
auricle was markedly distended with blood, the right ventricle less so ; the
left side contained a moderate quantity of blood. The tricuspid orifice was
contracted so as not to admit the points of two fingers ; the edges of the valve
were a little thickened. The mitral orifice was much contracted, admitting
only the forefinger ; the flaps of the valve were a good deal thickened ; there
was some glueing together of the chordse tendinesB. The aortic valves were
competent, but they were thickened and more rigid than natural, and must
have presented an obstacle to the forward progress of the blood. The pul-
monary valves were natural. The right ventricle was dilated and somewhat
thickened ; the left ventricle was a little dilated, but its walls were rather
thinner than natural. Dr Haldane observed, that from the very exhausted
condition of the patient on admission, the short time she was under observation,
and the feebleness and rapidity of the cardiac sounds, a completel^r satisfactory
diagnosis could not be established. In fact, the only murmur which could be
recognised was that which had doubtless been produced by regurgitation
through the tricuspid orifice. Its superficial character, the situation of its
greatest intensity, and the limited area of its propagation, had satisfied him

272 MEDICAL NEWS. [SEPT.

that the munnor wm due to incompetence of the tricospid valye. Poet-
Diortem examination had confirmed that opinion, and had at the same time shown
the existence of mitral and aortic disease, but the absence of characteristic mur-
murs was explained by the circumstances to which he had alluded.

The subject of the aecond observation was a woman thirty years of age, who
was admitted into the Royal Infirmary on the 8th of June, complaining of ex-
treme difficulty of breathmg, with pam in the epigastric region. She stated
that she had had an attack of rheumatic fever at the ace of twelve years ; from
this, however, she recovered completely, and remained in perfect health until
six years ago, when she had a second attack of the disease, on account of which
she was confined to bed for six weeks. From that time she always suffered
more or less from shortness of breath, with occasional palpitation. On admis-
sion, there was considerable general oedema ; the face had a dingy, mottled
appearance ; the hands were blue and cold ; the veins of the neck were pro-
minent, but did not pulsate. On percussion, the cardiac dulness was found
somewhat extended ; the apex could be pretty distinctly felt beating below
the fifth rib, a little to the left of its usual position ; pulse 80, somewhat
irregular. On auscultation a loud blowing systolic murmur was audible,
loudest at the right base, and extending up the large vessels. The character
of the second sound was doubtful ; sometimes it seemed to be pretty clear, at
others to be obscured by a murmur. At the apex of the heart there was a
rather rou^ presystolic murmur which merged into a blowing sound ; at the
lower part of the sternum a presystolic murmur was also audible, and firom
the fact that it was louder there than at a point intermediate between the apex
and the sternum, it was presumed that a double presystolic munnur was pre-
sent, the one due to contraction of the mitral, the other of the tricuspid orince.
There was some dulness over both backs, and coarse crackling was audible.
There was some hepatic tenderness. The urine was scanty, and contamed
urates, as also albumen, but no tubecasts were visible under the microscope.
Under the use of gentle diuretics and anti-spasmodics, combined with complete
rest, the patient appeared to improve ; the breathing became easier, the urine
became more copious, the oedema somewhat diminished, and the epigastric
tenderness disappeared. On the morning of the 16th of June (a week after
admission) the patient, in the absence of the nurse, was in the act of rising
to go to stool, when she fainted, and was dead before she could be seen by the
house physician. On post-mortem examination the pericardium was found to
contain between three and four ounces of clear straw-coloured serum. Before
the heart was removed it was noticed that the ri^ht auricle was excessively
dilated. The pericardium covering it was very thick and opaque ; the serous
membrane elsewhere was somewhat opaque, especially over the origin of the
aorta and pulmonary artery. The heart was of large size, but the auricles,
particularly the right, were disproportionally enlar^ea. The right auricle was
much distended with dark loosely coagulated blood; the left auricle much lesa
so. The ri^t ventricle was not fireer than natural, its widls were not
thickened. The left ventricle contained little blood ; its cavity was a little
dilated, and its walls were firm and of natural thickness. On examining the
valves the tricuspid orifice was found converted into an oval aperture, which
only admitted the point of the forefinger; the edges of the opening were some-
what thickened. The chordae tendinese were a good deal matted together, and
were much thickened. The pulmonary orifice and valves were natural, l^e
mitral orifice was converted into a buttonhole-shaped aperture with very thick
edges, which only admitted the point of the little nnger. The chordse tendine»
were completely matted together and much thickened. The aortic orifice was
much contracted owing to glueing together and ^eat thickening of the semi-
lunar valves ; it only admitted the pomt of the little finger. When examined
from*above, an opening of an irregularly triangular form was found to be left
between the apices of the valves. On passing water down the vessel it escaped
into the ventricle, but slowly, in consequence of the small size of the openmg.
Almost immediately above the valves the aorta became of the natuitd eize,

1864.} MEDICO-CHIBUBaiCAL SOCIETT OF EDINBURGH. 273

being verr Ihtle smiUer than the palmooAry mrtery. The foUowing

menu indicate in En^ish inches the diameter and circumference of the

aperturee : —

Dtaai* Clmua.

Tricospid orifice, '68 1-82.

Pulmonary do., *98 3*1.

Mitral do., 62 1-63.

Aortic do., -62 1-63.

Half an inch above the semilonar valvee the circumference of the aorta waa
2*8 inches.

Dr Haldane observed that this case waa of mat intereet, both on acconnt of
the very extensive lesions of the heart, and of the signs which indicated their
presence during life. The most striking anscnltatory pnenomenon was a sjrstolio
mnrmnr, loudest at the base, and propagated up the great vessek, indicative
of aortic contraction. But there were also presystolic and systolic mnrmnr*
both at the right and left apices, and it was accordingly presumed that there
was contraction both of the mitnd and tricuspid orifices. It had been found
impossible to decide as to the condition of the second sound at the base of the
heart ; from the condition of the valves, as revealed by dissection, they must
have been incompetent, but the frequent absence of the characteristic murmur
was probably to be explained by the small quantity of blood which could have
passed through the extremely contracted aortic orifice at each systole of the
ventricle.

n. PEBFOBATION OF THE APPENDIX YERMIFORMIS.

Dr Haldane showed the appendix vermiformis removed from a man who
had died of peritonitis occasioned by its perforation. The subject of the
observation was a young man who had lately been admitted into the Infirmary,
presenting the general and physical signs of advanced phthisis. Diarrhosa had
Deen almost constantly present, but had never been very ui^nt. The patient
was suddenly seized with the symptoms of acute peritonitis, and died within
forty-eight hours afterwards. The peritoneum was found on examination to
be covered with recent lymph, and there was a larse rent in the vermiform
appendix. The distal end of the appendix, where the rent was situated, was
dilated to nearly the size of a portion of small intestine. On examination a
stricture was found situated in tne appendix, at the distance of about an inch
from the coecum, through which a nne probe could with difS«ulty be passed.
Beyond this the appendix was dilated into an abscess ; this had burst into the
peritoneum, and produced the fatal result. There was prettv extensive tuber-
cular ulceration both of the small and large intestines, but there was no
appearance of this process in the appendix. Dr Haldane accordingly looked
upon the condition of the appendix as probably independent of the tubercular
disease. Chronic inflammation of the appendix had been set up, possiblv by
the presence of some foreign body which had given rise to a stricture or the
canal, and the formation of an abscess behind it. It was, howevw, possible
that there had been a tubercular ulcer of the appendix, which had cicatrized, and
led to the stricture ; this, however, it had been found impossible to determine.

ni. CANCER OF THE BLADDER. FRAGMENTS FORlflNQ URETHRAL PLUQB
DISCHARQED IN THE URINE. CONCENTRIC COLLOID BODIES.

Dr Sanders showed a preparation of extensive dendritic cancer affecting the
mucous membrane of the bladder, in the case of a man, aged 43, recently under
his care in the Royal Infirmarv. The case presented manv features of interest,
but at present he wished to allude to a few particulars only. The cancer was
of great extent, involving the whole interior of the bladder, and obstructing
completely the left ureter. The most important points in the case were, that
there was no hematuria at any time, and that the patient passed per ureihram
fragments of the cancer sometimes of small size like mere shreds, at other
times forming cylindrical plugs about an inch long, which often became

274 MEDICAL NEWS. [SEPT.

impacted in the urethra, and obstructed the flow of urine. Examined under
the microscope, these plugs consisted of epithelial cells more or less disin-
tegrated, among which coiud be observed peculiar concentric globular bodies,
from the dimensions of a starch globule to three or four times that size.
These concentric corpuscles, which presented various forms, consisted of a
central concentric portion of a coUoia or amyloid aspect (though not yielding
a decided amyloid reaction) ; and this central part was enveloped by flattened
epithelial scales forming peripheral concentric layers. From certain symntoms
of the case, it was considered probable that these concentric bodies mignt be
derived from the prostate, to the colourless concentric corpuscles of which they
bore a striking resemblance. The occurrence of similar corpuscles in cancer
was, however, also kept in view. The post-mortem examination showed
clearly that these concentric corpuscles belonged to the cancerous structure,
where they could be found in large numbers. Some of them presented the
characters of the corpuscles described as colloid bodies, others resembled the
laminated epithelial capsules of Paget, or the globes epiderndques of Lebert.

The preparation of the bladder, and the specimens of urethral casts were
shown, and the concentric corpuscles exhibitea under the microscope, together
with drawings of the urethnr casts and of the various forms of concentric
corpuscles.

IV. COAL MINERS* PHTHISIS. FRAGMENT OF COAL EXPECTORATED.

Dr Sanders showed a microscopic preparation illustrative of the •.matter ex-
pectorated in a case of miners* phthisis.

In a case of coal miners* phthisis, lately in his ward in the Royal Infirmary,
there were observed in the black sputum little hard specks havine aU the
appearance of coal. One of these specks, nearly of the size of a pin*s nead, Dr
Sanders sent to Mr James Bryson, optician, to prepare for the microscope, in
order to determine whether it was coal or not. Mr Bryson had succeeded
with some difficulty in ^rinding the fragment sufficiently thin, and, on compar-
ing the specimen exhibited under the one microscope with a specimen of
Dalkeith coal under the other, it would be perceived that they presented an
identical structure, consisting of bands of yellow material in a black matrix.
Tliis observation was of some importance in regard to the question still un-
decided whether the black matter m the coal miners* melanotic lung was due to
coal, or only to a deposit of pure carbon.

The patient had unfortunately left the hospital, so that the investigation
could not be pursued further.

V. THE ARSENIC-EATERS OP STYRIA.

Dr Craig Madagan read a paper on this subject, which will be found at page
200 of this number of the Journal.

PROCEEDINGS OF THE EDINBURGH OBSTETRICAL SOCIETY.

SESSION XXIU. — ^MEETING X.

nth May 1864.— Dr Pattison, Vice-PresiderUy in the Chair.

I. on craniotomy, by dr ANDREW INGLI8.

This paper will be found at p. 226 of the present number of the Journal.

Dr IngUs stated that since writing the paper he had had a case where crani-
otomy had to be performed. The patient, a young woman, was in labour with
her filrst child. The head was prevented entering the pelvis by a sharp anterior
curvature in the lumbar vertebrae. After some delay, with no advance being
made, Dr Weir saw the case with him. They applied Professor Simpson's
cephalotribe, but owing to the head beine so high up, the instrument was
found to be too short to take a proper hold. They then had recourse to the
ordinary craniotomy instruments, and with them they were able to extract a

1864.] OBSTETRICAL 80CI£TT OF EDINBURGH. 276

large portion of the occipital bone with part of the oa magnnm. With bodw
difficulty they finally socceeded in extracting the child ; the woman tank and
died on the tnird day.

Dr Cochraney in reference to Dr Inglis* ptper, thought that turning before
one had recourse to craniotomy would greatly tend to complicate the operation.

Dr KeUler said he had seen Dr Inglia* case when the natient had hem twelve
hours in labour, but had been oblured to leare. The head lay in an extended posi-
tion, and that partly accounted tor the difficulty of getting a proper bold with
Professor Simpson^s instrument. It was difficult to extract in sucn cases. The
great point to be attended to in all such operations was to keep the head well
flexed. As to the paper, the question started as to the advisability of crani-
otomy in many cases was an interesting one ; but as to the proposal of substituting
CsBsarean section for craniotomy, he thought it would prove a roost dangerous
proceeding, and he must hesitate before seconding such a suggestion. Uis
experience led him to believe that much injury was sometimes done by the
great force applied in extracting with forceps in some cases ; and he believed
there were many where craniotomy would nave been of greater safety to the
mother.

Dr Alex. R. Simpion siud he roust put in a word in defence of the cephalo-
tribe. They must remember that the instrument used was but an imperfect
and untried one, and had yet many improvements to be made on it. Notwith-
standing its defects, however, it liad assisted Dr Inglis, for he (Dr I.} stated
that he succeeded in removing a portion of the os magnum, and that could not
have been done by the ordinary craniotomy instruments. Another cause of
the £ulure of the instrument was, that Dr IngUs had not opened the head before
using the cephalotribe. This should always be done first, for if not, however
much you narrowed one diameter of the head, it could only be done at the ex-
pense of increasing some other diameter, there being no escape for the brain,
etc. Dr Keiller had also mentioned another point, vis., that the instrument
was applied too far forwards. With regard to the paper, from the want of
proper statistics, Dr Inglis had presented too narrow a view of the subject to
come to any definite conclusion. Also in overlooking the question of whether
the child is alive or not, he had left out a most important point in cominff to a
conclusion as to which method of delivery was to be adopted. He had used
the cephalotribe a few days previously with the most satisfactory results in the
delivery of a woman who had had rather an interesting obstetric history, and
some points in connexion with whose case had on a previous occasion been
brought before the Society. She had a contracted brim, and had been delivered
of two children by means of craniotomy ; had been delivered of a third pre-
maturely in consequence of being thrown out of an Irish car, on which occasion
the child lived; the fourth he (Dr A. R. S.) had delivered successfully by
means of turning ; the fifth, a huge child, had been bom dead by means of the
same operation performed oy a student ; the sixth had been bom alive after
the induction of premature labour by means of a catheter passed into the uterus,
and the subsequent application of the electro-magnetic current, as reported to
the Societjr by Dr Berryman, now of St John's, New Brunswick. On the pre-
sent occasion the patient had fallen back into her old reprehensible habit of with-
holding information as to the pregnancy until it was too late to interfere with
much effect in the way of inducing premature labour ; so that when Dr Watson,
who had kindly undertaken the management of the case, was called ib deliver
her, he found presenting at the os a large well-developed head, which f^ot
engaged in the inlet, but could not be got to descend through it, notwithstandmg
a repeated well-directed application of the long forceps. When he (Dr A. R.
S.) came to see the patient, had the child been still alive, he would have felt
constrained either to make a fresh attempt at delivery with the forceps, or, more
probably, would have had recourse to podalic version. But as the foetal heart
was no longer audible, and there was every indication that the child was already
dead, the alternative operation of cephalotripsy seemed to afford a better
ehance to the mother, and so, after pemrating the head, he applied Scanzoni's

VOL. X.— NO. III. 2 N

276 MEDICAL NEWS. [SEPT.

cephalotribe, and with great ease and speed safely effected her delivery. In
this instance, the fact that the child was already dead led at once to the pre-
ference of cephalotripsy to the alternative operations ; and in every case the
vitality of the foetus must influence us very durectly and decidedly in the choice
of our operative procedure.

Dr Bryce remarked that Dr Inglis^ case was one very similar to the one he
had lately communicated to the Society, where Scanzoni's cephalotribe was
used with success. The fault lay with the instrument used being an imperfect
one.

n. MALIGNANT ABDOMINAL DISEASE.

The Secretary^ in absence of Dr Wilson, exhibited a specimen of malignant
abdominal disease, the history of the case being deferred till Dr Wilson would
be present.

in. FIBROID TUMOURS AND POLYPI OF THE UTERUS.

Dr Alex. R. Simpaon showed a preparation of a uterus with a laij^ fibroid
tumour embedded in its anterior wall, and a couple of fibrous polypi growing
into its cavity. It had been removed from the body of a married woman about
forty years of age, who had never bom any children, and who had first come
under his care about five years ago. At that time she suffered from frequent
attacks of menorrhagia, with almost constant leucorrhoea in the intervals. On
examination with the sound the cavity was found to be enlarged, and occupied
by a polypoid growth. He introduced a series of sponse-teuts so as to dilate
the cervix, and removed the growth by means of the polyptome. The uterine
cavity seemed then to be smooth and regular, and though the walls were thick
no marked inequalities were discoverable in their contour. The patient had
remained well tor a length of time ; but about two years ago she had again
come under observation in consequence of a return of some of her old symp-
toms. Enlargement of the uterine cavity, and the presence of a morbid growth
in it, were again perceptible on the introduction of the sound ; and when a
simultaneous examination was made with the right forefinger in the vagina and
the left hand over the pubes, the contour of the uterus was felt to be altered
by the presence of a firm fibroid mass high up in the anterior wall, whilst the
part of the posterior surface accessible to the exploring finger felt Irregular,
and seemed very tender to the touch. She was put upon bromide of potassium ;
but the morbid growths were found to be steadily developing when she was
seen every three or four months ; and when on one occasion the cervix was
dilated with sponge-tents, lust sufficiently to admit the finger, the polypus was
felt to be becoming pediculated. Some months ago she came to town with the
view of having the new polypus removed, and a serious of sponge-tents were
introduced ; but on the withdrawal of a large tent on the second day there was
found to be a ver^ ticht band in the posterior wall, at the level of the os
internum, still undilated ; and as this rendered the neck of the polypus which
was attached above it very inaccessible, it was deemed advisable to allow the
uterus to close for the time, with the hope of effecting a more rapid and com-

Elete dilatation at some after period. About six weelu ago she was again seen ;
ut had come only to request that the operation might be deferred till her
husband — an old man — ^should have recovered from some attack of renal dbease.
On her return the cervix was dilated with tangle-tents, and the superiority of
these to the sponge-tents was very markedly seen in the completeness with
which the dilatation of the whole circle of the os internum was effected. But
whilst the dilatation was progressing the patient had very uncomfortable
threatenings of rigor ; and on the morning of the day on which the removal of
the polypus should have been effected she had a rigor so severe and prolonged
that he (I>r A. R. S.) feared some local inflammation was being set up, and
simplj withdrew the tent without subjecting her to what would have been the
additional danger of a surgical operation. No local tenderness, however, was
manifested; but the discharge from the uterus became excessively offensive, so

1864.] OBSTETRICAL SOCIETY OF EDINBUBGH. 277

that it was supposed the tiiinoar had become slonghy, and mi^ht perhaps break
down and be oischarged. The pulse had already nsen considerably, and con-
tinued to rise to 120 and upwards; the skin became hot and dry, and assumed
a dingy yellow hue ; delirium set in ; and the patient died on the seventh day
with sll the symptoms of a septic fever.

At the post-mortem examination no traces of any peritonitis or other local
inflammatory action presented themselves ; but on removing and cutting open
the uterus the large polypus in its interior, which was about the sice of a
duck's enSi ^"^u seen to be blackened, soft, and sloughy — a result which
had, in all probability, been brought about by the pressure of the expanding
and inelastic tangle-tent upon its neck. The pedicle had the thickness of
about two fingers, and could easily enough have been cut through with the
polyptome; and perhaps the extirpation of the polypus might have led to
a more favourable issue, although m view of the repeated and severe rigors
which the patient exhibited, the operation would have seemed almost un-
justifiable. Close to the pedicle of the sloughy polypus, which sprang from
the back wall of the uterus, immediately above the os internum, there was
another small tumour of the size of a hazel-nut just beginning to become pedi-
culated ; whilst an intra-mural fibroid of the size of a small cocoa-nut, and of
somewhat soft texture, was growing in the anterior wall, and formed the chief
part of the mass that had been felt through the abdominal wall on palpation
over the pubes. — He might add, although it seemed to have no bearing on the
clinical history of the case, that the extremity of the left ureter was foufid to
be folded on itself as it passed through the wall of the bladder, and was dis-
tended immediately above into a little pouch, larse enough to contain a pigeon's
egg. The cavity was occupied with an innumeraole quantity of small calculi —
one of which was of about the size of a pea, the others of the size of wild
mustard seeds.

HEBTINO XI.

I. ON 80ME CUSTOMS AMONO THE PEOPLE OF OLD CALABAB BELATiyS TO

PBEQNAMCT AMD PARTURITION.

The paper on this subject, by Dr Hewan, will be found at p. 220 of this
number of the Journal.

Dr KeUler remarked that he was highly gratified at hearing so interesting a
paper read before this Society. It would form an interestmg addition to a
similar paper communicated bpr Dr Wyse on Hindu midwifery.

Pro/e89or SimpBon said the facts were most interesting, ana were detailed by
Dr Hewan in a masterly way. The idea of twins being monsters, and that both
they and their mothers should be destroyed, was common among some savage
tribes. He was happy to learn from Mrs Hewan that she had frequently
twins brought to her at the mission station by the mothers, for the purpose of
savins them, and that now as they grew up tne natives were beginning to see
that they were not to be looked upon as monsters. Among the Basques of
Spain there still remained the strange custom of the mother getting up and

going to work immediately after her confinement, and the husband takmg to
ed and receiving the visits of congratulation, — a practice described by many
travellers in different lands, but one which was scarcely to be expected as a
remaining habit on European soil.

Dr Wniteford stated that the same custom existed amongst some of the
Indians of South America.

II. LARGE CALCAREOUS TUMOUR OF THE UTERUS. BY WILUAM TURNER, H.B.

The SecreUsry read the following communication : —

The tumour, a notice of which I propose giving in this communication, is
interesting, not only as an example of the size which tumours of its class may
occasionaUy attain, but from the singular mode of its discovery. The circum-
stances under which it was obtained are the following : — About three months

278 MEDICAL NEWS. [SEPT.

agOt in opening a grave in which, nine years previously, an old woman had
been buried, for the purpose of interring her husband, the pelvis of the pre-
vious occupant was exposed. Lying in the cavity of the pelvis was the tumour
in question. It had no connexion with the bones of the pelvic wall, and from
the destruction of the soft parts by putre&ction, it was quite loose, and easily
removable. From the short history with which I have been furnished, it would
appear that the woman had died at the age of 76 ; that she had never bom
ehddren ; and that for some years previous to her decease she had suffered
from incontinence of urine, but had not been confined to bed, save for a few
days before her death.

The tumour, from its size, hardness, and remarkable appearance, had occasioned
some speculation as to its nature, amongst those to whom it was shown ; and as
considerable difference of opinion was expressed, I was asked to state what I
considered it to be. From the examination to which I have submitted it, I
have no doubt that it is an unusually large specimen of a calcified fibrous
tumour of the uterus.

It equals in size the head of a young child, and weighs 2 lbs. 5| oz. It is
very hard and dense, irregularly tubercukted, and somewhat conu-like in its
aspect externally. The devations not unfrequently have deep depressions
between them, in some of which are scanty remains of organic matter. When
cut in two with a saw, the surface of the section was yeUowish-white, with
numerous irregular depressions, some shallow, others sinking for a considerable
deplh into the substance of the tumour. The deposit of lime salts in the
original fibrous mass had therefore been very irregular, and as it were in dis-
tinct centres, which had afterwards more or less perfectly coalesced ; and this
is the mode which generally prevails in the calcincation of fibrous tumours of
the uterus. It is probable that during life these depressions had been filled up
with the soft fibrous material of the tumour, ana that it had possessed an
external investment of peritoneum, so that it would not then have nad nearly so
irregularly tuberculatea an appearance externally as it now presents. At least
such is the case in those smaller specimens of calcified uterme fibrous tumours
with which all pathologists are, I suppose, familiar.

A thin slice examined microscopiouly exhibited that imperfect osseous struc-
ture which is so characteristic of an amorphous deposit of lime salts in a soft
texture, and which has been so well figured by Duncan that I need do no more
than refer to his illustration for a representation of it.

Although one seldom meets with calcified fibrous tumours of the uterus pos-
sessing the size of this specimen, yet more than one case has been recorded by
Mr Paget, m his Lectures on Surgical Pathology. In the museum of the College
of Surgeons of London, is one about five inches long (No. 226), which was
found m a grave-yard, and was sent to John Hunter as a urinary calculus.
Larger specimens are also in the museums of St George's and the Middlesex
Hospitals. And in the Anatomical Museum of the University of Edinburgh
is a section of one (No. 1799), which, in its entire state, weighed 5 lbs. It was
attached to the posterior part of the body of the uterus, and possesses a very
hard and compact structure.

Professor Simpson stated that calcareous degeneration was the sign of death
in a tumour, and after it had taken pUce they never increased in size. Had
we any means of inducing this degeneration, it would be a most useful method
of treating some such cases.

Dr KmUr stated that he had a patient with a large fibroid tumour, which he
hod frequently pointed out to his students as presenting a well-marked bruit.
He had lately examined the patient, and found that the bruit had ceased, and
the tumour had become harder and more nodulated. He had no doubt it was
becoming calcareous.

III. FIBROID POLYPUS OP THE UTEBUS, WITH ▲ CT8T,
Professor Simpson showed a specimen of the above, which he had removed
from a patient. Before removal it felt extremely like an inverted uterus. It
was soft and fluctuating, and on opening it, it was found to contain a cyst filled
with bloody fluid.

1864.] QBADUATION IN MEDICINE AT EDIKBURaH UNIYEBSITT. 279

GRADUATION IN MEDICINE AT THE UNIVERSITY OP EDINBURGH.

On the Ist of Aimut, the Annual ceremony of Graduation in Medicine took
place in the Asaenooly Hall, under the presioence of Sir David Brewster. The
following is the list of Graduates with the titles of their theses : —

••• Tho»e who have ciUained Priae» for ikdr J^^
** Thoie deemed worthy ofoompetmgfor the DieserUUion Prkes,
* Those commended for their DmerUUUme.

Anderson, Robert, Scotland. On the Pathology, Symptomatology, and

Treatment of Acute Rheumatism.
Baker, Robert, England. On Acute Hydrocephalus, and the Diseases

which simulate it.
*** Banks, William Mitchell, Scotland. On the Wolffian Bodies of the Foetos,

and their Remains in the Adult.
^ Barnes, Henry, England. On Gout and the Gouty Diathesis.
5 Barss, Andrew De Wolf, Nova Scotia. On Scarlatina.
Belgrave, Thomas Bowennan, England. On Hemiplegia.
Bentham, Thomas, England. On Gk)ttt.

Bottle, Alexander, England. On Variola, Varioloid, and Varicella.
Brims, James, Scotland. On Litholyte, or an Instrument for Dissolving

Stone in the Urinary Bladder.
10 Bruce, William, Scotland. On the Pathology of Jaundice.
Carmichael, James, Scotland. On Albuminuria.

Carter, William, England. On Pneumonia, its Pathology and Treatment.
Ghastellier, Evenor, France. On Gonorrhoea, bearing chiefly on its

relation to Syphilis.
Clifton, Herbert, England. On the Spinal Column.
15 Conyers, James Saltus, Bermuda. On some of the Accidents attendant on

Surgical Operations.
Cornish, George Bishop, England. On the Advantages and Defects of

Drainage and Ventilation.
Crawford, William Thomson, Scotland. On the Nature, Causes, and Treat-
ment of Ununited Fracture.

* Crichton, James Smith, Scotland. Observations on Clinical Medical Cases.
** Cunningham, Robert Oliver, Scotluid. On the Natural History and

Anatomy of the Solan Goose.
20*Dalton, Thomas, England. On the Pathology, Diagnosis, and Treatment

of Ovarian Dropsy.
Dixon, George, England. On Vesico- Vaginal Fistula.
Drummond, Edward, England. On the Fibrinous Concretions which occur

in the Heart and Bloodvessels during Life.

• Eddison, John Edwin, England On the Treatment of Ovarian Dropsy.
Ebnslie, William Jackson, M.A., Aberdeen, Scotland. On the Regular

Dislocations of the Hip- Joint.
25**Fox, Cornelius Beniamin, England. Concerning the Laryngoscope and

some Laryngeal Dbeases.
Grosvenor, Alfred Octavias, England. On Extra Uterine-Gestation.
Gunn, Robert, Scotland. On Dyspepsia.
Hamilton, David, Scotland. On Moral Lisanity and its Medical Juris*

prudence.
Harrison, Thomas Laurence, Shetland. On some points in Enteric Fever.
30 Henderson, Edward, Scotland. On Fracture.

Hope, James Johnstone Hyslop, Scotland. On Fistulo in Ano.
Howes, Frank Charles Plnmptre, Eneland. On Jaundice.
Hughes, David Erskine, Scotland. On Hysterical Convulsions.
Irvine, William Skipton, Ireland. On the Reciprocal Relation between

Heart and Lungs m Health and Disease.
35 James, Henry Northage Land, England. On Endemic Influence.

280 MEDICAL NEWS. [SEPT.

Jones, Andrew Pogsiey, New Brunswick. On Rubeola.

Jo^ce, Thomas, England. On Hepatic Abscess.

Laing, Alexander, Scotland. On Syphilization.

Livingstone, Robert Hamilton, New Brunswick. On the Treatment of

False Joint.
40 Lorraine, Walter, Scotland. On Goitre.

M' Andrew, Andrew Watson, Orkney. On the Pathology and Treatment

of Gastric Ulcer.
M'Closkey, Joseph Richard, Lreland. Phthisis ; its Causes, Symptoms,

Pathology, and Treatment.

* Macdonald, Angus, M.A., Aberdeen, Scotland. Notes of Three Renal

Cases, illustrative of Vasomotor Neuroses.
** Mackenzie, Stephen Coull, Calcutta. On Absorption by the Human Skin.
45 McNeil, William, Scotland. On the Conditions of the Respiratory Passages

in Health and Disease.

* Meiklejohn, Robert Morris, East Indies. On Criminal Abortion.
Messer, Thomas John Fordyce, Scotland. On Croup.

Miller, Alexander Gordon, Scotland. On Scorbutus.
Moffat, Jolm, Isle of Man. On Typhoid Fever.
50 Montizambert, Frederick, Canada. On the Prophylaxis of Hydrophobia.

* Morson, Alexander Kinnear, England. On Pneumonia.

Mouat, George Bridges, Scotland. On Iron ; its Chemical and Medical
Uses.
** Munro, Alexander Donald Neil, Scotland. On the Arrangement of the
Muscular Fibres in the Unimpregnated Human Uterus.

* Nankivell, Herbert, England. On Certain Fatal Cases which occurred in

Paton^s Ward, Royal Infirmary, Edinburgh, during the Winter Session
1863-64.
55*Na8h, Edmund, England. Clinical Remarks on Acute Rheumatism.

* Nivison, Thomas Renny Strachan, Scotland. On the Chronology of

Putrefaction.

* Oliphant, John, Scotland. On Chorea in its Relation to Rheumatism,

Disease of the Heart, and Pregnancy.
*** Parsons, Charles, EngUmd. ^ On a form of Bronchitis (simulating Phthisis),
which is peculiar to certain branches of the Pottery trade.
Purves, William Laidlaw, Scotland. On Bronchocele, a beneficial Physio-
logical Action.
60 Renton, William Matthew, England. On the Actions and Uses of Mercury.

Rigg, Thomas, England. On Jaundice.
** Roberts, John, Wsues. Researches in, and Contributions to. Medicine and
the Collateral Sciences.
Roberts, Thomas Edward, Gibraltar. On Fibroid Tumours of the

Uterus.
Robertson, Schoedde, Ireland. On the Integument ; its Appendages and
Adaptations in the Animal Kingdom.
65 Setnple, William Henry, Scotland. On the Myology of the Extremities.
Sewell, Colin Charles, Canada. On the Surgical IVeatment of Aneurism.
Shears, Arthur, England. On the Causes and Prevention of Death from

Chloroform.
Shedden, Arthur William, East Indies. On Bronchocele.
Sheldon, William, EngUnd. On Diabetes Mellitus.
70 Sinclair, William, Scotland. On the Acetate of Lead.
Skimming, Robert, Scotland. On Epilepsy.
Smith, James Taylor, England. On Arsenical Poisoning.
Squires, William Westbrooke, France. On Epilepsv.
** Taylor, Herbert, Darmstadt. Remarks on the Practical and Clinical
Value of Thermometric Observation in Disease, with facts relative to
the Variations of the Temperature of the Body in some forms of Specific
Fever.

18e4.] GRADUATION IN MEDICINE AT EDINBURGH UNIYERSITT. 281

75 Taylor, John William, Scotland. Obsenrationt on some Diseases of Joints.
Thomas, David, Wales. On Goat.
Thomson, James Clements, East Indies. On Scorbutus.
*** Thomson, Robert firemner, Scotland. Contributions to Vegetable Physi-
ology.
Thorbum, David Amo Smet, Scotland. On Pulmonary Phthisis, and its
Treatment by Climate and Cod Liver Oil.
80 Tumbull, Gkorge Hogarth, Scotland. On Air ; iu Physiology and Path-
ology.
Veitch, Andrew, Scotland. On Mechanical Occlusion of the Intestinal

Tube.
Walford, William, England. On Abortion.

* Warter, John Southey, England. On the Vis Medicatrix Natuns.

*** Watson, Alfred Marchmont, Jamaica. Observations on the Contractions
of the Uterus after Labour, and on the alterations in Form and Bulk
which it undergoes during the Lying-in Period.
85 Watson, James, Scotland. On Zymotic Disease.

* White, Francis Buchanan White, Scotland. On the Relations, Analogies,

and Similitudes of Insects and Plants.
White, John Gregorv, England. Concemine the Viability of the Child.
Wickwire, William Nathan, Nova Scotia. On Pneumonia.
Williams, Eyeton Owen, England. On Diphtheria.
90 Wood, Joseph, England. On Acute Atrophy of the Liver.

* Workman, Charles John, England. On Military or Vesicular Ophthalmia.
** Wright, Joseph Brampton, England. On the Chemistry of Oleum Ricini;

with specimens.
93 Wright, Robert, ScotUind. On Aneurism, and its Treatment by Pressure.

ARMY MEDICAL SERVICE.— ASSISTANT SURGEONS.

The Director-General of the Army Medical Department presents his compli-
ments to the Editor of the Edinburgh Medical Journal, and begs to enclose a
List of the Candidates who were successful at the Competitive Examinations
in February and March last, and who have passed through a Course at the
Army Memcal School, showing the combined results of the Examination.

Names,

J. Wallace,
W. Jobson,
J. Fleming,
W. Atkinson,
H. H. PhUlips,
T. W. Orwin,
R. C. C. Hickson,
T. G. Bolster,
H.F.L.MeUadew,
J. Middleton,

B. J. Finegan,
D. A. Leslie,
H. S. Muir,

J. W. Maxham,
R. Hyde,
T. S. Barrow,
M. Cogan,
R. Turner,

C. F. Churchill,
T. Babington,

StudUd tU Marlu,

Edinburgh, 5064
Edinburgh, 4755
GUisgow, 4584
NewCoLLon. 4547
Dublin, 4486

London, 4447

Dublin, 4157

Dub. & Cork, 4121
Lon. & Edin. 3981
Edinburgh, 3956
Dublin, 3880

Aberdeen, 3789
Glasgow, 3765
Edinburgh, 3642
Dublin, 3628

London, 3611

Dublin, 3594

Lon. & Edin. 3578
Dublin, 3493

Dublin, 3486

Namet.

Ambrose,

Atkinson,

Anderson,

Johnson,

Minty,

Atkinson,

Burke,

Gray,

V. T. Malcohn,

M. Kirkwood,

N. Watts,

W. Davies,

F. Dooley,
Dunlop,
N. Stock,
J.Bali,

G. King,
Lithgow,
P. Ross,

Studied ai

Jforftf.

Cork,

3479

Dublin,

3435

Manchester,

3402

Dublin,

3335

Aberdeen,

3306

Dublin,

3292

Dublin,

3257

Aberdeen,

3226

Edinburgh,

3226

Dublin,

3157

London,

3119

London,

3091

Dublin,

3073

London,

3036

Dublin,

3035

Dublin,

3030

London,

2975

Ed.Gla8.Paris,2964

Edinburgh,

2960

282 MEDICAL NEWS. [SEFT.

ARMY MEDICAL SCHOOL.
The following were the questions proposed at the dose of the eighth session
of the Army Medical tichool, Boyal V ictoria Hospital, Netley, between 26th
July and 3d August 1864 :—

A. — ^Written Questions.
I. MUUary Surgery.

1. Mention the several purposes for which the convex and concave spectacles
are supplied in the regimental optical and ophthalmoscopic case of instruments ;
and describe the method of using them, in conjunction with the test-types, for
distinguishing emmetropia, myopia, hypermetropia, whether simple, or compli-
cated with presb^ropia or amblvopia. Explain the theory on which the diagnosis
in each instance is established.

2. Describe the nature, effects, and proper treatment of osteo-myelitis after
gon-shot injuries of Ions bones, or of amputations consequent upon them.

3. Describe accuratehr, step by step, the operations of excising the shoulder
and elbow-joints, each by a single linear incision, as practised in the post-
mortem room.

n. Military Medicine,

1. From what date may cholera be said to have engrafted itself on the
epidemics of the soil of India? What are the conditions which appear to act
most powerfully as predisposing causes of the disease ? What influence do
high or low situations respectively exert (a) on the proportionate mortality of
those attacked ; (b) on the proportionate number of those seized. Explain in
what way excessively long marches appear to increase the virulence of an
epidemic of this disease in soldiers, native or European, in India. Give an
accurate description of the premonitory and actual symptoms (a) in the slight,
{b) in the severe forms of the disease ; and describe the effects of its presence
on the blood and secretions. What are the chief points to keep in view in our
endeavour to exclude this disease from garrisons, camps, and cantonments;
and to mitigate the severity of an epidemic when it appears? Give a descrip-
tion of the most rational treatment (a) in the premonitory ; (b) in the confirmea ;
(c) in the state of febrile reaction ; particularly stating in what stage and to
what extent opium is useful and safe.

2. What is the average weight of the liver, in health, in a man between the
ages of eighteen and forty ? Describe accurately its normal position and limits.
Explain tne most common causes of abnormal position of the gland. Give the
precautions necessary to accuracy in the use of percussion and palpation in
mvestigating hepatic disease.

3. Give as complete an account as you can of the therapeutic uses and value
of ipecacuanha in tropical medicine.

ni. Military Hygiene,
'1. What are the chief cases and effects of impurity of air in the habitations
of men?

2. How would you determine the amount of carbonic acid, watery vapour,
and suspended matters in the air ?

3. Enumerate the principal adulterations of wheat-flour, and state how you
would determine (a) the quality of the flour ; (6) the presence of pea-flour,
oats, and maize.

4. What has been the medical history of the West Indies, as far as Euro-
peans are concerned ? State explicitly what you would do in a West Indian
station, if there occurred (a) a considerable yearly number of diarrhoeal and
dysenteric cases ; (6) a considerable number of admissions from tvphoid fever ;
(c) a number of admissions from paroxysmal fever ; (<Q occasional outbreaks of
yellow fever.

rv. Pathology,

1. Give a classified account of the lesions in the kidney which were demon-
strated during the past session in the practical room.

2. Describe the nature and probable origin of the parasitic cyst in the liver,

1864.] ARMY MEDICAL SCHOOL. 283

which proved fatal in the case of Private , aa shown at the post-
mortem examination of 28th June 1864.

3. Mention the period of incubation, and describe the course and progress
of an infecting venereal sore; and contrast your account with similar details
relative to venereal sores which do not infect the system.

B. — Practical Examination.
1. Military Surgery^ and, li. MiUUsry Medicine.

Make an examination of the case of . Write concisely a history of

the case, your diagnosis, pro^osis, the probable effects of treatment, and' the
influence of the disease or injury on the man*s fitness for service as a soldier.

(Twenty minutes allowed for the examination, half an hour for tlie
description.)

III. Hygiene,

Examination of two specimens of water. Examination of adulterated roillc
and adulterated beer. Microscopical examination of adulterated wheat-flour.

IV. Pathology.
Description of various preparations and microscopic specimens, and exami-
nation of secretions.

MEMORIAL OF the ROYAL COLLEGE of SURGEONS of EDINBURGH.

TO THE RIGHT HOH. VISCOUNT PALMEBSTOH, K.G., FIB8T LORD OF THE TREABUBT.

Humbly Sheweth, — ^That the Hoyal College of Surgeons of Edinburgh have
long been charged with the duty of licensing Surgical Practitioners, and have
always endeavoured, to the utmost of their power, to promote the welfare of
the Medical Profession for the public good.

That the attention of the College has been called to the present state of the
Army Medical Department.

That it is obvious that that Department is not in a satisfactory condition,
there being, as the College have reason to believe, wide-spread discontent
among the Army Medical Officers, — the Medical Service of the Army having
become so unpopular that Medical men are repelled from it instead of being
attracted to it, — ^and that there is found to be great difficulty in filling up
vacancies as they occur, and that to an extent which seriously mars the
efficiency of the Service, and imperils the health of the Army.

That, under present regulations, 'the Service does not hold out inducements
sufficient to secure a supply of competent Medical men ; and that much fewer
high class Medical men than might be expected, under different arrangements,
oner themselves at the Competitive Examinations.

That, in consequence of this lack of candidates, the Army authorities have
been obliged to resort to the very extraordinary expedient of advertising for
Civilians to act as Assistant Surgeons, to whom appointments for Home Service
are offered without examination. That further, for the same reason, it has
been proposed by the Secretary of State for India to abandon Competitive
Exammation in the case of Army Medical Officers for the Indian Service, and
to return to what would be equivalent to the old system of patronage.

That a due regard to the health of our brave soldiers demands that they
should be protected from incompetent Medical Attendants, and that in that
important view a state of matters so unsatisfactory should be put an end to.

That various reasons have been stated why the Service should be at the
present time so unpopular ; — such, for example, as that the excellent Warrant of
1858, which gave so much satisfaction when it was originally issued, has not
been carried out as it ought to have been; that its operation has not been
extended to India, as was due to Indian Medical Officers ; that Medical Officers,
in consequence of the deficiency in their numbers, have a difficulty in getting
leave of absence, have an undue share of Foreign service, and are very slowly
promoted. That, moreover, they are slighted as regards rank, have degrading
VOL. X.— NO. in. 2 o

284 MEDICAL NBWS. * [SEPT.

duties unnecessarily imposed upon them» and, as regards pay and arrangements
as to retiring pension, are not renumerated as is due to men belonging to a
liberal and 8cienti6c profession, — qualifications in which can be attamed only
after long years of study, and at g^eat cost.

That the College refrain from giving an opinion as to the relevancy of these
alleged causes, believing, as they do, that the only satisfactory means of
ascertaining the real causes and amount of the evil, and of applying the proper
remedies, is the appointment of a Royal Commission to inquire into and report
re^rdine the whole matter.

That this College would therefore respectfully, but earnestly, petition your
Ijordship to advise Her Majesty to issue a Commission, constituted of men of
weight and impartiality, in whose judgment confidence may be reposed by aH
concerned, and especially by the public, who are so deeply interested in the
issue.

In name and by authority of the Royal College of Surgeons,

Benjamin Bell, PrendetU,
Edimbuboh, 4^ AvguMi 1864.

PETITION OF THE PRESIDENT AND FELLOWS OF THE FACULTY
OF PHYSICIANS AND SURGEONS OF GLASGOW,

To the Honourable the Commons of the United Kingdom of Great Britian
and Ireland in Parliament assembled, —

Humbly Sheweih^ — That your Petitioners have exercised the functions of a
Chartered College of Physicians and Surgeons since 1599; and, besides
examining and licensing Medical Practitioners, have idways taken an interest
in whatever has affected the Profession of Medicine.

That the inadequate remuneration of the Medical Ofiicers of Her Mapesty^s
Army, and their deficient authority in purely Medical questions, involving, as
this latter has done, alike the safety, in a sanitary point of view, of the troops,
and the wellbeing and comfort of the sick soldier, were long matters of regret
to your Petitioners.

That in 1857 your Petitioners had great satisfaction in finding the pay of
Army Assistant-Surgeons somewhat raised at the recommendation of a Com-
mittee of your Honourable House, and that in the following year the relative
status of Medical, as compared with Military Ofiicers, was placed by a Royal
Warrant on an honourable and satisfactory footing.

That your Petitioners regret to learn, nowever, that the advantages of the
said Warrant were speedily much modified, either by not being acted on, or by
authoritative alterations.

That the desirableness of the Army as a field for the efforts of young
Medical Men has become in consequence lowered, and the number of Candi-
dates for admission to the Service lessened ; and that from these causes, as well
as from numerous others originating with the Army Medical Executive, the
number of vacancies in the Medical Department of the Army has become
alarmingly great, and the safety of the Army, especially in the event of War,
has become much compromised.

May it therefore please your Honourable House to grant a Committee of Inquiry
into all the circumstances connected with the existing state of the
Medical Department of Her Majesty ^s Army, as they rekte particularly
to the relative rank and privileges, and the authority in purely Medical
or Sanitary matters of the Medical Officers of the Service, and also to other
subjects of complaint arising out of what your Petitioners respectfully
think the mistaken views of the Medical Executive.

And your Petitioners will ever pray.

Signed in name and on behalf of the Faculty of Physicians and Surgeons
of Glasgow, and sealed with the common Seal of the said Faculty.

CuAS. Ritchie, M.D., President,

1864.] THE MEDICAL WARRANT FOR INDIA. 285

THE MEDICAL WARRANT FOR INDIA.

1*BE lotig-etpected Warrant has reached India, and, as we anticipated, haa
caused bitter complaints. The text is published non-official)y by the Friend of
Indkiy and agrees so iar with that portion of it with which we were favoured
from a private source (the Lancet, vol. i. 1864, p. 652). It has not been
officiallv published even in India, but the text may be accepted as correct.
The Indian papers are loud in their complaints ; and by this mail we receive
many letters trom private correspondents confirming the general feeling of
intense dissatis&ction. The Bengal Hurkaru for 24th June says : —

" If we read this Warrant rightly, and are to understand that from the date
of its coming into operation all allowance for the medical charge of regiments,
except in the case of assistant-surgeons, and all staff allowances attached to
staff appointments, will cease to be drawn, then we can only say that the paper
before us is a deathblow to the medical service in India. Tne rates or pay
for the officers of the Indian medical service are certainly a liberal improve-
ment upon the miserable pittances allowed by the Company's Government ;
and the half pay pension for officers compelled to leave the service on account
of ill-health is also a boon as compared with the regulations on that head in
bygone times. But regimental surgeons in charge of British regiments in
India will be losers by this new Warrant, which appears to have been drawn
tip with a view to tempt assistant-surgeons into the Indian medical service by
slightly increased rates of pay, at the same time endeavouring to blind them
to the subsistence allowance which they will receive in their latter years.**

By this new scale surgeons lose pay ; assistant-surgeons with British regi-
ments get a slight increase ; assistant-surgeons of Indian service in charge of
regiments, etc., remain as they were. The following is the scale of old and new
pay, and the amount each surgeon loses : —

British Cavalry surgeons : Old pay, 960 rupees per month ; new pay, 679
rupees ; losers of 81 rupees per month.

British Infantry surgeons : Old pay, 916 rupees per month ; new pay, 789
rupees ; losers of 126 rupees per month.

Native Cavahry surgeons : Old pay, 860 rupees per month ; new pay, 789
rupees; losers of 71 rupees per month.

Native Infantry surgeons : Old pay, 720 rupees per month ; new pay, 789
rupees ; the only gainers, and this to a very small amount.

We have aJso received a copy of a memorial f^om Deputy Inspector-General
Hockin, complaining of the provisions of the Warrant in respect to pensions, as
a breach of covenant, and as wanting in liberality. — The Lancet,

CONTAGIOUS DISEASES BILL.

The following are the principal provisions of the Contagions Diseases Bill, as
amended by the Select Committee : —

The Admiralty and the Secretary of State for War shall, on the passing of
this Act, appoint a superior medical officer of Her Majesty*s navy or army to
be, during pleasure, Inspector of Hospitals certified under this Act, and may
from time to time, on the death, resignation, or removal from office of any such
inspector, appoint another such officer in his stead.

On the application of the authorities having the direction or management of
any hospital, desiring that such hospital should be certified under this Act, the
Admiralty and the Secretary of State for War may direct the Inspector of
Hospitals to examine and report to them on the condition of that hospital, and
on the regulations established for its direction and management.

If on such examination and report the hospital appears to the Admiralty
and the Secretary of State for War to be useful and efficient for the purposes
of this Act, and is certified in writing to be so by the Admiralty and the Secre-
tary of State for War, the same shall be deemed a certified hospital for the

286 MEDICAL NEWS. [SEPT.

purposes of this Act, and every such hospital is in this Act referred to as a
certified hospital.

The inspector shall, from time to time, visit and inspect every certified
hospital.

If on the report of the inspector respecting any certified hospital the
Admiralty and tne Secretary of state for War think proper to withdraw their
certificate, that hospital shall thereapon cease to be a certified hospital for the
purposes of this Act.

Where an information, in the form given in the second schedule to this Act,
or to the like effect, is laid before a Justice of the Peace by a superintendent
or inspector of police or constabulary authorized to act in any place to which
this Act applies, or by any medical practitioner duly registered as such, the
justice may, if he thinks fit, issue to the woman named m the information a
notice in tne form given in the same schedule, or to the like effect.

A constable or other peace officer shall serve such notice on the woman to
whom it is directed, by aelivering the same to her personally, or by leaving the
same with some person for her at her last or usual place of abode.

In either of the following cases, namely, —

(1.) If the woman on whom such notice is served appears herself, or by some
person on her behalf, at the time and place appointed in the notice, or at some
other time and place appointed by adjournment ;

(2.) If she does not so appear, and it is shown (on oath or affirmation) to the
justice present that the notice was served on her a reasonable time before the
time appointed for her appearance, or that reasonable notice of such adjourn-
ment was given to her (as the case may be) : the justice present, on oath or
affirmation being made before him substantiating the matter of the information
to his satisfaction, may, if he thinks fit, order such woman to be taken to a
certified hospital for medical examination.

Such order shall be a sufficient warrant for any constable or peace officer to
whom the order is delivered, to apprehend such woman, and to convey her with
all practicable speed to the hospital therein named, and for the authorities of
the hospital to cause her to be examined by some medical officer of such
hospital, for the purpose of ascertaining whether or not she has a contagious
disease, and in case, on such examination, it is ascertained that she has a con-
tagious disease, then to detain her in the hospital for twenty-four hours from
the time of her being brought there.

Within the said period of twenty-four hours, the authorities of such hospital
shall cause a certificate, signed by the medical officer who has made such ex-
amination, stating (if the fact be so) that on such examination it has been
ascertained that such woman has a contagious disease, to be made out and laid
before the justice by whom the order was made, or some other justice having
the like jurisdiction; and thereupon such justice may, if he thinks fit, order
the authorities of such hospital to detain such woman in the hospital for
medical treatment until discharged by such authorities, and such authorities
shall detain her accordingly.

If any woman ordered as aforesaid to be taken to a certified hospital for
medical examination refuses to submit to such examination, or if any woman
ordered to be detained in a certified hospital for medical treatment refuses or
wilfully neglects, while in the hospital, to conform to the regulations thereof,
or quits the hospital without being discharged from the same as aforesaid, every
such woman shall be guilty of an offence against this Act, and on summary
conviction thereof before two or more Justices of the Peace shall be liable to
imprisonment, in the case of a first offence, for any term not exceeding one
month, and in the case of a second or any subsequent offence for any term not
exceeding two months.

If any person, being the owner or occupier of any house, room, or place
within the limits of any place to which this Act applies, or being a manager or
assistant in the management thereof, induces or knowingly suffers any common
prostitute having a contagious disease to resort to or be m such house, room,

1864.] CX)NTA010U8 DISEASES BILL. 287

or place for the purpose of prostitution, every such person shall be guilty of an
offence against this Act, ana on summary conviction tliereof before two or more
Justices of the Peace shall be liable to a penalty not exceeding ten pounds, or,
at the dbcretion of the justices, to be imprisoned for any term not exceeding
three months, with or without hard labour.

Provided that a conviction under this enactment shall not exempt the
offender from any penal or other conseouences to which he or she may be liable
for keeping or being concerned in keepmg a bawdy house or disorderly house,
or for the nuisance thereby occasioned.

For the protection of persons acting in the execution of this Act, — all actions
and prosecutions against any person fur anything done in pursuance or execu-
tion or intended execution of this Act shall be laid and tried in the county
where the fact was committed, and shall be commenced within three months
after the fact committed, and not otherwise ; and notice in writing of such
action and of the cause thereof shall be given to the defendant one month nt
least before the commencement of the action ; and in any such action the de»
fendant may plead generally that the act complained of was done in pursuance
or execution or intended execution of this Act, and give this Act and the
special matter in evidence at any trial to be had thereupon ; and the plaintiff
snail not recover in any such action if tender of sufficient amends is made
before such action brought, or if a sufficient sum of money is paid into Court
after such action brought, by or on behalf of the defendant ; and if a verdict
passes for the defendant, or the plaintiff becomes non-suit, or discontinues any
such action, after issue joined, or if upon demurrer or otherwise judgment is
given against the plaintiff, the defendant shall recover his full costs as between
attorney and client, and have the like remedy for the same as any defendant
has by law in other cases ; and though a verdict is given for the plaintiff in any
such action, such plaintiff shall not have costs against the defendant unless the
judge before whom t|ie trial is had certifies his approbation of the action and
of the verdict.

This Act shall continue in force for three years from the passing thereof,
and no longer.

EXTENSIVE POISONING BY THE CALABAR BEAN.

In the course of last month, nearly sixty children were poisoned in Liverpool
by eating Calabar beans. A carter had thrown the rubbish which he had
been clearing from the hold of a vessel upon some waste ground, close to a
densely-populated low neighbourhood. The rubbish contained a CTeat quan-
tity of the beans, two explanations of which are given : either they had formed
part of the cargo of the vessel, and had escaped from the bags containing
them, through some imperfection ; or they were ori^nally in the ballast,
which had been taken from the banks of the Calabar nver, from which place
the vessel — the " Commodore," belonging to the West African Trading
Company — came. The beans were soon discovered by the poor half-starved
children of the vicinity, and greedily eaten, though not very palatable ; the
taste being bitter and rough, not unlike that of a horse-chesnut. They are
enveloped in so hard a rind, that it was only by fixing them on a stone and
breaking them with another that the contents could be got at.

It has been difficult to ascertain the exact number of beans eaten by each
child. Two, three, and four, seemed to be the most frequent numbers ; whilst
one child is said to have eaten as many as twelve, and yet recovered. Most
likely the sickness, which in her case set in at once, saved her.

The children were nearly all taken to the Southern Hospital, the names of
forty-six being on the books. From ten to fifteen were taken to the Southern
Dispensary. Their ages varied from two to ten years, the majority being under
seven. The S3rmptoin8 manifested themselves, as nearly as can be ascertained,
in from half an hour to an hour and a half after eating the nuts. The state of
the little sufferers on their arrival at the hospital, as described by Dr Cameron,

288 MEDICAL NEWS. [SEPT.

who wa6 there at the time, und Dr WoIUston And Mr Evans, the house-sur-
geons, was as follows : — They were very pale and cold, staggered when they
attempted to walk, quite prostrated, with extremely feeble pulse, and cold
clammy skin, presenting all the appearances of the nervous system having
received some great shock, amounting to complete collapse in the worst cases.
Vomiting commenced early in most of them, purging occurred only in a few.
In about two-thirds of them the pupils were contracted, and there was double
vision. A few complained of pam m the stomach and bowels, but not at first.

The treatment consisted in emetics of sulphate of zinc and mustard and the
use of the stomach-pump, and afterwards, where the prostration continued,
the administration of brandy. The children suffered greatly from thirst, and
so drank readily the large quantities of warm water offered to them. In the
worst cases there was greskt drowsiness, whilst others complained of giddiness.

Only one case provea fatal, a little boy of six years ; he had eaten six of the
beans, and lived only about ten minutes after his admission to the hospital,
and about two hours from the time of his taking the nuts. He presented
during that time all the symptoms above detailed in an aggravated form, except
the sickness, which even the emetics and stomach-pump failed to produce.
At the post-mortem examination of his body the next day all the viscera were
found healthy ; the stomach and duodenum were tilled with a pulpy substance,
evidently the beans in a partially dig^ested state ; a few red spots dotted the
mucous membrane of the stomach nere and there, not more than might be
caused by the mustard or sulphate of zinc. The stomach and portion of the
intestines with their contents were removed by order of the coroner for ana-
lytical examination by Dr Edwards. The brain and spinal marrow, as well as
every organ of the body, were examined and found health jr. With the excep-
tion of the one case, all the children recovered sufficiently in a few hours to be
able to be removed to their own homes.

The next day a woman who had eaten one of the beans c^me to the hospital
with all the symptoms well marked : staggering in her gait, double vision,
sickness, feeble pulse, and pale countenance. Twenty-four hours had elapsed
from the time of her taking the nut to the appearance of the symptoms.

From some experiments that have been made on animals with what is con-
sidered to be the active principle of the Calabar bean, it seems, when adminis-
tered internally, to paralyze the function of the motor nerves, and when applied
to the conjunctiva to cause contraction of the pupils. — The Lafioet,

A FEW WORDS CONCERNING BANTINGISM.

At the recent meeting of the British Medical Association, Dr C. B. Radcliffe
made a communication on *^ Bantingism," an abstract of which we extract from
the Medical Timee and Gazette : —

As every one knows, Mr Banting was a stout man who became reduced to
more seemly dimensions by the adoption of a particular code of diet. As every
one also knows, " Bantingism,'* or the struggle to become thin by following
Mr Banting^s example, is at present the fashion in many quarters. Is, then,
this fashion to be encouraged, or is it to be discouraged? Dr Radcliffe is of
opinion that it ought to be discouraged, and the present ** few words " are
intended to show in brief why it ouffht to be.

Mr Banting's rule is to take abundance of lean meat, claret, sherry, Madeira,
and tea, and to abstain as much as possible from bread, butter, milk, sugar,
beer, and potatoes — articles containing starch and saccharine matter — to abstain
as much as possible from the articles upon which Mr Banting had lived almost
exclusively m the days when he was a victim to obesity. The diet in Bantingism,
indeed, is essentially the same as that prescribed in training for the ring or for
the boat race. The chief peculiarity in each case is to allow a large amount of
lean meat, and if there be any difference it is that the Bantingist deals more
liberally with himself in this resjject than the athlete. What Mr Banting
allows himself is rather more than is eaten by the average-sized man in train-

1864.] A FEW WORDS CONCERNINQ BANTIMGI8H. 289

ing. It may be expected, therefore, tbat the known results of the process of
training may throw some light u]pon some of the consequences of fiantingitro.
It may be expected that Bimtin^sm cannot be carried heyond a certain point
with advantage. In training this is certainly the case, for after a certain time,
longer or shorter as the case may be, after within four months at the longest,
the person in training rapidly gets ^* out of condition.'* Nor is it otherwise
with Bantingism ; at any rate, Vr Radeliffe says that he has met with sereral
persons who, after trying Bantingism for a while with no disadvantage, have
thus got ** out of condition" in an unmistakable manner, some of them becoming
very gouty, and all of them experiencing a decided failure in strength ana
spirits.

Dr Badcliffe is disuosed to look upon this loss of " condition" in these two
cases of training and Bantingism as depending partly upon excess of nitro-
genized food, and partly upon deficiency of fatty matter. The nitrogen of the
food escapes in the mam by the kidney as urea or uric acid, and if tne kidney
be not up to its work the system is apt to become gouty from the accumuU-
tion of these products in the blood. Uence it ia not difficult to see how excess
of nitrogenized food may, sooner or later, lead to ill-health, and that especially
in the case in which a proper amount of exercise is neglected. Nor is it diffi-
cult to see how deficiency of fatty matter may tend to bring about the same
result, if, as Dr Radclifife supposes, a certain quantit3r of fatty matter be neces-
sary to the proper nourishment of nerve-tissue. It is not difficult to see that
nerve -tissue, wnich contains a large quantity of fat, may be starved if the food
do not contain a sufficient quantity of fat, and that this starving of the tissue
may involve a corresponding want of nervous energy. At an^ rate, Dr Rad-
chffe is disposed to look upon the diet in training and in Bantingism as calcu-
lated to nourish the muscles rather than the nerves, and he believes that this
may be one reason why prize-fighters, like Heenan, have often been so seriously
wanting in the power of sustained action, and why the followers of Mr Banting
have after a while begun to fia^ in the spirit which animated them at first.

In a word, Dr Radclifife considers that it is not safe to ignore the old standards
of food^so completely as is done in Bantingism. He thinks that milk and
bread are still typical articles of food. He gave reasons for believing that the
farinaceous, and saccliarlne, and oily articles of food are, in proper proportion,
not to be dispensed with without risk, inasmuch as they are the most suitable
fuel for keeping op the heat of the human body at the proper point ; and he
gave reasons also for doubting whether saccharine and mrinaceous matters in
excess have the same tendency to favour the formation of fat as oily matters
in excess. He is of opinion that certain persons may incline to the type of
vegetable feeders rather than to the type of animal feeders, and that these
persons may find the nitrogenized part of their food better in the albumen,
fibrine, and caseine of vegetables than in the albumen, fibrine, and caseine of

WHY ANIMALS TO BE EATEN MUST BE KILLED.

It is universally understood that animals which die from disease are not fitted
for our markets. It is also understood that when cattle have been overdriven,
their meat is notably inferior to that of healthy animals, unless they are per-
mitted to recover their exhausted energies before being slaughtered. Why is
this ? The first and most natural supposition respecting those which die from
disease is that their flesh is taintea ; but it has been found that prolonged
agony or exhaustion is auite as injurious, though in these cases there is no
taint of dbease. M. Claude Bernard propounds the following explanation.
In all healthy animals, no matter to what class they belong, or on what food
they subsist, he finds a peculiar substance analogous to vegetable starch,
existing in their tissues, and especially in their liver. This sabstance, glycogfne
or liver-sugar, is abundant in proportion to the vigour and youth of the animal,
and disappears entirely under the prolonged sufifering of pain or disease.

290 MEDICAL NEWS. [SEPT. 18C4.

This disappearance is singularly rapid in fish, and is always observed in the
spontaneous death of animals. But when the death is sudden none of it
disappears. In a rabbit, killed after suffering pain for five or six hours, no
trace was found of the sugar-forming principle, and its fiesh has a marked
difference in flavour. The same remark applies ~to exhausted, over-driven
animals ; their muscles are nearly deficient in glyoogine and yield a decidedly
larger percentage of water than muscle in normal condition. M. Bernard
likewise finds that animals which are suffocated lose more of this sugar-forming
substance than similar animals killed in the slaughter-house. To this let us
add the fact, that the blood of overdriven animals will not coagulate, or
coagulates very slowly and imperfectly; and we shall see good reason for
exercising some circumspection over the practices of our meat-markets. —
AfiiMol JScmtific Discovery,

HOMCEOPATHY AND MATHEMATICS.

The following calculation was originally published in the London Medical
Circular. It is hard to conceive how medicines are prepared, having such
extreme attenuations as some homoeopathists profess to use.

Mr Wharton, an able professor of mathematics and astronomy, has had the
kindness to answer the difiicult questions proposed below.

Q. — ^If homoeopathists give, as they profess to do, the decillionth of a grain of
medicine for a dose, and which decillionth can only be obtained bv dissolving
the grain of medicine in a decillion drops of some liquid — say alcohol — how long
would the grain of medicine last, if the population of the world were a thousand
millions, and if there were a thousand millions of such worlds, and if each inha-
bitant lived for a thousand years, and if they each took a dose per second
during their whole existence r

And what must be the dimensions of the vessel that would just hold the
decillion drops of alcohol ?

A. — The number of generations, each subsisting a thousand years, that the
grain of medicine would supply with the homoeopathic dose to each individual
per second, each generation consisting of the 1,000,000,000 inhabitants of the
1,000,000,000 worlds is 31,687,635,943,382,425,811,012,156,738,473; and the
whole number of years the grain of medicine would last the inhabitants of
those worlds is 31,687,535,943,382,425,811,012,156,738,474 X 1000, equal to
thirty-one thousand six hundred and eighty-seven quintillions, five hundred
and thirty-five thousand nine hundred and forty-three quadrillions, three hun-
dred and eighty-two thousand four hundred and twenty-five trillions, eight
hundred and eleven thousand and twelve billions, one nundred and fifty-six
thousand seven hundred and thirty-eight millions, four hundred and seventy-
four thousand years 1 1 1

The time it would take the trillion inhabitants of the thousand millions
worlds, each counting 500 ^ears per minute, without intermission, to count the
number of years the medicme would last is 120,494,090 years.

The vessel that would just hold the decillion drops of alcohol must have its
length, breadth, and depth, each 229,995,079,096,540 miles long.

Light, travelling 192,500 miles in a second, would require 378 years to travel
the length of one of the sides of the cubical vessel that would just hold the
decillion homoeopathic doses of medicine.

The spherical space which contains the solar system would hold only a very
small part of the decillion drops. The length of the major axis of Neptui^e s
orbit, and consequently the diameter of the sphere, is 5,706,893,200 miles,
which light would travel over in eight and a quarter hours. If the spherical
space which bounds the solar system, vast as it is, was increased so as to have
its diameter 40,300 times greater, it would be equal in length to a side of the
cubical vessel, but would not, of course, hold the decillion drops ; for if the
sphere was put into the vessel, it would touch it only at five pomts, or six, if
covered, and the angular spaces would be empty.

Ifitivt Jf^ivat

ORIGINAL COMMUNICATIONS.

Article I. — Oraduation Address to the Oendemen who obtained the
Degree ofM.D. in the University of Edinburgh^ \st August 1864,
delivered by PbofeBSOB Maclagan, Prom(^er.

It is my duty and privilege, in name of the Senatos Academicns,
to congratulate you on your obtaining the Degree, in virtue of which
we of the Faculty of Medicine give you the right hand of fellow-
ship as professional brethren* Ii I were to confine myself to the
discharge of dutj^ I might in a single sentence offer you our felicita-
tions, and heartily bid jovl God speed in the profession which you
are now entitled to practise. It has, however, long been the custom,
for the Professor officiating on such occasions, to address to the young
Graduates some general remarks, or to brin^ before them some
special subject, not embraced in ordinary acaaemic courses, which
he thinks ma^ be interesting or useful to them in their future
career. This is now my privilege ; and in requesting your atten-
tion for a little, I beg you to accept the assurance of my desire to
say something which may be useful, as a compensation for saying
much that may be tedious.

I have to congratulate you on your now being entitled to enter
upon the exercise of a profession at once honourable and useful. I
assume that it was in this persuasion, that you embraced it as the
future occupation of your hves ; and I trust that four years of closer
intimacy with it, have not affected that opinion, unless in the way of
confirming it. I do not set it before you as a smooth easy road to
eminence or affluence. It is rou^h and difficult, and in its earlier
stages especially, a good deal uphill ; yet, even where the gradients
* are consiaerable, you will find that there are things both pleasant
and profitable to be found on the line. It is a noble and an
honourable calling, — indeed, it yields only to that of the Divine^ in
so far as that which refers to the corporeal and temporal, must yield
precedence to that which deals with the spiritual and eternal. But
if the physician be but the rear-rank man of the minister of religion,
he at feast marches with him in close order, and is his not unworthy
comrade in combating those sufferings which assail humanity. It
is a noble and honourable calling, and one to which any man may

VOL. X.— NO. IV. 2 P

292 PROFESSOR MACLAOAN'S graduation address. [OCT.

take pride in belonging. See, then, that you so bear yonrBclveg as to
show that you are proud of your profession. Be jealous of its honour,
and give no man occasion to disparage it in you. But you must
not only be proud of your profession, you must love it ; if you do
not love it for its own sake, you will not succeed in it If you do
love it, and if you go into it with the sincere desire to discharge its
duties faithfully, earnestly, and honestly, I promise you that you
will have no cause to regret that you have cnosen it as your occu-
pation in life.

I know, however, that though all this may sound very well, for
you who have life before you there is the practical question to be
answered, — ^Where am I to find the field in which I can exercise
my profession ? Perhaps as regards some of you this question may
be auready answered, xou may have a father or brother or some
other relative who enjoys a good practice, and looks to you as his
successor. If so, you are indeed fortunate ; but let me earnestly
warn you against tmsting to this. No man can entail his practice
upon another as if it were heritable property. It must depend upon
your own exertions, whether or not you are to reap any advantage
from your connexions. Instead of being an inducement to you to
relax your efforts, it ought to be an incentive to exertion. Any
man may fail of success in practice firom finding the field pre-
occupied ; but here you have the ground cleared for you, and if
you fail from want of earnestness, your £ulure will look all the worse
firom its contrast with the success of your predecessor. I suspect,
however, that the majority of you will not be so fortunate as to find
a practice ready made to your hands, and it will still remain an
anxious question for ^ou, where you are to obtain suitable employ-^
ment for your professional acquirements. There are, of course, the
two distinct walks of civil practice and public service, which you
will doubtless contrast with each other in your minds. Let me
offer a few remarks on this subject.

I wish I could say, that in point of eligibili^ as a field for pro*
fessional exertion, civil practice and the public services were so
equally balanced that I had a difiiculty in advising you which to
select ; but unhappily the task is easy. If I am honestly to tell
you my opinion, 1 must say that the public services do not offer
such attractions as should induce you to prefer them, if you have
the prospect of even a moderate success in civil life. It is assuredly
from no desire to depreciate these services that I say this. Of ell
men, the last to do so should be one who has stood in the relation
of son, brother, and father to medical officers of the army and navy.
I know nothing of which a ]roung medical man might be more proud
than to serve in that unrivalled Navy which has made Britain
mistress of the ocean, or in that invincible Army which, in the words
of Macaulay, ^'has marched triumphant into Madrid and Paris,
Canton and Candahar." But the authorities who rule these
services have done their utmost to make this impossible. I am

1864.] PBOFE880B MACLAGAN'B GlUDUATION ADORE88. 293

bound in candour to saj that the Admiralty, under wholesome
presBure from without^ has done a ffood deal to improve the condi-
tion of the nayal medical Bervice. The aasiBtant-surgeon now has,
unless nnder exceptional circumstances; a cabin to himself^ he is a
wardroom officer irom the first ; he is eligible for promotion afiter
five years' service, and on an average gets that promotion in nine
and a-half years. He now has a uniform which characterizes him
as belonging to the medical department. His pay begins with
£180 a-year, and his mess expenses need not exceed" £50 or £60;
and thus to a youne man entering on professional life, without any
prospect of a good opening in civil practice, the naval medical
service does oner some advantages. ^But this is not the question
for us to consider here. The question is not. — Does the service
offer comparative advantages, on the principle that anything is
better than nothing ; but does it offer positive advantages such as
ought to attract well-educated medical men, and lead them to
adopt it as their employment for life? And in reply I say, that
till the naval authorities learn better what is the value of a good
medical man, — till they learn when they have got him to remun-
erate him and reward him better, — ^you wiU do well to ponder the
following opinion, communicated to me by one who served in the
navy with distinction, and is no grumbler : — ^^ It is a good service
for a man who has no prospect of anything better than the pay, but
I would not recommend any one to enter the navy as a doctc»r who
has anything like a chance of getting on on shore."

Of the medical service of tne srmj it behoves me to speak in
terms much more decided. The unavoidable expenses of li& in the
army are greater than those in the navy, whilst the rate of pay is
no higher, so that it is rarely possible lor the assistant-surgeon to
live upon or within his pay, as he in the navy may. The average
period of service before promotion is longer, and the allowances for
jretirement, at such an age as affords reasonable prospect of health
to enjoy them, are quite inadequate. Add to this that the assistants-
surgeon, alone of all the officers of a regiment, is called upon to
superintend the branding of deserters, with the damnatory initial
which stamps their characters upon their skins; that regimental
surgeons have been required to forward to headcjuarters confidential
(t. e. secret) reports as to the character of their assistants, and as to the
estimation in which they are held by the other officers ; and that
medical officers, of all grades, are subjected to vexatious redtapish
surcharges for extras and medical comforts, which deprive them of that
controUmg power and free agency in their own department, which
every practitioner in a decent civil hospital enjoys; — and you will
judge whether there are any particular inducements for me to recom-
mendyou to ioin this service. But this is neither all nor the worst of
it The real reason why you ought to be shy of making masters of
those who rule the army is, that they have been guilty of breach of
faith and violation of promise to their medical department It is

294 PROFESSOR MACLAGAN's GRADUATION ADDRESS, [OCT.

well known that, after the disasters of the Crimea, a commission
was appointed to inquire as to the sanitary state of the army, the
result of which was the issuing in 1858 of a warrant granting
certain important privileges to the medical officers. It is needless
to state in detail what tnese were ; suffice it to say that it gave
eeneral satisfaction to the army medical officers, and all bade fair
lOT the department being made permanently efficient and attractive.
But this state of matters did not last long ; one by one these privi«-
leges were eifher openly set aside by circulars fix)m headquarters, or
virtually abrogated by general and commanding officers, backed up
in this by the higher powers. At length a bold attempt was made,
by a second warrant to do away with the most important part of
that of 1858, but so loud a cry of indignation was raised, that the
then Secretary at War stood aghast, and speedily withdrew the
obnoxious document. The original warrant stands maimed, muti-
lated, never fully or fairly acted upon ; and the result is that the
army medical department is virtually in a state of disorganization.
I have neither time nor patience to discuss all the pretences that
have been put forward to account for this state of matters*
Journalists who perhaps are not, but write as if they were, " in-
spired," in the French political sense of the word, explain the
existing discontent, by referring it all to faults of the medical officers
themselves, and not to anything done at the Horse Guards. It is
said to be a question of bits of uniform, quite unworthy of the
attention of scientific men. This is not true m fact ; but what if it
were? Rank in the army is the index of the estimation in which
a man is held. Uniform is the sign of rank ; and army medical
officers would be quite right in insisting upon a proper uniform, so
long as they wear one, with all the rights and honours to which the
rank indicated by that uniform entitles them. It is also said to be
a wild ambition on the part of the doctors for military authority and
command. These writers see, or pretend to see, in army surgeons,
only what Jonathan Oldbuck saw in his vision, when in the height
of the old volunteering fever he went to consult his surgeon : —

" He came, but valour had bo fired his eye,
And such a falchion glittered on his thigh,
That, by the gods, with all that load of steely
I thought he came to murder — ^not to heal."

A complete delusion. Medical men as a class have, I hope, a
better idea of the value of their own professional functions, than to
think that the^ gain status by exchanging them for military work.
The office of him who comes " to heal is at least as honourable as
that of him who comes to fight. Grant that it be true, as has been
very loudly proclaimed, that two or three silly medical officers have

Sut forth military pretensions, does this so characterize a whole
epartment, which numbers its members by thousands, as to make it
necessary to keep them all, under a galling sense of tneir being in-
ferior to the comoatant officer of equal rank ? His Koyal Highness

18^.] PfiOFESSOR MACLAQAN'S GRADUATION ADDRESS. 295

the CSommander-in-Chief tells a deputation of medical men^ who
wait upon him on behalf of their brethren in the army, that it is all
for discipline. It is to maintain discipline that it is enacted, that
the surgeon of a regiment shall not assume military command, if the
combatant officers senior to him are disabled in action. Perfectly
right. Common sense asks, what has a doctor, who has had no
military education, to do commanding men in action, so long as the
youngest ensign is alive to give an order. But how, if this refers,
not to commanding men in action, but to boards of inquiry as to the
healthiness of barracks, hospitals, and other sanitary questions?
Here common sense would say that, as these are things specially
belonging to the doctor, he is the proper person to preside over sucn
boards. But no ; upon this principle of discipline we are told he is
to give place to the combatant officer. Is no one to be under
discipline but the doctor? If it is wholesome discipline for him to
yield to the combatant, though junior to him in rank, as regards
matters purely military, would it not be an equally wholesome dis-
cipline, for the combatant to jrield to the doctor, in matters purely
medical? If this be inconsistent with discipline, then it only
throws us back upon the melancholy conclusion, to which I am un-
willing to be driven, that discipline and common sense are incom-
patible. Neither the army nor the nation owe anything to people
who, either by their writings or their acts, sow the seeds of jealousy
between the combatant and the medical officer. Each has his own
duties to perform, and in the performance of them, each requires to
possess a share of the same soldier-like qualities. Is the medical
officer to be held as possessing less of that devoted courage, which
has always so nobly characterized British officers ? My answer is,
that the man who can coolly take up an artery under fire, requires at
least as much courage as he who, with the excitement of battle,
leads his battalion or his company. Do medical officers not display
this quality in actual warfare ? My answer is, that in proportion
to their numbers, more medical than combatant officers have earned
for themselves the Victoria Cross. Upon what principle, then, is
the medical officer to be placed on a lower stanaing than the com-
batant of equivalent rank? So long as he does his own duties
properly, and sticks to them, I maintain that the medical officer has
a full title to every advantage, every honour, every mark of public
consideration that belongs to his rank, whatever that may be ; and
it is the refusal to carry out fairly, the warrant of 1868 which pro-
mised these, that constitutes the real grievance of the army medical
department. It is a significant fact that there are in Her Majesty's
British and Indian forces about 200 assistant-surgeonships vacant,
and not a fourth part of that number of candidates for them. It
has within a short time been asserted that there is a host of young
men from Dublin and Edinburgh ready to apply for them. Let
Dublin answer for itself; but speak you for Edinburgh. The
Horse Guards have a traditional policy of yielding nothing to the

296 PROFESSOR maclaqan's graduation address. [ocr.

doctors except from necessity. Tell them tliat you decline to join
the army while things remain as they are. Tell them that you
decline to enter a. service, the head of which says — apparently with

Serfect satisfaction to himself — ^that the men at present joining the
epartment are good third-class men. Tell them that you decline
to place yourselves in that cate^ry. Let us as a profession, firmly
but temperately, tell the authorities what is the mmd of the profes-
sion on this subject; and let them candidly and dispassionately
weigh what we say to them. K we speak out unitedly, firmly, but
calmly, we shall be heard. What happened a short time ago, when
the House of Commons threw out a bill, which would have had the
effect of lowering the character of the Indian medical service, gives
me the assurance, that our voice will find in Parliament an echo,
which will reach the deafest ear of the War Office and Horse
Guards. Let them provide more adequate retiring allowances for
those who spend their best years in their service. Above all, let
them abjure all Punic faith, and give security that they will carnr
out warrants in an honest and faithful spirit, and then no one will
be more ready than I, to encourage young men to join a service, to
which any oi you might be proud to belong.

Let me suppose, then, that you elect to engage in civil practice.
It is but natural that you should wish, as soon as possible, to turn
the studies of the last few years to practical accoimt It is an
honourable and a proper feeling, that, as a large sum has been ex-
pended upon your professional education, it is incumbent upon you,
as soon as possible, to give substantial proof that it has not been
expended in vain. I respect this feeling ; but I beg you not to act
too precipitately upon it. Bear in mind that, however fully you
may have availed yourselves, of the opportunities of instruction
which this school affords, there are many things to be learned by
you, before you are thoroughly fitted for the duties of independent
practice. I do not allude to what every one continues to learn, so
long as he is engaged in practice — the lessons of experience. These
are the teachings of a lifetime. What I point to at present is habits
of business, punctuality in keeping appointments, methodicity in
work, and consequent economical employment of your time, which
you have not had opportunities of acquiring as mere students at a
University, but which are essential to your future success in your
profession. Take, if possible, an opportunity of acquiring these
Defore starting in practice on your own account. If you have not
the advantage of connexion with some senior member of the profes-
sion, as relation or pupil, you will find it advantageous to act for a
while as assistant to some one, who requires help in his work. This
will not only serve to introduce you to habits of business, but will
yield you good clinical instruction. Do not be so solicitous about
emoluments, as about the character and status of him under whom
you serve ; and if he be, as he ought to be, a man of worth and
weight, the fact that you have rendered him efficient aid, will be the

1864.] PROFESSOR MACLAOAN'S GRADUATION ADDRESS. 297

veiy best testimonial you can produce, when you enter upon inde*
pendent practice. There is, oi course, another well-known way in
which many seek to form a professional connexion ; — I mean br
paying a premium for it. I am not prepared to say that there is
any positive objection to this in the abstract, but I own to a liking^
for seeing a young man make his way in life, rather by his talents
than his purse. I do not say that such purchases are neyer advi»»
able, but I know that they sometimes turn out ill ; and I advise
you to think over the matter veiy carefully before you invest mon^
in such a transaction.

At all events, whatever be your scheme fer entering upon pro-
fessional life, see that during jrour earlier years, when your practice
is not so great as vou could wish it to be, — see that your tmie and
your mind are fully and profitably occupied. Eschew idleness as
the notorious mother of evil. By this I am putting no bar upon
proper relaxation. A professional man is not idle when, by
innocent recreation, he is bracing and strengthening himself for his
duties. Be methodical in this whilst you are methodical in your
work^ and be assured that your patients will never grudge you a
physician's holiday. It is a vacuous firame of mind that is mis-
chievous idleness ; and this is a state of matters that has no right
to exist in you. There is plenty for you to do, though you may
not have patients enough to occupy your whole time. Kemember
that the outer world has not been standing still, during the four
years that you have been down the shaft, digging in the mine of
professional instruction. You have plenty of leeway to make up
in studying subjects of general interest and information, whicn
are at once useiul and ornamental. Semember that an accom-
plished medical man is one who, with thorough knowled^ of his
profession, combines the enlargement of mind and general informa-
tion of a well-educated genUeman. Strive to store your minds
with general, as well as medical, knowledge; gather together a
fund of information, which will save you from the intellectual

S^verty of the man, who can talk of nothing but his profession,
e bores in the drawing-room, and disgusts at the dinner-table.
The physician, on the contrary, who has a fair share of general
accomplishments, though he may be young, if he do not overstep
the modesty that befits his years, will always find that he is
listened to with deference and attention. It is assumed that he is
a man of ^ood education, and men judge the young physician,
more by his general than his professional knowledge. He has
probably had no sufficient opportunity to give proof of it, and if he
nad, the public are not always correct judges of it ; but they can
form an estimate of his general knowledge^ and if they find him
deficient in it, they are apt to take up the impression, erroneously
perhaps, that he is not much better off as regards the other. There
18 prooably no better way of enlarging the mind, both professionally
and generally, than by visiting some of the great medical schools

298 PB0FE8S0B MACLAGAN'S GRADUATION ADDRESS. [OCT.

of the Continent. It is now that you have completed your formal
medical curriculum^ and when you are able to look at professional
matters, with somewhat of a critical, as well as an inquiring eye,
that you are most likely to profit by witnessing the practice of
acknowledged masters of our art elsewhere, especially those who
are of repute in special departments. I am not here to say that
you will see better practice abroad than in Britain, but there is a
tendency in all of us, when we have received our whole profes-
sional instruction in one medical school, jurare in verba magtstri ;
and it is well that the mind should be emancipated from this,
although it is perhaps, on the whole, an amiable weakness. And
seeing that enlargement of the mind is one of the chief benefits to
be derived fix)m foreign travel, remember that this extends to other
things than objects of professional interest. By all means make
the medical schools ana hospitals the prime object of your atten-
tion, for it is the visiting them which justifies you in spending time
and money in going abroad. But whilst you cultivate the medical
and useful, do not entirely neglect the sesthetical and beautifiiL
You will not be the worse practitioners, and you will certainly be
all the more agreeable members of society, if you bring home with
you some recollections of the scenery, the painting, sculptures, and
music of continental Europe.

And now, when you have by dili^nt work at home, by intelli-

gent observation of medical practice abroad, by cultivation of
terature and rational eniovment of nature and art, stored your
minds with useful knowledge and proper accomplishments, you
mav with reasonable expectations of success enter upon practice,
ana look forward to that which is, I believe, sooner or later in the
thoughts of every man who settles down to medical practice, the
assuming of a non-professional partner for life. I am not going to
enter upon a discussion of the question when this partnership should
be formed. I am not going to ar^e for what is, I apprehend, the
more popular, or to support what is regarded bv some as the pru-
dential, view. I will only say this much, that 1 have known many
medical men marry when comparatively young, and I have not
been able to see that they were at all the worse for it. Let me say,
however, that I have no respect for that stereotyped maxim, that a
doctor ought to marry young, that he may get on better in practice.
This is a degrading view to take of the tenderest and holiest of
human relationships. Rather let us reverse the sequence, and say
that the young doctor ought to strive to succeed in practice that
he may be able to marry. It is when he has, on a view of his
whole circumstances, come to the reasonable conclusion that he is
entering on a course of professional success, that he may, rather, let
me say, that he ought, to marry ; and I am sure of this, that tnere
is no stronger, purer, holier human motive, to stir him to all diligence,
and earnestness, and right-mindedness in his work. Like the
Laureate's King, I say —

1864.] PS0FE8S0R MACLAGAM's GRADUATION ADDRE88. 299

" Indeed, I knew
Of no more subtle master under hearen
Than is the maiden passion for a maid,
Not only to keep down the base in man,
But teach high thought, and amiable words,
And courtliness, ana the desire of fame,
And love of truth, and all that makes a man.**

I suppose 70U, then, tinder whatever circumstancesy hopes, or
aspirations, to have established yourselves in practioey and to be
getting patients. Let me brieflj touch on one or two points in
reference to your duty to them. I say nothing about the necessity
for diligence, earnestness, and fidelity in your work. Neither in
our profession nor in any other is success to be obtained or merited
without these. Let me beg you not to measure out the attention
which you are to bestow upon any case, by the low standard of the
prospect which it affords you of direct remuneration. I do not
alluae to this, as if it were a common thing in our profession, against
which you require to be warned ; whatever faults as a profession
we may have, to be sordid is assm'edly not one of them. I solicit
your skilful and kindly offices to the poor, not in the way of warn-
ing, but in the way of encouragement. You may get no immediate
return except some addition to your experience, and the satisfaction
of knowing that you have been the means of relieving a suffering
fellow-creature, iut reward may come to you — ay, and often does
— in a form and at a season least of all to be expected. Many a
time has it happened that the outpouring of a poor but thankful
heart, which has nothing to offer but gratitude, has flowed over into
places which it was never expected to reach, bearing with it the
praises of the unpaid physician's skill and kindness, and has, per-
naps by a circuitous course, come back to him in full stream charged
with that precious element —

" Quod Tagus et rntila volvit Pactolus arena.**

Let me also beg you to carry with you into practice all the philo-
sophy you can command, to enable you to bear with petty
annoyances and vexations. Ours is an anxious profession, and
you will not be long engaeed in it before you find, that it is pre-
cisely when you are most busy, or it may be most anxious about
cases of real severity and danger, that you are most apt to be
troubled by people coming to you with trifling ailments. Strive
not to be impatient with these. They do not know your other
anxieties, and they do not know that their own anxieties are
founded upon mistaken ideas of their own case. Give them the
benefit of your opinion, firmly but kindly. What are called
nervous subjects are not necessarily whimsical or fanciful. Their
complaints may be neither dangerous nor important, but still they
are real, such as they are. Beware of losing patience with them
because you have other more serious matters on your mind at the
time, ^beware of making a hasty superficial diagnosis that it ia

VOL. X. — VO. IV. 2 Q

300 PB0FE8S0R MAGLAQAN'S GRADUATION ADDRElBS. [OGT.

**all nervousneas," lest under this there should be some serious
malady, which a little more time and patience would have enabled you
easily to discover. Besides, even if there should be none, your quiet
patient investigation of the case is not thrown away. The kindness
and attention tnen bestowed will perhaps prove a sufficient remedy
for all that is complained of. And when we are speaking of good
temper as a professional qualification, let me intercede with you on
behalf of another class of patients, very helpless and very interest-
ing. I mean children. 1 ou must expect them to be fractious and
troublesome when ill, entirely averse to receive anv share of your
attentions, and of course totally insensible to the iBct that you are
there to do them good. Don't call them cross and ill-tempered,
and show crossness and bad temper to them. There is in truth no
such thing as a sheerly ill-tempered child, any more than an ill-
tempered lamb or kitten. A cross and peevish child means a
suffering child ; and what can it do but mewl and cry, and hide
itself in the sanctuary of its mother's embrace. If you have to
inflict pain, in order to avert danger, do it, if need be, with a hand
of iron. This is real kindness ; But see that the iron of the hand
is, like the gauntlet of a knight, smooth and polished, though it
cannot be soft. Trouble the little patients to no further extent
than is necessary to enable you to see with clearness what needs to
be done. When they are in their days of better health unbend a
little towards them, condescend to be amused with their prattle,
and don't think ^our dignity invaded if a little boy insists upon
jour lool^ing at his last plaything, or a tinv damsel expects you to
admire her new red shoes. They will all the sooner get rid of their
intuitive aversion to you as a troublesome stranger. In all that
you do to them be kind and gentle ; the man that can be rough to
a sick child, will not likely have much tenderness to bestow upon
those of riper years.

Lastly, with regard to all vour patients, attend to that portion of
your sponsio academica by wnich you have bound yourselves, not,
unless for grave reasons, to make known to others what concerns
your patients. This has been recognised as an obligation laid
upon medical men since the davs of Hippocrates. What you have
set your hands to this day, is almost in identical terms part of the
oath, which he exacted from his scholars. A gossiping doctor is a
social nuisance. The medical man in virtue of his office is admitted
into the very penetralia of the domestic temple, and he who carries
beyond it what he there sees and hears, commits a social sacrilege.
He makes himself detestable, and sooner or later will get into
trouble. It makes no difference that what he talks about may be
trifles, and though it be of no importance if all the world knew
them. So much the worse, indeed ; it shows that he is not only a
gossip, but a man of a frivolous mind.

Time will not permit me to enter, as I should like to have done,
upon the subject of your duty to your professional brethren. I can

1864.] PR0FS8A0B MACLAOAN'S GRADUATION ADDRESS. 301

do no more than address one or two hints to jou^ as joxmg men
entering npon professional life. Let it be a mling pnnciple with
you to cultivate a good understanding with all respectable medical
men, both in your own and other localities. The same apostolio
sentence which enjoins upon 70U to ^' be pitiful/' as I have asked you
to be to the poor, commands jou to ^' love as orethren" and to ^ be
courteous." Do not, when 70U settle in practice, look upon those
who are there before you with a jealous eye, and do not fancjr that
they necessarily so look upon yon. If any one does so, behave to him
with the studied politeness of a gentleman, which is always digniiied|
and thus " overcome evil with good." Strive to cultivate friendly
relations with professional brethren, especially in places where there
are but few of you, were it only as a matter of self-interest. You
do not know how soon you may be glad of a professional brother's
friendly counsel, nor how soon, in your own person or family, you
may be dependent upon his professional skill ; and how can you
seek these if you and he have not been on friendly terms? But I
beg you to proceed upon higher considerations than those of self-
interest, !Be friendly with jour brethren because it is right in the
sight of God, and because, m the sight of man, doctors' squabbles
are discreditable to your profession. Do not content yourselves
with avoiding unfriendly relations with them, but cultivate their
friendship professionally, socially, and in a moderate and temperate
way convivially. Many a little '^difficulty" has been happily
asphyxiated by the annual dinner of the local medical associationi
and it has been said to be not unknown even in high political places,
that fears as to the effect of a diplomatic contretemps have been
allayed by the assurance, une bonne soupe arrangera tout cela.

Let me offer to you, as young medical men, a further piece of
advice, which refers partly to your patients, partly to your profes-
sional brethren, and largely to yourselves. Let me ask you to
prepare yourselves for resisting that feeling of annoyance, almost
amounting to a sense of injury, which you may experience on
finding that your patients, or their relatives, wish to have additional
advice. I believe that almost every medical man. if he is frank,
will tell you that he has himself had to contend witn it I am sure
that I have. If you are assisting an established practitioner, you
will find people dropping unmistakable hints that they woula like
to see " the old doctor." If you are in the early years of practice
on your own account, and the case proves a severe one, be prepared
for finding some officious person suggesting that, as you are but
young, you may not have roily understood the malady. Do not be
surpnsed, but especially do not be offended at this, reople attach,
and very properly, much importance to experience, and it is no
imputation upon you, to say that you have not yet lived long enough
to acquire it. tn such cases your duty and policy alike are to
anticipate the wish for a consultation by yourseli suggesting it, or if
it is suggested by others, to accede to it willingly. Only insist

302 PBOFESSOR maclagan's graduation address. [ogt»

upon thisy which is your imdoubted right, that the person consulted
shall be reallj one to whom you can look with respect as an
honourable practitioner. If you have honestly and faithfully studied

four profession, as it was your duty to do, it will almost invariably
appen that the consulted practitioner will confirm your general
view of the case, though he may, out of the resources of his expe-
rience, be able to add something to the means which you have
employed, and his opinion will only tend to give your patients more
confidence in you, when they find that you possess not only pro*
fessional skill, but modesty, good temper, and common sense.

I should like very much to enlarge upon the topic of your duty
to your professional brethren ; but it is vain to attempt to set before
you a system of medical ethics on an occasion like the present, and
1 have already trespassed too much upon your patience. Questions
as to professional etiquette may at any time arise, and form subjects
of anxiety to the young practitioner, especially to him who is most
desirous to act in all things in a becoming manner. Let me sugg^t
to you three safeguards to which you may have recom^e when per-
plexed as to ethical questions of professional conduct. First, you
will seldom be wrong if you consult some senior medical brother in
whom you have confidence not only as a professional man, but as
an honourable adviser. Secondly, you will still seldomer be wrong
if you carry with you the recollection that medicine is the profession
of a gentleman, and if in any difficulty you sternly put to yourself
the question, — ^Are my motives and actions in this such as I could
without hesitation lay bare to a court of honour, composed of upright
and proper-spirited gentlemen? And, thirdly, You will never be
wrong it you remember that medicine is the profession of a Christian
gentleman, and if you devoutly put to yourself the inquiry, — ^Are
my motives and actions here such that I could ask and expect for
them the approval of Him "who trieth the hearts and reins?"
With these principles for guidance —

" To thine own self be tme,
And it muBt follow, m the night the day,
Thoa canst not then be fabe to any man."

Let me end, as I began, by ofiering you, on the part of the Senatus
Academicus, our congratulations on your obtaming the degrees
which have now been conferred upon you. We send you forth into
the world with truest wishes for your welfare and prosperity in life,
and for the bestowal upon you of every blessing which can be
implored for you from the Giver of every good and perfect gift.

1884.] DBH BABTLETT AND BINGER OH AGUS. 808

Article IL — 7W Ca$es ofAaue. with a few JtemarkB on the fame.
By JoflKPH Baktlett, L.K.C.S., M.R.G,8., and Bydnst
RiNGEB, M.D.

The following cases are published because they show that fits of ague
maj occur, which are indicated only by an alteration in the tem-
perature of the body, all the other symptoms being entirely absent ;
and further, as proving that where symptoms do occur which might
lead to the suspicion of a fit, the temperature of the body is the
only true test of the severity of the attack.

Case I. — John Ledstone, mi. 16; admitted into University
CioUege Hospital, under the care of Dr Jenner. At the age of 18
he had an attack of acute rheumatism. About nine months before
his admission, he went to the Gulf of Mexico as a sailor. Shortly
after the vessel sailed for Eneland, he, in common with many
others of the crew, was attacked with ague. The fits usually
occurred daily at about 1 P.M., but once or twice he was seized
during the middle of the niffht. This he attributes to his being
on watch during these nights, the vessel being short of hands.
The attacks ceased on his taking quinine, but recurred when
the supply of the medicine was exhausted. They, however,
obtained a fresh supply from an American vessel which they
chanced to meet; and, on returning to the medicine, the paroxysms
were much relieved, occurring only occasionally. After landing
at Liverpool he had two attacks weekly, and at that time his
£ace and legs were very greatly swollen. He now discontinued
the quinine, and the fits recurred daily. He again took medicine,
and again the attacks were relieved. He was admitted into Uni-
versity College Hospital, on 20th June. At the time of his admis-
sion he was very pale, but not verv thin, though he stated that
he had lost much flesh. He ooula walk about the ward with-
'out much fati^e. His complexion was very muddy. His spleen
reached antenorly to the umbilicus, and downwards almost to the
crest of the ilium. His liver was not increased in size. There was
a loud systolic murmur at the apex of the heart, a systolic and
diastolic murmur at the base, and a loud venous hum audible over
the veins in the neck. Moreover, a systolic murmur could be easily
produced by pressure on the carotid arteries. There was no oedema
of the body. His tongue was clean, and his appetite excellent.
No quinine was given him whilst he was under observation.

On the 22d of June a well-marked fit occurred, with a cold, hot,
and sweating stage, thoroughly developed. His temperature rose
to 1041.

On the 23d, 24th, 25th, and 26th, the temperature only rose to
99, though observations were made very often on each day.

On the 27th, the temperature rose to lOli. On the 28th, it reached
1025; on the 29th, lOU; on the 30th, 991; on 1st July, 98.

304 DBS BARTLETT AND RINGER ON AGUE. [OCT.

During these attacks lie had no rigors, nor any sensation of heat ;
indeed, he expressed himself as feeling quite well. He took his
food freely at these times, and was only kept in bed in order that
the observations might be made.

There was no excess of white corpuscles of the blood, nor anjr
albumen at any time in his urine.

After the fits above mentioned he took quinine, and diminution
in the size of the spleen quickly followed its administration^ so that
on 21st July it could not be felt under the margins of the nbs.

Case II. — Male, set. 5 ; admitted into University CJoUege Hos-
pital on 13th June, under the care of Dr Hare.

When three months old he was taken to Antwerp, and shortly
after his arrival he was seized with ague. His firiends could not
say whether the fits at the time were regular in their recurrence or
not. He returned to England in April 1863, and during the first
month after his arrival he was quite free from the paroxysms of
ague. After this, however, they recurred^ and have continued
since, the attacks being much worse dunng the simimer than
during the winter months. The fits were never regular in the
period of their recurrence. At the end of April 1864, he had an
attack of measles, and afterwards of scarlet fever, during which
time and for a fortnight afterwards the fits ceased, but again
returned.

At the time of his admission he was small in stature, and rather
backward in intellect. His spleen was considerably enlarged,
reaching forwards nearly to the umbilicus, and downwards nearly
to the crest of the ilium. On 4th August, the day of his discharge,
his spleen was considerabljr reduced in size, reaching only two
inches below the costal cartilages.

The other organs of his body remained healthy throughout the
time of his stay in the hospital.

Careful notes of the general state of the patient and of the tem-
perature of the body were taken daily for nfty-two days, from the
23d of June to the 4th of August. On fift;een of these days the
temperature rose to 100 and upwards.

Thus, on six days, the highest temperature attained varied from
100 to 101. One day the temperature rose to 101{ ; one day to
102*. Two days the highest temperature varied from 103 to 103| ;
five days from 104 to 1061.

Thus, the elevat'ion of the temperature was very considerable on
several occasions. On two of these, namely, when the temperature
rose to 1051 and to 106, the child had slight lividity of his hands,
and complained on one occasion of feeling cold. On no other occa-
sion were there any symptoms to indicate that the child was indis-
posed, except some drowsiness (it ought to be mentioned that he
was often drowsy when there was no elevation of the temperature)
and loss of appetite, although on one of these occasions the tempera-
ture rose to 105.

1B64.]

DBS BABTLETT AKD BINGBB ON AGUE.

305

During his Btaj in the hospital his appetite was generally good,
and he gained in weight. Uis blood was examined on the &j of
his discharge, but contained no excess of white corpuscles.

The paroxysms were never regular in the period of their
recurrence.

On 2d July, he was ordered two grains of quinine three times
a-day.

On 12th July, he discontinued the quinine, on account of it
causing some gnping pain in the abdomen.

On 21st July, the quinine was resumed.

His urine was frequently examined, and on many occasions it
contained a small amount of albumen. The specific gravity was
also found to vaiy greatly. Thus, on

Jane 16. .

. . Sp. gr.

1002

July 1.

7 a.m. .

None. Bp. gr.

1028

jf

19. .

No ■Ibomen. „

1001

fi *i

8 P.M. .

None. . „

1018

))

22. 2 o'clock

a^ ;;

1015

,, 2. 8 A.M. .

Slight amount. „

1026

f$

23. 6.30 A.M.

1021

If 11

12 noon.

Slight amount.

n

„ 9 a.m. .

None.

11 II

6 p.m.

None. . „

1017

It

„ 1p.m. .

Slight amoiint

11 11

7 p.m. .

Sliffht amount „
ine. Much albumen.

1017

11

„ 8 p.m. .

None. • fi

1013

II 3.

Night ur

11

'„ 6.45 p.m.

Slight amonot

,1 4.

2 P.M. .

None. . ,,

1016

It

24. 3 o'clock

Slight amount

It II

5 P.M. ,

None.

11

25. 9 A.M.

. Slight amount.

;, 6.

7 A.M. .

None. . 1,

1026

11

„ lP.M. .

Much albomeo.

ti ti

11 A.M. .

Slight amount „

1005

ft

„ 2.30 P.M.

Very UtUe.

II II

5 p.m. .

None. . „

1016

11

„ 4 p.m. .

None.

.1 6.

7 A.M. .

Slight amount
Fair amount

1}

26. 5 P.M, ,

None.

If II

12 noon.

11

„ 6 p.m. .

Some albumen.

11 II

5 p.m. .

Slight amount

If

„ 8 P.M. .

Some albumen.

II II

6 p.m. .

None.

It

27. 9 A.M. .

Good deal of alb. „

1022

II 11

7 P.M. .

None.

n

„ 2.30 p.m.

None.

7
If ••

7 A.M. .

None.

It

,1 6 p.m. .

None.

II 11

5 p.m. .

None. • n

1013

n

„ 8 P.M. .

None.

II II

8 p.m. .

None.

T1

„ 9 p.m. .

Some albumen. „

1023

„ 8.

11 A.M. .

None.

11

28. 8 A.M. .

None.

11 11

3 p.m. .

None.

11

„ 10 A.M. .

None.

II 11

5 P.M. .

None.

11

„ IP.M. .

None.

II II

6.30 P.M.

None.

11

„ 2 p.m. .

None.

„ 9.

7 A.M. .

Slight amount .,

1015

11

„ 8 P.M. .

None.

If 11

5 p.m. .

None.

11

29. 9 A.M. .

Slight amount.

It 11

6.30 P.M.

Slight amount

It

„ 12 nooD.

None.

.1 10.

7 a.m. .

None.

..." J

11

„ 3 P.M. .

Blight amount.

II 11

3.30 P.M.

None.

11

„ 6 P.M. .

Slight amount.

II II

7.30 P.M.

Trace.

•1

30. 10 P.M. .

„ 2P.M, .

None.
None.

11 II

8p.m« .

Trace.

It thus appears, as stated at the commencement of the paper,
that fits of ague may occur, the only indication of which is an
elevation of tne temperature of the body, and that when other
symptoms are present they are by no means necessarily propor-
tionate to the severity of tne fit. It is thus evident that correct
information concerning the severity or even the very existence of
the fit can only be obtained by aid of the thermometer.

These facts may perhaps explain the recurrence of the disease in
many cases in which it was presumed to be cured; for in such
cases it may be that the symptoms have merely disappeared, the
elevation of the temperature still continuing. Thus, in the last
case, had the general symptoms been alone relied on, we might

306 DB GREia ON INSUFFLATION [OCT.

have concluded that the fit was cured without the administration of
any quinine. And further, after the quinine was given to him, we
could onlj tell by the use of the thermometer that it had not, pro-
bably even at the time of his discharge, cured the disease; for
though he commenced to take large quantities of quinine on the
2d of Jul^, and continued its use with a short intermission till the
time of his discharge, still his temperature rose, on

July 4, to lOlJ. I July 19, to 100.

„ 11, to 104|. „ 20, to 101.

„ 18, to 100. I „ 21, to 100.

The thermometer thus becomes the best ^ide as to the period
at which the administration of quinine may be discontinued.

Another peculiarity in the case of the younger of these patients
was the irregular appearance of small quantities of albumen in his
urine. Its appearance was In no way connected with the attacks
of ague, or with the time of his taking food.

AbtiCLE m. — On Insufflation as a Remedy in Intussusception. By
David Greig, M.D., F.R.C.S.E., Dundee.

{Read hrfare the ForfarMre Medical Association^ at their Meeting in Dundee,

6th July 1864.)

Intussusception, or invagination of a part of the intestinal canal,
is by no means a very rare accident in early life, and is in general
one of the most fatal of infantile diseases. There are few practi-
tioners who have not met with cases of this kind in the course of
their professional duties. Many of these cases have been diagnosed
during life, and the dia^osis confirmed after death ; many, I have
no doubt, have died witnout a correct diagnosis having ever been
made ; in some, a correct dia^osis has been made, ana nature has
efiected a cure without any interference ; and in a few cases, the
physician, after having made a correct diagnosis, has been able to
render active and all-important service. The causes of intussus-
ception are unknown, but in all probability the most frequent is
spasmodic contraction of a portion of the bowel, and relaxation of
the adjoining part.

Intussusception occurs much more frequently in earlv life than
at any other period. Cases of intussusception are usually divided
into non-inflammatory and inflammatory, and may occur in any

Sart of the intestinal canal. The former, or non-inflammatory, no
oubt freauentlv takes place during life as a temporary derange-
ment, ana is frequently met with in the small mtestines when
post-mortem examinations are being made, where their presence was
never suspected, and which gave nse to no symptoms or tmeasiness

18<S4.] AS A BEMBDT IN HfTUflBUSCEPTION. 807

during life. The greater part of three hundred children, examined
hj M. Louis, who had died at the Saltpetri^re Hospital in Paris,
had two or more invaginations of the bowels, without anj inflam-
mation, or any signs that these had been injurious during life,
leading M. Loub to the conclusion, ^^ that an intuasusception maj
be formed and destroyed a^in by the mere action of the intes-
tine ; " an opinion confirmed by Dr Baillie, who, in his work on
Morbid Anatomy, says, — |*In opening bodies, particularly of
infants, an intussusception is not unirequently found, which had
been attended by no mischief: the parts appear perfectly free from
inflammation, and they would probably nave been easily dis-
entangled from each other by tneir natural peristaltic motion.'^
Even in my own experience I have very frequently met with cases
of this kind, and one case in particular which came imder my notice
in the Crimea, in which I found no fewer than twenty invaginations
in the small bowel. This was in the case of a strong robust
soldier, who was seized with cholera one momiug while on parade,
and died within four hours. The nature of the msease in this case
may account for the inva^nations.

These appearances are interesting in a pathological point of view,
but what we have to deal with at present is the true inflammatory
intussusception, which has always been recognised as a very fatal
complaint.

Every intussusception consists of three parts, the external part
or covering, which is formed by that portion of the bowel into
which the other has slipped, and the middle and internal, which
consist of the invaginated part doubled upon itself. It is these two
latter which are acted upon by the first, compressed, constricted,
strangulated ; and, as a matter ot course, inflammation and sloughing
ensue. Cases are recorded where inflammatory intussusception has
taken place in the small bowel ; these are, however, not very frequent.
By far the greatest number take place at the ilio-coBcal valve, and
are caused by the slipping of the lower portion of the ilium through
the valve and into the codcum. By the peristaltic action of the
coecum and colon, more and more of the small bowel is dragged
through the valve, whose spasmodic action will prevent any return-
ing; and when, owing to the mesentery, etc., no more can be
dragged through, the coecum is taken into the colon also, and this
is generally the state of matters when such a case is examined after
death. Tne peculiar anatomical characters of this part of the bowel
are what we should expect to favour the formation of an intussus-
ception, and to retain one when formed. That the great majority
of intussusceptions are into the larger bowel, is a practical fact well
worth bearing in mind, because an intussusception below the ileo^
coBcal valve is much more amenable to treatment than one above
it. This intussusception generally occurs in healthy children ; its
presence is shown by a regular series of well-marked and almost
unmistakable symptoms. The case, as might be expected, runs

VOL. X.— HO. IV. 2 R

308 DR GREIG ON IN8UPPLATI0N [OCT.

a rapid course^ and death generallj takes place on the third or
fourth day.

Much has been written ahout this serious complaint, but by far
the most complete and practical paper on this subject, is one by Mr
Gorham, in the third volume of Guy's Hospital Reports, which I
would beg leave to recommend to the perusal of all my medical
brethren who wish information on this subject. In that paper, Mr
Gorham not only gives a very good description of the disease, but
was, I believe, the first in this country who used insufflation as a
remedy for it, having taken the hint from some successful cases of
the kind recorded in the American Journal of Medical Science.
That nature does succeed sometimes in restoring the bowel to its
natural condition, there is every reason to believe ; but it is not by
any means a frequent occurrence. Dr West well remarks of the
cases recorded in medical journals, ^' I have observed only one
instance in which the symptoms of intussusception having existed
in a marked degree, at length spontaneously ceased, and were fol-
lowed by the restoration of the infant to perfect health."

The diagnosis, symptoms, and treatment of such cases will be
best illustrated by the narrative of five cases which came under my
observation, singularly enough, all within a very short period;
in consequence, my attention became specially directed to the
nature of this disease.

Case I. — M. S. G., a stout, healthy, female child, 6 months old,
always enjoyed good health, never having had a day's sickness ;
never haa any food ' except breast milk ; never troubled with
diarrhoea or bowel complaint. Was in her usual good health on
Monday, 13th October 1862, up to 6 o'clock in the evening, when,
without any obvious cause, she suddenly became fretful, kicking
with her feet, bending the body backwards, and screaming. In
about ten minutes she became very sick and vomited severely.
The skin became cold and clammy, the countenance pale, and the
lips livid. In a little while she revived, but soon became restless
and as sick as before. She seemed to have great pain in the abdo-
men, which came on in paroxysms, and to increase in intensity
until she vomited, when she would seem relieved a little, or at least
80 faint and sick as not to scream. When given the breast, she
would take it readily ; but as the sickness and vomiting, with a

faroxysm of pain, immediately came on, she latterly retused it.
mmediately when she was seized a spoonful of castor oil was
given, and hot fomentations were applied to the abdomen. The
castor oil was soon ejected from the stomach, as was also a small
purgative powder which was given. A warm-water enema was
attempted to be administered, but the bowel seemed to be in such
a state of spasm that none could be thrown up. About 8 P. M.,
tenesmus came on^ and she passed a little fluia blood, which con-
tinued to come with every paroxysm of pain during the night.
The abdomen was soft, sugntly tympanitic, and not painful on

1864.] AS A SEMEDT IN INTUBfiUSCEFTION. 309

pressnre, except dtuing a paroxysm of pain, when prepare seemed
to increase it. On deep pressure being made over the abdomen^
mider the umbilicns, a ver^ distinct hard tumour was felt, a little
to the risht of the mesial line. Seeing that the case was a serious
one, ana as the little patient was a near relation of my own,
I asked my friend Dr Pine to take charge of the case. He
attempted to give another enema, but with no better success, owing
to the very peculiar spasmodic state in which the bowel was. On
the mommg of the 14th, as the child was no better, and as Dr
Pirie suspected an intussusception, he requested Dr Nimmo to see
the case alon^ with him. In consultation it was decided that it
was a case of mtussusception of the bowel. The sickness still con-
tinued, but not so severe as on the previous day. The in&nt took
the breast readily, and after taking it would lie stiU for a few
minutes; pain would then seem to come on with sickness, and
the milk would be ejected from the stomach with great violence,
after which the child would seem exhausted and lie still for some
time. It seemed to have great thirst, and took cold water greedily,
which, however, was soon ejected. The pulse was about 130,
small. Injections were agam administered, but with the same
result as formerly. As everything had been tried, and nothing
had done any good, and as it was evident the child was fast
sinking, it was proposed to use the air injection which is men*
tioned in Dr Wesrs work on Diseases of Children, as having
been used with success by Mr Gorham. Fortunatelv, Dr Nimmo
had in his library the volume of Guy's Hospital Reports, which
contained Mr Gorham's paper on the subject, and after each of us
had perused that paper, it was resolvea to give the remedy a
trial, as a last resource, and in truth with no very great hopes of
benefit.

The nozzle of a small pair of bellows was introduced into the
anus, and air injected to a considerable extent. Contrary to our
expectation the air passed readily into the bowel, and seemed to
give the child great relief. After the injection it lay very quiet,
as if asleep, and evidently quite free from pain. In about twenty
minutes from the time the air injection was administered, a slight
rumbling noise was heard in the child's abdomen, followed by a
crack so loud and distinct as to alarm the attendants in the room,
who thought something had burst in the child's bowels. The
child, however, continued as if asleep and free from pain, and
in about half an hour a large feculent fluid stool, slightly mixed
with blood and mucus, was passed without pain. During the
night the child rested pretty well, had no return of vomiting, took
the breast as usual, and in two davs was quite well.

Case II. — ^W. C, a fine, healthy, male child, 9 months old,
never having had a day's sickness, was taken ill on Friday, the
7th August 1863. He was quite well in the morning, and his
bowels were freely moved about 5 A.M. At 12 noon, without

310 DR asEia on insuffultiom [oct.

any warning, he was suddenly seized with very severe sickness
and vomiting ; he became deadly pale, and his skin was covered
with a cold clammy sweat. In a short time he recovered from
this state ; he became warm, and his countenance resumed its
natural appearance. He was, however, restless, and seemed to
have thirst, but immediately on getting a drink of milk he fell
into the same £Biint state, and the milk was ejected from the stomach
with violence, the child, before tlie vomiting, evidently suffering
great pain. Even a spoonful of cold water was not retamed above
a few minutes. The child continued in much the same state until
1 saw it at 11.80 p.m. At that time it seemed to be suffering
from paroxysms of pain, which seemed to come on about eveiy
twenty minutes, and the sickness and vomiting continued almost
as bad as at first. The skin was warm and moist, the oounte*
nance pale^ pulse 120, thirst very great, and everything liquid
was taKen with great eagerness; it even took the breast with
as great relish as it did when in health. Immediately after any*
thing was taken into the stomach, it wonld lie quiet for a few
minutes ; it would then become restless, and this restlessness would
increase until, during one of the paroxysms of pain, everything
would be ejected from the stomach ; and this was repeated again
and again. The abdomen was flaccid and soft ; but a distinct, hard
swelling, or tumour, could be felt under, and to the right of the
umbilicus, which seemed to be somewhat tender on pressure. A
spoonful of castor oil had been given in the afternoon, but was
immediately vomited. The bowels had not been moved, but there
was some tenesmus, and before I had been long beside the patient,
about a spoonful of slime and florid blood passed from the bowel.
I had not the slightest doubt the case was one of intussusception, and
proceeded to administer a warm-water enema ; but the same pecul-
iar spasmodic state of the bowel, which was mentioned as existing
in the former case, was again found here. In order to overcome
this, I tried to plug the injection pipe into the anus with lint ; but
it was of no use, the injection seemed to give the child great

Eain ; very little of the water would go up the rectum, and the
ttle that 1 did succeed in throwing up, remained a very short time,
and only brought away more blood. Nothing came from the bowels
but fluid blood and frothy mucus, in which were found shreds of
mucous membrane. This state of matters continued until 2 o'clock
on Saturday afternoon, when I resolved to try the insufflation of
the bowel.
^ Having got the tube of an ordinary elastic enema fitted on to the
pipe of a small pair of bellows, I threw a considerable quantity of
air into the rectum. It passed very readily into the bowel, there
was no straining or attempt to expel it, and it seemed to give the
child great relief. It had taken some milk from the breast shortly
before this, and although the sickness was coming on as usual with
a paroxysm of pain, the insufflation seemed to relieve the pain, and

1804.] AS A SSHEDT IK INTUS8USCEFTI0N. 811

the milk was not vomited, I waited for an hour, and as the sick-
ness was again threatening to come on, and fearing I had not
thrown in enough air, I administered anouier insufflation, and oon«
tinned the process until the belly showed signs of considerable
distention, and the child seemed to be somewhat nneasj in conse-
quence. At this time I also administered a teaspoonftil of castor
oil, and was pleased to see the stomach retain that also ; and from
this time there was no more vomiting. After this the child fell
asleep, and slept for about half an hour, awoke, was inclined to be
amused, but still seemed uneasj. Warm fomentations were applied
to the belly, which seemed to give relief. From this time the child
seemed free from pain^ and for the most part slept until about five
o'clock, when a copious stool was passed, fluid in consistence, and
mixed with some blood. From this time the child was auite well,
took the breast with eagerness, retained what it tooK, bowels
became regular, and it soon made up in flesh what it had lost
during its short but severe illness.

Case III. — J. C, aged 10^ months, a healthy female child,
never had a^ay's sickness, had never been troubled with diarrhoea
or any irritation of the bowels, was in her usual good health on the
forenoon of the 30th October 1868. In the afternoon, when out
airing under the care of her nurse, she became somewhat sick,
vomited a little, and seemed very uneasy. When brought home,
at 5 P. M., she seemed in ^reat pain, crying and kicking violently.
Her mother, thinking a pin pricking her might be the cause of
this, undressed her, and nnding no cause, gave her a teaspoonful of
castor oil. Yeiy soon after this the child became restless, faint,
sick, and vomited. After the vomiting she seemed relieved, but
soon a paroxysm of pain would come on again, terminating in
sickness and vomiting or retching. When i saw her at 8 p. M.,
her pulse was 100 ; skin warm and moist ; the bowels had not
been moved since morning ; would not take the breast ; every now
and then a paroxysm of pain came on, when the child cried and
kicked violently. The abdomen was soft, but a very distinct
hardness could be felt in the right iliac region when pressure was
made over that part Warm fomentations were oraered to be
applied to the abdomen, and when I visited her at 10 P.M., she
seemed somewhat easier. Daring the night the paroxysms of pain
came on at longer intervals, and the child slept between them. On
the 31st, at 8 a.m., a little fluid blood passed from the bowel, and
this continued during the course of the day when the paroxysms of
pain came on. There was not much tenesmus ; what passed from
the bowel was pure blood in small quantity, and unmixed with
mucus. At 3 P. M. an injection of air and warm water was admin-
istered very slowly. The irritation of the bowel was not so great
as I expected, and a considerable quantity of water and air was
injected. The greater part of this came awa^ in about ten minutes,
bringing some blood and mucus along with it. It was noticed that
the air seemed to remain in the bowel ; the child seemed much

312 DR GRBIG ON INSUFFLATION [OCT.

easier^ took Bome milk^ and soon fell asleep. Early next morning the
bowels moved freely, and before I saw the chila in the forenoon,
they had moved three times. Next day the child seemed quite well.

Case IV. — D. W., a fine, healthy male child, aged 4 months,
who never had had a day's sickness, became somewhat suddenly
ill about noon on Thursday the 12th November 1863. About
8.30 A.M., the bowels were moved naturally, and the child seemed
quite in its usual good health. About midday, it seemed very
uneasy, began to cry and kick violently with its feet, as if suffer-
ing from pain in the belljr. Some food was given, which it took
readily, but which was immediately ejected from the stomach.
The nurse, thinking that the food had not a2;reed with it, in about
half an hour gave it some milk, which was also very soon vomited.
Some castor oil was given, which the nurse thought remained on
the stomach, and was not vomited. The child slept and cried at
intervals, and always, when crying, bent backward and kicked
violently with its feet. About half-past seven in the evening, a few
drops of blood passed from the bowel, and continued everjr now
and then during the course of the night, always increasing in
quantity, sometimes mixed with mucus, and accompanied with
great tenesmus. During the night the mother gave it a warm
bath, applied a sinapism over the abdomen, and gave it a little
more castor oil. In the morning, as the child was no better, I was
called to see it, and at once dia^osed a case of intussusception.
The child was not suffering much pain, was not taking any food,
was retching sometimes, but there was no vomiting. The mother
was sure it had not vomited the castor oil, and on the whole she
thought it somewhat better and easier ; pulse 120, shaip : skin cool ;
the countenance was not anxious, and tne eye was bnght. About
every hour a little tenesmus would come on, and at that time the
child would pass a little frothy bloody mucus. The abdomen was
not distended, but was slightly tympanitic ; and when deep pressure
was made at or around the umbilicus it seemed to give great pain.
No tumour could be felt in the right side of the abdomen, but a
very distinct hardness could be felt extending from the umbilicus
to the left iliac fossa, when deep pressure or percussion was made.
As the case did not appear to be very urgent, I ordered hot fomen-
tations to be kept over the belly during the day. In the evening it
was still much in the same state. I tried to administer a warm-
water injection, but the rectum was so spasmodically contracted,
that it was impossible to get any thrown up.

From the time when my former cases had come under my obser-
vation, I had had many conversations with some of my medical
brethren regarding them, and a very general opinion seemed to
prevail, that nature frequently removes these obstructions without
any interference on the part of the physician ; and that probably
had I left these cases to nature, a cure might have taken place
without me. Wishing to test how far this opinion was correct,
and as this did not seem as yet a veiy urgent case, I resolved to

I8M.] AS A REMEDY IK INTUBSUSCEPTIOK. 313

postpone the air injection until next morning^ and in the meantime
leave the case to nature. When I called next moijiine I found
the child dead. During the night it became much worse, lost much
blood from the bowel, and died quietly at 6 A.M., apparently from
loss of blood, after an illness of fortj-two hours.

Ten hours after death, I made a post-mortem examination of
the body. It was pale and exsangume. The rigor mortis was
very slightly marked. The abdomen only was examined. All
the abdominal organs were normal. The bowels from the stomach
down to within about twelve inches of the ileo-coecal valve were
pale, and only contained flatus. The half of the ascending, the
transverse, and the descending colon formed the external covering
of a hard tumour, which was found to be the invaginated boweC
The invagination consisted of the lower twelve inches of the ileum
and the coecum. This completely filled the colon and sigmoid
flexure to within an inch otthe anus. The external covering or
colon was pale, and neither congested nor inflamed ; the interior of the
tumour or invaginated part was very much congested and inflamed,
the mucous membrane, more especially of the ileum, being of a dark
colour, spongy in appearance, and ulcerated, very much like the state
of the mucous memorane of the bowel which is met with in severe
fatal cases of chronic dysentery in tropical climates. Owing to the
dragging of the mesenteiy, the tumour was fixed to the spine, and
extended in a curved direction from the imibilicus to the left
hypochondriac region, and thence to the rectum, chan^ng the posi-
tion of the colon, and accounting for the situation of the tumour.
After the removal of the tumour, the coecum was easily drawn out
of the colon, and restored to its natural position ; but the greatest
difficulty was found in getting the swollen small bowel reduced
through the ileo-coecal valve, which seemed even then to be in a
spasmodic condition.

Case V. — The following case, which occurred in the practice of
my friend Dr Pirie, and which I saw along with him, has been
kindly furnished to me by him as another successful instance of
insufflation in invagination of the bowel.

J. M., aged 4 months, a vigorous thriving child, awoke on the
morning of the 16th September 1863, crying, as it in great pain,
and continued during that day and the following night very restless
and uneasy, the bowels not having been opened since 6 o'clock
A. M. On the morning of the 17th, he passed some bloody mucus at
stool, but no feculent matter, and during the day vomited fre-
quently. At 5 P.M., when first summoned to see the child, I found
him with pale anxious countenance, hurried respiration, weak, quick
pulse, discharging per rectum bloody mucus ; and after learning the
above history, I discovered a round, hard swelling over the coecum,
and quite dull on percussion. Looking upon the case at once as a
case of intussusception, I withheld the use of purgatives, and
inflated the bowels, " per rectum," with air, by means of a pair
of small drawing-room bellows. This was accompanied by a

814 DR GREIG ON INSUFFLATION [OCT,

crackling internal sound aa of air distending the lower bowel, and
was followed hy temporaij relief from the uneasy restlessness, but
no fecal discharge.

19rt, 11 A.M. — The obstruction and vomiting continue, but the
child's aspect is not so sickly as yesterday. On inserting a long
tube into the rectum for the purposs of repeating inflation, a con-
siderable quantity of thin fecal matter came away, and I again
injected the bowel with air. 2 p.m. — ^Child keeps easier; skin
cool ; and vomiting has not returned since forenoon. The ccecal
hardness continues. Repeated inflation, and also gave a warm-
water enema ; but this was retained for a very limited time. Mother
states that child lies quieter, and appears greatly eased for a con-
siderable time after the air iimations. 11 P. M. — Tumour continues ;
no natural stool yet.

20A. — After rather a restless night, the child got a free fecal
discharge this morning at 6 A.M., and several times afterwards.
At 9 A. M., I found the tumour much reduced in size, the child
looking much easier, and taking the breast readilv. Gave a warm-
water enema ; but this was speedily ejected. Ordered a teaspoonful
of castor oil. By evening the swelhng at coecum had disappeared, the
bowels were freely opened, and the child was thoroughly relieved.

These I look upon as five very good specimen cases of true
inflammatory intussusception. Other obscure cases I have met
with in my practice, presenting some of the symptoms of this
derangement ; but with these we have nothing to do at present.
As an intussusception of the bowels cannot be seen or handled like
a hernia or a fractured limb, many medical men are very sceptical
when told that a certain remedv relieved such a case, and can only
believe an intussusception to oe present by seeing it at a post-
mortem examination ; this is certamly very conclusive proof, but a
kind of proof we would wish to avoid, however conclusive. To
my mina the symptoms of an intussusception are immistakable,
and may shortly be said to be, the sudden seizure, the obstinate
vomiting, the obstinate constipation, the paroxysms of pain, the
hard tumour in the abdomen, and chief y the passage of blood per
anum ; all these various symptoms may show themselves in other
diseases, but when combined together, and especially when the last
mentioned symptom, the passing of blood per anum is present, I
think no one can have any difficulty in formmg a correct diagnosis,
and must feel convinced that an intussusception is present, without
the necessity of a post-mortem examination.

The prognosis of such' cases is always unfavourable ; and it is
well that the medical man guard himself by stating so, whenever
he has made his diagnosis. It is true, numerous cases are on record
where nature has produced a cure by the sloughing of the strangu-
lated portion of the intestine, and the junction of the healthy parts.
About two years ago, Dr Hare had an opportunity of showing to
the Pathological Society of London how neatly nature completes

1864.] AB A REMEDY IN IKTU88U8CEFTION. 315

a cure of this kind^ a patient of his having died of tahercniar disease
only three months auer sufTering from intassasception, in which
several inches of the small bowel came away on the fourteenth day
of the attack. At the post-mortem examination it appeared that
the portion of the small intestine came away fifteen inches above
the caput coli, and so perfect was the cicatrix, that it appeared as a
mere line round the E)owel, with puckering of the omentum, etc.,
around it. I would not, however, advise any one to forego treat-
ment and trust to nature for a cure ; as, from my experience, nature
is not to be trusted even when the case appears to be one of no great
urgency.

As to treatment, purgatives in the first place naturally suggest
themselves ; but these are worse than useless^ rarely remaining on
the stomach, and if they do remain only stimulating the bowel
and aggravating the disease. Warm-water enemata are useful, but
can seldom be administered owing to the verv peculiar irritable
spasmodic condition in which the rectum usually is. In any case
where this spasmodic condition is not present, or only to a slight
degree, I have no doubt warm-water enamata, or, as I used in Case
III., warm-water and air thrown in by a syringe would be useful.
The ease, however, with which air is thrown into the spasmodically
contracted rectum, when it is impossible even to introduce a tea-
spoonful of warm-water, gives this agent a pre-eminence over all
others, and astonishes all who have seen it used. The remedy is
always at hand even in the poorest cottage, no matter how far away
firom town. Its application is so simple as to require no direction
for its use. The only necessity being that enough air be thrown
into the bowel to distend it as far up as the neck of the invaginated
portion, or, in other words, that the operation be continued until the
child begins to be uneasy, and the belly distinctly tympanitic.
Amongst other means for relief, cases are on record where the
abdomen has been opened for the relief of the bowel in intussuscep-
tion. It is difficult to reduce one by manipulation after death, and
I have no doubt it would be much more so to do it during life.

Article IV. — Tu>o Cases of Stramulated Inguinal Hernia. By
George Y. Heath, M.B., M.R.C.S., Surgeon to the Newcastle
Infirmary and Eye Infirmary.

{Conummicatedio the Northumberland and Burham Medical Socidy,)

1 . Case of Strangulated Inguinal Hernia of the Right Side. — Stricture
Divided without opening the Sac. — Recovery in Ten Days. — Opera^
tionpeTformedJifteen Hours after Descent. — Reported by Mr Forster.

J. R., a bootmakei^ aged fifty, residing in Stamfordham Court,
was seen by Mr T. Y. Thompson, on the 18th March, late in the

VOL. X.— NO. IV. 2 s

816 ML a. T, heath's two cases of [OCT.

eyening. He found him Iftbouring under an inguinal hemia, the

fut having descended whilst the man was drinking in a public-
ouse that afternoon, about five, and whilst he was in an intoxicated
stAte. J. E. had been troubled with rupture for several years, the

fut occasionally coming down, but not to such an extent as to pro*
ibit himself returning it He usually wore a truss.

On the 12th, the rupture had been down for about three hours ;
but his wife, with the assistance of warm fomentations, bad te^
turned it

On the 18th, however, it had got beyond their united endeavours^
and Mr Thompson was called in. After careful and patient endeft-^
vour to return the gut for nearly two hours, without success. Mr
Thompson then requested the assistance of Dr Heath, who, now-
ever, was not more successftil in returning the rupture. Dr Heath
then advised the use of injections, and an opiate pill to be admini-
stered {the man suffering a good deal of pain onix>uch)« Thus he
was left till the morning.

On the following morning, when he was again seen by Dr Heath
and Mr Thompson, the tumour was in the same condition. J.
R. was then prepared for an operation. Mr Thompson having
administered chloroform, Dr Heath commenced the operation by
pinching up a fold of skin over the neck of the tumour ; the base
of the fold of skin was then transfixed, and the integuments divided
by cutting from within outwards. Thus an incision was made
aoout an inch and a quarter long over the neck of the sac. After a
short dissection the external abdomitial ring was reached and
divided, the stricture existing at the ring, without in any way in-
terfering with the sac, and permitting the easy reduction of the gut

The wound continued to heal in the most satisfactory manner,
and on the 29th was closed.

In this case it will be observed that the operation was performed
about fifteen hours after the descent of the rupture.- The stricture
was distinctly in the external abdominal ring, on division of which
the bowel readily passed up; recovery took place rapidly, and
without an unfavourable symptom.

The second case was that of an Infirmary patient. The notes of
the case are supplied by Mr Hope, my clinical clerk.

2. Case of Strangulafed Lmtdnal fferma of the Lefi Side. — Opera-
tion Performed about ThirUf-Six Hours after Descent. — Sac
Opened: Death in Fourteen Hours after Operation*

Aih April 1864.— T. Y., aged 52, |)itman, Warkworth, admitted
into the Infirmary at 2.45 P. M., suffering firom strangulated oblique
inguinal hernia on the left side. The rupture occurred in the
morning of April 3d, about eight o'clock, whilst he was going to
stool. On inquiry, found he had been troubled with hernia about
three years, and had worn a truss. Whenever it came down he had

ISM.] SnUNOULATED IRQUINAL HBBNU. 817

•Iwsji been able to xeduoe it by applying heat, bat was nnable to
do 80 on this occasion.

A surgeon saw him at home, had him put under the influence of
chloroform, and tried yarious means to redace the rapture, unsuc-
cessfully. He had been yomitin^ several times before he came
here, but the person who aocomDanied him said the vomited matter
was not of a lecal character. The tumour was about four inches in
length, very tense, slightly red at its inferior part, and very tender
on touching it. An injection of warm-water and soap was given
him twice (altogether aoout three quarts), but he was not able to
retain it. A pill, containing pulv. opii. gr.ij., was given him at
3.5, but as he vomited a short time after, it was thought it
was ejected. At 5,15, according to Dr Bolton's directions, another
pill, of the same strength, was given him, and cold lotions applied
to the rupture constantly. Dr Bolton again saw him at 7 p.m.,
and found the opium to have produc»Bd no effect. He was
then put into a cold bath^ the tumour well bathed, and afterwards
another pill was given him. At eight oVlock one more pill was
given him, and as no effeot waa discernible, Dr Heath was
sent for. '

Dr Heath saw the patient at half-psst eight, and after examining
the rupture, advised him to have the gut returned by operation ; to
which ne consented. Chloroform was given him. Dr Heath then
made a longitudinal incision over the neck of the sac, and dissected
through the coverings as far as the sac. The external abdominal
ring, which was divided, was found stretched and exceedingly tense ;
an attempt was then made to reduce without opening the sac, but it
was found impossible to do so* The sac, which was very tense,
was then opened, a gurgling sound was heard on the incision beinff
made, and after a very careful examination the gut was returned.
There was no omentum within the sac. The portion of gut within
the sac was of a dark brown or chocolate colour, very soft to the
touch, and seemed as if a very little rough handling would injure it
There were well-marked lines of constriction on those portions of
intestine which had lain within the grasp of the stricture. The
intestine, above the lines, was of a normal appearance. The wound
was then closed by four sutures and strapped. The patient was
ordered beef-tea and whatever nourishing nuids he could take.

5th AprU. — ^Mr Hughes was sent for to see him at 8.30 a.m., and
found him comatose and breathing heavily. He sent for Dr Bolton,
who ordered Ammon. carb. gr^viii., Spt. iBther. Sulph. Co. Sss.,
Aquse |i., to be given eveiy two hours, and a poultice to be applied
over the abdomen. There was great tension of the abdominal walls.
Dr Bolton again saw him at half-past ten. The stitches were re-
moved, and a quantity of dark fluid oozed from the wound. He
did not complain of pain. He died at 11 a.m.

6<A April. — Upon post-mortem examination, at 11 a.m., in the
presence of Dr Heath, that part of the small intestine which had

518 DK G, T. heath's TWO CASES OP [OCT-

protraded was found in a semi-gangrenous state, the other portions
were congested. Within the abdomen was a quantity of dark
serous fluid, and a deposit of Ijmph was found upon the parietal
portion of the peritoneum.

In this case the operation was not performed until ahout thirty-
six hours after the descent of the bowel. Although the external
ring was found very tightly extended over the lower part of the
neck of the sac, nevertheless, the division of the ring external to
the neck did not so relax the parts as to permit the return of the
bowel. The neck of the sac itself was very narrow, and tightly
enclosed the upper portion of the intestine ; this constricted con-
dition of the neck continued up to the internal ring. Under these
circumstances it was necessary t6 open the sac, in order to relieve
the stricture.

The bowel was found very dark, but not more so than I have
sometimes seen it in cases wnere recovery has taken place.

The bowel, together with the sac, was removed after death, and
they are now on the table. The distended condition of the bowel
below the stricture, and the nipped state of the strictured part are
very apparent ; the colour is, of course, almost gone ; in the recent
condition of the parts the dark colour of the distended bowel and
the white appearance of the strictured portion were as striking as
the difference in form.

If the neck of the sac be examined it will be observed that that
part of it which corresponds to the internal ring presents a curious
appearance ; it is drawn into folds or plaits overlapping each other
and producing a sort of fringe all round the interior of the neck.
This fringe is about a quarter of an inch in width, and is evidently
the result of pressure.

In considering these two histories in their entirety, we cannot
avoid remarking the strong points of contrast presented by cases
which otherwise are so similar.

Here are two men, in the same condition of life, near upon the
same age^ and, with one exception, in ordinary good health.

Each IS the subject of hernia, oblique inguinal hernia of the
variety called scrotal, and in each the bowel becomes stran^lated
in consequence of the removal of the truss ; ultimately also m each
case an operation becomes necessary for the relief of strangulation.
So far the two histories are similar.

Henceforward they are diverse. We are first struck by the
different results,

J. R., the man first operated upon, recovers without a bad
symptom, and is well enough in ten days to be up and wear his
truss; the second man, T. Y., dies in a few hours after the
operation.

Whence this great difference?

If we analyze the progress of the two cases subsequent to the

1864.] 8TBAM0ULATED INGUINAL HEBNIA. S19

period of Btrangulation, we shall find such diversitj in the treatment
as would naturallj lead to the different reaults.

In the Buccessfol case, a fair attempt at redaction verj soon after
the descent of the bowel failing to return it, one grain of opium is
given by the mouth, and an injection administered. The next
morning, some fourteen hours after the descent, strangulation still
continumg, the operation is performed, and the stricture divided
without opening tne sac.

In the unsuccessful one, reduction is attempted under chloroform
soon after the descent, but is not effected. The patient being at
a country place, where the operation could not be conveniently
performed, is sent by train to the Infirmaiy, where he arrives at
2.45 P.M. Here an injection is administered, and between the
period of admission and 8.30, the period of operation, four two grain
opium pills, given by the mouth, — one of the pills was probably
vomited. The cold bath is also used.

Between 8.30 and 9 p.m., i.e. about thirty-six hours after the
descent, the operation is performed, and the stricture being seated
mainly in the neck of the sac, this of necessity is opened, and the
bowel is found much discoloured.

There are, then, three points on which the treatment adopted in
the two cases differed, viz., the treatment previous to the operation,
the time after the descent of the bowel at which the operation was
performed, and the opening of the sac.

The treatment previous to operation. —

In the unsuccessful case eight grains of opium were taken in
about five hours ; two grains were probably vomited, leaving six.
At the period of the operation the patient did not seem much
affected by the opium ; but the pupils were contracted ; the circum-
stances, however, by which he was surrounded, his position in the
Infirmary^ etc., and particularly the cold bath, were all unfavourable
to the action of opium.

It is quite possible that the drug would act more powerfully after
the operation, when the patient was left quiet. I understand from
Dr Bolton, who directed the treatment previously to the operation,
that he has known the use of opium, in tnis way, effect the reduction
of the bowel in cases of stranmilation.

The use of opium in large coses in cases of undoubted strangula-
tion, like almost every other mode of treatment short of operation,
is open to the serious objection that valuable time is lost by it, ana
that the patient is placed in a less favourable position afterwards for
the operation. Might not so large a quantity of opium facilitate
the depression and sinking so apt to come on after hernia operations,
where the bowel has been long and severely nipped?

I quite agree in the opinion expressed by the late Mr Liston on
this nfatter. Substitutmg only chloroform for bleeding or the
warm bath.

Speaking in the first person Liston used to say, " If I were the

820 PR a. T, hkath's two casks of [oot-

«ttbjeet of stranguUted rapture I might submit to be bled and luire
the taxis employed during the faintness arisine from loss of blood
or from a warm bath, but reduction not being &us effected, I should
certainly be operated upon a few minutes afterwards."

And I should say, that where strangulation undoubtedly existSi
if the bowel cannot be reduced by careful taxis imder chloroform
the sooner the operation is performed the better, and all other treats
ment is but thrown away.

This brings us to the period after the descent at which the
operation was performed.

This was, in the unsuccessftil case, about thirty-six hours ; no
doubt we meet with cases in which the operation is successftd after
eyen a longer strangulation than this ; much will depend upon the
tightness of the stricture. In the present case the neck of the sao
compressed the bowel with great tightness, and the bowel itself was
distended with eas, and exceedingly tense.

The effect oi such compression upon the bowel, eyen for a few
hours, would be yery great, and all the more felt towards the end of
the time ; in other words, the effect of pressure must be progressiye
and increasing, so that each hour's pressure becomes more and more
destructive.

The time which elapsed from the period of descent until the
operation was, in the successful case, only fifteen hours, the difference
was therefore twenty-one hours; quite long enough to produce
mischief, and it is no doubt to this point that we must chi^y look
for the difference in the result.

I haye had considerable experience in strangulated hernia, and I
do not remember seeing a fatal termination after an operation imder-
taken within twent}^-four hours of the descent of the bowel, and I
haye seen the operation performed in yery old persons ; a few months
ago on a lady of eighty-four, who recoyered.

Lastly, in the unsuccessful case the sac was opened.

This step was unavoidable, the stricture being chiefly in the neck
of the sac : we must, nevertheless, consider this measure as being
on the uniavourable side, and as conducing in some decree to the
£&tal result ; the exposure of the bowel, the handling of it, and'the
opening into the bag of the peritoneum, all of which necessarily
follow the laying open of the sac, are circumstances which aggravate
the danger of the operation.

There are few improvements in surgeiy of greater practical value
than the division of the stricture external to the necK of the sac of
a rupture. I invariably practise this mode of operating where it
can De done, and in a considerable number of cases have not seen
one death.

I am desirous of stating my impressions with regard to this
method, as some surgeons even yet appear to prefer the old* opera*
tion. Mr Le Gros Clerk, in a work recently published, seems to
favour opening the sac ; and Sir John Fife^ in a letter published in

liei.] SnULKOULATBD INOUIKAL HUMIA. Sit

the Lane^ dome yean ago, adrocated, if I remember rightly, the
same mode of procedure.

The objectione usually urged against the procedure without
opening the sac are, first, that the intestine, not oeing examined, it
may be returned in a gangrenous state ; and, seoondly^ that bands
of adhesion may exist in the sac, by which strangutadon may be
continued, even though the bowel be retomed or seem to be
tetumed.

With regard to the first objection, it can only apply to cases
where the strangulation has been allowed to continue a much loneer
time than any good surgeon would permit, unless firom unavoidaole
circumstances ; moreover, where gangrene of the intestine has taken
place, there is usually some external evidence of this, either in the
altered colour of the integuments, the presence of crepitation from
gannene in cellular tissue, or in the dark colour of the sac, the
smell of putrefaction, etc.

With re»rd to the second objection, I have always found that
where banos of adhesion existed within the sac, so placed as to
produce strangulation oi bowel, this could not be returned at all
until the sac had been opened and the bands divided. I cannot
conceive the existence of adhesions which should at once strangu-
late the bowel, and yet admit of its return into the bell;^.

I cannot, therefore, allow that these are valid objections against
tiie operation without opening the sac, and hold that this should be
the ordinary procedure m all cases where the position of the strio*
ture permits its practice, and where strangulation has not existed
BO long as to make destructive changes in the bowel highly probable,
if not evident

There are ruptures, m<Mreover, in which this mode of procedure is
more than usually desirable ; those of lonf^ standing, for example,
where the mouth of the sac becomes exceedingly wide, and its cavity,
therefore, almost directly^ continuous with that of the peritoneum.

In umbilical ruptures in particular, it is most desirable to avoid
opening the sac ; the two operations here being almost equivalent
respectively to life or death for the patient

To return now, briefly, to the two cases whidi are the subject of
lliis paper. The analysis which has been made shows pretty plainly
that the fetal result in the unsuccessiul case was owmg mamly to
the length of time which the strangulation had existed previous to
the operation. The vitality of the gut was thus impaired to so
great an extent that no recovexy took place, even when the stran*
gulatton was relieved.

The opening of the sac must be looked upon also as weighing
the balance on the unfavourable side ; the bowel would undoubtedly
have been in a better position for recovery had the sac remained
intact.

The opium treatment and the cold bath had no chance of success
in a case where the stricture was so close as it turned out to be in

322 I)R heath's strangulated INaUINAL HERNIA, [OCT,

this case ; whilst valuable time was thus consumed and the condi-
tion of the patient for the operation not improved.

In conclusion, it mav be said that these two cases bear out most
iuUj the opinion of those surgeons most conversant with hernia,
that where undoubted strangulation exists no time should be lost
in relieving it by operation ; that one complete and skilful attempt
at reduction having failed, and another attempt with the assistance
of chloroform or the warm bath having also failed, the division of
the stricture should be at once resorted to, and performed, if possible,
without opening the sac Performed in this way early, before the
gut is irretrievably damaged, and without interfering with the
peritoneum, the operation for strangulated hernia is one of the
most brilliant triumphs of surgery; one of the safest and most
successful operations, and affords the most satisfactory results to
both surgeon and patient.

Article V. — Loss of the Second Phalanx of the Left Thumb with
the Tendon of the Flexw Longia PoUicis. Bj W. Stuart Munro,
West Hartlepool.

Cases of loss of one or more of the phalanges of one or more of the
fingers are of almost dailj^ occurrence in a large surgical practice
such as I have here, but in only one instance has a case occurred
where it has been accompanied by that of a tendon in its entire
length.

E. C, aet. 20, a healthy and robust Irish labourer, when at work
on 9th June last at one of the highest chimneys of the Iron Rolling
Mills here, stumbled, and so as to avoid falling a distance of some
150 feet, caught hold of a rope that passed over an iron pulley, on
which a weight of several hundredweights was being raised at the
time. The second phalanx of the left thumb with the tendon of
the flexor longis poUicis in its entire length were at once pulled
away ; the fibres of the belly of the muscle hanging like a fringe
irom its tendinous insertion.

Cold-water dressings were applied for two or three days, and
antiphlogistic treatment adopteo. The cartilage on the end of the
first phalanx was not removed.

After inflammatory action had subsided, the wound was dressed
with turpentine liniment, and completely healed without a single
bad symptom on 30th July, since which time he has been at work.

1864.] DEGENERATION AND ATROPHY OF THE CEREBRUM. S23

Article YI. — Ckue of Degeneration and Atrophy of the CerArum^
causing Unilateral Epilepsy. By Kenneth M^Leod, A.M.,
M.D.; L.R.C.S.E., Assistant Medical Officer, Dnrham Coimty

Asjlttniy SedgefielcL

The following case is so interesting in many of its features^ and so
important in toe character and site of the lesions found after death,
that after a careful and thorough investigation of its peculiarities, 1
have considered it worthy of being put on record in extenso.

History. — J. M., »t. 32, a vagrant, was admitted into the Durham
County Asylum on the 9th April 1863. No insanity or nervous
disease is admitted to have existed in the fieunil^ of either narent
Father and mother both possessed strong constitutions ana good
health, and were free from any nervous disease, eccentricity, or
-vice. Former died in 1841, »t. 61, of heart disease. The latter,
up to the period of his admission, wandered about with the patient,
begging, and using him as a means of exciting commiseration ; she is
63, enjoys tolerably good health, is active, and of average intelligence.
J. was the second of nine children, six of whom are said to have
died in infancy, of convulsions. He appears to have been healthy,
strong, and intelligent up to the age ot 13, an apt learner, of souna
faculty, and average strength ot mind. At that age he had a
severe attack of typhus fever, which left him demented and epileptic.
His condition has never improved, but rather declined ; fits becom*
ing more frequent and severe, and imbecility more profound. He
has been quite incapable of taking care of himself; of expressing
himself rationally ; hardly able to articulate a word ; tolerant of
considerable physical exertion and discomfort ; tractable and well-
tem|)ered, except when hungry. He appears to have been fond
of his mother, to whom he looked for the gratification of the only
desires he possessed, — namely, for food and tobacco. He was
also fond of children. He appears to have been unable to under-
stand anything said to him, to observe any object, or to know or
remember any names, except "mother," "pipe," "tobacco," and
"bread." When irritated, he manifested considerable ferocity,
biting, scratching, kicking, etc His mother says that he has been
always well fed^ and never starved beyond the want of an occa-
sional meal, violence to his mother was the immediate cause of
his being sent to the asylum. He was admitted in a state of great
raggedness and filth.

On admission, a systematic examination was made, with the
following results : —

1. Physical Peculiarities. — ^Height, about 5 feet 5 inches; de-
velopment of body good ; bones large ; muscles not bulky ; limbs
well formed ; cavities ample and symmetrical ; habit of body slovenly ;
stoops, and stands awkwardly; bodily condition low. Cranium
small in every dimension, but symmetrical and proportionate;

VOL. X.— NO. IV. 2 T

324 DR m'LEOD^S case of degeneration [OCT.

skeleton of face strong ; snperciliaiy ridges and cheekbones promi-
nent; jaws large: ossa nasi well developed; palate broad; teeth
large, regular, and well shaped, several decayed or lost ; posterior
molars of upper jaw imperfectly developed; a greater amount of
decay in the teeth of the upper than the lower jaw, and on the left
than right side. Ears very large ; peculiar in shape, and unequal
in size ; left ear larger than the right in eveiy dimension ; its axis
also more oblique; cartilage of pinna hard; dilated capillaries
visible on the surface. Eyes deeply placed in orbits; aperture
small ; lids normal ; conjunctiva ana cornea healthy ; irides hazel ;
pupils equal, regular, and moderately dilated. Skin wrinkled;
complexion coarse ; facial capillaries dilated ; no dragging of fea-
tures to any side ; hair coarse and red ; testes small, — right smaller
than left.

2. Chneral Health and fimction of body good ; appetite voracious :
digestion and assimilation good; circulation feeole; heart and
lungs found healthy on physical examination.

3. Mental PecuiiarUiea. — Mental condition generally of a very
degenerate character ; faculties rudimentary, and ill developed.

A careful analysis gives the following result : —

I. Presentative Faculties. — Patient appears to acquire and retain
a very imperfect, vague, and general impression of objects, persons,
and events, with which he is and has been in relation. The
number of these which stimulate to any kind of manifestation, or
operate as motive to action, awaken desire, exertion, or emotion,
are very few, and these are familiar, immediate, and in intimate
relation with his body and its requirements.

1. Sensation is normal all over the body, apparently neither
exalted nor depressed over any particular area. Titillation, pinch-
ing, or infliction of discomfort or pain, cause emotion, and effort to
escape ; no resentment, unless severe,

2. Sensesy except that of vision, seem to be healthy. Is short-
sighted ; impressions conveyed by his senses don't appear to pro*
duce anv interest. He does not energise to bring them in relation
with objects, and is not stimulated by any except those relating to
his immediate wants, bodily safety, and comfort, or impressions of
a violent and unusual kind.

3. Perception appears to be limited as to subject, and vague as to
character. Does not appear to entertain any definite knowledge of
any object, person, or occurrence, which he has not been habituated
to by intimate association and constant repetition.

4. Attention and Apprehension are almost wanting. If spoken
to calmly he gives no heed, — ^neither seems to understand, nor
attempts any kind of response. Loud talking simpljr excites emo-
tion. A few words he seems-to understand the meaning of, or asso-
ciates with them some pleasure, significance, or kind of sensation.

6. Memory seems to be totally absent. There is no evidence of
its existence. He does not even remember the way to the water-

1864.] AND ATROPHY OF THE C£R£BBUM« 325

closet, thongh frequently brought to it Meal-times, and hours of
rising and going to bed, he is equally unconscious of. Certain im«
pressions arouse or stimulate a certain desire or manifestation which
resembled what he had given rent to before. This is all that can
be called memory.

II. Ideatitm^ or the process of thought, appears to be quite want*
ing. He does not say or do anything to any purpose, except feed
himself, when food is placed before him. No new impression begets
new expression or manifestation of any sort. (He has subsequently
been heard to say that ^' his mother had gone with another man ;
this was probably learnt from others, and was repeated whenever
his mother's name was mentioned.) He seems to possess no
notions, and comparison, abstraction, generalization, conception,
ima^nation, and judgment are quite out of question. Volition is
feeble and hesitant.

III. The Bepreseniative Faculties are veiy rudimentary. Repre-
sentations simple, few in number, and general.

1. His Posture is peculiar. He sits somewhat crouched, and
leaning forwards ; his shoulders bent, head thrust forward, and face
raised, turned a little towards the left : arms flexed. , He stands
in an awkward position, legs bent, and leet placed far apart

2. His Gestures and Motions are slow, slovenly, and feeble. He
is generally torpid. Mode of walking clumsy ; left foot seems to
be drag^a. He has no repeated gestures or gyrations.

3. His Expression is singularly meaningless. The only varia^
tions it is capable of are expressions of emotion, anger, joy, satis-
faction, pain, etc. His eyes are half-closed, eyebrows drawn
together, and upper lip raised in a sort of insignificant grin.

4. Speech is limited to a very few words and fragments of sen-
tences, which are uttered occasionally.

IV. Habits and Conduct, — His existence generally was found to
be almost purely vegetative. He was inoffensive and passive, sub-
mitted to the processes of cleaning, dressing, and imdressing, etc.^
without murmur. He fed himself when meat was set before him,
holding his spoon in a peculiar way. His desires were few, namely,
for food, defeecation, tooacco, and sleep ; if these were satisfied, he
was perfectly content. He conceived no attachments or antipathies,
and aid not incline to exert himself. Once or twice, when annoyed,
he became savage, and attempted to bite and kick, but not to strike.
He indicated when he wanted to go to the water-closet, but could
not find his way thither. He asked for tobacco, and would take a
pipe from any patient smoking beside him. He never became ex-
cited, or gesticulated, the only acute manifestation observed being
the expression of rage above noted. He seemed pleased to see his
mother when she visited him, but did not evince any active emotion.
He seldom wetted or soiled himself.

Progress and Termination. — ^Very shortly after admission he was
observed to take fits, which were of two sorts. — 1. Slight verti-

826 DR m'leod's c:a8E of degeneration [oer.

ginoos seiznrea, without conyulsions, occurring as he sat or stood,
aud sometimes occasioning a fall^ and frequently accompanied hy
slight dragging of features and turning of face to the right side.
They were of very short duration, required close observation to
detect them, recurred sometimes in rapid succession, and wero
soon recovered from. 2. True epileptic paroxysnis, of varying
severity, going through all the stages of unconsciousness, tonic
spasm, clonic spasm, and coma. The contractions and spasms
were observed to involve only the right half of the body, and all its
muscles. He generally fell on the right shoulder, never on his face.
The duration was short, and recovery rapid. During the early
part of his residence fits were comparatively unfrequent, being
mostly of the first description. He was benefited by the adminis-
tration of stimulants, ether, ammonia, etc., when slight fits succeeded
each other frequently. Latterly, the severer form became more
common, and he averaged three or four daily.

His mental condition and conduct continued exactly as described.
He became stouter and ruddier, and, with the exception of a slight
attack of diarrhoea, enjoyed uniform good health.

lat September. — Began to take fits at 9 A.M., and had an uninter-
rupted succession of them till 6 p.m. They recurred with great
regularity at an interval of a very few minutes. The convulsions
were limited to the right side of the body, on which he lay. Pulse
rose to 144 beats per minute; breathing became rapid. Face
flushed, and grew livid. He became very hot, and perspired. In-
tervening coma very profound. The course of a fit was as follows : —
He manifested a little uneasiness ; eyes turned to the right ; right
brow was raised; mouth dragged to right side; face paled, and
pulse became feeble and irregular. The right arm was now
raised, pronated, and flexed ; the thumb being included in the
fingers; the right le^ was also raised and flexed.; breathing was
interrupted^ and consisted of a few gasps. Eyes and facial muscles
twitched slightly, then the arms, and then the legs. The spasms
became more severe, and by degrees subsided by becoming less
frequent Face flushed and grew very livid. He frothed at the
mouth, drew a deep sonorous breath, snored, and whiffled, until he
was again seized. The pulse was now full, regular, and rapid^
140 to 160.

The means employed consisted of — 1. Subcutaneous injection of
M. iij. Tinct. Verat. virid. ; and, 2. Terebinthinate enemata.
These measures have been found of signal benefit in other similar
eases. The former did not produce its full physiolo^cal efiect
— (vomiting and reduction of rapidity — not force — of circulation).
The instrument was broken, and it could not be repeated. He
was much exhausted towards afternoon. He continuea free of fits
till 10 A.M.

2d. — Fits have occurred very frequently during the night, and
still occur with short interval and great severity. Pulse 108, weak

1364.] AND ATBOPHT OF THE CERSBBUM. 327

and flattering; respires very rapidly. Exhaustion pragressing.
To have Tinct. yalerian co.| 3j. eyery two hours. Seemed to
be rather restored by this drag, and took a little beef-tea. Fits
succeeded each other rapidly during the whole day. He became
manifestly weaker after each.

3d. — ]Sfo intenruption of fits during the night. Continue to seise
him eyery few minutes. Pulse 72, hardly perceptible. Respira-
tion 48, stertorous. Vital activity declining rapidly.

Lingered on till 4 p.m., when he died, immediately after a fit, of
pure exhaustion.

A Post-mortem Examination was held during the afternoon of the
succeeding day.

I. External Appearances. — Body well nourished; deep lividity
on dependent siutacea of trank and limbs ; post-mortem rigidity
present in slight degree; cutaneous veins distended all over the
surface; patches of congestion on thorax; right arm pronated,
flexed, and rigid ; thumb included within the fingers ; no cicatrix,
bruise, or surface abnormality.

II. Cavities and Contents. — 1. Cranial — (a.) Scalp thick and
congested, adhered more closely than usual to the surface of the
skull ; (b.) Surface of cranium smooth ; ramiform congestion seen in
patches ; cranium short, narrow, and low ; deficient in every dimen-
sion, but symmetrical and well shaped; sutures well closed; no
hollow or ridge alone their line ; bone much thickened ; greatest
thickness ^ inch, smallest j'v^ average /,. No condensation ; dipl5e
and internal surface much congested ; osseous development strong ;
processes and prominences well pronounced.

Capacity of cranial cavity veiy small. Measurements at the
plane of division gave the following result: — Length, 6^ in. ; breadth,
at 1 in. distance from inner frontal edge, StV in. ; at 2 m., 4^ in. ; at
3 in., 4tV in. ; at 4 in., 4tV ; at 5 in., 3f in. Greatest breath, at 3^
in.. 4ii. in.

The occipital depressions were unequal, the left being the deeper.
The cerebellar hoUows were symmetrical and deep. The foss» of
the middle lobe were also unequal.

An accurate cast was taken of the interior of the cavity, which
gives the following results when compared with another of the
cranial cavity of a well developed subject, J. H.

The following measurements show Uieir respective size and
capacity : —

J. M.

J. H.

1. Horizontal circumference of whole mass,

174 in.

20

2.

of right lobe,
of left lobe, .

81 .

lOj

3.

9 ^

10

4. Vertical (tranBverse)

of whole,

14| ^

16

5.

of right lobe,
of left lobe, .

n^

8

6. ... ...

• 7*.

8

7. ... (ant. post.)

of right lobe,
of left lobe, .

lU^

13

8. ... ...

llj^

12i

Amount of water displaced,

• . . •

30 oz.

56 oc.

328 DR Mcleod's case of degeneratiox [ogt*

A series of transyerse diameters at a similar level of each, namely,
a horizontal plane passing through the most advanced points of the
occipital and frontal lobes, and measured from points at inch dis*
tances on the circumference with callipers, gave the following re*
suit, commencing anteriorly : —

J. M. J. H. J. H. J. H.

1. ... 3J 31

5.

4

6i

6.

... 2f

4i

7.

0

3i

2. ... 44 4|

3. ... 4i 5

4. ... 4i 6A

The outline of this plane was more ovoid and pointed at each end
in the case of J. M. ; the frontal extremity being in the other
subject blunt and broad.

Long diameter of riffhthemiBphere, ....

of len hemisphere, . . .

From point of occipital to point of middle lobe, right side,

left side,
From point of frontal lobe to most posterior
Bur&ce of cerebellum, .... right side,

left side,

Vertical radii taken fix)m the hollow formed in the cast by the
posterior clinoid processes to points at 1 in. distances of the greatest
vertical circumference of each hemisphere gave the following result,
commencing anteriorly at the point of the frontal and ending at the
point of the occipital lobes : —

J. M. J. H. J. M. J. H.

Right. Left Right and left

J. X.

6^ in.

J. H.

6J

6|»

6*

41'

H

6i»

H

61 ,

6i

8J'

H

Bight.

Left.]

1.

... 2\

n

2.

... 2«

2*

3.

... 2«

2H

4.

... 3*

3tV

6.

... 34

3^

6.

... 341

3il

7.

4

4

3*

3H

!'»
4A

8. ... 4 4 4VW

9. ... 4 4 4tV
10. ... 3VV 31 4i
U. ... 0 0 4*

''"d^s^;}^ 3, 3t

These figures sufficiently explain themselves. On comparing the
profile of the two casts, the greater acuteness of the frontal extrem-
ity, the more circular outline of the smaller cast, and the very slight
projection of the occipital lobe beyond the cerebellum, are the most
remarkable circumstances. In jl M. the right occipital lobe did
not project so far back as the left.

(c.) I)ura mater slightly adherent to internal surface of cranium ;
membrane much thickened, especially over the Sylvian fissure,
where it was ^ in. in thickness. The longitudinal smus was occu*
pied with firm fibrinous and dark sanguineous coagulum. It was
penetrated abundantly on each side of this sinus by arachnoidean
villi. A small quantity of fluid existed beneath the membrane.

(rf.) The arachnoid was considerablv opacified. A large amount
of sero-gelatinous fluid existed beneath it. This was collected into
two deep wells over the frontal and occipital lobe of the right side,
and a third collection of fluid existed on the left frontal lobe, oppo-

1864.] AND ATROPHY OF THE CEREBRUM. 329

site to the more anterior of the former : no convolutions conld be
seen here. Adhesions existed between the applied surfaces in the
mesial fissure.

{e.) The pia mater was much congested, both arteries and veins
being distended with dark blood. Distribution and coats of both
healthy.

Carotids quite healthy; equal in calibre; equally filled with
blood, and giving off the same number and size of branches.
Basilar artery large ; vertebrals e<iual and weU sized. Ventricles
contained little serum ; structures displayed on opening them healthy.

Commissures normal; soft commissure large. The posterior
comu on each side ran deep into the posterior lobe of the brain,
curving inwards beyond the internal perpendicular fissure. Hip-
pocampus minor, corresponding internally to the included convolu-
tion of that fissure large and prominent. Corpora striata and optic
thalami equal in size and normal in structure. Hippocampus major
normal.

(/.) The whole cerebral mass weighed .... 34| oz.
The cerebellum pons and medulla oblongata together, 6^ »

Cerebrum, 28^ ^^

Right lobe of cerebrum, 13l m^

Left, : 15 ir

Each lobe of the cerebellum weighed, . . . 2\ j^

Whole mass of cerebellum, ^i "^

The following proportions result from these figures : —

Cerebellum, pons varolii, and medulla oblongata to whole

mass, as 1 to 5'5

The same structures to the cerebrum, • . as 1 to 4*5

Cerebellum to whole mass, . • , • • as 1 to 7*7

to cerebrum, as 1 to 6*3

to right lobe, as 1 to 2*9

to left lobe, as 1 to 3*4

The convolutions of the cerebrum were much atrophied. Those
of the middle lobes and basal aspect were well sized, the superior
frontal and occipital gyri being excessivehr wasted. The nature
and extent of this atrophy will appear from the more detailed
description of the convolutions given below.

The substance of the brain seemed to be healthy. The cere-
helium, which was examined with very great care, was found to be
normal in size, weight, configuration, and structure. The sur-
rounding membrane was congested, and vessels throughout the
or^n dilated.

The pons varolii, medulla oblongata, and cerebral nerves were
found to be exceedingly health^.

2. Thoracic Cavity. — Capacity and configuration good. Car-
tilages of ribs not ossified. Very slight pleural adhesion on left
side, more general and firm adhesions on right side. A small
quantity of sanguineous fiuid existed in each pleural cavity.

(a.) The right lung weighed 26 oz. Its lobes were glued to each
other; middle lobe small. Anterior edge veiy emphysematous.

330 DR Mcleod's case op degeneration [oct.

Posterior portion of upper and whole of lower lobe strongly con-
gested and solidified, with occasional apoplectic patches. Substance
dense ; colour deep red. A frothy sanguineous fluid oozed off the
surface. The vessels emitted a dark fluid, and a red froth issued
out of the bronchi, which were of a deep colour internally. The
lung was much pigmented, and a few cretaceous and caseous nodules
existed in the apex.

(J.) The left lung weighed 22 oz. Its condition was in every
respect similar to that of me right lung.

(c.) The pericardium was healthy. There was a good deal of fat
deposit around the heart, which was moderately distended. The
right cavities contained a firm fibrinous clot and small quantity of
dark blood. Valves healthy ; walls thin, composed mainly of fat
Left cavities more contracted, contained also a small amount of
fibrinous clot. Valves healthy. Posterior flap of mitral valve
rather atrophied. Walls fatty. No atheroma of aorta. Oigan
weighed 11 oz.

3. Abdominal Cavity. — ^Walls of abdomen contained a consider-
able amount of fat, subcutaneous and subperitoneal. Peritoneum
healthy, and omentum and mesentery contained a large amount of
fat Appendices epiploicse of considerable size.

(a.) Stomachj etc, — Small and large intestine healthv and mode-
ratelv filled. No accumulation of faeces. A terebinthinate odour
could be perceived as far as the coecum. Mesenteric glands healthy.

(i.) Liver weighed 46 oz., very fatty and considerably congested.

\c!) Spleen weighed 6 oz., firm and healthy.

{cL) Kidneys weighed each 4^ oz. Configuration and structure
healthy; slightly degenerated around the base of the pyramids.
Supra-renal capsules and pancreas healthy.

Anatomy of the Cerebral Convolutions, — In describing more
minutely the anatomy Qf the cerebral convolutions, I shall follow
the system and nomenclature of Gratiolet,^ which, if not the most
philosophical and simple possible, is at any rate the best known
and most frequently emploj^ed.

I. The Central tjobe^ or island of Reil, which occupies the floor of
the Sylvian fissure (S), and interdigitates with the columns of the
marginal convolution of this fissure, is almost exactly symmetrical,
and of normal size and shape. It seems to be rather more super-
ficial and easily seen in the fissure than in a well-developed brain.

II. Temporo-Sphenoidal Lobe, — This lobe is also large ; its con-
volutions well sized and rounded ; its sulci deep ; and the symmetry
easily discernible. It consists of five convolutions, starting from a
common origin at the point of the middle lobe, and diverging some-
what, proceeding backwards and upwards to join convolutions of
the occipital lobe. Thev are arranged circularly and communicate
by digitations, and by both sunk and superficial plis de passage.
They are : —

^ Memoire sar les Plis Cerebraux de FHomme et des Primates.

1864.] AND ATSOPHY OF THB CEREBRUM. 831

1. Superior Temporal Ccmvolutions (plis marginaux Buperiean, 7^ 7,
figB. 1 and 2) J forming the posterior lips of the Sylvian fiasores, are
▼erj Bjmmetricaly and terminate bj joining the lobules of the
marginal conrolutions (A, A, figs. 1 and 2).

2. Middle Temporal ConvoluHone (8, 8, Figs. 1 and 2).— These con-
Yolations are broader — are limited on each side by deep Bulci — and
become deeply indented by sulculi as they ascend, becoming broader
and split up into several gyruli. The most anterior of these are the
curved convolutions (Plis courbfes, 6, 6, Figs. 1 and 2). The more
postericf join the occipital convolutions, and form the third and
fourth so-called plis de paeeage^ where they connect the two lobes
(y, i, Figs. 1 and 2).

3. Infirior Temporal Convolutions (9, 9, Figs. 1, 2^ 3, and 4) arise
in common with tne preceding, and run parallel with these along
the base of brain, reaching to the occipital lobes, and becoming
continuous with some of their convolutions. They are bounded on
each Bide by sulci ; those of each side symmetrical and unatrophied.

4. Internal Temporal Convolutions (6, 6, Figs. 3 and 4).-^The8c
are smaller than the last, and do not reach the point of the lobes,
ending in a point or joining those above it.

5. Middle Internal Temporal Convolutionsy or Lobule of the Hip^
pooampus (5, 5, Figs. 3 and 4). — Th6se are the most superior in-
ternally ; are bounded above by the fissures of the hippocampi^ and
end at the point of the occipital lobes. They are large, symmetrical,
and well developed.

III. Occipital Lobe. — The convolutions constituting this lobe
are considerably narrower in the right hemisphere, the superior
being atrophied. They are, in reality, short curved convolutions
crossing transversely between the widened extremities of the tem-
poral convolutions. On the internal face of the lobe, between the
internal perpendicular fissure and the fissure of the hippocampi, is
a triangular mass of small convolutions — the internal occipital lobule
(3, 3, Figs. 3 and 4). This is also smaller on the right side.

IV. Parietal Lobe. — This lobe consists of two convolutions
(first and second ascending), two lobules, the lobule of the second
ascending, and marginal: the curved convolution, and several
smaller annectent convolutions, or pUs de passage.

1. The First Ascending Parietal Convolution (4, 4, Figs. 1 and
2), lying in iront of the fissure of Bolando (R. R, Figs. 1 and 2),
and extending upwards and slightly backwaros from the margin
of the Sylvian fissure to that of the great mesial fissure, is de-
cidedly narrower, more plicated, and shorter on the right side.
Otherwise, they are very symmetrical.

2. The Second Ascending Parieted Convolution (6, 5, Figs. 1 and 2),
lying behind the fissure of Rolando, and running parallel to the
last, is also less massive on the right side.

Its lobule {5% Figs. I and 2), formed by the junction of a pro-
cess from its posterior surface, near the superior extremity, and an

VOL, X.— NO. IV. 2 u

332 DR Mcleod's case op degeneration [oct.

annectent or bridging gyrulus, or pK de passage^ bom the apex of
the marginal lobule of the Sylvian fissure, is also more insignifi-
cant on the right hemisphere.

3. The Lobule of the Maruinal Convolution of the Sylvian Fissure
(A, A, Figs. 1 and 2), which is in reality the plicated bend of that
convolution at the apex of the fissure, is less bulky on the right
side, and reaches nearer the margin of the hemisphere (about f in.).

4. The Curved Convolutions (6, 6, Figs. 1 and 2), proceeding from
the posterior aspect of this lobule, and bending sharply round the
apex of the scissure parallel^ becoming continuous with the middle
temporal gyrus, are very equal, symmetrical, and comparatively well
developed.

6. The Annectent Bridging Convolutions^ or Pits de Passaae, are as
follows : — (a.) A small, short gyrulus proceeding from the lobule
of the marginal convolution to that of the second ascending. This
is superficial, well developed in the left hemisphere ; short, shrunk,
narrow, low, concealed, hard, yellow, and devoid of nervous matter
on the left. (B, Figs. 1 and 2.)

(i.) A similar gyrulus close to the last, passing from the apex
of the pit courb^ to near the insertion of the last. An eicactly
similar contrast obtains in this case. (B, Fig. 1.)

(c) A deep, narrow convolution (a. Figs. 1 and 2) separating
the internal (I, I, Figs. 3 and 4) from the external perpendicular
fissure (P, P, Figs. 1 and 2), and connecting the parietal and
occipital lobes along the margin of the hemisphere, more strictly
the quadrilateral lobule, and the internal occipital (1 and 3, Figs.
3 and 4). This on the left side is ftiU, round^ soft, superficial,
though rather narrow. On the right it is a simple transparent
fibrous lamina, without a vestige of nervous substance. It is not
superficial.

(d.) A broader convolution (£, Figa. 1 and 2), passing below and
rather behind the latter, from the ©Af courb^ to the occipital lobe.
On the left side it is broad and full; on the right, hard, contracted,
low, and narrow, in a state of degeneration, wasting, and indura-
tion, similar to the rest on this side. Two gyruli below this
form the remaining ^Zw de passage (J, Figs, 1 and 2).

V. Frontal Lobe. — This most important lobe consists of a
series of narrow convolutions, extending between the marginal con-
volution of the fissure of Sylvius and that of the hemisphere.
There is more want of symmetry in their number and distribution
in man, than of any other portion of the brain. They have been
divided artificially by Gratiolet into three stages, and in the lower
brain this is easily verified, but in man the arrangement seems to
be this, — that a variable number of narrow pits de passage run
obliquely upwards and forwards from one marginal convolution to
another, and are connected themselves by a series of annectent gyruli,
the most posterior of these coming from the first ascending parietal.

On general comparative inspection, the sharpness, smaUness, and

isdi.]

AND ATROPHY OF THE CEREBRUM.

333

narrowness of the right frontal convolution is most remarkable.
Both are much atrophied, the middle and superior stages most
completely ; but on the right side this condition is extreme, and in
place of the superior stage, a hollow exists, with small, hard, cord-
tike convolutions running along its floor.

The orbital lobule (1") and superior portion of the superior frontal
stage (S'', Figs. 1 and 2) maj be considered as a portion of the
. marginal convolutions of the hemisphere and great mesial fissure
(external aspect of 2, 2, Figs. 3 and 4). and are not much affected ;
the latter being atrophied slishtlj on tne right side. The charac-
ter of the remaining ridges is minutely exhibited in the following
description, commencing posteriorly : —

1. First Frontal Ascending. (3, Figs. 1 and 2.)

LEFT BIDE.

The commencement and ter-
mination is superficial, and its
middle portion concealed and
sunk. It leaves the fore border
of the anterior parietal by a
double root ; the lower, superfi-
cial J in. broad ; the upper, deep
and narrower. There is a deep
sulculus between them. There
is another sulculus above, and
in front of this, on the gyrus.
Immediately in front of this the
gyrus disappears and becomes
completely atrophied. It is J in.
high, and Vv in. broad and con-
tinues in this condition for f in.
From the termination of this por-
tion it sends forwards a sunk
ridge of the same character, ^ in.
long, which communicates with
the gyrus in front of it. The
remaining portion gradually rises
into view, is J in. broad, J in.
long, and is inserted into the
great marginal convolution. Su-
perior to it there is a broad deep
smooth sulcus, and inferiorly the
sulcus is more irregular and
crossed by the gyrulus described.

2. Second Ascending Frontal. (2, Figs. 1 and 2.)

RIGHT SIDE.

The convolution on this side has
two roots, one proceeding from a
sharp bend forward of the anterior
parietal, and another from the
mar^nal gyrus of the fissure of
Sylvius. They are both small,
narrow, and atrophied. There
is also an atrophica communicat-
ing ridge going forward from the
junction of these. On this junc-
tion is situated a pea-like nodule
of cerebral matter. The rest of
the gyrus is 1 in. long, ^ in.
broad, and high ; slants forward
as an irregular cord along the
fioor of the smooth, deep chasm,
which separates the marginal
convolutions of the great mesial
and Sylvian fissures.

The convolution is completely
atrophied with the exception of
the nodule described ; hard,
rough, and of a reddish colour.

BIOHT BIDE.

This atrophied ridge rises
from the marginal convolution

LEFT SIDE.

This convolution is about 1^
in. long, and parallel to the last,

834

DB Mcleod's case of degeneration

[OCT.

of the fissure of Sylvius, and

Sroceeda as a narrow, nodulated,
iminishing cord, parallel to and
beneath the trunk of that ^yrus ;
after giving oflF a short ridge of
communication to the gyrulus
in front of it, it aAoends perpen-
dicularly, and crosses the chasm
which separates the great mar-
ginal convolution from the mar-
final convolution of the Sylvian
ssure. This portion of it is
iin. long, ^ broad and high,
t its insertion it becomes a^ain
thicker. It contains very httle
roper cerebral matter, being
ard, shrivelled, and contracted.

f

hi

communicating with it by the
atrophied rid^ described, and
with that in front by another, ^
in. long and ^ in. broad. It is
very narrow at its commence*
ment, about ^ in., and continues
so for ^ in., at which point it is
most completely atrophied, and is.
joined here by the communica-
tion from behind. It then be-
comes broader (^ in.), and goes
to be inserted in the great mar*
ginal convolution, giving off, at
the commencement of its broad
part, a small ridge of communica-
tion with the gyrulus anterior
to it. It has smci on each side
of equal depth, and crossed by
the ridges notea.

3. Third Ascending Frontal (1, Figs. 1 and 2.)

RIOHT SIDE.

This gyrus is very similar to
that of the other side, and is as
complex. It has two roots of
origin, one superior, superficial,
and broad, and one inferior, sunk,
and narrow, with a deep irregu-
lar sulculus between, it has a
narrow insertion into the great
marginal convolution. The body
is broad, irregular, and dimpledf.
It has a third root and origin
which also receives the communi-
cating ridge from behind.

LEFT smE.

This gyrus is triangular in
form, swings by a broad two-
legged oase from the gyrus of
the Sylvian fissure. It is inserted
by a point into the great mar-

fmal. Its direction is almost
orizontal. There is a deep
sulculus between the legs, and
another in front of that The
upper leg of origin is sunk, nap-
rower than the lower, and is
joined by the communicating
ridge from behind. Above is a
deep sulcus, with columnated
sides and broad floor. Below it
is a sulcus separating it from
the commencement of the great
marginal gyrus, and not so broad.

VI. The internal aspect of the Fronio-Parietal Lobes (Figs. 3
and 4) presents no abnormality, except the great shrinking and
atrophy of the quadrilateral lobe on the right side (!', Figs. 3 and
4). The disparity in size is very striking. The other convolu-
tions, marginal (2), and that of the corpus callosum (1), are bulky
and symmetrical.

The foregoing description exhausts the geography and indicates
the peculiarities of the convolutions. The more normal and better

1864.] AND ATROPHY OF THE CEBSBBUtf. 385

developed have been described generally, and the atrophied more
minutely.

Besum£.

I. Convolutions unatrophiecL

1. Central lobe of each hemisphere.

2. Temporal conyolutions of each hemisphere.

3. Three occipital of left side, and two lower occipital of right

hemisphere.

4. Ascendmg parietal convolations.
6. Convolutions of corpus callosum.

6. Marginal convolution of left hemisphere.

7. Qaaarilateral and internal occipital lobules of left hemi-

sphere.

8. LoDule of marginal convolution of fissure of Sylvius, and

pli courb^ of Doth, and lobule of second ascending of left.

9. Orbital lobule, and lower frontal stage of each.

II. Convolutions partially atrophied.

1. Superior occipital of right hemisphere.

2. Quadrilateral lobule of right.

3. Inferior pli de jKtssage of right.

4. Lobule of second ascending of right.

5. Mar^nal convolution of mesial nssure of right.

6. Middle of right and superior frontal convolutions of left.

III. Convolutions completely atrophied.

1. Three annectent convolutions of right

2. Middle and part of superior frontal stage of right.

CoMMBKTART. — ^The function of a commentary upon a case being
to state in general terms the facts more minutely detailed in the
text, and to bring these thus ^neralized into relation with ^neral
principles or other cases, I shall content myself mainly with the
former of these processes, pursuing the division followed in the
detail of the case as the most simple and natural.

1. As to the etiology — ^hereditary predisposition, as far as evidence
exists, may be eliminated, except that on the assumption of its
absence, convulsive derangement (mania of musculo-motor centres)
affected such a large majority, 7 to 2, of the issue of the (cerebrally)
healthy pair. The cause " assigned " and occupying the greatest
prominence in the history, is a purely physical one. Up to the
period of attack by the typhus fever, the subject was developing,
physically and psychologically, satisfactorily. Then occurred an
event causing defective nutrition of the brain, from contami-
nated and deficient supply and excessive waste of substance with
little or no repair. There may have been, coupled with this, a
presumed tendency to imperfect development of the nerve centres.
At any rate, at this point of the life history (thirteenth year), the
development of the brain was arrested, and a process of degeneration
and atrophy set in with the effects displayed in the detail. It is

336 DR Mcleod's case of degeneration [ocr.

also remarkable that this occurred before or during the period of the
third dentition ; that, in fact, the perfecting of organization and
action which that process expresses was obtained neither as to body
which was infirm, and to a certain extent deformed, organs whicn
were small and degenerated, — brain which was small, simple, and
imperfect — nor the teeth themselves, which were abnormally small
or wanting.

2. As to the condition of the patient at the thirtjr-second
year, and his subsequent history, his physical organization was
fair, and functional condition in moderately good state. He was
small, awkwardly built, slovenly in motion, but of arthritic diathesis,
and in possession of good general health. His cranial development
was meagre as to the capacity of the cavity, strong as to the features
of the osseous walls. The testes were ill developed. The body
generally exhibited no asymmetry; but the awkward misshapen
ears were unequal ; the left (that on the same side with the sounder
hemisphere) being larger. The " wisdom teeth " of the upper jaw
were imperfect, that on the right side (the side of tlie worse hemi-
sphere and smaller testicle) being wanting; and while the teeth
of the upper jaw, as is usual, were most decayed, there was a
greater amount of caries and destruction on the left side, the side
opposite to the more atrophied brain. The psychological condition
of the patient was one of pure and profound dementia ; that variety
of dementia whose substantial cause is deficient substratum. The
impairment of every faculty except the most degraded in the scale
was great, but his state can bear comparison with no animal lower
in the scale. He was superior to all in the fragmentary capacities
of impression, expression, and adaptation which he had, which, even
in their broken and impaired state, had a greater likeness to the
human than any other being ; ^ut he was inferior to all, inasmuch
as he was unable to provide for the continuance of his own life
and comfort, and must have starved, and lived in nakedness and
filth, if others did not supply his wants and minister to him. He
had too little nerve substance for an adult human being, but too
much for any other animal. He exhibited as a mode of life the
phenomena which are produced in animals when portions of their
brains are removed, considering their respective characters and
conditions of life. The case is singularly satisfactory, in that the
pathological conditions are capable of fully and easily explaining^
the psychological peculiarities. The epilepsy also, which was such
a prominent feature in the history, has also a rational explanation.
It was a pure example of what 1 believe to be more common than
is generally allowed, — ^namely, cerebral epilepsy. There was no
disease of cerebellum, medulla oblongata, pons, or ganglia, suffi-
cient to account for it, — it alternated with cereoral symptoms, vertigo,
and loss of consciousness, and was unilateral, the convulsions
occurring on the side opposite to the larger mass of nervous matter.
The other side was semi-paralyzed. What aroused the (compara-

18«.] AND ATBOPHY OF THE CEREBRUM. 337

lively) excessive hemisphere into excessive action cannot be easily
explained otherwise than by stating that it was the mode or ex*
pression of life of the nerve centres constituted as they were. At
the last the morbid action assumed a rhythm and repetition which
aeems to declare that a degree of inequality and disproportion was
obtained which rendered tranc^uil or static existence impossible, and
unilateral convulsions accordingly appeared with the regularity of
the respiratory or circulatory action proceeding downwards from the
muscles, whose centres are more related to the psychical centres to
those more remote from these.

3. As to the morbid anatomy of the body, the autopsy revealed
an advanced state of necrobiosis of several important organs, fatty
degeneration of the liver, kidneys, and heart, and pigmentary de-
generation of the lungs ; a state of age of these organs out of pro-
portion or correspondence with the age of the individual, a process
of natural or vital decay occurring in the well developed and
healthy far on in life, when tissues and organs are nrone to assume
organic forms low in type, or inorganic forms. In this ill-developed
subject these changes were far advanced when structure and func-
tion should have been in greatest perfection. The mode of degenera-
tion of the brain, which will receive special investigation, appears
strongly to confirm the notion that tnroughout it contains con-
nective tissue corpuscles, which, here, seem to be the only remaining
constituent.

4. As to the brain itself, its small size and lightness are the most
prominent facts. Next comes the inequality of the hemispheres,
the atrophy, and the particular portions atrophied. These are
minutely set forth in the detail. The most interesting fact of the
case is, that those masses of central nerve substance which occur
low on the nervous system, cerebellum, medulla oblongata, pons
varolii, central ganglia, and basal convolutions, were as large and
sound as the same portions of a healthy brain. The most elevated or
abstracted ; the centres of the most refined, remote, and complex
cerebral processes were those involved in the maldevelopment and
wasting. The symmetry of the convolutions was remarkable, but
the symmetry of the morbid process still more so. The case also
has an interesting bearing upon an eminent discussion as to the
classificatory value of the brain which occupied the attention of
scientific men last vear.

Dr George Kolleston, in an excellent lecture delivered at the
Royal Institution, summarizing the affinities and difierences between
the brain of man and the brains of certain animals {Med. Times and
Oazettey 15th March and 22d February 1862), says : " The doubly,
and more than doubly greater weight, the doubly greater coi-pus
callosum, the first and second pit de paasaqe (the bridging con-
volutions), and those complexly convolutecl frontal lobes, are, I
believe, the four points in which the human brain asserts its supe-
riority over that of the ape."

338 DEaENERATION AND ATBOPHT OF TH£! CEREBRUM. [OCT.

In this case, the cranial capacity and weight are greatly deficient
— ^the so-called bridging convolutions atrophied and sunk, and the
frontal convolutions still more so. The degree of overlapping of ^

the cerebral lobes over the cerebellum is exhibited bj the casts,
which show a great shortcoming in this respect ; and it was found
that the posterior horn of the lateral fissure and the notable hippo^
campus minor were both considerable features.

FiQ. 1. External Surface of Left Hemisphere— Exact Size.
References after GrcMUU

5, S, S. Fissure of Sylyios.
R, R, R. Fissure of Rolando.

Py p. External perpendicular fi&sure.

1. Inferior frontal stage.
: \\ Orbital lobule.

2. Middle frontal stage, partially atrophied.

3. Superior frontal stage.

Z\ External aspect of marginal convolution.

4. First ascending convolution.

6. Second ascending convolution.

6^ Lobule of the second ascending convolution.

6. Curved convolution — pli courbe.

7. Inferior marginal or superior temporal convolution.

8. Middle temporal convolution.

9. Inferior temporal convolution. ^

10. 11, 12. Superior middle and inferior occipital convolutions.

A, A, A. Lobule of the superior marginal convolution. •)

B, B''. Small annectent or bridging convolutions connecting 5

with A and 6.
«. First bridging convolution— pli de passage.

C, Second do. do.

7. Third do. do.
4. Fourth do. do.

Fig. 2. External Surface of Right Hemisphere— Exact Size.

References as for Fig. 1.

Almost complete atrophy of middle and superior frontal stages,
and superior bridging convolutions displayed.

Fig. 3. Internal Surface of Left Hemisphere.

F, F, F. Fissure of fronto-parietal lobe.
I, I. Internal perpendicular fissure.
H, H. Fissure of the hippocampi.

1. Convolution of the corpus callosum — gyrus fomicatas.

2. Marginal convolution.
V» Quadrilateral lobule.

8. Internal occipital lobule. ^'

4. Inferior internal pli de passage.

5. Superior internal temporal convolution.

6. Middle internal temporal convolution.

9. Inferior temporal.

10. 11, 12. Occipital convolutions.

Fig. 4. Internal Surface of Right Hemisphere.
References as for Fig, 3.

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1864.]

PRELIMINABY AND PBOFESSIONAL EDUCATION.

339

INFORMATION REGARDING THE REQUIREMENTS IN PRELIMINARY

AND PROFESSIONAL EDUCATION OP THE VARIOUS

LICENSING BODIES.

At the meetiDg of the General Council of Medical Edncation and Registration

held last May, the following Report from the Select Ck>minittee on Education

was laid before the Council : —

" The Committee appointed on 3d May, relative to professional edncation,
have to report that they have carefully considered all the points referred to
them by the Council.

" They understand the object of the Council to be, that this Report should
comprise a statement of all recommendations as to professional education,
arising from the late discussion in Committee of Council, as to which there
appears to be a general a^eement in the Council, and which mav be sent forth
this session as recommenaations to the several licensing bodies of the kingdom,
or suggestions to them for information. The Committee trust that they have
kept this object steadily in view in the following recommendations : —

I. REGISTRATION.

^ The Committee recommend under this head, that the regulations proposed
in the Report of the Sub-Committee on registration be adopted, with a slight
change in No. 3 of these Regulations, which will then stand as follows : —

" 1. That the registration of medical students be placed under the charge of
the Branch Registrars.

" 2. Thai every student be registered at the commencement of professional
study.

" 3. That the several licensmg bodies be reouested to furnish to the Branch
Registrars, at the beginning of January annually, a Ust of students who have
been registered for the first time during the preceding year, according to the
subjoined form : —

Form o/Eegister of Medical Students.

Name.

AgelMt
BirthdAf.

Prelim. "Ryi^tntn- and Date.

DeteofRefistratton.

PlatseofBtody.

" 4. That from the lists of the licensing bodies, each Branch Registrar shall
frame an accurate register of medical students of the division of the United
Kingdom of which he is registrar.

" 5. That the register of each licensing body be closed within fifteen days
after the commencement of each session or term.

" 6. That the register of medical students so prepared by the Registrars,
after examination by the several Branch Councils, be transraitted to the Registrar
of the General Council, who shall, under direction of the Executive Committee,
prepare and print an alphabetical list of all registered students, and supply a
copy of this authorized list to each of the bodies in Schedule (A) to the Medical
Act.

'* 7. That the several licensing bodies be requested, after October 1868, to
abstain from examining any candidate for license or degree whose name does
not appear on the authorized list of medical students, as having passed the
preliminary examination in Arts, or whose name is not already on the " Medical
Kegister."

*' 8. That the Branch Councils be desired to take means to make these
regulations known to the medical students at the various Medical Schools.

'* 9. That exceptions allowed by the licensing bodies to any of the preceding
regulations as to registration, together with the reasons for such exceptions, be

VOL. X. — ^NO. IV. 2 X

340 REQUIREMENTS IN PRELIMINARY [OCT.

transmitted in a separate list, to the Branch Council of the part of the United
Kingdom in which they have been granted.

II. AQE FOB LICENSE TO PRACTISE.

" The Committee, after having taken into consideration Mr Romsey^s notice
of motion, — that the earliest age for obtaining any license to practise medicine
or surgery should be twenty-two, — ^recommend that the Resolution 17 of the
Recommendations of Council in 1863 be adhered to in the following shape ; —

" 1. That the age of twenty-one be the earliest age at which any professional
license shall be obtained; and that the age shall, in all instances, be duly
certified.

{The above recommendaHoni of the Committee have been adopted b^ Ae ComcU;
the following have still to be comidered,)

m. PROFESSIONAL STUDY.

" The Committee have taken into consideration the notices of motion as to
professional studv, y ven by Dr Thomson, Dr Parkes, and Dr Storrar, and have
come to the followmg recommendations, in which not only these gentlemeOi
but likewise every other member of Committee present have concurred : —

" 1. That no license be obtained at an earlier period than after the close of
the last winter session of four years of study, after the registration of the
candidate as a medical student.

" 2. That the course of study required for a license shall comprehend attend-
ance during not less than four winter sessions, or three winter and two summer
sessions, at a recognised Medical School ; and that evidence shall be produced
that the remaining period of the four years has been passed in the acquisition
of professional knowledge.

" 3. That, in reference specially to Dr Parkes* notice of motion, as to dura-
tion of sessions and of courses of lectures, the r^ulation of the duration of
sessions, and the extent and duration of courses of Isctures and instruction, be
left for the present to the several licensing bodies.

** 4. That it be recommended to the several licensing bodies that the courses
of instruction required by them should* be framed in such a manner as to secure
a due share of attention, both to preparatory branches, and to those more
strictly connected with the Practice of Medicine and Surgery ; and that it be
suggested accordingly to these bodies, that their regulations should be such as
to prevent attendance upon lectures from interfering with hospital and clinical
study.

'*5. That, while avoiding for the present all other details, by which this
object may be attained, it be recommended, that no subject of lectures be en-
forced bv regulation, to be attended oftener than once.

" 6. That the Council intimate, that they will view with approbation any
encouragement held out by the licensing bodies to students to prosecute the
study of the natural sciences before they engage in studies of a strictly pro-
fessional character.

" 7. That the several licensing bodies be requested to furnish a short statement
of the mode in which their exammations are now conducted, whether by written,
oral, or practical examination, and of the length of time a candidate is under
examination in each or all of these ways.

IV. EXAMINATIONS.

" The Committee have considered the subject of examinations with peculiar
care ; which was rendered imperative by the proofs brought before the Council
in the late discussion on education, tluit the examinations of the licensing
boards, however conscientiously carried on under the present system, are not
always sufficient for their purpose. The subject is one confessedly of much
difficulty. The Committee have resolved to recommend: —

*| 1. That the licensing boards be advised to encourage the periodical ex-
amination of students at their several classes.

" 2. That the final examinations of the licensing boards be so carried on as

1664.] AND PROFESSIONAL EDUCATION. 341

to be an efficient test of the practical acquaintance of candidates with the
several branches of medical knowledge, and especially with the Practice of
Medicine and Surgerv.

** 3. That the professional examination for any license be divided into two
parts ; the first embracing the primary or fundamental branches of Medicine ;
and the second the branches directly connected with the Practice of Medicine
and Surgery ; that the former be not undergone till after the close of the winter
session of the second year of professional study ; and the latter, or final ex*
amination, not till after the close of the winter session of the fourth year of
such study.

" 4. That the examination in Chemistry, Botany, and Natural History may
be undergone at an earlier period.

" 5. That the professional examinations be conducted both in writing and
orally; and that they be practical in all branches in which they admit of
beine so.

"6. That the professional examinations be held by the several licensing
bodies, except in special cases, at stated periods, to be publicly notified.

<* 7. That returns from the licensing boaies in Schedule (A) be made annually,
on the Ist of January, and in the subjoined form, to the General Medical
Council, stating the number and names of the candidates who have passed their
first as well as their second examinations, and the number of those who have
been rejected at the first and second examinations respectively ; and that the
Registrar forward a sufficient number of forms, with a notice for their being
returned, in due time.

Form o/Bdum of Exandnaiumt, and their RemdU.

Paubd.

1 Rkjbctsd.

1st Examination.

Sd Examination.

II 1st Examination.

2d Examination.

No.

Mam«.

No.

Nam«.

No.

No.

T. BUPEBYI8I0N OF EXAMINATIONS.

'* So much has been truly said in the late discussions in the Council, as to
the duty which lies with the Council to carry out the enactments of the Medical
Act relative to the supervision of the examinations of the licensing boards,
that the Committee have felt a great desire to recommend some definite course
which the Council might at once pursue for establishing such supervision.

" They fear, however, that the Medical Act is defective in this respect, inas-
much as it has not contemplated either the great amount of time and labour
required to carry on a really effective su]^ervisiou of the ver^ numerous ex-
ammations of the licensing boards of the kingdom, some of which do not meet
for examination at the seats of the Branch Councils, or the amount of qualifi-
cations and professional position necessary to constitute a staff of efficient
visiters of examinations ; and, consequently, has omitted to provide the means
of remunerating them for their important services. But, notwithstanding this
obstacle, the Committee recommend that a trial of visitation be immediately
made, on such a scale as may be a guide to the Council for further regulations
on the subject, at a future meeting. For this end they recommend that the
Branch Councils be instructed severally to organize a set of trial visitations on
a scale which may enable them to report upon their success, the conditions for
efficiency, and the requisite means for rendering them adequately extensive.

VI. SUGGESTIONS FOR OBTAINING INFOBMATION.

"To these recommendations, which it seems to them advisable that the
Council resolve now to adopt, the Committee think it right to add others, as to
which the opinions of the licensing bodies and of the Meoical Schools connected

842 BEQUIBEMENT8 IN PRELIMINARY [oCT.

with them, should be requested in time for the consideration of the Council at
its next session, viz. : —

" 1. Whether, in the opinion of the licensing bodies, the commencement of

Erofessional study, by which the duration of it must be regulated, should be
eld to be only entrance on such study at a recognised Medical School.

" 2. Whether a " Medical School" may be better or otherwise defined than
as one where there is an opportunity of studying at a General Hospital, con-
taining at least eighty beds for patients, and also a teacher of Practical Anatomy
recognised by a ucensing body ?

" 3. Whether entrance on apprenticeship should be held as another way of
constituting the commencement of professional study ?

" 4. Whether the same privilege oe extended to pupilage under a registered
practitioner, who has charge of a union workhouse, a dispensary, or an hospital,
thoiu^h destitute of medic^ or surgical teachers?

'* 5. Whether any other mode of study may be similarly recognised as the
commencement of professional study ?

" 6. Whether, looking to the great extension of the primary or fundamental
sciences of Medicine during the last forty years, the subjects embraced in
courses of lectures on these sciences may not be better arranged and treated
than now; so that they may be made more applicable than they are at present
to the practical instruction of medical students, as distinguished from general
atudents ?

*' 7. Whether it be advisable or not, and if advisable, whether, and how, it
may be practicable to adopt, in part at least, the principle of ad eundem
examinations ; so that a candidate, who has been satisfactorily examined, in
part or completely, for any professional title conveying the right of practice,
ehall not be subject to re-examination on precisely the same branches by
another examining body, before whom he may appear as candidate for the
same, or a different, qualifying professional title?

" 8. Whether it be advisable and practicable, for the relief of candidates for
licenses from superfluous examinations, to establish in England, Scotland, and
Ireland, severally, a conjunct examining board, before whom candidates may
be subjected to a single series of examinations for the " double qualification^*
of physician and surgeon.

" 9. Whether it be desirable that the oral and practical parts of the profes-
sional examinations should be so conducted as to oe open to registered medical
practitioners and registered medical students.

" Lastly f — In conformity with the notices of motions by Dr Acland, the
Committee recommend the Council to appoint a Select Committee, to consider
and report at the next session of the Council, what are the subjects of examina-
tion which should be required of all students prior to commencing the pre-
scribed course of professional education, and what are the professional subjects
of examination which should be required of all candidates oefore they receive
the license to practise medicine, or surgery, or medicine and surgery.

With regard to some of these recommendations and suggestions we have a
few remarks to make.

It has been objected to the General Council, that hitherto they have done
but little to elevate the medical profession, and that they have not even
attempted to enforce their own recommendations. It must, however, be borne
in mind, that the Council is a somewhat unworkable body ; that the members
of it represent very different interests ; and that the powers they possess for
enforcing their recommendations are very limited. We are therefore prepared
to give them all credit for their good intentions, and must hope that the
various licensing bodies will, of their own accord, carry out such recommenda-
tions as meet with the general approval of the profession. With regard to
the judiciousness of the recommendations of the Council, as to the registra-

18«4.] AND PBOFESSIONAL EDUCATION. 343

tion of medieal stadents, and the age at which a liceoBe to practiae may ba
obtained, there can, we think, be little difference of opinion. The only way
to raise the position of the medical profession, is to raise the standard of gen-
eral or preliminary education < As to mere professional training, that of the
medical man is quite equal in extent to what is required of candidates for any
of the other learned professions. But it must be confessed, that too many
medical practitioners, if not absolutely illiterate, have not those general attain-
ments which are expected of a gentleman. Hence the great cause of tha
inferior social position too often complained of. The only way to remedy thia
is to institute such preliminary examinations as shall efficiently exclude all
those who, from natural deficiency, or imperfect education, are certain to
bring discredit on the profession.

Much has been said and something has been done in thia respect of lata
years, but until the examination in general acquirements be made preliminary^
not merely to the professional examinations, but to the entrance upon profea-
sional study, the benefit will be very inconsiderable. It seems Tery hard,
after a student has passed two or three sessions in medical studies, to throw
him back on account of ignorance of Latin or some other preliminary subject ;
and examiners under such circumstances are necessarily tempted to undue
laxity. If, however, the student has to be examined on general subjects before
he commences his medical studies, the preliaiinary examination will become
what it ought to be, a test for his fitness to enter upon these studies. In thia
way, no doubt, a certain number of men who are not adapted for a learned pro-
fession will be excluded altogether, while in all of these who are permitted to
go forward, a certain degree of mental cultivation will be secured. We trust,
therefore, that all the licensing bodies will agree to admit no student upon the
register of medical students until he has passed the preliminary examination.
We believe that the Universities and other licensing bodies in Scotland are
prepared to take this course; and it is probable that after October 1865,
the passing of the preliminary examination previoua to registration will ba
compulsory.

With regard to the recommendation of the Committee of the General
Council as to the duration of professional study, there will probably be more
difference of opinion. In Eng^d, where the large proportion of studenta
have gone through part of their apprenticeship before commencing their medi-
cal studies, four years may be thought too long ; but we trust a change aa
to apprenticeships will soon take place. An apprenticeship, as usually gone
through, is not a suitable introduction to a liberal profession such as medicine ;
an immense deal of time is lost ; the student is taught a certain routine prac-
tice before he has acquired any principles to guide him) and it is the direct
tendency of the system to raise up a race of empirics. We cannot look
upon four years as too short a period for the education of a medical man ;
no doubt there are exceptional cases, but in general no shorter time will be
required to educate a man in Medicine, Surgery, and Midwifery, and the
accessory branches.

One of the recommendations of the Committee under the heading " Profes-
sional Study," is to the effect, that " no subject of lectures be enforced by
regulation, to be attended more than once." If by the word " lectures " be
understood subjects which are taught in systematic courses, we should have
no objection to such a recommendation; but if by the term be included
Clinical Medicine and Clinical Surgery, we think the recommendation injndi-

344 REQUIREMENTS IN PRELIMINARY [OCT.

ciouB, and that each board shonld be left to determine for itself how much of
thene subjects it will require from its candidates.

The " suggestions for obtaining information " are likely to raise some im-
portant questions, to one only of which we can allude. One of the most
important points is as to what is to be held as constituting the commencement
of professional study. We have already stated that, in England, apprentice-
ship is very generally held as such a commencement ; but, for the reasons
hinted at, we disapprove of this system. We therefore are clearly of opinion
that no other mode than entrance on such study at a Medical School should
be recognised as the commencement of professional study. Apprenticeship
undertaken at a later period, or pupilage for a year or two, has undoubtedly
many advantages ; but in no case would we allow these to take the place of
regular systematic instruction.

In conclusion, we have to express the hope that the General Council, at ita
next meeting, will be prepared on the various points contained in the Beport
of its Select Committee to utter no uncertain sound, and that the various
licensing bodies will afford all facilities for carrying out what we consider, upon
the whole, as valuable recommendations.

An addition has been made to the regulations of the University of Edinburgh
which may have important results in the mode of conducting the final profes-
sional examinations. It has been felt that an ever-increasing burden has been
laid upon medical students ; Medicine and the accessory sciences have enormously
increased, and the professional examinations have grown in number and minute-
ness. Expression was given to this feeling by Professor Syme in a very emphatic
manner in a lecture delivered before the College of Surgeons, and we cannot but
consider the new regulations as a practical carrying out of his suggestions.

The regulations we allude to are the following : —

** 1. The Senatus recommend that there should be from three to five special
class-examinations in the medical classes during each session, > conducted by
means of questions and written answers, without aid from books or notes.

" 2. That with each Medical Professor who conducts written class-examina-
tions, there shall be associated one or more assessors, to be selected by the
Medical Faculty from the Examiners in Medicine, or from the members of
the Faculty, to whom the questions to be proposed shall be submitted for
approval, and who, along with the professor, shall examine the answers and
determine their value.

" 3. That in the event of a student gaining 50 per cent, or more, but less
than 75 per cent., of the available marks in any department, his certificate to
that effect will be taken into favourable consideration when he appears for his
Degree-Examination.

" 4. That in the event of a student gaining 75 per cent, or more of the available
marks in any department, his certificate to that effect will be taken into still
more favourable consideration when he appears for his Degree-Examination.^*

We believe that this system of class-examinations (which in themselves we
look upon as of the greatest advantage both to the teacher and the taught)
may be introduced with advantage into several of the departments of medical
study. There is more difficulty in carrying it out in the practical subjects, such
as Medicine, Surgery, and Midwifery. On these subjects the examining bodies
stand between students and the public, and the latter have a right to expect
that those who obtain licenses to practise shall prove at the time they obtain

1864.] AND PROFESSIONAL EDUCATION. 345

them that they have such a knowledge of these subjects as shall make them at
the least safe practitioners. The system of class-examinations was in practical
operation in Edinburgh last winter, and proved popular among the students.

The following pages contain an abstract of the regulations of the various
licensing bodies ;— Pages 346-352 contain, in a tabular form, the requirements
of the different boards under the head of prelimbary education. The first two
pages contain the requirements of the English and Irish Educational Bodies.
The Middle Class Exammations of the Universities of Oxford, Cambridge, and
of Ireland, are divided int6 two classes — a senior and a junior. After Ist
January 1863, only the former of these will be accepted ; and for this reason,
and also in order to save space, we have only given the requirements of this
elass. Candidates for the Oxford and Cambridge Examinations must be under
eighteen years of age, and must pass in all those subjects to which an asterisk
is not attached, and in at least two of the sections which are so designated.
At the University of London Matriculation Examination, candidates must pass
in all the subjects specified, except that a knowledge of eUher French or
German will be sufficient. At the Regbtration Examination of the University
of Durham, a knowledge of French is not imperative. At the Queen's Univer-
sity in Ireland, candidates must pass in the four first sections of the Table, and
in at least two of the others.

The four succeeding pages show the requirements of the Scottish Universities,
of the Irish Colleges, and of the Colleges of Physicians and Surgeons in the
three kingdoms. In the case of each of these bodies, the candidate must pass
ia aU the subjects to which no asterisk is attached, and in two of the others so
designated. The only exception is in the case of the College of Surgeons of
England, where candidates are required to pass in only one of the extra branches.

By the new statutes of the Scottish Universities, three medical degrees have
been instituted, those, namely, of Bachelor of Medicine (M.B.)i Master in
Surgery (CM.), and Doctor of Medicine (M.D.). The degree of CM. is not,
however, conferred on any one who does not at the same time obtain the
degree, of M.B. All candidates for the two first degrees are required to pass
the full ^preliminary examinations, and to have been engaged in professional
study for four years before being admitted to the final examination. The
degree of M.D. may be conferred on any Bachelor of Medicine twenty -four
years of age, who has been engaged, subsequently to his having received the
degree of M.B., for at least two years in medical and surgical practice, pro-
vided that he is either a Graduate in Arts of a university, or that he has
passed an examination in Greek and in Logic or Moral Philosophy, in addition
to the other branches of a preliminary examination. Those, however, who had
commenced their medical studies previous to the period at which the statutes
caine into force at the different universities, are entitled to graduate either
under the system in force before that time, or under that now established,
according as they may prefer to comply with the regulations in force before or
after these dates. Consequently, those who began their medical studies pre^
vious to the dates mentioned below, may either take the degree of M.D. at the
age of twenty-one, and without a preliminary examination, except in Latin ; or
they may obtain the degrees of M.B. and CM., in which cases, however, they
will be required to pass the full preliminary examination. This alternative refers
to candidates who began their medical studies before the following dates : —
In Edinburgh, before the 4th of February 1861 ; in Glasgow, before the let of
October 1861 ; and in Aberdeen, before the 5th of November 1861.

346

TABLE OF PBELliflNABT EXAMINATIONS OF THE

SubJeeU of Eumiiuitlon.

UnTZBBrxT or Oxporo.
Mid. Clu8 ExamlnatioD.

UxiYusmr or Caxbvdoc.
Mid. Class Examination.

UHivBBsmr or Lovnoir.
Matriculation Examination.

ENGLISH.

OmnnuLr and
Compoiltion.

Grammar and
ComposiUon.

Grammar and
Composition.

«>

HISTORY.

OnUlnflfl of English.

OnUines of English.

English, to end of

GEOGRAPHY.

Europe.

Particnlarly of Enrope.

Modem.

ARITHMETIC.

PrlndplMuidPnotiee.

Principles and Pnctioe.

Ordinary Rules, indvding
Fractions and Extraction
of Square Root

RELIGIOUS
KNOWLEDGE.

The two Books of Kingfc,
Gospel of St Matthew, and
AoU of Apos. Catechism
— Morning and Evening
BezTlce. The Litanj.

'Old TesUment to accession
of Baal. Oosp.of StMattb.
Morning and Evening
Service. HoraPanlina.

...

GEOMETRY.

EoeUd, Books L to IV.

•
Eodid, Books I. to VI.
Plane Trigonometry.

EucUd, Books L to iV.

ALGEBRA.

9

ToradofOnadratio
Equations.

ToendofQnadratle
Equations.

To Simple Equations
Inclusive.

NATURAL
PHILOSOPHY.

•
General knowledge of.

9

Elementary Principles.

Mechanics. HydrosUtics,
Pneumatics, Acoustics,
Optics.

1

LATIN.

•
« A fUr knowledge."

Cicero pro Mnrena,

Horace, Epistle, Book I.

Rngljgh into Latin.

Livy, Book XXI.

Horace, Odes, Books

II. & 111.

-♦

GREEK.

•
* A iklr knowledge.*'

•
Herodotus, Book VT.

Homer, Odyssey, Book I.
Xenophon, Anabasis,
Book I. ^

FRENCH.

•
* A fair knowledge."

•

Racine, Athalie.

Miguel. Marie Stuart.

English into French.

•
Comeille, Horace;
BoUeau, Le Lutrin.

GERMAN.

•
« A Ikir knowledge."

•

Dahlmann, Chapter III.

to VII.

Schiller, Wallenstein.

English into German.

•

Arohenholx, History of

Seven Years' War, Books

L*n.

Lessing, Emilia Galotti.

BOTANY.

•
Vegetoble Physiology.

9

Description and Classi-
fication of PLints.

...

ZOOLOGY. -

•
Animal Phfriology.

•
Description and Classi-
fication of Animals.

...

CHEMISTRY.

General Principles.
Analysis.

•

General Principles.

Inorganic.

General Prindplee.
Inorganic

VABIOUS XBDICAL IiICENHlTO BOOm.

847

UnTBUiTT or Ddibam.

PuBLOi UimrBaannr.
TranrrCoubM^

Qaaui'i UnrvaaiTT,

Ian.An>.

llld.ClanBzamtaiation.

CoLUMB OF Pascirmw,
FtxatClaMiCerttfcale.

'^

OnmiiMr Aod
Ifrittng to Dietotton.

^iffmpiiffif^,

Oiammarand
Conpoiltlon.

andUtan&n.

EB8llili,lM8B«r
Anae.

EnfflidL

Kn«lMieq»eleltror
reifn of Queen Anna.

KiWUsk^leeidlorBiili.
taenth Centnry.

Great Britain, Fxanee,
Spain.

Modern.

Chiefly Enropa.

Ganaral.

OidbuoT Kales, inelodtaw
VnlKar and Dedmia
Fractionik

PrIndpleaandPtaotlea.

OfdlnairBnlea.

(hdlBarjSalaa.

•*•

...

lataadMSaMMl,

AetsorthaApoatJ#s.

BtLnkeu

BadU,ilookI.

«.

•
Baelid,BeQtaI.toiy.

...

Fbat Foot Rnlee and
FtMtiona.

•

ToandoTQaadraties.

^

...

...

•
Mechaalea^Hydroetatlea.

Anj branch.

•«

Oneofthefonovlng:
CMar, de Bell. GauTI. IT.

Virgfl,.fiiiel4,BookII.
Uorace,Odee, Book III.

Twooftbefollowiiv:
LlT7,Ln).ni.lV.;Vlrrfl,
^Deld,Lib.I.II.III.VI.;
Salhiat; Horaee. Odee;
Hor.BatiiMAEFlatlee:
Terence, Andria and

"AMrknowJedfe."

Ballast Catiline, sad Vliv

Ir Gieero,de Seneetnte,
and Uoraee, Od. Lib. L
toIU.

Xanophon's MemotabUla,
Qxanuaar.

Two of the following:
Homer. Iliad, L.L to III.;
Greek Test., GoepelB St
Lake and St John, AeU;
Eorilddei, PhceniaHi;

Socratee; Luoien: Xen-

to III.; the Greek Tes-
tament i pr Ewlpideiy
Medea.

Voltafn^BUtoinda

CbarlesXU.

Grt&uaar.

M.

"AMrknowMg^."

Books not auMvwed.

^
»

*••

-

•
"AftkkBovMga.^

Bodes not amMBOSd.

p**

...

•
VegeteUeFhyriologr.

...

...

...

•
AaiaialFhydelofj.

...

rpr

...

•
General Principles.
Piaetleal Analfsis.

OcDtralknovlad^.

"

TOL. X.— NO. ]

rv.

2y

348

TABLE OF PBEUMIMAST EXAMINATIONS OF THE

8aldecUofF.Tain1mtim».

UVXTBBSITT OF EDimUBOR.

VtayMEam of Glasgow.

Uvnmsmr of AnuMEBjr.

ENGLISH.

WritinfffromDicUtioii,
Compodtioii.

ComposiUon.

Composltton, Writing to
Dictation.

HI8TOKY.

...

•»•

...

OEOORAPBY.

...

...

...

ABITHHETIC.

DednuJi.

Dedmals.

Common Rules, inelndlng
Dedmals.

OEOMETST.

Endid, Books I., II, and

EneUd,BookL

£udid,BookL

To Simple Eqnatloiu.

...

To Simple Equations.

MECHANICS.

Laxdnex'f Meehuics.

Lardnei's Elements of
Natuial PhUoeophy.

Golding Bird's Elementa,
PartI.,0rGalbnithanZ
Haughton's ManuaL

LATIN.

Virgil, JSnald, Lib. V,
A Latin Proie Author.

Casar, de BeUo GaUico.
Lib.n.;TiigU,.£neid,
Llb.L ' • '

CMsar, de Bdlo GalUoo,

1

OBEEK.

•
Xenophon*! Cyropaedia.

I« or Gospel acoording
to St John.

^'^isf^

FBENCH.

•
DemogeoL Hlit da Lltt.
Franc., Cnap« 87 to end.

•

yolUlre,HlBtoirede

Charles XU.

•
Voltaire, Histoiie de

GERMAN.

Goethe's Egmont, Schiller,
Brant Ton Measiaa.

9

SchUler, William TeU.

Schiller, William TelL

HIGHER
MATHEMATICS.

•
Euclid, Book. L to VL

Sections.
Algebra.

•
Endid, Books L to YL
Algebra, inclading Quad-
ratics, ElemenU of Tri-
gonometry.

•

Quadratic Equations.
Binomial Theorem.
Logarithms.

NATURAL
PHILOSOPHY.

Elements of by Golding
Binl and Brooke.

Bird and Brooke.

•

Gliding Blid,

Light, Heat, Eleetridty.

"^

LOGIC.

•
Formal AVerbal Fallacies.
Theory and Methods of
Indnetion.

9

Whatel^s Logic, Books

•

Thomson's Laws of

Thought; M-Morell'sHand-

Book of Logic.

m

MORAL
PHILOSOPHY.

•

Dngald Stewart'!

OntUnes.

9

Dngald Stewart on the
Active Powers ; or Dx
Fleming's Manual.

•
Raid's Actire Powers; or
Wayland's Elements of
Moral Sdenoe.

NATURAL HISTORY.

...

•
Geology or Zoology.

Classification of Animal
Kingdom, Vertebrata.

▼ABIOUS HEDICAL LICEKSntG B0DIS9 — (cotUmvecL)

849

QUCM'S COLLBOI,
BCLFAST.

MftirlenUtion EumiiuttoiL

QUSn'S COLLBOB, COBK.

QuBsir'a CoLLioi»

Galwat.

MatricnUtion Exam.

BOTAL COLLBOS OV

PBraiciAiia. Lobikw.
Preliminary Examination.

w

Onunmarand
Gompoiitioii.

Grammar and
Compoaition.

Grammar and

Grammar and
Compodtioii.

•

Bomui, to dMth of Nero.

Grecian, to death of
Alexander the Great;
Boman, to Angnatoa.

OotUneaofGredaaand
Roman.

...

Oatlines of Ancl«st and
Modem*

OatUnea of Ancient and
Modem.

Ontllnea of Ancient and
Modem.

...

Common RqIm, ineladln;

eat, and Extraction of
BqoareBoot

Common Bulea, including
DecimaU and Slmpla
Intox«at.

Common Rnle^ladad-
ing Decbaaia.

Dedmala.

BiMlld,BookaI.aiidU.

Bnclld, Book I.

EoeUd^Bookl.

To Simple Eqnatioiia,
inclaaire.

InoIoaiTe.

InclnaiTe.

...

...

...

^

^
^

Anv two of the following :
Horace, Yligil, Cicero
in CatiUnam, Salluat,
Liyy^Csaar.

One of the following:
yiivU,.fineid,LIb.I.and

II.; Balluat, Catllin*.
Csaar^deBelL Gall, Lib. L

Caaar, de Bello Galileo,
Lib. T- Of Yfrga,
.Aneid, Lib. I.

EngUah Into Latin.

Tadtt AgricoU; Tirgail
GMigica. Lib. IIL; or
C0aar,deBeU.GaU.Lib.
IV.; Horace, Odef, Book
IIL

Any two of the following :
Homer, niad, Booka I,
n.-,Enriplde8,AleeatU;
Xenophon'i Anabaala,
BookaI.andII.;Lndan.

One of the following :
Homer, Iliad, Books I. and

baala, Booka I. and II.;
Lndan.Walkei'aSelec-
tlona.

Xmiophon'a AnabaMi,

Book I.

Grammar.

...

...

...

...

•..

...

...

...

...

...

...

...

«.

•*

...

...

...

Meohanlca, Aoonatica,

Optia^HydroataUca^

Pneomatiea.

%

...

...

...

•••

...

...

...

...

.••

...

...

860

TAOLE OF PBBUUIRABT EXAiaNATIOITS OF THK

SQlJMitiofBUmliUttloiL

ROTAt. COLLCOI 01^

Phtsiciajts, Ediitbuboh.
Ptellminaxy ExamlaaUon.

Kno'a A QuBXn'a Coll.

Pmra^ lasLAim.
PrellminaiT Examination.

Rot At Coll. ov Bomomoan,
Ekolaxd.

EMGLIgH.

CompoBltloii and Writing
toDiototion.

CompoiltioB.

Onunmaraad
Compoattion.

HUTOKT.

...

M.

OntllneaofEngUah
Hlatorr.

GEOGRAPHY.

...

...

^^ISttSwSi^*'*

ABITHMETIC.

Oomnum Rales, Indnding
DeelmAli.

To end of Dedmal
FiactkniB.

To end of Decimal
Fractiona.

LATm.

CMif, de Beno Oaffioo,
Llb.iy.;yifsl!,^naid,
BookYI.

yiM,JEneid,Ln>.Land

OrSaUnst.

Or Cmmr, de BeU. QaU.,
Lib. L and II.

•

C«aar,deBeU.GaIL,

BookL

GEOMETRY.

•

Eudid, Books I., 11., and

III.

•
Eodid, Booka L and IL

inclosiTQk

...

inelnalTe.

>

NATURAL
PHILOSOPHY.

•
HfdTMtatieB and Pnemnar
tloa (Laidaar'a Hand-
book)!

•#«

•

GREEK.

•
8tMark*BQo«ML

BooklL ^

HoDMx's Iliad, Book I.
Or Xenophoo's Anabaaia,

Or Walkec'a Lndan.

•
StJobn'sOocpeL

FRENCH.

•

Toltalre, Hiatoln de

Charies XTT.

One Book, at option of

Crl'Uliilt*

•

Ydtaire, Hiatoln d«

CbarieaXU.

GERMAN.

•
SehUler, G«icbMite dea

One Book, at option of

•
Sebnier. Geaehiehta des

Books Tandll.

BOTANY.

•

Anatomy and OiviBo-
•and LiUaieen.

...

•
ClaasUleatkm of Planta.

"^
^

ZOOLOGY.

•
Yertelirata.

...

9

ClaasUleatloii of Animals.

•

CHEMISTRY.

...

...

Elementary Facta.

VASIOUS MEDICAL UCEKSHIO tODa»—{contmued.)

851

«

BoTAi CoiA. Binuwoin,
Edixbuboh.

H0TALCOLL.BUBa.,
laSLAJfP.

FAOULTTOVpHTa.*

Buioa., Glamow.

ArOTRWAUW' COT.»

LoiTDoa.
Prrifantnary Exam.

ArOTHBCAUBf'

Hall, lasLAinib
Praliminary Eia.

toDktatloB.

•••

WiltlaftoDieta.
Hon.

podtloB.

...

...

...

EnKlUh-.thaBlnart
Fttnod.

EngUfllu

...

.M

...

...

-

Common Rule*, iadodinc
I>eeimali.

...

Common Xnlea^ttt-
dndlng Dadmala.

Common Rnlei. to
•ndofDMlmaU.

To the end of
Deetanala.

Conur, 4a Bello Oallleo,
BookVi.

^a?i-»

Caaar^deBelLaalL,

Lflj.IV.
VirgUfiBnMd, Ltk.

CMar^BolLCtTfU,
^Vir^^GaoTflea,
OrCtotte^troHUona.

8aIliut,Catnim:
Vlrgl], wEneld,
L.^I,U,aJl

•

EiielHBookgL,II.,aiki
111.

...

Bocaid^Bookal^IL,

BoeUd^Bookl.

£odld,BookaL
andIL

y

^

T.8taj*B^

...

inelDBiTVb

iSJ^EiSSSf

ToendofBimple
Efoatieaii

•

HydnwUtlM and Pn«n-
miitlGtCUrdMr'fHuid-
book>

...

•
Hjdrottatkt and

Pnenmafclcfl (Lard-
ner'a Handbook.) ,

EtamntoofBlatlGa
and Dynamics.

Elemento of By-
drostatiei, Hy-
draolks, ami
Pnemnatlea.

•
BtMArk'tOoMw].

Book II. ^

8t John's Oofp«L

•
8i Mark's Qoqwl.

•

Tannnhim MmiMwa.

buikT^

OeepeloTBtJohn.
Lodan, 90 Dla-

k>cne&
^ Homer's niad,

Books Land 11.

•

yolUln,Hi8toii«dA
ClurlMXII.

...

•

yoliaira,HU«oirada
CharlatXIL

^

TdltaIi«,HlstoirB
daChaclesXn.
Or Telemaqne.

•

...

•
Behffler^QMeMehto
dM dTBlsdgtiQi.
rl^Krt««7^k.

^

w.

<«

•"

•

Anatomy and Orsaao.
ffraphy^-OnidfonB^ Um-
Umt^tm, Legnminota^
AndLiUiMM.

...

•

Anatomy A Ongm-

ography. — Cmei-

fen^Umbellltek

LegnmtnoMi, and

...

...

•

9

GeaanlClMrifleatloB-
Tertebrata.

...

General Claaaiiloa-
tlon-Yertebista.

•-

-

...

.•«

»••

•-

.-

352

COURSE OP STUDY.

[OCT.

••OIVMIJ JOOp

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1864«]

MEDICAL 8CHOOL8.

858

MEDICAL SCHOOLS OP SCOTLAND, 1864-66.
WHTSB 8X88I0H.

Bwwcn,

nnysaoTT

or
Edotbuboh.

BcTMSOsa*
Ball,

EOXXBUMH.

UvimsiTT
GLAaoow.

Amnaos'i

Unrssarrr,
Glaboow.

UnrnanT

ov
Abbbobbv.

VvrrBBarrr

or Br
AvoBswa.

Pnotical^with
Demonstntions.

Profeeeor
Goodelr.

Dr

Handyalde.

Dr
A.Tliomaon.

DrOeonn
Boehanan.

Piofeaaor
Btmthera.

...

or Medicine.*

Dr Bennett

DrBanderiL

Dr
A.Baehanatt.

DrB.WatM».

Dr

OgttTle.

Dr

ChemUrtry^nd
Pnctleal
Chemletry.

DrPUyfclr.

Dr
Macadam.

Dr
T.Aaderaon.

Dr Penny.

Profeaeor
Brasler.

Dr

F. Heddle.

lUtexUMedica

end

Thanpeatioi.

Dr

ChrUtiKm.

In Bummer.

DrEaaton.

Dr Morton.

In Summer.

...

Practice of
Medicme.

Dr Leycock.

Dr

W.BegbIe.t

Dr

Haldane.

DrGairdner.

Dr Cowan.

Dr
MaeroUn.

...

Snrgerf.

Proieeeor
Spenoe.

Dr Wataon.f
MrEdwafda.
DrJoa.BeU.

Mr
Annandale.

PioflLiBter.

DrMaeleod.

Profeaaor
PIrrie.

•-

MldwUBrj.

Dr BImpaon.

In Bummer.

DrPl«an.

In Summer.

DrDycfc

...

Fhlloeophy.

ProfeMor
Tait.

MrLeea.

FrofeaeorW.
Thomaon.

Dr Taylor.

Profeaaor
Thomaon.

Profeeaor
Flacher.

Ketanl
Hietory.

Proieeeor
Allman.

...

DrBogen. '

...

Profeaeor
Nieol.

...

Oenenl
Pathology.

Dr
Henderwn.

Dr Grainger
Btewart

...

•••

...

...

Clinleel
Medldne.

Drs Bennett,
Layeoek.

and
Maelagan.

Dra

Haldane^and
J.M.Dnncan.

DrBell

and
DrHlteUa.

DrKUgour.

•••

CUnlcel
Surgery.

Profeaeor
Byrne.

DrQIUeeple.

Dr A. Buchanan
and
DrLyon.

Dr Keith.

*•*

* This conrae ia equWalent to that given under the name of General Anatomy and Ph/aiology In
the English Schools. Special achedulea are iasned by the London Boarda for their Bootco atudenta,
which should always be Inquired for.

i These ara not conjoint couraea, but separate onea by the gentlemen named.
Thla ia a Joint course.

354

JCEDICAL 8CH0OUI.

lOCT.

MEDICAL SCHOOLS OF SCOTLAND, 1864-65.
8ITKKSB 8S88I0H.

BuBtwon,

vMif aaui'i'

OF

EoorBimaB.

SDmOBOH.

Ujhtxhitt

OF

Glamow.

AvoSBflOS*!

UimriMRT,
Qlamow.

UlRTRBTT

or
Asnomr.

Pnetical AjuAomj
ftnd

Profeiaor
Ooodflir.

DrHandyride.

Dr
A. Thomson.

Dr George
Bniihanan.

Protesor

Btrathen.

Botany.

DrBalfonr.

DrW.Ainott

MrHennedy.

DrDlBkte.

Mateiia
Medloa.

Dr Sooresby.
Jackson.

.^

...

DrHaiTsy.

Hidwiftry.

...

DrKeiUcr.*
DrDnncan.

...

.Dr Wilson.

•M

Medical
JuriBpradenoe.

■

DrMaolagan.t

DrBalny.t

DrLetshman.

DrOgston.t

ComparaUre

Frofesior
Goodsir.

DrHandyside.

Dr
A. Thomson.

-.

Prof.NlooL

Hiitology.

Dr Bennett

DrSanden.

•••

...

DrOgUrie.
J.ThQmioD.

Praetioal
ClMiiiiatry.

DrPIayiUr.

I>r Macadam*
DrCniBiBnMnL,

Dr

T.Anderson.

Dr Penny.

Piofl Brasier.

Nataral
Philosophy.

...

Mr Lees.

...

...

Professor

TlMMMSn.

Natural Hiatoiy.

Professor
▲llman.

*••

DrBogers.

...

Pzof.Nlool.

Clinieal Medidne.

Drs Bennett,
I*yoock,

and
Maolacan.

DrsW.BegWe4
Bandera,

and
J. M. Dvnoan.

DrFraser

and

DrR. Scott Or.

DrKilgonr.

Clinical Surgery.

Prof. Byrne.

DrGiUeapie.

Dr Morton

and

Dr G. BuehanaiL

Dr Keith.

* These are not ooi^ofnt eoorses, hot separate ones by the gentlemen named,
t Drs Bainy and Ogetoo dettrer tbelr ooarsea only in winter. Dn MMlagan jud Utt]i||olui gW«
eoBTses during both the winter and sammer sesalou.
X This is a Joint course.

For additional Sammer Coones on speoial sal^eots, see the Prospe^tw «f mipIi Beboot

1864.] LIST OF HOSPITAIiS, DISPENSARIES^ ETa 355

LIST OP HOSPITALS, DISPENSARIES, ETC., IN CONNEXION
WITH THE MEDICAL SCHOOLS OF SCOTLAND.

EDDTBUBOH. '

Royal Infirmary, including Lock Hobpital. Upwards of 660 Bedf i
Visits daily from 12 till 2 p.m. Physicians— Dra Bennett, Laycock, and
MaclM;an, Professors of Clinical Medicine ; Dr Simpson^ Clinical Professor
for Diseases of Women ; Drs J. W. Begbie, W. R. Sanders, D. R. Haldane,
Clinical Lecturers ; Dr J. Matthews Duncan (on Diseases of Women).

Surgeons — Mr Syxne, Professor of Clinical Surgery ; Professor Spence ; Dr

Gillespie, Clinical Lecturer; Dr P. H. Watson. Assistant Surgeon, Mr

Edwards. Consulting Surgeon, Dr Dunsmure. Ophthalmic Surgeon, Mr
Walker. Pathologist, Dr Stewart.

Chalmers' Hospital for the Sick and Hurt. 24 Beds for medical and
surgical patients. Physician, Dr Halliday Douglas ; Surgeon,

Royal Maternity Hospital. 36 Beds; 279 in-patients and 380 out-
patients annually. Consulting Physicians — Drs Simpson and Moif. Physi-
cians— Drs Thomson, Weir, Keiller, A. Wood. Consulting Physician, Dr
Begbie. Ordinary Surgeon, Dr Dunsmure.

Royal Hospital for Sick Children. 40 Beds ; A^enwe number of out-
patients, about 4000. Consulting Physicians — Professor Christison and Dr
C. Wilson. Physicians-T-Drs Graham Weir, Keiller, and Moir. Extra Phy-
sicians— ^Drs Stephenson and Ritchie. 8urgeon*Dentist, Dr Smith.

Royal Public Dispensary and Vaccine Institution. About 11,000
patients annually. Medical Officers — Drs Spence, Pattison, Sommervilld,
Wright, Sanders, Husband, Littlejohn, D. Wilson, Ritchie, Stephenson, Cairns,
Linton. Physicians- Accoucheurs — Drs Keiller, Matthews Duncan, Wright,
Pattison. Superintendent of Vaccination, Dr Husband. Visits daily at 2 P.M.
Vaccination on Wednesdays and Saturdays at 12 noon.

New Town Dispensary. 7800 patients annually. Medical Officers — Drs
J. Hunter, Watson, Dycer, Scoresby-Jackson, Inglis. Consulting Surgeon,
Dr Maclagan. Physicians-Accouche^rB— Drs Dumbreck, Pa^an, Simpson^
Inglis. Superintendent of Vaccination, I)r J. Hunter. Visits daily at 2 P.M.
Vaccination on Tuesdays and Fridays from 12 to 1.

Royal Asylum for the Insane. About 660 patients. Physician, Dr
Skae. Lectures and Clinical Visits in summer.

Eye Infirmary, George Street. Surgeons— Benjamin Bell, Esq., P.R.C.S.,
and Dr Watson, F.R.C.S. Consulting Surgeon, Dr Hamilton. Open daily at
1 P.M.

Eye Dispensary, Cockbum Street. 1150 patients annually. Surgeons —
Mr Walker, Dr Wilson. Consulting Surgeon, Dr Duncan. Open Monday,
Wednesday, Uid Friday, at 1 p.m.

Ear Dispensary, Cockbum Street. Dr T. Keith. Tuesdays at 12.
Ayerage, about 20 cases daily.

Ear Dispensary. Dr Jackson. Mondays and Fridays, 11 to 12.

Dental Dispensary, Cockbum Street. Consulting Surgeons — Professor
Goodsir, Professor Spence. ConsultingSurgeon-Dentist, Mr Nasmyth, F.R.C.S.
Ordinary Dentists— Dr John Smith, Dr Orphoot, Mr Hutchins, Dr Roberts,
Dr Hogue. Daily, 9 to 10 a.m. Average number of patients 3000 per annum.

VOL. X.— NO. IV. 2 z

£56 LIST OF HOSPITALS) DISPENSABIES, ETC. [OCT.

GLASGOW.

Royal Infikmary. 600 Beds. Ylsits d&ily at 8.30 a.m. Physicians— Dn
Frazer, Scott Orr, W. T. GuirdDer, Leishman. Fever Ph^Bician, Dr Steven.
Physicians to out-patients — Drs Perry and A. Buchanan, jun.

Surgeons — ^Drs Lyon, J. Morton, G. Buchanan, and Professor Lister. To
out-patients — ^Drs Dewar and Macleod.

Lock Hospital. 47 beds. Medical Officers— Drs Qt. H. B. Macleod and
D. Forbes.

Lying-in Hospital and Dibpensaby. 24 Beds ; in-patients 326, out-
patients 353. Physicians — ^Drs J. G. Fleming, J. G. Wilson. HouBe-Surgeon,
Mr G. Gentle.

University Lying-in Hospital and Dispensary. In-patients about 760,
out-patients about 2500. Physicians — Drs Pagan and Leishman. Assistant
Physician, Dr S. Johnston Moore.

Western Pubuc Dispensary. Medical Officers— Drs A. B. Buchanan,
David Forbes, T. M. Anderson, and John Caughie. Surgeon-Dentist, Mr G.
Buchanan.

Royal Asylum for the Insane. About 680 patients. Physician-
Superintendent, Dr A. Mackintosh.

Eye Infirmary* 24 Beds ; 160 in-patients ; 2497 out-patients annually.
Consulting Surgeons — Drs Rainy and A. Anderson. Ordinary Sui^ons — Urs
W. Mackenzie, A. Anderson, W. Brown. Assistant Surgeon, Dr G. Rainy.

Dispensary for Skin Diseases. 1172 patients annually. Medical
Officers— Drs M'Call Anderson and A. B. Buchanan. Lectures and Practical
Instruction in sunmier.

ABXBDEEV.

Royal Infirmary. Upwards of 280 beds. Visits daily at 10 a.m. Con-
flulting Physicians— Drs Dyce and Kilgour. Physicians — Drs Williamson,
Harvey, Smith, and Keith.

Surgeons — Messrs Keith, Pirrie, Kerr, Fiddes. Ophthalmic Surgeon, Dr
Wolfe. Pathologist, Dr Beveridge.

General Dispensary, Lyino-in, and Vaccine Institution. Upwarda
of 6000 patients annually. Medical Officers — Drs Forsyth, Sutherland, and
Christie; Messrs Smith, Paterson, and l^Vaser. Visits daily at 9.30 a.m.
Vaccination every Wednesday at 3 p.m.

Lunatic Asylum. Above 300 patients. Consulting Physician, Dr
Macrobin. Resident Physician, Dr Robert Jamieson. Clmical Lectures in
summer.

Ophthalmic Institution. 500 patients. Surgeon, Dr Cadenhead.

ISM.] BOTAL COLLEQE OF PUT81CIAN8. 357

ROYAL CX)LLEGE OF PHYSICIANS OP EDINBURGH.

REOUULTIONB BEQABDING THE FELLOWSHIP AND MEMBEB0HIP OF THB

COLLEGE.

I. Ofth^FdUfwMp.

1. No one shall be elected a Pellow of the College until he has been at least
one year a Member thereof, and has attained the aee of twenty -five years.

2. Every motion for the election of a Fellow shall be maae at a quarterly
meeting of Fellows by one of the Fellows present, and seconded by another ;
and this motion shall be determined by ballot at the next quarterly meeting
of Fellows, — a majority of three-fourths being necessary to carry it in the
affirmative.

3. If an urgent reason satisfactory to the Council be assigned, a Candidate
may be proposed at an extraordinary meeting of the Fellows summoned for
the purpose, and his petition may be balloted for at an extraordinary meeting
of the Fellows specially summoned for the purpose ; provided that the holding
of this special meeting be agreed to by a majority of five-sixths of the Fellows
present at the meeting at which the Candidate was proposed ; provided also
that not less than one week intervene between the two meetings, and that due
notice of the intended ballot be given in the billets summoning the second
meeting. The Candidate shall in this case pay to the Treasurer a sum of ten
guineas in addition to^the ordinary fees.

4. Every Fellow resident within five mOes from the General Post-Office of
Edinburgh shall, on his election, have his name placed on the roll of attend-
ance, and shall pay the annual contribution, and ne subject to all the laws of
the College regarding fines. Fellows resident beyond &ye miles shall have
the option of having their names on the roll of attendance or not ; but if their
names be on the rofl of attendance, they shall pay the annual contribution, and
be subject to fines.

5. Any Fellow may petition that his name be taken off the roll of attend-
ance ; which petition shall be determined by ballot at next Quarterly meeting.

6. Any Fellow whose name is not on the roll of attendance may have it
inserted by giving notice to the Secretary, who shall report to the next
quarterly meeting ; after which, the Fellow shall be entitled to all the privi-
leges of the Fellowship, and may take his seat at the first meeting of the
College.

7. Any Fellow leaving Edinburgh for a length of time, and omitting to
petition to have his name taken off the roll of attendance, or wishing the same
to be continued on it during his absence, shall be charged with his annual
contribution and fines.

8. Fellows whose names are not on the roll of attendance shall not hare
the use of the library and reading-room, except in the cases specified in Laws
9 and 10.

9. Fellows whose names are not on the roU of attendance, on comins to
reside in Edinburgh, or within five miles thereof, for a perioa not exceeding
six months, may, with consent of the Council, be allowed the use of the
library and reaaing-room.

10. Fellows not on the roll of attendance, who reside permanently in Edin-
burgh, or within five miles thereof, but are not engaged in practice, may,
with consent of the Council, be allowed the use of the library and reading-room
on payment of the annual contribution.

II. Of ike Membership.

1. Any Licentiate of a College of Physicians, or Graduate of a British or
Irish University, with whose knowledge of medical and general science the
College may be satisfied, may be admitted a Member of the College, provided
he slmll have attained the age of twenty-four years.

358 BOTAL OOLLEGEB OF [OCT.

2. Every motion for the election of a Member shall be made at a quarterly
meeting of Fellows by one of the Fellows present, and seconded by another ;
and this motion shall be determined by ballot at the next quarterly meeting, —
a majority of three-fourths being necessary to carry it in the afiirmative.

3. Every Member on the roll of attendance, whose address has been com-
municated to the Clerk, shall be summoned to attend all meetings of the
Fellows and Members.

ni. OfihsFees.

1. The fee to be paid by a Member shall be thirty guineas.

2. When a Licentiate shall be raised to the rank of Member, he shall pay
twenty guineas.

3. When a Member shall be raised to the rank of Fellow, he shall pay
thirty guineas, exclusive of stamp-duty. The stamp-duty on the Fellowship
payable to Government is £25.

4. All Candidates for Fellowship or Membership must lodge their Fees, and
the amount of stamp-duty payable at the time to Government, with the
Treasurer, previously to presenting their petitions.

ROYAL COLLEGE OP SURGEONS OF EDINBURGH.

ABSTBACT OF BEQULATIONS FOR THE FELLOWSHIP.

1. No person shall be received as a candidate for the Fellowship who is not
in possession of the diploma of the Royal College of Surgeons of Edinburgh,
or of the Royal College of Surgeons of England, or of the Royal CoUege of
Burgeons of Ireland, or of the Faculty of Physicians and Surgeons of Glasgow.

2. No person shall be admitted as a Fellow who is under twenty-five years
of age.

3. Every candidate for the Fellowship shall lodge with the President a
petition for admission, and shall be recommended by two Fellows as proposer
and seconder, of whom one at least shall be resident in Edinburgh.

4. Candidates for the Fellowship shall pay £25 to the College funds, includ-
ing all fees. The money shall be payable to the Treasurer immediately after
die presentation of the petition to tne College.

5. The billets calling the meeting at which the petition is to be presented,
•hall intimate the name and surgic^ qualification of the candidate, his profes-
sional appointments, if any, and the names of his proposer and seconder.

6. The petition shall be considered at a subsequent meeting, to be held not
sarlier than a month after the first; and in the meantime, the petition, witii
the names of the proposer and the seconder, shall be hung up in the library ;
and the billets calling the second meeting shall contain an intimation in tne
same form as those of the first.

7. At the meeting for considering the petition of the candidate, the votes
shall be given by ballot. Three-fourths of the votes are required to entitle the
candidate to be admitted ; and the number of those voting shall not be less
than twenty.

FACULTY OF PHYSICLAJ^S AND SURGEONS, GLASGOW.

ABSTRACT OF REGULATIONS FOR THE ELECTION AND ADMISSION OP FELLOWS.

1. A candidate for the Fellowship of the Faculty as a Physician must be a
Doctor of Medicine of a University of the United Kingdom, or of a Foreign
University recomised by the Faculty. A candidate for the Fellowship as a
Surgeon must be a Licentiate of the Faculty, or a Fellow, Member, or
Licentiate of one of the Royal Colleges of Surgeons of the United Kingdom.

2. A candidate must be proposed, in writing, by two Fellows^ at an ordinary
meeting of the Faculty. But no proposal shall be received until the candidal

1864.] PHYSICIANS AND BUBGEONS. 3fi0

shall haye intimated, by letter, to the President, the medical or sui^gical quali-
fication (as the case ma^ be), in virtae of which he desires admission to the
Fellowship. After havmg been proposed he shall submit to the Council all
necessary evidence of his professional qualifications, and of his being of un-
exceptionable moral character.

3. A copy of the proposal shall be placed in the reading-room till the next
ordinary meeting of the Faculty ; when, the Council having reported as to his
eligibility, and no reasonable ground for delay being shown, the Faculty shall
determine, by a ballot, whether or not the candidate shall be admitted as ft
FeUow.

4. For the election of a Fellow, two-thirds of the votes given most be In
£svour of his admission. An excerpt of the minutes of the meeting, giving the
result of the ballot, shall be sent by the Clerk of the Faculty to the candidate,
who, if elected, shall, at the next meeting of the Faculty or of the Council
thereof, be enrolled as a Fellow, upon making and subscribing the declaration
required by the Faculty.

5. The entrance fee (to be deposited at the date of his proposal) shall be
£50 ; but from this sum a Licentiate of the Faculty shall be entitled to a
deduction of whatever amount he may have already paid for his diploma.

6. A candidate residing beyond ^ve miles from the Faculty Hall, on being
elected in the usual way, may, upon pa3rment of £25 (subject in the case of a
Licentiate of the Faculty to deduotion of one-half of the license fee) be
admitted a Fellow.

ARMY MEDICAL DEPARTMENT.

WHITEHALL YARD.

QUALIFICATIONS AND EXAMINATION OF CANDIDATES FOR COMMISSIONS IN THE
ARMY MEDICAL SERTICE.

1. Every candidate desirous of presenting himself for admission to the Com-
petitive Examination required for the Army Medical Service must be unmarried,
lie must produce a birtn certificate from the District Registrar, or a certificate
of baptism in which the date of birth is stated ; or if neither of these can be
obtained, an affidavit from one of the parents, or from some other near relative
who can attest the date of birth, will oe accepted. The certificate or affidavit
must show that the candidate is not above 26 (for the examination in February
1865, the limit of age has been extended to 30) nor under 21 years of age. He
must also produce certificates of moral conduct and character, one of them
from the parochial minister if possible.

2. The candidate must make a declaration that he labours under no mental
or constitutional disease, nor any imperfections or disability that can interfere
with the most efficient discharge of the duties of a medical officer in any
climate. He must also attest his readiness to engage for general service
immediately on being gazetted.

3. The candidate must possess a diploma in Surgery, or a license to practise
it, as well as a degree in Medicine, or a license to practise it in Gireat Britain
or Lreland.

4. Degrees, diplomas, licenses, and certificate of their registration in accord-
ance with the Medical Act of 1858, and certificate of character, must be lodged
at the Army Medical Department, for examination and registry, at least one
week before the candidate appears for examination.

5. On producing the foregoing qualifications, the candidate will be examined
by the Examining Board in the following subjects :— Anatomy and Physiology,
Surgery, Medicine, including Therapeutics, the Diseases of Women and
Children, Chemistry and Pharmacy, and a practical knowledge of drugs.
(The examination in Medicine and Surgery wilt be in part practical, and will
include operations on the dead body, the application of Surgical Apparatus,

360 ARMT MEDICAL DEPARTMENT. [OCT.

and the examination of Medical and Surgical patients at the bedside.) The
eligibility of each candidate for the Army Medical Service will be determined
by the result of the examinations in these subjects only. Candidates who desire
it will be examined in Comparative Anatomy, Zoology, and Botany, with
special reference to Materia Medica, and the number of marks gained m these
subjects will be added to the total number of marks obtained in the oblij^tory
part of the examination by candidates who shall have been found qualified for
admission, and whose position on the list of successful competitors will thus be
improved in proportion to their knowledge of these branches of science.

6. The names of candidates who pass the preliminary examination of the
Examining Board will be sent to the Director- General and communicated to
the Professors of the Army Medical School. The names will be arranged in
the following classes : —

Class I. — Names of those who have passed a pre-eminently distin^ished
examination, arranged in their order of merit. Characters which distmguish
the excellence of each. Fitness for special service.

Class II. — Names of those who have passed a creditable examination,
arranged in alphabetical order. Statement of the topics in which each has
individually excelled or fallen short.

^ Class III. — Names of candidates who have passed the minimum examina-
tion, arranged in alphabetical order. Statement of the particular* branches of
science in which each has been found to be deficient.

This information will enable the Professors of the Army Medical School to
carry out their instructions with a definite aim as regards each class.

7. After passing his preliminary examination, every candidate will be
required to attend one entire course of practical instruction at the Army
Medical School before being admitted to his examination for a commission, on

1.) Hygiene; (2.) Clinical and Military Medicine; (3.) Clinical and Military
jurgery ; (4.) Pathology of Diseases and Injuries incident to Military Service.
These courses to be of not less than four months* duration.

8. At their conclusion the candidate will be required to pass an examination
on the subjects taught in the School. The examination will be conducted by
the Professors of the School. The Director-General, or any Medical officer
deputed by him, may be present and take part in the examination. If the
candidate give satisfactory evidence of beins qualified for the practical duties
of an Army Medical officer he will be eligible for a commission as Assistant-
Surgeon.

9. During the period of his residence at the Army Medical School each
candidate will receive an allowance of 58. per diem, with quarters, or 7s. per
diem without quarters, to cover all costs of maintenance; and he will be
required to provide himself with uniform (viz., the regulation undress uniform
of an Assistant-Surgeon, but without the swoi^J).

10. All candidates will be required to conform to such rules of discipline as
the Senate may from time to time enact.

The Assistant-Surgeon is subjected to three separate examinations within
the first ten years of his service, each examination having a definite object.
The first, to ascertain, previous to his admission into the service as a candidate,
his scientific and professional education, and to test his acquirements in the
various branches of professional knowledge. The second, after having passed
through a course of special instruction in the Army Medical School, to test his
knowledge of the special duties of an Army Medical Officer ; and the third,
previous to his promotion, to ascertain that he has kept pace jvith the progress
of medical science.

g

1864.] NAYT MEDICAL DEPARTMENT. 361

NAVY MEDICAL DEPARTMENT.

ADMIRALTY, SOMERSET HOUSE.

REGULATIONS FOB CANDIDATES FOR THE OFFICE OF ASSISTANT-SUROEON IN
THE ROYAL NAVY.

A cAndidate for entry into the Royal Nav^ ahall make a written application
to that effect, addreBsea to the Secretary of the Admiralty ; on the receipt of
which application he will be furnished with the regulations and a printed form,
to be filled up by him, to show if he posseases the required qualifications.

As vacancies occur, the number of candidates required will be ordered to
attend at the Admiralty Office, bringing with them the requisite certificates,
showing that they are fuUy qualified by a^e, professional ability, etc., when
they will be examined by a board of medical officers, to be named by their
Lordships.

That no person be admitted as an Assistant^Surgeon in the Royal Navy who
shall not produce a certificate of being registered under the Medical Act, and
a diploma from one of the Royal Colleges of Surgeons of England, Edinburgh,
or Dublin, from the Faculty of Physicians and Surgeons of Glasgow, from
Trinity College, Dublin, or from other corporate body lesally entitled to grant
a diploma in Burger^r : nor as a Surgeon unless he shall produce a certificate
from one of the said colleges, faculty, or corporate body, founded on an
examination to be passed subsequent to his appouitment of Assistant-Surgeon
as to his fitness for the situation of Surgeon in the Navy ; and in every case
the person producing such diploma and certificate shall also undergo a further
examination, touching his qualifications in all the necessary branches and
points of Medicine and Surgery, both at the time of his entry and after serving
three years to render himself eligible for Surgeon ; and that previously to the
admission of Assistant-Surgeons into the Navy, it will be required that they
produce proof of having received a preliminary classical education, and that
they possess, in particular, a competent knowledge of Latin ; also.

That they are of good moral character ; the certificate of which must be
signed by the clergyman of the parish, or by a magistrate of the district.

That they have served an apprenticeship, or have been engaged for not less
than six months in Practical Pharmacy.

That their age be not less than twenty years, or more than twenty-six years.

That they have actually attended a recognised Hospital for eighteen months
subsequently to the age of eighteen, in which Hospital the average number of
patients is not less than one hundred.

That they have been engaged in actual dissections of the human body twelve
months, the certificate of which from the teacher must state the number of
subjects or parts dissected by the candidate.

That they have attended Lectures, etc., on the following subjects, at estab-
lished schools of eminence, by Physicians or Sun^eons of the recognised Col-
leges of Physicians and Surgeons m the United Kingdom, for periods not less
than hereunder stated; observing, however, that such Lectures will not be
admitted if the teacher shall lecture on more than one branch of science, or if
the Lectures on Anatomy, Surgery and Medicine be not attended during
Winter Sessions of six months each: — Anatomy 18 months; or Generiu
Anatomy 12 months, and Comparative Anatomy 6 months. General Surgery
12 months, or Military Surgery 6 months, and General Surgery 6 months.
Theory of Medicine 6 months, Practice of Medicine 6 months ; if the Lectures
on the Theory and Practice of Medicine be given in conjunction, then the
period required is 12 months. Clinical Lectures (at an Hospital as above) 12
months ; on the Practice of Medicine 6 months, on the Practice of Surgery 6
months. Chemistry 6 months ; or Lectures on Chemistry 3 months, and Prac-
tical Chemistry 3 months. Materia Medica 6 months. Midwifery 6 months,
accompanied by certificates stating the number of Midwifery cases personidly
attended. Botany 3 months.

362 KAVT MEDICAL DEPARTMENT. [OCT.

A favourable conBideration will be given to candidates who have obtained
the degree of M.D. at either of the Universities of Oxford, Cambridge, Edin-
burgh, Dublin, Glasgow, London, or Aberdeen ; or who, by possessing a know-
ledge of the diseases of the eye, and of any branch of science connected with
the profession, such as Meaical Jurisprudence, Natural History, Natural
Philosophy, etc., appear to be more peculiarly eligible for admission into the
service.

By the rules of the service, no Assistant-Surgeon can be promoted to the
rank of Surgeon until he shall have served five years (two years of which must
be in a ship actually employed at sea), and can produce a certificate from one
of the before-mentioned colleges, faculty, or corporate body; and it is resolved
that not any certificate of examination from anv of the aforesaid institutions
shall be admitted toward the qualification for Surgeon, unless the certificate
shall be obtained on an examination passed after a period of not less than three
years* actual service ; observing, that no one can be admitted to an examination
for Surgeon, unless, as hereinbefore mentioned, he can produce a certificate,
together with the most satisfactory proof, that he has performed, on the dead
body, under the superintendence of a professor or teacher of known eminence,
all the capital operations of Surgery, and is perfectlv competent to perform
any operation with skill and dexterity, and thoroughly acquainted with the
anatomy of the parts involved in such operation ; without which qualification
no one nereafter can be promoted to the higher branches of the service ; and
whenever Assistant-Surgeons already in the service (whose professional educa-
tion may not be in accordance with the above) obtain leave to study previously
to their passing for Surgeon, they will be required, on their exammation, to
produce testimonials of their having availed themselves of the period of leave
to complete their education agreeably to these regtdations generally.

^art Secontr.

REVIEWS.

Outlines of Surgical Diagnosis. "Rj G. H. B. Macleod, M.D.,
F.R.C.S.E., F.F.P.S.Glaag., etc. London : 1864.

The diagnosis of disease is commonly said to be half its cure.
Happy the man who can attain to such results by intuition, who
can, without care and circumspection, avoid the pitfalls which
stupidity, ignorance, design, or nature throws in his way, and
without let or hindrance reach the end of his career without some
blot in his reputation. This book is not intended for such a man ;
he never could be induced to take the trouble of reading it, for it is
a work for study rather than ready reference, for the exercise of
undisturbed thought rather than a rapid glance shot obliquely down
the page. No woodcuts adorn its leaves j it is all letterpress from
the title-page to the end ; and, furthermore, has been constructed
upon a somewhat inconvenient plan, so that the alphabetical arrange-
ment of its contents severs kindred subjects from each other, and

1864.] DR MACLEOD'S OUTLINES OF 8UB0ICAL DL4GN0SIS. 363

almost necessarily requires repetition, or, what is more distracting
stilL a reference to subjects dealt with on some other page.

To escape from this awkwardness, an introductory chapter and a
copious index have been added. In the former, the means are dis-
cussed by which surgical disease is diagnosed, and the broad
Seneral symptoms which require most frequent consideration are
welt upon and illustrated.

An^ work on Surgical Diagnosis constructed on this plan must of
necessity contain only so much morbid anatomy and pathology as
shall enable its author to justify his classification ; it must contain
chiefly the symptomatology ana semeiology of the diseased condi-
tions enumerated, described and contrasted with other symptoms
and appearances nearly allied or liable to be confounded with them.
Virtually, therefore, such a work is a surgical dictionary mutilated
of its just share of morbid anatomy and pathology, and with the
whole subject of therapeutics sunk out of sight.

To the junior student of surgery, therefore, it is not likely to
prove an attractive book, as he must of necessity apply elsewhere for
much important information which the lecture-room, clinical study,
and terror-inspiring examinations all teach him is imperatively re-
quired. By the practitioner in doubt, who seeks for certainty in
circumstances of a difficult kind, it can scarcely be a satisfactory
prospect when he has a swelling of some kind in the groin to deal
with, to wander with hurrying glance through the whole subject of
Abscess, Adenitis, Aneurism, Fatty Tumour, Cystic Tumour, Erectile
Tumour, Medullary Tumour, and Hernia; or in the case of an injury
of the shoulder-joint, to turn vainly from Acromion to Scapula^ taking
the Clavicle and Humerus on his way, and reading the articles on
Bruise, Dislocation, Fracture, and Sprain for enlightenment.

It is the fashion in the clinical teaching of some schools, or at
least of some teachers in these schools, to instruct their pupils
by an elaborate system which may in the matter of diagnosis
be pretty accurately designated as "how not to do it." This
indirect method of diagnosis carried to its full perfection consists
in a very elaborate enumeration and description of everything in
the case which can and cannot be seen, heard, and felt, followed
by a statement of every possible disease to which these symp-
toms may be referred, and commented on with the object of
showing which of these it is not, reserving, as a bonne bouchsj some
three or four, which it may be, for more minute inquiry, and recom-
mending reticence and patience, ere deciding upon which of these
conditions the disease really is. Such a method reminds one of
the plan of mnemonics, by which to recollect a forgotten name, when
the whole letters of the alphabet are gone over in hopes of chancing
upon the missing word ; or of ringing all the bells on one side of
the street in search of a friend's house which stares one in the face
upon the other side. It may give the practitioner a ready know-
ledge of symptoms, and a power of ringing the changes on them ;

VOL. X.— NO. IV. 3 A

864 DB MACLEOD'S OUTLINES OF SURGICAL DIAGNOSIS. [OCT.

or the oblivious memoij a familiarity with the alphabet ; or the
frequent caller an acquaintance with door bells and street knockers ;
but so long as the diagnosis of diseases^ the remembrance of names^
or the recognition of friends is what is really desired, the other accom-
paniments should surely be permitted to occupy a subordinate
position. Still, what in the analogies of everyday life becomes
absurd, is practised constantly and regarded as the only truly
scientific method of research m the instance of the diagnosis of
disease by men, who would repudiate the other puerilities we have
adduced, except in a few exceptional cases, and tolerate these simply
because nothing better was attainable. This indirect method of
diagnosis of disease has, however, had many followers, and specially
befits our patient, painstaking, scrutinizing German friends. It
is, however, thoroughly at variance with our English character ; and
although it may be calculated to fill up time when clinical materials
are deficient, it may very reasonably oe doubted whether the time
so spent may not more reasonably be said to be wasted.

The first object in diagnosis to be arrived at is certainty, so
determined as to enable the practitioner, not tentatively but confi-
dently, to prescribe what shall prove sufficient in effecting a cure.
Anything which aims short of this is mere trifling ; and although
such certainty may oftentimes, especially in a young practitioner,
be difficult to attam to, that should not the less make him set it
ever before him as the great aim in examining a patient who

})resents himself to his notice. To encumber the mind with aU the
iBu^ts of a case, to hamper its fi'eedom of action by considering all
the opinions which can be entertained in regard to it, to weary its
powers by balancing all the m-ounds for and against these views
were very folly, and calculated to convert the intellectual faculties
into a lumber-store, rather than the receptacle of well-selected,
well-considered, and well-arranged facts. Such a procedure woula
resemble that of the gold-picker who, fearful of losing the smallest
particle of the precious metal, should fill his panniers with dross and
pebbles as well. Were he a novice, he might have some excuse ; but
with any knowledge of the ore he was in quest of. with any experi-
ence in such a search, the true wisdom would surely be to collect not
what was worthless, but what was valuable, — ^not what must some
day be "shot" as rubbish, but what would remain as golden and true.
To make a diagnosis, in our way of thinking, is not to attempt
to appreciate all the elements of a case, but rather to look through
these elements with a view to select those, and those only, which are
of real importance for forecasting its progress and deciding upon its
treatment.

If such a line of conduct is suitable in medical diagnosis, it is
essential in surgical ; there the nature of the case lies upon the sur-
face, and less opportunity is afforded for weighing the possibilities and
probabilities in the balance. Any such hesitancy would communi-
cate to a sensible patient a feeling of insecurity, and if to some

1864.] DR MACLEOD'S OUTLINES OF SUBQICAL DIAQN06IS. 366

poor mahde imcmnaire it afforded a temporaiy gratification, that
would verj soon lose its influence in his search after something new.

In investigating the symptoms which present themselves more or
less palpably to oar notice, some are, when recognised, more defi-
nite than others, and to these a young practitioner vjery naturally at
once resorts for assurance. This may not always be the wisest plan.
With more method and less effort he might have rendered the
diagnosis far more certain, and attained his object with less pain to
his patient, and a greater sense of security in his own opinion. For
example, in the case of an injury in the neighbourhood of the
wrist-joint, when the idea of a multure of the radius or of the bones
of the forearm at once enters into the practitioner's mind, nothing
more immediatel}^ tells the surgeon of experience from the novice
than the manner in which the diagnosis is effected. The latter at
once seizes the hand, and by a series of twists and wrenches
attempts to detect the existence of the crepitus of a broken bone.
The other hears how the accident happened, where the greatest
pain is situated, and observes the deformity wnich exists before he
ever lays a hand upon the injured limb. From the symptoms he
then observes, he in all probability forms his diagnosis with such
accuracy that he manipulates the limb, not to recognise the crepitus,
but to reduce the deformed member to its pristine shape ; and, in so
doing, has his diagnosis confirmed and crowned by th^ development
of the symptomatic grating.

The great difficulty experienced by every young practitioner
entering upon the practice of his profession is to learn the art of con-
verting the knowledge he has acquired from books and lectures into
such shape that he can apply it to the investigation of actual instances
of disease. In systematic treatises a given disease is described
minutely not as it exists in a single case, but in its abstract form
as deduced from an infinite experience in such cases ; and it may pos-
sibly so happen that the ideal representation as portrayed, bears but
a small resemblance to the individual instance which presents itself.
What a young practitioner, therefore, greatly desiderates, in a work on
Surgical Diagnosis, is not a mere abstract of a systematic treatise on
any special form of surgical disease described under the name by
which it is currently known in medical nomenclature, but such a
reasonable description of those modifications of structure, form, and
function, occurring singly or combined, as shall enable him to
determine what the malady is which comes before him. In the one
plan, the subjective method of description is employed, and the
name of the malady must be known before any reference can be
made to its symptoms ; in the other, the objective method is
adopted, and the accumulation of evidence gathered from the
symptoms builds up a case of disease to which a certain name,
prognosis, and plan of treatment is at once applicable.

!No doubt the composition of a work npon Diagnosis, written
^pon the objective principle, is a far more dimcult and arduous task

366 DR MACLEOD'S OUTLINES OF SURGICAL DIAGNOSIS. [OCT.

than the compilation of a work npon the subj/sctive system. The
former is at the same time capable of far less minuteness of division
and subdivision, nay, may at first sight appear confused in the
extreme, and unlike the latter, afibrds little opportunity for a parade
of authority and book-learning in its composition. It is, however, by
the practical employment of this objective method that a knowledge
of surgical disease becomes impressed on the mind of the practical
surgeon"; and it is just the necessity of translating the subjective
into the objective which constitutes the whole difficulty in recog-
nising a disease when seen in nature, even to those whose abstract
knowledge of its symptoms as described in text-books is irreproach-
ablv accurate.

It has long been a well-recognised fact, that after a competent
knowledge of surgical pathology has been acquired, no reading
is more improving than that of well-told cases. And this is true,
because such accounts of cases, when well written, are the nearest
approaches to the cases themselves, with this important differ-
ence, that as the symptoms have been selected from the other
unimportant and accessory circumstances, and so arranged as to give
a prominence to what is really of moment, an appreciation of their
characteristics is a much simpler matter for a beginner than it
would be for him, unaided, to make such an investigation for him-
self But while well-told cases are thus instructive, a painstaking
enumeration of every circumstance in the history and progress of a

Satient becomes most intolerably irksome, and renders the case so
evoid of character, as to make it incapable of leaving any per-
manent impression upon the mind of the reader.

The more nearly, therefore, that an author in a work upon
surgical diagnosis can copy the mental processes which go on
through the medium of his senses in the investigation of a case of
disease or of injury, the more interesting and useful will his work
become, the greater hold will it take of the reader's memory, and
the greater impression will it be likely to produce upon his practice.
On the contrary, the more formal, unreal, and tabulated tne char-
acter of such a work, the more of a labour will its perusal neces-
sarily become, — the more difficult will it be for the reader to
translate its learning and erudition into the language with which
practice makes him best acc^uainted. Whenever such a work
becomes fancifully refined in its distinctions, or aims at drawing
hairbreadth differences between conditions which in prognosis ana
treatment it is of no moment to differentiate, or is overlaid with
pathological refinements which can only accurately be determined by
the investigations of morbid anatomy, so much the more unreal and
unnatural does the work become ; and thus its value is diminished,
its interest detracted from, and its general utility lessened as a
medium fitted to minister to the wants of students and young
practitioners.

In fact, by leading the inexperienced to discover points of re-

1864.] DB MACLEOD'S OUTLINES OF 8UB0ICAL DL4QN0SI8. 367

semblance between . conditions which have nothing in common|
except that| in some individual example, a mistake in diagnosis has
been committed by confomiding the one affection with the other,
mnch mischief may be done. The c;reat object of sorgery is to
attain to the ^^ quod certum et efficax ; anything, therefore, whether
in the shape of written or oral instruction, which, on the contrary,
leads to a feeling of uncertainty, and which communicates a sense
of want of entire confidence, is just in so far dangerous and objec-
tionable. The great rule, therefore, in teaching and writing, with
a yiew to instruction, is never to bring difficulties to the surface
without providing some means equally clear and accessible by which
they can be overcome, circumvented, or avoided. Nothing is pro-
ductive of more mischief than the method of some who, in teaching
a practical subject, surround it with a halo of mystery, or who, to
magnify their own office and practical sagacity, lead their pupils to
imagine that there are obstacles to be met with in practice which
require more than common powers of head and hana to surmount.
It is perfectly true that the attention and understanding may be
painfully exercised in training for the medical profession ; but in
most cases it is not the examples of disease as they occur in
practice which occasion this, but the elaborate dressing with which
the subject has been wrapped in its systematic consideration.
What man has done man may do, and no presumption is more
intolerable than that of a teacher who presumes that nis pupils are
more stupid or less capable of sagacity than himself. The excep-
tions to general rules, and the stumblingblocks in practice, of one
kind and another, occur frequently enough in every man's expe-
rience ; but what constitutes a difficulty to one individual, never
troubles another. The lesser elevations and irregularities of the
road, which trip the palsied limbs, have no existence in the walking
experience of the man of sound and healthy extremities ; and thus
what may be considered as difficulties and obstacles in practice to a
teacher might never occur to his pupil of less morbid mental con-
stitution, were it not that they hsui been diligently pointed out and
animadverted on by his well-intentioned but mistaken preceptor.

We do not wish to diminish one tittle from the importance of
exceptions* in their proper place. Exceptions we know quite well,
in a certain acceptation, prove the rule ; and^ in surgery, exceptional
conditions stamp the impress of the rule which they transgress more
firmly upon the perceptions of the observer. But because they
have this value to him, they should not be allowed to bulk too
largely in the scheme of his teaching, else, so far from proving
ancillary to the rule in the mind of his pupil, the^ are almost
certain to create confusion, or even to usurp the chief place in his
memory. Were illustration needed, the examination papers of
students in the class-room, or of candidates for appointments and
diplomas, would afford the most varied, amusing, or painfully
absurd testimony. As, for instance, when a young man, in a recent
examination for a public appointment, stated a common cause of

368 DR MACLEOD'S OUTLINES OF SURGICAL DIAGNOSIS. [OCT.

retention of urine to be the dislocation of the head of the feraor
into the perinaeum. The wounding of the lobulus Spigelii bj the
desperate thrust of a sharp gorget in the hand of a venturesome and
ruthless lithotomist, as a lecturer's argument against the employ-
ment of such an instrument, is scarcely a less palpable instance
of the danger of the exceptional method of teaching ; for, while
good matters of fact are every day found to be omitted from the
answers to examination questions, this most apocryphal story is
sure to crop up in a large percentage of the papers.

The great object of a teacher of objective surgery, and of any
work which professes to educate the student of surgery in observa-
tion, is not to cram the mind with facts culled from every sourcci
but to instruct his perceptions in such a manner as shall enable
him to observe for himselT, and thus fill up the natural capacity of
his intellect with materials in such form as are best fitted commo-
diously to occupy its spare space. We contend that this constitutes
the great distinction between Clinical and Systematic Surgery, as
also between a work devoted to Surgical Diagnosis, and a systematic
treatise on Surgical Pathology and Treatment. The one should
contain nothing but what commends itself to demonstration in
special cases, the other should contain what is mature, sound, and
standard, as applied to the condition considered abstractly.

We have been particular in thus expounding our views of the
subject of Diagnosis, not to condemn Dr Macleod's work on
Surgical Diagnosis, because it departs from our ideal, but because
in approving his labours in the path which he has chosen we
coula nave wished that he had adopted a different mode of treating
the subject. His labour is chiefljr one of his own mind supplying
its materials from the writings of others, which, with great success,
he arranges in such form as to produce strong lights and shadows
in his consideration and description of the symptoms of the diseased
conditions of which he treats.

In illustration of the style and method of Dr Macleod's treatise,
we introduce the following extracts. The first from the introduc-
tion, the second from the body of the work.

That portion of the introduction from which we quote is devoted
to the means employed in the investigation of the symptoms, and
is directed to guide the practitioner in considering the history of
the affection from which the patient suffers.

" Frequently we gain the confidence of the patient better, allow him to oyer-
come the little nervouHness excited by our yisit, and get time to watch his
expression, constitntion, strength, and those many important details taken in
almost intuitively by the eye, when we allow him first to tell us his story before
we proceed to examine the part for ourselves. On the other hand, the import-
ance of determining the condition of the part is so clamant, that we prefer
giving that portion of our duty the lead. This last remark is especially true
of many surgical complaints, where, for example, an injury is the sub^'ect of
investigation. In the case of children, or lunatics, or persons insensible, or
from any cause unable to tell us ausht of their complaint, then, of course, we
are wholly thrown on the personal examination of the case; while in those
diseases which only manifest themselyes by functional derangement (as in

ia64.] DB MACLEOD'S OUTLINES OF SURGICAL DIAGKOSIB. 869

many of those of the nerroos syttem), withoat any appreciable lesion, we jnust
be mostly guided by the statement and explanations of the patient.

" It ma^ be here remarked, that in his interro^tions ana all his interconrse
with the sick, the surgeon must be most kindly m his manner if he wifthes to
elicit the information he seeks. Patience and tact are often much required in
dealing with the ignorant. ' To question fitly is the art of a master/ says
Rousseau. The advice of Sydenham is worthy of constant remembrance, when
he says, that the surgeon, in his dealings with the sick, should recollect ' that
as he is himself not exempt from the common lot, and is liable and exposed to
the same laws of mortality, the same miseries and pains, as are all the rest, so
he may ehdeayonr the more diligently, and with the more tender affection, at
being niroself a fellow-sufferer, to help them who are sick.* The ignorant are
often so conscious of their ignorance, that they are at once confused if ques-
tioned sharply ; while with all it is desirable to use plain, concise, and simple
language, and try by kindness of look and manner to ^ve confidence. We
should interfere as little as possible with the patient in his narrative, so as that
nothing be suggested to him at first. In putting Questions, let them be as *
much as possible such as only demand a 'yes* or a * no, and we must be sure that
the question be perfectly understood before the answer is noted. The intelli-
gence, education, and even the prejudices of the patient must be borne in mind,
and the questions and mode of examination varied accordingly." — Pp. 7, 8, 9.

The nature of this work, the vast extent of subject which it com-
prises, of course prevents us from entering into anything like even
an examination of its varied contents ; in fact, in choosing the second
extract we have been influenced quite as much by the desire to find
some subject complete in itself, and, at the same time, so sufficiently
brief as to enable us to transfer it to our pages without such
abreviation as would desti-oy its character as an illustration of the
author's style and method of dealing with his theme.

" Pyoemia, or purulent infection, arises from the circulation in the blood of
some decomposing or poisonous ingredient, derived from suppuration in some
of the tissues ; and, in consequence of this intermixture, the blood tends to
coagulate in the vessels during life. Pyoemia gives rise to symptoms of low
typhoid fever, accompanied by embarrassment of function in those organs in
which the secondary or metastatic abscesses form, which constitutes one of the
leading features in the pathology of the disease. If there is a wound, it may
or may not change its character when the pyoemia sets in ; and the veins and
lymphatic vessels leading from it may or may not show signs of inflammation
or irritation.

A rigor setting in suddenly, and being severe in its character, followed by
profuse perspiration, is the most common of the early symptoms of pyoemia.
The rigor, in some cases, is slight and evanescent ; but more commonly it is
severe, and may recur irregularly, or at such stated periods as to present all
the appearance (with the succeeaing sweats) of a quotidian or double quotidian
ague. Nausea, too, and vomitine ; a rapid pulse, which soon flags and becomes
feeble and intermittent ; irregular action of the bowels ; a brown, dry, and
furred tongue ; high-coloured urine ; pains of a wandering or fixed character in
the limbs or joints ; a yellow colour of the skin, which varies in shade from
bright yellow (rare) to a dark dirty hue, are further symptoms. The discolor-
ation referred to begins on the trunk, and sometimes appears later in the con-
junctivae. The breath and sweat have a peculiar sweet smell, like new hay,
A stitch in the side, accompanied by dyspnoea and dry cough, or pleurisy,
pneumonia, or pulmonary abscess, occur. Effusions into the joints, accom-
panied usually by most atrocious pain ; erratic ervsipelas ; hiccup ; ^eat pros-
tration ; anxiety of countenance (which gets pincned and wan) ; rapid emacia-
tion ; often delirium, and death in from one to many weeks. Such is the train

370 DR MACLEOD'S OUTLINES OP SURGICAL DIAGNOSIS. [OCT.

of Byxnptoms commonly observed; and though all the symptoms are seldom
fully portrayed (several of them being frequently much modified or even
"wanting), yet they constitute the typical progress of the complaint. The chest
or the joints may become implicatea, ana pus be poured out, without any pain
or embarrassment of function being complained of.

Sometimes the disease invades the system most insidiously. There are no
marked rigorsi but intense prostration and low intermittent fever. The
breathing will most usually be embarrassed and the skin icteric ; and if there
are visceral inflammations and effusion, other sisns will be shortly added.

It may be said that if, during the progress of a suppurating wound, we find
rigors followed by sweating suddenly and rapidly settmg in, and being repeated
and followed by prostration and typhoid symptoms (brown tongue, sordes, low
delirium, etc.), and especially if the skin gets yellow and the sweat and breath
have a sweet smell, and further, if there is any evidence of visceral inflammation
or effusion, we can have little doubt as to the formidable enemy which has
taken possession of our patient. Even if, without other apparent cause, a
*patient, during the progress of a suppurating wound, becomes suddenly pros-
trate and tvphoid, though no other sign be present, we may have a very strong
mupicion of what has occurred. If abscesses form in the soft parts, the doughy
feeling the)r communicate to the hand, and the red blush over them, will
indicate their presence.

Pyoemia has in some of its stages or t3rpes to be distinguished from

(1.) Low or typhoid fever; (2. J rheumatism; (3.) visceral inflammation; (4.)
glanders ; and in general the distinction is easy.

(1.) Low or typhoid fever does not present the same recurrence of rigors.
There is not the same early prostration ; the yellow colour of the surface ; and
the peculiar odour of the sweat and breath.

In pyoemia, too, we have not the abdominal symptoms and peculiar eruption
seen usually in true idiopathic enteric fever.

(2.) In rheumaliam the articular pains are primary, and do not follow other
symptoms, having no connexion with rheumatism, as in pyoemia. The joint
pains in pyoemia, if disconnected with the rest of the symptoms of the disease,
cannot be confounded with those of rheumatism ; and tnen there is not the
erysipelatous redness and oedema which mark the purulent effusions into the
jomts.

(3.) Visceral inflammations (lungs, liver, etc.) are not accompanied by the
other signs which denote pyoemia.

(4.) In glanders^ the history, the peculiar eruption, and nasal discharge, all
point out the character of the affection, though doubtless pyoemia is often con-
joined with glanders.

In taking farewell of the work we wish it every sncoessi and
congratulate its author upon the varied attainments, the manifest
diligence, and great patience which he has brought to bear upon
the elaboration of its contents.

InJtroductixm to Anthropology. By Dr Theodor Waitz. Trans-
lated by J. F. CoLLiNGWOOD. Published for the Anthropological
Society of London, by Longman & Co. : 1863.

On the Phenomena of Hyhridity in the Genus Homo. By Dr Paul
Broca. Edited by C. Carter Blake. Published for the
Anthropological Society of London, by Longman & Co. : 1864.

The place of man in Nature ; the date of his appearance on the
&ce of the earth ; his primeval habits ; his co-existence with various

1864.] PUBLICATIONS OF THE AHTHKOPOLOQICAL 80CIETT. 871

animals now extinct; his relations to the lower animals, more
especially to the anthropoid apes ; the modifications which climate,
food, clothing, and education induce in his external form ; — are topics
which have excited much interest and discussion of late years, not
only amongst students of, and workers at, the natural sciences, but
amongst the most intelligent of the general public. The important
discoveries which have recently been made, not only of implements
evidently made by human hands, but even of portions of crania and
other human bones, in localities and under conaitions which indicate
a considerable geological antiquity— one much greater than has
usually been regarded as the date of his first appearance — have
tended much to arouse an interest in all general questions concern-
ing man and his nature. Various works have also issued from the
press treating of these questions, and amongst these are the two
whose titles head the present article. The Introduction to An-
thropology, by the late Professor Waitz, is much the more important
of the two treatises,— one which will bear a careful perusal by all
engaged in the study of the subject on which it treats. With
characteristic Oerman industry, he has collected together, and, on
the whole, judiciously arrangea, a vast amount of information on the
subjects discussed in his comprehensive treatise. But we must
confess that his omnivorous appetite for collecting materials has
more than once led him to give a value to statements which later
and more accurate investigations have shown to be not in accord-
ance with facts. The nature of the book may be judged of by the
following general reaumS of its contents. There are chapters on the
physical changes to which man is subject ; on the chief anatomical
and physiological difierences which distinguish the various races ;
on the results of intermixture of different types, and the peculiarities
of the mongrels ; on the principal theories regarding the unity of
mankind; on the classification, specific characters, and primitive
state of man ; and on the various degrees of civilisation and the
chief conditions of its development.

One of the most interestmg chapters in the volume is that in
which the author discusses the question of the unity or plurality of
origin of mankind. The conclusions which his investigations have
led him to form are summed up in the following paragraph : —

" That the known facts not only permit the assumption of the unity of the
hnman species, but that this view presents less difficulties than the opposite
theory of specific differences ; because any number of species assumed, appears
equally arbitrary. But as the principal arguments in favour of unity of species
rest upon the mutability of tne human organism by internal and external
influences, the limits of which are unknown to us ; and as, in the absence of any
exact information as to the length of time they were in action, we cannot
decide whether the power of these influences was sufficient to produce the
existing differences, the question of unity of species remains an open one.
Even if it were satisfactorily proved tliat the magnitude of the changes which
a human family may in course of time undergo, equalled the differences between
the negro and the European, it would still remain uncertain whether, in fact,
the one descended from the other. The question as regards unity of species

VOL. X.— MO. IV. 3 B

372 DR S(X)RESBY-JACKSON ON THE [OCT.

might then be considered as answered ; bat not unity of descent. We possess
scarcely any facts which may serve as a basis for the solution of the latter
question, and in whatever way it may be decided, the solution can only claim
some degree of probability.*^

The hybridity of the races of man, which forms the subject of
M. Broca's memoir, has more than once received attention in the
earlier numbers of this Journal, and we may refer our readers to
the papers by Messrs Alexander Harvey and Heywood Thomson,
in the volumes for 1850 and 1851, for a discussion of the statement
made by Strzelecki, that the aboriginal women of New Holland,
after having had children by Europeans, were unable to procreate
with native males. M. Broca carefully reviews all the evidence
which has been advanced in support of, or in opposition to, this
statement of Count Strzelecki, and concludes, that the assertion was
too general, though in many cases it had a foundation in fact
From a careful consideration of all the documents bearing on the
cohabitation of whites with the native Australians, if. Broca
believes that the alliances between these races are but little prolific,
and that the mulattoes sprung from such intercourse are too rare to
have enabled us to obtain exact particulars as to their viability and
fecundity. Thus, whilst admitting without any hesitation that
certain mtermixtures of races are, as he terms it, engenesic (t.e.
entirely fertile), he concludes that there are other intermixtures
notably inferior in prolific power.

On the Influence of Weather upon Duease and Mortal^, By R. E.
Scoresby-Jackson, M.D., F.R.S.E., etc., etc* Transactions of
Eoyal Society of Edinburgh, 1863,

The relations which disease and mortality bear to the weather
have not been sufficiently studied. In fact, it is only of late years,
since the use of delicate instruments has become general, ana
meteorological observations have been multiplied, that an attempt
to work out these relations in a scientific manner has become pos-
sible. The subject is full of interest and practical importance, and
Dr Scoresby-Jackson comes before us as the writer of a valuable
memoir on this subject. The inquiry is limited to Scotland, and
extends over six years, from 1857 to 1862 inclusive ; the meteoro-
logical data are taken fi-om the collected returns firom the stations
of the Meteorological Society of Scotland, as reduced by the
Astronomer-Royal ; the mortality tables are constructed fi-om the
returns of the Registrar-General. The meteorological points to
which attention is paid are the temperature, the atmospheric
pressure, the degree of dryness or moisture of the air, and the
influence of winds. The influence excited by electricity and ozone
are not considered ; with regard to the first, Dr Scoresby-Jackson
had no information, and in the case of ozone, his information was

1864.] INFLUENCE OF WEATHER UPON MORTALITY. 373

not to be depended upon. In regard to ozone, be sajs, ^^ I submitj
witb all deference, that until the chemiatiy ot ozone is more fully
understood, its physiological action cannot be accurately definea.
So long as it is left to each observer to determine the amount of
ozone present at his station by the varying depth of colour on a
slip of paper, our knowledge of the true quantity present must
depend upon very slender evidence, and consequently be of very
questionable accuracy. It is quite possible that six different
observers might, with exactly the same indication on the test-
paper, refer the amount of ozone present to as many different
shades on the reference paper. Whether the paper itself affords
a true indication of the presence of ozone, and to what extent,
in the atmosphere, is a disputable matter. At all events, under
existing circumstances, I should hesitate in comparing the ozone
returns with the death-rate."

The first part of the work consists of an endeavour to discover
the influence of weather, and its individual meteorological com-
ponents upon mortality from all causes ; the second treats of the
influence of weather upon mortality from special causes. This
difficult inquiry has been conducted by Dr Scoresby-Jackson with
ereat ability and in the most careful manner ; he has also constructed
four large diagrams which present to the eye in a very striking
manner the results of his inquiries. It is impossible for us to
follow the author into the data from which he draws his conclu-
sions ; we must be content with giving some of his general results.

The following is Dr Scoresby-Jackson's recapitulation of the
influence of the weather on the mortality from all diseases : —

"A. Temperature. — 1. Below 50" Fahr., the relatioDship exist ing between
mean temperature and the death-rate from all causes is inverse — the lower
the temperature the higher the mortality; but above 50° the relationship
becomes cHrectf the death-rate increasing with the temperature. The months
during which the latter condition is observable, are probably July and August ;
but in Scotland the mean temperature does not often rise so high as to render
it a cause of alarm.

**2. Over the whole year the relationship between the monthly range of
temperature and the death-rate is inverse ; but during the months of July,
August, and September, it is direct. A similar relationship exists between
the mean daily range of temperature and the death-rate.

" 3. It is probable that dry cold is more fatal than humid cold.

" 4. Extremes of temperature are always fisital, but eminently so when long
sustained.

" B. Atmo^heric Pressure. — 1. The results afforded by comparison of the
relative height of the barometer with the death-rate from all causes are con-
flicting, but there is probably a preponderance in favour of the supposition that
the relationship between the two is inverse in the colder, and airect in the
warmer months.

" 2. The relationship between the monthly range of the barometer and the
death-rate is direct.

** C. Drought and Humidity. — The relationship existing between humidity
(irrespective of temperature) and mortality appears to be direct in the colder,
and inverse in the wanner months.

" D. Winds. — Winds blowing from a point between N.W. and S.E. (north
about) attend a high death-rate. Winds blowing from a point between S.E.

374 INFLUENCE OP WEATHER UPON MORTALITY. [OCT,

and W. (south about) occur more frequently during months m which the mor-
tality from all causes is low."

The most interesting portion of the second part of this memoir is
that which treats of the influence of the weather on the mortality
from phthisis pulmonalis and bronchitis. The following aie Ur
Scoresby-Jackson's conclusions : —

In regard to phthisis, —

" 1. Tliat a low mean temperature of the winter months gives rise to an
increase in the death-rate from phthisis, and that this relationship is the more
clearly observable if the low temperature be sustained for some time without
intermission, as in the case of the months from November 1859 to February
1860 inclusive. A high summer temperature joes not seem to increase the
fatality of phthisis. It is only when the temperature of winter is remarkably
low that the increased death*rate from phthisis is distinctly traceable to that
cause.

" 2. That the relationship between the monthly range of temperature and
the death-rate from phthisis is uncertain, and tliat the Tatter is not under the
control of the former.

** 3. That the daily range of temperature exerts no constant influence upon
the death-rate from phthisis.

"4. That there is no constant relationship observable between the mean
monthly height of the barometer and the death-rate from phthisis.

** 5. That if there be any indication of a constant relationship between the
monthly range of the barometer and the death-rate from phthisis, it is that the
death-rat^ increases with the range.

** 6. That the rainfidl bears no constant relationship to the death-rate from

Shthisis. It is possible, however, that it may be inverse in the colder and
irect in the warmer months.

" 7. That possibly an increase in the number of days during which north,
north-east, and east winds prevail, may give rise to an increase in the death-
rate from phthisis."

In regard to bronchitis, —

** 1. That there is an inverse relationship between temperature and the death*
rate from bronchitis in all seasons, but that this is more remarkable in the winter
months, and especially when the cold is severe and protracted.

" 2. That possibly there may be an inverse relationship between the monthly
range of temperature and the death -rate from bronchitis over the whole year;
but the relationship varies with the season.

" 3. That the relationship between the daily range of temperature and the
death-rate from bronchitis also varies with the season ; but there is no indica-
tion of any constant correspondence.

" 4. That possibv the relationship between the mean height of the barometer
and the death-rate from bronchitis may be inverse in summer and direct during
the remainder of the year. And that there is no constant relationship between
the death-rate from bronchitis and the monthly range of the barometer.

" 6. That the rainfall does not influence the death-rate from bronchitis. To
the last two suggestions it may be added, that although the tables do not indi-
cate any constant correspondence between them, nevertheless it is highly pro*
bable that the state of the barometer, and the hygrometric condition of the
atmosphere, do exert a powerful influence upon the mortality from bronchitis,
and that the reason why such influence is not more distinctlv visible is this,
that whilst a dry atmosphere with a high barometer is prejudicial to one class
of bronchitic patients it favours another, and vice versa ; so that, the one
class balancing the other, the Influence is not discoverable upon the whole
death-rate.

" 6. That the north, north-east, and east winds decidedly tend to increase
the death-rate from bronchitis."

1864.] PRACTICE OF MEDICINE. 375

PERISCOPE.

PRACTICE OF MEDICINE.

ON THE PHYSIOLOGICAL ICEANINO OF INFRAMAMUART PAIN. BT DR 8. MARTTN.

If we recall to our minds what has of late been done for the Phymology qf the
Nervous System, and the labours represented by the yolnminous essays of our
friends and contemporaries (I need not mention names), how evident does it
become that a revolution is taking place in many of our prevalent ideas ; new
groups of symptoms must be connected with well-known lesions, and vice vered ;
while a revision of all remedial treatment must follow in the wake of newly
demonstrated causal connexions. But life is short ; and the registration of
nervous manifestations for inductive reasoning necessarily very long. Till
some hypothesis has been set up, this re^tration cannot even begin ; and thus
it is that, while time flies, vast opportunities of noting these diseases afforded
by our hospitals and infirmaries are apt to be lost.

It is with a view to contribute something to this developing insight, that I
have thrown together the following brief remarks.

I wish to advance a theory for one of the most frequent, intractable, aad
mysterious nervous affections with which we have to do : that particular pain
in the side, known as ** inframammary pain.'* The disease is aistinct enough
in its leading symptoms, and its literature is extensive ; so much so, that tima
would not allow me to attempt a reeumS of it in this place. I have, however,
gone carefully over what has been said, and taken into account the arguments
on various aides, besides retaining notes of very numerous cases in my own
practice.

My definition of the affection to which I am alluding would be this : PatM,
very common, either continuous or intermitting irre^larly, and brought on by
movement. Sex, more frequent in women (as 20 : 5). Locality ^ superficial,
and confined to spots in the sixth, seventh, and eighth intercostal spaces, those
oftenest affected being inframammary, the next in frequency near ttie spinal or
sternal end of those intercostal spaces. Side ajffected, mostly the left (13 : 7,
Valleix), sometimes both. Temperamenif the nervous. Duraiion, indeter-
minate, according to Basse, often through other diseases till death.

It is no/ a rheumatic pleurodynia; for the pain is not so violent nor so
diffuse, nor is there a febrile state. It is not dry pleurisy nor angina ; for the
breathing is free, and the lung-sounds are normal. It is not menmgitis of the
cord, nor softening, nor caries of vertebrae ; for from all these a diagnosis may
readily be made. It is a true intercostal fteuralgia. Not to ^o further into
detailed description of a state which these points will suffice to identify, it was
the entire absence of a satisfactory proximate cause assigned for this pain that
led me to look over my cases, and review the subject more closely.

I may here allude to what I think is the most recent discussion of this topic,
and which is contained in the volume of the British Medical Journal for 1858.
The controversy lasted through the year, and the variety of new theories pro-
posed, or old ones defended, shows clearly enough the difficulty surrounding
the subject. In this discussion, the opinion first in point of time was Dr
Inman's, that the pain is a true " myalgia/' the exponent of fatigue or mal-
nutrition, and successfully treated by a generous diet. Next comes a paper by
the late Dr Charles Coote, read before the Harveian Society, in which he
divides the affection mto classes, combats the myalgic theory on the ground

376 PERISCOPE. [OCT,

that it affords no explanation of the localisation, throws over " spinal irritation *'
as meaningless, " uterine irritation " as illogic^J, because this pain occurs in
men, and hnally reverts, himself, to Henle^s pressure theory. This Uieory ia,
that the left inframammarv region must be specially liable to venous conges-
tion, from the anatomical fact that its veins run into the azygos ; so that, if the
azygos happen to be obstructed, the veins would be over-Sled. On this Dr
Coote very aptly remarks, that there is one link wanting, viz., " some proof
that in these cases vascular disturbance exists." He might have added that
there is no proof or even likelihood that simple venous congestion could pro-
duce the acute pain of intercostal neuralgia.

Dr Coote's own theory was very ingenious ; he held that the vaso-motor
nerves of the whole body were disordered, causing irregular contraction and
dilatation of the minute arteries ; this occasioned various mischief, and, in the
left inframammary re^on, being combined there with the tendency to congestion
(of Henle), produced mtercost^ neuralgia. I regret that amongst so much that
is valuable in the admirable paper by Dr C. Coote, this, the last link, should
be so weak, that I think he would himself scarcely have continued to maintain
it. It would not be difficult to show that such a theory is improbable ; but
what we ask for, first, is some proof in its support, or some explanation of the
formula that systemic vasomotor derangement, pltu this hypothetical venous
congestion, are equal to the production of circumscribed neuralgia 1 To return
to the discussion of 1858, no new theory besides these was advanced, except
that Mr Holmes Coote pointed out the 6equency of inframammary pain as a
sign of commencing lateral curvature.

Dr Fuller, however, after pointing out the errors of various explanations,
gave so graphic an account ot an attack he himself experienced, that I cannot
forbear quoting it. *' It first attacked me in the month of June, when I was
thoroughly exhausted by incessant work at my profession, and enervated from
want of active out-door exercise. At that time it did not annoy me much, and
I felt it chiefly after I had been sitting long in one posture, as in writing ; but
graduallv it increased in intensity, and was rarely absent, except when I was in
a recumbent position. I was unable to stoop without much pain, and quite
unable to lie on my left side, so acute did the pain become when I attempted
to do so. . . . It was accompanied, when severe, by superficial tendemesSi
so acute as to be aggravated by the slightest pressure, and though the pain
seemed to pervade a considerable portion of the inframammary region, the ten-
derness rarely covered, at any one time, a space much larger than a shilling. On
26th August, being thoroughly * out of condition,* I went for three weeks to Scot-
land, where I hoped to walk on my troublesome enemy ; but the fatigue of walking
the moors and carrying my gun increased the pain rather than diminished it.
My health, however, improved vastly, and to my great joy, the pain disappeared
within a week after my return to town life and bodily repose. In common with
every other member of our profession, I have met with numberless instances of
this form of inframammary pain. ... I felt then, as I do now, an inability
to account for its attackingthe left inframammary region in preference to any
other part of the body." This is Dr Fuller's account ; as a pendant to which
I may add, that I have myself suffered from this pain so severely as to be
unable to move in the morning, for many successive days, before the use of
a mustard plaster.

Now, in tne cases under my own observation, I have found two conditions which
seem never to be absent : the one, a state of general muscular weakness ; the
other, increased rapidity of the hearths action, except when the lowest amount
of propulsive force is required, as in perfect repose of body and mind, when the
pulse IS often abnormally slow. Of these two points, the disordered action of
the heart was the one which attracted my attention ; and though I am aware
that Professor Yalleix, in his essay on dorso-intercostal neuralgia, does not
allow any peculiarity of the pulse, 1 have satisfied myself by all subsequent
observation of my correctness on this point. In cases of intercostal neuralgia,
it will be found that there is palpitation on any exertion, and that in most cases

1804.] PRACTICE OP MEDICINE. 377

the pain and the palpitation have a distinct connexion. The question was
this : Why is pain almost invariably confined to the sixth, seventh, and eighth
intercostal spaces of the left side ? The answer seemed to be, — a rdaiian to
ikehtart.

Reflected or radiated pain is now recognised as extremeljr common. In
cases of sensory nerves entering a great centre at the same spot, if the peripheral
end of one be irritated, we feel pain in, or refer it also to, the periphery of
the other. The irritation brougnt by the phrenic from the diaphragmatic
pleura is referred to the end of the supra-acromial branches of the cervical
plexus ; uterine irritation is referred to the cutaneous region of the sacrum ;
and so on in other instances. The question thus arose, are there any nerves
supplied to the heart, and to the sixth, seventh, and eighth intercostsl spaces
from the same central region ? And then there appeared a most important
anatomical relation to be taken into account. The aortic arch impinges on the
left side of the third dorsal vertebra ; and opposite the fourth, fifth and sixth, it
receives contributions to its plexus from the corresponding ganglia of the sym-
pathetic, while its plexus again contributes to the heart. These sympathetic
ganglia, have, however, just received branches from the intercostal nerves
themselves ; and so it is that the heart and the intercostal spaces (four, five,
six) are supplied by branches of the same nerves. Moreover, this is on the
left side and above only, for on the other side, most of these branches go to the
OBsophagus, while below, those from the sixth ganglion chiefly go to form the
splanchnic nerves. Now the fourth, fifth, and sixth intercostal nerves are
those which give off large lateral cutaneous branches, descending over two ribs
before they terminate in the skin over the sixth, seventh, and eighth intercostal
spaces, or the site of inframammary pain. Smaller twigs of the same nerves
suppler the ends of the same intercostal spaces, where the pain may also be
perceived.

I had made up my mind as to this nervous circuit, but felt the great difficulty
in attaching any particular importance to the first few dorsal spinal fibres sup-
plied to the heart, when the researches of Von Bezold, in 1862, seemed to
throw light upon this point. I have not repeated his vivisections, but he has
done so himself a great number of times, and I think some importance may be
attached to his conclusions. Von Bezold poisoned rabbits with curare to get
rid of irritability of voluntary muscles ; then, the sympathetic and pneumo-
gastric nerves in the neck having been all carefully divided, artificial respiration
was kept up. When the spinal cord had been divided at the seventh cervical
vertebra, irritation of its distal cut end produced violent increase of the heart's
movements, while irritation of its proximal end did not. This was one of a
series of experiments which led him to the conclusion that the chief motor
centre for the heart in relation to sensation and psychical impression, and one
which contributes three-fourths of the motor impulse, is in the medulla
oblongata. From this centre the fibres do not pass down to the heart through
the vagi or syinpathetics in the neck, but through the cord. Emerging from
the cord near tne upper part of the dorsal region, these nerves pass to the
base of the heart, tmrough the sympathetics, and with contributions possibly
from ganslia below.

Thus the anatomical nervous connexion between the heart and the region of
inframammary pain became endowed with a great significance, and it seemed
more than ever probable that the sensorium received the impression of 9ome
dUUress in the heart through nerves which enter the grey posterior columns of
tiie cord at the same point as those from the sixth, seventh, and eighth inter-
costal spaces. The central impression is radiated, and referred by the mind
to the sensitive skin, according to the laws of reflection.

In the case of aneurism of the descending portion of the aortic arch, the
same nervous circuit accounts for the pain in tne side, which is indeed a more
aggravated form of inframammary pain. In severe instances of intercostal
neuralgia, painful spots are also to be found neax the sternum and spine, at
peripheral ends of cutaneous nerves, and even in the arm, which, tnrough

378 PERISCOPE. [OCT.

intercosto-hameral branches, receives also sensory nerves from the same source.
In these and other ways, I think the theory here laid down explains the actual
phenomena. For instance, the pain may be (thoogh always to a much less
extent) felt on the right side also. Now, although the furst internal dorsal
branches of the sympathetic on the right side go to the oesophagus, some of
them do run on from it, and under it, to the aortic arch. Again, though the
•ixth, seventh, and eighth intercostal spaces form the habitat of this pain, it
may be felt in the fifth and in the ninth also, this being readily accounted for
by the delicate and very irregular filaments which run from the first and second
dorsal gangUa, as well as from the great variations in the mode by which the
dorsal sympathetics form the great splanchnic. So far, then, 1 believe there is
some reason, on anatomical, physiolo^cal, experimental, and oathological
grounds, for adopting this theory, — that inframammary pain U a r^fiex neuralgia
expressive of some dutreae in the heart

In our present extremely limited knowledge of cardiac enervation, I am
scarcely prepared to support strongly any further conjectures as to what the
exact nature of this cardiac distress may be. My own view is that it belongs
to the cases of partial reflex paralysis, and that thb is the reason why general
muscular debility is its concomitant. Although the heart possesses nerve-
centres of its own, we have seen that there is some ground for thinking that its
action is regulated by the vaso-motor system through the cervical sympathetic
and the vagi, while the great direct motor stimulus of mental and sensational
acts goes to it from the medulla oblongata. If the proposition be true, that (as
Brown-S^quard tersely puts it), " almost all parts of the body may be affected
with paralysis in consequence of an outside excitation," why should not the
heart be placed under a list which includes the ** arm, hand, face, eyes, neck,
trunk, pharynx, oesophagus, bladder, etc.?"

Let me illustrate this hypothesis by an example. Nothing is more common
than inframammary pain on exertion, in cases of lencorrhoea. Now, no one
denies the ^eat influence on the nervous system of irritation in the cervix
uteri or neighbouring parts, these effects extending to the encephalon itself.
There is nervo-muscular fatigue of the whole system, and the pulse becomes
irregular as well as quick, especially when inframammary pain is or has been
present. But a quick pulse here means a weak heart, unable to produce suf-
ficient propulsion in the normal time. This weakness is not defective nutri*
tion, for it occurs frequently in the well-fed and luxurious. May it not be a
neurosis expressing the exhaustion of a centre (in the medulla oblongata) by
continued irritation (uterine nerves) ? Dr Fuller's case, as another type,
would be explained by a similar temporary exhaustion of the nerve -centre for
cardiac action by a worried brain, the muscular build of the heart perhaps
predisposing it to be overworked.

In conclusion, as to the treatment which we should expect to answer if our
theory be true ; this must remove the source of irrtttUionf relieve the heart of its
cverwork, and allay die pam. Now, to allay the pain for a time is not difficult ;
counter-irritants or simple plasters will do so, blisters, small and numerous,
have been much used, and I nave been satisfied with aconite and belladonna,
especially the admirable linimenta of the new Pharmacopcsia. The next indi-
cation is to relieve the heart, for which, of course, repose in the horizontal
position answers best, for the time causine the pain to disappear. The Turk-
ish bath, for obvious reasons, acts in this direction. But the great point is to
seek for a permanent cause ; for though much may be done by direct spinal
stimulants, as strychnia or cold bathing, etc., no ultimate good will result,
except exhausting nerve-irritation be removed. Cure the gastric or ut^nne
irritation, the leucorrhoea or the haemorrhoids, g've repose to the fatigued
spinal cord or worried brain ; and, pari passuj as the heart's action improves,
and is no longer too slow in repose, and too quick during muscular or mental
exertion, so will there result a corresponding diminution of the inframammary
pain. — British Medical Journal^ September 10, 1864.

1664.] PRACTICE OF HEDiaNE. 379

ON SOME POINTS IN THE TREATMENT OF DIABETES.
BY FBANCIS EDMUND ANSTIE, M.D.

The fact has long been recognised, that great good may be effected by the
regular use of a diet in which the nitrogenous matters shafl be represented, for
the most part, by meat, and the hydrogen and carbon by some form of oily
food. It is necessary to avoid the administration of the hydrates of carbon
which enter into the composition of any ordinary diet ; since, in the peculiar
state of the system whicn distinguishes this disease, unchanged sugar would
be left to circulate in such large proportions in the systemic blood, that the
latter fluid would infallibly exert an irritant influence on the kidney, and pro-
yoke a saccharine diuresis. Hydrogen and carbon must therefore be admin-
istered in the form of oil or fat rather than of starch or sugar ; and It has been
stated that it is not only necessary to adopt this kind of resimen, but that the
stomachs of diabetic patients easily accept oleaginous food. I have to notice
ft class of patients in which this does not take place.

During the last four or five years, I have met with several instances in
which sufferers from diabetes not only did not readily accept, but positively
loathed almost every kind of oleaginous food which could be proposea to them.
This singular loathing of an aliment which is especially necessary for the

Ktient^s welfare, reminds us of the similar peculiarity which Dr Edward Smith
s noted in a large proportion of phthisical persons, and which Dr Radcliffe
has observed in the sufferers from neuralda. It is to be met with firmness
and perseverance on the part of the medical attendant, who must try one form
of fatty food after another, till he does find one which the patient will take.
In several instances I have tried everything in vain, till at last pure cream,
taken in pretty lar^^e (quantity, has fulfilled the desired indication. In another
case, the almond-biscuits proposed by Dr Pavy answered very ^cU.

It may seem almost unnecessary to insist on the necessity of this particular
portion of the dietary treatment ; but, in truth, it is often neglected ; and I
am aniious to call attention to the evil consequences of such neglect. These
are, of course, partly seen in the emaciation of the patient ; but by far the
most serious effect is the severe nervous distress which soon begins to afiiict
him. Nearly all these cases are distinguished by a persistent and most
troublesome insomnia; and I have now attended several such patients in
whom this condition had brought about the habit of opium- eating. The effect
of this practice upon diabetic patients is so peculiar that I think it worth
while to relate some of the observations on this point which I have made.

The sufferer from diabetes quickly finds out that a small dose of opium is of
no good to him ; the fact beine that, with the abnormal flow of urine which
constantly goes on, a considerable proportion of each dose is quickly elimi-
nated from the system. Accordingly, he onicklv advances to the use of a
quantity of opium equivalent, perhaps, to from four or five to twenty grains
daily. Having found the level of opium consumption which gives him com-
fort, he does not necessarily increase the dose any further, but remains, per-
haps, stationary for many months, or even years, at the same dose.

Now, this is doubtless an unsatisfactory and undesirable condition for a
patient to get into ; but I wish to direct attention to the fact that where once
the habit has been fully formed, and the daily quantum of opium is not being
increased, the medical attendant incurs much risk if he suddenly cut it off.
Under such circumstances, both the nervous distress and the excretion of
suffar are apt to increase to an alarming extent.

On the other hand, there is no doubt in my mind that, where the patient
has advanced to the use of truly narcotic doses of opium (a fact which may be
known by his suffering distinct depression and languor, with great contraction
of the pupils, about half an hour after taking a dose), he is putting himself in
no little peril. True narcotic or paralyzing action has always a tendency to
aggravate diabetes ; and opiiun, given in large doses, shares in this respect the
properties of the ansBSthetics, chloroform and ether. Whenever, therefore, the

VOL. X.— NO. IV. 3 c

380 PERISCOPE. [OCT.

patient mforms us that he has carried opium-eating to an extent which inYolres
any depressive effects, we are bound to interfere at once.

The only true substitute for narcotic stimulants, where a diabetic patient
has to rely upon them, is the speedy adoption of a dietary calculated to
improve the special nutrition of the nervous system. It is here that we par-
ticularly need to insist upon the use of a high proportion of fatty ingredients
in the daily food, and (where the stomach will bear it) the medicinal employ-
ment of cod-liver oil. There Lb one other ingredient of nervous tissue which
is also not improbably indicated in these cases — I mean phosphorus. Acting
on this idea, I have several times administered this remedy with decidedly
good effect ; the form which I have selected is that of the hypophosphate of
soda or lime, which I agree with Dr Radcliffe in believing to be by far the
most efficient preparation of phosphorus, where we desire a food-tonic to the
nervous system.

I stated that the habit of opium-eating, where the doses have not been car-
ried to a large extent, and have remained stationary for some time, is not to
be rashly interfered with, at least till a neatly improved scale of dietary baa
been established. The truth appears to oe that the instinct of opium-eating,
dangerous as it may be, is one which has not unfrequently arrested disease at
a cntical moment when it was about to assume a new ana more serious devel-
opment. It is well known that this practice has a tendency to arrest com-
mencing phthisis ; and there is little doubt that, when not carried to excess,
it has lukd this effect in the case of diabetic patients, who, from defective diet
and other sources of depression, would almost infallibly have developed
tubercle. The true moral of this observation should be an increased solicitude
for that sort of improvement in the nutrition of the patient which would do
away with the nervous distress, which is, after all, the central and most threat-
ening feature in the clinical history of diabetes; and in comparison with
which, the elimination of sugar and the waste of fatty tissues are but second-
ary and unimportant matters. If these brief observations have any effect in
enforcing this important maxim, the frequent neglect of which has been exem-
plitied by cases which have come under my notice, both in private and in
hospital practice, the purpose of this paper will be answered. A. considerable
proportion of diabetic patients are, I imagine, practically starved, and this
notwithstanding a nominally high standard of diet, simply from the need of a
more plentiful supply of fat than is administered to them. Mere animal diet,
or animal diet plus gluten bread and the less starchy vegetables, will not fill
the place of this, nor will anything else. — BriMi medical Journal, SepUmber
17, 1864.

ON A NEW REMEDY IN THE TREATMENT OF CERTAIN FORMS OF DROPSY.
BY DR W. ABBOTTS SMITH.

In March 1863, 1 brought under the notice of the Medical Society of London
a remedial agent, which, in consequence of its diuretic and local tonic pro-
perties, 1 had found very efficacious in the treatment of certain forms of dropsy ;
and as I have since had opportunities of observing its medicinal value, I venture
to make it the subject of a few remarks.

The remedy to which I refer is the Erodium cictUarium, or common stork*s-
bill, an indigenous plant which belongs to the natural order Geraniace», and

frows abundantly in sandy situations near the seaside. My attention was
rst drawn to it by some observations made in the Medical TimeSj by Mr
Byerley, F.L.S., of Seacombe, in Cheshire, who stated that it had been pro-
ductive of great benefit in a case of dropsy which had come under his treatment.
The first case in which I prescribea the erodium was that of a man, about
forty-five years of age, who had been a patient of mine at the Metropolitan
Free Hospital, for a period of two months, owing to his suffering from renal
disease, complicated with anasarca, and subsequently with ascites. During
the time that he had attended as an out-patient he had taken squills in smaU
doses, digitalis, scoparium, and many of the diuretics ordinarily given, without
any permanent good results. The digitalis appeared for a short time to keep

1864.] 8UBGERT. 381

tbe effusion in check, but it soon lost that power. I had also administered
elaterium, the pulvia jalapa compoaUus of tne London Pharmacopoeia, and
other drastic purgatives, but as they certainly weakened the patient without
being productive of any adequate degree of benefit in the reduction of the
dropsical effusion, their use was abandoned. At this crisis I commenced the
administration of the decoction of erodium, in three-ounce doses, four times a-
day ; and in order that I might be enabled to form an impartial opinion of this
remedy, and also that I might avoid the fallacy of arrivmg at a pott hoc, ergo
propter hoc conclusion, I ordered the discontinuance of all previous prescriptions.
Upon the patient*s next visit to the hospital I had the satisfaction of learning
that the swelling of the legs had considerably diminished, and that the abdomen
was smaller, as was shown by the comparison of a measurement, made by means
of a tape passed round the body, at a point about an inch below the umbilicus,
with the dimensions noted upon the occasion of the patient^s last visit. The
flow of urine was stated to have been very copious. The medicine was con-
tinued for three weeks longer, after which time the patient was placed upon a
short course of tonics. At the end of November 1862, he was discharged
cured, and since that date he has been able to follow his usual out-door avoca-
tion— that of a cooper.

Another case in which I tried the erodium was of an equally unfavourable
character. The patient, a man of about sixty years of age, had suffered from
repeated attacks of ascitic effusion, consequent upon enlargement of the liver,
caused by excesses in drinking spirituous liquors. The decoction of erodium
was given for a fortnight, in four-ounce doses, three times daily, unaided by
any other medicine than an occasional compound colocynth pill, for the purpose
of keeping the bowels open. At the expuration of a fortnight the abdominal
effusion had nearly disappeared, and the patient was subsequently placed upon
a course of alterative and tonic medicines, with a more nutritious diet, which
soon completed the cure. •

In some other cases of a similar nature I have found the erodium valuable.
The form in which I have generally employed this remedy is that of decoction,
which is best made by placing two ounces of the dried plant in three pints of
boiling water, which should be allowed to simmer until the quantity of fluid
is reduced to two pints ; the remaining liquid should then be poured off and
strained, so as to render it fit for use. An extract has been prepared by
Messrs Clay and Abraham of Liverpool, but my experience of that preparation
is too limited to allow of my speaking decisively or its merits.

I do not, of course, advocate the substitution of erodium for all other remedies
used in the treatment of dropsy, as this disease depends upon so many different
causes that it would be absurd to suppose that a specific could be discovered
for every form of dropsy. I believe, however, that it is often worthy of a
trial, and that it will be found a serviceable adjunct to other plans of treatment,
especially in the laree class of cases of dropsy in which, although we may feel
that diuretics would greatly facilitate the cure, we yet hesitate to resort to
their use, owing to the serious complications which not unfrequently follow the
administration of those commonly employed, through their excessively stimu-
lating action on the kidneys. — Medtccu Mirror,

SURGERY.

ON PERFORATIONS OF THE PHAKYNX. BY DR CHARLES H. MOORE.
The consequence of the formation of unnatural openings in those canals of the
body which are provided with muscles for propelling their contents is a frequent
subject of observation. The contained matters escape through the aperture,
and produce effects varying with their quantity, with their qualities, with the
vehemence of their ejection, and with the structure which they invade. Blood,
air, and some fluids are commonly innocuous ; whilst urane and the heterogene-
ous materials from the digestive canal — some gaseous, some liquid, some solid
— ^when they are extravasated, are most frequently destructive.
Though this occurrence is familiar enough in many parts of the body, it does

382 PBRI8C0PB, - [OCT,

not appear to have been sni&cientlj commented upon in the case of the phaiTDx.
Indeed, 1 have been unable, in some surgical works which I have examined, to
find any allusion to it. Yet the most serious and even fatal consequences do
result from the ejection of foreign matters into the cellular tissues of the neck
under the poweiful action of the muscles of deglutition. My first object in this
lecture accordingly is, to call attention to the fact that such extravasations
from the fauces and pharynx do occur.

I say ** most frequently " destructive ; for there are circumstances in whidi
they are not so. Even urine escapes sometimes, to the amount of several pints,
without consequent sloughing : this occurs in cases of accidental rupture of the
pelvis of a kidney, the secretion of which is healthy or well diluted. And
there are circumstances in which the mischief produced by extravasations from
the digestive canal is or may be limited to suppuration : this is particularly the
case with the fauces and pharynx. M^ second object, therefore, is to advert to
a practical conclusion, tnat the injurious consequences of perforation of the
fiiuces and pharynx are to a certain extent under control.

Wmmd behind the Tonsil^ Penetrating the Pharyngeal Fascia ; Extensive EaOra-
fxuationf with Sloughing of the Neck; Phlebitif; Fatal Arterial Hcemorrhage.

A yonng man died of arterial hsomorrhage from the mouth. He had had
Bvmptoms of phlebitis, with a wound or ulcer of one tonsil, and tumefaction at
tne side and back of the neck. I had seen him shortly before his death, when
it appeared that he had wounded his throat with his tobacco-pipe. The injured
part was smooth and spoon-shaped, not ragged. The man was entirely free
D>om syphilis, his skin being fair and his aspect perfectly healthy.

At the post-mortem examination, the right side of the neck from the larynx
to the occiput was found to be much swollen. The muscular and cellular
structures in those parts were black, sloughy, and fetid. The destruction was
greatest near the base of the skull, where a piece of the occipital bone, about
half an inch square, was necrosed. A small part of the petrous bone, exposed
in the slough, was in the same state. The ulcer in the tonsil was three quarters
of an inch in length, smooth, and excavated ; at its deepest part it opened
uj^ward through the pharyngeal muscles and fascia, and the hole connected it
with the sloughy tissues outside the pharynx. The ulcer itself was not sloughY-
A part of the internal jugular vein was so disorganized as to be indistinguish-
able ; but its upper and lower portions were plugged with adherent coaguliun,
which in the higher part reached to the torcular HerophUi. There was much
vascularity of the brain, particularly at the pons Varolii and the cerebellum ;
and there was recent lymph between the cerebellum and the infiamed right
lateral sinus. The only artery which could not be traced was the occipital,
where it passed through the slough above the transverse process of the atlas.
The right vertebral artery was sound.

This case is not unique. Another also came under my notice, in which
mischief of the same kind followed a similar accident. For sevei*al days ex-
travasation went on through the aperture in the fauces, and extensive sloughing
and suppuration of the tissues of the neck ensued. The narrow end of the
tobacco-pipe in this case was lodged in the common carotid artery; and when
it loosened, arterial bleeding came on, of which the man died some days after
the lieature of the common carotid. The case was detailed by Mr Vincent in
the Medico-Chirurgical Transactions (vol. xxix. p. 38).

PerforcUion of the Pharynx by the Superior Comu of the Thyroid Cartilage;
Extensive Abscess in the Neck ; Bronchitis and Pneumonia ; Death,

Mr Shaw has obliged me with the particulars of this case, which was admitted
under his care on the 2lBt of October 18G2. An aged man, when mounting his
horse, was thrown or fell over on the opposite side. His head was bruised,
and one leg lacerated. About a fortnight after the injury an abscess appeared
in the front of his neck, which was. so large and extensive as to occasion
dyspnoea. It was opened close to the pomum Adami, a great quantity of pus
was evacuated, and the discharge continued for a week. He survived the

1864.] BUBG^T. 888

injury till the end of December, when he died with bronchitis and congestive
pneumonia.

On opening the pharynx, a circular aperture was found in its left wall. It
was on the level of the top of the arytenoid, and precisely at the upper end of
the left superior comu of the thyroid cartilage, its calibre was nearly that of
a writing quill, and it was smoothly lined by inverted mucous membrane of the
pharynx. Outside the pharyngeal muscles it opened into a large abscess,
whicn separated the pharynx and part of the oesophagus from the left carotid
artery, and, burrowing amongst the tissues of the neck in various directions,
reached across the front of the larvnx, trachea, and thyroid gland to the right.
On that side of the neck it formed one large cavity, extending from the coma
of the hyoid bone to the sternum.

Woimd of the Pharynx vnih a FragmejU of Straw ; Suppuration in the Ntck;
Bemoval of the Foreign Body through a Sinus ; Recovery,

A man was under my care in the Middlesex Hospital some months ago
having abscesses, both superficial and deep, in various parts of his neck. They
were all acute, and excessivelv tender. He said that a piece of straw had
pierced his throat somewhere behind his tongue. The aperture was beyond
sight. The foreign body was eventually removed from one of the abscesses in
the neck, and the man recovered. Although the wound in thia man*s phar3mx
was doubtless small, yet the food escaped through it, and appeared by its irrita-
tion to be a chief cause of the peculiar sensitiveneas as well as of the first
occurrence of the sinuses and abscesses in his neck.

Wound of the Throat unlh a Piece of Toothed Graee :Ahece8$ in the Neck, from
which the Grose was Extracted; necovery,

Mr Hulke has informed me that a similar case occurred to him ; and that he
was able, after an abscess had formed, to extract the foreign body from it in
the front of the neck. The patient seems to have been playing with this
dangerous grass in his mouth, and, by successive acts of deglutition, to have
forced it through the wall of the pharynx.

There were omerences in these cases depending, probablv, on the situation
of the puncture, and, consequently, on the layers of cellular tissue which
receivea the contents of the pharynx and fauces. And when, as in Mr Shawns
case, the infiltration and suppuration of the textures detach the larynx from the
superficial muscles and fascu^ an additional obstacle is presented to the repara-
tive process by the mobility of the parts. Such circumstances, however, do
not luter or affect the principles on which all the cases should be treated.
Wholly, or in part, the patient should be nourished by enemat*. None but
the bUndest food should be given by the mouth. The pain attending every
act of deglutition may render this caution superfluous, but some patients may
need to be advised to abstain from whatever might irritate. Of every substance
that enters the fauces a part must escape into the cellular textures of the neck^
and these can only be injured by stimulating drinks and medicines — ^by brandy ^
or colocynth, or salt. Such matters, if required, should be administered by the
rectum, whilst milk only, or such nutriments as jelly and arrowroot, which have
the least solid residue when digested, should be swallowed. The quantity, idso,
of even these articles of food should be limited, since it is clear that the extent
of the infiltration will depend on this, as the severity of the injury will corre-
spond with the nature of the misdirected aliment.

When the accident under consideration is known to have occurred, and the
foreign body has not been extracted through the pharynx, the earliest abscess
should be opened in the neck as soon as it is considered right to do so. Should
the foreign oody not come forward in the abscess, and any tendency to fresh
suppuration appear, a careful search for it should be made in the abscess, under
chloroform if necessary. The removal of the foreign body, providing and
maintaining a free outlet for the contents of the first abscess, and avoiding the
introduction of irritating foods into it, appear to be the best means of arresting
the mischief, and of repairing it. — The. Lancet.

384 PERISCOPE. [OCT,

CASE OF SUCCESSFUL LIGATION OF THE INNOMINATA.
To the Editor o/the American Medical Times,
Sir, — ^I CRDDot express to you the gratification I feel in enclosing yoa this
letter. It is a copy of one in my possession, from my old and distinguished
pupil, Dr David L. Rogers, now of the Army of the United States, dated
New Orleans, July 31, 1864. I have expressed myself to my class for many years
past, that I would like to live long enough to see the innoroinata successfully
tied for aneurism. For this surgical achievement I am more than gratified —
/ am delighted. On the brow of Dr A. W. Smith of New Orleans will always
rest the laurel of the first successful operation of ligature of this great artery.
Time never can rob him of this surgical achievement. To Dr Rodgers we no
doubt are indebted for the cardiac operation upon the innominata in this case,
rather tlian the distal upon the third division of the subclavian. Dr R.*8
original idea was carried out in this case, which I long since recommended, and
intended to use, should another case have presented itself to me. (See Dr
Rogers's " Surgical Essavs.") The subsequent haemorrhage being completely
arrested by a ligature ot the right vertebral is confirmatory of the correctness
of this idea. On the 9th inst., as I was about to answer his letter, Dr Rogers
called upon me (having arrived the day before from New Orleans), and stated
that the aneurismal tumour had entirely disappeared, that the wound had healed,
and that the man was well and walking about. — Yours, &c. V. Mott.

Neir York, August 16, 1884.

The following is Dr Rogers's letter to Dr Mott : —

Sir, — ^To you, the originator of the operation for ligating the arteria inno-
minata, is due the first notice of success. Permit me to offer you my sincere
congratulations, that after so many failures you have been spared to enjoy a
triumph in verifying the noblest conception in operative sursery. I beg to
offer a brief history of the case, as presented on the 9th of May last, in the
Charity Hospital of this city. I received an invitation from Dr A. W. Smith,
the able Surgeon of that institution, to witness the ligation of the subclavian
artery upon the distal side of an aneurismal sac. The subject was a mulatto
man of thirty-three years of age. The tumour was large, with a strong pulsa-
tion. Being satisfied, for reasons which it is not necessary to mention, that
the operation proposed would certainly fail, I urged upon Dr Smith and those
present that tne prospect of success would be much greater by applying the
ligature to the arteria innominata and the carotid artery at the same time, as
proposed by me in 1849. (See " Surgical Essays,** p. 45.) After some dis-
cussion it was concluded to postpone the operation for some days.

On the 15th, Dr Smith informed me that he had concluded to perform the
operation as proposed by me. In the presence of several civil and military
surgeons he performed the operation agreeably to your direction, and ap{)lied
a ligature to the arteria innominata and to the right carotid about one inch
above its origin. The wound was dressed in the usual manner, and the man
removed to bed.

28th : The ligature came from the carotid artery. 29th : Haemorrhage from
the wound, but arrested by slight pressure. 30th and 31st: The haemorrhage
returned. June 1st : The hsBmorrhage returning, Dr Smith removed the lint,
and filled the wound with small shot. 2d : Ligature separated from the arteria
innominata. 17th : A part of the shot removed from the wound, followed in
a few hours by haemorrhage. The shot returned. July 5th and 8th :
Haemorrhage returned.

Believing the haemorrhage must be supplied by the vertebral artery, through
the subclavian, it was determined to ligate the artery, and accordingly Dr Smith
secured the vertebral artery on the 9th of July. 19th ; >?o return of
haemorrhage. The ligature separated from the vertebral artery this day. A
doubtful pulsation may be felt in the right radial artery. The aneurismal
tumour has disappeared. 30th : General health much improved since the last
report. The wound is nearly closed. He walks about the ward, and is
desirous of returning to his home. We have every reason to believe that the

1864.] 8URQERT. — MEDICAL NEWS. 385

operation is in every respect a Buccess. — With great respect, your humble
servant, D. L. Rogers.

New Orleani, JxHj 31, 1864.

Within six years of half a century ago, Dr Mott first performed that most
daring and brilliant operation, the ligation of the arteria innominata—an opera-
tion which, though he does not himself consider it the most difficult that he
has executed, had added more largely than any or all others to his great
reputation. His patient so far recovered as to be able to walk about, but
finally succumbed to successive haemorrhages on the twenty-sixth day. The
operation has been repeated thirteen times since, but with an invariaSly fatal
issue. Dr Mott has, we believe, never doubted the final success of the opera-
tion, and has often expressed his desire to live to witness the consummation of
his hopes. The boon has been granted him, and in another column we have
the pleasure of recording his expressions of satisfaction and delight at the
successful issue of the case reported by Dr Rogers. The correspondence is
full of interest.— iSof. American Medical Times,

DR E. SMITH ON DIETETICS.
At the meeting of the British Association on the 15th of September, Dr
Edward Smith gave an address on the present state of the dietary question, in
which he reviewed the actual dietaries in public institutions and in private
fiunilies, and then ^ave a general outline of the position of the science. In
reference to public mstitutions, he showed that the dietaries of workhouses are
practically devised by the guardians of the poor, and that as there are 700 of
them, and yet not two alike, it could not be presumed that all were properly
adapted to the wants of the paupers of both sexes and of all ages. The dietary
of tne army and navy had been most defective in the quality, want of variety,
and the cooking of food, and was now greatly improved ; but from the necessity
of the case could not become models for the dietary of the working classes.
An excess of meat is and ought to be allowed in such dietaries. He considered
that the dietary question in convict and county prisons was most unsatis-
factory, and showed that changes had been made convulsively towards increase
and then towards diminution, without the necessity for the changes having
been proved on scientific grounds, and showed how great the responsibility of
those who thus hastily and unadvisedly recommend a dietary which may be
either in excess or in defect of the requirements of prisoners. The changes in
convict prisons had been based upon a most inefficient inquiry into the dietary
in county gaols, and the recommendations had been modified by the directors
of convict prisons, while in county prisons conclusions had been arrived at
without the inquiries which the Home Secretary and Lord Carnarvon's Com-
mittee had deemed necessary, and while discarding the use of scientific know-
ledge— conclusions based only on the opinions of the visiting justices of gaols,
and transferring the responsibility of the change from the committee which had
recommended it to the surgeons of the gaols under whose eyes it had to be
efifected. In reference to private schools he quoted the dietary of a cheap
school in the neighbourhood of Wolverhampton, and of a large school or
collegiate in>titution in the north of England, to show the insufficiency of
the food given to the pupils in many scholastic establishments in this country,
and dwelt upon the importance of this, since it occurred at the period of
growth when a deficiency can never be subsequently supplied. Much ieebleness
of body and mind he believed to result from this deficiency of food. In
reference to the dietary of families he referred to that of the richer classes only
to show the principles upon which Bantingisra is founded, and the serious evifc
which are now flowing from the use of that system of dietary. He pointed out
that the proper course to pursue is to allow the usual admixture of food, and
to lessen the quantity of the carbonaceous kindH, without increasing the quantity
of nitrogenous kinds, as meat, and stated that in proportion as the system is
worked out rapidly upon an individual, so would De the tendency to heart-

S86 MEDICAL NEWS. [OCT. 1864,

disease, to defective assimilation, and to gout. He affirmed that the present
movement was likely to benefit more than one undertaker and one surgeon ,
and that, in the result, both these classes of persons had a common interest.
In reference to public institutions he was of opinion that there should be a
Government officer of the highest reputation upon dietary questions, to whom
such questions should be referred by the Government, ana that in the dietaries
of the poor the wives and children are ill fed much more so than the husband ;
that a large part of the infant mortality, and the deaths at puberty from con-
sumption, is aue to a deficient supply of milk and of other good food, and to the
almost exclusive use of tea, etc. ; he also insisted that a man*s first duty is to
provide sufficient nourishment for his family, even if it were only dry bread, and
that until this had been effected, nothing should be spent merely to j^ease the
taste ; and in order to turn the labourer*s overtime to profitable account, it was
very desirable that he should have the opportunity of growing plenty of
potatoes. Dr Smith concluded by reference to the present state of the question
considered as a science, and pointed out what science had done, and what were
still the most important defects.

ELECTION OF PROFESSOR TO THE CHAIR OF SURGERY IN
THE EDINBURGH UNIVERSITY.

A MEETTNQ of the Curators of the University of Edinburgh was held on the
7th of September — ^the Lord Provost presiding — ^for the purpose of electing a
Professor to the Chair of Surgery, rendered vacant by the oeath of Professor
Miller. Latterly there were only two candidates for the office — Mr James
Spence, Senior Surgeon to the Edinburgh Royal Infirmary, and Mr Joseph
Lister, Professor of Surgery in the University of Glasgow. The curators who
were present at the meeting held within the College, were the Lord Provost,
Sir William Gibson-Craig, Mr David Mure, Mr Adam BUck, and Bailie
Johnston. Letters were read from the Right Hon. W. E. Gladstone, Chancellor
of the Exchequer, and Sir David Brewster, who were prevented attending the
meeting. In' their communications both these gentlemen intimated their
intention of voting by proxy for Professor Lister. A long discussion took place
in regard to the legality of receiving votes by proxy in the Curators* Court ;
but ultimately it was decided to- receive the proxies and proceed with the
election. The Lord Provost moved that Mr Spence be elected to the vacant
chair, and this motion was supported by Mr Mure, Mr Black, and Bailie
Johnston. For the election of Mr Lister, Sir William Gibson-Craig voted,
and the claims of this candidate were also supported by the proxies of the
Chancellor of the Exchequer and Sir David Brewster. Mr Spence was
accordingly declared elected by a majority of 4 to 3.

PUBLICATIONS RECEIVED.

Battnra,— LUiver dans le Midi. Par A. Kellie,— Saline Treatment of Cholera. By

Buttura, D.M. Paris, 1864. J. Kellie, M.R.C.S. Bristol, 1864.

Byrne, — Lunacy and Law, together with Kestner, — Etnde sor le Trichina Spiralis.

Hints on the Treatment of Idiots. By T. Par H« K&stner, D.M., etc Paris, 1864.

£. D. Byrne. London, 1864. Mddecine et de Chirurgie prati<|aes, Nonveau

Ctfpenter and Power, — Principles of Human Dictionnaire de. Tome premier : deuxi^me

Physioloijy. By W. Carpenter, M.D. partie. Paris, 1864.

Sixth Edition. Edited by Henry Power, Moore, — Corpulency. By A. W. Moore,

M.B.Lond., etc., etc. London, 1864. M.R.C.S. London, 1862.

Cobbold, — Entocoa : An Introduction to the Parsons, — A Form of Bronchitis (simulating

Study of Helminthology, with Reference Phthisis). By Charles Parsons, M.D.

more particularly to the internal Parasites Edinburph, 1864.

of Man. By T. Spencer Cobbold, M.D., Schivardi,— Mannale Teorico Practico di

etc. London, 1864. Elettroterapia. Per Plinio Schiyardi, D.M.

Dickson,— Report on the Health of the Milan, 1864.

Officers of li. M, Customs. By Walter Wilson,— An Inquiry into the Relatiye Fre-

Dickson, M.D. quencj, the Duration, and Cause of Dis-

Heath,— Practical Anatomy : A Manual of eases of the Skin. By Erasmus Wilson,

Dissections. By Chris. Heath, F.B.C.S. F.R.S. London, 1864.

London, 1864.

^part iFirjft

ORIGINAL COMMUNICATIONS.

Article I. — Amputation at the Eip-Joint. By J. Fayrer, M.D.,
P.R.C.S., and F.R.S.E., Professor of Surgeiy, and Surgeon
in the Medical College Hospital^ Calcutta.

Amputations of the hip-joint are so rare that each case, successful
or unsuccessful, should be recorded. I have therefore given the
following in detail, as it presents many points of interest.

As far as I can ascertain, it is the second successful case recorded
in India. The first of which I can find any notice is that related
in the Lancety vol. i. p. 411, of 1850, by Mr Wigstrom, of the 14th
Dragoons, who operated successfully, by antero-posterior flaps, in
November 1849, on a patient who was sufiering from diseased
femur and profuse suppuration extending nearly to the hip.

In February 1853, 1 also operated in a case of ffun-shot wound
of the head and neck of the femur ; and this, thou^ death ensued,
may fairly, as far as the operation was concerned, be recorded as
successful, for the patient died not of the operation,^ but of teta-
nus, a month aflter the amputation, when the wound was all but
healed.

The case I now record is interesting, not only for its own sake
as an amputation at the hip-joint, but because it was a secondary
amputation following that of the thigh, and performed when the
patient was very low, sufiering from clear indications of blood
contamination, the result of a diseased condition of the medulla
(osteo-myelitis), which is unfortunately frequent here after section of
the long bones, and the cause of many unsuccessful amputations.

I have noticed this subject more at length in another communica-
tion to the " Annals," but I may here remark that the present case
is a good illustration of. the disease osteo-myelitis, and the con-
stitutional and local symptons it gives rise to ; it also clearly demon-
strates the advantage of amputating above the next joint to the bone
afiected, provided the operation be performed before the systemic
poisoning have gone too far.

I regard the details of this case as so interesting, in both a
surgical and pathological point of view, that I have not hesitated to
give them in extensOy though, as a general rule, such prolixity is
objectionable.

^Amputated on 16th February. Died of tetanus on 17th March 1853.
VOL. X.— NO. V. 3d

388 DB FAYBER ON AMPUTATION AT THE HIP-JOINT. [NOV.

It 18 to be remarked that the operation was performed, and the
recovery occurred, at a very hot season of the year, the thermometer
ranging from 86° to 104*. Cholera and other diseases were very
prevalent at the time.

iShekh Asghur, aged sixteen years, a slight and somewhat deli-
cate lad, a carriage-driver by trade ; accustomed to drink six or eight
ounces of bazaar spirit daily, thin, sallow-looking, and with con-
genital cataract in the left eye, was admitted into the Medical
College Hospital on the night of the 10th April 1864, suffering
from injuries sustained by a fall from a horse which trampled on,
or kicked him, after he fell. He had a wound on the chin slightly
exposing the bone,^ one on the lip, and some smaller ones on
other parts of the body. The most severe injury was on the inner
aspect of the right knee-joint, the integument being torn and
bruised, the muscles and tendinous structures exposed to tne extent of
3i hy 2^ inches. The joint was injured, but not apparently opened,
though it. appeared prooable that the bruised tissues would slough
and open it. He had had a good deal of pain and serous discharge.
Ordered cold applications and perfect rest of the limb on a splint.
The other wounds were also dressed.

April 12th. — The wound again carefully examined, and through
the bruised and injured tissues the joint was felt, the point of the
finger passing into it ; the inner condyle of the femui^ roughened ;
fluid collecting in the joint ; jpulse quick ; no pain. In consultation
with Mr Partridge, I decided on amputation.

At 9 A.M., I removed the limb, under chloroform, bv modified
circular amputation at the lower third of the thigh. All bleeding
points being secured, the edges of the flaps were secured by meti3
sutures. I observed that the muscles at tne posterior aspect of the
thigh had a bruised and discoloured appearance.

April ISth. 8 A.M. — Is feverish ; pulse 120 ; no haemorrhage j
tongue moist. Ordered cold applications to the stump, perfect qmetj
diet of milk and sago.

14th. — ^No fever this morning. The posterior part of the stump
is gangrenous to a small extent, corresponding to the discoloration
of 3ie muscles observed during the amputation.

15th. — The sutures have given way, and the interior of the stump
is exposed. It is somewhat sloughy in appearance: the end of the
bone is denuded of periosteum and necrosed ; medulla discoloured at
the point of section, may be living below the surface. I observed
during the amputation that the periosteum and the bone were both
healthy, and that the membrane adhered closely to the bone at the
line of division ; most of the ligatures on the smaller vessels came
away to-day. He had slight fever yesterday evening^ but has none
now; pulse 100. Ordered nutritious diet, port wine, 4 ounces.
Let the stump be kept washed with a weak solution pf chloride
of zinc.

^ From which, Bubsequently, a Bmall piece of bone exfoliated.

1864.] 0R FATBEB ON AMPUTATION AT THE HIPSJOINT. 889

16th. — ^Pulae 100; tongue clean. Had no fever yesterday;
took his food well; stump cleaning; gangrene not extending*
Continue the treatment of yesterday.

17th. — Pulse 100; stump cleaning; takes his food fairly {
bowels loose. Continue all as yesterday.

18th. — Pulse 100 ; tongue clean ; bowels re^ar ; stump clean«>
ing ; a considerable portion of the bone^ especially one side of it,
denuded of periosteum. The state of the medulla is not discernible^
as the end is discoloured^

Idth. — Pulse a little over 100 ; soft parts of the stump look well ;
sloughs have separated (they were very su{)erficial). Ligatures
have all come away. On one side the periosteum is aah§rent
almost to the end of the bone, on the other it is denuded for more
than two inches ; the bone is dry^ and I fear dead. Passed a long
probe into the medulla; it entered four inches of dead and putrid
tissue. I fear the shaft is diseased throughout; osteo-myelitis
from end to end.

His system is not yet much affected ; no diarrhoea ; tongue clean ;
good appetite ; pulse 106 to 108.

20th. — Pulse 100 ; has a peculiar thrill ; stump looks clean and
healthy with the dry half-dead bone protruding from the centre.
Has taken his food welL Continue all as usual.

21st. — Soft parts red and granulating, discharging healthy pus ;
one side of the bone covered with granulations, the other bare and
dead. Bullet probe passes fully ten inches down the medulla in
dead fcetid matter. At that distance it seems to be sensitive ; it
must be close to the epiphysis. There is a chance that nature may
limit the mischief there ; but can so large a mass of bone be thrown
off? The alternative is death or amputation at the hip.

Pulse this morning is 104 ; tongue clean ; bowels regular ; takes
his food well ; on the whole, he does not look so bad, but there is a
nasty thrill about the pulse, which is excitable and quickens easily.

2id. — Pulse has risen to 120; skin heated in evening. Con-
tinue all as usual.

23d. — Pulse this morning over 130, very excitable, quickens to
160, and falls again, with a peculiar thrill. He has had diarrhoea
since yesterday, and fever in evening ; the house surgeon gave him
astringents in addition to the port wme.

24m. — Pulse over 140 this morning, and of the same character as
yesterday. A probe passes down to the head of the bone and
causes pain there. He is feverish ; tongue moist, but the papillffi
are becoming obliterated. The diarrhoea continues, and he has a
peculiar tremor of the muscles all over the body. Sonorous r&les
in the tisi^ thorax, with cough, but no hepatic or abdominal ten-
derness.

In consultation with Professors Chevers and Partridge, I de-
termined to amputate, either through the trochanters or at the
hip-joint, to be determined when the bone was exposed and its

390 DR FATREK ON AMPUTATION AT THE HIP-JOINT. [NOV.

condition examined. The operation was performed at 9 A.M., under
chloroform administered by Mr Hayes. The knife was entered a
little above and in front of the great trochanter ; it emerged at the
root of the scrotum. The flap being raised, the femoral artery was
tied before the posterior flap was cut; on dividing the bone at
the great trochanter drops of pus oozed out of its cancellated tissue.
I therefore seized it with the Lion forceps, and dissected it out
without loss of time. The acetabulum was healthy. Tied all
bleeding points, venous and arterial. The loss of blood was very
small, less than eight ounces. His pulse, which was over 150 when
the operation was commenced, was very little weaker after it was
over. Gave him stimulants and applied hot bottles.

I was assisted by my friend Professor Partridge, and my house
surgeon, Baboo Money Lall Dutt.

24<A, 3^ P.M. — The house surgeon reports that there is no
bleeding ; that the pulse is 132 ; tongue moist Has taken milk
and sago, beaf-tea, and wine. Has no fever ; respiration easy ; says
that he feels easier.

25<A, 8 P.M. — He has had only one loose stool since the opera-
tion ; no haemorrhage, pulse 106, skin hot, but moist. Thermometer
in axilla 106". Tongue moist and clean, tending to a glazy condition.
No hepatic tenderness; bronchial r4les on either side. Pleuritic
friction in right upper chest. He is too weak to be examined on
the back. He has had beef-tea, and brandy 3 measures (6 ounces),
since last report. Continue all as yesterday.

26th, 8 A.M. — Pulse 132 to 140; skin cool and moist. Ther-
mometer in axilla 102". Tongue clean, tending to dryness in the
centre. He has no pain. Bowels moved once yesterday. He has
taken his food well, out rejected part of it. Is cheerful and in good
spirits, smoking his hookah. The stump looks very well; from
the outer angle a dark watery dischar^ j from the rest, healthy
well-formed pus. Washed out the cavity from the external angle
with a weak solution of chloride of zinc. Let him have brandy six
ounces, and food as yesterday.

27th, 8 A.M. — Yesterday evening, as on other evenings, the pulse
quickened to 160, and the skin got hotter. This morning it is not so
hot. The tremor of the muscles is nearly gone. Pulse 132 to 142.
Spirits good. Bowels more regular. The discharge is becoming
healthier.

28th, 8 A.M. — Pulse 140. Thermometer in axilla 102**; skin
moist ; bronchial rftles still exist ; slight moist r&le in upper right
chest. Bowels opened once ; stump looks well ; discharge purulent,
but from the acetabulum it is thin and dark coloured ; injected it
with a weak solution of chloride of zinc, gr. 1 to oz. 1. One ligature
came away to-day. He is to have the same diet as yesterday, and
two or three raw eggs beaten up with brandy. He is reported to
have been feverish again in the evening.

29tL — He had slight fever after 4 p.m. yesterday until early this

1864.] DB FATBEB ON AMPUTATION AT THE HIP-JOINT. 391

morning. Thermometer rose to IDS'" in the axilla ; bowels opened
once. Took his food well before the fever came on. This morning
he is cool; pulse 128. Thermometer in axilla 101^ Tongue
clean, moist; and smooth ; stump looks well. Discharge improving.
One ligature came away. Ordered quinine gr. 2, every fourth hour.
The same diet, and brandy.

30th 8 A.M. — Had fever a^in yesterday at 4 p.m. Thermometer
lOS**. Could not take his food. He is better this morning ; skin
cool and moist. Pulse 120 to 128; chest sounds improving;
tongue clean and moist ; bowels moved once ; stump looks healthy.
Discharge improving and pretty free; one ligature came away
to-day. The same met as yesterday. I should have noticed that
he has the thorax rubbed daily with a turjpentine liniment.

May Isty 8 A.M. — Fever came on at 2 a.m. He was well all
yesterdav. There is now slight heat of skin. Thermometer in
axilla 102'; pulse 124; tongue slightlv dry: stump looks very
well ; four more ligatures came away to day. Kemoved also one or
two of the wire sutures in the flaps. Discharj^ healthy and not
profuse ; moist rftles in upper right chest ; respiration more natural
on left side. Bowels moved twice naturally. Takes his quinine,
brandy, and food as usual. He is very cheerful^ and askjs to be
cured quickly.

2d, 8 A.M. — He had no fever yesterday, but the pulse quickened
to 140 in the evening. Axillary temperature 103* ; tongue now
clean and moist ; pulse 128; thermometer 100"* ; skin cool; bowels
have acted three times, but not loose. Has taken his food well ;
several ligatures came away, only two left ; all the sutures remain-
ing removed. The flaps have nearly united; slight and healthy
discharge chiefly from the glenoid cavity, rather flakey at times,
as though the cartilage were disinte^ting. The stump is now
strapped with adhesive plaster. Contmue the same diet.

3dy 8 A.M. — He had slight fever yesterday afternoon, and three
loose stools, for which the house surgeon gave him some chalk
mixture. Looks rather low this morning ; pulse 128 to 130 ; skin
moist with sweat. Thermometer in axilla 98* ; stump not looking
quite so well ; granulations pale. The discharge much as usual.
The two last ligatures on femoral artery and vein came away.
There has been a change in the weather ; rain has fallen, and the
hot dry air (thermometer 100"* to 104**) has become damp. This is
probably the cause of his not being quite so well. The chest
sounds are better, rAles less sonorous; moist rAle in upper right
chest less crepitant. Continue the same diet and stimulants.

Stump has all but healed, except a sinus at each side, which
appear to communicate with the acetabulum, and one where the
two last ligatures came away. .

Athy 8 a.m. — Had no fever yesterday. Thermometer in axilla
now 100*" ; pulse 128 ; bowels moved only once ; stump looks well ;
discharge from sinuses getting thicker.

892 DB PAYRBB OH AMPUTATIOIT AT THE HIP-JOIOT. [KOV.

6thy 8 A.M. — ^No fever yesterday. Thennometer in axillA 100";
pulse 124; stump looks well. Took his food well yesterday,
xlespiratory sounds almost nonnal.

6thy 8 A.M. — No fever yesterday ; pulse quickened in the evening ;
slept well ; has taken his food well ; pulse 128 ; thermometer in axiUa
98* ; skin moist ; bowels moved twice ; chest sounds improving.

7th. — ^Pulse 120. It is excitable, and rises when 1 visit him.
I believe it falls lower when he is alone. Stump looks well j dis-
charge diminishing. The femoral artery can be telt pulsating very
distinctly in the anterior flap.

8th. — Pulse 120, but it is reported to have been down to 104;
thermometer in axUla 99"*. He is gradually improving ; is gaining
flesh and strength. Says he feels very well. Discharge firom two
sinuses healthy.

9th. — Pulse has been down to 108. Thermometer in axilla 99*.
Is doing well in all respects. Bowels slightly loose ; discharge
very healthy.

10th. — In all respects doing well ; pulse 104 to 116 ; had two
evacuations ; eats well, and is getting stronger daily.

11th. — Had two loose evacuations ; the nurse says he ate too much
yesterday. Put him on sago and beef-tea to-day. He looks well.
Thermometer in axilla 100° ; pulse 120 at 8 A.M., but it has been
lower ; dischar^ healthy, contains what appear to be fragments of
exfoliating cartilage.

12<A.— Better to-day ; discharge less* In all respects he is doing
well ; let him have more food to-day.

14th. — Doing well in all respects ; pulse fluctuates between 96
and 120 ; discharge gradually diminishing and very healthy.

15th. — Doing well. Thermometer in axilla 99', yesterday even-
ing; pulse varies from 90 to 120.

18th. — Wound nearly cicatrized, all but two small sinuses; the
inner one discharges a small quantity of sero-purulent, the outer
purulent matter.

20th. — Left off all dressing, except over the sinus, applied oxide-
of-zinc powder over the cicatrix, and a bandage as ususlI to support
the stump.

22e/.— X esterday his skin was rather hot. Thermometer in axilla
102*; pulse slightly quickened in the evening. In dressing the
stump the house surgeon pressed out a small collection of sero-
purulent matter from the inner angle. In all respects, however, he
IS doing well. This morning, on pressure, some serum exuded
from the inner sinus.

SOth. — Slight discharge from the sinuses. He is gaining strength
rapidly ; has a good appetite. Takes his food well, and still has
his two measures of brandy. He has also begun to take and retain
cod-liver oil ; he had attempted it once or twice before, but as it
caused sickness it was discontinued. He is getting quite stout, is
very cheerful, sits up in his bed, and with support mores about the
ward.

1864.] DB FATBER ON AMPUTATION AT THE HIF-JOINT. 393

8l8t. — Is very well thia morning, and was supported abont the
ward as he took a little exercise. There is still a small Quantity of
pus to be pressed from the outer angle of the wound. The inner
sinus has closed ; the cicatrix also is less osdematous.

June 4th. — ^The sinus is nearly closed ; a few drops of healthy pua
exude on pressure. He is in very good health ; eats and sleeps
well; is gaining flesh rapidly, and walks about the ward on
cmtohes. He taxes four ounces of cod-liver oil daily, and full diet.

10(A. — He is in good health and spirits ; is able to walk about
the hospital on his crutches, and is getting stouter and stronger
daily. There is still one sinus at the outer angle of the dcatnx,
from which a small quantity of purulent discharge can be pressed.
The rest of the stump is perfectly healed. He went out and had
his photograph taken a few days ago.

llfA.— He has been eating sweetmeats brought in by his friends,
and has diarrhoea in consequence. Ordered ol. ricini, 3yi. statim,
chalk^mixture after it. Put him on arrowroot and soup, and keep
all his friends away. The discharge has somewhat increased, the
cicatrix become oedematous, and the mouth of the sinus ulcerated
to the size of a 4d.-piece. He is in capital spirits, and yery anxious
to be about on his crutches.

12<A. — He is better to-day ; bowels natural ; good appetite ; sinus
contracting ; discharge less. Let him have more to eat again.

18^. — He is in excellent health ; appetite good ; bowels regular ;
sleep sound. The sinus is still discharging, but less than it has
done. The cicatrix still somewhat oedematous, but contracting
daily. He was present, and walked about the room on his crutches
at the last meeting of the Medical Society.

22d. — He is getting fatter and stronger daily ; goes about the
hospital on his crutches. Still the sinus is open, discharging a few
drops of pus daily.

2dth. — For the last day or two the discharffe has been slightly
increased, and this mommg I find that he nas had slight fever
yesterday, and that there is a collection of pus at the inner angle
of the stump. This I opened and gave exit to about 2 ounces of
pus. He is pretty well in other respects. Passed a probe into the
sinus, but could detect no extraneous substance.

30^. — ^No fever, no pain ; discharge less.

July 5th. — Sinus almost closed. He is in capital health, not the
slightest pain or tenderness in the stump. The cicatrix contracted
almost to a line. He is placed under tne hospital durzee, and is
learning to make himself useful as a tailor.

8^. — ^A few drops of pus can still be squecEcd out of the sinus,
but there is no pain. He is in excellent health and getting fat.

He may fairly be returned as cured, for his health, spirits, and
appetite are excellent; he goes to his work with the hospital
durzee daily. The stimip is free from pain or tenderness, the
cicatrix is contracted to a narrow line, and the sinus, out of which a

394 DR HJALTEUN ON THE USE OF MEECUBY [nOY.

few drops of discharge can be squeezed in the morning, is not larger
than an ordinary probe.

A few days after the last report on the 8th July, the sinus com-
pletely closed, and he is now, on the 31st July, perfectly cured,
xhe sinus closed, the cicatrix firm and contracted, the stump well
formed. He goes to work regularly as a tailor, and is in robust
health. He uses crutches and gets over the ground rapidly; is
getting fat, and is much grown in height as well as circumference
since his accident.

He was admitted on 10th April 1864. Thigh amputated on
12th April 1864. Hip amputated on 24th April 1864. Perfectly
cured on 31st July 1864. Just 100 days from the operation.

Article IL — A few Words on the Evidence against the Internal
Use of Mercury in Syphilis and other Diseases. By John
Hjaltelin, M.D., Inspecting Medical Officer of Iceland.

When I, nineteen years since, for the third time visited Grermanjr.
the controversy between mercurialists and anti-mercurialists was, I
thought, at its highest point; and in the second volume of the
great clinical work of JDr C. Canstatt, published in 1847, the
controversy seemed to be settled scientifically, as may also be seen
in several other articles from Canstatt's Jahresbericht, between
1848-62. But from the Medical Mirror of February of this
year, I learn that Dr Charles Drysdale has begun the old battle,
and has brought it to "evidence." I wish it were so; but I am
pretty sure that the battle is just begun, but not ended, in Great
Britain. There are some expressions in the above-cited article
which are rather provoking for old practitioners, especially those
who for thirty years or more have followed the progress of their
science with due attention and conscience. Tne treatment of
dangerous and malignant diseases is a serious matter : people can
die but once, and if we have omitted something that might have

saved them, our responsibility is very heavv. The old proverb of
Hippocrates, — " Experimentatio periculosa," still holds good ; and
it IS a dangerous thing to cast away some old experience if we
have no better thing to put in its place.

The history of medicine shows clearly how dangerous innovations
have been, and are still ; and it is perhaps too strong an expression
to give the name of " evidence " to an unproved proposition. Most
of us certainly know the excellent work of The Inductive Logic,
by Mill ; and its German translation by Dr Schiel in 1849, has,
since 1850, been one of my favourite books ; but it is just this
excellent man that demands the greatest circumspection in all our
inductions^ and this was for long time since accepted by the
imr" ' 1, for he says, — " Non fingendum, nee excogitandum,

1864.] IN SYPHILIS AND OTHEB DISEASES. 895

sed inveniendum, quid natura faciat et ferat." Yes, it is just this
we must never forget ; and therefore we must be very cautious in
accepting all innovations.

The modem treatment of syphilis has of late been one of the
great arguments against mercurialists, but we have been happy
enough to state the fallacy of Dr Fricke's treatment without
mercuiy. His dangerous system has, under our own eves, in
1838, shown its insufficiency at the Allgemeine Krankenhaus in
Hamburg ; and it is therefore a worthless argument for us, when
Dr Diysdale takes his treatment of 15,000 cases as an argument for
the success of the non-mercurial treatment, and we wonder that the
learned Dr Drysdale has not read the strong arguments that were
brought against Dr Fricke's innovation in many German medical
journals. I have myself been eye-witness to the dangers his
patients had to undergo after they had left the Allgemeine Kran^
Kenhaus as quite cured ; and one very accomplished Dutch physi-
cian, who also was an eye-witness to the same, as I myself, said in
a provoking voice, — " Hier konnen sie lemen, meine Herm, dass
man die syphilis nicht curiren darf:" "Here vou may learn,
gentlemen, that we ought not to cure syphilis. I regret very
much that I now, during twenty years, have been eye-witness to
so many unhappy trials of the Epsom-salt cure (Entziehungskur
of FricKe), ana I wonder really that the minds of medical men have
been so tolerant a^inst that treatment. There are no doubt manv
ulcers of the genital organs which are not really of a syphilitic
nature, and these may no doubt be cured with mere cleanliness,
without any medical treatment at all ; but if there is a real consti-
tutional syphilis, or, in other words, if the syphilitic poison has
been absoroed into the system', we look upon the non-mercurial
treatment, at least in many cases, as dangerous and insufficient ;
and we are glad, in this respect, to be able to quote one of the most
able medical men, viz.. Professor John Erichsen^ for he says, in his
excellent work of Science and Art of Surgery, London, 1861, page
486, — " Of the value of mercury in constitutional syphilis every
surgeon of experience must have had abundant proof." Page
487, — "Looking, therefore, upon mercury as the only remedy
we possess that influences directly and permanently the venereal
poison."

We would lengthen these remarks if we should enumerate all
the dangers we with our own eyes have observed from the
Entziehungskur. The poor patients may imagine that they are
cured, ana the physician may, Ixmd Jide^ accept this as granted,
but has he then observed their fate afterwards ? has he any logical
proof that the poison is gone out of the system ? for does he know
now long it may be in a latent state in the system ? We have
many undeniable facts where it has been latent for years, and this
proof is perhaps nowhere better to establish than in this country :
how little share it may seem to be able to take in the medical

VOL. X.— NO. V. 3 b

396 DR HJALTELIN ON THE USE OP MERCURY [NOV,

experience; but the reason of this singularitjr is this, there is no
endemical syphilis in this country, and our strict laws against that
disease have quite succeeded in protecting the poor inhabitants of
this country from that horrible and dangerous disease. In the
meantime, a good many cases have come under mj observation
where Icelanders who have been affected with syphilis in foreign
countries, apparently cured for it by the Entziehungskur, have
had the most dangerous secondary and tertiary sjrphilitic affection,
which only could be cured by the Judicious use of mercury.

This is a sad experience, and convinces me of that opinion, that
the now so much extolled non-mercurial treatment in real constitu-
tional syphilis will sooner or later fall with a general crash. I will
here speak nothing of the Norwegian inoculation of the svphilitic
virus. The time is still too short to show its real effects, for it has
as yet not been practised for more than eight or nine years.
Horrible as it is, its judgment is sure in time to come ; may it then
not show itself as a dangerous experiment with a frightful poison.
Medical treatments, have, alas ! changed according to fashion ; and
we can hardly foretell what changes some proposed " evidences "
may have in time to come. Our duty is to observe ; for as one of
our old masters said, — " Ars tota in observationibus." The latest
observations of Dr Beyran show clearly how dangerous the syphil-
itic poison is.

Regarding Dr Drysdale's opinion of the inutility of mercury
against inflammatory diseases we will say very little. We know
very well that he talks perhaps fashionably of the uselessness of
that remedy, but we do not think tha^ his opinions are in accord-
ance either with general practice or with extensive experiments,
made on animals by the most able veteiinarians in our days. There
is only one thing we must remind him of, and it is this ; diseases
are no entities, and when he speaks of so many pneumonias treated
by Hughes Bennett and other renowned physicians, we want to know
how much of the lungs was in a state of inflammation. We know
very well that many lobar and lobular pneumonias may often do
well without any treatment, but we have seen other pneumonias
where the whole of the one lung, or the lower lobe of both lungs
have been inflammated at once, in a short time, and accompanied
by the most dangerous symptoms. We always look on diseases,
not as entities, but as pathological processes in the system, which
may vanr very much according to age, causes, epidemical constitu-
tion, and several other circumstances ; and it is just from this cause
that the numerical methods applied to this and other diseases may
often be very fallacious and nearly worthless.

When Dr Drysdale, in order to prove his evidence a^inst the
internal use of mercury, adduces several renowned names, beginning
with Mr T. S. Mill, who has really never spoken of mercury, ana
has, as far as I know, no right to take part in such a debate, we
may easily be ready with him; the other names, as Professor

1864.] IN STPHIUS AND OTHEB DISEASES. 397

Hughes Bennett, Professor Syme, Dr Williams of Boston, etc., are
great authorities, and must be highly estimated hy all scientific
men ; but we must remind our learned Dr Drj-sdale, we have other
names to put against them, names which we hope are not out of
^^ medical debate ;^^ we mean the names of Wunderlich, Hertvig,
Headland, Watson, and Fuller. We have at least seen nothing
more clearly written on the uses of mercury than the propositions by
William Headland, exposed in his work, ^' An Essay on the Action
of Medicines in the System ;" and the articles written by him in
The Lancet of 1858, March 27. Nothing is more clear, more in
accordance with the logical axiom of Mr Mill (above quoted), than
the writings of this accomplished physician. We will not speak of
the propositions of Professor Hertvig and Professor Wunderlich.
they are written down in the late medical works of Germany, ana
every medical man can be convinced by them if he pleases. The
name of Dr Thomas Watson must be so familiar in Great Britain
that we need not speak any more of that.

We think that Professor Syme will have hard work to do, if he
shall be able to demonstrate that the ravages of syphilis amongst
the soldiers of Charles the Eighth, in Naples, ana its spreading
afterwards in 1494-98 through the most of the southern countries
of Europe, were due to the mercurial treatment of this disease ; for
it is a well-known fact that this tremendous disease was not in the
beginning treated with mercury, but with the " leano aanto^^^ and it
was in most cases not treated at all, as may clearly be seen by the
old history of this disease, as it has been handed to us by Aetruc^
OtrtanneTy K, Sprengely and Heneler,

Dr Frederick August Walch says that it was in the beginning
not treated at all, but left alone with all its frightful ravages ; and
he adds that the ulcers spread so quickly that often complete de-
struction of the internal parts of the mouth follows, and the soft and
hard palate and tonsils are lost. The ulcers also often attack the ex-
ternal parts of the face, and then the lips, nose, and eyes may be lost.

It is true, as early as in the beginning of the sixteenth century
some sorts of mercurial ointment were used by some quacks against
syphilis, but we challenge Professor Syme to show us an evident
historical account of such a factum that the ravages of syphilis in
Naples and other southern countries of Europe, which are so re-
nowned in the end of the fifteenth century, or from 1493 up to 1500,
have been due to any mercurial treatment.

The 80-often misjudged Paracelsus was, according to our notice,
the first medical man who made the internal use of mercury against
syphilis known, and this was about 1539. This was in that time
a great discovery; perhaps even as great as the vaccination itself;
and this great man is not to blame if his followers did not under-
stand his doctrine. Professor Liebig has, of late, clearly shown the
great merits of this man, whose doctrine has often been misinter-
preted.

398 DR HJALTKLIN ON THE USE OF MERCUBY, ETC. [NOV.

But we will not loneer speak of this now. Younff physicians of
modem time may think that there is nothing to be Teamed but by
the microaccpe and the test-tubey and that the old physic is good for
nothing. We certainly admire and are fond of all discoveries the
modem microscopists are producing, but we will only remind them
of this, that what the^ show us now is only the morphology of
pathological products in our days ; we might also see the micro-
scopical facts of medical history written down in the annals of our
science, but scattered about and neglected to a great shame of our
science. We think that if these facts were clearly selected with a
due criticism, we might come to some conclusions which as yet are
unknown to us. There were great geniuses at all times in the
world, and it is very unphilosophical to think that great geniuses
are only created in the nineteenth century. Vixerunt fortes
ante Agamemnemem. We think we ought to follow the method of
the modem geologists ; they are not only looking at the morphology
of matters as it is now, but they are deciphering the metamorphoses
of matters in the history of our globe, written down on the older
and newer rocks. They are, in short, in the most strict logical
manner following the eternal metamorphoses of matter, and all the
combined actions resulting from them. The medical annals and
the history of diseases ought to be our rocks, whose hieroglyphic
letters we ought to understand, not only as they are now, but also
as they have been in former days. By following such a course we
would most likely come to some other conclusions regarding life and
diseases than we have now. We would be better acquainted with
the chance in laws which govern nature and produce unknown
metamorphoses in all the quarters of physical phenomena within
our reach of observations.
Reykjavik, 2Ut April 1864.

P. 8, — Should these incomplete and in a great hurry written re-
marks come before the public, we will request our readers to look
upon them, not as a defence of an injudicious and quack use of
mercury, but as a defence of this remedy when used with due caution
and circumspection. We know very well that its abuses have
occasioned a great many mischiefs, but we know also the truth of
the old proverb, " Abusus non toUit usum." We were, curiously
enough, just now when writing this, asked to look to a young sailor,
who for three months since had been treated for a primitive chancre
with some caustic and the Ep^om-salts cure, and dismissed from one
of the great foreign hospitals as quite cured, after a treatment of two
months, but who is now affected with the most frightful symptoms
of secondar)r syphilis. Such occurrences are very common m my
practice during the summer months, and Dr Drysdale's article will
give me occasion to make them known to the medical publicum.

1864.] EMPLOYMENT OF CHLOBOFORM IN DENTAL SUBGEfiT.

Article III. — On the Employment of Chloroform in Dental Surgery,
By J. Smith, M.D., F.ir.C.S., Surgeon-Dentist to the lloyal
Infirmary, Koyal Hospital for Sick Children, Dental Dispensary,
etc., Edinburgh.

The administration of chloroform in dental surgery is attended
with some special difficulties, which lead to its employment being
avoided in many cases where it might otheiwise be of considerable
service. In operations within the mouth, the inaccessible nature of
the locality, tne severe pain attending such operations, and the
untoward complications apt to accompany the anaesthetic state, con-
tribute in making the exhibition of this agent freauently unsatis-
factory. Certain extra precautions are therefore here necessary,
and certain rules must be followed to secure a prospect of success.
And it should be recollected that failure in this instance is much
more detrimental in every way than if ansesthesia were never
attempted at all.

In exhibiting chloroform for such operations as tooth extraction,
everything should be so arranged that the patient may be kept
under its influence for as short a time as is compatible with the
requirements of the case. The sooner the anaesthesia is produced
after inhalation is commenced, and the sooner the patient can be
relieved from its effects when they are no longer desirable, so much
the better. With this view all preparatory measures should be
nude before commencing with the anaesthetic. The instruments
likely to be required should be selected, and laid out in order, and
covered by a napkin. The chair or couch to be used should be
arran^d so as to suit the operator's convenience. Any mere
exammation of the mouth or teeth should also be made at this
time, and the services of one or two competent assistants secured.
The presence of friends or relatives, — unless medical, — of the
patient should as far as possible be discouraged. They seldom
assist in any way, frequently keep the patient wakeful, and some-
'times embarrass the operator.

Always bearing in mind that the part to be operated on should
be placed so that the surgeon shall have the greatest possible
facility for examination and manipulation, the most convenient and
much the safest attitude for the patient is the recumbent or hori-
zontal position. For this purpose a low couch or sofa raised at one
end, and without a back, will be found most serviceable ; the patient
being laid in a semi-recumbent posture, with the head supported on
the raised end of the couch, and the face turned towards the light.
The dress about the throat and neck should be loose ; the neck
should in all cases be without any covering whatever in front,
and any coverings on the chest should be so arranged that all the
movements of respiration may be at once and easily observed.

In operations within the mouth it was, and to a less extent it

400 DR SMITH ON THE EMPLOYMENT OP [NOV.

still continues customary to introduce a cork or some such sub-
stance between the teeth previous to and during the exhibition of
the anaesthetic: such a practice is far worse than useless. The
very first inhalations of chloroform produce in many patients a
slight degree of irritation in the fauces, often promote an accumu-
lation of fluid in the mouth, and generally excite a desire to
swallow. This latter act cannot be accomplished so long as any-
thing keeps the jaws apart ; the patient eventually struggles to
rid himself of the difficulty, his struggles are mistaken for mere
cerebral excitement, and a contest takes place between the half-
insensible patient and his attendants, probably with the result that
the attempt to produce anaesthesia is in the end abandoned. Instead,
then, of introducing any substance of this nature between the teeth,
nothing of the kind should at this stage be attempted. The patient
should be left the perfectly unconstrained power of deglutition, and
the chloroform should be inhaled in an easy and placid manner
through the nostrils. Any forced or rapid inspirations do little
good, and sometimes give rise to difficulties, as they are almost
always followed by a cessation for a time of the respiratory act
altogether. This symptom above everything else is to be guarded
against; and on anything like interruption to the regularity of
the breathing being observed, the chloroform should be at once
withdrawn.

In order that speedy insensibility may ensue, perfect silence should
be maintained. The patient ought, if possible, to be without any
apprehension that the anaesthetic is hazardous^ or that no effect can be
produced by it in his case, or that the operation will be commenced
Defore a sufficient quantity has been inhaled. Wherever a patient is
nervous or anxious about such matters, it will be found that much
more time and a much larger quantity of chloroform will be required
than would otherwise be the case. Another point of some importance
is the frame of mind in which a patient comes under the influence of
this anaesthetic. If an effort be made to go quietly to sleep, there is
little chance of much struggling or involuntary restlessness. On the
other hand, especially in tne case of all minor operations, if a patient
entertain the belief that under the influence of chloroform the con-
duct is necessarily outrageous, it seldom fedls that such an idea is prac-
tically realized. Indeed, in not a few instances it would almost
appear as if the patient had premeditated the display sometimes made
during the exhioition of such agents ; and in all cases it is advisable
that he should be instructed to remain as (juiet as possible so long
as sensibility is retained. In this way, with a little effort on the
patient's part, the whole operation may be rendered much more
satisfactory both to himself and the surgeon.

The means of exhibiting the anaesthetic itself has been a subject
of considerable discussion ; and in dental surgerv this is a point of
some importance. Various forms of inhalers nave from time to
time been brought forward, each being by its own advocate described

1864.] CHLOBOFORM IN DENTAL SUBGEBT. 401

as superior to all the others, and all of them as preferable to exhi*
biting such agents on a napkin or handkerchief. It must be kept
in mind, however, that the less we have to attend to besides the
patient the less risk is there of danger ; whereas, if attention has to
De bestowed on the working of an apparatus, complicated as these
inhalers occasionally are, it necessarily interferes with that close
watching of the patient which is in all cases absolutely essential.
Much importance has been attached to the waste of cbloroform
resulting from the use of a napkin. A very little consideration,
however, will show this to be a waste of the most trifling descrip-
tion, comparatively of no moment whatever, never in any case
amounting to more than the value of a sixpence, and seldom to any
appreciable amount at all. Again, it has been argued that the
patient gets too much chloroform by using a napkin. To this it
may briefly be replied, that this is tne fault of those administering
it. If the chloroform be properly managed, in all probability the
same quantity will require to be inhaled to produce the same effect
in a given time whatever apparatus be used, unless, indeed, its
exhibition be frittered away in a repetition of very small quantities,
when a great deal more will be inhaled with a much less satis-
factoiT result, and that only after subjecting the patient to an
uncalled for and inexpedient protraction of every stage of anaesthesia.
Another circumstance rendering any extra complication in the
" inhaler " objectionable, is the frequency with which the inhalation
requires to be suspended and renewed. This especially applies
to operations on the mouth and in its neighbourhood, as, for
instance, in the extraction of a number of teeth at a time. Ilere the
patient often becomes conscious during the operation, and requires
an additional dose of the ansssthetic to be administered, while
perhaps the position of the head and the condition of the mouth
would render any special apparatus difficult to adjust, not to speak
of the flow of blood rendering it dangerous. The simplest ana the
safest method of administration, then, is by using a napkin or
handkerchief folded several times, so as to prevent the too sudden
evaporation of the anaesthetic, and pouring upon it the chloroform
in quantities not less than a dessertspoonful at a time, and renewing
it as soon as the former supply has passed off. The napkin should
be held at first about two mches from the patients face, enjoining
him to close the eyes so as to avoid the smarting otherwise apt to
be occasioned. As the anaesthetic effects begin to appear, the
napkin may be brought into closer proximity with the face, until at
last it may even be applied in actual contact with the mouth and
nose, and kept there, unless there be any contrary indication, until
anaesthesia is complete. Instead of iblding the napkin, it has been
proposed to use a single layer placed over the mouth and nose, and
to arop the chloroform upon this, keeping it constantly moistened
with a small quantity of the anaesthetic. This method answers
well in many cases where the patient is lying down, and not rest-

402 DR SMITH ON THE EMPLOYMENT OF [NOV*

less or excitable, but it is attended with some difficulties when
the semi-recumbent posture is adopted ; and in the case of tooth-
extraction, another drawback to this mode of administration exists
in the apparent tendency to move the head about, as if in appre-
hension that the operation was about to be commenced. For
simplicity, for safety, and for convenience in the facility of its
withdrawal and reapplication, over and over again, there seems no
method so well adapted for operations about the mouth as the
napkin folded and used as already described.

The quantity of chloroform inhaled before perfect anaesthesia is
induced varies very much in different patients. There is also a
great difference in the degree of rapidity with which one patient in
comparison with another will inhale a given amount of chloroform.
Owing to these two circumstances, the time required to produce
complete insensibility ranges among various patients from a period
of a few seconds' duration, upwards, to cases where the inhalation
requires to be kept up for nve or ten minutes or more before a
sufficient effect is obtamed ; and so far as my own experience goes,
it is among the latter class of cases that vomiting and after-sickness
most frequently occur. This is of some consequence where tooth-
extraction is to be the operation performed, as expedition obviously
becomes essential for success when such occurrences are to be
expected.

I have stated that previous to and during the exhibition of chlo-
roform, no substance should be placed between the teeth with the
view of keeping the jaws apart. After the anaesthesia is complete,
however, it will in general be found necessary to separate the jaws
widely, and to retain them so in order that the operator may com-
mand a ready access to, and a full view of, the parts. And it may
be asked, how is this to be done ? When the anaesthesia is suf-
ficiently deep for performing painlessly any such operation as the
extraction of a tooth, little aiftculty will commonly be experienced
in merely opening the mouth ; since, from the muscular relaxation
induced, the lower jaw will tend to drop on simply allowing the
head of the patient to fall back to a slight extent. Exceptional
cases do occasionally occur where the teeth, and even the lips,
are closely and forcibly kept shut. But in no instance is the
difficulty so great as not to be easily overcome by merely inserting
between the front teeth the end of any thin flat body, such as the
handle of a tooth-brush, and rotating it so that the teeth, or where
these are absent the gums, shall be separated by and rest upon its
edges. This being once accomplished any suitable gag may be
introduced between the molar teeth of the side opposite that to
be operated on, and by moving it further back or forwards, the
same size ef gag mav be made to retain the mouth open to .various
different degrees. In 1854, I published, in the Monthly Journal of
Medical Science for April of that year, an account of a speculum
for purposes of this nature, and which in certain cases I still con-

1864.] CHLOROFOBM IN DENTAL 8UB0EBT. 403

tinne to employ, as it remains more steadily in position than those
generally used, and dispenses with the necessity for being held by
an assistant, — a proceeaing sometimes interfering with the required
amount of light and space. The instrument is tolerably well
known, and for further particulars I must refer to the above
publication. On the whole, however, as with the use of inhalers,
etc., the simpler all such auxiliaries are the better, and with a
little judicious management, nothing in ninetv-nine cases out of a
hundred will be found necessary for opening the mouth and retain*
ing it so beyond the measures already described. It need scarcely
be said here, that where both upper and lower teeth are to be
extracted, the operator should commence with the lower ones, as
the flow of blooa does not in this way tend so much to interfere
with his subsequent proceedings.

Allusion has been before made to the care with which any im-
pediment to the respiration must be avoided in the administration
of chloroform. This seems to be of much more consequence than
watching the pulse, or indeed than all the other usual precau-
tionary measures put together, as by far the most frequent and
most imminent source of danger lies in the risk of suffocation.
This, I am aware, is no new or singular opinion, but it is one
by no means practically enforced in every case. It is, however,
a point to which too much attention cannot be directed, and in
such operations as those under notice, most danger is likely to
occur m this manner at the very time when it is most likely to
be overlooked, and that is during the operation itself. One cause
of this is obvious, and has been alreaay explained, namely, the
inability to swallow while the mouth is open. If it appear then,
on looking into the mouth, that any obstacle to the entrance of air
exists at the back of the cavity or in the pharynx, so that the open-
ing of the larynx might be closed, this it need not be said is to be
immediately and effectually removed. During the state of complete
unconsciousness, and especially where the patient is lying horizon-
tally on the back, the tongue is apt to fall, or to be retracted some-
what towards the gullet, and in this way a danger of suffocation
has been apprehended. The practice of some of our highest
surgical autnorities is on these occasions to draw forward the
tongue with artery forceps or a tenaculum, and sometimes by
means of a ligature passed through its substance. In certain
cases these proceedings may be demanded, particularly in such
as those where much time is likely to be occupied, and where it is
desirable to keep the tongue drawn forward for a considerable
period continuously. But we must recollect, that by keeping the
larynx uncovered — ^if such be the effect of this measure — the
entrance of fluid as well as air is promoted, and that an accumula-
tion at the orifice of the larynx of a quantity of saliva or bloody
fluid will choke a patient as readily as if it were closed up by the
epiglottis or tongue lying there. Now, to rid himself of an obstacle

VOL. X. — NO. V. 3 P

404 DR SMITH ON THE EMPLOYMENT OF [NOV.

to the respiration, such as saliva or blood, the patient always endea-
yours to swallow. But where the tongue is kept forcibly-extended
this is impossible, while the lodgement of fluids on, and their passage
into the larynx is rendered more likely to occur by its exposure.
Such a mode of procedure, then, will be of little avail, unless at
the same time the entrance to the larynx be sedulously kept free of
fluid matters. There seems no absolute necessity, however, in the
majority of dental cases for thus hooking forward the tongue at all.
Bo long as the respiration is seen to go on, no interference of the kind
is required ; and when there does occur any tendency to disturbed
or obstructed or arrested breathing, the chloroform should be with-
drawn, and merely the forefinger thrust well back into the pharynx,
where, by a few simple movements, the fluid can be cleared away,
deglutition, in all probability, at once excited, and the tongue
pulled forward if necessary. I may here be permitted to remark,
that in the experience of between one and two thousand cases of
complete anaesthesia for dental operations, I have never had occa-
sion to resort to any other measures than those last mentioned.

It is seldom before, and generally after, the accession of insensi-
bility that sickness with vomiting commences. And it is only
when it commences before or at this stage that it forms anything
like a serious impediment to the surgical procedure, as after this is
effected its occurrence is of but little consequence. When vomiting
begins about the time of the operation being commenced, the ansss-
thesia is generally so well established, that on the first paroxysm of
sickness passing off a very little more chloroform will restore the
andBSthetic state so speedily, that before the re-accession of vomiting
the operation in most instances may be successfully completed.
When it begins earlier than this, however, the difficulties are
increased, and in some cases render it injudicious or impossible to
continue the administration of the chloroform. It is superfluous to
say that, of all operations, those in the mouth and its vicinity are
such as are most interfered with by vomiting. In this way it
becomes a complication of a very troublesome nature to the surgeon.
But it by no means rests here^ for it also entails serious risk to
the patient, inasmuch as in many cases there results from this
cause great danger of sufibcation. The vomiting, when ansBsthesia
is deep, often seems to be imperfect, the contents of the stomach
^gling up into the mouth, in small quantities at first, while there
IS an apparent inability to eject the vomited matters any farther.
In this way these are sometimes accumulated at the upper part of
the gullet and pharynx, and unless due caution be exercised the
larynx may thus be shut up and respiration prevented. The
ordinary rule is not to exhibit chloroform until the expiry of several
hours after the last meal, so that the stomach may be empty, — ^a
condition in which it is supposed tliat sickness is less likely to occur.
Patients, however, sometimes deceive the operator in this respect ;
and in other cases digestion seems to proceed at a very slow rate

1864.] XHLOBOFORH IK DENTAL BUBOEBT. 405

previous to the expected operation. In this manner, then, with a
patient unconscious and utterly helpless, an oj^eration half-completed
within the mouth, and a stomach charged with half-digested food,
vomiting may be conceived to be an occurrence by no means void
of danger.

Vomiting in many instances does not occur until the anassthetic
condition is passing off, and it is not improbable that in certain cases
the mode of rousing the patient has something to do with the acces-
sion of this after-sickness. No violent measures should be resorted
to for such a purpose ; no shaking of the patient ; no loud speaking
or vociferating into his ears ; no attempt of any kind to awake him
the moment the operation is over ; and, certainlv, no allusion of any
kind should be made to sickness or vomiting. The patient ought to
be allowed to lie perfectly quiet — ^to have free access of air, and not
be permitted to speak or be spoken to so long as any mental con-
fusion exists.

In concluding these remarks it may be observed, that so far as
concerns the typical progressive stages of anaesthesia manifested in
any individual instance, the practical experience of one or two cases
would be more instructive than any amount of description. Certain

Srogressive degrees of insensibility have been attempted to be
eterminately laid down, and the distinguishing features peculiar
to, and characteristic of, each of these stages to be mapped out
This has been done as a guide for the administration of such agents
with the view of averting danger. But the indications of the
various degrees of narcotism vary with the nervous constitution of
the patient, as well as with the amount of chloroform exhibited.
And so far as danger is concerned, this does not manifest itself
exclusively at any particular stage or degree of the anaesthetic state,
but has occurred at its very commencement as well as at its com-
pletion, and even occasionally after its apparent subsidence. In
this way it would seem that no ratio can be well established
between any series of phenomena and either the progress of the
anaesthesia or the proportionate risk accompanying each stage. An
observant eye and a sound judgment, a practical acquaintance with
the use of anaesthetics, and a readiness lor all emergencies likely to
complicate their action, are the true safeguards and the essential
quahfications for the employment of such agents in dental surgery.

As a resum^ of what has been now stated, the following points
may be briefly recapitulated : —

Isty The difSculty attending the administration of chloroform
in dental surgery arises from the nature of the locality and the
severity of the pain in such operations ; together with the incon-
venience and danger here incurred by any untoward complication
accompanying the anaesthesia.

2c?, Everything should, therefore, be so arranged that the patient
may be kept as short a time as possible under the anaesthetic.

406 DR G. BUCHANAN ON EXCISION OF [NOT.

The operation ought not to be commenced before the Ml effect
of the chloroform is produced ; and the details of the operation
itself must be adapted to the passive resistance of the ansBSthetic
state, and to the limited time at our disposal.

3fl?, The patient should be in the recumbent posture. Nothing
should be placed between the teeth while exhioiting the chloro-
form. The respiration above all should be closely watched, and on
any symptom of its being impeded or arrested, the chloroform
should be at once withdrawn, and the pharynx cleared of saliva or
any other fluids.

4thy On completing the operation the patient should be allowed
to awaken quietly, and without hurry or molestation of any kind.

Article IV. — Excision of Superior Maxillary Bone. By Georgb
Buchanan, A.M., M.D., Surgeon and Lecturer on Clinical
Surgery to the Glasgow Koyai Infirmary; Lecturer on Ana-
tomy, etc.

J. M^T., aged 60, two months ago had his attention first directed to
his present disease, by a severe pain in the ^m over the left molar
teeth of the upper iaw, one of which was diseased. He supposed
it to be a gumboil, and had the decayed tooth removed. This
afforded some relief to the pain, but caused no diminution of the
swelling, which continued to increase rapidly till it interfered with
deglutition and articulation. It now gives him great uneasiness,
and frequently prevents sleep at nieht.

At present the appearance of the disease is somewhat as follows : —
The left side of patient's face is completely distorted by a large
tumour, which protrudes the cheek at least an inch bevond that of
the opposite side, and encroaches considerably on all the facial
cavities. It bulges somewhat into the nasal fossae, and raises the
eyeball above its natural level. It can be felt in the zygomatic
fossa behind the malar bone. The anterior wall of the antrum is
completely absorbed by the pressure of the growth which protrudes
in nodules underneath the cneek. The posterior half of tne alveo-
lar process on the left side is invaded by it, and it can be partly
felt behind the velum. It causes the patient great pain ana dis-
comfort, and he is anxious for relief.

On the 16th of May 1863, 1 performed excision of the upper jaw in
the following way : — The patient was put deeply under the influence
of chloroform, and though he occasionally became so far conscious
during the operation as to assist in spitting out blood, and turning
his head as aesired, he assured me afterwards that he felt no pain
at all. An incision was made from the angle of the mouth to the

5rominence of the malar bone in the line of the zygomatic muscle,
'his divided the cheek into the mouth. Next I cut through the

1864.] 8UPEBI0R MAXILLARY BONE. 407

upper lip in its centre, and dissected it along with the ala of the
nose from its attachments, and so turned off a flap consisting of the
whole of the left cheek. With a narrow saw I divided the zygo-
matic arch, the outer wall of the orbit, the nasal process of the
superior maxillary bone, and completed this part of the operation
by separating the intermaxillary suture with the cutting pliers.
By placing the thumb on the lower wall of the orbit, having pre-
viously divided the attachment of the eyeball, and pressing farmly
downwards, the bone was easily dislodged from its position, and
came away, carrying with it the greater part of the tumour which
bulged from it on all sides. A part, however, remained attached
to the back part of the cavity which was left by the removal .of the
bone. I scooped and tore away all that was within reach, and
succeeded in removing everythmg which seemed of a suspicious
nature, so that when the wound was spon^d out, the anterior
aspect of the pterygoid process was clearly m view. To prevent
the chance of leaving any tissue of a morbid kind, I applied a small
actual cautery, and destroyed the soft parts at the Dottom. The
cavity was tilled with folded lint, ana the wound stitched with
silver wires.

The patient recovered without a bad symptom, and was dis-
missed on the 29th June, the wounds being entirely cicatrized.

He returned occasionally to show himself at the infirmary, and
when I saw him last, in May 1864, a year after the operation,
there were no signs of any return of the disease. The cheek was
retracted with the cicatrization of the wound, but he could speak,
eat, and swallow with facility. A band of elastic hard substance
could be felt under the skin, stretching from the prominence left by
the section of the zygomatic arch, across the cheek. This seemed
to me to be formed by a band of partially ossified periosteum
which may have been pushed out by the tumour, and had been
dissected off with the cheek flap. The most careful examination of
the cavity of the mouth, fauces, and glands adjoining failed to
detect any symptoms of a return.

When the tumour was examined after removal, it had all the
appearance of epithelial cancer, and the place of its first appearance
confirms this view. It sprung from the gum, and first attacked
the alveolar process, then extended into the antrum, and projected
ifrom it wherever it found readiest egress, — that is. into all the
adjoining cavities. The manner in which it broke under the
fineers, the nodulated character of its protrusions, and the everted
ana thickened edges of its ulcerated part in the mouth, point to the
same conclusion, which was confirmed by microscopic examination.

The case is interesting as affording proof that this form of
disease, even when it attacks a part so extensively connected as the
upper jaw, can be removed with success, provided the incisions are
made free of the diseased tissue, and sufficient care be taken to
eradicate every trace of morbid structure.

408 DR ARTHUR GAMQEE ON AN ALLEGED FALLACT IN [nOY.

Article V. — On an Alleged Fallacy in Marsh'' s Process for the
Detection of Arsenic By Arthur Gamoee, M.D., Assistant to
the Professor of Medical Jurisprudence in the University of
Edinburgh.

In the Journal de Pharmade et de Chimie for December 1863^ M.
Blondlot published a highly interesting little memoir, entitled
" Recherches toxicologiques sur la transformation de TArsenic
en hydrure solide, par I'hydrogfene naissant, sous Tinfluence des
composes nitreux ou de la pression." The statements made in this
paper are of the greatest importance to toxicologists, as, if proved
to be true, the gravest doubts would be cast upon a large number
of the analyses for arsenic which have been performed in medico-
legal cases during the last few years. It is needless to insist upon
the propriety of being accurately acquainted with the fallacies to
whicn any scientific process is liable, more especially of a process
furnishing evidence wnich may lead to the death of a fellow creature ;
on the other hand, it is equally important that we should not be
deterred by alleged fallacies, which have no existence except in
the imagination of their originators, from using with confiaence
valuable and really reliable methods of investigation.

It has long been known that under certain circumstances either
the conversion of arsenical compounds into the gaseous hydride
of arsenic (AsHs), through the agency of nascent hydrogen, is
altogether prevented, or the gas having been formed, is subse-
quently decomposed. Copper, mercury, and chlorate of potash
have been shown to act m this way.* M. Blondlot has, in the
memoir to which allusion has already been made, endeavoured to
show that under two other circumstances the conversion into

faseous hydride of arsenic is prevented, the solid hydride of arsenic
eing instead produced.

These circumstances are —

1«^, When the acid used for the evolution of the hydrogen con-
tains a nitrous compound.

2d^ Under the influence of pressure.

The first of these circumstances is the one which is of greatest
interest to us in a toxicological point of view, and the accuracy of
which I hope to disprove.

According to M. Blondlot, if the sulphuric acid made use of in
Marsh's process * happens to contain a trace of a nitrous compound,
as well as a trace ot arsenic, the hydrogen evolved by its action
upon zinc will, when tested, be found to be perfectly pure. On
heating a tube through which the gas is passed, no deposit of

^ See Dr Taylor on Facts and Fallacies connected with the Research for
Arsenic and Antimony, etc., in Guy^s Hospital Reports, Third Series, vol. vi.,
1860.

' M. Blondlot seems to assnme in his paper that sulphuric acid is invariably
used for evolving the hydrogen.

1864.] MABSH's process FOR TUE DETECTION OF ARSENIC. 409

metallic arsenic will take place, the arsenic present in the sulphuric
acid having, under the influence of the trace of nitric acid, been
converted into the solid hydride. The operator will therefore
assume the purity of his reagents. When he now proceeds to add the
fluid which he wishes to test, if the latter contain any organic
matter, it will neutralize the action which the nitric acid alone
would exert, and any arsenic present in the sulphuric acid would
then be evolved in the form of the gaseous hydride ; the operator
will consequently obtain a deposit in the tube through which the
heated gas is passed, due (he will suppose) to arsenic present in the
substance examined, but in reality orfginally present in the sul-
phuric acid which he had erroneously considered to be pure.

The formation of solid hydride of arsenic is, according to
Blondlot, most easily seen. If zinc be treated with dilute sulphuric
acid containing a trace of a nitrous compound, and then an arsen-
ical compound be added, brown flocculi will soon be seen to float
about the fluid ; these flocculi consisting of solid hydride of arsenic.
Solutions of cane sugar^ or almost any organic matter, will check
this reaction.

The statements of M. Blondlot are of so important a nature,
and have been made in so positive a manner, tnat I undertook,
at the request of Professor Maclagan, a series of experiments,
to endeavour to determine their accuracy; and the results to
which I have arrived are so entirely at variance with those of
the French chemist, that I have thought fit to publish them.
They show conclusively, I believe, that m actual practice nitrous
compounds do not interfere with Marsh's process, and they
almost disprove the formation of a solid hydride of arsenic under
the influence of these compounds. Before proceeding to an account
of my own experiments, I may call attention to the fact that
Blondlot has not given the least proof that the solid hydride of
arsenic is formed under the circumstances which he alleges. He
merely noticed, I suppose, that under certain circumstances, when
adding an arsenical compound to a mixture of zinc and dilute
sulphuric acid containing a little nitric acid, no arsenical mirrors
were obtained on passing the gas evolved through a heated tube,
and that in these cases brown flocculi were always seen floating
about the fluid. M. Blondlot has not sufficiently considered that
the fact of not obtaining an arsenical mirror is no proof of the non-
evolution of gaseous hydride of arsenic, and that no inference
whatsoever can be drawn from brown flocculi floating about the
fluid of Marsh's apparatus, as such are nearly always formed on
dissolving even the present zinc used in toxicological investigations.^

^ I have been quite unable ever to obtain a piece of pure zinc which was
entirely soluble in dilute sulphuric or hydrochloric acids, certain traces of
flocculi being always left undissolred. My experience on this point is, I am
certain, that of every one. I am at present engaged in an examination of
their nature.

410 DR ARTHUR GAMGEE ON AN ALLEGED FALLACY IN [nOY.

The first experiments which I undertook in order to test M.
Blondlot's statements were directed to the investigation of the
following points : —

Istj Does a trace of a nitrons compound so interfere with Marshes
process as to prevent the formation of mirrors of metallic arsenic ?

2d, If nitnc acid, or any other nitrous compound, does so inter-
fere, to what extent does it do so ?

Sdj Does the addition of organic matter to the fluid containing
dilute sulphuric acid, nitric acid, and arsenic, promote the evolution
of arseniuretted hydrogen ?

The plan of my experiments was the following : — I made certain
standard solutions which contained a known amount of arsenic in
a certain volume. I determined how large a deposit of metallic
arsenic I could obtain from different quantities of these solutions
when subjected to Marsh's process ; the bulk of the dilute acid
being always the same, as also its composition (56 cubic centi-
metres, or about 2 fluid ounces, of a mixture of one part of
chemically pure sulphuric acid of specific CTavity 1838'76, and five
parts of distilled water, being used). I then added the same
quantity of the standard solutions to the same quantity of dilute
sulphuric acid and zinc, the acid containing a known percentage
of nitric acid, and I observed whether I obtained mirrors of metallic
arsenic, and if their size was equal to that of the deposits obtained
when the pure acid was used.

The number of standard solutions which I employed was three,
which were labelled A, B, and C.

Solution A contained 1 gramme (15"434 grains) of pure arsenious
acid in 1000 cubic centimetres of distilled water. One cubic
centimetre of this solution was therefore equal to "001 gramme, or
between the one and two hundredths of a grain of arsenic

(•0154^.)-

Solution B was made by diluting 100 cubic centimetres of solu-
tion A to 1000 cubic centimetres. One cubic centimetre of this
solution was therefore equal to the 10th of a milligramme, or
between the one and two thousandths of a grain of arsenic
(•00154391).

Solution C was prepared by diluting 100 cubic centimetres of
solution B to the bulk of 1000 cubic centimetres. One cubic centi-
metre was therefore equal to the 100th part of a milligramme (or
to between one and two thousandths of a grain) of pure arsenious
acid.

These solutions enabled me to add with the greatest accuracy
excessively small and known weights of arsenious acid. The
apparatus I made use of for the performance of Marsh's process
was fitted up exactly as Dr Alfred Taylor recommends; the
evolved gas being made to pass through a sufficiently large
chloride-of-calcium tube, which contained, besides chloride of
calcium, a considerable quantity of cotton wool which had been

1804.] HABSH'S process FOR THE DETECTION OP ARSENIC. 411

diDped in solution of acetate of lead and then dried. To the
chloride-of-calcium tube was fitted a tube of hard German glass,
firee from lead, which was drawn out in two or three di&rent

; laces, so that its diameter did not exceed the tenth of an inch*
i'he free extremity of the tube was either drawn out to a jet, or
bent at a right an^le, for the convenience of dipping it into liquids.
As stated above, me bulk of the dilute sulphuric acid employed,
whether pure or containing a percentage of nitric acid, was always
the same, so that the experiments amnit perfectly of comparison.
Before aading the portion of fluid containing arsenic I nearly always
lighted the jet of hydrogen, so as to have a Knowledge of the rate of
the evolution of the gas, and heated the horizontal tube behind one
of the constrictions to dull redness. Operating in this manner I
found that I could obtain from one cubic centimetre of solution B
(containing l-lOth of a milli^mme or O01543 grain of arsenious
acid) a l^ge mirror of metallic arsenic, which could be abundantly
identified. On the other hand, one cubic centimetre of solution C
(corresponding to the 1-lOOth of a milligramme, or between the one
and two ten-thousandths of a grain of pure arsenious acid, yielded,
after heating the tube through which the ^bb was passed for nearly
an hour, a faint, but very pretty and distinct minor of metaUic
arsenic.

The first experiment which I tried to ascertain whether nitric
acid checks the development of gaseous hvdride of arsenic, or
prevents the formation of mirrors in the tube through which the
gas is passed, was a comparatively rough one.

Expisriment 1. — A Marsh apparatus had placed in it pure zinc
and two ounces of a mixture of one part of sulphuric acid of specific
gravity 1838-71, and five parts of water. When hydrogen was
freely evolved, tne gas delivery tube was heated to redness behind
the constriction, and 30 grain measures of nitric acid were
added ; then one cubic centimetre of arsenical solution A (contain-*
ing one milligramme =s '015434 of pure arsenious acid). A very
distinct mirror of metallic arsenic was obtained in the constricted
portion of the tube.

JExp. 2. — ^A Marsh apparatus had placed in it pure zinc, and
the acids exactly as in last experiment. Two cubic centimetres of
solution B (containing 2-lOths of a milligramme, or *00154 X 2
of pure AsO,) were added. No mirror was obtained. A large

Quantity of a saturated solution of cane sugar was added. iNo
eposit, however, was obtained.

Jay. 3. — Two oz. of mixture of dil. HO,SO, and 1 cubic centi-
metre of solution B (= 1-lOth of a milligramme, or '0015434 of
pure AsO.) added. Two very good deposits obtained.

These experiments were repeated, and identical results obtained.
They show, 1st, that when sulphuric acid contains an enormous
percentage of nitric acid, the production of mirrors from very small
quantities of arsenic is cnecked, although this property seems to be

VOL. X.— NO. V. 3a.

Atji J>B ARTHUR QAHOEE ON AK ALLKGSD FALLACT IN [K0T»

possessed only to a slight extent, as sulphuric acid, containing
about 13 per cent, of anhydrous NOa, prevented the formation of
mirrors from the dOOth of a grain of arsenic, though not from
the 100th« In experiment 2, when no deposit was obtained,
sugared water was largely added, but no eroct followed; in all
my experiments when 1 found that nitric acid prevented the forma-
tion of mirrors, I added to the apparatus a saturated solution of
sugar, invariably with the result that no deposit resulted ; results
altogether at variance with the statements of M. Blondlot My
subsequent experiments were conducted with sulphuric acid con-^
taining always the same quantity of nitric acid, rive cubic centi-
metres of nitric acid of specific gravity 1400*27 (containing about
67 per cent, of nitric anhydride), were diluted to 100 cubic oenti-
Inetres with sulphuric acid of densitjr 1838*76 (containing about 96
per cent* of the monohydrated acid). The mixture of nitric and
sulphuric acids contained, therefore, nearly 3 per cent. (2*99 parts)
of NO^ in 100 of the mixed acids. The mixture was diluted to
600 cubic centimetres.

-Erp. 4. — ^A Marsh apparatus worked with two fluid ounces of
the above-mentioned mixture of dilute nitric and sulphuric acids.
One cubic centimetre of solution B (= '0001 gramme of AsOt)
added. A very good mirror of arsenic was obtained. This mirror
was mixed with a little white deposit in'Bide the tube, which was
taken to be sulphur. (See JEiy. 5*)

Exp. 3. was repeated, and exactly the same sized deposit was
obtained. It was compared with a deposit obtained by adding
1-lOth of a milligramme to a Marsh apparatus worked with dilute
sulphuric acid, containing no nitric acid. In the latter case the
mirror appeared to be rather larger than the one obtained in Exp. 3.^
and there waa no white deposit inside the tube.

The above experiments, which are merely some of a numerous
series, and which were thoroughly confirmed by repetition, appear
to show, l^e, That when, in Marsh's process, the ffas is evolved by
the action of dilute sulphuric acid upon zinc, if the sulphuric acid
contains an enormous quantity of nitric acid, the formation of
mirrors from an extremely minute quantity of an arsenic^ com-
pound is checked ; the extent to which this occurs, depending both
U{)on the amount of the arsenical compound added to the acid
mixture, and to the amount of nitric acid present in the latter.
Thus, whilst sulphuric acid, containing 13 per cent, of anhydrous
NOft, did prevent the formation of mirrors from about 1 -500th of a
grain of arsenic, it did not do so when the quantity of arsenic
amounted to the 1-lOOth of a grain. On the other hand, with an
acid containing about 3 per cent, of nitric acid, good mirrors were
obtained from the lOOOth of a grain, although their development
was to a certain extent checked.

2dltfy That when nitric acid prevents the formation of mirrors of
arsenic, the addition of an organic fluid, such as sugared water^
exerta no influence in causing their appearance.

1864.] VABSH'h PB0CE88 FOR THE DETECTION OF ABSENIC. 418

The practical objections to Marsh's process, conducted eyen with
dilute sulphuric acid containing a trace of nitric acid, fall to the
eround completely, as no sulphuric acid will be, I presume, ever
found in commerce containing as much as 3 per cent, of anhy*-
droos N0«. the point at which the acid appears at all perceptibly to
influence tne formation of a mirror.

Having disposed of the practical bearines of M. Blondlot's
memoir, there remains only for solution the foUowing question : —

When nitric acid, mixed with the dilute sulphuric acid used in a
Marsh apparatus, cnecks the promotion of mirrors of arsenic, does
it do so by preventing the evolution of arseniuretted hydrogen ?
and if so, does it give rise to a solid hydride of arsenic ? The
following experiments give a decisive answer, I think, to this
question : —

Easp. 5. — A Marsh apparatus was worked with two ounces
of dilute sulphuric acid (1 — 6) ; when the evolution of ^as had
taken place freely, I added 30 grain measures of nitnc acid.
The gas delivery tube was then heated, and 1'5 cubic centimetre
of solution B of AsOt added (= '00231 grain). No mirror
of arsenic was observed, but a white film formed inside the con-
stricted portion of the tube exactly where the mirror of arsenic
ought to have made its appearance. ^ When the tube had cooled,
the deposit inside the constricted portion of the tube was examinea
microscopically ; it toaa found to constat of a magnificent ring of
cryatala ofAsOn.

Exp. 6. — ^A Marsh apparatus was fitted with a gas delivery tube
bent at right angles. Two ounces of dil. sulphuric acid, mixed
with half a drachm of nitric acid, were placed in it, and th^n
1 cubic centimetre of solution B (1-lOth of a milligramme of
AsOa) added. The end of the tube was made to dip into a small
quantity of a strong solution of nitrate of silver. Before the
arsenical solution was added, no blackening of the nitrate of silver
solution occurred ; but immediately after, the solution became quite
dark. As means had been taken for arresting any sulphuretted
hydrogen which mi^ht have been generated in the apparatus, the
blackening was evidently due to the action of arseniuretted
hydrogen upon the nitrate of silver.

The two last experiments prove very conclusively, in my
opinion, that when nitric acid checks the formation of a mirror
of metallic arsenic, in Marsh's process, it does so, not by preventing
the evolution of arseniuretted nydrogen, as M. Blondlot supposes.
They show, moreover, how it is that mirrors of metallic arsenic
are, under these circumstances, not obtained. When very dilute
nitric acid acts upon metallic zinc, protoxide of nitrogen is evolved ;
if this gas be mixed with arseniiuretted hydrogen, and the mixtuie
of gases transmitted through a heated tube, the arseniuretted
hyd^gen will be oxidized, arsenious acid and water being formed
as products* This is, doubtless, what occurs in all cases whence

414 DB ABTHUR GAMGEE ON AN ALLEGED FALLACY, ETC. [NOT.

dilute sulphuric acid containing a small quantity of nitric acid, acts
upon zinc and an arsenical compound.

From the above experiments, we can legitimately deduce the
following conclusions : —

Istlyj When the acid used in Marsh's process contains a very
small quantity of nitric acid, mirrors of metallic arsenic are obtainea
from extremely minute quantities of arsenic added to the apparatus ;
in other words, a trace of nitric acid present in the sulphuric acid
in Marsh's process does not perceptibly interfere with the formation
of mirrors of metallic arsenic.

2dlyj When the acid used in Marsh's process contains a con-
siderable percentage of nitric acid, the formation of mirrors is
checked ; the extent to which this occurs depending upon — (a) the
proportion of nitric acid present in the sulphuric acid, (b) the
quantity of arsenic present m the apparatus.

Sdlt/y That imder these circumstances the addition of an organic
fluid to the apparatus does not promote the formation of mirrors.

4thlyj That when nitric acid prevents the formation of mirrors of
metallic arsenic in Marsh's process, it does not check the evolution
of arseniuretted hydrogen, but prevents its being decomposed by
heat into arsenic and hydrogen, by causing its oxidation ; a ring of
crystals of arsenious acid being, under these circumstances, formed
inside the tube.

University of Edinburgh, Ockher 1864.

Article VI. — Case of Popliteal Aneurism a second time treated
euccessfuUy hf Compression. By A. P. LocKWOOD, Surgeon-
Major, 2d Dnigoons.

In the number of this Journal for December 1861, 1 recorded the
case of Sergeant May, where compression proved successful in pro-
ducing the cure of a popliteal aneurism in the left leg. The disease,
as will be seen by the following notes, returned in the vessel, but
at a somewhat higher point, and again coinpression proved successful.
28tA June 1863. — Since November 1861, when this man was
discharged from hospital, after having been three months under
treatment, he has been in tolerably good health ; has never ridden
since that period, but has done his duties, which have been chiefly
of a sedentary nature. States that about an hour after he got into
bed last night he felt a throbbing sensation in the left popliteal
space, which was shortly after followed by swelling of the knee,
accompanied with ereat pain. When seen at 10.30 A.M. the cir-
cumference of the left knee was 16f inches (the right being 14 in
the same position), the leg below the knee was slightly swollen,
but the swelling did not extend upwards ; there was considerable heat
in the parts, and pressure caused pain. Pulse 80, not strong;

1664.] DB LOCKWOOD'S CABE OF POPLITEAL ANEURISM, 416

tongae furred; tendency in the syetem to hypersemiai limb was
semiflexed, and any attempt to extend it caused pam ; habits
temperate ; has not been exerting himself violently m any way of
late. The old seat of aneurism m the popliteal space has a hard
whipcord-like feeline ; swelling prominent on each side of patella,
chiefly over intemsd abductors; bruit distinctly heard over this
region, pulsation also very distinctly felt here ; the bruit less audible
along the course of the artery upwards. He was ordered a purge,
and an evaporating lotion with ice was directed to be applied to the
knee.

Vesper. — Bowels weU acted on ; has taken no nourishment to-
day ; feels very weak from purgation and want of sleep ; to have a
little weak brandy and water. Refrigerant lotion to be continued.
' 29tk. — Passed a restless night ; limb, especially the knee,
painful ; circumference of parts increased ^th of an inch ; pulsation
and bruit as before, not perceptible in the ham. It would appear
that there is lesion of the coats of the vessels at some point above
the original seat of aneurism, most likely at the lower part of
abductor canal.

Director-general written to for Cartes' compressors, as their use
was attended with success on the former occasion.

The patient was seen by Mr Pemberton, an eminent civilian
surgeon, who kindly gave the loan of Weiss's double padded
compressor. This instrument was applied at 6 P.M., the point of
pressure being at the femoral trunk m Scarpa's triangle, relieved
by use of other pad two inches lower ; this was kept up until 3 A,M.,
when it could no longer be borne,
Be-applied at 7 A.M.

30th. — Slept a little during the night; states that the pres-
sure caused by this instrument is more painfdl than that which
was caused by Cartes' ; bowels moved once this morning ; tonmie
still furred ; pulse 84 ; face rather flushed ; pulsation ^ebly felt
on inner side of patella ; bruit very indistinct when the pad is on the
artery. The position of the limb was altered ; the wnole leg was
elevated ; a flannel roller was applied from foot to calf; leg still
semiflexed ; measurement in altered position, circumference 17^
inches. Ic^ cloths to be kept to knee.

Vesper. — The limb is hot and red ; flow of blood through femoral
apparently, but slightly impeded by the use of the instruments ;
half an inch larger in measurement ; apparatus carefully adjusted.
Two assistants to relieve each other during the night ; and, when
pressure of instruments can no longer be borne, to arrest circulation
at femoral by digital pressure.

IstJiUv. — Pressure from instruments found insufficient; digital
pressure xept up through the whole of last night by means of a
relay of men ; leg measures ^th of an inch less ; did not sleep more
than an hour; looks exhausted. The pelvic apparatus has been
applied, and the position of the patient changed ; so that it fits better

416 DE lockwood's case of poputbal aneurism, [nov-

on the vessel at the arch. Bruit muffled, decidedly less distinct
To continue the pressure as well as it can be borne. Ordered ao
opiate.

3d. — ^Passed a very good night ; moderate pressure only being
kept up at the groin hj the instrument ; sise^ 17^ ; no difference in
bruit. Continue iced cloths, etc.

Vesper. — One of Cartes' compressors arriyed from Director^
general, and was applied at 4 p.m« i^ Liq. opii Sed. m xx, ft. H*

Ath. — Slept at short intervals ; looks restless and anxious ; bruit
very indistinct when instrument is applied; parts becoming sore
where pressure has been kept up ; appetite keeping tolerably good ;
measurement, 17^.

5th. — Had m« xx. of Liq. opii Sed. Slept well for five houis ;
pulse good: is more cheerful; takes his food well^ able to bear
pressure. No change in state of aneurism. To contmue the use of
mstruments. Circmation in leg good ; feet not cold.

7th. — ^No change in symptoms yesterday. Passed a bad ni^ht,
but bore the instruments ; parts are getting sore and look a litde
bruised. Pelvic apparatus arrived from Director-general, — ^makers,
Whittaker and Blaise. Patient removed to a bedstead with a firm
wooden bottom; leg bandaged as far as knee, and elevated; the
new instrument, applied at 12 noon, fits well ; pressure directed on
femoral at groin ; bruit at seat of disease scarcely heard. Iced
cloths applied to leg.

8th» — Pressure borne continuously during the night

Qth. — Slept well ; took anodyne as usual ; looks exhausted and
wearv, but able to take all his food. Functions normal ; less bruit
beam with the instrument. Continue pressure.

10th. — ^Passed a restless night, owing partly to sultry state of
weather ; new instrument been on seventy-two hours. On relieving
the pressure, pulsation heard distinctly at sac. Pressure resumed ;
iced cloths, etc

11^ — It was thought advisable to relieve the bruised state of
the parts by relaxing the screws. This was determined on after a
consultation with Mr Pemberton. The limb carefully measured round
the knee and thigh, and was found to be 18 inches in both places.

12th. — ^Passed a very good night ; instruments have been kept
on, but the pressure has been very li^ht ; measurement, 17^ in same
places as yesterday ; venous congestion has doubtless been relieved ;
no pain in the sac; no numbness or peculiar feeling in foot or 1^;
heat about normal; bruit heard as before.

13th. — Had a very good night; took draught as usual; no pain
or uneasiness in limb ; knee, 17^ ; thigh, 17 ; oruit heard apparently
in centre of sac.

14th. — Bruit less distinct ; leg diminishing in circumference, ^
inch ] superficial pulsation alone felt ; pressure to be borne slightly
at thigh; strips of Emp. saponis applied in a decussating manner

IBM.] DB LOCKWOOD'S CASB OF POPLITKAL AKBURISM. 417

OTerthesac; calico roller placed smoothlj over all ; limb eemiflezed
and elevated at knee, object being to give nnifonn preaaiire to the
flac to favoiur conaolioation.

2lst. — There has been little change in the leg since last report;
the parts have been undisturbed ; the bandage has become loose,
owing to sabsiding of swelling ; bmit heard indistinetlj through
strapping.

28e&. — ^The bandage was removed to see what change there waa
in the state of the limb ; no change ; bruit still heard : suffers occa-
sionallv from epistaxia; bleeding excessive last night; looks ex-
hausted ; heart sounds weak, but normaL 9 Acid gallici, gr.xviij.y
conf. rosa, q. s. ; ft. pil. vj.

29th, — Strapping removed ; limb smaller ; bruit still heard ; no
pulsation felt ; cantharidine tissue to knee.

ilsL — Bandage and strapping re-applied.

4th Auffust.—DBJidsLge removed ; umb reduced in size ; no pul-
sation ; iMmdage re-applied ; sleeps well without an anodyne ;
functions regular.

8^. — Bandage removed; limb reduced in size; measures 16^
inches round knee ; no pulsation.

12th. — Same state, but above the inside of knee-joint the thigh
is somewhat red and painful to the touch. To be fomented.

ISth. — ^Better ; less pain on pressure ; there is a hard swelling
about the size of a hen s eg^, the result probablj of the prolongea
flexion. Foment and poultice.

18c&.r-The tumour nas increased in size, become more prominent
and softer ; there is no pain ; sleeps well ; ftmctions regular.

20^. — Similar report continue.

23d> — ^The tumour is more prominent, and softer ; general good
health.

27<i.-^Tumour continues stationary.

Slst. — ^Tumour is more red, and somewhat painftd ; leg is less
flexed ; slight epistaxis this morning, which soon ceased.

5th September.'--'The tumour has gradually increased in size, and
become softer ; was this morning opened, giving exit to about §iv.
of healthy pus. Continue catap. lini.

6th. — rassed a good night j slept well. On withdrawing pledget
of lint from the wound made yesterday, about two ounces of heal&y
pus escaped.

7th. — ^A considerable quantity of thin matter escaped. To be re*
moved to another and larger ward for change.

8^. — Thin discharge decreased ; feels stronger, and in better
spirits ; ftmctions regmar.

10<A.-^Discharge greatly diminished ; swelling of knee and leg
much decreased.

14A. — Greneral health has improved; very slight discharge of
serum from abscess ; functions regular.

Idth. — Sits up every day from 2 to 6 P.M. ; general health im-

418 DR LOCKWOOD'S case op popliteal aneurism. [NOV.

proving ; the chronic swelling of knee has conaiderably reduced j
there is venr slight sanious discharge from abscess.

20^. — Was assisted down stairs to hospital sergeant's room and
yeranda, where he remained some hours.

25th. — Has gained flesh and strength ; can extend the limb, and
move the knee-joint more freely ; abscess still open and discharg-
ing a little yellow serum daily. Drove out in a cab for two hours
accompanied by the hospital sergeant.

26m. — ^Appearance much improved.

27th. — ^Was seized with a severe rigor, which lasted from 8 A.M.
to 10 A.M. Surface of body quite cold, face very pale, lips blue,
pulse 80, small and weak. At 1 p.m. broke out in a profuse per*
spiration ; after which he felt much better, but still very weak.

28th. — Passed a good night ; feels much tenderness on pressure
over calf of leg. The sheets were changed on 27th, and were very
damp.

29th, — ^There is a considerable increase in the discharge from the
abscess this morning, which is of thick purulent matter. Slept
well ; general appearance improved. Linseed-meal poultice to be
applied.

l8t October. — ^Thick purulent discharge still continues ; the skin
is red and tender on pressure immediately below popliteal space,
which is to be fomented.

2d. — ^Purulent discharge from abscess considerably increased;
bowels confined.

3d. — Bowels freely opened ; purulent discharge still continues ;
tenderness on pressure below nam decreased.

9th. — There is a deep-seated fluctuation, with a glistening ap-
pearance of the skin on the back of the leg below the knee. A
Lancet was introduced and some healthy pus escaped.

11th. — No discharge from either of the abscesses this morning.
Patient appears to be in good general health. 01. Murrhuss, fss.,
ter in die.

15th. — Has much improved in general healthy appearance during
the last few days. There is a very slight discharge of serum from
the abscess in the thigh, and none from the one recently opened
below the ham.

18^ — General health continues to improve.

20^. — ^Recommended a pass for fourteen days, to enable him to

Iroceed to a farm-house seven miles distant, for the benefit of his
ealthj which is likelv to be much improved by the change. He
accordingly went thither on the 23d.

He returned at the expiration of fourteen days very much im-
proved in general health. Abscess healed, and more motion in
knee-joint. No pulsation can be felt in the thigh below Poupart'a
ligament.

Is employed in the sedentary occupation of orderly room clerk.
Ist February 1864.— Carefully examined j his general appear-

IWiJ] DR LOGKWOOD'8 CASE OF FOPLtTBAL ANEURISM. 419

ance is indicative of robust health. There is no pulsation to be felt
below Poupart's ligament, immediately above there is.

There is no puLuition in the femoral or popliteal arteries ; a small
artery can be felt pulsating over the inner surface of the knee-joint.

The knee-joint has acquired much more motion, but is still slightly
flexed. As there is no disease of the cartilages, the knee will, no
doubt, recover firee motion as after the first aneurism.

Article VII. — On Supporting Ae Pmnmm as a Pteveniitm of
LaceraJtUm at ChtldbStlu Bjr Geo. K. H. Patbrbon, L.R.C.F.
and S«E., Balbeggie, Perthshire.

In recording my experience on this subject at present, I am fully
aware of the very able and candid opinions, pro and oon, given
forth for some time past, by members of the profession in reference
to it. However, in my own practice I have invariably acted on
the principle of giving support immediately before and at childbirth,
during more than twenty years, and have never regretted doing so*
but rather am fully convinced that had I not given such support, I
should have had a good number of lacerated perinaeums to witness
and attend to. How the perinaeum can undergo less risk of being
torn by withholding than by giving support to it previous to and
during the expulsion of the head of the infant, I must confess I
am as yet unable to understand. It must be allowed that laceration
of the perinaeum at childbirth is equally to be expected amongst
the wives of the Scotch peasantry as anywhere else ; and having
attended many of these during past years, of stout make, and of
ruddy colour, the infants being generally large, it has always
appeared to me that due and proper support prevented laceration
of the perinaeum, even when it seemed most likely to take place ;
especially where the patient had "been left unaided, and when the
perinaeum had been long stretched, owing to the unyielding and
unadapted state of the vaginal appendages and head of the foetus,
while the expulsive pains were violent and recurred frequently:
and it is oftenest in such instances, I presume, that the obstetrical
practitioner may look for a lesion of the perinaeum as likeliest to
occur, unless prevented by means of support applied with the
bare flat of his right hand when the fcetai head is resting firmly
on the perinseum, and coming forth under the continued expulsive
uterine pains. When the propriety of afibrding support at this

I'uncture of the case is convincingly felt by the medical attendant,
lis hand should be so applied as to compress and include within it
the vertex of the foetal head, and also to pilot it if anything a little
forwards; and while it is emerging quickly from the vulva, he
ahould keep the hand steadily in apposition, and at the same
time depress backwards gently the perinaeum over the face and

VOL. X.— NO. V. 3 H

420 LACERATION OF THE PERIN JSUM AT CHILDBIRTH. [NOV,

especially the chin of the infant as it is being expelled into the world.
There is often a diflSculty and danger to the perinaeum in certain
cases, and far more so in my mind when unaided, in getting it
safely clear of the chin when towards the sacrum ; and no better
method have I found than the above so as to prevent laceration
from occurring. In the married and unmarried country females
and out-of-door workers, consisting of those of stout make, and also
of little stature, who bear children very frequently-, this mode of
giving support is undeniably of great advantage ; out I make no
exception, as I apply it in all my cases of head presentation. And
I do think in regard to supporting the perinaeum, that its advantages
ought to be more generally appreciated, as in the rapid and violent
expulsive pains, accompanied with large and hard or ossified head
and rigid perinaeum, vagina, and vulva, I am confident by keeping
with the hand well appliea the head of the foetus as often as
possible back a little, instead of hastily delivering when pressing
strongly on the perinaeum, that I have saved several lying-in women
from inevitable laceration ; and such a procedure it is reasonable
to suppose allows the perinaeum. etc., to expand more ^dually,
and renders the risk referred to less to be apprehended in conse-
quence, even when most likely to take place. But truly I have
never found it to occur when such preventive practice has been
followed.

Although it is said that no labours are so easy, or so soon
recovered from as those of the wives of wandering mountaineers in
barbarous countries, still their whole lives are so dissimilar to
civilized life in this country, that little good seems derivable from
a comparison of Iving-in women under such different circumstances ;
and 1 do not think that the non-occurrence of rapture of the

Eerinaeum among the former should be an argument for our with-
olding support to the perinaeum among our own patients.

Article VIII. — Some Observations on Scrojula on the North-East
Coast of Scotland. By D. Carmichael, M.D., Buckie.

{Read at the Meeting of the Banff ^ Murray^ and Nairn Medical Association.)

The manners, customs, and mode of life of the fishing population
being so distinct from those of other people, it might be expected
that the progress of some diseases snould show a corresponding
difference. Those within my range of observation occupy the
western portion of the seacoast of Banffshire, — a district which
contains the most dense fishing population of any similar extent in
Scotland, — and among these I have noticed an almost total absence
of all the ordinary forms of scrofulous diseases. I am not, however,
aware whether the same has been observed by the medical men in
the coast-towns of Murray and Nairn.

1864.] DR CARMICHAEL ON SCROFULA. 421

Every medical man must have seen cases of injury and disease
wliich in one individual are easily healed, while the same injuries
in other individuals are slow and lingering in their progress, and
perhaps will not heal at all. The latter individuals are usually
scrofulous.

I do not intend to attempt to give a complete definition of scrofula,
a disease which appears in so many different forms; but as it
appears to me remarkable, that among the fishing portion of the
population of the county of Banff, at least in the parish of Rathven,
scrofula, in its usual forms, is almost if not entirely awanting,
though common among the tradespeople and other persons that
live among them, — it is my intention to make some general observa-
tions on what I consider may be the cause of scrofula in general,
and of the remarkable difference in that respect between the fishing
population and the other inhabitants of the same place.

And as there is no rule without exceptions, I intend to begin by
recording a remarkable case of scrofula, or one at least with many
of the usual characters of that disease, occurring in a young fisher-
woman of Porteasy, now thirty years of age. The case is one of
necrosis recurring during the last seventeen years, at six different
times, on as many different portions of the boay. It appears to me
that this exceptional case, and the circumstances connected with it,
such as the character of the residence, etc., will help, in no incon-
siderable decree, to illustrate the causes of scrofula.

H. M'K. IS a fisherwoman of Porteasy, now thirty years of age ;
when about thirteen years of age she received an injury of the left leg
from a kick. It continued painful for years, and after a considerable
time, a tumour appeared over the shin-bone, which ulcerated and
extended formidably, without any appearance of healing. When
about seventeen years of age, another tumour appeared on the^ right
side, which also ulcerated. Some time after this she came under my
charge ; there was then caries of the bones both of the leg and face.
After more than twelve months both sores were healed, after
removal of large portions of bones of the leg, upper jaw, and cheek.

These sores had not been more than eighteen months whole when
a tumour appeared on the right side of the skull. The tumour ulcer-
ated, and left quite bare a large oval portion of the skull, upwards
of three inches long by two and a-hali wide. After a considerable
time, the outer part of this bare portion of skull was removed
by exfoliation and absorption, and left exposed a large portion of
the dura mater, the bloodvessels of which were distinctly seen
pulsating, large and tortuous. A central portion of bone remained,
and continued firmly adhering to the parts below for some months,
while a large portion of the dura mater, and its vessels which supply
the brain with blood, were exposed all round. In this state of
matters, the adherent portion of skull in the middle had the
appearance of an island, with the dura mater exposed all round.
This portion of bone at last dropped away, and after about sixteen

422 DB CARMICHAEL ON BCBOPdLA. [NOT.

months from the first ulceration of the scalp, the whole healed up,
and was covered over with a very thin covering of integuments,
without the lost portion of the skull being restored. Some time
after, a tumour appeared on the right side of the back, which ulcer-
ated, discharging a large portion of rib. At another time a portion
of the right humerus beciftme diseased, and was removed bj ulceration,
exfoliation, and absorption. More lately, a considerable portion of
the left thigh-bone went through the same process. The parts are
all whole at present.

On all these occasions the general constitutional disturbance was
moderate ; the pain, during the wasting and removing of the bones,
was severe, but local. The discharge from the ulcers was copioas ;
the soft parts became converted into a soft fatty matter, which came
away in portion with the sanies, in the manner usually seen in
scrofulous sores. The most remarkable general symptom was
debility, and great want of inclination for exertion. The appetite
was in general moderate, the menses usually suppressed during the
discharge of the ulcers.

One of the most noticeable facts in this case is the number of
times that necrosis has attacked the various bones. It will be
observed that at six different times, and in as many different portions
of the body, has necrosis taken place, and considerable portions of
the bones have been removed Dy the usual process of ulceration,
absorption, and exfoliation. Another noticeable fact while the
skull was affected, was the absence of cerebral disorder, not only
when a large portion of the skull was in process of removal, but
also when several square inches of the dura mater were bare, and
the meningeal arteries of the brain were distinctlpr seen pulsating.
In another particular this case differed from what is commonly seen
in necrosis ; in ordinary cases the old bone seldom comes away till
after the new bone is at least partially formed ; and as the new bono
is generally larger than the old, when the cure is complete the parts
are usually fuller than before. In this case, however, neither the
bones nor soft parts have been reproduced, except in the most
scanty manner.

The parts that were ulcerated are now small and wasted, — a con^
siderable portion of the right upper-jaw and cheek-bones are awant*^
ing, — a large portion of the left tibia is gone, and what remains is
covered only with a brown dry parchment-looking substance, that
supplies the place of flesh and skin, — a large portion of the skull,
about three inches by two and a-half, or about seven square inches, is
entirely absent, the place being now covered over with a thin brown
membranous expansion without hair, which is the only covering
the brain has in that place. About two inches above the right
elbow-joint, the humerus and soft parts are so defective that it
looks as if the fore-arm would easily drop away from the upper part.
The shoulder, space over ribs, the left thigh at the places that
were diseased, are all very defective, both in bone and soft parts.

1864.] OR CARMICHAEL ON 8CB0FULA. 423

It 18 to be observed that among the fisher population of the parish
of Bathven^ scrofula in any form is veiy rare. The scrofulous
ulcer^ the chronic abscess, the chronic glandular tumour, and the
swelling of the abdomen from disease of the mesenteric glands,
called tabes mesenterica, are never met with among them. Chronic
diseases of the joints, such as morbus ooxarius, white^swelling of
the knee and other joints, are extremely rare, if not entirely want*
ing among them. This is the more remarkable, as among all
classes that live amon^ them the above affections are not at all
uncommon. Scrofula is common in all the country parts of the
parish of Rathven, and also among the tradespeople and others
living in the towns. All the above forms of it are aJso not uncom*
mon among the families of sailors. Pulmonary consumption is oc-
casionally met with among the fishers, but is not common, and
the cases met with I do not consider scrofulous.

The case, however, of H. M^K. is imdoubtedly one of scrofula,
and has the ordinary distinguishing characters of that complaint,
showing a very marked exception to the rule of the place. The

Satient being brought up in a very confined and damp house, very
ifferent irom the houses of fishermen in general, is a circumstance
that accounts, in a great measure, for this marked difference.

How are we to account for the marked exemption firom scrofula
of the fisher population in general, so different firom what is seen
in regard to the people they live among? Marrj^ing near rela-
tions IS supposed to be one cause of scrofula. If this were correct,
as fishers generally marry among themselves, we might expect
strumous complaints to be firequent among them, but the reverse
is the case. Perhaps some will say that cod-liver and other fish
oil, not taken in the form of oil, but in the substance of the fish
they eat, which always contains some portion of oil or fat, is the
cause of the exemption firom this disease. I do not consider that a
suflScient reason. But, in order to arrive at the true cause, it will
be necessary to inquire, What are the causes of scrofula in general?
and are the fisher people more exempt firom these causes than others ?
A comparative examination of the structure and fimctiona of
plants ana animals, and their diseases, has been the means of throw-*
mg much light on the sciences of human pliysiology and pathology,
and has shown that there is a very close analogy to, identity even
in many cases in their diseases, with those occurring in the
human species. And a knowledge of the causes of diseases in the
vegetable and animal kingdoms nas often led to a more perfect
knowledge of the causes of the analogous diseases in the human
species. As, for in^^tance, the microscopic lichens and fun^
existing on, and forming the cause of some chronic ulcers, are said
to be identical with some of those found on decayed apples and
other soft fruits ; and the well-known connexion between the
cysticercus of the pig, and tape-worm in the human species, the
one containing the embryo of the other.

424 DR CARMICHAEL ON SCROFULA, [NOT.

Are there any of the diseases of vegetables quite analogous to
any of the forms of human scrofula ? The essence of scrofula is a
want of vitality. The vis medkatrixj as well as the other vital
powers, is weak, and perhaps in some parts wanting. The oon-
seouence is, premature or partial death of some part.

One form of human scrofula is a tendency to chronic cutaneous
disorders : at one time it is herpes, at another ichthiosis, at another
lepra or itch, or something else, or several forms combined. In
these patients such complaints are difficult to cure, and readily
appear again in the same or some other form. These people, in
popular language, are said to be given to scurvy. It is more
correct to say, their constitutions are scrofulous and deficient in
vitality. These generally have their beds in dark confined places,
where cleanliness is not over particularly looked after. Their
appetite is good, but assimilation is bad, and a defective supply of
oxygen to the lungs, and a languid elimination by the various
general emunctories, cause an accumulation of effete matters in the
system, that form material for the growth and nourishment of
chronic cutaneous disorders, many of which are known to be caused
by prolific parasitic vegetations and microscopic animalcules.

In the vegetable kingdom, if we look into a forest of trees, we
may see a number of larches, for instance, some with bark all clean,
ana branches vigorous, others covered all over with innumerable
ftmgi, lichens, and parasitic animals, with branches and trunk

foing to decay. If we examine the wood internally, we shall
nd, in the latter cases, portions of the wood quite dead, — ^what is
called by workmen royed^ — that is, owing to some cause, the tree
is deficient in vitality ; like the case of H. M'K., some portion of
the woody skeleton is affected with necrosis, and the lichens, etc.,
like a cutaneous infection, find in its surface and decaying juices
a nidus, and nourishment for their growth. If we examme into
the cause of the disorder in the tree, we shall find some defect in the
soil or climate, — that is, in its supply of food, or the air it breathes, if
I may say so, or of the substance of the tree itself, causing deficiency
of assimilation, decay of vitality, and the other morbid phenomena
observed above. In a healthy tree, and where the vital principle
is strong, the parasites can find no proper nourishment, and are
cither wanting or stunted in their growth.

I consider these cases of the diseased trees just mentioned quite
analogous to the cases of cutaneous scrofula mentioned above, and
also in some measure to that other form of scrofula — necrosis, or the
death of a portion of the bony skeleton.

It is well known that the young of various domestic animals,
such as calves, lambs, and pigs, are liable to various strumous or
scrofulous disorders, — one of^ which is known among country people
by the name of " gut " or " gout," another by the name of " string-
ling" or " stringliver." These complaints are identical with two
forms of strumous or scrofulous disorder we frequently meet with

1S64.] DB CARMICHAEL ON SCROFULA. 425

among children and jroung people. The "gut" of calves, etc., is
just the white-swelling of the joints of young people; and the
" stringling" of young animals is the tabes mescnterica of children.
This complaint in children is one of the disorders which, by the
mothers, is vulgarljr called "hive" or "hove," or "bowel-hive."
The name " stringhng" seems expressive of the appearance of the
disorder. The liver, stomach, and mtestines have frequent adhesions
to the omentum, the mesentery, the peritoneum, and to one another,
and give the idea of being tied by strings. The name hive, or
hove, or bowel-hive^ has arisen from the complaint, when occurring
in young people, bemg always accompanied oy tympanitis, as well
as tumour of the mesenteric glands. «

The above affections in animals and persons are induced by one
and the same causes. In animals, gut, stringling, etc., are known
to be caused by cold and moisture, but, above all, by want of pure
air to breathe. I consider the rearing up of young animals m a
space too confined and small for the number contained, to be the
most usual, or rather the universal, cause of the above affections.
In the same way, I consider the scrofulous diathesis in persons to
be induced by their being brought up during infancy and growth in

$ laces too small and confined for the number of the family contained,
lany other causes are mentioned by medical writers as conducing
to scrofula, — such as, food deficient in quality and quantity, cold,
moisture, etc., etc These certainly operate as exciting causes, but
they will develop scrofula only where the predisposition called the
scrofulous diathesis already exists. And this, I consider, in every
instance to be caused by deficiency, and consequent impuritv of the
air breathed. Carpenter, in his Manual of Pliysiology, ed. 1856.
page 438, says : — " The due elaboration of the plasma of the blooa
IS undoubtedly prevented by an habituallv deficient respiration.
The scrofulous diathesis is thus frequently connected with an
unusually small capacity of chest." I will mention one or two
instances as illustrations.

An improving farmer, by cultivating and taking in a large

Jiuantity of new ground, extended his farm to more than twice its
ormer dimensions, and increased his stock in the same proportion.
His calves and lambs became so given to " gut" and " stringhng," —
that is, to " white-swelling of the joints" and the " belly-hive," —
that it was with great difficulty that he could raise any of his own
stock. I had there and then, in my student days, frequent oppor-
tunities of examining in his stock these and various other scrofu-
lous disorders, which at that time I acknowledge were a great
puzzle to me. This farmer, however, got entirely rid of that
annoyance. And how? When he extended his farm, and in-
creased his stock, he was at first content with the small set of office-
houses originally calculated for less than one-half of what he now
possessed. The consequence was, the young animals were most
scantily supplied with one species of nourishment most essentially

426 DR CARMICHAEL ON SCROFULA. [KOT.

necessary for their healthy growth — ^pure air to breathe. He after^
wardSy however, extended his buildings, and erected a spacious set
of offices, suitable to the increased state of his farm and stock,
when these disorders suddenly and entirely disappeared.

Several years ago, the young family ot a farmer under my care
were often ailing ; a^cted with glandular tumours, cutaneous com*
plaints, cachectic disorders, morbus coxarius, white^swelling of some
joint, chronic abscess, consumption, or some of the various other
forms that scrofula assumes.

It is well known to medical men how difficult it is to make
some parties use ventilation when it is particularly requited* Some
hollow excuse is always at hand. A house, perhaps, is said to be
cold and damp, and that is made the excuse for shutting up every
possible opening within reach. It is not considered mat a fir^
current of air is the surest way to remove dampness, and breathing
air with its due proportion of oxygen is the surest way to raise up
the animal heat. We know c[uite well that the principle that
causes heat in a fire or furnace is the same with that which causes
heat in the animal body. In a furnace or fire, heat is generated
by the combination of the oxygen of the air with the carbon and
hydrogenous matters of the fuel. In animal bodies, heat is also
generated by the combination of oxygen with the carbonaceous and
hydrogenous matters of the food and tissues. The degree of heat
developed in either is just in proportion to the amount of oxygen
consumed. No wonder^ then, that persons living in closed habi-
tations, and breathing air deprived of its due proportion of oxygen,
are always sensitive to cold. They habitually deprive themselves
of the principal means of keeping up heat and strength and health.
In most cases, however, the advice of the medical practitioner is
attended to to some extent, or as far as practicable ; and within the
last few years, a very marked improvement can be observed in the
Bleeping customs of^^all classes, with consequent improvement in
health.

All our towns and villages have greatly increased during the
last few years, by the addition of many substantial and com-
modious houses ; still this increase of dwellings has not kept pace
with the increase of population. The consequence is, while the
better classes are commoaiously accommodated, the worxing classes
and poorer people are obliged to put up with less ample accommo-
dation than formerly, and that is a reason why screfulous disorders
are oftenest met within them. Notwithstanding this, I have
observed that neither white-swellings of Joints, nor tabes mesen-
terica in children, nor any of the severer rorras of scrofula are now
so often met with among any classes of peo[)le as they were thirty
years ago. The bowel-hive, so well known to and feared by the
older matrons is hardly known even in name to most of the younger
wives, some of whom now apply the name to quite a different com-
plaint, an acute disorder, accompanied with swelled belly. I attri<"

1864.] DB CABMICHAEL OK SCROFULA. 427

bute this improvement to the fact that a great change of custom in
sleeping-places has universally taken place. The boxed beds, with
foldmg doors, and the beds with curtains drawn down during sleep,
have now gone almost quite out of fashion, and also the custom so
tiniversal in this quarter of covering with a cloth the faces of infants
while lying in the cradle, — ^the excuse of the mother being that it
kept the light from their eyes.

This change of fashion in sleeping places, combined with other
causes, such as commodious and well ventilated schools, has not
only lessened the freauency and severity of strumous disorders^
but has also g^satly lessened the virulence of many febrile and
other disorders. This change, I have no doubt, has been brought
about in a great measure bv the direct and indirect influence of
the medical profession, influencing, and insensibly leading on
society in general, to adopt improvements so often recommended
to them.

Among people of sedentary occupations, who pass much of their
time within doors, and, in particular, where young people sleep in
confined places, that do not admit of ventilation, scrofulous and
chronic glandular disorders are often found. There are many
instances of this among the ordinaiy people, residing both in town
and country.

Among the fishing population, on the other hand, these sorts of
complaints are very rare. The nature of their occupation requires
cleanliness and ventilation ; the want of these would soon show in
an ofiensive manner. The newer of their houses are comj)ara-
tively commodious; all the larger apartments that will admit of
it, containing two good windows, one on each side. The older
houses are not so commodious, but the mode of their construction,
mostly with roofs open from end to end of their houses, admits of
perfect ventilation, which, in general, is well attended to. Their
beds are in airy places, and the connned sleeping closets, that so
many other people use, are not in general use among them. Their
doors are frequently open, and when weather permits, they prefer
to do much of their work in the open air, sitting outside of^ their
houses, shelling mussels, preparing lines, etc., and the younger
children are much nursed outside by other children a few years
older than themselves. These habits appear to me to be good
reasons why scrofulous disorders, which are caused by deficiencjr of
pure air to breathe, are almost unknown among the fishing
population.

It might be asked if there are anv circumstances in H. M'K.'s
case likely to induce a disorder whicn is so exceptional in one of
her class. The house she resides in is in a damp situation. It
has onlv one apartment, partially divided by two or three beds.
Originally it had. one openmg in front and another in the gable :
the front one being sometimes filled with glass, but oftener with
turf. During a necessary repair, a few years back, the opening in

VOL. X.— NO. V. 3 1

428 DR CARMTCHAEL ON SCROFULA. [NOY.

front was enlarged to admit of a window containing nine small
panes, and more lately, with the assistance of the parochial board,
another window was inserted. It was the only house in all the
sea-villages of the parish, that I remember, which is inhabited by
a family, and without any chimney of some kind^ the smoke of the
fire having to escape through a hole in the roof. About four or five
feet from the front of the house, a copious stream of water can-
tinually flows from the only public fountain in the place. The
earth floor is sunk so far below the level of the surrounding ground
without, that its general surface is about eighteen inches below the
level of the stream of water. From the exceptional kind of house,
it may be expected that there is among the inmates an exceptional
kind of living. The rest of the inmates are not decidedly unhealthy^
but some of them are soft, and all without the usual energy so
characteristic of the fishermen of that place. The father, though
now a fisherman of Porteasy, is a native of Koss-shire, son of a
cadger or fish-carrier of Helmsdale. This mav account for this
specimen of the architecture of the West Highlands having been
introduced into Porteasy.

In the case of H. M'K., it is to be observed, that the first occur-
rence of the disorder in the leg was caused by an injury done to the
bone by a kick, and she has had five other attacks of the same
disease in as many different parts of the body, without any external
hurt to account for any of them. From this I am inclined to
suspect a very poisoned state of the system. The poison, generated
in the body by cachexia, and the decomposition of the humours and
tissues, was assisted by a morbific influence, which disposed it to
attack, in preference, textures of the same kind as that first
attacked, which were in this instance the bones. We often see a
disposition of this same kind in various other complaints, both
chronic and acute.

Article IX. — Remarks on the Commdsory Vaccination Act for
Scotland. By Dr Lyell, Newburgh, Fife.

Now that this Act has been in operation for nine months, it may
not be amiss to take a glance at its operation, especially at its
medical aspect.

From the first and second sections of the Act, parochial boards
are required to meet and appoint public vaccinators, at a certain
rate of allowance per case f Is. 6d. and 2s. 6d.) " successfully vac-
cinated by such vaccinator." One would naturally expect, from the
wording of the Act, the appointment to be in some degree profitable
to the vaccinator: and this opinion was certainly prevalent both
amongst parochial boards and medical practitioners, as at some
boards there was actually a contest for the appointment A little

1864.] DR LTELL ON THE VACCINATION ACT. 429

time has dissipated this delusion : the appointment turns out to be
one of much trouble and little or no paj. In the Act as first
printed, there certainly would have been the pay, 3s. 6d. and 2s. 6d.
per case ; but then the egregious blunder was committed of turning
over all the children of a parish or district for vaccination to the
public vaccinator. The child of one practitioner, or of his friend,
was thus to be compulsorily vaccinated by his unacceptable rival.

Passing firom the appointment of the public vaccinator to his
duties, not only has he, in common with nis brother practitioners
not appointed to this office (sections 8 and 9), to fill up and sign
certificates of successful, postponed, and insusceptible vaccination,
but he has to do this in duplicate, and also keep a book ana
register all these particulars (section 21). This book at all times
is to be open, firee of charge, for the inspection of the registrars and
others engaged in carrying out the Act. Moreover, he must yearly,
or at such other times as tne Board of Supervision may direct, make
a return of these and all other particulars that board may require :
and as if this were not sufficiently burdensome, he is required
(section 23) to send in to the registrar of his district or parish,
^^ the particulars contained in such certificate " . • • ^' within
forty-eight hours," • • • " under the penalty of twenty shillings
for each omission."

In the next place, let us see what remuneration the vaccinator
has under the Act for all this trouble. As vaccinator, he has only
to vaccinate those children sent to him by the Inspector. These
consist of pauper children (section 8) and such as nave not been
certified in due time according to the Act (section 17). For such
of these as he successfully vaccinates, he is to be paid Is. 6d. if
within a mile, and 2s. 6d. if over a mile, of his residence. I need
scarcely say that pauper children are very few in Scotland, — being
made up of a posthumous child in a poor family, or an illegitimate
one occasionally. Of the other class failing to give in a certificate in
due time, there is little likelihood of the vaccinator's services being
required ; ere a case can come to him, the father or guardian of the
child must have paid a fine of twenty shillings, or been imprisoned
for ten days (section 17). As public vaccinator for three parishes,
with a united population of fully 6000, I have not yet had to
vaccinate one under either of these heads.

It will thus be seen that the Vaccination Act for Scotland im-
poses a very considerable amount of labour without any or the
merest possible contingent remuneration to the vaccinator. During
a recent very prevalent epidemic of smallpox, I put the query to
the Board of Supervision, whether a poor person, not a pauper,
might not have his child vaccinated at the expense of the parish,
by applying to the inspector for an order on the vaccinator. The
reply was, that the Board of Supervision had no power to issue
such order on parochial boards. Yet the Act (section 5) requires
all parochial boards to '^conform to the regulations which may

430 DR LTELL ON THE YJLOCINATION ACT. [nOV.

from time to time be issaed by the Board of Supervision *' . . •
(''which the- Board of Superyision) hereby required to make and
iasue." And ''vaccination (section 7) shall not be considered
parochial relief^ and shall not affect the parochial settlement of any
poor person so vaccinated."

These ai^p the points which mainly affect those practitioners who
have accepted office under the Act, and sufficiently burdensome
thev certainly are vnthout, or almost without any compensation ;
and it remains to be seen whether medical men are to continue thus
to perform this thankless labour. Cut bono f What is the need of
the office of public vaccinator at all ? By the Act the certificate of
any registered practitioner is equally valid with that of the public
vaccinator, and I certainly question whether the Act can compel
the vaccinator to certify, renter, and make returns (section 21) for
any besides those he vaccmates cia public vaccinator. I do not
think that the Act can take any account of those he vaccinates in
his private capacity, any more than it takes account of those vac-
cinated by his brother practitioner who has no public appointment ;
who, when he vaccinates a child successfully, bom since 1st January
1864, signs the certificate given to the parent of the child at regis-
tration, and his work is done. And what is the use of an impenect
register kept, and double certificates granted by the public vac-
cinator? One perfect and complete register, so far as vaccination
is carried out, is kept by the registrar, and surely that is enough
for all government purposes?

I have already shown that the public vaccinator as such can only
be required to vaccinate a very few children ; (in nine months, out
of a population of 6000, 1 have not vaccinated one) and surely the
few could quite well have been left to the parochial medical officer,
without creatine any new office or officer. I have said it remains
to be seen whether medical men are to continue to perform all this
needless, unreasonable, and profitless labour ; certainly they may
resign, and indeed were they all to do so at once, it would ana could
not affect the efficiency of the Act in the least Vaccination would
go on just the same ; ordinary children would be vaccinated by the
ordinary practitioners, and pauper children by the parish doctors,
without all this burdensome law. For myself I vaccinate none as
public vaccinator, and in my tabular returns to the Board of Supers
vision in July, appended my signature to none — ^none — ^none. I
will return only such as the inspector requests me to vaccinate.

I have made these few observations on the medical bearing of
the Act for the consideration of my medical brethren, and trust they
may be of use in calling attention to what the law really demands.
Every practitioner truly desires that vaccination should be as
thorough as any law can make it^ and this it quite well can be
without all this cumbersome machmety, and stringent exaction of
profitless labour.

1664.] THE MEDICAL SERVICE OF THE ABMT. 481

THE MEDICAL SERVICE OF THE ARMY.

PROPOSITIONS AND SUGGESTIONS.

The following suggestions are intended to proceed from the starting
point of certain facts which no one is likely to ^nsaj.

It is intended, in the course of them, to avoid the expression of
any opinion, one way or another, on what may be called subjects
of current controversy^ and to refer to these only in so far as they
may indicate data wmch are not open to dispute.

The Propositions are, —

1. That there exists, rightly or wrongly, profound discontent
and inquietude among tne medical officers of the army.

2. That the profession at large thoroughly sympathizes with
these feelings, and that the sympathy so felt has penetrated to
all classes, fit>m the President of tne Qeneral Council to the
youngest student.

3. That these feelings, in great measure, owe their origin to
assaults, real or ima^nary, on amour propre, or that just, yirtuous.

manly form of pride, which may be called professional Ssprit;
also, that they stand in the relation of cause and effect to the
ugly words " broken faith," whether these words are used rightly
or wrongly.

4. That discontent, so caused, is always deep in its effects, and
lasting in its results.

5. That the .profession^ as offering its services to the public for a
money value, is in a position to rnSke for itself better terms now
than was the case^ say, twenty years ago.

6. That preliminary education^ more elaborate and higher instruc-
tion, deferred age tor graduation, the many new openings for
profitable employment of one's life and energy which are yearly
offered to the middle classes, and many other coe^iate considera*
tions, make it reasonable to predict that the pro^ssion will, year
by year, be able to demand better and still better terms.

7. That on the outbreak of war, the present supply of officers
would be found quite inadequate, and that even the offer of very
high terms would then fail to procure a sufficient supply.

8. That, in effect, the supply of candidates is now insufficient,
and the quality indifferent.

9. That the prospect of promotion for assistant-surgeons is now a
very bad one, which is daily becoming worse, and that for surgeons
there is next to no pro.'pect of promotion whatever.

10. That the purchasing power of any given rate of full or half-
pay is now less than it was, say, twenty years ago, and that the
demands on any given rate of full pay are now greater than they
were twenty years ago.

11. That it is most desirable, in the public service, as in all

432 THE MEDICAL SERVICE OF THE ABMT. [NOT.

other businesses of life, while satisfying all just claims, to combine
the strictest economj with the highest efficiency.

12. That the system of so-called medical administration in the
army is yery costly, while its usefulness is, at least, open to doubt;
that it is quite unknown to the profession elsewhere, and is essen-
tially opposed to all professional instincts and tendencies ; while,
speaking militarily, it is altogether diyergent from the fundamental
principles of discipUne and good order.

One more proposition before going further. —

The true conception of the position of a medical officer, as regards
his duties, is this, —

1. He nas to treat sick ; that is, to take a man into hospital
when he is sick, treat him there, and discharge him when he is
whole.

2. He is required, on occasion, to declare principles of sanitationi
and to make recommendations and suggestions in that sense.

Beyond these he has no functions whatever.

SUOGESTIONS.

I. — Abolish the Medical DepartmenL

II. — Diligently search for the ahleat^ toiaesty ahrewdest^ sendblest
man in the medical service^ a man of experience^ who has been
instructed by experimcej arid place him in the War Office as the
admser on all health-questions of the Secretary for War, Lei all
statements^ retumsy and letters relating to the healthy and health"
conditions of the army pass to that offixxr through the hands ofrespec-
tive commanding officers. TheUy on all these matterSy the so-con-
stituted adviser vxndd take actiony speaking in the name of the
Secretary for War,

It may surprise some people to be told that a commanding
officer of a regiment ought to be acquainted with all reports
relating to his command ; that, in one word, he ought to command
it ; but, in fact, it would be just as reasonable to say that one man
should command at the stem of a ship and another at the forward
part, as to say that a commanding officer sliould command one part
of his regiment and that a surgeon or a principal medical officer
should command another part. It is quite contrary to the yery
first principles of discipline that any report relating to a regiment
or otner command should be, in the first instance, addressed to any
person whateyer other than the commanding officer.

For regulating the medical affairs of the army, the old Medical
Boards lamentably and ayowedly proyed utter failures. It is not
too much to assert that the more modem system of a so-called
Director-General — ^we are speaking of a system, not of persons —
has failed as signally. It can imply no disparagement of the able
and laborious officers who haye successfully filled the office to say

1864.] THE MEDICAL BERVICE OF THE ARMY. 433

tbat it would be sarprising if it were otherwise. Selected on the

g-onnd of distinguished ability in the discharge of quite other
notions, these men are expected to perform prodigies with powers
quite incommensurate. In fact, the very name and title of Director-
Greneral involves an assurance and a prediction of failure. It
implies an amount of power which does not, and, in the nature of
things, cannot exist. To some eight hundred officers of his own
department he is a supreme being, expected to satisfy every indi-
viaual wish, with little power to do one thing or another, and to
maintain, on all points, tne requirements of professional dignity, in
the presence of all opposition. To about the same number of war-office
clerks, he is " only a doctor," and, therefore, a ready target for their
sharp, obstructive pens. Our sanitary adviser, on the other hand,
would, on all subjects within his province and to all men, speak in
the name of the Secretary for War, all responsibility resting on
that high officer. Instead of the medical section being in an
attitude of seeming quasi-independence and possible antagonism
it would be in harmonious subordination to and unification with
the central authority. Thus, by surrendering an elevation of
rank which is more apparent than real, there would be a gain of
directing power and an immense simplification of routine.

An officer similarly selected, and with like functions, would be
attached to the staff of any army in the field.

As for India, the detail of these duties has been provided for by
the recent commission.

III. — Place the direction cf all matters relating to the appointing^
tramferringj promoting j and all other movements of medical officers^
as are the movements of other officers^ in charge of the Adjutant-
OeneraL

IV. — Publish a code of sanitary regulations^ having the force
of t/te general orders and regulations of the army^ ana adapted to
the army as it is.

It is characteristic of the way in which the War Office takes
care of the public money, that the most marked result of the out-
break of feeling on sanitary questions a few years a^o was an
extension of the costly and cmnbersome system of administration,
and that an elaborate scheme for reporting, inspecting, advising,
and, in one word, circumlocutionizing, on these points, was laid down,
while the sanits^ rules and regulations were of the most meagre
and perfunctory character.

It is odd, under the circumstances, that this extension and, so to
speak, authentication of the administrative system should have
been effected in such a way as to seem as if it was the immediate
consequence of the severe condemnation of it which had just been
recorded by such authorities as Lord Herbert, Miss Nightingale,
and the Scutari Commissioners. But so it was. It would hardly
be possible to use stronger language than that in which this sys-
tem was condemned by mese persons.

434 THB MEDICAL BEBYICE OF THE ARMT. [nOY.

When we think of the miles of weaij and purposeless peram*
hulation, the yards of q^nite ineffective re[)orts, and the amount of
personal vexation and inter-departmental jealousies and misunder*
standing that would have been saved by the simple expedient of
publishing a code of regulations six jears ago, one may safelj
assert that the grand problem of ^^ how not to do it " has, in this
instance, been more than achieved.

In one word, a code of regulations would be an immense boon to
all parties. The promulgation of it would be a long step towards
simplification, and it would remove one excuse which ma^ be urged
for the maintenance of the present system of administration.

V. — There is no occasion for medical ojffloera to wear a uniform^
nor need they he members of messes.

Most of the unhappinesses of which we have heard lately seem
to be connected with these two matters.

There is really no intelligible reason why a surgeon should be
dressed in uniform, and there are some reasons why he should not.
In the field, before an enemy, it would be very easy, if deemed
necessary, to discover some means of distinguishing him without
offending himself or any other people. Already, by a recent order,
a certain section of medical officers has been excepted from the
necessity of wearing uniform, and there does not appear to be any
valid reason why the boon should not be extended to the permanent
officers which has been bestowed on their " more favoured orethren "
of the acting staff.

The exemption from compulsory mess-membership would be a
benefit to all parties. When the other members do not wish a
medical officer to join them, it would be strange if he wished to force
himself into their social gathering. If they wished his company, it
would be still practicable for them to seek it. Further, the mem-
bers would be relieved from the pain of a possible conflict between,
on the one hand, prejudices whicn are jperhaps not very unnatural,
and on the other, their respect for the Queen's authority on the un-
happv question of precedence, while the medical officer would be
savea from the possible most unpleasant duty of insisting on the
Queen's authority on that point being attended to.

YL — Establish a rate qf optional half-pay y to commence at a low
ratCj at saj/j ten yearsy to increase arammly until it culminates in
18tf. 6dl ai twenty years^ service^ with permission^ at all periods^ to
return tofdlpay until the age of fifty-five is attained^

It would be a pity to increase the present full-pay rates. The
jealousy that would be excited by any such increase would not be
counterbalanced by any possible degree of improvement of the rate.

For a young surgeon looking out for a career there are two in-

^ At present there is a half-pay rate of IGs. 6d. after twenty years, bnt that
is only procurable on evidence of bad health, and the officer is brought back
for five years* more fall-pay service as soon as his health is re-eatabliiued.

1864.] THE MEDICAL SERVICE OF THE ARMT. 435

ducements which may possibly determine him to seek the army
medical service. These are, in a slight degree, the red coat ; in a
greater degree, the notion that he may be able to make both ends
meet on £182, lOs. After a very brief acquaintance, the first loses
its attraction, and he is very apt to find that he has made a mistake
about the second. Very few enter with the intention of making it
their life-business. They think that they can spend, in the army,
profitably and agreeabhr, the few years which must intervene before
they can be held qualified for good practice. When the time comes,
however, at which they had thought of leaving, they are abroad, or
they have no money to start with, or other considerations intervene,
and they hold on till a more convenient season. They see their
military comrades, with whose prospects they cannot help, errone-
ously perhaps, comparing their own, looking for progress and pro-
motion, gaining promotion, making progress, in fact, in many ways.
For themselves, they see no such prospect. Then, year by year,
quite imperceptibly, time flows on till they begin to think that it
would be foolish to sacrifice so long service Tor no return. At
length, they approach the stage when they sedulously fix their eyes
on the twenty-five years' retirement, count the days till that period is
to be reached, look on the ^^ style of surgeon-major" as a pleasant
mile-stone on a weary road, and, sighing for liberty, they remain in
what they foolishly call bondage until the fugacious years have all
glided past, and they think, too late, alas! that their life. — the
working, healthy, vigorous days of it, at least, — has been thrown
away.

The Commission which sat in 1857 was urged to recommend an
optional retirement, at a low rate, at twenty years. This would be a
boon to the exceedingly small number of ofiicers who possess private
means ; but their number is so small that the granting of it would
not appreciably affect promotion or the general interests in any way ;
while, for the same reason, it would be quite safe, in the interest of
the public, to concede it.

A rate of retirement, obtainable at a comparatively early period,
would enable many -to pass out into private life, and it may be
assumed that a certain proportion of such would always be willing
to return. It would diffuse much general contentment, and would
tend to procure the services of a very good class. It would cause a
happy interchange, which now hardly exists, between civil and
military practice. It ought to be remembered, in this connexion,
that famous men of whom the public services are most justly proud,
as John Hunter^ Sir John Pringle, Brocklesby, and Sir Gilbert
Blaine, did not, m the modem sense, belong to their respective de-
partments at all.

Eighteen shillings and sixpence after twenty years may seem a
large sum, but, under existing circumstances, that being now obtain-
able after twenty-five years, any lower rate would have no effect
whatever, except to remove the small number already referred to who

VOL, X.— NO. V. 3 k

436 THB KEDICAL SBHTICE OF THE ASMT. [kOT.

may possess private means. A man who is without any private
means will hold on until he can get the largest sum procurable.
Many would take advantage of the ISs. 6d., but of these a large
proportion would soon grow tired of want of employment, and be
anxious, after a little, to return, and they >vould then serve cheerfully
and contentedly until the fatal period of fifty-five years of age. In
that way, if the thing was looked at boldly, and adopted, it would
not result that the Treasury suffered to nearly such an extent as
might, at first sight, be anticipated, while a wholesome current of pro^
motion would have been set m motion. It may be objected that the
non-effective list rmghtj thereby, be made to bear a disproportion to
the effective list, and, on general grounds, that is an objection of
moment. But tlie question is, whether or not there exist, in the

S resent instance, sufficient groimds for running the risk of a possible
eparture from abstract rules. Again, if this good early retirement
dia add to expenditure, consider how very much would be saved by
the extinction of the wnole class of ^^ medical administrators ;" not
merely in actual or prospective pay, but in allowances, clerkfl|

Suarters, foolscap, red tape, and many other items. The mode of
eath selected for them would necessarily be gradual. It ought to
be made easy, even luxurious.

The very large sum so saved would make it possible to grant, in
addition to half-pay, a certain number of good-service pensions.
This would be a great boon, and the good e^t of it would be far
beyond the mere value of the money expended.

This (|uestion of the condition, present and prospective^ of medical
matters in the army, is one of really considerable public importance.
If pressing for settlement now, it will be much more urgently press-
ing in the event of an outbreak of war. It is just one of those
questions, small as compared with many others, which require for
tlieir solution a mind incapable of being biassed by prejudice,
judicial, statesmanlike. A delay can cause nothing but more em->
Darrassment, a more plentiful crop of illusions, and a further inter-
change of deplorable vituperation. And it behoves those who have
eaten the bread of the service for years, and who have not — as in-
deed many can say — ^found it very bitter, thinking moderately, to
speak dispassionately on a subject so nearly affecting the interests
of their profession.

It is related that, once, when Ambrose Parb was thrown into a
besieged place, the drooping spirits of the garrison were thereby
raised to such a degree as to cause a stout ana successful resistance.
This was because they felt that they had a surgeon amonff them
who knew his business, and who would not dress their wounds with
boiling pitch, or use the actual cautery for the arrestment of
hssmorrhage. It is really quite possible that, on some future critical
Occasion, the fate of events may turn on whether there is present
a sufficient number of sound, skilful surgeons, or only a meagre

1864.] THB MEDICAL BBBYIOE Or THE ABMT. 437

supply of men modelled after the type of that enterprising and now
famouB neophyte who is prepared to take off the quarter of a man'9
body in case of the femoral artery being punctured.

One has only to look about him to be convinced that the arrange^
ment inaugurated in 1858, and with regard to which such high
hopes were entertained, has proved a failure. When speculating as
to what plan ought to supersede it, — and some radicaUy new plan
must be devised, sooner or later, — ^it is the part of a wise man to
ascertain where there has been weakness^ and then, by the light of
that discovery, to provide for the future. What is nost ought to be
held to be past and gone, and potent elements of discord and dia^
order ought to be avoided or thrown aside.

^art S^ecotOr.

REVIEWS.

CUnical ObservcUiona on Functional Nemom Disorders. By C,
Handfield Jones, M.B. Cantab. ; F.R.C.P. Lond. ; Physician
to St Mary's Hospital London: Churchills: 1864. .

No class of diseases is of greater interest to the physician than those
affecting the nervous system, and regarding none, until very lately,
has so much uncertainty prevailed. Kecent anatomical and phvBio«
logical researches have cleared up much that was obscure, and our
increased knowledge of structure and function has been gradually
leading to clearer views of the morbid conditions to which the
nervous system is liable. It is the object of Dr Jones in the work
before us to consider from a clinical point of view those nervous
diseases in which no manifest orgamc lesion can be discovered.
Since pathological anatomy has been successfiiUy cultivated it has
been a constant subject for discussion, whether any disorders are to
be considered' as purely functional; advancing knowledge and finer
methods of observation have been constantly diminishing the
number of functional diseases, and the admirable researches of
Lockhart Clarke have shown that there may be advanced dis<-
organization of nervous structure, which is quite inappreciable to
the naked eye. It is, in fact, very doubtful whether such a thin^ as
a purely functional disease can exist ; we may indeed suppose it to
be functional in its commencement, but very speedily, possibly
before any symptoms manifest themselves, an organic change takes
place. JJr Jones, while adopting the division of diseases into

438 DR C. H. JONES ON FUNCTIONAL NERVOUS DISORDERS. X^OV.

organic and functional, does so only on grounds of convenience.
To use his own words, " I do not intend to deal with the results of
manifest organic lesion, but to confine mj attention chiefly to such
disorders as are termed functional. It seems to me a vain dispute,
whether in strict accuracy there are, or are not, any such disorders.
The probability is that there are not — that in all morbid action the
cells and the fibres of the organs undergo some molecular chan&ne
from their perfectly normal condition. It is, however, perfectly
certain that there are very grave disorders in which the most careful
scrutiny fails to detect any actual change, in which complete
recovery is perfectly possible, and in which tne " juvantia" are such
as operate more in modifying the power of the organs than their
texture."

Having in the first or introductory chapter expressed his opinion
regarding the general physiology of the different parts of the
nervous system, Dr Jones proceeds in the second chapter to con-
sider their general pathology, and gives a very fair view of what is
at present known on this subject. We do not, however, agree with
what he says regarding reflex paralysis. By " reflex paralysis"
(for our knowledge of which we are chiefly indebted to Brown
S^quard) is meant a paralysis not due to a primary affection of a
nervous centre, but dependent upon an irritation of some peripheral
part, which irritation is conveyed by afferent nerves to the nervous
centre, modifies its nutrition, probably by leading to contraction of
its bloodvessels, and the nutrition, and consequently the vitality of
the centre being impaired, paralysis of a part supplied by it is
occasioned. Forms of paralysis which, by Brown-S^quard, are
believed to be " reflex," are by Dr Jones viewed as " inhibitoiy."
The term "inhibitory" is of recent introduction into physiological
language, and is intended to express a power possessed by nerves
under certain circumstances of repressmc instead of stimulating
action. That such a power is possessed by some nerves is un-
doubted, but the mechanism of the phenomenon is not yet clearly
imderstood. Pfltiger believes the inhibitory function to be possessed
by certain nerve-fibres, whose sole function is to arrest or diminish
action. Lister (and his results have been in the main confirmed by
Hufschmidt and Moleschott) believes " that one and the same afferent
nerve may, according as it is operating mildly or energetically,
either exalt or depress, the functions of the nervous centre on which
it acts. It is, I believe (he says), upon this that all inhibitory
influence depends ; and I suspect that the principle will be foimd
to admit of a very general application in physiology." Our author
thus expresses his own view on this subject — " I modify the state-
ment of^Mr Lister, so far as to believe that it is not the energetic
operation of an afferent nerve that causes inhibitory action, but its
being injuriously affected by some impression made upon it. The
enfeebled state of the nerve itself, or of the centre to which it pro-
ceeds, or the severity or malignity of the impression, may give rise

1864.] DR C. H. JONES ON FUNCTIONAL NERVOUS DISORDERS. 439

to the peculiar effect." As an illustration of inhibitory power in
producing paralysis, Dr Jones gives the following cases : —

"0. J., aet. 37, got a whitlow on the last phahinx of left thumb; the
lymphatics were inflamed, and the axillary glands swollen ; the whole arm was
very painful. While the limb was in this state, one morning he found that he
saw double, and had a squint in the left eye. At the Ophthalmic Hospital, it
was found that the external rectus muscle was completely paralyzed, and he
had circumorbital pain. It was supposed that there was periosteal inflamma-
tion about the orbit, and pot. ioaid. was given ; the whitlow was poulticed,
and the arm fomented. After a month of this treatment, there was no im-
provement of the eye, but the arm inflammation had quite subsided. A piece
of dead bone was now removed from the seat of the whitlow ; soon after which
the squint disappeared, as well as the pain in the arm and about the orbit.
The external rectus had quite recovered its power. In this instance, pain in
sensory nerves about the orbit and paralysis of a single motor nerve were co*
results of the morbid impression conveyed from the diseased finger to the
centre. Dr Watson refers to the production of amaurosis without visible
change in the eye, in consequence, apparently, of irritation of the dental nerves,
the blindness ceasing after the extraction of some teeth which had grown
irregularly. He quotes from Mr Lawrence an interesting case, in which the
extraction of a carious tooth, with a splinter of wood projecting from one of its
fangs, procured the restoration of the sight of the eye of the same side, which
had been entirely lost for thirteen months. In such cases, the paralysis of the
retina or of the optic tubercles may fairly be designated inhibitory.

After some examples of a similar character, Dr Jones goes on to
say—

" The only objection which can be made, I conceive, to the above evidence
b, that in the instances cited the paralysis depended, not on a direct morbid
influence exerted on the tissue of the nervous centre, but on ansemia of the
part, produced by the reflection of the original irritation on the vaso-motor
nerves supplying its arteries. This is what Dr Brown-S^quard supposes to
occur in reflex paralysis, — a form which appears to me to be similar to inhibi-
tory. In reflex paralysis, the loss of motor power appears to depend on an
actually existing irritation, with which it increases or diminishes, and with the
removal of which it ceases. This is evidently almost identical with what we
have described above. The only difference is, that in some instances of inhi-
bitory action the paretic statd of the centre persists for an indefinite time after
the cessation of the cause which has morbidly affected it. Tlie grounds which
lead me to believe that Brown* S^qoard^s view is incorrect are, — IH, It is
difficult to suppose that a spasm of reflex origin should be limited to such a
very small extent of vessels as would be involved in some instances, e. ^., palsy
of one sixth nerve, ptosis of one eye. 2d, It is almost impossible to believe
that a contraction of vessels shoula be so persistent as the liypothesis requires.
Can we suppose, in the case of amaurosis above cited, that the arteria centralis
retinsB was spasmodically occluded for thirteen months? Sd, It has been
found by Gull that irritation of the renal nerves does not cause contraction of
the vessels of the spinal cord, nor paralysis of the lower limbs, as Brown-
S^quard stated in explanation of the paraplegia from renal disease. 4th, In
some cases of paralysis from exposure to cold and wet, — v. one related bj Dr
Copland (Diet, of rract. Med., art. Paralysis, 76), — ^the paralysis contmues
long after the exciting cause has ceased, and is removed by stimuli applied to
the sensory cutaneous surface. Here the paralysis must be non-organic ; and
yet it can scarcely be supposed to depend on anaemia of thex^entres resulting from
arterial spasm. On the other hand, it is intelligible that the nerve-cells might
be thrown into a state of enfeebled action by the cold, etc., from which they
could not easily recover."

440 DB 0. H. JONKS ON FUNCTIONAL NERT0U8 JDI80BDEBS. [NOV,

The subject is far too wide to admit full discussion ; but we are
by no means satisfied hj Dr Jones' arguments of the non-existence
of reflex paralysis. We must refer our readers to Brown-S&juard's
works for a fall statement of his own views on the subject ; but
with regard to Dr Jones' arguments we have a very few words to
Bay. The JSrst argument tellsjust aA much against the one hypo*
thesis as against the other. We do not attach any very great weight
to the thirdj because a few isolated experiments are not sufficient in
themselves to set aside the conclusions come to as the result of a
large collection of observations, aDd because it is difficult or impos*
sible in such experiments to imitate exactly the effects of morbid
processes. The answer to the second and fourth objections is very
simple* It does not follow because the paralysis has been of long
duration that the contraction of the bloodvessels has been equally
permanent. It is quite possible that the nutrition of the nervous
centre may have been so modified by a temporary cutting off of its
supply of blood that it may never, or only after a long time recover
from it While, therefore, not denying inhibitory influence, we are
not inclined to allow to it so large an influence as is assigned by Dr
Jones, and we must, in the meantime, express our general concur-
rence in the opinions of Brown-S^auard.

The body of Dr Jones' work is devoted to the consideration of a
large number of special diseases, including cerebral and spinal
ansemia and hypersemia ; cerebral and spinal paralysis (or paresis,
as Dr Jones calls it) ; various convulsive diseases ; severid forms of
neuralgia, and various others. The descriptions are generally
clearly given, and in many cases are illustrated by interesting cases.
Instead, however, of following Dr Jones into a consideration of these
separate disorders, we prefer directing the attention of our readers
to his last chapter headed ^^ remedies," and shall then quote a few
of his general propositions.

The first of the nervous remedies noticed by Dr Jones is gminme.
The peculiar effects produced by it are supposed to be due to the
circumstance '' that it tones and excites vaso-motor nerves to such
a degree that the arteries of the ears, eyes, and heart become con-
tracted, and the parts they supply anfiemic. Its overaction in this
way may be deciaedly injurious." It therefore appears that quinine
is most likely to be useful where the nervous power, and especially
where the vaso-motor system is much depressed. On the other
hand, it may act as an irritant to various tissues, so that in sthenic
inflammatory affections its use is contra-indicated.

Arsenic is in many respects analogous in its actions to quinine,
the principal difference being that arsenic ^' is much more' of a tissue
irritant, and has more special localities for its operation:"

" Strychnia is a nervine tonic which addresses itself specialhr to
the motor-nervous apparatus of the cerebro-spinal system. It finds
its opportunity in all cases where the nerve cells of the centres are
weak, and cannot furnish the requisite stimulus to the motor nervesi

1864.] DB 0. H. JONES ON FUNCTIONAL NEBV0U8 DTB0BDBS8 44t

whereas it is injurious in all conditions of an opposite kind. It is
not usually considered to have any action on tne brain, but some
very positive evidence has convinced me that it affects the superior
as well as the spinal centres, arousing and increasing their nervous
energy when it is defective. On the sympathetic system it acts
much less evidently." Dr Jones agrees with Dr Fleming in
recommending that strychnia should invariablv be administered
in the form not of solution, but of pill. In tnis way there is no
danger of its supposed cumulative effects being manifested.

Dr Jones' remarks on digitalis are very interesting, and although
this passage is rather long for quotation we give it entire.

'^ DigUaUi has long been employed and ranked aa a depressant agent, and
that it may be used as such very effectively there is no doubt. Latterly^ how*
ever, various obseryers have satisfied themselves that it may under certain
circumstances produce diametrically opposite effects, acting in fact as a power-
ful cardiac toner or stimulater. I stated my belief of this in 1859, v. Brit.
Med. Jour., 17th Dec, and since then evidence has accumulated considerably
proving that such is the case. Winogradoff' and Traube show by exact
experiment that digitalis, if not given in excess, does not diminish, but actually
increases the pressure m the arteries. The former states that digitalb acta
both on the regulating and motor nerves of the heart (the vagi and sympa-
thetic cardiac neryes), and that the degree of pressure in the aortic system is
the conjoint result of these two factors. The first action of digitalis on each
is to excite, and the second to paralyze. If then the motor are more stimu-
lated than the regulating nerves, the arterial pressure will be increased, and so
it wiU be if the regulating are enfeebled while the motor are excited. On the
contrary, the arterial pressure diminishes when the reflating nerves are
more strongly excited than the motor. In a dog after division of the va^, the
pressure rose after injection of digitalis from 124 to 260, declining in ten
minutes to 176 millim. Repetition of the injection speedily arrested the
heart's action. There seems to be a remarkable correspondence between these
observations and those of Uufschmidt and Moleschott as to the effect of irrita-
tion of the medulla oblongata and spinal cord on the frequency of the pulse,
t^. p. 10. In addition to the results quoted there, it may be mentioned that they
found that irritation of the medulla Mongaia was conducted to the heart through
the pneumogastric, and not through the sympathetic nerves, while irritation of
the spinal cord was transmitted to the heart through both sets of nerves. From
the above evidence there seems good ground to conclude (1) that digitalis in
the milder degrees of its action has a stimulating influence upon the heart,
acting through the medulla oblongata and spinal cord or the cardiac nerves
proceeding from them ; (2) that its stronger action has the reverse effect, like
galvanism or mechanical irritation, arresting the heart's movements. How
this arrest is produced is not clear. On the one hand, it may be supposed that
the over-stimulus tetanises the heart, producing such strong contraction that
the ventricles no longer relax to admit blood, which of course would bring the
circulation to a stan£till. Tliis view is supported by the fact that, according
to Dr Fuller's observations and my own, the heart after death from digitalis is
found with its cavities firmly contracted, contrasting remarkably with the con-
dition produced by aconite and chloroform. On the other hand, the arrest
may be regarded as the result of inhibitory action, the excessive stimulus pro-
ducing a morbid and depressing effect. This view is on the whole, I think,
the most probable, as we are frequently meeting with analogous instances
where it appears that an unnatural or unsuitable stimulation tends to paralyze
nervous power. Besides the amount of stimulus, the degree of excitability of
the cardiac nervous and motor apparatus is a highly important factor of the
Bitimate xesult. This is demonstrated by the following quotation from Mr

442 DR C. H. J0NB8 ON FUNCTIONAL NERVOUS DI80RDEBS. [NOV.

Lister's most valuable paper: — *In a healthy state of the nervoas system,
very gentle irritation of the vagus increases the heart's action, while a slightly
stronger application ' diminishes the frequency and force of its contractions.
• . . . When partial exhaustion has occurred, a much stronger galvanic
stimulus is required to produce the same effect upon the heart than at the
commencement of an experiment ; and thus an action of the battery, which
when first applied causes marked diminution in the number of the beats, may
after a while come to have the opposite effect, and increase the heart's action
as decidedly as it had previously lowered it ; while at an intermediate period
it may seem to have no influence at all.' Just in the same way, I conceive,
digitidis tones and strengthens the action of a feeble heart, but lowers that of a
vigorous one.

** Clinical observation in various particulars confirms the above views.
Thus there is some evidence that digitalis acts in a like way upon the vessels
as upon the heart. It is said to check epistaxis, and Dr Brinton affirms it to be
the best remedy for haemorrhage from pulmonary cavities in doses of n\^ 30 to
90 Stis vel itis horis. In the case of menorrhagia it is considered to act on the
uterine tissue rather than on the vessels ; but this seems to me problematical,
seeing that the muscular fibres in the unimpregnated state are undeveloped.
However this be, it is certain that it produces contraction of contractile tissue.
Digitalis is spoken of highly by some observers for its efficacy in neuralgia.
Mr Hardwicke has also used it in * tic douleureux' with the happiest results,
siving gr. } of the powder every three hours even in cases where he much
feared its depressing effects on account of the great debility. M. Serre reports
the cure of several long-standing cases of hemicrania, including his own of
fifteen years' duration, by means of Debout's pills, consisting of quin. gr. iss
-|- pulv. digitalis gr. { in each, one taken every night for three months. The
Quantity of quinine is too small to produce any material effect. Boison says
tnat a pill of musk, gr. i -|- extr. digitalis gr. iss -f~ opii gr. |, has a magical
effect upon neuralgia. There can be no doubt that the drug act« in such
instances in the way of a tonic, probably much like the quinine with which it
is associated, and which has in large doses a like power of slowing the heart's
action. The advantage of giving large doses of digitalis in cases of delirium
tremens seems to me sufficiently proved, and I think it nearly as certain that
it is only the asthenic variety of the disease which is capable of being thus
benefited. If further observation establish this point, it will be an additional
evidence in favour of the primary tonic action of the remedy, and will accord
with what we have just seen of its curative influence in neuralgia. Dr Wilks
has performed a most interesting crucial experiment which absolutely proves
that digitalis may revive and restore the failmg action of the heart, and there-
fore cannot possibly be a mere depressant. The patient was a woman, who
having long suffered from disease of the heart, had a severe flooding after
labour. She was apparently in articulo mortis, her limbs were cold, face livid,
no pulse at the wrist, and a mere fluttering to be heard when the ear was
applied to the region of the heart. The body was covered with a deathly
cuuinmy sweat. Brandy and ether had failed, but l^ss. doses of tr. digitalis,
o. Aora, restored her after seven had been given ; and she recovered. I had for
some time intended to use the same means if a fitting opportunity occurred,
and had spoken of the same to several of my friends as a possible succoiu* «n
exbremxB, Two cases which I recorded, v. Medical Times and Gktzette, 13th
December 1862, of the tonic and restorative action of digitalis in debilitating
disease of the heart, are worth referring to by any one who has doubts on the
matter. The diuretic power of digitalis is not unfrequently very evident, but
it partakes of the family infirmity Belonging to all its congeners, that it is very
uncertain. Dr Christison is inclined to uelieve that its two actions, the
diuretic and sedative, are incompatible. I think this is very likely; and
further, that in any case where it acted principally on the heart as a toner or
as a sedative, its renal action would be less developed. Dr Christison speaks
very decidedly as to the non-increase of renal irritation in the cases where he
has administered it for the relief of the dropsy of Bright's disease."

1864.] DB C. H. JONES ON FUNCTIONAL NERVOUS DISORDERS. 443

In the remainder of this chapter varions other nervine remedies
are treated of, and we would more particularly direct the attention
-^ of our readers to the observations on opium and belladonna.

From an appendix headed " vindemiatio," or vintage, we extract
a few of Dr Jones' conclusions.

" (2.) The same cause may give rise to very various and even apparently
opposite effects, according to the state of the nerve or nervous centre on which
it acts ; thus, an irritation may either paralyze a muscle, or throw it into con-
vulsion, or into risid spasm ; may cause pam or numbness or local tenderness ;
^ ma^ produce cerebral excitement or depression. Much depends on the degree

of irritation, a moderate may excite, while a powerful may depress. The same
may be said of the kind or quality of the irritation, an appropriate kind stimu-
lates, while one which disagrees has an opposite effect.

" (3.) The result of a stimulant or of a sedative may be different according aa
it affects the cerebro-spinal or vaso-motor nerves. The constriction of the
arteries produced by the action of a stimulant on the latter may diminish or
temporarily arrest fanctional power, and vice ver$d dilatation of arteries produced
by a sedative may give rise to excessive action. The operation of these agents
on the cerebro-spinal nerves or centres is just the reverse.

" (4.) Hypeneraia from paralysis of vaso-motor nerves is very common, and
may, under conditions of general exhaustion or local irritation, pass on into
actual and complete inflammation. This hypersemia or mflammation is always
diffuse.

" (9.) Spinal excitement (tetanus) is to be re^rded more as a dynamic than
a toxic affection. Its affinity to paralysis, and its relation to prostrating influ-
ences, as prolonged heat and cold and wet should be borne in mind. Catalepsy,
^ a variety of tetanus, is sometimes produced by exhaustion.

" (10.) The epileptic paroxysm is immediately dependent on spasm of all the
encephalic arteries in the greater, and those of the hemispheres only in the
minor form. Sudden temporary ansemia is thus the necessary condition of the
^ occasional paroxysm, but in prolonged convulsions, as puerperal, exantheroatic,

of tubercular or of ursemic origin, it is probable there is direct irritation of
the tubercula quadrigemina and adjacent parts with more or less secondary
hypenemia. The latter when primary may no doubt be a predisposing, but if
it stop short of actual inflammation, is scarcely ever an exciting cause of con-
vulsions. H^peraesthesia of the excitable districts, quite analogous to that
affecting peripheral nerves, is, however it may be excited, the fundamental
cause of convulsions. According to the qualUy of this hyperaesthesia counter-
irritants, sedatives, or tonics, or a combination of them may be requisite.

" (11.) Chorea is in most cases a dynamic disorder of debility, involving a
greater or less extent of the cerebro-spinal centres, sometimes only the motor
apparatus, sometimes the hemispheres also. Paralysis agitans, when not of
organic origin, is a similar but more limited affection involving some part of
the spinal centres.

" (13.) Wherever nerves exist, neuralgic affections may and do occur. As
to their quality, they may present either that of hypersBsthesia where tender-
ness and excitement predominate and sedatives relieve, or that of neuralgia
« characterized by pain and depression, and relieved by stimulants. These are

the typical forms, out of course intermediate and mixed ones are most common.
As to their origin, they are in most cases intimately connected with depressing
agencies, or with maUuria, but may be dependent on remote irritation, or gouty
or syphilitic poison.

" ri4.) Headache may be produced either by neuralgic affection of the brain
^ itself, or of the nerves of the parietes, and maj be characterized by hyperaes-
thesia, or by prostration. Like other nerve disorders, it may be produced by
direct or remote irritation.

" (16.) Angina pectoris is essentially a cardiac neoralgiai consisting as so
VOL. X. — NO. V. 3 L

444 DR BANKS ON THE WOLFFIAN BODIES OF THE FGETUSy [nOT*

often observed in other situations of sensory and motor disorder, pain, and
spasm. It may be produced by very different causes as well as other 'cardiae
neuroses.

" (18.) The convulsions attending on pertussis and other severe coughs do
not depend on hypersemia of the brain, but on propagation of the motor dis-
order to the nerves of the cerebral vessels.

"(23.) In treatment, large allowance must be made for idiosyncrasy; the
kind of remedy may be clearly enoueh indicated, but it may not be easy to
determine the particular one required. It is idso essential to ascertain the
proper dose ; a remedy may fail because given in too large or too small an
amount, or because it has not been given tor a sufficient length of time."

In conclusion, we can heartily recommend Dr Jones' work as
quite on a level with the present state of physiological and patholo-
gical science, and as containing much valuable practical information.

On the Wolffian Bodies of the Fa&tus. and thebr Bemains in the AduU ;
including the Development of the Generative System. By William
Mitchell Banks, M.D. Prize Thesis. Edinburgh : Mac-
lachlan & Stewart : 1864. Pp. 103. Six Plates.

Medical readers generally, are not apt to be interested in topics of
pure anatomy, and still less of embryology. Yet we feel that little
apology is necessary for directing attention to the able and original
treatise of Dr Banks, both on account of its merits as an anatomical
investigation, and because the results arrived at bear upon questions
at once curious and important. It may, perhai)s, be remembered
that about eight years ago, Dr Cleland, in his prize thesis at Edin-
burgh University, cleared up the anatomy of the Gubemaculum
Testis ; the present essay of Dr Banks is a continuation of the
same line of research. Like its predecessor, Dr Banks' thesis is
founded on the results of the author's own observations and dis-
sections. He has worked out the details for himself with marked
success, and his paper constitutes a real and valuable addition to
our knowledge upon a subject of considerable difficulty, upon which
the opinions of the best authorities are still divided. When we
consider how little use or purpose is served by most graduation
theses at home and abroad (far less so than ought to be), it is very
gratifying to meet with one which displays so much diligence,
skill, and talent : creditable to its author, and calculated to uphola
the reputation of the school of anatomy in our university.

The study of the development of the. generative organs is of
great importance for obvious reasons. In the first place, it aifords
the only satisfactory method of establishing clearly the homologies
of the male and female sexual organs, t.e., of determining which
parts in the male apparatus correspond to those in the female,
points which, although commonly held to be settled, are as yet
undecided, or at least are not decided as told us in our text-books,

1864.] AND THEIR BEMA1N8 IK THE ADULT, ETC. 445

but rather in the opposite way. And, secondly, it is by facts
derived from embryology that the mysteries of the curious sexual
malformations called hermaphroditism can alone be solved. Ques~
tions as to sexual homolo^es, etc., are probably nearly as old
as the fables of hermimhroditism ; both date from the most ancient
times, yet we are only now approaching their solution in a dif-
ferent direction from that commonly anticipated. It is to the
Germans that, in recent times, we are chiefly indebted for the
elucidation of these questions, both in embryology and pathology.
French authors have also made important discoveries, uiough, as
not unusually happens, their views are in direct opposition to the
Germans. In Bntain, although the subject of embryology in its
relation to hermaphroditic malformations was long since ably
investigated by Professor Simpson, we are not aware of any recent
contributions to the embryology of the generative system, with the
exception of the treatise of Cleland before alluded to, and the
present work of Dr Banks.

Before alluding specially to the author's results, a few remarks will
explain the position of the subject, from a general rather than a spec-
ially anatomical point of view. In regard to the evolution of the
male and female sexual system in the mammaUa, for our present pur-
pose, two theories may be selected, among those generally advanced.
According to the opinion all but universal, which may be styled
the single sex theory, the mammalian embryo, in its early stages,
contains the rudiments of the generative apparatus of one sex only.
These rudiments present at first nothing distinctively male or
female ; they may oecome one or other, but not both ; and in the
course of development they soon assume exclusively either the male
or the female type. In antagonism to this view, the double sex
theory has been brought forward by few anatomists, and not
hitherto received with any favour, tt maintains, that the mam-
malian embryo possesses at first the rudiments of the generative
organs of both sexes, and is, in fact, naturally hermaphrodite.
In the animal destined to become male, it is alleged that the
masculine structures of the common emoryonic apparatus alone

grow to maturity, while the feminine portions atrophy or disappear,
onversely in the female, the feminine organs come to perfection,
and the male parts remain undeveloped, leaving in the adult mere
rudimentary traces of their former presence. This latter view
reminds us of the literal interpretation of the passage in Genesis
(i. 27} describing the creation of Adam, ^^ Male and female created
He him." It has been adopted by a few anatomists only, wh' "se
attention had been arrested by striking instances of true her -
phroditic malformation in the adult. Such appears to have /
gested it to Dr Knox thirty-four years ago. It is evident, ind
that such abnormalities are more easily accounted for on the

S»sition of double than of single sexual apparatus in the em'
evertheless, iaucts have till ktely been wanting in support

446 DR BANKS ON THE WOLFFIAN BODIES OF THE F(ETU8, [NOY.

It is curious, therefore, to find that the theoiy of double sex,
although not borne out in regard to the whole sexual apparatus, is
proved by recent researches to approach much nearer the truth than
the commonly received opinion of original single sex. And, as
the whole explanation of the homologies and of malformations
plainly depends upon the determination of primaij singleness or
duplicity of sex in the embryo, we shall indicate briefly tlie resultB
which have now been reached in the inquiry.

We may consider the generative apparatus of either sex to con-
sist of three divisions. Istj The genital glands (testis, ovary) ; 2rf,
The conducting passages, which may be termed collectively, in the
male, Spermiduct (vas deferens, and vesiculse seminales), and
in the female. Oviduct (including Fallopian tubes, uterus, and
vagina) ; and, 3J, External organs (penis and scrotum, clitoris and
labia) The correspondence of the external organs in the two sexes
is too obvious and of too little importance to need any comment ; the
difficulty meets us only when we consider the internal organs, viz., the

genital glands, and the conducting passages. In regard to the former,
owever, the theory of double sex is at mult, and the unisexual view
holds good.' The most recent researches have failed as yet to show
any tendency to duplicity in the type of the genital glands. Each
embryo has only one on each side ; that one ma^ become either an
ovary or a testis, but cannot form both. In this particular, which
is in some respects the most essential of aU, the human embryo is,
therefore, formed on a unisexual and not on a hermaphrodite plan ;
the rudiments of testis and ovary are not simultaneously present.
Pathology is here in accordance with embryology, in so Mir, that
in no well-authenticated case of hermaphroditic malformation in
mammalia has a double set of genital glands been found. The
utmost that has been witnessed has been the presence of an ovary
on one side and a testis on the opposite side, but never testis and
ovary present simultaneously, belonging to the same side.

But with the conducting passages for the sperm and ova, it is
different. Pathology and comparative anatomy have supplied us
with indubitable instances of true hermaphroditic conformation in
the adult mammal, where the uterus and Fallopian tubes have been
found co-existing with a vas deferens and vesicular seminales. It is
true that in these cases one set of passages is usually less developed
than the other, according as the male or female type has pre-
dominated, but the conducting organs of both sexes are unmis-
takably present, and often in a very perfect state. In many
animals, this condition, in a developed form, may be said almost
to exist normally, as in the Free-martins, which Hunter first
described ; in most animals some rudiments of it are found, and
however improbable and " transcendental " it may at one time
have appeared, few anatomists would now dispute the accuracy
of Weoer's discovery, that the prostatic vesicle in the human
male urethra is a rudimentary uterus, or more precisely uterus and
vagina.

1864.] AND THEIB REMAINS IN THE ADULT, ETC. 447

This coexistence of male and female stractures in the same
individual has received different explanations from patholo^sts, and
almost invariably on the unisexual theory. Embryologists, also,
have not hitherto been agreed in their description of the primary
evolution of these parts. On this disputed point Dr Banks'
researches are calculated to throw mucn light. He has with
much care and labour traced, in the mammalian embryo, the
earliest development of the whole internal generative apparatus,
more especiallv in its relation to the Wolffian bodies, those curious
transitory embrvonic glands, which, although themselves disap-
pearing, form the nidus or matrix in connexion with which tne
whole internal genital system is produced. It is satisfactory to
find that Dr Banks' dissections, which are opposed to the views of
French observers, confirm, for the most part, the views at which
the best German embryologists have recently arrived. From these
researches it results, that there are always two ducts associated
with each Wolffian body. One of these ducts, the excretory or
Wolffian duct, is at first the proper excretory canal of the Wolffian
body, which at this early perioa performs the function of a kidney.
Subsequently, when the Wolffian body atrophies, the Wolffian duct
becomes connected with the genital ^land (testis), and is devel-
oped into the spermiduct or male genital passages, forming in the
male the vas deferens and vesiculse seminales, but remaining rudi«
mentaiy in the female, where the only traces of it are the Gaertner's
canals, found only in certain animals (cow and sow). The other
duct, termed MuUer's duct from the name of its discoverer, merely
lies upon the Wolffian body, but does not in any way communicate
with Its secreting structures ; and, in fact, its upper end is free and
terminates in an open mouth. Out of this MUUerian duct the
oviduct or female passages, in their whole extent of Fallopian
tubes, uterus, and vagina, are exclusively formed. They grow to
full maturity, however, as will be readily understood in the female
animal only ; in the adult male they are represented chiefly by the
prostatic vesicle. We have already mentioned that the genital
glands are a single pair only, and form either ovaries or testes ;
and so far the embryo is essentially unisexual. But in regard to
uterus and seminal ducts (vas deferens), it will be observed that
the embryonic type is truly hermaphrodite, the Wolffian duct
which forms the male passages co-existing at an early period with
the MuUerian duct, from which the uterus and other female organs
arise.

We have not space, and it would be out of place here, to enter
more fully into the details of the homologies of the different parts
of the genital system as laid down by Dr Banks and others. We
must content ourselves with repeating the general result, that in
regard to the genital glands (testes, ovary), the type is single or
unisexual ; but, on the contrary, the rest of the generative apparatus
of mammalia is originally hermaphrodite or double, consisting in

448 DR BANKS ON THE WOLFFIAN BODIES OF THE FCETUS^ [NOT.

each indmdual of the rudimentary stnictures of both male and
female organs. Doubtless the formation of testis or ovary deter- .
mines which apparatus^ male or female^ shall be developed, and
which shall atrophy. It is a curious renection, that upon the single-
ness of type of the genital glands, it most probably depends that
one kind of sexual apparatus is alone matured in each mdividuaL
Had the rudiments of the genital glands been double, male and
female, as the ducts are, instances of complete hermaphroditism,
perhaps likewise functionally perfect, instead of being unknown in
man, might have been at least as frequent as male uteri and Free*
martins are now. Knowing the prodigious fertility of those lower
animals which are naturally hermaphrodite, what would any
Malthusian think of such a possibility m the human species?

There are many points of detail in Dr Banks' essay of much
interest to the scientific student. It is a strictly anatomical and
scientific treatise, and as such it should be studied. We can only
advert to one of several points in which the author's views are
difierent firom and in advance of those of previous observeis.
According to Dr Banks, the globus major of the epididymis in the
male, and the corresponding parovarium in the female, are not
developed from the upper part of the WolfiSan body as Kobelt first
described, and as is now generally believed, but are formed firom
a " new structure," formed on the summit of the Wolffian body (a
kind of supra- Wolffian body, if we may so call it) first pointed out
by Dr Cleland. But we must content ourselves by referring those
interested in such inquiries to the work itself, where the author's
views are clearly explained, and are well illustrated by the en-
graved plates copied from his dissections. Although future inves-
tigations are necessary to add confirmation and correction on a
subject presenting so much difficulty, yet we believe the descrip-
tions given and the views advocated by Dr Banks are substantially
correct.

We subjoin the general conclusions of the author : —

'* 1. The Wolffian bodies do not enter into the construction of the genital
system, and form no part of it whatever.

" 2. In connexion with them are found two ducts, which open below into the
sinus urogenitalis : (1.) The excretory [ox; Wolffian! duct, receiving the com-
ponent tubes of the organ. (2.) MiLUer s duct, a tube quite unconnected with
It, though lying upon it, and terminating above bv a free extremity.

" 3. At a certain period, on the summit of the Wolffian body, a new structure
forms [supra- Wolffian body], distinct and separate from it, though apparently
continuous with it ; this structure is a distinct formation, and is not an altered
condition of the upper tubules of the Wolffian body. In the male this forms
the globus major of the epididymis, and in the female the parovarium.

*' 4. In the male the excretory duct of the Wolffian body forms the body of
the epididymis, globus minor, and vas deferens, and its upper end emerges mto
the new structure on the summit of the Wolffian body, and becomes connected
with the tubules in that structure, which form the future coni VHSCulosi. A
short cord passes from the new structure to the head of the testicle, which is
at first sollu, but afterwards splits up longitudinally to form the vasa efferentia.
In the female the excretory ducts form the can^ of Gaertner.

^

1864.] AND THEIH HEMAIK8 IK THE ADULT, ETC. 449

'' 5. In the female the npper parts of the Munerian dacts form the Fallopian
tubes, and in animals the comua uteri also, and their lower parts meet together
into one canal, and form the uterus and vagina. In 4he male, the upper parts
form the hydatid of Morgagni, and certain small superficial cysts along the
course of the epididymis, and their lower united ends, the resicula prostatica.

" 6. The hydatid of Morgagni is the analogue [homolo^e] of the fimbriated
extremity of the Fallopian tube, and not of any veside or vesicles found
thereon. The parovarium is the analogue [homologue] of the globus major ;
and the vesicula prostatica that of the uterus and vagina.

" 7. The sinus urogenitalis forms the vestibulum vaginse of the female, and the
membranous and a very smaU part of the prostatic portion of the urethra in
the male.

" 8. The remains of the Wolffian body proper are to be found as small frag-
mentary tubules and granules scattered about in the neighbourhood of the
parovarium ; in the male they form the organ of Qiraldds, and some of the
tubules still remaining in connexion with their excretory duct (the body of the
epididymis) form the vasa aberrantia of Haller.

" 9. The majority of seminal cysts are to be found on the eaptU qndidjfmis^
and are probably formed from dilatations of the tubules of that body ; those
found on the spermatic cord may possibly result from the dilated enas of the
vasa aberrantia.

" 10. The organ of Giraldds may give rise to cysts on the spermatic cord,
which, however, never contain spermatozoa."

On the VartaHans of the FertUt^ and Fecundity ^ Women according
to Age. By J. Matthews Duncan, M.D. From the Transac-
tions of the Royal Society. Edinburgh : 1864.

This is an interesting paper on a subject which has not met with
the attention it deserves. The question has not altogether escaped
the attention of physiologists; but, hitherto, attempts have been
made to solve it, eitner by a reference to general principles, or by
referring to analogies derived from the lower animals. Dr Matthews
Duncan, on the other hand, discarding h priori reasoning, appeals
to facts, which have been principally aerived from the Itsgisters of
Births in Edinburgh and Qlasgow for the year 1855, a year in
which a variety of important details were given^ which have since
been discontinued, xhe following passage will show that the
opinions regarding the fecundity of women have hitherto been
founded upon very unsatisfactory data: — "The views hitherto
entertained regarding the influence of age on fecundity have been
various. ^ In regard to age (says Burdacn) fecundity is diminished
in the first and last portions of the continuance of the aptitude for
procreation. The elk, the bear, etc., have at first only a single
young one, then they come to have most frequently two, and at last
again only one. The young hamster produces only from three to
six youn^ ones, whilst that of a more advanced age produces from
eight to sixteen. The same is true of the pig. This rule appears
to be general, since it applies also to the entomostraceas ; according
to Jurme, the number of the young of the Monocvlvs pulex is at first

450 ON THE PERTILITT AND FECUNDITY OP WOMEN. [NOT;

firom four to five, afterwards rising gradually as high as eighteen.
We scarcely ever encounter the births of three or four children,
except in women who have passed the thirtieth year. Precocious
marriages are not only less fertile, but the children also which are
the result of them have an increased rate of mortality. According
to Sadler, every marriage in the families of the peers of England
yields 4*40 children when the woman was married below sixteen
years of age; 4*63 from this age to twenty; 5*21 from twenty to
twenty-three; and 6*43 from twenty-four to twenty-seven.' The
notions here expressed by Burdach are in the main correct ; but it
is evident that they are very indefinite. They are to be regarded,
also, more in the light of happy guesses than of well-founded
opinions. Burdach evidently places chief reliance on the evidence
afforded by the numbers at a birth. From many quarters I have
received corroboration of Burdach's statements regarding the in-
crease and subsequent decrease of the number proauced at a birth
by pluriparous animals, and I have received similar information
regarding bitches, guinea-pigs, the fertility of hens, etc When I
first paia attention to this subject, the plural births of women
appeared to me to form a simple key for the determination of the
fecundity of women at difierent ages. But I soon became dissatis-
fied with the materials I quickly collected. Woman is not a
pluriparous animal, neither does she produce so regulalrly, or accord-
ing to season, as the animals with which she is compared. In her
the occurrence of .twins and triplets is an exception to the normal
rule, and the number of children bom by her cannot be so simple
and sure a test of fecundity, as in the case of animals having
multiple litters at stated periods. Indeed, it is apparent that the
evidence derived from plural births alone in women may positively
mislead, for a woman may be more fertile bearing one child at a
time frequently than another bearing twins or triplets more seldom.
In this place I shall only say, that tne numerical study of twins, in
reference to the age of tne mother, yields interesting results, which
do not confirm Surdach's statement regarding them, yet are not
hostile to the conclusions of this paper. Burdach, in his work,
describes an annual rise and fall in the fecundity of some pluriparous
animals. This annual variation forms a series of wavelets in the
course of the great wave running from youth to old age, and cul-
minating in middle life. This annual rise and fall of fecundity he
attributes to the influence of cold."

Dr Duncan's own conclusions, established by a number of care-
ftiUy constructed tables, are the following : — " In this paper, then,
I have, inter alva^ shown that the ^eat majori^ of the population
is recruited from women under thirty yea) s of age ; but that the
mass of women in the population, of from thirty to forty years of
age, contribute to the general fertility a larger proportional share
than the mass of women of from twenty to thirty years of age.

<' Further, that the wives in our population, taken collectively as

1864.] DR PARSONS ON A FORM OF BRONCHITIS. 451

a mass, show a gradually decreasing fecundity as age advances ;
but that the average individual wife shows a degree of fecundity
which increases till probably about the age of twenty-five, and then
diminishefl.

" The fertility of the average individual woman may be described
as forming a wave which, from sterility, rises gradually to its highest,
and then, more gradually, falls again to sterility/'

On a Form of Bronchitis {simulating Phthisis) which is peculiar to
certain branches of the Potting Trade. Prize Thesis. By
Charles Parsons, M.D. Edinburgh : Maclachlan & Stewart :
1864.

This thesis, for which a gold medal was awarded at the Gradua-
tion at the University of Edinburgh in August last, contains an
interesting account of a hitherto-undescribea form of pulmonary
disease which is common among the potters of Staffordshire. Dr
Parsons' attention was first directed to the subject in 1859, shortly
after being appointed House-Surgeon to the North Staffordshire
Infirmary. The symptoms of the disease much resemble those of
ordinary tubercular pnthisis, with which, indeed, it has generally
been confounded. The presence of tubercle does not, however,
appear to be an essential element, and the disease is evidently of
the same character as miners' or knife-grinders' phthisis.

Dr Parsons gives the details of three cases which came under
his own observation, and from these and some others he has
drawn up the foUowmg general account of the symptoms of the
disease: —

" The malad;^ is essentially progressive, and consists of three distinct stages*
At the ontset it differs neither in physical signs nor symptoms from an ordi-
nary bronchitic attack. There is nothing to arouse suspicion of more serious
mischief. The features are well marked and characteristic, so that no doubt
can be left on the mind that the first stage is one of acute, or more commonly
sub-acute bronchitis. This gradually passes, after an interval varying in
different cases, into the second stage, that of confirmed chronic bronchitis, with
more or less emphysema. And now it is, when the patient is compelled through
increasing dyspncea and continuous cough, to seeK medical advice, that the
real nature of the malady is suspected. Throughout the chest a general
wheezing is heard, with much rhonchus and less sibilus; expiration sound
greatly prolonged ; bronchial breathing is usually audible about the middle of
each lung (supposing the disease to be symmetrical), or rather above the mid-
dle, bronchopnony being less constant ; respiratory sounds generally are coarse
and harsh, differing greatly from those of simple exaggerated respiration.
There is dulness.on percussion mostly about four fingers*- breadth beneath the
clavicle ; and exa^erated resonance over either lung towards the median line
anteriorly, which is never absent in these cases. The other sounds are some-
times more audible behind than in front, but rarely so ; and occasionally they
may be heard equally well in both positions. There is some emaciation, and
the patient says he has been losing nesh ' a good while.* The expectoration is

VOL. x.— NO. V. 3 m

452 DR PARSONS ON A FORM OF BRONCHITIS. [NOV.

copioQB and parulent in character, varied every now and then, when the attack
is aggravated, with frothy liquid. The dyspnoea is persistent, and does not
occur in paroxysms. The respiration is peculiar, nearly asthmatical in charac-
ter, and instantly arrests the attention. So striking is this symptom, that I
was able, after closely observing many cases, to diagnose accurately in nine
cases out of ten, both the patient's particular occupation, and the state of his
chest, from his general appearance and this characteristic respiration. To
pass from this condition into the third stage is an easy gradation, and is only a
question of time. I am not prepared to say that the transition is inevitable,
out I have yet to see the patient who has remained stationary in the second
stage. The symptoms which obtain in the third stage have already been
related in detail in the narrative of the three cases, so that nothing more need
be said respecting them in this place."

The sputa, it will be remarked, are not of the black colour which
is so characteristic of miners' phthisis, but it is stated elsewhere
that they are occasionally streaked with blood.

The morbid anatomy of the disease is still somewhat imperfect
in consequence of the great prejudice existing in the Staffordshire
potteries against post-mortem examinations. The following, how-
ever, are the appearances commonly met with: — Very generally
there are firm pleuritic adhesions ; the lungs are of dark colour,
generally emphysematous anteriorly, and studded with black
masses, and with firm opaque whitish patches. The section of the
white masses is gritty, of the black smooth ; cavities are found
scattered through the pulmonary substance, generally filled with
thick creamy pus. The minute bronchi are much indurated, and
thei'e is great puckering and thickening of the pulmonary tissues.

The disease is no doubt occasioned, as suggested by Dr Parsons,
by the sudden transition from the highly heated and very dry
atmosphere of the workshop, to the cold and damp air of the street,
and by the constant inhalation of the particles oT fine dust which
abound in the atmosphere of the manumctory.

We trust that Dr Parsons will continue his inquiries, and give
the profession the benefit of his farther observations.

Practical Anatomy : A Manual of Dissections, By CHRISTOPHER
Heath, F.R.C.S., Assistant- Surgeon to. and Lecturer on
Anatomy at, the Westminster Hospital. London : Churchills :
1864.

Oreat changes have taken place since the day when almost the
only choice the student of practical anatomy had, lay between the
Dublin and Edinburgh "Dissectors." Such works are now far
fuller and more practical than formerly, and the latest improvement
has been the copious introduction of illustrations. The present
volume has been got up in the usual admirable style of Mr
Churchiirs manuals, and cannot fail to be acceptable to the student.
The directions to the dissector are clear and sufficiently copious ;

1864.] MR heath's PRACTICAL ANATOMY J ETC. 468

the descriptions are accurate; and the illustrations, both original
and selected, will be found faithful representations of nature. Not
the least merit of this work is its comparative brevity; while
nothing reallj essential is omitted, the student will not find that
excessive minuteness which is often a barrier to his progress.

Nouveau Dictionnaire de Midecine et de Chiruraie vratimiea.
Directeur de la redaction, le Docteur Jaccoud. Vol. I. Parts
1 and 2. Paris : J. B. Baillifere et Fils : 1864.

The French have always shown a great partiality for the encyclo-
pediac form of literature. It is well adapted to their tendency to
systematize, and to the clearness and accuracy of their scientific
language. Numerous dictionaries of medicine have been published,
the contributors being the most eminent men of the day. The
present work edited by Dr Jaccoud, is in this respect in no way
inferior to its predecessors ; the list of contributors embracing many
of the best known medical men in Paris and the Departments. In

5 roof of this we may merely mention the names of Trousseau,
'ardieu. Hardy, Liebreich, OUivier, Bemutz, Nelaton, Ricord,
Gosselin, Alph. Gu^rin, Girald^s, and Gintrac. The two parts
before us complete the present volume, and carry us on as far as the
word " Ambulance." Among the principal articles contained in this
volume may be mentioned the following papers, — Ahc^^ by Laugier ;
Abdomen (symptomatology and medical pathology), by Bemutz;
AcclimatementjDj Rochard: Accouckementy by Stoltz and Lorain;
Acney by Hardy '^zV, by Tardieu; Albuminuriey by Jaccoud; and
Alcooltsmey by Foumier. The subjects of these and the other
articles are treated of in an able and exhaustive manner, and the
work, when completed, will give readers in this country, at a very
moderate cost (the price is only ten francs per volume of 800 pages),
a complete view of the present state of medical knowledge and
opinion in France. Another valuable feature in the work is its
reference to the writings of foreign authors. It was long a reproach
to French writers that they entirely ignored the works of all but
their compatriots ; but this reproach is being rapidly removed. In
the present work constant references are made to foreign writers,
and a copious bibliography is attached to each article ; tne English
School of Medicine \n particular is fully represented. As an fllus-
tration we may allude to an article by Girald^s on Acupressure, in
which a good account is given, and a favourable opinion expressed
of this new method of arresting haemorrhage.

We hope that the new dictionary will meet with many sub-
scribers in this country.

456 PERISCOPE. [NOV.

not, like it, make the nerres sluggish ; hence, it follows that, for physiological
operations, morphia is far preferable to codeia. Bat it is especially in the
phenomena of awakening that the effects of codeia are distinguished from
those of morphia. The animals treated with equal doses of codeia do not
awake in a state of terror, there is no paralysis of the hind-quarters, and they
have their natural disposition ; they present none of those mental disturbances
which follow the employment of morphia. Amon^ the very numerous experi-
ments which I have made on this subject, I will limit myself to a single instance
which indicates well the differences 1 am pointing out.

Two young do^s, accustomed to play together, and both rather below the
middle size, had mjected into the cellular tissue of the axilla, the one five
centigrammes of hydrochlorate of morphia dissolved in a cubic centimetre of
water, and the other five centigrammes of hydrochlorate of codeia, adminis-
tered in the same manner. At the end of about a quarter of an hour both
does experienced the soporific effects. Each was laid on his back in a trough,
and they slept calmly for three or four hours. They were then awakened, and
exhibited the most striking contrast. The dog which had received the
morphia ran about in the st^le of a hyena, the eve haggard, no longer recog-
nising any one, not even his canine comrade, who in vain plagued him and
jumped on his back to play with him. It was only on the following day that
the dog which had been treated with morphia resumed his gaiety and his
ordinary humour. Two days afterwards, the two dogs being in gooa health, I
repeated exactly the same experiment, except that I gave codeia to the one
which had formerly had morphia, and vice verad. The two dogs slept about as
long as on the previous occasion, but on their awakening the conduct of the
animals was exactly the reverse of what it had then been. The dog which
two days before, after codeia, had awakened alert and gay, was now terrified
and semi-paralyzed, whilst the other was lively and joyful.

The sleep produced by narceine participates at once in the nature of the
sleep produced by morphia and codeia, while at the same time it differs from
it. Narceine is the most somniferous substance contained in opium ; with
equal doses, the animals are in much more profound sleep with narceine than
with codeia ; nevertheless, they are not weigned down with a leaden sleep as
with morphia. Their sensory nerves, though blunted, are not struck with a
very appreciable sluggishness, and the animals manifest pretty quickly pain-
ful sensations when their extremities are pinched. But that which particularly
characterizes the sleep produced by narceine, is the profound calm and absence
of excitability by noise which we have remarked with morphia, and found at its
summum of intensity with codeia. On wakening, the animals put to sleep with
narceine very speedily return to their normal condition. They only present in
a very slight degree feebleness of the posterior extremities and a terrified
expression, so that their awakening after narceine resembles that of codeia.
I may add that the sleep produced by narceine is very suitable for physiologi-
cal experiments ; the dogs, overcome for several hours by a profound sleep,
make no resistance, and if they make any sound of suffering, the^ neither
attempt to run off nor to bite. The animals are then in such a condition that
one would believe that thev would never waken. At the Society of Biology, at
a meeting in the month of July last, I injected under the skin of the axiUa of a
young dog seven or eight centigrammes of narceine dissolved in two cubic
centimetres of water. At the end of about a quarter of an hour, the animal fell
into a sleep which became so profound that, in order to convince the President
and various members of that laborious society, which has proved itself so
useful by the nature of its efforts for promoting medical science, I was
obliged to present the dog at the next meeting to prove that he was not dead.

To sum up, the three soporific substances contained in opium each give rise
to a form of sleep which, up to a certain point, is characteristic. I have
established this result, not only in the case of dogs, but in cats, rabbits, guinea-
pigs, rats, pigeons, sparrows, and frogs. In all, the effects of the three sub-
stances offer the same characters and the same differences, varying according

1864.] MATERIA MEDICA AND THERAPEUTICS. 457

to the special sasceptibility of the animals ; while albino rats, which are very
easily narcotised, are also very suitable for showing the differences I have
pointed out in the sleep produced by morphia, codeia, and narceiue. If we
put into the same cage three rats, sent to sleep by these three substances, if
we shake even very slightly the bars of the cage, the rat treated with codeia
leaps into the air, the two others remain quiet ; if we shake the bars more
strongly, the rat which has had codeia, and that which has had morphia,
tremble, but the first much more than the second, while the rat which has
had narceine does not move, and remains asleep. On awakening, the rat
treated with codeia resumes its gaiety first, then the rat treated with narceine,
while the rat which has had morphia remains stupid for a long time.

The differences which I have pointed out between morphia and codeia were
already known to physicians ; they had observed in man that morphia pro-
cures a heavy sleep, followed by headache, whilst codeia occasions a much
lighter sleep without headache on awakening. But narceine had not yet been
tried on man. But after my very decisive experiments, two physicians of
Paris, well known for their scientific attainments, Dr Debout and I>r B^hier,
have made experiments on men, which agree perfectly with the effects of
narceine which I have observed on animals. At present, I merely mention
these results, because they will soon be published ; I may, however, state that
even now narceine has entered into human therapeutics on an equality with
the two other soporific principles of opium. I must also remark, that the
lower animals as well as man, are much more sensitive to the effects of mor-
phia, codeia, and narceine, when they are young than when they are adult.
They also speedily become habituated to the soporific action of these sub-
stances, so that, in order to obtain the results of which I have spoken, it is
better to take fresh animals, for I have observed that these phenomena of
habituation are sometimes of long duration.

II. Poisonous Prapertita of the Alkaloids of Opium. — ^The six principles of
opium which I have studied are all poisons, but no relation can be established
between their poisonous properties and their soporific action. I was led to
make investigations regarding the toxic action of these substances, because I
had observed, in^tupifymg animals for physiological operations, that the gummy
extract of opium was relatively more dangerous than morphia. In fact, experi-
ments soon showed me that morphia was one of the least poisonous alkaloids
of opium, and that as a poison thebame was the most active principle. To
give an idea of the difference which exists between these two alkaloicfs, I may
say, that one decigramme of hydrochlorate of thebaiue, dissolved in two cubic
centimetres of distilled water, and injected into the veins of a dog between
fifteen and sixteen pounds weight, kills it in five minutes ; whilst I have injected
as much as two grammes of hydrochlorate of morphia into the veins of an
animal of the same size without causing death. After thebaine comes, as to
poisonous properties, codeia, which is also much more dangerous than morphia.
The contrary opinion is prevalent among physicians, who prescribe codeia in
larger doses than morphia. The cause of error comes from this, that in
practice morphia produces very quickly, and long before a poisonous dose has
been reached, such symptoms as headache and vomiting ; whilst codeia, which
is less soporific, does not produce these accidents to the same degree, although
much more poisonous. The dose of hydrochlorate of codeia which, injected
into the veins, kills a dog, is much smaller than the dose of hydrochlorate of
morphia, which may be injected in the same way without causing death. But
the principles of opium are at once poisonous and causers of convulsions ; that
iff to say, they produce death, with violent tetanic convulsions. These convul-
sions are followed in the case of some of the principles, and particularly in the
case of thebaine, by cessation of the action of tne heart, and by a speedy
cadaveric ri^dity, as is seen with the muscular poisons. Narceine is the only
exception ; it is not an excitant, and does not cause convulsions ; given in a
poisonous dose, the animals die in a state of relaxation.

I confine myself at present to these summary indications, as the poisonous

468 PERISCX)PE. [NOV.

action of the alkaloids of opium ought to be andertaken analytically for each
one of them with the greatest care ; for it is only by studies of this kind that
we shall find the explanation of the soporific action, and the various therapeutic
properties of these substances. Opium has already been the object of a great
number of isolated experiments, but, as we have seen, these have not been
sufficient. We must undertake, methodically and analytically, the study of
each of the alkaloids of opium with the means which experimental physiology
puts at our disposition.

III. ConcludoTu and Eeflectioru, — There are three principal properties in the
alkaloids of opium, — 1. Soporific; 2. Excitant or convubive; d.Foisonous. The
following is the order in which we may range the six principles which I have
studied relatively to these three properties. In the soporific order, we have
in the first rank, narceine ; in the second, morphia ; in the third, codeia. The
three other principles do not possess soporific properties. In the order as con-
Tulsives, we find, — Ist^ Thebame ; 2e/, Papaverme ; 3df Narcotine ; 4^, Ck>deia ;
tthj Morphia ; Gih, Narceine. In the order of poisonous action, we have, l«f,
Thebame; 2df Codeia; Sd^ Papaverine; Hh, Narceine; 5^, Morphia; 6/A,
Narcotine.

To obtain the preceding classifications, it is absolutely necessary to experi-
ment upon animals which are very readily compared, because there are shades
which otherwise could not be seized. Such is the difference of poisonous
property between morphia and narceine, which is very slight. It would be
impossible to obtain these comparative results in dogs or rabbits, for instance,
because these animals var^ as to age, size, race, etc. It is also necessary to
guard oneself from drawing conclusions from experiments performed on
animals which have already been submitted to the action of the preparations
of opium, for habituation to all their actions is so rapid and so great, that in
these circumstances a second experiment never exactly resembles the first.
We see, then, that in physiology more than in anything else, and that on account
of the complex nature of the subjects, it is easier to make bad experiments
than to realize good ones, — that is, such as are comparable. This is the cause
of the frequent differences we meet with among experimenters, and it is one of
the principal obstacles to the advance of medicine and experimental physiology.
Frogs are animals which are more comparable with one another than dogs, but
they were not sufficiently sensitive ^r my experiments. I chose for this
purpose young sparrows, which are very abundant in Paris in spring. These
animals, fresh from the nest, consequently of the same age and size, admit of
as accurate comparison as possible, and are, besides, very sensitive to the
soporific, convulsive, and poisonous actions. To administer the active solutions,
I made use of the small syringe of Pravaz, provided with a fine puncturing tube.
By this means I introduced into the subcutaneous cellular tissue, drop by drop,
the active principle with a precision almost mathematicd.

As I said at first, this paper is no more than a sketch, and although the
results which I have pointed out rest upon more tlian two hundred experiments,
it is evident that the study is only at its commencement, when we think that
it is necessary, even before entering upon a consideration of the intimate action
of each of these substances to determine their effects on the digestion, the
circulation, the excretions, and to explain the singular phenomena of the
habituation of organs to the effects of opiates.

At present I only desire to draw the attention of physicians and physiologists
to the studies which I consider as the basis of scientific therapeutics. The re-
searches are so long and the questions are so difficult, that the efforts of all of us
are necessary for their solution. Therapeutics already offer sufficient difficulties
of themselves, without our increasing them by continuing to employ complex
medicines, such as opium, which only act by a resultant which is often variable.
It is necessary to analyze the complex actions and to reduce them to actions
more simple and exactly determined, with liberty to employ them singly or to
associate them if that is necessary. Thus, with opium we can never get the
effect of narceine, which produces sleep without excitability ; but we may, on

1864.] MATERIA MEDICA AND THERAPEUTICS. 459

the contrary, find very variable efiects dependent on individual Busceptibility,
being greater for snch of the active principles which compose it.^ Ex-
periments on animals will alone enable us to make suitable analyses which will
clear np and explain the medicinal effects observed in man. We see^ in fact|
that every thine which we observe in man is found in animals, and vice vena,
only with peculiarities which are explained by the differences in the ominism ;
but at bottom the nature of the physiological actions is the same. It could
not indeed be otherwise, or we could never have either physiological or
medical science.

I shall conclude with a remark which comes naturally from this subject.
We see, by the example of opium, that the same vegetable forms principles of
which the action on the animal economy is ver^ different, and in some sense
opposed. We may thus obtain several very distinct drugs from the same plant ;
and, in the case of opium in particular, I think that each of these principles
is destined to become a separate medicine, so much the more as some of these
principles possess a very marked influence on the organism without being
poisonous, in virtue of the energy of their action. It is thus that the hydro-
chlorate of narcotine, for example, possesses a very strong convulsing property,
although it is the least poisonous among the principles of opium which I have
examined. We must not, then, believe any longer that plants of the same
family ought to have always the same medicinal properties, when we see the
same vegetable furnish active products so various in their physiological pro-
perties.— Archives GSnSrales de Midedne^ October 1864.

ON THE THERAPEUTIC EFFECTS OF THE ALKALOIDS OF OPIUM. BY DR OZANANE.

Opium is a substance of so complex a composition, and its effects are so various,
that it is important to analyze its elements and to penetrate the mystery of its
nature. May I then be permitted, while the learned Claude Bernard treats the
question
from a 1
last ten

morphia^ codeioj narcotine^ apiamne^ and narceine, Peevdo-morphia^ meoonine,
and propylamine have also been noticed, but the two first appear devoid of
action, and the third has no action upon the brain ; the consideration of these,
therefore, may be postponed. Morphia is so well known that little need be
said of its effects, it is the first and most abundant of the somniferous principles
of opium. Its action appears to be general, for it is exerted on the one hand
on the brain (sleep, coma, contraction of the pupils), on the other on the spinal
cord or the motor nerves (weakness of the limbs, especially of the legs, general
muscular relaxation), and on the sensory nerves (itching of the skin, abohtion of
pain). Finally its action extends to the ganglionic system, and to the vaso-
motor nerves. We see under its influence certain secretions diminish (saliva,
intestinal secretion), and others increase (urine). Further, the general con-
gestion of the vessels, especially of the brain, shows that the energy of the
vaso-motor nerves is diminished to an extreme degree. Perhaps even it is
this state of turgescence of congestion of the vessels which, by slightly com-
pressing the cerebral substance, causes sleep. Or rather, perhaps, the retarded
circulation accumulatmg in the distended veins a large quantity of carbonic
acid, produces a phenomenon analogous to that of breathing the gas, that is to
say, a sort of ansesthetic sleep. Morphia is then a calmative, an ansesthetic of
the brain at first, and of the whole nervous system. Opianine is very little
known by its effects. Hintuberger, who discovered it, and Orfila, agree in
regarding it as a calmative and stupifier of the brain, like morphia. Codeia is
a proteus, sometimes an excitant, sometimes calmative, and even stupifying,
according to the dose. It behaves exactly like the anaesthetics. In very large
doses, 20 or 25 centigrammes, it stupifies like morphia, or produces ansesthesia,
like ether or chloroform ; in a moderate dose it produces, like them, a period
of excitement followed by a period of calm ; in a small dose there is no excite-
ment or hardly any, there is only a calm. But besides this general action, it
VOL. X.— -NO. V. 3 N

460 PERISCOPE. [not.

has a special effect on the cerebellum and medulla oblongata. On the cere-
bellum, for we have several times seen retroprogression produced; and in
animals which have been killed these parts have been found gorged with blood.
On the medulla oblongata, whence its action is often heroic against attacks of
cough and gastralgia through the medium of the pneumogastric nerve. In
short, codeia is at once stupifying in large doses, exciting in moderate doses,
and calmative in small doses, and its action is chiefly eiert£d upon the cere-
bellum and the medulla oblongata. Narcotins has a well-marked exciting action,
an action on the whole nervous system in the opposite sense from that of
morphia. According to some authors, when dissolved in oil it is calmative ;
dissolved in acetic acid, exciting ; dissolved in hydrochloric acid, neuter. I
have employed it, sometimes in the crude state rubbed up with sugar, aome-
thnes in the form of acetate or hydrochlorate, and I have always found it
exciting. I have often admlnisterea it io the dose of five or ten centigrammes
in cases where the vital powers were failing, either after surncal operations,
in paralytics, or in dying persons, and constantly I have found the stren^h of
the pulse and the heat increase, and the patient enter upon a sort of factitious
life. I may cite, among other cases, the observation of a well-known physician,
Dr Colembat, of Is^re, who, completely paralyzed owing to frequent attacks <^
apoplexy, had fallen into a state of extreme feebleness, and seemed dying. A
erain of acetate of narcotine ffiven daily reanimated his strength to such a
degree that he lived for more than six months. Narcotine is, then, a general
excitant of the brain. Thebatne is more violent than narcotine; whilst in
moderate doses the latter excites and reanimates, thebaine agitates and tetanises.
Some time ago, I gave progressive doses, rising from three to six centigrammes,
to a patient affected with paralysis of both legs ; but the agitation, accompanied
by sleeplessness was such, and there was such general uneasiness and excitement
especially of the neck and arms, that it was necessary to discontinue it. This
fact perfectly agrees with the experiments of Orfila and Magendie, where dogs
inoculated with thebaine had tetanus and violent convulsions of the upper
limbs, while the lower were scarcely agitated. Thebaine is, then, the particular
excitant of the upper or cervical portion of the spinal cord. Nareetne is, on
the contrary, a valuable calmative. In ordinary doses of from one to two
grains, it does not put to sleep, but the patients to whom I have given it have
always said that without sleeping they enjoyed calm and perfect comfort.
Besides this general but little intense action on the encephalon, narceine appears
to have a more special action on the inferior or lumbar part of the spinal cord.
During the last five years I have administered frequent doses of it to a patient
attacked with paralysis and subject to painful aggravations. Of all the alkaloids
of opium whicn I have tried upon him, narceine is the only one which calms his*.
But it has remained quite faithful, and has never disappointed me. Under its
influence the painful crises have disappeared, and the paralysis has diminished
by the supjsression of the repeated congestions. Narceine appears, then, to
exert a special action upon the lumbar portion of the spinal cord.

Thus opium, this complex and mysterious drug, seems by its elements to
penetrate into the intimate structure of the frame ; like the panacea of former
days, it has a remedy for all evils. It calms and excites at once ; each element
finds in its alliance with others its natural corrective, which keeps its action
within just bounds. It calms by the morphia, the opianine, and tne narceine.
It excites by the narcotine and the thebaine. Between the two extremes
Stands codeia as a bond of union which is exciting or calmative according to the
dose. Viewed with regard to anatomical localisation, opium penetrates and
dissects so to speak the nervous s^rstem. Morphia, narcotine, and opianine act
especially upon the brain. Codeia acts especially upon the cereMlam and
medulla oblongata. Thebaine acts upon the cervico-dorsal portion of the cord.
Narceine acts upon the lumbar portion.

Opium is therefore an admirable remedy, which no other can replace ; and
science, by investigating its composition, and isolating its elements, teaches us
every day to appreciate its value and its power. — lUfme de Thirapeuiigne
Medieo-ChirurgicaUy 15th October 1864.

1«64.] MATERIA MEDICA AND THERAPEUTICS. 461

ON THE EFECTB OF DIGITAUNE IN LABGE DOSES. BY DB FAURE.

Dr Faube commences his paper b^ statinff that dogs are unaffected by dosea
of digitaline which would be sufficient to kill several men. Thus five or six
milligrammes would be considered a full dose for a man ; while, in dogs, five
centigrammes produce no effect, and not less than ten centigrammes are required
to produce a certainly fatal result. Dr Faure then considers the character
of the vomiting produced by digitaline. All authors who have written regarding
digitaline have alluded to the violent and prolonged vomiting which u occa-
aions. This, however, is not enough ; for various other substances. have very
energetic emetic properties. Dr laure considers that the vomiting produced
by digitaline is peculiar. In vomiting, what usually appears as the principal
cause is the necessity for expelling something on the part of the stomach ;
this is the main circumstance, the convulsive movements are, so to speak, con-
secutive ; this, at the least, is the case with ipecacuantuL sulphate of copper,
morphia, and in cholera and asphyxia, where the convulsive phenomena are
sometimes so violent. It is different in the case of digitaline ; tne effort of the
stomach, far from being the principal circumstance, is only the result of a
series of convulsive contractions which have commenced in the most distant
parts of the body, and which only commence in the upuer parts after having
shown themselves in the limbs and the lower part of tne abdomen ; then the
thorax contracts, or, to speak more correctly, is drawn in upon itself; as, in
the movement of most forced expiration, the ribs are ilattened and are thrown
backwards. Under such circumstances, the internal organs are exposed to
an extreme pressure and reject their contents. The vomited matters are
invariably mixed with bile, sanguinolent mucus, and the fluids of the stomach.
These vomitings are intermittent, and a remarkable circumstance is, that during
their intermissions, however violent the crisis has been, the animal appears
but little affected ; he recovers rapidly, and appears in his natural condition
until another crisis again prostrates him. Suppose an animal which has
already vomited twenty times ; he gets better ; for some time, twenty minutes
perhaps, you see him walk about as if nothing were the lAatter. At length
he stops ; he conceals himself in a corner ; then he faHa into a state of great
prostration, as if foreseeing what was going to happen. Accordingly, the re-
spiratory movements soon increase in volume and depth ; the belly contracts,
he is drawn together in all directions ; then appear paroxysms of vomiting ;
they are often so violent that the animal seems as if aoout to be turned in&ide
out ; finally, he expels a few drops of a frothy fluid, greenish and stained with
blood ; the crisis has arrived ; he appears immensely relieved, and in a few
aeconds everything is as it was before. It is only after vomiting very frequently
repeated, almost in the last moments before death, that the animals, excessively
enfeebled, remain lying stretched out upon the floor. In the first paroxysms,
the vomited matters, often composed almost entirely of frothy matters, are very
abundant, but very soon they are extremely scanty. Dr Faure has often seen
animals discharge, after a most severe paroxysm, not more than a teaspoonful.
When death does not close the scene, however violent the paroxysms may have
been, recovery is very rapid. Dr Faure has seen animals, where the vomiting,
having continued for six hours consecutively, suddenly ceai>ed, and the]^ re-
covered at once their normal condition without any period of uneasiness
appearing to indicate a period of transition between the moment when thev
were profoundly affectea and that when they were completely recoverea.
Sometimes the effects of digitaline are directed towards the intestines ; the
animal has the same convulsions, but in the opposite direction, and after
having expelled stercoraceous matters, he rejects, after extraordinary efforts,
a gjAiry? greenish substance, often tinged with blood.

Dr Faure then considers the state of the heart, and asks, How, when it is so
generally admitted that digitaline exerts a powerfully depressing influence
upon its action in man, he is to explain that this effect has not been so clearly
jnanifested in his experiments ? It must be borne in mind, he states, that ii^

462 PERISCOPE. [NOV.

hiB experiments, digitaline was administered in Ift^e doses ; and no one sfaonld
confound the therapeutic with the poisonous effects of a drug. The first
effect of the administration to dogs of digitaline is vomiting ; Dr Faure has
never, in spite of the most careful examination, observed as a primary pheno-
menon any notable change on the heart ; but after the animal has had numerous
attacks of vomiting such as above described, does it follow, if there is any
modification in the action of the heart, that this is exclusively due to the
action of the digitaline on the heart ? If the heart be examined immediately
after a paroxysm of vomiting, the pulsations are found exaggerated in
rapidity and force, as is seen after any kind of violent exertion ; if the
examination be made a little later, when the animal is in that condition of
depression which always follows a stage of over-excitement, the pulsations
may be below the usual standard. Are we then justified in saying that
digitaline has the power, sometimes of exciting, sometimes of depressing, the
action of the heart ? Is it not the case, that if the animal had been treated
with sulphate of zinc, or ipecacuanha, a similar result would have been seen ;
but we ^ould not have said that these substances had any special action on
the heart. Dr Faure says, that in a case of poisoning he would not lay much
weight upon the state of. the pulse. If the patient had violent vomiting, even
iJthough the pulse continued high, he would not dare to sa^ that digitaline had
not been administered. If, on the other hand, after violent and repeated
Tomiting he saw the pulse fall as the general condition became worse, he
would not conclude that digitaline had been administered, for vomiting, what-
ever its cause, when it has lasted beyond a certain time, exercises a depressing
influence on the circulation. Some experimenters have stated that they have
noticed depression of the action of the neart, and have even been able to follow
its gradual diminution. Dr Faure has, however, never seen this ; and, farther,
the general movements of the animal retained a force which seems to him in-
compatible with this condition. He once saw a man who was dangerously,
though not mortally, poisoned with digitaline, and his state, no doubt, differed
much from that of the animals he had experimented on. But this patient had
been under treatment /or several clays with digitalis and digitaline, on account
of subacute articular rheumatism. One day, he took by mistake an overdose ;
his pulse fell to 35. When seen by Dr Dr Faure he was extended on his bed,
immovable, and incapable of any movement ; he was of a cadaveric paleness,
his skin was covered with moisture ; he respired with difficulty, and at rare
intervals ; he was insensible to excitants ; in fact, he was in the state in which
the animals experimented on only arrived immediately before death.

Dr Faure does not attach much importance to the state of the heart as found
on post-mortem examination. The organ in the majority of cases had its
ordinary volume and consistence ; it was always either wholly or partially
filled with liquid or coagulated blood, — a circumstance which excludes the idea
of contraction takins place some time before death. In one case, fibrinous
concretions of considerable size were found. It has been said that temporary
contractions sometimes take place after death, and Dr Faure once met with
an example of the kind ; but he asked himself whether the occurrence of a tem-
porary contraction of the heart after death, whether a phenomenon essentially
r active manifesting itself in the heart when all activity had disappeared from the
rest of the organism, should be considered as a proof of a special sedative
action exercised upon that organ.

Dr Faure considers, in conclusion, the effects of the different modes of
administering digitaline. In the commencement of his paper he had stated
that the characters of the vomiting were such as might lead us to recognise
the effects of digitaline ; the following is a case where the nature of the vomit-
ing might be the only indication to guide us. An ordinary poisoner would
give digitaline in pills, in a draught, etc The patient vomits, the matters are
collected and examined, and the crime is discovered. But suppose the poisoner
has paid some attention to the subject ; he will then know that the results are
much more sure and more prompt when digitaline has been placed upon a raw

1864.] MATERIA MEDICA AND THEBAPEUTICS. 40S

surface than when it is injected into the stomach; he will then take care
to appl^ the poison to the surface of the body, either on the raw surface
of a blister, or a wound of any kind. The poison will act, yomiting will
occur, extremely abundant and painful. The poisoner, although knowing
that digitaline is absorbed and disappears among the tissues, will, out of
excess of precaution, and in order to leaye no detail omitted, wash the
wound on some pretext or other a few moments before death, and in the
subsequent inquiry will perhaps be the yery first to call for an examina-
tion of the yomited matters I Seyeral animals in which Dr Faure inserted
digitaline into wounds, died from the effects of smaller doses than could
be administered with impunity by the stomach. At first he made a wound in
the groin, but although it was carefully sewed up after the digitaline had been
inserted, the animals soon tore it open and licked away the poison ; at the end
of thirty or thirty-fiye minutes yomiting occurred, but soon ceased, and the
animals speedily recoyered their normal condition. Latterly he made a wound
of the skin in the back of the neck which they could not reach, and the
digitaline was consequently all absorbed. The symptoms then soon acquired
a terrible yiolence, and a fatal result was unfailing. In short, the fiye animals
out of twelve which died had received the digitaline by a wound, not by the
stomach ; in several, not more than ten centigrammes had been employed, and
all died within six or seven hours. This does not show that the others could
not have been poisoned by the administration of larger and repeated doses, but
it proves the greater efficacy of the poison when placed among the tissues than
when introduced into the stomach. In several cases Dr Faure found that the
digitaline had been entirely absorbed. This he did by passing the tongue gently
over the parts where the poison had been placed an hour or two before ; the
smallest portion, on account of its extreme oittemess, would have revealed its

Sresence, but no trace was found. The greater effect of digitaline when intro-
uced subcutaneously had been long ago observed by M. Trousseau, who
ascribes the cause of the slighter efficacy of the poison when swallowed to this,
that " the assimilative power of the stomach mm been sufficient partiidly to
digest the digitaline.'*

The effect of poisons introduced endermicaUy is well known, still if such a
case arose it might occasion a good deal of embarrassment. There are several
substances which, applied in this manner, might occasion death ; each, how-
ever, has its peculiar train of symptoms.— ^rcAtve* GMraks de MSdecme,
October 1864.

ON THE USE OF IODINE IN THE TREATMENT OF ENLARGED GLANDS.

At a Meeting of the Society of Medicine of Paris, held on the 20th of Sep-
tember, M. Kicord, in the name of a commission composed of himself and
Messrs Devergie and Gosselin, read a report on a paper by Dr Prieur, entitled
'* On Iodine in the Metalloid State in the Treatment of Scrofulous, Cervical, and
Submaxillary Glandular Swellings, and of Inguinal Syphilitic Swellings.**
'* This work," said M. Ricord, " contains facts which deserve to attract atten-
tion, for they assign to metallic iodine a well-marked absorbent action in the
cases indicated, as well as the property of producing epidermic eschars, which,
in general, leave no cicatrix, or any kind of mark. The process consists in
applying over the enlarged glands layers of iodine enclosed in cotton wadding,
the iodine being rapidly vaporized under the influence of the heat. The
quantity of iodine employed is usually a centigramme (about ^th grain) to the
square centimetre (about {th inch), spread out as regularly as possible at the
half, the third, or the quarter of the thickness of a sheet of wadding, which
ought to be covered with a leaf of gelatine, of which the circumference should
adhere to the integument, so as to concentrate on the desired point the vapours
of the iodine. This application is left on from twenty-four to forty-eight hours.
The result is a vesicle filled with dark, purulent or sanguinolent serum. M.
Prieur states that he has treated by this method during the last ten years a
hundred and twenty patients, and that he has caused the disappearance of
about three hundred glands, aU much enlarged.''

464 PERISCOPE. [not.

M. Ricord expressed his regret that in speaking of inguinal syphilitic swell*
ings, the author of the paper had not specified whether he referred to swellingf
symptomatic of the infectine chancre, or only to buboes sympathetic of the
soft chancre, or of virulent ouboes consecutive to this form of chancre, wad
containing within them a ganglionic chancre. But the region of the groin is^
not less than that of the heck, a favourite seat of scrofmous swellings, and
frequently a chancre or a gonorrhoea is only the cause of the development of
these enlargements. These swelling have the same appearance and the same
termination as those which occur m persons evidently scrofulous, and they
yield to the treatment with iodine. Very often in these cases we find in the
patients cicatrices, the results of former suppurations of the same nature. M.
Kicord had tried M. Prieur*s treatment in eight cases of well-marked scrofuloas
swellings, and the results obtained confirm that gentleman^s statements. The
duration of the treatment was from six weeks to three months, — a very short
period for this kind of affection. M. Ricord did not agree with M. Prieur as
to the painlessness of this method ; in fact it was very painful, the pain some-
times continuing for six or eight hours. As to the action of the iodine con-
secutive to its absorption, M. Ricord was led, if not to deny it absolutely, at
least to reduce it to very little. In no patient were any symptoms of iodism
manifested. On the whole, M. Ricord was of opinion that M. Frieur*s method
was a real addition to our therapeutic means.— Jounuii cfe Midedne et di
Chirurgie praiiquea, October 1864.

ON THE COMBINATION OF BUBCARBONATE OF BISMUTH WITH FEPSINE.
BY DR AUQ^.

When Dr Corvisart published the results of his valuable inquiries on pepsine,
it was supposed that we should be able to combat every form of dyispepsia
with this new agent. Nevertheless, disappointments occurred, and it is now
known that starchy substances, the digestion of which in many cases is painful,
laborious, and even impossible, resist the action of pepsine. An inquiry was
then instituted, whether it would not be useful to employ against this morbid
condition a principle which should be for the starchy elements what pepsine
IB to the albuminoid, and an endeavour was made to associate two chemical
elements, which should have the effect of bringing the patients to a physio-
logical state. This attempt has been crowned with success, and a distinguished
pharmaceutist of Paris, M. Rover, has discovered an excellent preparation,
composed of pepsine and subcaroonate of bismuth, which answers perfectly in
the case of a large number of dyspeptics.

In therapeutics the mistake has hitherto been committed of employing
only the subnitrate of bismuth ; but this salt is very slightly soluble in the
gastric juice, and hence it is inefficacious in the great majority of cases in
which it is indicated, and often occasions a feeling of weight in the stomach.
The subnitrate of bismuth colours tlie stools black, which proves that the
drug has passed through the intestinal canal without being absorbed, and
indeed it can be detected in large quantities in the evacuations. Subcarbonate
of bismuth, on the contrary, is soluble in the gastric juice ; it produces no feeling
of weight in the stomach, it rarely constipates, it acts very quickly, it colours
the stools much less than the subnitrate, and does not fatigue the stomach
even after its prolonged employment. The tonic-digesiive powder of Boyer has
the immense advantage, thanks to the happy association of pepsine and sub-
carbonate of bismuth, of neutralizing the excess of acids which may be present
in the stomach, of allaying vomiting, of checking diarrhoea, of relieving cramps,
and of getting rid of the eructations and other disagreeable svmptoms with
which dyspepsia is accompanied. Under the continued use oi the medicine
the tongue resumes its normal colour, the appetite improves, the gastral^c
physiognomy loses its character, and the unhealthy coloration gradually dis-
appears. In the case of children this preparation is of great use in allaying
vomiting, whether dependent on dentition, or as the result of frequent in-
digestions. The diarrhoea, which is often so violent at the period of weanin|;,
is promptly cured by the use of this medicine. The tonic-cuigestiTe powder la

1864.] MATERIA MEDICA AND THERAPEUTICS. 466

taken either in a little sugar and water or a spoonful of syrup, and, according to
1117 experience, its use ought to be continued for ten days after the complete
cessation of all gastric symptoms. — Gazette dee BSpitaux^ 16th October 1864.

ON THE EMPLOYMENT OP BENZINE IN TRICHlNIAglS. BY PROPE880B M08LER. V

In his late work on intestinal worms (Hdminthologtsche Studien und Beobach-
tungerif Berlin, 1864), Professor Moslcr directed attention to the poisonous
influence which benzine exerts upon trichinae in the intestinal canal, and he
further narrated an experiment wnich seemed to show that the trichinae in the
muscles did not perhaps altogether escape from the action of this substance.
A pig which haa been infected with tnchinsB was treated during four weeks
witn increasing doses of benzine. It then died. The trichinad with which its
muscles were crowded had a peculiar appearance, and showed no move-
ments even when the temperature of the flap in which they were placed was
laid. A rabbit fed by Dr Hosier with the flesh of the animal died in eight
days, and only presented intestinal trichinse in very small number. X)r
Leuckart sent a certain quantity of the same flesh to three of his friends, who
administered it to a series of rabbits. The experiment failed completely in all
these animala except one, in which, after great trouble, a single trichinae was
found. It seemed from these results that the benzine had killed the immense
majority of the trichinae in the muscles of the pig. But it was believed that
the pie had been poisoned by the benzine, and hence it was not to be expected
that this substance could be used successfully to combat trichiniasis in man.
Later experiments have, however, proved to Dr Mosler, that larger doses than
he had given in this case can be supported with impunity ; the death of the

Sig had been caused by a pneumonia, which had been occasioned by the acci'
ental penetration of b«nzine into the air-passages, the result of a faulty mode
of administration. It was thought a very interesting question to determine if
benzine in lar^e doses could be borne oy the human economy in the febrile
condition which exists at the commencement of trichiniasis. Dr Mosler had an
opportunity of studying the question on a large scale during the alarming
epidemic of trichiniasis which desolated Quedlinburg at the beginning of the
present year. He went there on the 20th of March, and the treatment by
benzine was immediately put in force by himself and the resident physicians.
At first it was given in capsules of gelatine, but this method was soon given up
as expensive and troublesome. The following mixture was usually given:
benzine, two drachms; liquorice juice, mucilage of gumarabic, of each an
ounce; peppermint water, four ounces. A tablespoonful every one or two
hours, the bottle having first been well shaken. In this form' benzine was
easily taken and well borne. Many of the patients stated that under this treat-
ment they soon felt better, and that the pain in the limbs was relieved. The
largest doses were given by Dr Rndolfl', who gave as much as two drachms daily,
and this was continued for from four to six days. Dr Mosler had the oppor-
tunity of satisfying himself that in none of the patients, even in those in wliom
the fever was high, did any bad effects show themselves ; in particular, there was
no appearance of nervous or pulmonary affections, which are so often observed
when benzine is administered to rabbits. Dr Mosler undertook a fresh series
of comparative experiments upon pies, putting himself as far as possible in
the same position as a physician would be, both as to the doses of tlie remedy
and as to the time when the treatment was commenced ; that is to say, com-
mencing a week after the injection of the trichinae, a period at which trichi-
niasis can be diagnosed in man. The following are the conclusions to which
Dr Mosler has been led by his observations and experiments : — ^Tbat benzine,
which holds the first place among; all the anthelmintic remedies, may be ad-
ministered to man without bad efiect in larger doses than was formerly thought
possible : That, given in doses which the human organism can tolerate per-
fectly, it kills with certainty trichinae in the intestinal canal, and so prevents
the emigration of the embryos ; and that therefore benzine is the only rational
treatment to be employed in the trichina disease of man. — Berliner klinische
Wocheruckrift, No. 32, 1864.

466 MEDICAL NEWS* [KOT.

MEDICAL NEWS.

PROCEEDINGS OP THE EDINBURGH OBSTETRICAL SOaETY.

SESSION XXIil. — MEETING XII.

22d June 1864.— Dr Gkaham Weir in the Chair.

1. SPECIMEN OF MAUGNANT DISEASE OF THE OVARY.

The Secretoary^ in the absence of Dr WiUon^ exhibited a specimen of the
above. The history of the case was delayed till Dr Wilson should be present.

n. ON A CASE OF ABORTION.

Dr Moir showed a beautiful specimen of an early abortion, expelled with all
the membranes entire. The patient sunk shortly afterwards from renal disease
complicated with fever.

Dr KeUler remarked that death after an abortion was rare. He had lately
seen a case where it ensued from pyaemia with abscesses forming in different
parts of the body, one of which over the liver he opened.

Dr Weir had nad a similar case with hydatids, where pyaemia occurred with
secondary abscesses. He had endeavoured to promote their opening, but
failed. He considered the prognosis of such cases more favourable where the
abscesses opened, and a drain was established.

Dr Alex, Simpwn was able to confirm Dr Weir's opinion by a case in the
hospital, of a patient suffering from vesico- vaginal fistula and pelvic cellulitis,
where pyaemia occurred, all the symptoms of which were relieved as soon as a
seton was established in the abdominal wall.

UI. " WHAT CONSTITUTES LIVE BIRTH ?"

Dr KeUler read a paper on the above subject.

IV. CASE OP HAEMORRHAGE INTO AN OVARIAN CYST.

Dr KeiHeTf in the absence of Dr Thomson^ showed the preparation of the
above, and read the following notes of the case : — " I saw the poor woman for
the first time on the evening of the 2d of June ; she complained of acute pain
in the lower part of the belly, where I found a tumour about the size of a
child's head, tender in the last degree to the touch. She had no fever, no
excitement of the pulse, nor heat of the skin. She looked, however, pale and
anxious. She had known the tumour was there for about six months, but it
had given her no annoyance until a few hours before I was called, when she
became suddenly ill, and, to use her own phrase, had the sensation of some-
thing having given way within her. I saw her again next morning ; the pulse
was giving way, and she was evidently worse. I saw her again on the evening
of the 3d ; she was paler, and palpably sinking ; the pulse was imperceptible.
She died on the morning of the 4th. Thirty-six hours only had intervened from
the period of the acute seizure. As she was still menstruating, or had been
very lately, it was a little difficult for me to be sure whether it might not be a
case of tubal pregnancy; but the probabilities of it being an ovarian cyst
which had accidentally ruptured were so great, that I had no hesitation in
saying so to her friends the first night I saw her, and to state at the same time
my opinion that there was scarcely the shadow of hope of her recovery.

1804.] OBSTETRICAL SOCIETY OF EDINBURGH. 467

/' Post-mortem Appearances. — ^The tumonr was found in the me»ial line a little
above the pubes, and extending to the umbilicus. There was slight tympanitis
over the abdomen. The abdominal cavity contained a large quantity of bloody
serum, but there were no distinct clots. There was very uttfe peritonitis, and
that only in the immediate neighbourhood of the tumour. The tumour, which
had burst into the peritoneum, was attached to the uterus by a distinct pedicle,
which was quite healthy. The uterus was quite healthy, and containea only a
few small fibroid tumours, not much larger than a pea. There was a multilo-
cular cyst of the other ovary, which appeared to be quite simple. The liver
was ansBmic. The tumour, on being divided, was found to be made up of
several cysts ; some of them containing a dark bloody grumous fluid mixed
with blood ; others containing pus, and others a gelatiniform fluid. The whole
tumour presented a dark, blooay appearance.**

y. CASE OF PELVIC HJEMATOMA TERMINATING SUDDENLY FROM THE
OCCURRENCE OF PULMONARY EMBOU8M.

Professor Simpson exhibited the preparation of the above. The patient was
admitted into his ward in the Royal infirmary, but he had no opportunity of
seeing her during life ; for during the night following her admission she was
suddenly seized with great dyspnoea, and died before an examination could be
made. At the post-mortem examination the cause of death was found to be
a large plug in the pulmonary artery, and the tumour for which she was
admitted proved to be a large pelvic hamatoma. Dr Bamsay of Broughty
Ferry has supplied the following notes of the case : —

The woman was the mother of one child fifteen years of age. She had
menstruated regularly, and had only passed one perioa without. When I saw
her for the first time six weeks ago, she was suffering intense pain from the
tumour, relieved only by opiates. The tumour was not very perceptible from
without, but was easily detected by examination per vaginara, and the uterus
with its elongated neck could be felt right in front, so that the tumour was not
0^, but might be somehow attached to the uterus. I did not see her again for
five weeks, as she became easier. When I last saw her, the tumour was large
and very hard, like a uterus (ly^g rather to the right) at four and a half
months* pregnancy. On examination per vaginam, the passage was found filled
with the tumour projecting like the head of a child through the walls of the
uterus. I had very great difliculty in discovering the os ; at last, in the front
reflexion of the mucous membrane, I felt it as an aperture merely. Without
the previous examination, it would at this time have oeen extremely difficult to
say that the tumour was not uterine.

Professor Simpson^ in answer to a question, said we were warranted in opening
such tumours when the patient was suflfering roach inconvenience and com-
plaining of much pain, or when suppurative inflammation supervened. You
urequently found a very large quantity of clots.

Dr Weir remarked that ne often found a peculiarity in these tumours, where
fibrous bands ran across the sac, preventing you emptying them all at once.
You had often to break them up befcMre you were able thoroughly to empty
the sac.

YI. CASE OF ATELECTASIS PULMONUM. BY DR WEIR.

The patient, a boy 2^ years of age, was admitted in January last to the
Hospital for Sick Children, sufiering firom purpura. He was a marked illustra-
tion of very extreme rickets. The woman who had him out to nurse stated
that when she first got him a year ago he had the same shape of chest, but not
to the same extent. About that time he took measles, complicated with severe
bronchitis, and was very ill. Upon admission, he was small and imperfectly
developed, and could neither walk nor speak. Tlie chest was greatly deformed,
the ribs being bent in beyond the cartilages, so that there was a deep vertical

froove on each side of the chest. The breadth of the chest in front was only
i to 3 inches. On inspiration the sides of chest were drawn in, and the
VOL. X.--NO. T. 3 o

468 MEDICAL NEWS. [nOY-

groove increased in depth. The stemnin was pnshed forward and upward, so
that the clavicles were greatly arched. The spme was somewhat twisted.
There was also the ordinary enlargement of the ends of the long bones seen in
rickets. For some time he improved greatly under the hospital regimen.
For a few days, however, before death, he suffered from dyspnoea, and did not
take his food as usual. That morning he was not worse than usual when he
suddenly began to sink, and died in a few hours.

Po8t-martem ExaminaUon, — Some fluid was found in the abdomen. The
spleen was greatly enlarged and very hard, showing the usual d^eneration in
such cases (albuminoid infiltration). The liver and kidneys showed the same
degeneration. Heart normal ; lungs were deeply indented by the pressure of
the incurved ribs. At the anterior margin of the left lune were some portions
collapsed, others emphysematous. The greater part of tne upper lobe of the
right lung was in a state of collapse. Tbere was general congestion of the
lungs. Weight of organs : liver, f lb. ; spleen, 4^ oz. ; kidney« li oz.

Dr Weir exhibited a dried preparation of the sternum, which showed in a
remarkable manner the deformity of the chest. The sternum and cartilages
were arched throughout their whole extent, and at the union of the cartila^s
and bone there was quite a knob protruding inwards, many of the ribs being
quite bent upon themselves, and presenting the appearance as if they had
been fractured.

MEETING xm.
27ih July 1864.— Dr Keiller in the Chair.

I. CASE OF CEPHALOTRIPST.

Dr KeUUr related the particulars of a case where he had performed this
operation. The patient, a young girl, was in labour with her first child. When
first seen the membranes had ruptured, but the os was only partially dilated,
and the head seemed high up. There being no urgent symptom, she was left
for a few hours. Seen a^in in the evening, much in the same condition, paint
very slight. Next morning there was still no improvement. She had now
been twenty-four hours in labour, with pains all the time. In attemptiii^ now
to turn, the brim was found to be contracted so that there was some difficulty
in getting the hand through. The uterus, moreover, proved to be firmly con-
tracted, so the attempt was given up. The long forceps were now tried, bufc
without efiect. It was accordingly determined to use the cephalotribe. The
instrument used was that of Professor Simpson. The heaa lay in the first
position, but was jammed to the right side of the pelvis. The first blade was
mtroduced with ease, but with the second there was considerable difficulty on
account of the position of the head. The head had previously been perforated,
but this was also done with difficulty from it not being fixed in the brim.
A good hold was obtained, care having been taken to keep the head well fiexed
on the body, and the child extracted with less force than had been employed
with the forceps. The base and occipital region was fairly broken up. The
placenta came away very soon. The brim was found upon examination to
admit with difficulty Dr Keiller^s closed hand. The woman made a good re-
covery. One point of interest is, that the mother of the woman had also a
narrow pelvis. *

n. NOTES OF MIDWIFEBT PRACTICE IN HINDUSTAN.

Dr AUkm^ Professor of Midwifery in Madras College, related some interest-
ing particulars eonoeming Hindu midwifery.

m. CASE OF TWINS WHERE ONE FOSTUS HAD DIED SOME WEEKS BEFORE BIRTH.

The Secretary, in the absence of Dr Malookn^ showed a preparation of the
above, with the placenta. The fntofl was small, withered, and considerably
flattened.

1864.] OBSTETRICAL 80CIETT OF EDINBURGH. 468

rv. CA8B OF VAOmiB UTBRINU8.

Dr Fraaer read the following notes of the case : — By the term yagitUB
Qterinus I suppose is meant not the crying of the child after rupture of the
membranes when the external air can reach it, virtually a phase of extra-
uterine life, but the crying of the foetus in utero while the ovum is entire.

Two instances of this rarely obseryed phenomenon occurred in a patient of
mine, from whose statements, which haye been corroborated by her husband,
I haye made the notes of the occurrences, which I beg to lay before the Society.

One Sunday evening, Mr Q. and his wife, who was within ten or twelve days
of her first confinement, were at home by themselves. Mrs G. was resting on
a bed, suffering patiently much annoyance from very vigorous movements on
the part of the child, ana listening to ner husband, who was reading the Bible,
while he knelt on a sofa beside her. All at once they heard with amazement
a cry like that of a newborn babe. Though somewhat muffled, the sound was
yet so distinct and so evidently arose from the place beside him, that Mr G.
could not help exclaiming, — Mercy on us. Is the child in the world ?

Mrs G. was quite sure (she declares) that It was the child within her that
cried, and was so much overcome that, for some time, she could not summon'
words to assure her husband that burth had not taken place.

Up to the time of birth the child, which proved to be a boy, was not noticed
to cry again, though it exhibited other signs of a strone vitality.

In the next two subsequent pregnancies, the fruit of which was a girl and a
boy, both very healthy children, no vagitus uterinus was heard.

in the fourth pregnancy, however, the phenomenon was again noticed.
The circumstances were much the same on this as on the former occasion.
It was on a Sunday evening, eight or ten days before Mrs G.*s confinement.
She and her husband were m a room alone ; the children were in bed in another
apartment ; and the house was quiet. The patient was reclining on a sofa,
annoyed as on the first occasion by the strong movements of her unborn child,
and her husband was sitting nine or ten feet off, engaged in reading, when she
heard a sound like the bleating cr^ of a newborn baby, which seemed to come
from her womb, and which sne is positive did come from that part. 'Her
husband also heard It where he was sitting, and so distinctly, that, dropping his
book, he started to his feet and thought for a moment that the cmld was
really bom.

In this instance as in the former the cry did not last long, no longer than
might be supposed to arise from a single expiration, and was not repeated
durii^ the remaining time of pregnancy. The child was a female. Since then
Mrs G. has bom two children, but has not heard it with either.

Eemarks and Queries. — Botn instances occurred when mother was at rest.

Is quietness on her part necessary to the production of the sound ?

Is it not likely that mstances pass unnoticed during sleep ?

Whence the air which enables the foetus to cry ?

Is it excreted by child itself or by the membranes ?

If it be admitted that a child can cry in utero, it must also be admitted that
the lungs can be more or less expanded before birth, though the child be after-
wards bora dead; hence another reason for caution in judging from the hydro-
static test.

STATISTICAL ACC50UNT OP CASES ADMITTED INTO THE CLINIQUE

OF M. VELPEAU AT LA CHARITE, DURING THE YEAR 1863-^4.,

Bt MM. BuRLAUD, De Montpumat, akd Roques, House Surgeons.

There were admitted into the clinical wards of La Charity during the scholastio
year 1863-64, 1014 patients; of these, 98 merely passed through the wards,
either because they were cured within twenty-four hours, or because their
residence in the hospital was unnecessary ; 916 patients were treated, of whom
641 were men, and z75 women.

470 MEDICAL NEWS. [NOV.

The resaltfi of tFeatment and of operations were the following : 743 were
cured ; 108 were relieved ; 35 were dismissed unrelieved ; 30 died.

The patients whose diseases were properly speaking medical were the fol-
lowing; 4 affected with tonsilitis, of whom 1 was treated by emetics, 2 by
alum gargles, 1 by excision ; in one of these an abscess formed. There was
1 case of diphtheria, and 1 of sloughing sore throat. All these inflammatory
affections recovered. A case of contraction of the larynx, consecutive to an
old oedema of the glottis for which tracheotomy had been performed, was not
submitted to any treatment. Cases of condylomata of the tonsils, a case of
tubercular syphilitic affection of the skin, and cases of syphilitic pains were
treated with mercury. A case of external otitis improved under the use of
emollient injections. Two patients remained in the wards for a few days, on ^

account of rheumatic pains.

The traumatic lesions were distributed in the following manner : contusions
of the head, 18 ; of the upper limbs, 19 ; of the lower limbs, 38 ; of the loins, 3 ;
of the thorax, 15. There were the following contused wounds : of the head, 26 ;
of the upper limbs, 24 ; of the lower limbs, 24 ; of the thorax, 7.

These lesions gave rise to the following complications: erysipelas, 6;
angioleucitis, 3 ; abscess, 4 ; purulent and putrid infection, 5 ; one contusion of
the abdominal walls producea death by rupture of the intestine and subacute
peritonitis.

The following was the distribution of 100 fractures : base of the skull, 5 ;
clavicle, 10 ; scapula, 1 ; humerus, 4 ; fore-arm, 2 ; lower end of radius, 16 ; ulna,
1 ; ribs, 12 ; costal cartilages and sternum, 1 ; shaft of femur, 6 ; neck of femur,
3 ; lower extremity of fibiui, 13 ; patella, 2 ; leg, 14 ; tibia, 5 ; bones of hand and
foot, 5. Five fractures were complicated with wounds and suppuration, and
one was followed by arthritis and purulent infection. There was 1 case of
erysipelas ; 1 of diffuse suppuration ; 1 of encephalitis after fracture of the
cranium, which nevertheless recovered. J

^ Fourteen burns came under observation ; 6 of the upper, 7 of the lower
limbs ; 1 of the thorax. Only one fatal case occurred in a woman with an ex-
tensive bum of the chest. Death in this case seemed due to exhaustion or
excessive pain ; the patient died on the day of the accident.

The cases of inflammation were the following : 1 of erythema : 6 of primary
erysipeUs of the face ; 27 difiuse abscesses, 18 of the upper, 16 of the lower
limbs, 3 of the thorax. There were 13 cases of circumscribed suppurations ; 7
of the upper, 2 of the lower limbs ; 4 in other situations. The complications
of the phlegmons were : purulent infection, 2 ; angioleucitis, 2 ; glandular en>
largement, 1.

There were 59 phlegmonous abscesses ; 4 of the axilla ; 2 of the submaxillary
region ; 6 of the upper limbs ; 19 of the lower limbs ; 28 t)f the abdominiu
wall, the neck, and various other regions, and which were followed by erysipelas
and more or less gangrene of the integuments. ^

The following was the distribution of cases of anthrax, 8 in men, 1 in a
woman ; 4 were on the nape of the neck. All the cases of anthrax were treated
by incisions and poultice. There was no death, or any complication.

There were two cases of nails growing into the flesh.

The cases of whitlow were the following : 5 of the thumb ; 9 of the index,
3 of the middle, 2 of the ring, and 3 of the little finger ; 5 of the great toe. In
6 of these cases the bone was involved ; as complications, there was an arthritis
of the wrist, an angioleucitis, and an abscess.

The diseases of the bones and joints were thus distributed ; 1 caries of the
bones of the thumb ; 1 caries of the os calcis ; 3 sub-ungual exostoses.

Ei^ht dislocations were observed ; 3 sub-pectoral, and 3 sub-scapular dis-
locations of the humerus ; 2 dislocations of tne elbow backwards. All these
dislocations were recent, and were reduced under chloroform. There was also #

an incomplete dislocation of a metatarsal bone, which was reduced spontane-
ouslv.

There were 4 cases of white swelling; they occurred at the kneOi the
shoulder, the hip, and the tibio-tarsal joint.

1864.] CASES IN M. YELPEAU'S CLINIQUE. 471

There were 17 sprains ; 3 of the wrist, 14 of the instep ; 1 was followed hj
erysipelas and purulent infection.

Eleven cases of hydro-arthosis were treated ; 10 were cured ; 2 were treated
b^ puncturing and the injection of iodine, of these 1 was radically cured ; cure
with persistent thickening of the synovial membrane was the result of the
second operation.

There were 5 cases of acute arthritis ; 2 of gonorrhoeal arthritis ; 3 of chronic
arthritis of the knee were treated by rest and blisters. The acute cases were
cured, the chronic remained stationary.

The inflammations of the lymphatic system were thus distributed : glandu-
lar enlargement of the parotid region, ^G; of the sub-maxillary, 9; of the
axillary, 7 ; of the inguinal (venereal buboes), 2. Of these 24 cases, 22 were
cured, 2 were relieved. Ei^ht patients were admitted with angioleucitis, 3 of
the upper, 5 of the lower limbs. Among^ the last was a case of diffuse sup-
puration and erysipelas of the leg, with ^grene of the foot and putrid infec-
tion. In addition, 11 cases of angioleucitis occurred in persons affected with
traumatic and inflammatory lesions.

Gases of affection of bursse were 12 in number ; 1 of painful crepitation of the
tendons of the wrist ; 1 of chronic affection of the bursa of the patella ; 1 of the
popliteal space ; 2 acute abscesses of the bursa of the patella ; 2 serous abscesses
of the same bursa ; 2 abscesses of the bursa over the olecranon ; 3 abscesses in
the bursa of the feet. Of these, 10 were cured ; the abscesses in the bursso of
the ^eat toe were relieved.

Eight cases of hernia came under observation ; 5 cases of inguinal hernia, of
which 2 were strangulated and 1 influned. The inflamed hernia was reduced,
the other 2 were operated on. A congenital inguinal hernia, in a man 25
years of age, required operation. Two hemis of the linea alba were seen ;
one was reduced ; the other was strangulated, had been reduced with the sac,
and required operation. An inguinal hernia, an umbilical hernia, and a
hernia of the linea alba were treated by the application of a bandage. The
four patients operated on for hernia died of peritonitis as will be mentioned
further on. Tne hemis of the linea alba, and the umbilical hernia, were in
women.

The diseases of the male genital organs were the following : — ^Vesical calculi,
4, treated by lithotrity ; 3 were cured, 2 presented febrile symptoms, 1 died.
The patient who recovered without any unpleasant symptom had been sub-
mitted to five sittines of lithotrity. Three cases of chronic cystitis, and 1
of hsematuria were observed. There were 7 cases of retention of urine caused
by paralysis of the bladder ; 2 by stricture of the urethra ; 2 by enlargement
of the prostate. In no case was puncturing of the bladder necessary ; the
catheter left in the bUdder relieved the retention of urine caused by enlarge-
ment of the |)ro8tate. There were 20 hydroceles, all cured by puncturing
and the injection of iodine ; 1 serous cyst of the cord was curea ; 2 cases
of tubercle of the testicle were relieved ; 14 cases of orchitis were cured, 6
were treated by punctures of the scrotum and poultices. Two cases of
phimosis were seen, 1 complicated by adhesions of the prepuce to the glans ;
they were operated on by mcision and recovered after presenting an inflamma-
tion of the penis. An operation for phimosis was performed on a patient
affected with calculus, in order to facilitate the introduction of the lithotriptic
instruments. Two cases of gonorrhoea were treated ; 14 cases of stricture of
the urethra were submitted to progressive dilatation by allowing the bougie to
remain ; 7 were cured, 7 relieved ; among the latter, 2 had urinary scrotal fistulse,
which were only treated by cauterizations. Five sarcoceles were observed in
patients having a mean age of 35, the youngest was 30, the oldest 39 years.
Three were operated on, and the tumours were found to be composed of fibro-
plastic and enceplialoid tissue. Two patients recovered ; 1 was attacked with
phlegmonous inflammation of the abdominal walls, and died of purulent infec-
tion. Two patients were not operated on.

Of the tumours observed : lo were cancroid ; 1 of the lobe of the ear ; 1 at

472 MEDICAL KBWS. [NOT.

the anffld of the eye ; 1 of the left cheek ; 5 of the lower lip ; 1 of the angle
of the lips ; 1 of the nose ; 1 of the alveolar border ; 4 of the tongue ; 1 of the
left hand ; 1 of the foot. Two enchondromata were obseryed ; 1 of the thorax,
which was followed by oanceroos metastaeU of the lungs, and 1 of the parotid.
There were 3 fibro-plastic tumoors of the thigh ; 1 keloid of the nape of the
neck ; 1 cancerous tumour of the parotid ; 1 naso-pharyngeal polypus com-
plicated by cancerous tumours in the neighbourhood ; 1 steatomatous tumour
of the scalp ; 1 lipoma of the subscapular fossa ; 1 tumour of the ischiatic
region, consisting of a sanguineous cyst, the walls of which were transformed
into a fibro-plastic tissue ; 1 cancer of the superior maxilla ; 1 tumour of the
axilla, which seemed a relapse of a hypertrophy of the sudoriparous glands.
The greater part of these tumours were operated on (as will be seen further on) :
6 died.

One erectile tumour of the lip was treated by the ligature and cured. There
was a cyst of the thyroid body in a man. One hare-fip of the upper lip alone
was operated on.

Among the diseases of the eye were : 26 cases of keratitis and kerato-oon-
junctivitis ; 14 of simple and scrofulous conjunctivitis ; 1 of purulent, 1 of
granular conjunctivitis ; 1 of simple, 1 of syphilitic iritis ; 15 cataracts were
seen, 11 were operated on by depression, in 3, only one eye being affected ; 6
patients recovered sight or were improved, 1 patient died of erysipelas ; in 3
there was iritis which prevented cure. One case of anthrax of the upper lip,
with severe general symptoms, was seen in a person who had been operated on
for cataract.

There was 1 case of amaurosis ; 1 case of convergent squint was operated on
by internal section ; 1 fistula lachrymalis was cured by excision of the lachry-
mal points ; 1 staphyloma of the cornea was cured by cauterization ; 1 non*
suppurating phlegmon of the eye was seen, it was treated with leeches and
recovered.

One ectropion was not treated on account of erysipelas ha^ng come on,
which provea fatal ; one case of agglutination, one of eoch^nosis of the eye-
lids, complete the list of diseases ofthe eyelids observed this year.

Diseases of the breast were 35 in number ; 22 abscesses, 2 glandular enlarge-
ments, 1 tubercular tumour, 1 cyst, and 1 contusion of the breaat. Mammary
tumours were thus distributed : scirrhus, 7 ; encephaloid, 5 ; adenoid, 3 ; h3rper-
trophy, 1. Eleven tumours were operated on ; twice there was erysipelas.
In some cases the incisions healed by the first intention. Of the three
adenoid tumours, one presented the singular phenomena of almost complete
disappearance under the use of pressure and iodide of potassium.

The list of diseases of the anus and rectum includes 16 fistulie in ano, of
which 13 were treated by incision and excision, 1 by simple excision, and 1 by
the application of the galvano-caustic. One patient was not operated on.
Fourteen times the operation was successful. There were 4 cases of abscess
at the margin of (he anus, of which 1 was symptomatic of disease of the bone.
Five hemorrhoidal tumours were treated by cauterization ; 3 patients were
relieved, 2 cured. One vegetation at the anus was treated by the li^ture,
and was cured. Of 4 fissures of the anus which were treated successfully, 2
were treated by forced dilatation, and recovered. One case of stricture of the
rectum in a woman was relieved by dilatation bf means of a sponge-tent.
Two cases of the anus, probably of syphilitic origin, were relieved by the
use of dressing covered with mercurial ointment, and of an antisyphilitio
treatment.

Eighteen women were delivered at the full time, and the only accident was
a metritis ; there was one abortion without any bad symptoms. There was 1
case of flooding symptomatic of a retro-uterine hssmatocele, and 5 sympto-
matic of uterine polypi; the 6 patients recovered. Four multilocular
ovarian cysts, 2 complicated with ascites, and 11 unilocular cysts, were admitted
into the wards; in the two cases of ascites the patients were tapped, and
relievedi but not cored. Of the 11 cases of unilocular cysts, 4 had already

1864,] CASES IN M. YBLPEAU's CLINIQUE. 473

been tapped several times ; 10 were punctured. Three of the patients died of
peritonitiH ; 1 of them presented the singular pbeuonienon of extensive gan-
grene of the left leg. One patient who was at the commencement of pregnancj
was not treated. A unilocular cyst of the ovar^ which had been siready
tapped was treated by leaving in a canula ; the patient died.

Six fibrous tumours of the uterus were observed in women whose age ranged
between 28 and 45 years ; 6 of the patients were relieved by rest and blister-
ing ; the sixth was attacked with articular rheumatism complicated witli peri**
tonitis, and died. Of 16 cases of metritis, one was a simple uterine congestion ;
2 cases of gnmular metritis of the neck of the uterus were treated by cauteri-
zation with nitrate of silver. Twice the metritis was complicated with cir-
cumscribed peritonitis ; once the metritis caused abortion. There was 1 case
of hypertrophy of the neck of the uterus ; 2 cases of uterine carcinoma ; 1
polypus of the uterus, which was removed ; 3 cases of cancer of the neck
of the uterus. There were 6 abscesses of the labia migora^ 1 vaginitis, and 1
syphilitic vegetation on the labia.

Five patients affected with varix presented four times examples of phlebitis.
Once there was rupture of a varix. (These numbers give no idea of the actual
frequency of varix, for patients seldom come into the hospital on account of
simple varix.) Three somewhat inflamed varicose ulcers were treated by rest,
poultice, and pressure.

The patients admitted with erysipelas were 6 in number; 4 presented a
spontaneous erysipelas of the face, which, treated by compresses of elder-water,
recovered. One patient admittea with erysipelas of the leg, complicated with
diffuse suppuration, died from purulent infection. One erysipelas of the left
foot recovered. Erysipelas twenty times complicated wounds and operationS|
without counting the cases where it was joined with phlegmons and ang^oleu-
citis which accompanied traumatic lesions ; and without counting the cases
where it showed itself on wounds at the last period of purulent infection.
Seven times erysipelas appeared around contused wounds of the head. It
arose around a fistula consecutive to a necrosis of the parietal bone. Once
erysipelas supervened on a contusion of the nose. Erysipelas occurred after
the following operations : — ^After removal of a sebaceous cyst of the eyebrow ;
of a cancerous tumour of the parotid ; of a fibro-plastic tumour ; of a cancroid
of the lower lip ; of a glandular tumour ; of a steatoma of the scalp ; of an
enchondroma of the parotid. It also appeared after an operation for ectropion,
and after one for cataract ; three times it appeared after operations upon the
breast. Two patients died ; the one in whom it supervened after the operation
for ectropion, and the one in whom it occurred after the operation for cataract*

After wounds and operations, counting all the deaths, there were 7 cases of
purulent, 1 of putrid infection. Three patients died from the cancerous
cachexy ; 7 died of peritonitis, the 4 who had been operated on for hernia, the
patient who had had a contusion of the abdomen and an intestinal perforation,
one patient affected with a fibrous polypus of the uterus. Two patients
affected with erysipelas of the face ana scalp only presented congestion of the
meninges.

In five cases the autopsy could not be made. Finally, one patient died of
pleuro-pneumonia, another of pulmonary tubercles, another of hypostatic
pneumonia in connexion with symptoms of purulent infection, which he had
manifested during his last moments. One patient died in consequence of the
results of a vast bum.

Opsratioms.— 102 patients were operated on, 84 were cured, 8 were relieved,
10 died.

Nineteen hydroceles of the tunica vaginalis were punctured and injected.
Only one accident was observed, an abscess of the scrotum. All the patients
were cured. A oyst of the cord and a h»matocele were punctured and
cured. Three times castration was performed ; only one patient died of inflam-
mation of the abdominal wall and purulent Infection ; it was the case of a
tumour of the si^e of a large cucamber, and consisted of a fibro-plastic growth

474 VEDICAL NEWS. [KOF.

in the tissae of the testicle, with a secondary hydrocele. A phnnosis operated
on by incision was cored. Six ganglionic tumours were operated on by inciaioii
of the skin and enucleation of the growth. Nine cancroias were remeyed with
the knife. All these operations were followed by cure. There was only one
accident after the removal of a ganglion in the parotid region, where incomplete
facial palsy followed.

Two sebaceous cysts were oj^rated on ; one was followed by erysipelas, the
other by cure. A synovial cyst was treated by puncturing ana the injection of
iodine, and was cured. A cyst of the body of the thyroid was punctured and
injected with iodine on two occasions ; the patient quitted the hospital with
the cyst, but it was diminished in sice and seemed in progress of cure.

A keloid of the nape of the neck was removed.

A sub-ungual exostosis of the little toe was removed ; an erectile tumour of
the lip was removed by ligature. Two lipomas, one hssmatic tumour of the
buttock were removed. All these patients recovered without accident. A
haematic tumour of the thorax was removed ; the patient was attacked with
erysipelas and purulent infection. A necrosed metatarsal bone was removed ;
the patient was cured. One case of hare-lip was operated on.

Three amputations were performed ; an amputation of the thigh on account
of a fibro-plastic tumour of the thigh ; a primary amputation on account of a
crushing injury of the leg. These two patients died. There was an amputa-
tion of the fingers on account of an injury of three fingers of the left hand.
This operation consisted in regularizing the wound, the metacarpal bones had
been cut with a chisel in front of their articulation with the carpus.

Ten cases of scirrhus of the breast were operated on ; 4 encephaloids were
removed. The wounds were not brought together with pins ; the lips of the
wounds were kept in contact with strips of diachylon plaster. Erysipelaa
occurred twice.

Four adenoid tumours, an hypertophy of the mamma, a cyst of the breast
were removed. After the operation in the last case erysipelas occurred.

Four stran^lated hemis were operated on ; the patients died. The stran-
gulation in all the cases had existed for several days.

Two fibrous polypi of the uterus were removed, and in both cases a cure
followed.

Ten fistulfld in ano were operated on ; one patient died.

Thirteen cataracts were operated on with the results already stated. Two
of the patients died, one from erysipelas of the face and scalp, the other from a
malignant anthrax of the upper limb ; in both cases the death was unconnected
with the operation. — Oazette dea HSpUaux, 20th and 22d September 1864.

ON THE PAINLESS EXTINCTION OF LIFE IN ANIMALS

DESIGNED FOR HUMAN FOOD.

By Hbnry MacCokmac, M.D.

No one, I should hope, will be inclined to contest that the extinction of life
in animals designed for human food should be as painless as possible. The
poor dependant brute is placed entirely at our disposal. We are called upon
Dv every motive, human and divine, to inflict upon him no seedless or avoid-
able suffering. Very many have interested themselves m the welfare of the
brute, principally, however, in regard of his treatment during life. Few have
the immediate opportunity, and fewer care to dive into the painful mysteries of
the slaughter-house. Not many, therefore, have exerted themselves, directly,
to lessen the sufferings of the brute in death. The subject is repulsive. It is
withdrawn from public gaze, and even the most humane persons have not
ventured to interfere in a matter which was hardly deemed remediable.

It was a great advance when, some time since in Paris and more recently in
London, slaughter-houses were removed from these respective capitals. This
step still remains to be followed up universally. I would call upon the Legis-

1864.] DR HACCORMAC OK ANIMAL FOOD. 475

latnre to interdict all slaugbter-houses in towns. It is not right or proper to
snffei; the gutters of our towns to run with gore, and animals to be put to death
in the vicinity of, nay, in the very shops where their flesh is sold.

Persons should be licensed to slay animals properly. It ought not to be
tolerated that every incompetent or half-competent fellow should flesh his gory
axe or prentice-hand without proper control and direction, at the cost oi the
suffering brutes whose frames we allow ourselves to appropriate for the better
sustentation of our own.

Some short time a^o the humanity of the public was shocked at the accounts
published of vivisections. But all the horrors, real or aHeeed, of vivisection
sink into nothingness contrasted with those of the slaughter-houses which
abound all over the land. Our mode of killing animals is still as barbarous as
it was in the darkest ages — is yet as savage as among any savages.

Attempts have been made bv what is called piUwng^ also by the insufflation
of air or water into the pleural cavities, so as to hinder the lungs from actinff|
to lessen the panes of the expiring brute. Pithing, when properly performed,
puts a speedy end to life. But a slight movement on the part of tne animal to
be sacrificed, or any want of skill on the part of the operator, lessens the
certainty of the trenchant blade reaching the spinal marrow through the
restricted triangular space at the nape of the neck by which it is alone acces-
sible. Blowing air into the jugular vein, or forcing air, water, or other fluid
into the cavitv outside the lung by a sharp- pointed tube, to which the bag of
fluid is attached, thrust in between the fifth and sixth ribs, though perfectly
efficient as methods of destruction, require considerable skill to perform, ana,
taking into account the character of the operation— the coercion to which the
impatient animal would have to be subjected, and the more or less protracted
preliminaries — ^would I conceive entail as great or even greater suffering than
the methods already in use.

Under these circumstances, I come forward with a proposal to render the
parting of life to the creatures which we require for our use, if not absolutely
painless, at least as nearly painless as it is possible to ima^e. The act of
uying, I affirm, may be rendered painless, or next to pamless, while the

freliminanes need entail no bodil^r suffering of any kind. At the same time,
do not expect that the community at la^ will at once abandon its time-
honoured customs at my suggestions. I, therefore, do not appeal to butchers
or their ordinary customers only, but to the humane and intelligent ; in par-
ticular, those who feel and know that God has not handed over his brute
creation to us except on the tacit but not less binding condition that we should
work them no avoidable ill.

I cannot tell I am sure why no one, so far as I am aware, before now seems
to have entertained the humane idea of putting animals designed for human
food to death by means of carbonic acid gas, except that the first origin and
growth of all useful ideas are slow. And yet the fact that carbonic acid gas
takes away animal life speedily and even painlessly has long been well known,
nay, was continually pressed as it were upon men*s attention by the terrible
casualties ensuing in consequence of persons falling into brewers' vats and
other receptacles charged, either through Nature's operation or man's interven-
tion with the gas in question.

When in my youth I was a student under Dupuytren, the great surgeon of
his day, at the Hdtel Dieu in Paris, the poor women, many of them who kept
stalls for the sale of fruit and other provisions in the public markets, were
brought in almost every day, burnt dreadfully, and yet unconsciously, while in
the trance or insensibility occasioned by the gases, the carbonic acid and car-
bonic oxide — ^namely, which issued from the little dkOujfeiretUi or braziers filled
with burning charcoal which the poor creatures were wont to place between
their feet in order to ensure warmtn during the severe winter chills. They fell
asleep, unconsciously as it were, narcotized by the gases I have named, and in
this state, unless haply rescued in time, often incurred, as I have said, their
clothes taking fire from the incandescent charcoal, the most frightful burns I
ever beheld. I questioned many of these poor victims on the subject, but one

VOL. X.— NO. v. 3 P

476 MEDICAL NEWS. [nOY.

and aU they sevenlly assured me, that never had thej experienced the slic^fatest
pain. Of coarse it will be understood that I speak of pain as inflicted doriiig
the period in which the injury was incurred.

The extinction of life in small animals, as dogs, has long been performed as
a sort of exhibition at the Grotta dd Cane, therefore so named, at hake Ag^nano,
nigh Naples. With this property it would seem Pliny was well acquainted,
since he has adverted to it in his Natural History. In modem times the cir-
cumstance has engaged the attention of various naturalists, and it has long been
ascertained that carbonic acid gas is the agent at work. But although the
period of nigh two thousand years, and perhaps yet more, has elapsed since
this property, as attaching to carbonic acid, first attracted notice, it has never
hitherto led to any practical inference or result In England the sacrifice of
human life from fallmg into brewers* vats takes place from time to time ; it is
detailed any time these past hundred years in the pages of the Gentleman's
Magazine^ say, but it occurred to no one during that long period to liberate
animals designed for food from the cruel inflictions to which they are so com-
monly subjected, by means of the agent which acts so painlessly on man. It
is not long, I confess, since the thought of its great applicability in the case of
the inferior animals occurred to me, and I earnestly suomit that the suggestion
is one which should not be made in vain.

On Wednesday, the 25th of March 1863, a boy at Sion Brewery, Southsea,
mounted on a forty barrel vat, and while looking through the man-hole, fell
among some wet hops, and speedily became a victim to the carbonic acid gas
which emanated from them. The engineer, finding what had taken place,
descended by a rope-ladder, and forthwith became senseless. Another maiu
although cautioned, also descended, and shared the fate of those who preceded
him. The vat was then broken open, and the lifeless bodies were removed.

On the 21 St of August of the same year, an inquest was held in Bromley, on
the person of a man who had descended by a ladder into a lar^e vat in order
to stir up the contents. No sooner had he gone down than he cried out —
although he had tested the vat by a candle previously — '* There is gas here;"
and the next instant fell back dead.

These occurrences are rekted in the journals of the day, and Ifte events
generation after generation have been detailed in other journals without leading
to anv desirable result. Now, the useful, the all-desirable result to which I
would refer, and whose adoption I would so strenuously urge, is the painless
extinction of life through the instrumentality of carbonic acid gas, as regards
animals that are designed as food for man.

I conceive, and would fain hope, that the simple publication of this proposal
will induce the proper action, and lead to the universal adoption of a procedure
so simple, painless, and effective — a procedure whose undesigned efficacy has
so often been tested at so much cost and so many sacrifices in the case of our
own species. I cannot see a colour of objection to it. I see everything, on
the contrary, in its favour. The frightful scenes of the slaughter-house, so
repugnant to all right feeling and sense of humanity, would come to an end,
and the animals designed for human subsistence would be bereft of life almost
without a suffering or a pang. They need never see or smell the slaughter-
house, for the lower animals, as I have more than once observed, entertain as
great an aversion for the sight or scent of blood as we do ourselves. They will
not, if they can avoid it, even pass the spot where it has been shed. Of course
I confine my remark to animals designea for the sustentation of man.

Some persons may, perhaps, entertain an objection to the flesh of animals
that have not been blea. But the abstraction of the blood, if desired, may as
readily be effected after death by the process which I advocate as when it is
taken away in the usual manner. But I would most strongly urge the dis-
continuance of the blood loss altogether. The blood is as wholesome and
digestible as any portion of Ihe flesh of animals, and there is no way in which
it can so readily be made use of as by leaving it in the tissues wherein it subsists
in life. The practice of bleeding animals entails a certain loss of from five to

1864.] DK MACCORMAC ON ANIMAL FOOD. 477

ten per cent, of otherwise available hnman food material. Some blood wonld,
indeed, be lost, unless otherwise made use of— I mean that which is lodged in
the great vessels and in the cavities of the heart. But this loss would prove
comparatively immaterial. In animals that are bled to death, first the large
vessels are emptied, then the small ; the meat fibre is blanched and impoverished,
becomes at once less succulent, juicy, and wholesome, and, in a word, less
nourishing and less digestible. It b quite a prejudice that proscribes the use,
as food, of blood. Flesh, in fact, is nothing out the blood solidified, nor is it
better fitted for the food of man than the blood itself. The recommendation
that animals should be well bled is merely a butcher's preiudice, and undeserv-
ing of the slightest attention. I appeal to any one who has partaken, as most
of us have done, of the flesh of animals that have been destroyed by the hunter
instead of being butchered and bled — such as venison, winged game, and even
homed cattle — whether the meat was not almost invariably more succulent,
tender, and digestible than that which had passed through the butcher's hands.
Game, however, it may be alleged, is more agjreeable as game, the flesh more
animalized, higher flavoured. No doubt it is so; nevertheless this greater
agreeability, this higher animalization, and this superior flavour, are all to a lars^e,
if not the entire extent, ascribable to the circumstance of the blood being for
the most part left in the tissues of the various kinds of meats instead of being
drained out of them. The butcher's prejudice about well bled meat is one
which they have imbibed from their superiors, and has no colour of support,
whether in reason or fact.

The new method which I propose for taking away life in the case of animals,
large or small, designed for the table, is simple in the extreme. A carbonic
acid gas generator of suitable dimensions, fed with a little chalk and sulphuric
a^id, must be had to hand. The sort of generator made use of by the soda-
water manufacturers would answer every purpose even on the largest scale.
The gas might be conducted by a pipe or duct into a stone or wooden reservoir
or chamber, for carbonic acid gas is so much heavier than air, where the
animal should be led. Even gas mixed with air would sufiice. No sooner
should the line of the gas rise above the level of the zone of respiration than,
as in the case of the UroUa del Cane, or the brewer's vat, the animal would at
once fall prostrate and insensible, and, without experiencing any appreciable
pain or suflerins, expire.

A sort of india-rubber hood or bag could otherwise be adjusted to the
creature's head, and when so adjusted the gas might be led on by a treadle
pressed by the operator's foot The instant the gas should surround the
respiratory outlets, the animal's consciousness would cease. In order to
prevent reanimation the creature would have to be left a few minutes untouched,
after which the butcher might resume his functions. In the name of universal
humanity, and for the sake of the beings who share this world along with us,
let this humane and painless procedure receive the attentive consideration to
which the great importance of the subject so well entitles it.
Belfast, lUh October 1864.

GREAT MORTALITY IN THE WASHINGTON HOSPITALS.

A CAREFUL inspection of the Hospitals at Washington made recently by a
medical member of the Sanitary Commission supplies some interestins; informa-
tion respecting the excessive mortality which these exhibit, in spite of the great
care ana attention paid to the wounded by^ the able and efficient men who now
preside over these institutions. He mentions four causes as especially contri-
buting to this great mortality. 1. The chief of these is excessive exhaustion
from fatigue of prolonged transport, and great suppuration. There seems to
be no doubt of the inadequate care and subsistence during transport, the suffer-
ings of some of the wounded men being terrible. The greatest sufferers were
the subjects of compound fracture of the thigh and severe wounds of the knee
and leg, the means for supporting these being utterly inefficient, great pain and

478 MEDICAL NEWS. [NOY.

inncli loss of life eonseqnently resulting. The seyere chsrmcter of so ixumr oC
the wounds bronght out folly the detects of the means of transport. Ld a
single hospital there were 107 compound fractures of the thigh, 42 seTere
injuries to the knee, and 225 amputated limbs; and the surgeon in charge of it
stated that he had seen 45 patients die in a single day — ^nearly all from ex-
haustion during transport. A^n, of 20,930 wounds, 749 were compound
fractures of the femur, 480 havrng been transported unamputated ; 242 wera
wounds of the knee, 138 unamputated ; and 948 fractures of the leg, 650 un-
amputated. There were also 566 gunshot wounds of the lungs and thorax.
It has been found that a transported fracture had to be moved, off and on, at
least fourteen times before resting in a general hospitaL The number of more-
ments is often much more, and yery few of the fractures which were brought
to Washington had any supporting appliances. 2. Pyaemia is the next caoae
of excessive mortally, abounding everywhere in the hospitals, of which it ia
the great scouree. tt can only be prevented by supplying the wounded with
ffood and varied diet and means of support during transport as well as in the
hospital wards. 3. Secondary hflemorrnage occurred with frightful frequency
and fatality, chiefly arising from the low vitality of the subjects. 4. Tetanu
was of daily occurrence during the period of low vitality from exhaustion, the
number of cases rapidly diminishing with the general improvement of the ap-
pearance of the wounds consequent on greater care and better diet. Exposure
to cold, chills, and damp, during transport, were fertile causes. The remedies
suggested by the Commissioner are — 1. Improvement of the diet of patients in
the field, during transport, and in hospitals. 2. Special means for improving
the local atmosphere of the wards, etc, in hospitals. 3. The establishment of
hospitals at higher altitudes and in healthier localities. 4. Supplying mora
adequate material aid to the surgeons in the field for the support and care of
fractures.

In contrast with the above statement we have a Report to the Emperor
from the French Minister of War upon the diminution which has taken place
in the mortality of the army, in continuation of a former communication which
we have already noticed. He states that, according to the official returns made
in 1846, the annual mortality among the troops of tne interior was 19 per 1000
men, this rising for the troops in AJgeria to as high as 64. In the years 1862
and 1863 there were but 10 deaths per 1000 in the interior, and about 12 in
Algeria, showing a diminution of 48 per cent, in the one, and 82 per cent, in
the other. As a consequence of this progress, the number of days of treat-
ment in the hospital, which in 1842 amounted to ^y ^^ ^^^ effective force, waa
lowered to ^ in 1852, and to ^V ^ 1862. The Minister, while' fully admitting
the great benefits which have resulted from the improved hygienic condition of
the army, especially with regard to the food and more healthy lodgement of the
troops, maintains that the principal cause of the favourable resets which he
announces is to be found in that entire modification which the French army
has of late been undergoing with respect to pay, re-enlistment, provisions for
pensions, and other advantages comprised under the term " doiaiion,^^ by which
men have been induced to assume cheerfully as a profession what had often
hitherto been an irksome and wretchedly paid occupation. Prior to the year
1855, the number of soldiers who had served more than seven years in the army
scarcely amounted to 9 per cent., while at the present time it reaches 33 per
cent. The coincidence of this changed proportion with the dimmntion of
mortality has led, he says, to a scientific investigation ; and the calculations of
medical statistics have established that the intimate relation of cause and effect
exists between these two facts. The following statement shows that there can
be no doubt upon this point: — ^The deaths which take place from disease
among soldiers who have been less than one year in the service amout to 11*45
per 1000 men ; from 1 to 3 jears' service, 14*38 ; from 3 to 5 jrears* service,
9*30 ; from 5 to 7 years* service, 7*40 ; from 7 to 14 years' service, 5*35 ; and
/^ abovcu^ears* service, 7*11. Thus, soldiers from 7 to 14 years of service, are

* those who exhibit the lowest mortality ; while those of more than 14 years'

1864.] TELLOW FEYER AT BERMUDA. 479

service, although the veterans are included among them, furnish better results
than the four categories of the first seven years. The " doUUion^^ law having,
as shown above, almost quadrupled the number of men who have served more
than seven years, we can at once see what a preponderating influence it must
have exercised in diminishing the mortality of the army. "This law," Marshal
Randon concludes his report b}[ observing, with justifiable pride, he having
been its origmal proposer, " which has given greater solidity to our military
power, and constituted a profession for the common soldier, furnishes, there*
fore, also the most £etvourable results as regards the sanitary condition of the
army, the undeniable proof of which I have now the pleasure of laying before
your Majesty." — Meduxil Times and Gazette.

A FRENCH ACCOUNT OP ENGLISH HOSPITAL PHYSICIANS.
M. Lecorcu^, in the Uftum Midioale, is publishing some articles upon the
London Hospitals, which, although fair enough in their scope and intention,
contain some statements that will not a little surprise our readers. Thus we
read that owing to the absence of the concoun for appointments to the
hospitals, our young medical officers, pursuing the bent of their inclination,
select limited portions of pathology for illustration, and thus give rise to that
infinity of specialties which the writer declares to be characteristic of this
country. " Even among the honorary consulting medical officers attached to
the large hospitals, scarcely any other than specialists are to be found : one
confining his attention to diseases of the heart, another to those of the liver, and
a third to gout. Few, indeed, are there in the hospitals of physicians in the
full acceptation of the term, treating all diseases indifferently." While admiring
the absolute power placed in the hands of the medical officer of prescribing
whatever he thinks proper in the way of food or drink without having to con-
sult any hospital superintendent, a power largely availed of, he tells us that we
are, on the other hand, subject to a species of surveillance unknown in France.
" The governors, in fact, constantly exercise this. There is in every hospital
what is called a house committee, which may visit the different wards at any
hour, and which inquires of the sisters and of the patients themselves as to the
manner in which the service is conducted, and on receiving complaints may
summon any of the surgeons or physicians before the weekly board, in order
to furnish the necessary explanation." The following passage indicates that
the posts of assistant-physicians and surgeons are more prohtable than they
usually get the credit of being : — ** These posts are much sought after, for they
are not merely honorary. Their emoluments are indeed sometimes more con-
siderable than those which accrue from the appointments of phvsician and
surgeon, which is easily understood when the enormous loss of time they
entail b considered. Moreover, those who hold them may deliver lectures in
the hospital medical school, which are always attended with more or less
profit."— Jfeefica/ Timee and OazeUe.

YELLOW FEVER AT BERMUDA.

The Montreal Herald of 24th September says :— " Out of eleven surgeons who
left this city on the I7th ultimo, we have had within thirty days the intelli-

fence that five have been assaUed by the fever, and that two, if not three,
ave died. As an example of the extreme suddenness and virulence of the
attacks, it \& mentioned that when the steamer St George was leaving the
island on her last trip, five men rowing to the vessel in one boat were attached
before they came alongside, and had to put back and go into hospital We
regret to say that we have receivedfa communication, stating that not only
were the steps which every well-informed person understands to be usual and
efficient for preventing or mitigating such calamities omitted, but also that the
ad^ce of scientific men, professionally tendered, was disregarded. The use of
open-air lodgings on high and dry ^oond, in an atmosphere fresh from con-

480 MEDICAL NEWS. [ifOV.

tsmination, is thoroughly understood by every ciyilian, and in frequent instances
bodies of troops attacked by pestilence of one kind or another have ceased to
lose a man from the moment that they were marched out of barracks to bivooac
on the turf and live out of doors, free from the death-dealing miasma of their
close and infected quarters. Yet it would appear from the information fur-
nished by our correspondent, that this well-known method of saving the lives
of soldiers did not suggest itself, and when suggested by others was rejected by
an officer sufficiently experienced and high in rank to have military command
of the station, and that the men were kept encamped on low ground, and the
millti^ry hospital not only not disused (as was advised by the medical officers), but
overcrowded, though its walls were impregnated with yellow-fever poison. For
the sake of an old officer, and of the service to which he belongs, we must express
a sincere hope that there were some circumstances not known to the gentleman
who has written to us. We learn that the fever was conveyed to Bermuda,
where it is a very unfrequent visiter, by the blockade runners. They have also
taken it to Nassau, where it is raging almost as badly as at Bermuda. The
crews of these vessels have also themselves suffered very severely ft'om the
disease, and some of them are left without officers or crew, except, perhaps, a
solitary negro cook or seaman.^*

THE LATE DR MILROY.
The name of this excellent young officer is now added to the melancholy list
of those brave men who have fallen at Bermuda in the dbcharge of their
humane but extremely perilous efforts to stay the progress of a terrible visita-
tion. His career has been comparatively brief, but marked by devotedness to
his country*8 service and distinguished eminence in the studies belonging to his
profession. He entered the army at the outbreak of the war with Russia, and
continued throughout all that memorable campaign. Bravely did he fulfil his
duties in the battles of Alma and Inkerman under the fire of the enemy, and in
the trenches before Sebastopol, for which services, in addition to the Crimean
and Turkish medals, he was decorated with the Order of the Medjidie. On the
termination of the war he continued with his regiment in Ireland, the Mediterra-
nean, and for the last three years in Canada, where he is well known, and has
left many devoted friends. To his fellow-officers he was greatly endeared by
his gentleness of manner, fine cultivated taste, hifi;h honour, and genial dispo-
sition, while the private soldiers of the 30th held him in affectionate veneration
for his unwearied efforts to advance their comfort and intellectual and moral
improvement. — TimeSj October 11.

THE LATE Dr CLARKE, 15th FOOT.

This jroung officer, who has perished among the seven military surgeons in
the epidemic at Bermuda, is the second of one &mily in the Army Medical
Department who has lost his life in the service. His brother, Assistant-
Surgeon William Clarke, of the 35th Regiment, when the other two officers
were killed in the affair at Arrah, in India, and the men were retreating, drew
his sword and rallied them until shot down himself mortally wounded. John
Clarke served throughout the war in the Crimea, including the Alma and
Inkerman, and through the whole of the Indian campaign under Sir Hugh Rose.
His services in the Crimea were considered great, and he was brought to notice
in despatches in the Indian mutiny. He was generally beloved and respected
by both officers and men, and had made many real friends among officers of
very high rank. He died September 4, 1864. — Medical Times and Gaxette,

FACULTY OP MEDICINE, PARIS.

The following changes have lately taken place in the Faculty of Medicine of
Paris : —
M. Rostan has resigned his Professorship of Clinical Medicine.

1864.] PARISIAN MEDICAL FACULTY. 48 L

M. Grisolle, Professor of Therapeutics and Materia Medica, is appointed
Professor of Clinical Medicine in room of M. Rostan.
r M. Trousseau, Professor of Clinical Medicine, returns to the chair of Thera-

i- peutics vacated by M. Grisolle.

M. Piorry is spoken of as likely to be appointed to the chair vacated by M.
Trousseau, in which case M. N. Guillot wQl take the place of M. Piorry.

M. TROUSSEAU AND THE CHAIR OP THERAPEUTICS. ^

A LETTER from M. Trousseau to the editor of the TJiwm Midicale, explaining
his reasons for resigning the chair of Clinical Medicine and returning to that
of Therapeutics, contains the following passage : —
'* The extreme facility of m^ address, and the clearness which are attributed

_ er^ I

to be acquainted with every new idea which is brought forward. ^This labour
has endangered my eyes ; I could no longer continue it without great risk of
losing my sight. Accordingly, last August, I wrote to the Dean of the Faculty
begging him agun to lay my resignation before the Minister, being determined
to appeal to the Council of State if I was refused. The Dean and several of
my collei^es expressed to me their lively regrets on seeing me retire from
teaching, in which I had as yet lost none of the favour of the pupils ; and as
the resignation of M. Rostan left his chair vacant, and as M. Grisolle, Pro-
fessor of Therapeutics, passed to that chair, the chair of Therapeutics was
thrown open, the Dean and the Minister expressed their wish that rather than
quit the Faculty, I should resume a subject which I had taught for fifteen
years with some success, and which required from me less labour. I consented
to this proposal. I continue physician to the Hotel Dieu, and I return to the
chair of Therapeutics ; and I nope that the few years of green old age during
which I may be able to continue my instructions may not be useless to the
youth of our schools. I should much have preferred repose, which I have
gained a perfect rightAo ; but I have felt compelled to yield to the wishes of
the Dean, who is my excellent friend, and to tnose of my colleagues."

Professor Trousseau now counts thirty-three years of service in the Faculty,
but he carries his sixty- three years with the ease of a man scarcely arrived at
fifty.

ROYAL COLLEGE OF SURGEONS OP ENGLAND.

The annual report of the receipts and expenditure of the College has just been
published', from which it appears that the former amounted to £13,806, 14s. 8d.,
Deing an increase of £1396, 13s. 8d. over the preceding year. The principal
source of revenue is derived from the preliminary, primary, and pass examina-
tions for the diploma of membership, which collectively produced £10,331, 5s.
The certificates of qualification in dental surgery realized £924; the fees
derived from the fellowship amounted to £377, 10s. ; rent, £702, 158. 6d. The
disbursements amounted to £12,844, 13s. 3d., or only £425, 168. 2d. more than
last year. The College department is put down as absorbing the largest
amount, viz., £7998, 178. Id., including fees to Council Courts of Examiners,
diploma stamps (£1 each), list of members, coal, salaries, wages, and law
expenses. The Museum department costs £2264, 138. 8d., for catalogues,
specimens, spirit, bottles, salaries, and wages ; and the Library department, for
tne purchase and binding of books, salaries, etc., ia put down at .the moderate
sum of £601, 18s. The annual list of Fellows, Members, etc., has just
appeared, from which it seems that the total number of Fellows, in whose hands
the elections into the Council are vested, amount to 1296, of which number
300 write " exam." after their names. The Licentiates in Midwifery number
926. There appears a great increase over last year in the number of dentists,
who are now 280 strong. The gentlemen who obtained the diploma of
membership are on the increase, as evidenced in the receipts above mentioned.

482

MEDICAL NEWS.

[NOV. 18C4.

ROYAL COLLEGE OP SURGEONS OF EDINBURGH.

At a meeting of the R07RI College of Surgeons of Edinburgh, held on the 19th
October, the following office-bearers were elected for the ensuing year : —

PresidenL Benjamin Bell. Treasurer, John Gairdner, M.D. Ltbrarum,
Archibald Inglis, M.D. Secretary, James Simson, M.D. Prendenfs Council —
Richard Uuie, M.D. ; James S. Combe, M.D. ; Andrew Wood, M.D. ; Robert
Omond, M.D. ; James Spence; James Dunsmure, M.D. Ex-ojfido, John
Gairdner, M.D. Examinera— John Grairdner M.D. ; James Simson, M.D. ;
Richard Huie, M.D.; William Dumbreck, M.D.; Archibald Inglis, M.D.;
Andrew Wood, M.D. ; Robert Omond, M.D. ; James Dansmure, M.D. ; Peter
David Handyside, M.D. ; James D. Gillespie, M.D. ; Henry D. LittTejohn,
M.D. ; Patrick H. Watson, M.D. Assessors to Examiners — James S. Combe,
M.D. ; James Syme ; William Brown ; James Spence. Conservaior of Museum^
and Registrar of Students^ Tickets, William R. Sanders, M.D.

THE LONDON MEDICAL SCHOOLS.

Thb entries of students at the London Hospitals is lower this year than in either
1862 or 1663. According to the list on the 17th October, 302 new students had
been registered, 325 second year men, and 353 third year. Guy*s still stands
at the head of the list, next comes St Bartholomew's, then Universitjr College,
then King's College. The highest number entered at one School is 77, the
lowest, at two Hospitals, 9.

PUBLICATIONS RECEIVED.

Agricultural Society of England, Journal of
the. Vol. 25 : part 2. London, 1864

Banks,— The Wolffian Bodies of the Foetas,
and their Remains in the Adalt, etc. By
William MitcheU Banks, M.D. Edin-
burgh, 1864.

Clark, — Practical Observations on the Hy-
ffiene of the Army in India. By Stewart
Clark, M.K.C.S.Eng. London, 1864.

Fox, — Skin Diseasei) ; their Description,
Patholo^, DiaffnoBis, and Treatment. By
Tilbnrj Fox, M.D., etc. London, 1664.

Qny's Hospital Reports. Third Series.
Vol. 10. London, 1864.

Parkes,— Manual of Practical Hygiene, nre-
pared expressly for Use in tixe Memcal
Service of the Army. By E. A. Parkes,
M.D., etc. London, 1864.

Poachet,— The Plurality of the Human
Race. By Oeorees Ponchet, M.D. Trans-
lated and Edited by Hugh J. C. Beavan,
F.R.Q.a Published by the Anthropolo-
gical Society, 1864.

PERIODICALS RECEIVED.

American Journal of the Medical Sciences, —
July. Philadelphia, 1864.

Berliner kllnische Wochenschrift, Kos. 18
to 21, 23 to 37.

Births, Deaths, and Marriages, Monthly Re-
turns of, for July, August, and Septem-
ber; and Quarterly Return, ending 30th
June 1864.

British and Foreign Medico-Chimrgical Re-
view,— October. London, 1864.

British Medical Journal,— July 30 to Got
22, 1864.

Bulletm G^n^rale de Th^rapeutique, — May
15 : July 15, SO ; Aug. 30, 1864.

Dublm Medical Pres8,~-July 27 to Oct. 26,
1864.

GazettedesHdpitaux,— No8.86tol23. Paris,
1864. ^

Gazette Hebdomadaire de M^decine, etc. —
July 29 to Oct. 21. Paris, 1864.

Gazette M^dicale d*Orient,— -June.

GazetteM4dicaledeParis,—No831to 42,1864.

Glasgow Medical Joutna],— October 1864.
Henke*8 Zeitschrift ftir die Staatarzneikunde,

— Nos. 2 and 3. Erlangen, 1864.
Journal de M^dectne et de Chirurgie, —

Aug., Sept., and October. Paris, 1864.
Journal of the Scottish Meteorological So-
ciety,—No. 4, October.
Journal fOr Kinderkrankheiten,— May and

June. Erlangen, 1864.
Journal of Brituh Ophthalmology,— No. 1,

October, 1864.
Journal of Mental Science,— October 1864.
Medical Times and Gazette,— July 30 to Oct

22, 1864
Ophthalmic Review,— No. 3. October, 1864.
Revue de 1 h^rapeutique Medico-Chirurgi-

cale,— Aug. 1, 15; Sept 1, 15; Oct, 1, 16;

Paris, 1864.
Vierteljahrschrift ftir die praktische Heil-

kunde,— Vol. 3. Prague. 1864.
Virchow's Archiv,— Vol. 30, 31. Berlin,

Vort jf^ivnt

ORIGINAL COMMUNICATIONS.

Article I. — 7%« Hdinburgh School ofSuraery: An Introductory
Lecture. By James Spence, F.B.C.S.E.^ Professor of Surgery
in the University of Edinburgh.

•
Sciences are slow in their progress towards perfection* A science
is not projected into^ existence as if by some volcanic force j
like the coral island, it is reared slowly and almost imnerceptibly
by the labours of many workers during long ages. Even those
great discoveries which throw new light upon and seem to revolu-
tionize a science, though they may at first sight appear rather as
intuitions of a higher intelligence, tiian as the mere results of study
and research, have after all their foundations in the past Some
master-mind has, as it were, been able to see existing things in
their true relations, and to clear away misconceptions ; in a word,
has been able to use aright and turn to account what had gradually
been preparing for his use.

If the fact of this slow development be true, even in regard to
what are termed the exact sciences, we can readily conceive how
slow and subject to vacillation, in consequence of changing opinions,
must be the progress of such sciences as Medicine and Surgery, in
which, in our attempts to .arrive at correct and fixed principles, we
have to deal with conditions ever varying, and witn phenomena
so recondite, and difficult to investigate as those of Life.

The history of such sciences, if properly written, may be useful,
not only by telling us of what has been already accomplished, but
by informing us of the means by which that has been accomplished,
and by showing us what causes have nromoted and what retarded
their successful cultivation ; and may tnus serve to guide us in our
efforts for their future advancement.

With this view, gentlemen, I would now seek, as introductory to
the course of lectures I begin to-day, to direct your attention to a
brief review of the history of the Edinburgh School of Surgery — ^a
School which has acquired a hijgh and distinctive character. The
histoiy presents some peculiarities ; in the causes of its slow pro-
mss at first, and its rapid rise in later years, we shall, I thmk,
find matter for instruction.

To take the history of one school, however, entirely apart, would
be like detaching a text fix>m its context ; impairing its true mean-

VOL. X.-i NO. VI. 3 Q

484 PROFESSOR 8PENCE ON THE [DEC

ing, or leading to a wrong interpretation. It is necessary, therefore,
that we take a somewhat wider view of the history of Surgery, in
order to look at our own school in relation to others.

As there may be some present who have listened to mj intro-
ductory lectures in times padt, let me allay their apprehensions, by
telling them that it is not my intention to go fiBir back into the general
history of Surgery. I shall leave our old friends of the Homeric
period, as well as the Romans and Arabians, to enjoy an unwonted
repose in the .present lecture. I sliall not even ask you to visit
that venerable ecclesiastical Council of Tours, which, Levite-like,
shook off Surgery from the Church from fear of the soil of blood,
and devolved the binding up of wounds upon Samaritan barbers ;
but hurryinff through the dark ages of sur^ry, let us emerge from
them with the sense of relief experienced in escaping from a dark
railway tunnel, and find ourselves in the Boyal Gaindens at Paris,
on a summer morning about the beginning of the eighteenth
century, where M. Dionis is about to open his demonstrations of
surgical operations, which, he informs us, is given by special order
of the king $ which are a sequel to the course of general principles
of surgery delivered during the winter, and which have become
so popular that ^^ we have been forced to issue sealed tickets to
prevent the entrance of merely curious persons." We learn from
this Introductory Address of M. Dionis, in what high estimation
Surgery was held in his day, as in quaint but forcible style he sets
forth its claims to be an art and science combined, neither of which
can possibly be separated without rendering the whole imperfect
Even in the word Chirurgeon, which would limit it to handicraft,
Dionis finds cause for magnifying his office : — " I call Chirurgery,"
says he, " first an Art, in order to confine myself within the bounds
of its etymology, which derives it from the two Greek words keitj
which signifies a hand, and ^gouy which imports operation ; so that
chirurgeon and manual operator are synonymous terms, common to
all who work with the hand* Though by this etymology the
chirurgeon seems to be confounded with all other artistes, 'tis
thence redounds his greatest glory; since it distinguishes him
from, and places him above all the rest. The ancients, who gave
names to all arts, called him a Painter who painted pictures,
Sculptor him who carved images, etc. But, by way of excellence,
have left that of Chirurgeon to him who, operating on human
bodies, has for his object tne noblest of beings* We might indeed
somewhat justly bestow on Chirurgery the name of a science
contrary to the opinion of some who will have it to be barely a
mechanic art ; 'tis true, it operates with the hand, but its perform^
ances being only such as reason dictates, it does not less deserve the
name of science than the mathematics, which trace out on ^per
those figures and demonstrations which the mind suggests. 3oth
these sciences equally require their proper instruments ; and as the
use of mathematical one^ belongs only to the mathematician, so

1864.] EDINBUBGH SCHOOL OF SUBOEST. 486

chimrgical are pecnliax to the ChiniTgeon ; for the separation of the
theory from the practice is equally impossible in both these sciences :
and as we should think him an ignorant mathematician who could
neither delineate his figures, nor frame his demonstrations, we
ought also to believe him incapable of helping those who require
his assistance who stands in need of any hand besides his own to
cure the diseases of which he boasts the discoveiy. We may, if
we please, not only rank Chimrgery among the sciences, but look
on it as one of the noblest, most certain, and most necessary of them
all. That which ennobles a science is the dignity of its object. Can
the Chirurgeon alledge anything more! glorious for himself, than
that God, after having made man, and ^ven a form and figure to
all parts of his body perfectly proper and suitable to the actions to
which they were destined, left him in the Chirurgeon's hands to
take care of his preservation, and to keep up the symmetry of all
the parts which ne received from the Creator. The certainty of
Surgery, too, is manifestly proved by the wonderful effects which
it produces. In couching of cataracts, it instantly restores sight
to the blind ; emptying the breast, by the empyema, it makes the
dumb to speak ; and by reducing luxations of the leg and foot,
makes the lame to walk." " To prove the absolute necessity of
Chimrgery, we need only consider that all other arts and sciences
are no ftirther necessary to man, than as they contribute to his com-
modious living ; but that Chimrgery is absolutely necessanr, even
in order to his very living; for at the moment of his birth, he
implores its help to make the ligature of the navel, without which
he would perish as soon as he was bom."

If enthusiasm for the science he tai:(^ht, and a desire to vindicate
its high claims, impel Dionis to soar into that dangerous region of
the sublime, where the boundary is so apt to be overpassed, it is
only in his Introduction, The Demonstrations which are thus
introduced are models of practical arrangement and conciseness.
They were not merely demonstrations of operations, but embodied
a full view of practical Surgery as it then existed. The separate
diseases and injuries requiring operative interference or dressing,
are treated of; carefril directions for planning and executing the
steps of each operation are given ; and great attention is bestowed
on mstmction in dressing, with a view to fit his pupils for creditably
passing the " Mastei^proof," which every one waa obb'ged to undergo
before entering the Society of Surgeons.

In Paris, then, we find in the end of the seventeenth and begin-
ning of the eighteenth centuries a well-rmodcUed and veir complete
School of Surgery. Demonstrations on anatomy, and lectures on
general surgical pathology were delivered during the winter, fol-
lowed in summer by the course of practical surgery just described :
whilst the great hospitals of the Hdtel Dieu, and La Charity
afforded the students ample opportunities of witnessing the treat-
ment of surgical disease, and the performance of operations on the

486 PB0FE8S0B BPEKCE ON THE [DEC.

living ; indeed, 6wing to the concentration of Surgery in the metro-
polis at that time, the opportunities for witnessing the performance
of some operations were such as are not likely to occur again in any
one school. The Demonstrations given bj JDionis were continued
by Garengeoty Petit, Le Dran, and other eminent Surgeons who
succeeded him, and ultimately developed into the great Surgical
School of Paris. Then the manner in which candidates for the
degree of '^ Master of Surgery " were tested seems to have been
complete and practical. It was no mere nominal title conferredi
but an honour awarded after thorough proof. Every candidate was
obliged to perform ^* twenty-five acts " of operations, and dressings,
and to explain the rationale of his procedure to the four Provosts
charged with the duty of superintending the proof. Dionis ex-
presses ^eat confidence in the ^'Master-proof" as a guarantee for
the surgical qualifications of those who passed it, and emphatically
deprecates a tendency to relax its stringency as being likely to im-
pair the character of the Parisian School, in language not altogether
without significance in the present day. '^ God grant," says he,
^' that the easy and conniving admissions and superficial examina-
tions which have introduced into our Society several who thought
themselves not able to incorporate themselves hj the Master-proof,
do not diminish its ancient splendour, and bnng it to relax the
regularity of its acts, by prodigally allowing to be " Masters "
persons unworthy of that title, and that the School of Paris may
Keep up its former reputation of being the best in the world."

Whilst Surgery had obtained so high a position in Paris, and
was producing so many eminent men, and when surgical literature
was being there largely cultivated, the London School of Sur^rjr,
which hs3 been gradually growing up around the large hospitals,
had also attained considerable eminence. About the period of
which I am speaking, we find our great English surgeon Cheselden
attracting forei^ers to England by the brilliancy and success of his
operations for lithotomy ; whilst his works, and those of Cowper on
Anatomy, show how carefiiUy that science was studied and taught.
Percival Pott, who was contemporary with and succeeded Cheselden
at St Bartholomew's, was one of our ablest surgeons and authors ;
indeed this, and the immediately succeeding period, form perhaps
the most brilliant epoch in the annals of English Surgery, or at
least of the London School : for the names of Cheselden, Pott,
Gooch, and John Hunter are associated with it. In the London
School, however, the instruction given at first was extremely con-
densed, and the variety of subjects taught by individual lecturers
was such as to argue either that there was more of the Admirable
Crichton in the lecturers of those days than is to be found now,
or that a very small amount of instruction was deemed sufficient.
Even at the time that John Hunter studied, one lecturer professed
to instruct his pupils "in totam rem anatomicam," in twenty-
three lectures 1 whilst another, " like four single gentlemen rolled

1864.] EDIKBUBGH SCHOOL OF SUBOERT. 487

into one/' profeflsed to teach Anatomj, PhyBiolog^^ and the general
principles of Pathology and Midwifenr^ in tnirty-nine discoorses. It
18 strange to observe how things ana fashions revolve in cycles. I
read an article lately^ in which the writer attempted to prove a rela-
tion between the penod of the century, and the fashion of the gar-
ments ; showing that the width of the garment uniformly increases as
the century wanes. I almost suspect some similar law must regulate
medical education, but in the inverse ratio as to dress ; for the very
condensed style of instruction I have alluded to, existed towards the
middle and closing periods of the last century, just when the skirts of
our greatgrandfal£ers' coats were at their maximum, and when our
greatgrandmothers' hoops would have stood their ground against
any modem development ; and now, when the present century is on
the decline, and the width of the garment is on the increase, we find
in many quarters a great desire again to contract the extent of
medical instruction ; and some of the more advanced apostles of this
doctrine would even reduce surreal instruction to anatomy and
hospital teaching ; declaring all else to be waste of time and vexa-
tion of spirit. So thought not the great men who had felt the want
of proper teaching, and who had to overcome the difficulties conse-
quent on it. It IS true, that the energy and practical character of
the English mind triumphed over all these obstacles ; but the very
men who overcame were those who, afterwards, by extending and
arranging the instructions in medical, surgical, and the collateral
sciences, and by increasing the requirements of the Licensing
Boards, did so much to diffuse professional science and practicid
skill throughout the country at large.

I have thus shortly sketched the state of the Surgical Schools of
Paris and London, as they existed in the early and middle portions
of the eighteenth century. Let us now inquire what was the condi-
tion of the Edinburgh School of Surjgery at the same period. It can
scarcely be said to have existed. This may startle some of my hearers
who know how long Edinburgh has been celebrated as a Medical
School, or who, like myself, have had the pleasure of hearing
or stuaying the interestme and instructive lectures of Ihr John
Gairdner on the History of the Royal College of Surgeons of this
city. Nevertheless, I must repeat, that as a Surgical School, having
a distinctive character in its teaching, or giving a special impress to
the Sturgeiy of the time, I can find no trace of it till near the close
of the centuiy. Its rise was as rapid as it was brilliant. It was, in
truth, this very peculiarity in the progress of our School that led me,
as I nave already stated, to bring it before you to-day.

There were, doubtless, causes connected with the political state of
Scotland, as compared with France or England, most unfavourable
to the development of science. France, though the elements of
that terrible revolution which was soon to convulse her were surely
and rapidly accumulating, as yet ^ave no si^s of the evil day ; all
was quiet on the surface. Though engaged in foreign wars, all was

488 PsoFEsaoR spekce on the [dec.

peace within her own bordeis ; and literatuie^ arts, and sciences
were royally patronized, and flourished. In like manner, England,
from the termination of the great civil wars, had, with the brief
episodes of a short and partial insurrection and a bloodless revoliH
tion, enjoyed a long period of internal peace and its accompanying
blessings. In Sootlimd the state of things was far different : the

Eeriod which followed the restoration of Cnarles II. was one of re-
gions war and persecution, and the revolution of 1688 was not so
quietly- accomplished as in England. Though the death of Dundee
established the power of William, yet in Scotland, his and the
succeeding reigns, were constantly disturbed by plots, which cul-
minated in the rebellions of 1715 and 1745. Even when at last the
sword was broken at CuUoden, and the men who had wielded it
had perished, or were fugitives in other lands, it was long ere the
minus of men in Scotland settled down into that calm frame necessaiy
to the cultivation of science. But, besides these conditions, so evi-
dentlv obstructive of the progress of all sciences, there were otners of a
strictly professional character affecting the progress of surgical science
in Edinburgh, to which I wish specially to draw your attention.

The first condition worthy of note is this, — That in no other,
certainly in no other British school, was attention earlier given to
teaching the science which forms the basis of Surgery, — viz.,
Anatomy. So far back as 1505, in the first charter of the Corpora-
tion of Surgeons, there was a provision made, '^ that we have anis
in the veir ane condampnit man efrer he be deid to mak anotomea
cty quhairthrow we may haif experience, — ilk ane to instruct
uthers ; " and fix)m the researches oi Dr Gairdner. already alluded to,
we learn that for upwards of two centuries the Corporation of Sur-
geons had occasionally caused dissections to be conducted in terms
of this charter.

In 1694, Alexander Monteath, a member of the College of Sur-
geons, instituted a course of instruction in Anatomy. The
College improved upon and systematized this instruction, and
appointed regular demonstrators, or operators, as they were called,
m>m its members, to conduct these dissections and lecture to
the apprentices. Next, a Professor of Anatomy for the city was
elected periodically by the. College, conjointly with the Town
Council, to lecture in the theatre of the college ; and this city Pro-
fessorship, in the person of Alexander Monro, terminated in the
institution of the chair of Anatomy, and the transference of the
city Professor to this University.

The second condition in the early Medical School, is, that whilst
Chemistry, Theory and Practice of Physic, and Botany were gradu-
ally added to the Anatomy, Surgery as a distinct subject was not
taught; and even so late as 1777, when the College of Surgeons
petitioned the patrons to institute a separate Professorship of Surgery
m the University, they were opposea by Monro, then Professor of
Anatomy, as interfering with his subject ; and he succeeded in get-

-yj,;

1864.] EDINBURGH SCHOOL OF SUSGEBT. 489

. ting his commiBsion altered; so as to include Sorgeiy, which was
thus made a mere adjunct of the anatomical course, and continued
to be so taught (if it could be said to be taught) until the institu-
tion of the chair of Surgery in 1831.

The last feature which I shall mention, and perhaps the most
peculiar in regard to the Edinburgh School, in contrast with the other
schools I have spoken of, is that, until 1729^ when the Surgeons and
Physicians opened a house for the reception of poor patients, no
Hospital existed in Edinburgh ; and the Royal Infirmary, wnich
has now obtained so wide-spread and well-deserved a reputation for
the benefits it has conferred both on the suffering poor and on
medical and surgical science, was not founded until the year 1736.

Here, then, we have a Scnool in which Anatomy, the basis of all
surgical science, had been taught regularly firom a very early period ;
and yet in this school so little advance had been made, that not only
do we find no works emanating from it, but until a comparatively
recent period Surgery was not even taught as a separate subject

Now this may teach us a lesson: that however valuable and
important any one science, its true value consists in its being an
applied science. Anatomy is all-important as the foundation of
burgery ; but we must use it as a foundation, and raise the super-
structure on it, and not content ourselves with merely laving the
foundation. Important and interesting in itself as a natural science,
to the student of medicine and surgery, the true value of anatomy is
as a means to an end, — the great end we have in view, of curing di-
sease and alleviating human suffering j and it is quite possible to
possess a knowledge of anatomical facts without being able to apply
them usefully to the dia^osis and treatment of disease, or to the plan-
ning of surgical operations, unless the habit of doing so have oeen
cultivated. Then, as to the want of systematic orw instruction in
Surgery, that is so very obvious a cause of retardation of surgical pro-
gress that the question naturally suggests itself. What could be the
reason that, whilst other branches of medical teaching were super-
added to the anatomical lectures, Surgeiy was not amongst them ?
The answer to this is not far to seek : I think it will be found in
the last peculiarity I mentioned of the early Medical Schoob of
Edinburgh, namely, the non-existence of a great Hospital ; for if
we look to other i^hools, we shall find that the^ all arose round
hospitals. This alone seems sufficient to explain why surgical
lectures were not given, and why surgical science made little pro-
gress ; for without that field for the observation and study of sur-
gical diseases, and that experience which hospital practice alone
can give, compiled lectures representing merely the opinions
of others^ and the current doctrines of the day, almost imtested
by ^e Lecturer, would be but cold and lifeless, and little cal-
culated to advance science. Teachers and taught alike would
feel but little interest or enthusiasm in a subject in which their
field of observation and practice was bo limited.

490 PROFESSOR SPEKCE ON THE [DEa

I now turn to the more Dleasing phase of onr Edinbnrgh School of
Sorgeiy, namely, its rapia development, the high. position to which
it soon attained, and to a brief notice of some of the ^reat men^to
whose labours that development and distinction are marnlj due.

There can be little doubt that the institution of a Hjospital in
Edinburgh, and the introduction of clinical instruction, did more than
anything else to constitute it a great Medical School ^ and the in-
fluence of this on Surgerv was soon apparent in duecting more
attention to the subject. Monro, the Professor of Anatomy in the
University, who had been an active promoter of the hospital, de-
livered occasional clinical lectures on tne surgical cases, and though
not himself an operating surgeon, yet, fix>m his great fame as an
anatomist, he gamed a ni^h reputation as a consulting surgeon.
These lectures in the hospital, and the more practical character which
his hospital observations gave to his ordinary lectures, speedily in-
terested others in the subject ; and although he wrote no special
treatise on Surgery, yet he published various, and some of them im-
portant papers on surgical suDJects, which are still worthy of attention.

The earlv arran^ments of the hospital, by which all Fellows
of the College of Surgeons were entitled to act in rotation,
though not the most jucUcious, nor the plan best fitted to raise up
great surgeons, nevertheless had at least this effect, that it forced
the necessity of studving Surgery upon all, and hence gave it more
general interest. The fruits of hospital ODservation and experience
gradually led to the cultivation of Surgeir as a special subject, and
attracted to it the attention of men of talent, who, emulating what
had already been done in medicine and other departments of science,
in raising the fame of our city as a seat of learning, soon gained for
Edinburgh Surgery also, a high and distinguished place. Amongst
the earliest of those whose names are connected with the Edinburgh
School as a writer on systematic surgery, was Mr Benjamin BeU,
who practised about 1772, and whose System of Surgery, in seven
volumes, still forms a standard work among our surgical classics.

But perhaps the man to whom we owe more than to any other for
having given an impetus to Edinburgh surgeiy, both by his practice
and his writings, and for stamping it with his own bold and cUstinc^
tive characters, was John Bell. He was no ordinary man, but a
real surgical genius, of great natural talents, and imbued with that
enthusiasm which is a mark of genius, and which does so much
to create enthusiasm in others. He devoted himself from the first,
with indomitable perseverance and energy, to study his profession
so as to take a high place in it, and to advance it. Possessed of a
taste for literature and the fine arts ; an accomplished draughtsman
and etcher j and so general a reader, that it is said there were few
works of literary note, either ancient or modem, with which he
was not conversant, and that there was scarce a book in his libraiy
that did not bear marks of his perusal, in the shape of pencil criti-
cisms ; possessed also of great tact and a keen perception of the

1864.] EDINBURGH SCHOOL OP SURGERY. 491

ludicrous ; he seems to have bent all this varied talent to one ^reat
end, — the elevation of the science he so lovedt His lectures oil Sur-
gery, which he commenced in 1786) were highly esteemed, and
largely attended, and were only abandoned ten years afterwards, in
consequence of his increased private practice as a consulting and
operating surgeon preventing him from attending to the lectures. His
fame as a surgeon attracted patients from all quarters to Edinburgh,
and hence drew attention to this School. His great work on the
Principles of Surgery, unlike many of the works of the present day-
was only published after he had ceased to lecture, and after he haa
enjoyed such an amount of experience as falls to the lot of few. It
is an epitome of the man — of nis energy of character — of his varied
knowleiige and descriptive power. It is no mere system of Surgeir ;
for John Bell was scarcely the man to plod on writing in regular
system. It is a series of monographs on some of the most import-
ant subjects of Surgery, written by a man who only wrote when his
heart was in the work, and whose graphic pen makes every sentence
instructive and memorable. He is a great word-painter. With
the exception of Macaulay and Carlyle, I scarcely know of anv
writer who so identifies himself, and leads his readers to identinr
themselves with what he is describing* How he interests us in his
cases by his mode of narration, and by associating them with col-
lateral circumstances I What student of Surgery is likely to be
seduced from the simple treatment of wounds, who reads his vivid
description and criticism of the case of that unfortunate French
duellist, doomed to be treated ^^ secundum artem^'^ by having a cord

fulled through his chest twice a-day to ensure the deep wound
ealing properly ? What a description of the symptoms ana ravages
of hospital gangrene, and its causes, is his account of the state of
Yarmouth Hospital after the battle of Camperdown ; and what a
melancholy episode in the history of Duncan's great victory, is that
pen-and-pencil sketch of the poor boy Joiner, of the Triumph, slightly
wounded by a splinter during the battle, but dying from the then
terrible scourge of hospitals, — an evil which the writings of Mr Bell
did so much to remove. This is a book for all time. I do not
indeed bid you look into it, expecting to find all the advancement
of modem Surgery, but I bid you look there for the spirit and en-
thusiasm which are the sources of all true advancement. I grant,
that my favourite author has his faults ; that he is perhaps some-
what severe and sarcastic, and not always just in his criticisms of
others : — that his brilliant descriptions of great operations sometimes
lead to exaggerations, but after all they do not mislead us. When
he speaks, for example, of a bold free incision two feet long in a
space, the longest axis of which could scarcely measure one, we do
not try to solve the problem as one in the exact sciences ; we look
upon it as a specimen of hyperbole, and as meaning a very free in-
cision indeed. John Bell's work, m truth, is occasionally the very
romance of Surgery ; and if, to enhance the interest of some subject,

VOL. X.— NO. VI. 3 B

492 PROFESSOR 8P9HCE ON THE [DEC.

kis genius colours it rather highlj, we must allow him somewhat of
poetic license ; his style is more enthusiastic than exact. He might
with advantage give a cantion to his readers, like our neat Scottish
Bomancist in his Marmion, and saj in regard to detauSi —

" Such things in chronicles are writ ;
Go I seek them there and see;
Mine is a to^ of Flodden field,
And not a hittary*^^

Besides this, his great work on Surg^, Mr Bell was the author of
a System of Anatomy, a Treatise on Wounds, a Series of Plates of
the Anatomy of the Human Body, drawn and engraved by himself.
Nothing, indeed, is more astonishing, as exemplifying the energy of
the man, than his literary labours, and that engaged as he was, in
the anxious practice of a consulting and operatmg surgeon, with a
lar^ amount of professional correspondence, and mixing so much
as he did in society, he should have found time to produce so many
great original works. And besides all this, he was a great contro-
versialist ; with his powers of ridicule and sarcasm, and a style as
trenchant as his scalpel, he was a dangerous and remorseless adver-
sary. The controversy between him and the great Professor
Grefforjr, may give some idea of what controversy was then, — no
small sixpenny pamphlets, or letters in a, medical journal, but
goodly quarto volumes, printed in the best type, and on the finest
paper ; — verily ! they must have been in large demand. We fear
there must have been many who enjoyed the displays of temper,
and weak points of character in the combatants, and who might
have joinea in the confession of Lady Mary Montague, — ^^ I own I
enjoy vast delight in the folly of mankind, and, God be praised,
that is an inexhaustible source of amusement" But I must bid
him farewell, and I always do so with regret. I feel that to his
works I am indebted for imbuing me with some small portion of
his own enthnsiastic love for the subject, and for sending me back
to the old surgical lore to learn much that is valuable, even in the
light of modern science. I recommend his writing to the advanced
student, as tending to excite a love for his profession ; and I repeat,
without detracting from the merits of the many great men who were
his contemporaries, or who have followed him, that as an original
thinker, a powerful writer, and a great practical surgeon, John
Bell stands out pre-eminent as having excited the spirit which
stimulated the advance of Surgeiy in Edinburgh, and impressed it
with the distinctive characters of simplicity in treatment, and sim-
plicity and boldness in operating.

From the begmning of the present century, the Edinburgh School
of Surgery took a high place m advancing surgical science, and has
produced so many good practical surgeons tliat the very " embamu
des rtchesses^^ makes it necessary to select.

At first, the advance in surgical teaching was outside the Univer-
sity, where, with the exception of the nominal connexion of Surgeiy

1864.] EDINBUSGU SCHOOL OP SUBGEBT. 498

with the Chair of Anatomy^ Snrgery was not taaght. In 1803, the
Begins Chair of Clinical Snrgei^ was created, bnt was, as then in-
stituted, a very peculiar class — indeed, all tne more curious that
clinical teaching in Medicine had been long one of the great and
most valued features in the Edinburgh school ; and its fame in this
department depended on the fact that it really was clinical instruc-
tion. But in regard to Clinical Surgery as at first instituted in this
University, it was an admirable example of the play of Hamlet,
with the part of Hamlet omitted ; for the great characteristic feature
of all true clinical teaching — the bedside visit, which enables the
teacher to point out to the student what to observe as to the nature
and progress of the cases under his care — ^was omitted. The Pro-
fessor had no patients under his own charge, but lectured on those
of the Surgeons of the hospital, and hence we not unirequently
enjoyed the opportunity of hearing two opinions as to the nature
and treatment of cases, one from the actmg Surgeon at the visit,
and the other from the Clinical Professor in the lecture-room«

In the private medical school, however. Surgery was admirably
taught. When I myself first commenced my meaical studies, the
Surgical School of Edinburgh was represented by such an amount
of surgical talent as was hardly to be found elsewhere, and is not
likely to be met with again. When I mention the names of Liston,
Lizars, Syme, and Fergusson, I feel sure you will agree with me
that I have not said too much. Of these, two have passed away,
and two remain. Of the two still spared to us I will not speak
further than to say, that the one is the honoured occupant of the
Clinical Chair in this University, which he has so long adorned, — a
man of world-wide £Gime, who has done much for Scottish Surgery ;
the other, is the Professor of Surgery in King's College, the repre-
sentative of Edinburgh Surgery, and one of the first burgeons of
the first city of the world.

The name of Robert Liston needs no panesjrric. It would be a
strange review of modem Surgery, in wnich his name did not find
a foremost place. In Scottish Surgery I think it holds the foremost
place. I may perhaps speak strongly, and with the partiality of
an old pupil, but I speak after some experience, and after testing
the principles he taught. As a bold, and cool, and dexterous
operator i have scarcely seen his ec^ual. His very pre-eminence
in that department has led to his being often spoken of merely as
a great operator ; but he was at least equally great as a scientific
surgeon. His great power in diagnosis, the wonderftd faculty he
possessed of perceiving, as if b]^ intuition, the true natul:e of a case
m all its bearings, and of adopting adequate measures for its treat-
ment, were such as are rarely to be met with ; and in the general
treatment of his cases, his success as a skilftd practitioner was quite
as remarkable to those who carefully followed his hospital visits, as
were his displays of unrivalled dexterity in the operating theatre.
As a lecturer he had no pretence to eloquence, but he was one of the

494 PROFESSOR SPENCE ON THE [DEC.

most instructive teachers I ever listened to. His short, some-
what abrupt sentences were like aphorisms, full of meaning, always
to the point, and easily remembered. As a writer, his earher works
on the Surgical Anatomy of Hernia, and on Stricture of the Urethra,
bear evidence of research and ori^nal observations ; whilst his Sys-
tem of Surgery, and his later work on Practical Surgery, embodying,
as they do, the results of his great experience, must always hold a
high place amongst our standard surgical authors. Fortunately for
himself, and for surgical science, his fame as a surgeoji led to his
being called to fill the chair of Clinical Surgery in University Col-
lege, London. There his talents soon gained him the highest place
amongst the surgeons of the Metropolis, and rendered the then
recently erected medical school of University College one of the
most popular in London. In some respects he now ceased to be
connected with the Edinburgh School, but truly he was its repre-
sentative man, and vindicated for Edinburgh Sursery a high position,
and gradually introduced its teaching into England. The charac-
teristics of Listen's surgery were — clear and definite views in regard
to diagnosis, and discrimination when and in what cases to operate,
simplicity in dressings and surgical apparatus, care in planning
operations, and coolness and dexterity in operating.

The name of John Lizars was long welt known as a teacher of
Anatomy and Surgery, and as the author of the System of Anatomi-
cal Plates. He hieul been an assistant to John Bell, and was an
enthusiast in his profession, and a daring operator. He was the first
who carried the idea of Ovariotomy into practice, an operation then
viewed with great dislike by our principal surgeons, but which the
success of recent times has established as a regular operation in sur-
gery. Mr Lizars was Professor of Surgery to the Koyal College of
Sur^ons of this city, and the last who held the office, which was
abolished on the institution of the chair of Surgery in this University.

The institution of a Professorship of Surgery did not take place tul
so late as 1831. Prior to this, indeed, there had been instituted a
Chair of Militaiy Surgery, which was long ably taught by the late
Sir George Ballmgall, the author of " The Outlines of Military Sur-
gery," but until the period I have mentioned, no chair of Systematic
Surgery existed in this University. In 1836, this Chair reclaimed
from London one who had originally belonged to the Edinburgh
School, and whose name was fitted to throw lustre upon any School
— the late Sir Charles Bell. Educated by his brother John Bell, he
was of a finer and more sensitive organization ; well known through-
out the world for his physiological researches and discoveries in the
nervous system, he was at the same time an ardent cultivator of
surgery. The conceptions of some of his numerous surgical works
are very happy, as, for example, his application of healthy and
morbid anatomy and physiology to practical surgery. As an author,
his style, though not possessing the imaginative character or force
of that of John Bell, is more exact and philosophic. As to subject

1864.] EDINBUBOH SCHOOL OF BUBQEBT. 495

matter, his works are models of the application of anatomy and
physiolog;^ to surgical diagnosis and practice, and contain many
original views of pathology, which I fear are not sufficiently ac-
knowledged by, perhaps not known to, some modem investigators.
Like his brother J ohn, he was endowed with great artistic talent —
his powers in painting and modellinff were of a very high order.
It was wonderful to see what a few bold touches of his magic pencil
could effect ; and in the rapid production of telling artistic sketches
on the board with chalk, I have never seen him equalled except
by Haydon. Specimens of his more finished paintings and sketches
in oilj and of his wax^modelling, or, to speak more correctly, of a

eculiar stvle of colouring casts in wax, are to be seen in the
useum of the College of Surgeons ; in which is contained that
great collection of healthy and morbid anatomy which his energy
and industry had amassed. Sir Charles Bell was no day-dreamer,
but an earnest able worker, one whose unremitting labours had no
small share in the advancing not only Scottish but British Surgery.

Since his death in 1842, for two and twenty years, the duties of
this Chair have been ably falfiUed bv one loved and honoured, not
only by the students whom he taught, and by the members of his
own profession, but by the public, to whom his large-hearted
efforts in the cause of Christian and social advancement, enforced
by the appeals of his fervid eloquence and consistent life, made him
so generally and favourably known. And now that his sun has
gone down while it was yet day — ^when to many of us it must
seem but yesterday that he mingled with us in our professional and
social life — ^when the echoes of his frank kindly voice have scarcely
died away, I feel this is neither the fitting time nor place to enter
on a critical: review of his labours. But this much I will say, that
few of the great men of whom I have spoken, possessed natural
talents of a higher order than the late Professor Miller — ^none of
them perhaps such powers of eloquence. Popular as a teacher, and
successful as a practitioner, he added to all, and above all these,
such an earnest desire and such unwearied endeavours to promote
the highest interests of his students, as should endear his memory to
the Edinburgh Medical School, and to those for whom he laboured
and whom he so truly loved.

In this hasty and consequently imperfect sketch of the Edin-
burgh Surgical School, and the men who mainly raised it to
its present high position, I have had it for my object to make it
teach us some useful lessons, and stimulate us to emulation. If
I have made the history at all intelligible, the application need
be but brief. First, then, as to the lessons deducible from the His-
tory of our School. In speaking of the causes which seem to me
to have retarded its progress, I pointed out that the mere teaching
of Anatomy and other subjects without instruction in surgical princi-
ples, and the observation of disease in the hospital, could never
constitute a school of Surgery ; and so in the case of the individual.

496 PBOFESSOK 8PEKCE ON THE [D£a

DO amonnt of other kinds of knowledge can ever constitate a S/at"
geon. If excellence in Surgery be your special aim, then Surgeiy
and the collateral sciences which more directly bear upon it, most
be your primary and special objects of study. At the same time
beware how you make them your only study. An acquired
knowledge of the Sureeiy of the time may exist in a School, or
in the individual, and ^et there may be little or no pogress.
You may have noticed m some pool left by the receding tide,
a sea^anemone clinging to a rock or stone. It gave signs which
left you no doubt that it was an organized being, enjoying a
certam range of existence ; but how limited a range mien compao^d
with the living, thinking, acting man, turning to acooont all within
and around him, and possessing powers to render life enjovable and
usefuL So in any Scnool of ourgery where the collateral sciences,
and other branches of knowled^ are studied and applied, there will
not be merely existence, but advance of smrgical science. Do you
wish to excel in Surgery; not merely to rest in what has 1)een
aecomplished, but to advance its progress to perfection? Then,
whilst you should make anatomy, surgery, and hospital attendance,
the special objects of your cultivation, study your profession as a
whole in all its branches, — and not merely so, but ^add both as
many, and as much of other sciences and accomplishments as yon
ean, without neglecting your own spiecial business ; and these having
been acquired, bend aU your attainments to the improvement of
surgical science.

ixk my sketches of the men whose names stand prominently forward
in advancing our Surgical School to its present high position, my ob-
ject has been to induce you to emulate their laboius. I bid you aim
nigh^ because, as in the material world, the law of gravitation tends
to drag earthwards the projectile in its course, so in the moral world
there are deflecting influences, and the man who is content to make
mediocrity his mark is sure to fall below it. I bid you copy the
excellences of these great men, not their eccentricities or their
errors j — ^for when you come to study their histories and characters
more closely, you will find that as they were human, so they had
their £uilts. Do not fall into the silly mistake, that by copying
these you resemble them. The men were great in spite, not in
consequence of such defects. Use them as the mariner uses the
beacon light — ^at once guiding him on his way, and revealing to
him the dan^rs of the rock on which it stands.

In conclusion, gentlemen, let us, as teacher and students, feel the
responsibility which rests upon us in our several spheres^ to do
what in us lies to maintain and advance the reputation of this great
Medical School As your teacher, I feel this responsibility deeply,
when I think of the CTcat names which have preceded me ; but I
will yield to none of them in the desire to advance the science which
I teach. Though I stand to-day in a new sphere in the Edinburfi;h
School, I am no stranger in it I have had some experience in me

1664.] EDINBUBOH 8CH00L OF 8UKQEBT. 497

teaching of Soxgery, I can at least piomiae to teach jon tmth*
fully what I have obeenred and tested. For fifteen years I ha^e
taught Surgeiy : in the same spirit as I have taught it hitherto,
so will I teach it now.

You, as students, have your responsibilities. To say nothing
of your own welfare, on your future much of the honour of the
Universi^ of which you are pupils will depend. In opening my
address, I compared tne rise of a science to the gradual formation
of a coral island. Let me revert to that comparison. As in
that formation every worker did its part, did what it could, and
all had share in rearing the mighty mass : so all of you, whatever
your peculiar talents or powers, are bound to use them earnestly.
Let not the talented think that his talents will shine whether culti-
vated or no. The silver dulls and tarnishes by mere disuse. The
fable of the tortoise and the hare is stale and trite, but it is very true,
and is often re-enacted in student life. Would any here excuse him-
self firom the task, as being only intrusted with the ^^ one talent?"
You will not be called to account for more than your trust ; but
you are bound to use your talent for the purpose ror which it was

g'ven ; you may not wrap it up in a napkin and hide it in the earth.
5 earnest in your work. Some plan great things for the future,
but never make a beginning; others commence enthusiastically,
but, tiring of the irksome initiatory work, console themselves by
day-dreams of what they will do on the ever-receding to-morrow,
and only awake too late to the consciousness of a wasted life.
Avoid such procrastinations and delusive tendencies.

" Build to-day, then, strong and sare,
With a firm and ample base ;
8o, ascending and secure,
Shall to-morrow find its place/^

I Article II. — On the Weight and Lenathafthe Newly-Bom Child
in Relation to the Mother's Aae. By J. Matthews Duncan,
M.D., F.R.S.E., Lecturer on Midwifery, etc., etc.

In the course of an inouiry into the influence of the age of the

mother upon fecundity, I desired to find out if any light could be

j thrown upon the subject by the variations, if an^, of the weight and

.J length of mature children bom of women of different f^es. I in«

V tended to assume that the weight and length of the child might

increase or diminish with the high or low state of the fecundity of

woman, or of the vigour of the generative functions. A part oi the

results of the inquiry referred to has been published in the Transact

tions of the Royal Society of Edinburgh lor this year. The present

subject is there alluded to in the following words : — ^^ I have made

I various other inquiries with a view to throw light on the topic of

this paper. They refer to variation in sex, size, and weight of

newly-born chil4ien according to the age of the mother, also to the

498 DB MATTHEWS DUNCAN ON THE SIZE OF THE CHILD [DEC.

frequency of twins and triplets according to the mother's age. But
the results of these investigations have been so imperfect or unsatis-
&ctory that I do not now describe them." In the meantime, and
notwithstanding imperfections, I wish to produce one part of these
subsidiary inquiries.

The ODservations upon which all my conclusions are founded
have been drawn from the records of the Edinburgh Royal Maternity
Hospital. They amount to 2070 pregnancies with 2087 children.
They are not nearly so numerous as I could desire, but no more are
available to me.

I. On the Irifluence qf Primogeniture on the Weight of the Newly-

Bom Child,

Before entering on the proper subject of this paper, I have a few
remarks to make on some observations of Professor Hecker of
Munich, closely relating to it. This ffentlemaUj in a recent work,*
publishes some calculations made to snow the mean weight of the
children of primiparse as compared with those of phiriparse, and he
finds that the latter exceed the former in weight His figures are as
follows: — 378 children of primiparae weighed, on an average, 7*07 lbs.
each; 718 children of pluriparae weighed, on an average. 7 "38 lbs.
each ; sunong these 1096 infants, the average weight of tne mature
children of primiparse was less than that of the mature children of
. multiparas by '309 lb.

My observations on 2053 children confirm those of M. Hecker.
The average weight of 1011 children of primiparous females was
7*170 lbs* ; the average weight of 1042 children of pluriparous females
was 7'277 lbs. ; the average weight of mature children of primiparse
being less than that of the mature children of multiparse by '107 lb.

If these results are subjected to some study, their apparent value
almost entirely disappears. Hecker^ evidentljr, would imply that

{>rimogeniture is the circumstance which determines the comparative
ightness of first-bom children, and vice verad. But it is evident
that in order to a just comparison of the weights of children of
primiparsB with those of multiparaB, the children compared must be
Dom m circumstances as nearly identical as possible. Especially
care must be had that the known influence of age be taken into
account, and this care M. Hecker has altogether omitted.

In the following investigation it will, I think, -be nearly estab-
lished that the great influence producing variation in the weight of
the newly-born child is not primiparity or pluriparity, but the age
of the mother at the time of the birth. No doubt, any statistic of
a population or of an hospital will show greater weight in second
and subsequent births than in first^ because the great majority of
primiparee are young, and their age, anticipating the arrival of the
climax of fecundity, tells upon the size of their of&pring. The
following considerations seem to me almost to prove the nullity of
influence on weight exercised by primiparity.

^ Ellnik der Geburtskunde. Von Dr C. Hecker und Dr L» Bahl, s. 46.

■ i

18«4.]

IN BELATION TO THE KOTHEB'S AOE.

499

/

/

i
I

I

1. The weight of the children of primiparsa is not nearly uniform,
bat varies according to the law of the age of the mother. (See
Table V.)

2. The weight of the children of all mothers, whether primiparse
or plnriparsB. varies according to the same law of motner^s age.
(See Table IL)

3. The following Table (I.) of the mean weights of the children
of first and subsequent pregnancies shows no increase or decrease
according to the number of the pregnancy. No doubt, the children
of first pregnancies are lightest^ but this is accounted for hj age.
After the nrtt pregnancy there is no variation according to any law.
There is, indeed, ^eat uniformity in pregnancies after the first I
have appended a Ime of mean ages to show that even the average
woman of seventh and subsequent pregnancies has not passed into
the ages in which the decline of fecundity is strongly marked. It
is prooably on this account that no gradual diminution of weight is
observed in the more advanced pregnancies. I may add that 1 have
an impression that, were data lortncoming to extend this table to
eighth, ninth, tenth, eleventh, twelfth pregnancies, and so on, a
marked diminution of the mean weight of the children would appear,
and that it would correspond to the average age of the woman,
advancing in these pregnancies into years of decided decline of
fecundity.

Table I. — Showing the Atjerage Weight of Children bom in Firtt and
Subsequent Pregnancies.

No. of
Pregnancy.

1

2

3

4

5

6

7, etc.

Total

Weight of
Child.

IbB. OS.

7 3167

11m. OB.

7 4-897

IlM. OS.

7 6-597

Ibt. OB.

7 3046

lbs. OB.

7 7-223

1^ OB.

7 5-076

IbB. OB.

7 4-991

IbB. OB.

7 4-109

Age of
Mother.

22-787

25-806

27-701

30-321

30-424

32045

35-562

25-625

Before advancing^ I may here interpolate a remark regarding the
difficulty and danger of labour in primiparas. The popular notion
of the increased difficulty and danger of a first labour in a woman,
no lon^r voung. finds its explanation, in part at least, in the in-
creased bulk of the child as indicated by its increased weight and
length in such women. I have often heard that an old primiparous
woman passes through labour more easily than one somewhat
younger, and we may possiblv find this also accounted for by the
comparatively small size of children bom in the latest periods of
fecundity,

II. ITie Vartatian of the Weight of the Newly-Born Child according
to the Age of the Mother.

I have in the paper already cited shown that the fecundity of the
average individual woman increases to about the age of 25 years.

VOL. X.— NO. VI. 3 8

600 DR MATTHEWS DtJHCAN ON tHE SIZE OF THE CHILD [l>EC-

This cOncrttsion receives very interesting corroboration from the
following Table (II.) of the average weights of mature children "bom
of mothers of ages gradually rising to 25 years. The weight of the
child gradually increases to its climax in the age of from 25 years
to 29. After this age the weight of the children declines, but the
diminution goes on by very slow degrees. This slowness is entirely
out of proportion with the*rapid diminution of fecundity of women
of similar ages. But this disproportion would not be worth mention-
ing, seeing that no similarity could be expected, were it not that it is
desirable to point out the proper objects of comparison in this case.

Table U.— Shotting the Average Weight of Children bom ftfMoihets of
Different Ages.

Age of
Mo^er.

Number of

Total Weight

Ayenge Weight.

lbs. OS.

Ibft. OS.

15-19

209

1459 10

6 15-741

20-24

832

6008 74

7 3-647

26-29

570

4220 4

7 6-463

30-34

278

2020 6

7 4-281

36-3^

139

1011 2

7 4-388

40-44

38

272 0

7 2-626

45-49

3

20 12

6 14^666

The decrease of children*s weight should not be compared with
the decrease of fecundity, for this last decrease is produced chiefly
by women entirely deserting the category of the fecund, and bearing
no children for comparison. The decrease of the fecundity of the
average individual woman is not produced by diminished fertility
of the individual fecund woman, out chiefly by the arrestment or
disappearance of fecundity in women previously fertile. I cannot
refer to any printed evidence of this, but I hope soon to publish it.
The decrease of the fertility of women continuing fertile is very
gradual, at least till the child-bearing period of life is far advanced ;
and it appears to me that it is with this gradual decrease of the
fertility of fertile women that the diminishing weight of newly-born
children should be contrasted, not with the diminishing fecundity
of the average individual woman.

III. On the Influence of Primogeniture on the Length ofihe Newly-

B(yrn Child.

It will be interesting now to inquire if Hecker'A opinion regard-
ing the influence of primogeniture be confirmed by a study of the
varying lengths of children. Hecker himself has made no obser-
vations on this point, and it must, I think, be admitted that length
is not nearly so good a test of growth and nourishment as weignt.
Yet it will immediately appear tnat interesting corroboration of other
allied laws, if not of Hecker's, may be drawn from a study of
lengths ; and it was not to be expected that the estimation of such
measurements should be omitted by an obstetrician who has laid
great stress on the value of length as an indication of maturity,

1864.]

IN RELATION TO THE MOTHER'S AGE.

501

enunciating the doctrine that good evidence of maturity cannot be
obtained so satisfactorily by weighing as by measuring.

Among 2053 mature single chil<£en, there were 1011 bom of
primiparsB : the avera^ length of these was 19*213 inches ; — there
were 1042 bom of pluripara ; the average length of these was 19*202
inches ; the average length of mature children of primiparaB exceed-
ing that of the mature children of pluriparae by 'Oil inch. The
difference here in favour of primiparss is so slight that it may be
disregarded. No notable difference in this respect, therefore, is
made out between primiparsB and pluriparse, a circumstance which
shows that weights and lengths of children have no direct or certain
relation, one to another, if the figures adduced have been carefully
ascertained and are numerous enough to justify such a statistical
conclusion.

The remarks which I have already made in connexion with the
corresponding observations on the weight of children of primiparse
and pturiparsB are so closely applicable mutatis mutandis to the pre-
sent topic also, that I shall not repeat them. I shall only here give
a Table of the lengths of children Tbom in first and succeeding preg-
nancies, to show that there is no increase or decrease of length
according to the number of the premapcy ; that length does not
seem to be imder any law connected with the first or subsequent
occurrence of pregnancy.

Table in.— /S^otdn^ the Average Length cf Children horn in First and
Subsequent Pregnanciee,

No. of
Pregnanoy.

1

2

3

4

6

6

7, etc.

Total.

Length of
Chad.

Inches.

19-197

Inches.

19-239

Inches.
19-304

Inches.

18-959

Inches.

19-273

Inches.

18-962

Inches.

18-991

Inches.
19188

Age of
Mother.

22-787

26-806

27-701

30-321

30-424

32045

35-562

25-625

Although, however, the facts here adduced do not show the in-
fluence of age in conjunction with primiparity, I have no doubt that
a large enough collection would show comparative shortness of
primiparous children, just as comparative lightness has been shown^
and for the same reason, namely, because primiparous women are in
a very large proportion young,

IV. The Variation of the Length of the Newhf-Bom Child according
to the age of the Mother,

Although the observations I have tabulated bear no evidence in
regard to the influence of primiparity or of multiparity, yet when
thrown together so as to be questioned regarding the influence of
maternal age, they support the doctrine which 1 have elsewhere
maintained. Length of the newly-born child is shown in Table
IV. to increase as the mother gets older until the period from 25 to
29 is reached : after this, the length of the child graaually diminishes.

602

DB M. DUNCAN ON THE SIZE OF THE CHILD, ETC. [DEC.

^

Table TV. ^Showing ihe Average Lbmoth of Children horn o/Meihen of
Liferent Age$,

Age of
Mother.

No. of
Cliildreii.

Total Length.

15-19
20-24
25-29
30-34
35-39
40-44
45-49

209
839
574
280
142
39
3

InehM.

3,9724

16,082i

ll,109t

5,384i

2,683f

737*

544

Ineliea.

19-007
19-168
19-355
19-229
18-899
18-910
18-166

It appears, then, that a careful study of the weights and lengths of
newly-born mature children lends support to the doctrine that the
vigour of the female reproductive system waxes till the age of about
25 years is reached, and then wanes.

I here append two general Tables containing numerous details
which speak for themselves : —

Table Y. —Showing the Average Weight of Children bom at variom Agee
and Pregnandea ofMothere.

Ill

Preg-
neaoj

1

Preg-
nancy

2

Preg-
nancy

8

Preg.
nancy

4

Preg-
nancy

5

Preg-
nancy

6

Preg.
nancy

7, eto.

TotaL

209

832

670

278

139

38

3

1

15-19
20-24
25-29
30-34
3!h^
40-44
45-49
50 —

lbs. OE.

6 15-772

7 3-455
7 4-836
7 5-283

7 0-846

8 8-000

Ib>. OB.

6 10-733

7 4-486
7 7-481
7 1-733
7 5-846
6 7-200

lbs. oz.
11 5-000

6 13-735

7 8-451
7 2-971
7 13-444
7 12-000
6 0-000

•••

Ibi. OS.

7 12-273
7 1-447
7 1-864

6 15-364

7 10-750

8 *8-000

lbs. OB.

6 16-273

7 13-565
7 6-097
7 5-167
7 14-000

•••

lbe.os.

8 4-000
7 9-400
7 3-520
7 2-765
6 13-333

Ibe. OS.

5 S'-OOO
7 2-125
7 10-270
7 4-289

6 15-000

7 6-000

Ibe. OB.

6 15-741

7 8-547
7 6-463
7 4-281
7 4-388

7 2-526
6 14-666

8 8000

ATer.

Toua,

7 3-157

7 4-897

7 5-597

7 8-046

7 7-223

7 6-076

7 4-991

7 4-109

Mean
Age of
Mother.

22-787
Yean.

25*806
Yean.

27-701
Yean.

30-321
Yean.

30-424
Yearfc

52-045
Yean.

36-562

25*625 f
Yean, j

Table VI

.—Showing the Average Length of Children bom
and Pregnanciee ofMothere,

at variotie Ages

^1

Prog-
nancy

1

Preg-
nancy

2

Preg-
nancy

3

Preg-
nancy

4

Png.
nancy

5

Preg-
nancy

6

Preg-
nancy

7, eto.

Total.,

209

839

674

280

142

39

3

1

15-19
20-24
25-29
30-34
35-39
40-44
45-49
50

Inebea.
18-992
19-142
19-399
19-739
19-115
19-750

Indiiea.
18-966
19-171
19382
19-250
19K)86
18-500

Inebea.
22-500
19-321
19-455
18-819
19-600
18-750
18-500

Inches.

19-682
18-697
19-125
18-250
19-260

21-000

Inchaa.

19*636
19-435
19-218
19-028
18-500

Inohea.

18-000
19-225
18-640
18-941
20-333

Inebea.

18-000
19-687
19-487
18-685
18-605
18-000

Inches.
19-007
19-168
19-355
19-229
18*899
18-910
18-166
21-000

Arer.
Totale.

19-197

19-239

19-304

18-959

19-273

18-962

18*991

19-188

Mean
Ago Of
Mother.

22-787
Year&

25-806
Yean.

27-701
Yeara.

30-321
Yean.

30-424
Years.

32-045
Yean.

35-562
Years.

25-625 7
Years, j"

1864.] ADVANTAGES OF A MORE EXTENDED UBE OF YEBSION. 503

Abticle IIL — On the Advcmtagea qf a more Extended Use cf
Version in Cases of IHsproportUm. By Andrew Inglicl
M.D.,F.R.C.S.E.

In a fonner paper I mentioned the increased use of turning to be
one of the principal meaoB by which the emplojonent of craniotomy
has been diminisnedy and suggested that it might be practised still
more extensively than hitherto, as a means both of avoiding crani-
otomy, and also of rendering it less dangerous where inevitable ;
and, moreover, stated it to be my opinion, that, where the dispro-
portion was very ^reat it was the only available means for the
certain determination of the propriety of craniotomy. I recom-
mended that, in all head presentations in which the forceps will not
succeed, turning should be attempted, even though there should be
no hope of extracting by means of it alone.

The adyantages of such a use of version seem to be the follow-
ing : — laty That, by enabling us to ascertain definitely the propor-
tion between the size of the child and that of the passages, it may
prevent recourse being had to unnecessarily seyere operative pro-
cedure, which might otherwise be resorted to from ignorance of that
proportion* 2J, That in cases which, without turning, would
require craniotomy, the application of forceps to the head, (ifter
tuminffy will often be sufficient to effect delivery with a better
result to the mother, and frequently without injury to the child.
Sdj That, even in the cases where version does not enable us to
avoid craniotomy, its previous employment seems to render that
operation easier of performance without adding in any degree to
the risk.

There can be no doubt with re^d to the first adyantage, viz.,
its usefrilness as a means of dia^osis, enabling us to avoid needless
seyerity of operation, because it is manifestly the only method by
which the relative size of the child to the passages can be determined ;
and, in the absence of such evidence, mistakes, proving serious both
to mother and child, have often occurred even in good hands. I may
mention, in illustration of this, that in cases of tuminj?, where nothing
else than craniotomy coidd haye otherwise been performed, the child
has often been unexpectedly extracted alive. Moreoyer, there have
been cases in which craniotomy has been performed, although the
deformity was so great as to detain the breech of the child, aiid
the result has been, as far as I haye been able to discover, imiformly
fatal. Some cases also have been recorded where, after craniotomy
had ifailed, the Caesarean operation had eventually to be performea.
Now, in these cases, had turning been attempted, as a means of
diagnosis, it would haye been ascertained at once whether the
breech could pass or not, and thus a great amount of time would
haye been sayed, and unnecessary injury avoided, and the propriety
of Caesarean section at once discoyered.

The second benefit gained I have stated to be, that the use of

504 DB ANDBEW INGLIS ON THE ADVANTAGES [DEC.

forceps with turning as a preliminary, may often enable us with
advantage to avoid craniotomy. Such a use of forceps has never
found its way into general practice, although there has been good
authority for it Smellie was the nrst to propose it, and when he
did deliver by this method, his results were highly satisfactory.
Dr Granville of London has followed his example, and found the
forceps so useM in such circumstances, that he has twice recorded
a series of successfdl cases. I have also met with others who, from
their success in this mode of operating, strongly advocate it.

The third advantage which I have stated to be derived from
turning, is that, should the forceps fail to procure delivery, or ap-
pear inadmissible, the operation of craniotomy will be more easily
performed after turning^ and with probably less risk than if the head
were presenting. I have been led to form this opinion principally
from the good recoveries cases are generally reported to nave made
where craniotomy has been performed after extraction of the body,
and also from the invariable shortness of the description given of
the operation. Dr Bamsbotham, in speaking of craniotomy under
such circumstances, says, that perforation alone is generally suffi-
cient; and in only a very few cases have I heard of the head
requiring to be farther broken *up. It has often happened that,
after turning, the extraction of the head entire has been found im-

Sossible ; but the description of the operation required to complete
eUvery has, in every report I have been able to find, been very
concise, leading to the inference that no great difficulty was ex-
perienced. As an instance, I may refer to the first volume of the
Transactions of the London Obstetrical Society, where the descrip-
tion of a case runs as follows : — " The occiput was perforated, the
brain washed out, the cranial bones crushed inwards, and the head
extracted. The placenta followed, the bleeding ceased, and the
patient recovered without an ill symptom." The late Dr Bams-
t)otham met with a number of cases of the kind, and yet in record-
ing them, he gives us no reason to suppose the operation to have
been rendered either more difficult or more dangerous by the mal-
position of the head. Smellie also seems to have founa it an easy
operation, if we can jud^ from the contrast between his lengthy
details of the ordinary form of craniotomy, and his concise and
simple accounts of the use he made of his crotchet after the birth of
the Dody.

On the other hand, when craniotomy is done on the head while
presenting, great difficulty is often met with, and many hours have
often been spent on the operation, even where the pelvis was so
wide as easily to permit the subsequent passage of tne body. In
addition, I would point out the fact, that cases have been related
where craniotomy alone having failea to effect delivery, turning has
succeeded in procuring extraction with such ease that we must con-
clude that, though the head had not been sufficiently broken up to
permit its propulsion through the pelvis, it had yet been broken up

1864.] OF A MORE EXTENDED USE OF VERSION. 505

much more than was tequired to allow its being drawn throBgh after
the body.

From all this I infer^ that instead of adding to the danger of the
operation of craniotomy, taming must diminish it, by enabling us
to dispense with an amount of breaking up of the head which, pw
se. is much more likely to do harm than the " operation" of tummg.
Tnere are many who, from their experience of version under ill
circumstances, assert that there is at least very little danger to be
apprehended from the operation when properly performed, even
without chloroform to quiet the uterus. Dr Kamsbotham states^
that he never saw any bad reisults from even the most difficult cases
of turning ; and his employment of the operation has been consider-
able. I mav also refer to Dr Figg's well known views and ex-
perience. Moreover, Mr B. Hicks has improved greatly on the old
method of operating, which had already been considered highly
satisfactory. I have turned frequently for malpresentation, and find
that, where the pelvis was normal, the mother has recovered much
better than after an ordinary presentation. In some, where the
pelvis was so contracted as to prevent their having a live child
without turning, the results have been quite as good. Also, in the
few cases I have had where the deformity was such as to require
traction so great, that one or two of the bones of the pelvis and
trunk of the child gave way, the recovery has been invariably as
rapid as after an ordinary labour. lii such cases I have never
hesitated to use a great deal of force in drawing the body through,
with the full confidence that, even if it came to the worst, the head
would be more easily and safely extracted in that position than if
acted on when presenting in the usual manner. The reason so
much less fracture is required after turning than before, seems to be,
that, as the occiput is the greatest obstruction^ and requires to be
fractured as near the neck as possible, when craniotomy is performed
on the head presenting, one or both parietal bones, the greater part
of the occipital, and often the frontal, have to be cut away to aUow
of that point being reached ; whereas, after turning, it is the nearest
point, and perforation alone should almost always be sufficient to
allow the bones to fall in as requited. If, on the other hand, more
than simple perforation be necessary, the hold affi^rded by the body
should be a great assistance. Besides, it must be recognised as of
the utmost importance that, in delivering the head, the force applied
is Prciction at tne centre of the resisting part, while in cases where
the head presents, it is proptUaion by a hook inserted behind the
head, involving either the employment of a much greater amount
of force or a much greater extent of fracture. An idea of the com-
parative merits of the two operations maj be obtained by the foUow-
mg illustration. If we take a hollow india-rubber ball and try to
press it through a round aperture a little smaller than its diameter,
we shall find that it will flatten out and thus increase in diameter :
and, if we make an incision in the part protruding, it will

506 ADVANTAGES OP A MORE EXTENDED USB OF TEBSION. [DEa

flatten oat still farther ; but If^ on the other hand, we attempt to
pull it through by means of a string attached to it, the ball will
elongate, and so diminish in diameter; and, if incised, will coUajpse,
even although the aperture be a small one, without farther Imiit
than is imposed by the substance of the ball.

I have now given reasons for holding that preliminary turning
lessens the danger of craniotomy by rendering the operation less diffi-
cult, prolonged, and extensive. I have further to state, that it
lessens the danger bv enabling us to perform the operation at a
much more favourable time. In all cases where the forceps are
unsuitable, or have failed to procure delivery, if turning is had re-
course to, it will be performed at once, and thus craniotomy, if ne-
cessary, will be demonstrated to be so, and consequently resolved
on and performed at a much earlier, and to that extent more favour-
able period of the labour than would be the case if the head were
allowed to remain presenting.

Besides the danger resulting from exhaustion, etc., caused by the
delay both previous to, and in the performance of craniotomy on the
presenting head, there is, it must be noted, some risk of rupture of
the uterus before delivery by the operation in question. If the
uterus ruptures during labour, the lesion always takes place after
the OS is pretty well dilated ; and a very large proportion of the
cases of rupture have met with the accident either while the opera-
tor was waiting till the labour was sufficiently advanced for the
performance of craniotomy^ or during the operation. If, on the
other hand, turning is applied to such cases, it will almost certainly
be performed before the labour has advanced so far as to render a
rupture of the uterus at all likely ; and the body being once delivered
there* is no risk of such an accident during the extraction of the
head, however lon^ the operator may delay m breaking it up.

From these considerations, I w;ould therefore strongly recommend
turning to be attempted in all cases of disproportion too severe to
permit of delivery by the forceps, unless the necessity of Cassarean
section be plainly indicated, with the full assurance that, if farther
instrumental procedure be required, instead of complicating, the
turning will be found to render extraction much more easy.

Moreover, I think, that those who admit that in cases of diffi-
culty the head can be more easily extracted by version, on account
of the advantage gained by the improved position, combined with
the increased power of adaptation consequent on that position, must
concede that, if the power of adaptation be increased by subsequent
crushing, the assistance derived from version must also in these
cases be increased.

Finally, even though great improvements in the manner of break-
ing up the head should be introduced, still the use of version as a
preliminary will continue to be a great assistance, and its advan-
tages as a means of determining the cases in which the necessity
for craniotomy exists must also continue to be of the utmost im«-
portance.

1864.] PR p. J, SIMP80N ON STPHTLIZATION. $0?

Abticlb ly. — JRemarka on Syphiliaatton w a Cure for ConstiMional
p Syphilis. By Dayid James Simpson, M.D.| Senior: Freaident

01 the Boyal Medical Society of Edinburgh.

V (Bead before the Royal Medical Society, 26<A February 1864.)

Th£9£ are few or no diseaaea in the attempted cure of which 09
many different medicines have been employed as in that of consti'^
tutional syphilis. From its first appearance in Europe down to tl^§
present day, numerous endeavours nave been made to discover some
drag which would prove a spedfio for this formidable mfblady^ but
without success. After we nave ransacked the domains of medicinei
and iilmost exhausted the pharmacopoeia in vain, the sister sciepce
of surgery has placed at oiur disposal a simple operatioui by the
employment of which the disease may with certainQr be cured.
This operation, which consists of repeated inoculations of phancres
upon tne bodies of persons labouring under constitutional syphilis,
has been named by Au^ias-Turenne, its discoverer, Syphilid
ZATION, The announcement of Aiizias^Turenne, that the syphi^
litic taint could in this way be removed from the constitution Wj
^ during the last eleven years, been verified by the es^periments of

M, Sperino. of Turin, and more especially by those of Professor
Boeck, of Qhristiania, to whose labours we are indebted for thq
^ greater part of our knowledge of this wonderful remedy.

Before proceeding to the consideration of the treatment itself,
allow me to lay before you an abstract of two cases of very severe
constitutional syphilis which defied the ordinarily employed curative
means, but which, imder the care of Professor Boeck, yielded at
once to syphilization.

Case 1. — Mr -^ — , contracted a chancre in the year 1853. After
the lapse of a few months^ the tonsils began to ulcerate. The ulcers,
however, healed up under repeated applications of nitrato of silver,
Iodide of potassium was then exhibited internally in conjimction with
sarsaparilla. No ftirther symptoms manifested themselves until th^
month of March 1858) when an ulcer fi)rmed on the inner side of
^e right knee, which healed up after being blistered and strapped.

In December 1859, the tonsils and soft palate became extensively
ulcerated. No local application seemed to be of any ayail in check-
ing the ulceratioD, and the constitutional treatment by iodide of
potassium and sarsaparilla proved eoually powerless. In August
* 1861. the patient came to Edinburgh tor advice. He was e:iamined

at this time by several of the most eminent physicians and surgeon^
in the city. His tonsils and soft palate were almost entirely der
stroved by ulceration. He looked quite cadaverous, and was so
wealc that he had the greatest difficulty in walking His condition
was the more alarming, as seyeral members of his family had died
pf phthisis. He was advised to proceed to Christiania, and submil^
as a last resource, to treatm0i>t by sypbili3i^tion. This he did { wd

VOL. X.— NO. VI. . 3 T

508 DB D. J. SIMPSON ON STPHILIZATION. [DEC.

arrived in Christiania on the Ist of September 1861. On his arrivaL
he put himself under the care of Professor Boeck, who commenced
treatment at once by inoculating him on the chest with matter from
an indurated chancre ; re-inoculating eveiy third day with matter
from the previous pustules.

At the end of a fortnight, the patient's appetite, which he had
almost lost, became ravenous. He could also walk without experi-
encing much fatigue. Three weeks later, inoculation failed to pro-
duce any result ; the successive crops ot pustules having become
graduallv smaller, the last proving abortive.

Inoculation was then tried on the arms ; and pretty large pustules
followed. After thi^ee weeks' treatment, the pustules aborted here also*

The patient left, completely cured, on the 1st of December 1861,
having gained three stones in weight, and expressing himself as
^' almost as well as he ever had been in his life.

Case n. — Mr was advised, in the summer of 1861, to go to

Christiania and to place himself under the care of Professor Boeck.
for a very severe attack of tertiary syphilis. Six years had elapsea
since he contracted a chancre. In the summer of 1861, when he
came to Edinburgh seeking advice, he had a large syphilitic ulcer
over each tibia, and one over the left clavicle. Perforation of the
palate had taken place, and some pieces of bone had come awa^
from the interior of the nose. The frontal bone was swelled, indi-
cating the commencement of a corona veneris. The ulcers were
very obstinate, and continued to increase in size, in spite of treat-
ment.

The patient had previously undergone a complete course of
mercury on two or three occasions. He had been treated by the
heads of the profession in Edinburgh, London, and on the Continent
of Europe, without experiencing the slightest benefit, and despairing
of recovery, he determined to go to Christiania. So reduced was
he, that he had to be carried on board the steamer on leaving
Britain, and from it on his arrival in Norway. He underwent a
course of syphilization ; and so rapid was his return to health and
strength, that within two months after the time of his landing in
Norway, he was able to hunt. After an absence of three months,
he returned home perfectly cured.

The cure in this case was the more remarkable, as the patient
was labouring under an enormously enlarged liver, which he had
acquired in China, when serving there as an officer in the army.

I had an opportunity of seeing both of the patients whose cases
I have described immediately after their return from Christiania.
Both spoke in confident terms of the treatment Up to the present
time, neither of them has had the least sign of a relapse.

. Syphilization may be practised in one of two ways ; either with
matter from a aofi;^ or with matter from an indurated chancre. A
patient comes for advice labouring under constitutional syphilis,
whom we purpose to treat by syphilization, employing only matter

1864.] DB D. J. SIMPSON ON STPHILIZATION. 509

obtained from gqft chcmcrea. K pustules resulted from inoculation
with matter from a soft chancre^ we would re-inoculate the patient
on the third day with matter fix)m such pustules, continuing this
treatment till further re-inoculation failed to produce pustules. We
would then commence anew with fresh matter from a soft chancre,
and proceed in this way until no matter from a soft chancre which
we could possibly procure would produce pustules.

The same may be done by connning ourselves to the employment
of matter from indurated chancres; for, contrary to the doctrine
commonly promulgated, that no pustule will result from the inocu-
lation of matter from an indurated chancre, the practice of sphili-
zation has shown us that matter from an indurated chancre is very
nearly, if not quite, as capable of inoculation as that from a soft
one. Matter from a soft chancre, however, is capable of transmis-
sion through twice as many generations as matter from an indurated,
f.e., if matter from an indurated chancre is worked out after twenty-
five consecutive re-inoculations or generations, fift^ generations will
have to be reached ere a like result be obtained with matter from a
soft chancre. Thus we see that if we confine ourselves to the
employment of matter from indurated sores, a cure will be efiected
in much less time, and with the production of fewer chancres than
if matter from soft sores were substituted. Further, by this means
the chance of relapse is reduced to a minimum ; for. during the
last three years, during which time he has confinea himself to
inoculation from indurated chancre. Professor Boeck has not re-
corded a single relapse} whereas, for the seven or eight years
immediately preceding, during which time he made his inoculations
from soft chancres alone, the relapses amounted to nipe and a-half
per cent.

The long duration of the treatment is a very commonly advanced
ground of objection to the practice of syphiliaation, But we see
mat, by substituting the indurated for the soft chancre, not only is
the cure more perfect and the chance of a relapse diminished, but
the duration oi the treatment itself is immensely' curtailed.

Most late writers on the subject of syphilis maintain that the
poison giving rise to an indurated chancre is essentially different
irom that which causes a soft chancre ; but Professor Boeck has
pointed out that both forms of chancre are the result of one and the
same virus. According to him, it depends only on the difference
of intensity of the virus whether a soft or indurated chancre be
produced. If the virus be very intense, a soft chancre results, the
intensity of the virus givine rise to so much inflammation as to
prevent absorption. The indurated chancre, on the contrary, is the
product of a weaker virus, in which case the inflammation developed
IS not so great as to lay any impediment in the way of absorption
into the system taking place. Very intense virus gives rise to a
aUmdard aofij less intense, to a standard indurated chancre. Virus
intermediate in intensity to these two extremes gives rise to inter-

bio Dtt b. Ji filMI^SON 6N STPdltH^TtOKi [DEC.

mediate formd, so that otur prognosis must be tilways eitremely
guardod as to whether Seoonaary symptoms will ultimately Supei^
vene,

I'he following result is often ohserred in syphilizating a pfttieht)
atid to my mind nndeniably proTcs the unity of the Tims.

Whenever we inoculate with matter from a chancre suppurating
profusely, such inoculation is almost certain to succeed. In many
cases some of the ulcers, ^nerally a small proportion^ will begin
to become indurated at the base. As the inauration increases, the
suppuration diminishes, the secretion from the surface of the ulcer
becomes gradually more serous, and it is almost impossible to
proToke sores by inoculation. Finally, inoculation will fail in Mo.
When such a result is arrived fcit, if we cover the chancre with lint,
at the end of about twenty-four hours we shall find a copious, thick,
and purulent secretion re-established, the inoculation of which wijlj
in most cases, give positive results, even when the induration is
excessive.

This also shows that the syphilitic vims may decrease in in-
tensitv ; for, starting with matter which gave positive restttts, we
find that as we proceed with our inoculations the matter becomes
less powerAil, as is demonstrated b^ the ulcers becoming induiated
at the base, and failing at last to give any result.

But as in some cases the strength of the syphilitic matter gradually
diminishes, so in others an increase of virulence is remarked.

Inoculation with matter from pustules which are abeady under-
going the healing process only produces small pustules, which dis-
appear in a short time. But by persevering in our inoculations we
shall be rewarded by producing larger pustiues in the ensuing gene-
rations. I will quote one example in support of this statement.

A man presented himself at the Christiania Hospital with com-
mencing constitutional syphilis, and with an indurated chancre not
entitiely cicatriBed. He was inoculated with the matter from his own
chancre. Very insignificant, almost abortive pustules resulted ; but
by continuing the inoculation every third day fix)m the preceding
pustules, in the sixth generation small ulcers were at length obtained.
From this moment perfectly characteristic chancres were developed
during several succeeding generations.

The results of the first five cases subjected to treatment bv sphili-
totion by Professor Boeck prove even more positively that the viitis
may increase in intensity.

Two syphilitic patients weiis inoculated with matter from a soft
thancre. The duration of treatment in both cases exceeded six
months before complete immunity was obtained; 222 chancres
having been produced on the one, and 290 on the other. After
they had been under treatment for four months, matter was trans-
planted fipom one of them to two other patients labouring under
xsonstitutional syphilis. Immunity was obtained in the two latf)er
at the end of three months; one having had 133 chancres, the

1864.] DB D. J. SIMPSON ON 8TPH I LIGATION* 511

Other 168. A fifth patient was inocokted with matter fix>m the
first two after thej nad been under treatment for five months.
Immunity was obtained at the end of two months, 71 chancres only
haying been neoessarr.

Thus we see that the varieties of chancres glide by slight pada--
tions into one another, their different forms bsing due to variations
in the intensity of the virus, and possibly to some disumil^ty of
constitution in the persons affected.

No satisfactory tneoxy to account for the extraordinary disappear-
ance of the constitutional sjinptoms under a course of syphilization
has yet been advanced. l5r Daniellsen, of Bergen, has mooted the
idea that the action of the remedy is purely depuratory. This
theory he grounds on the fact, that when syphilis has advanced to
the tertiaiy stage^iature very often eflfeots a cure by the production
of deep ulcers. Dr Daniellsen is an upholder of the duidity of the
syphilitic virus ; and as he confines himself to the employment of
matter from soft chancres for syphilization, he believes that he
effects a cure by means of supemcial ulcers caused by a simple
irritating virus. If this be the proper view to take of his reasons
for practising syphilization, any other irritant would serve his
purpose equally well. In consequence of many persons holding
this view, experiments were set on foot in Christiania to ascertain
whether by means of irritants an equally happy result could be
obtained as by sjrphilization. Pustules producea by friction with
tartar emetio ointment were the media employed. The committee
appointed to investigate " Tartarization" report as follows :> — ^' The
members of the committee all agree that they do not know any
manner of treatment which works more efficaciously or even so
efficaciously as syphilization does in oases of secondary syphilis in
individuals not previously treated by mercury."

That the ulcers produced should lie syphilitic, and syphilitic alone^
seems to be the ^reat secret of success, as is shown by nature herself
throwing off the disease by the production of tertiary syphilitic ulcers^
This is also seen in the method nature employs to get rid of the
vims of a soft chancre. In this case the inflammation is excessive,

S'ving rise to a suppurating bubo in one or other groin ; and by
is suppurating surface the poison is apparently thrown off.
Instituting a comparison between syphilization and the other
methods in common use for the treatment of s^hilis, syphilization
undoubtedly bears off the palm. The following tables nave been
drawn up from the records of the Christiania Hospital, and give
the results of the cases of syphilis treated there since 1825. The
tables include the results obtained by (1) mereury, (2) iodide of
potassium, (3) syphilization, and (4) tartarization : —

Table L—Bemlta of treatment hy Mercury from 1825 to 1856.

Three thousand two hundred persons have been treated by
mereurv in some form or other* The duration of treatment in
these three thousand two hundred oases amounted to four hundred

512 DB D. J. SIMPSON ON 8YPHILIZATI0N. [DEC

and one thousand nine hundred and sixty^nine dajSj giving an
average of about one hundred and twenty-five days for the treat-
ment of each case.

Of these three thousand two hundred cases, ten hundred and
thirty-six had a relapse, which gives an average of about thirty-
two per cent.

One hundred and eight of the patients died. Twenty-nine of the
hundred and eight died when under treatment for a relapse.

Table IL — ResuUa of treatment by Iodide of Potassium from
1838, when it %oas first generally adopted in the Christtania HospitaL
till 1856.

One hundred and eighty^six persons have been treated by iodide
of potassium. The duration of treatment in the hundred and eighty-
six cases amounted to ten thousand nine hundred and four days,
giving an average of about one hundred and eight days for the
treatment of each case.

Forty out of the hundred and eighty-six had a relapse ; which
gives an average of about twenty-one per cent.

Two of the patients died whilst under treatment.

Table III. — Results of treatment by Syphilizaiion from 1852
to 1862.

Up to the beginning of the year 1862, Professor Boeck had
treated for constitutional syphilis by the process of syphilization
two hundred and fifty-two persons who had not previously under-

fone a course of mercury. The duration of treatment for the two
undred and fifty-two cases was thirty-three thousand eight hundred
and twenty-eignt days, giving an average of about one hundred
and thirty-four days for the treatment of each case. In four of
these cases, two of which were cases of syphilis of a malignant
type^ iodide of potassium was employed in conjunction with syphi-
lization.

Twenty-three of the patients had a relapse. Twenty of them
re-entered the hospital for treatment, three naving been treated in
the town by iodide of potassium. Of the twenty who re-entered
the hospital, nine were treated again by syphilization, one of whom
had a second relapse, and was again subjected to a very short course
of syphilization. One was treated by iodide of potassium, and ten
by^ external remedies ; the duration of treatment in all the cases
being very short.

From this it appears that the average of relapses after syphiliza-
tion was nine ana a-half per cent.

Eighteen infants with hereditary syphilis, one infant with ac-
quired syphilis, and one woman aged 60, died. The infant attacked
by syphihs died of croup, and the woman of dysentery.

Fiftv-four individuals were syphilizated who had formerly been
treated by mercury, and had had a relapse. The duration of

1864.] DR D. J. SIMPSON ON STPHILIZATION. 513

treatment m the fiftj-fonr cases was ten thousand three htmcbred
and thirty-fiye days, giving an average of ahout one hundred and
^ ^ ninety-one days for each case. In addition to syphilization^ iodide

of potassium was employed in ten cases. Ten oi the fifty-four had
a relapse, or about eighteen and a-half per cent. Seven of the ten
^ were sjpnilizated anew, the other three being treated by iodide of

potassium. '

Six individuals were treated and cured by syphilization, who
had been previously treated by mercury, witnout any cure what-
ever having been effected. The duration of treatment in the six
cases was two thousand two hundred and forty-four days, giving
an average of three hundred and sevenlr-four days for each case.
Two of the six had a relapse, or thirty-three and a-third per cent

Table IY. — Remits qf trecUmeiU by Sores jproduced by JricHan
with tartar emetic ointment.

One hundred and fifty-seven persons have been treated by sores
produced by friction with tartar emetic ointment. The duration of
treatment in the hundred and fifty-seven cases amounted to twenty-
seven thousand nine hundred and ninety-four days, giving an
^ average of about one hundred and seventy^-eight days for the treat-

ment of each case.

Thirty-one of the hundred and fifty-seven had a relapse, which
t gives an average of about twenty per cent.

In comparing the average of relapses afteir the different methods
of treatment, we see that after mercury thirty-two toer cent, relapse ;
after iodide of potassium, twenty-one per cent. ; aner syphilization,
only nine and a^half per cent. As 1 previously statea, however.
Professor Boeck, since he has confined nimself to inoculating with
matter firom indurated chancres, has not had to record a dingle relapse.

The two modes of treatment which claim our chief attention,
are syphilization and tartarization. Afteir tartarization twenty per
cent, relapsed, after syphilization only nine and a-half per cent.,
or, accoraing to Boeck's last series of experiments, not otoe» The
greatly diminished chance of relapse, as well as the possibility of
arriving at a certain point of immunity where we can pronounce
our patient caredy which cannot occur with tartarization* — ^as in the
latter case we can produce sores ckf ir^nitum — shows the superiority
of syphilization ovef every method of treatment which has yet
\ ^ been proposed.

X At its first introduction, discredit was brought on the practice by

its discoverer, Auzias-Turenne, proposing to employ the remedy as
a prophylactic, like vaccination. This, of course, is revolting to the
mmd of every practitioner. Moreover, syphilization does not act as
a prophylactic, as one or two cases after having been cured by the
treatment have subsequently contracted a fresh chancre, which has
been followed by constitutional syphilis.

Nor is its employment as a remedy for the primaiy sore in any

614 D« T>. J. SIMP0ON ON 8TPHIU:SATI0N. [P£a

degree a justifiable prooeeding; for we can never tell whether
any chancre will be for certain followed by constitutional syphilia.
But as a remedy for the (Hm^dtutional disease it stands pre-eminent,
for syphilization appears capable of curing every oase of consti*
tutional syphilis.

Surely, instead of being summarily rejected, as it hits been in thia
country, the remedy is entitled to a fair and impartial trial,

ABTICI4E v. — Introductory Lecture at ike Medical Sckcol, Surgeone^
Ball By SrfiVENaoN Macadam, Ph.Dt, F.B.S,f!,| Lecturer on
Chemistry,

The commenoement of a Winter Session in this Medical and
Surgical School has for a number of years been made the oppor-
tunity of the delivery of an introductory address ; and, in order of
seniority of lectureship, I am called upon to-day to fulfil the task
of brea&ing the silence of the vacation, and of sounding the alarm
note which is the prelude to the regular work of the session,

To the senior students who have returned onoe again to these
benches, and whose familiar faces connect bygone years with the
present, let me, in a word, in the name of my colleagues and myself.
Did jou most heartily welcome back again to the scene of your p»^
fessional labours : and to the junior students, who this year begin
their medical career, and who occupy the benches of a medical ^d
surgical class-room for the first time, let me 9S heartily bid you
welcome to these rooms.

That senior and junior students should each in their turn have
imparted to them an enlightened and well-grounded knowledge of
the. profession of medicine and surgery is we earnest desire of all
my colleagues and myself, and that after-success in life may be the
lot of you all is the heartfelt wish of each one of us.

In the professional study of medicine, many branches of science
require to be attended to ; and though some may be reckoned a^
more important than others, yet none can be regarded as not
essential. It is true that a surgical operation, to be successful, need
not require a knowledge of the chemistry of the bone qk the muscle ;
and it is equally true that the administration of an opiate or ^Hpy|{£^
gative does not necessitate a knowledge of systematic or practicSlN^
surgery. '^

At no previous time, however, has it been more apparent, that
the various branches of medical science form part 01 one great
whole ; and that it is alniost impossible to draw the line between
one branch and another. It would be hard to say where chemistry
ends and materia medica begins, or where chemiistry ends and
physiology begins ; for the chemical properties and actions of sub-
stances can be scarcely understood without a knowledge of their
chemical composition ; and the relations of food to the animal system

1864.] DR STEVENSON MACADAM'S INTRODtlCTORY LECTURE. 615

in the building np and breaking down of the animal frame, can only
be darkly determined without a knowledge of the composition of
^ ^ diet and of tlie bodily structure. And more than that, the physi-

cian and surgeon of the present day is required to learn the lesson
that his duties demand that he shall not only be well versed in the

^ treatment of serious ailments, and the performance of formidable

operations, but that he should know well the common-sense science
of every-day life. That he should understand the natural relations
of man to the world around him, and remember that prevention
is better than cure. That he should intelligently advise and arrest
the causes of those little illnesses which enfeeble the constitution and
render it open to serious ailments.

Much can undoubtedly be done by preventive measures; and
though at first sight it would appear to narrow-minded men to be
bad policy for the physician ana surgeon to keep people well and
prevent them from getting ill. yet the intelligent and n^ht-minded
medical practitioner knows tnat, whilst much ill health m a family
betokens, in most instances, pinched means and scanty fees, better
health signifies family prosperity, more liberal fees, and grateftd
hearts ana thanks besides.

^ Much attention has recently been devoted to the important

question of the diet of all classes ; and the British Government has
tne credit of being the first to institute an official inquiry into the
,• relative nutritive values of the various diets. This country is still

the only one where the food of the people has been made the sub-
ject of a Government commission. The dietary scales adopted in
this country are of the most varied description, not only in regard
to kind or G[uality, but also in regard to (quantity. And whilst each
household is free to use what special article of diet they may fancy,
even prisons, workhouses, and barracks conform to separate systems
or scales, which often present the greatest anomalies.

The inquiry is of great moment to all classes ; not only to the
under-fed class, who ought to be told what articles and mixtures of
food are most profitable in a nutritive point of view, and how they
can best spend their pence, but to the over-fed class of all grades,
so that they may know what quantities of food are consistent with
the healthy state of the system, and bevond which indulgence must
lead to superfluity, which is surfeit, with the evils attendant thereon.
The whole question of the diet of the people is of the greatest im-
portance to the medical practitioner, who may be called upon to

■# report upon the victualling of barracks at home and abroad, who

may have the medical charge of men-of-war at home or at foreign
stations, or who may have the medical convoy of emigrant or troop
ships : who may also have the medical supervision of prisons or
workhouses, or who may have the more general work of a parochial
sur^on. Questions as to the sufficiency of the diet, or as to the
advisability of an alteration therein may be submitted to him, and
the many awkward changes which have been made at times in the

VOL. X,— -NO. VI. 3 u

616 DR STEVENSON MACADAM'S INTRODUCTORY LECTURE, [DEC.

diets of the poptilation of our prisons and workhouses show that a
knowledge of tne principles which ought to regulate the diet of a
people has not received that professional attention which the im-
portance of the subject demands.

The first attempt at a proper scientific classification of diet was
made by Liebig, who divided the elements of food into heat-^r<H
ducing and jlesh-jbrming ; and he likewise noticed the importance
of the saline substances which generally accompany and are par-
taken of along with the more ordinary food. Dr Edward Smith
has recently gone into the whole subject of the classification of food
with the greatest care, and he is inclined to determine the value of
the components of food according to the quantity of carbon and of
nibrogen. This view is practically the same as that of Liebig ; for
the neat-proditcin^ elements of food are those whose carbon can be
readily burned within the living system, and thus supply the animal
warmth ; whilst the fieah-forming ingredients are those which con-
tain nitrogen^ and whose particular office in the living firame is to
replenish the flesh or muscle which is daily being disintegrated,
and the momentary destruction of which, constitutes the ordinary
wear and tear of the animal svstem.

The relative proportions of the heat-producinq or carbon elements
and the flesh-forming or nitrogen elements of /ood vary much, and
the cost of their purchase, likewise, differs greatly in even the more
common articles of ordinary consumption. Besides, there is the
important question of the relative digestibility of the various in-
gredients found in food, as exemplified in the cases of starch, gum,
sugar, and oil, on the one hand, and lignin or woody fibre on the
other; the latter being as strictly one of the heat-producing or
carbon elements of food as either of the former. A good instance
of the difference of the feeding value of similar substances occurs
in the case of white bread and brown bread. The former or white
bread, when dried at 212** F., yields about 2*27 per cent, of nitrogen,
which is equal to 14'8 per cent, of flesh-forming ingredients ; whilst
the brown bread contains about 2*63 per cent, of nitrogen, which
is equivalent to 16*43 per cent, of flesh-forming ingredients. The
brown bread, therefore, which is made from the whole grain, is
richer in nutritive matter than the white bread ; but the husky part
of the grain which ris present in the brown bread, and contains some
of the nitrogen, is much more difficult of digestion than the finer
flour. Moreover, the brown bread, firom the comparative gritty
character of the husk, causes an irritation in the alimentary canal,
and tends to purge the individual, and thus causes the nutritive
matters to pass oat of the system before time has been allowed for
their proper digestion and assimilation. In fact, the bran acts
medicmally, and a knowledge of its tendency to physic is very
much the reason of its employment in part by the better classes.
The giving of brown bread to the farm labourers of England has
proved that the diet is not a satisfying one, and its adoption in some
of the prisons for a short time led to me eiuiibition of symptoms of

1864.] DR STEVENSON MACADAM'S INTRODUCTORY LECTURE. 617

an inBurrection ainon|; the inmates. Children, likewise, who have
often correct instinctive notions regarding the value of articles of
food, almost universally dislike and condemn brown bread.

Dr Edward Smith, taking ordinary white bread as his standard,
has constructed several instructive tables of the relative values of
the various articles of diet One lb. of white bread contains about
2000 grains of carbon and 89 mtins of nitrogen, and costs, on the
average, Ifd., nearly l^d. ; and reducing these proportions to the
value of Id., the following table of the amount of carbon and
nitrogen which can be purchased in various common articles of
food for Id. has been constructed : —

Id. worth of—

Carbon.

Nitrogen

«

( Ordinary white brej
Oatmeal, .

&d contains . 1450 grains
. 1613 „

and 66 grains.
„ '76 „

1 Indian com or maiz

e, . . 2800 „

„ 121

From
Vegetable <
Kingdom.

/ Peaa, whole,
\ Rice,

. 1820 „
. 1380 „

„ 36

J Potatoes, .

f VegeteblcB (mean).

. 1640 „

„ 49

,1

. 1230

I 42

19

k Sugar,

. 622 „

»

19

f^Beef,

. 320 „

» 23

)>

Mutton,

. 415 „

„ 20

f)

Pork,

. 483 „

!, 18

19

From

Fat (suet), .

. 667 „

» —"

99

Animal <

: Butter,

. 327 „

fj ~"~

,y

Kingdom.

New milk (mean), .

. 409 „

;; 33

99

Skimmed milk (mea

n), . . 874 „

„ 87

99

' Butter milk (mean),

. 1676 „

,,176

99

^ Cheese (mean).

. 667 „

„ 81

99

The relative values at which the carbon and nitrogen elements
in food can be purchased may be more readily observed from the
following statements.

The standard quantity of carbon procurable from Id. worth of
wheaten bread may be obtained in maize or Indian com for \^.y
in peas, vegetables^ potatoes, rice, buttermilk, and oatmeal at from
^. to Id., in skimmed-milk cheese, from 1^. to 2d., in suet, sugar,
and lard, from 2d. to 2^d. ; in new milk, pork, mutton, beef, ana
butter, fix)m 4d. to 4^.

The standard amount of nitrogen as derived from bread at Id.
may be procured from buttermilk, peas, and Indian com, at ^. ; frx)m
skimmed-milk cheese and oatmeal, at fd. ; from potatoes and vege-
tables, at 1^. : from rice and new milk, at 2d. ; from beef, mutton,
and pork, at 3a.

The average daily allowance of carbon and nitrogen for an adult
has been calculated to be 4600 grains of carbon, and 300 grains of
nitrogen, as these proportions of carbon and nitrogen are evolved
as carbonic acid and ammonia by the lungs and the pores of
the skin, and as urea, uric acid, and other compounds by the
kidneys and bowels. Dr Edward Smith has calculated that the
labouring classes of England receive dailv in their food an average
proportion of 5279 grains of carbon, and 216 grains of nitrogen,

518 DB STEVENSON MACADAM'S INTRODUCTORY LECTURE. [DEC.

and they preaerre their health ; so that these proportions may not
be regarded as under the proper allowance. A mixed diet of
vegetable and animal matter is preferable^ as the vegetable
matter is generally deficient in nitrogen, but contains an excess of
carbon, and the animal matter has a deficiency of the carbon
element and an excess of nitrogen ; so that when the vegetable and
animal matters are conjoined, the proper proportions are obtained.
Animal food^ moreover, is readily assimilatea, and hence, thoa|^h
dearer at first cost, yet is more valuable from the facility of its
appropriation by the animal frame. Vegetable food, on the other
hand, nas an important influence in sustaining the animal svstem in
a good, healthy condition; and the benefits derivable nom the
lib^al use of fresh vegetables and fi-iiits in scurvy are well known.

The allowance of food in the British navy is from 31 to 35^^ oz.
of djy food per day : of which about 26 oz. are vegetable, and the
remainder is animal. The ordinary ration of a British soldier is
f lb. of mutton or beef, 1 lb. of bread. 1 lb. of potatoes, and tea
and cofiee for breakfast and supper. These quantities are regarded
as barely sufficient for the wants of a recruit at hard work at drill^
but sufficient for a corporal, who has less expenditure of muscular
force, or for an old soldier who is leaving the ranks. In the
military prisons in Ireland, the soldiers who are prisoners receive
daily 8 oz. oatmeal, 8 oz. Indian com meal, 8 oz. wheaten bread,
and 1^ pint of milk j the whole being divided into three mealsj
and the healthiness of this diet is observable in the fact that, whilst
the mortality in the British armv was at the rate of 17 in 1000,
that in the military prisons in Ireland was only 2^ per 1000.

The avera^ proportional Quantity of food oonsumed by various
classes of society has been reckoned as follows :--»

Agricultural labourers, , . . . 122

Artisans, Qrst class, , . . . .140

Paupers, ...... 150

Soldiers, . . , . . .168

Prisoners in jail, . . . . .217

Convicts in hulks, of transported felons, . . 237

#
In the prisons of England the quality and nature of the diet
varies so much that the cost per head ranges from Is. 2d. to 5s.
and even 7s. each week.

In common-sense cooking, when soup only is being prepared,
the meat is put into the water when it is cold, and the whole is
then gently warmed : whilst, when the meat is required as well, it
should be placed at first in hot water, which coagulates the exterior
albuminous ingredients, and thus forms a skin or coating which
retains the most of the nutritious elements. Even in the latter
case, however, some of the feeding qualities of the meat pass into
the soup, and therefore the latter should be partaken of along with
the meat. Till lately, the meat supplied to the soldiers of the
British army was boiled, and the soup being thrown away, the

1864.] DB STEVENSON MACADAM'S INTRODUCTORY LECTURE. 519

boiled meat was alone giyen in the rations. This system of robbing
the meat of much of its strength has been done away with, and the
establishment of a school of cookeiy at Aldershot nas done much,
and will still do more, to place the cooking for the army on a satis-
factory footing. I trust that the medical men of the army will
keep pace in the science of the soldiers' food with the military cook
in the practice of that important and necessary art. Bad cooking
undoubtedly leads to mucn waste of useful material ; whilst good
cooking may be regarded as a saying of the necessaries of life.

Becently, much public attention has been directed to the plan of
reducing corpulent personages, known as the Banting sj^stem. There
can be no aoubt that the plan has been successml in ^ying the
necessary relief to many persons, but I am strongly of opinion that
there is great cause for the protest which Dr Edward Smith has
made in regard to the adoption of this plan by all and sundry of our
more corpulent brethren, and the necessity for caution being obsenred
in adopting the system, except imder medical superyision.

The true cure for corpulence is a restriction in the absolute
quantity of food, more than in the relatiye proportions of the con-
stituents. The abstraction of starch, sugar, and such like heat-
producing or carbon elements, and the supplying of flesh-forming or
nitrogen elements in their stead, can only lead to an unnatural diet,
which loads the system with a superabundance of the flesh-forming
or nitrogen elements.

In the diet of a large number of prisons, Mr Chadwick has ob-
seryed a curious anomaly in regard to the effect of an increased
amount of stimulating food. Out of 104 prison returns, he contrasts
the health of the prisoners in relation to the quantity and expense
of the diet. Thus —

Food
per week

UlOODCeB.

Cost per
per week.

Sick

in

100.

Deaths

m
1000.

20 prisons, lowest diet, 188
20 „ medium diet, 213
20 „ highest diet, 228

Is. lOid.
28. 4id.
38. 2d.

3
18
23i

4

Augmentations of food, therefore, are apparently mischieyous, and
where the diet does not exhibit satisfactory results, recourse should
be had to yariety of food rather than to increased quantity.

In so simple a matter as the condition in whicn food should be
partaken of, there is eyen a difference of opinion. The high condi-
tion in which game is often eaten in this country is open to question
in a health point of yiew, as there can be no chemical difference be-
tween a putrefying grouse or black cock and a putrefying leg of
mutton or roast of beef. The inhabitants of the Faroe Islands con-
sume their meat in a decayed state, and conclude their meal by a
tit-bit of flesh, fowl or fish, which is full of liye maggots. The
Faroese are yery subject to intestinal complaints.

Another important matter which claims special attention at the

620 DE STEVENSON MACADAM'S INTRODUCTORY LECTURE. [DEC

S resent day is the question of public health ; and whilst it is not my
esire to enlarge upon the topic as to whether smells or stinks are
bad things to live amongst, or whether it is advisable to remove
from our neighbourhood the effete and putrefying remains of our
ever-decaying bodies ; believing, as I do, that common sense dic-
tates that stinks are not only abominable but pernicious when they
are given birth to by decomposing animal matter, I am still desirous
that certain facts in regard to public health should be laid before
you.

Our knowledge regarding sanitary matters has been principally
collected and arranged by the labours of the Earl of Shaftesbury,
Southwood Smith. Edwin Chadwick, Rawlinson, Simon, and Dr
Farr; and the Public Health Act of England, introduced first in 1848
and revised in 1858, as well as the Police Improvement (Scotland)
Act of 1862, are the results of the knowledge obtained in sanitary
affairs, and the public expression of the opinion that much can be
done to remove causes ot disease and ill-health, and alleviate^ to
some extent at least, the miseries of our poorer brethren and of our-
selves.

The average death-age of the people of England is 46 years, and
it is considered by sanitary reformers that if the various conditions
essential to the preservation of perfect health attainable by man
were complied with, that the death-a^e need not be less than 80
years. In certain of the agricultural districts of England, compre-
hending a population of 1,000,000 persons, the rate of mortelity is
17 in 1000 ; whilst the worst urban districts show a death-rate of
36 in 1000, and the average of all England is 22 in 1000. About
half a million people die in England every year, and if the average
mortality could be reduced from 22 to 17 in 1000, which is ^e
death-rate of the better districts, there would be a saving of 100,000
lives every year.

The average death-rate in any countrv is necessarily much influ-
enced by the position of the people, and the age of the individuals
likewise leads to great variations. Thus in England : —

AVERAGE AGE OF DEATH. RATIO OF DEATH.

AUages.

Adalts.

ChildreiS^

44

60

lin4i

25

51

lin2i

22

49

lin2

Gentry,

Small tradesmen,

Labourers,

And thus it is plainly observed that the well-to-do people have a
greater expectation of life than those in less favoured circumstances.
The average death-rate in Scotland is 1 in 48 persons, which in-
cludes all districts. In the eight principal towns of Scotland the
death-rate is 1 in 37 ; in Edinburgh, 1 in 42 ; in Leith, 1 in 45 ; in
Fife, excluding two towns, 1 in 57 ; in four northern counties, 1 in
62 ; in four lowland counties, excluding two towns, 1 in 65 ; and in
Berwickshire, 1 in 70. The increase in the mortality of a district

1864.] DR STEVENSON MACADAM'S INTBODUCTORT LECTURE. 521

also denotes an increase in the sick-list — ^in those little illnesses
which do not result in death. The 100,000 deaths re^rded as
preventibie in England would certainly represent ten times that
number, or 1,000, WO, of preventibie illnesses, and the mere money
value of such can hardly be over-estimated. Indeed, during a life-
time, the amount of sickness which falls to the average lot of us all
is truly alarming when correctly estimated. One of the provident
societies has shown from its statistics, that for one death of a
member there are 465 days of sickness amongst the whole members,
which in reality gives an average of about one and a quarter year's
illness to each of their members after joining the society and before
his death.

In the navy the death-rate for the three years up to 1858 was,
from disease, 18*70 in 1000 ; and from accident, 4'63 in 1000 — in
all, 20*25 per 1000; and the merchant service for the same period
showed a death-rate from disease of 10*98 in 1000 ; and from
accident, 8*87 in 1000— in all 19*85 per 1000. The average death-
rate in the merchant service for the ten years 1852 to 1861, was
20*66 in 1000.. The men who are attached to the navy are
generally picked men, ranging from 18 to 45 years of age. They
have been subjected to medical inspection, and are constantly under
medical supervision.

The same remarks apply to the army. Till lately the death-rate
in the army at home averaged 17*5 in 1000, though now, by aflFord-
ing more sleeping space, and by paying more attention to the
cooking of food and tne clothing of the men, the average mortality
has been decreased to 8^ ; whilst at Aldershot and Shomcliife, by
the labours of Miss Nightingale and others, the mortality on the
average of the three years 1858, 1859, and 1860 was only 4*7 in
1000. This saving in the lives of the men of the army is ftJly 12
in 1000, and in an army of 80,000 is equal to 960 men a-year, or
an entire regiment of trained soldiers. The Crimean campaign was
a most disastrous one for our army in respect to sickness. From
the time of leaving our shores till its return, the army, on an
average strength of 34,500 men, had lost no less than 20,800 men,
of whom only 5000 died in action or from wounds, and the 15,800
died from cholera, fever, and other causes. Out of 12,000 men who
marched from Varna to the well-known malarial region on the
south of the Danube, only 7000 returned to Varna ; and so severe was
the attack of disease, that out of one regiment, 300 men were attacked
within a few hours, and the majority of these died. Had the army
been placed in the healthier districts of England, with the mortality
of these districts, only 610 deaths would have occurred from disease
in the two and a-nalf years of the Crimean war, in place of
15,800.

The mortality in the convict prisons of England, where sanitary
regulations are enforced is now very satisfactory, considering the class
of people and the habits of those from whom the prisoners are

522 DB STEVENSON MACADAM'S INTRODUCTOBT LECTURE. [DEC.

recruited. Thus the death-rate of convicts on the average of the
five years 1868 to 1862 was :—

Male, 11*86 in 1000, or, with pardons on medical grounda, 12*82

Female, 13*68 m 1000, „ „ „ „ 16-17

Mean, 11-95 in 1000, „ „ „ „ 13-32

The aver^ death-rate of the people of similar ages in the 24 large
towns of England was 11*9 in 1000^ and taking Manchester alone.
12-4 in 1000.

The health of the British armj^ in India has called forth public
attention, and has formed the subject of a royal commission on its
sanitary state. The mortality among the European troops in peace
and war times has averaged 69 in 1000, and this excessive propor-
tion on the army strength of 73,000 men is equal to 5,037 deaths
per annum. Much of this mortality is due to want of proper
oarrack-room, and to over-eating and over-drinking. The average
death-rate of the native army is 20 in 1000, and in the healthy
stations only 10 in 1000 ; whilst the mortality in the civil service,
where the ages are similar to those of the soldiers — ^viz., 18 to 45
years — ^is, on the average of a century, only 14 to 18 in 1000. It is
true that the civil servants may more readily leave the country
on furlough, or ascend the moimtains on sick leave, but, under any
circumstances, the death-rate of 69 in 1000 of the army is excessive,
where the average mortality of the civil and military service does
not exceed 30 in 1000.

It is satisfactory to know that, even with our limited sanitary
arrangements, the death-rate of this country contrasts favourably
with that of other kin^oms. Thus the aimual death-rate in
various European countnes is as follows :-^

Scotland, .... 206 in 1000

England, . . . . 22*1 in 1000

Prance, .... 23*6 in 1000

Belgium, .... 25*2 in 1000

HoUand, .... 27*6 in 1000

And taking Scotland alone, and determining the mortality in
various parts in 1861, it is found that the death-rate was : —

Insular district, 185 inhabited islands, » . . 16*1 in 1000

(population 160,733) ;
Mainland district, excluding towns of 10,000 and upwards, 17*5 in 1000

(population 1,763,377) ;
Mainland district, towns of 10,000 and upwards, . 26*4 in 1000

(population 1,138,184.)

The mortalitv amongst children is much higher than that amongst
adults, and the variations in the death-rate in different localities,
and under dissimilar circumstances, are much greater. Last century,
the pauper infants in the London workhouses died at the rate of 23
in 24 ; in fact, out of the average of 2800 children, 2690 died,
and thus only 1 in 24 lived till the close of the first year. An Act

1864.] DR STEVENSON MACADAM'S INTRODUCTOBT LECTURE. 623

of Parliament was obtained which obliged the children to be sent to
the country^ and the mortality decreased to 450. In happy contrast
to this, we have the statistics of the Dublin Protestant Orphan
Societies^ where 'the children are boarded with poor Protestant
families in Wicklow and other counties, and where the average
deaths are only 1 per cent., or 10 in 1000. In England and Wales,
at the present day, about 173,000 children under 5 years of age die
annually, and indeed one-fourth of all the children die before they
reach the fifth year.

In the north-western counties of England, the mortality among
children is 2^ times as high as in the north-eastern counties, and
the following are the proportions of deaths in 100 children before
they reach tneir fifth year in several towns and localities : —

Scotland, 8 principal towns, .

41-82 per cent

Aberdeen,

32

Edinburgh, .

37

Leith,

45

Manchefiter, .

60

Glasgow,

54

In Edinburgh, the annual death-rate amongst children under five
years of age ranges from 48 in 1000 in the best localities to 173 in
1000 in the worst localities ; and whilst the general mortally in
England ranges from 15 to 30 in 1000, the death-rates of inmnts
under 1 year of age is enormously greater, being in the

Healthy districts,
Medium districts,
Unhealthy districts.

77 to 100 in 1000
100 to 200 in 1000
200 to 300 in 1000

The causes of the excessive or preventible mortality in various
localities, are partly special and partly general in their character.

The special causes of the high mortality amongst children, are
improper food, scanty clothing, unhealthy parents, the administra-
tion of cordials or opiates, and bad treatment ; whilst the special
causes of the preventible aeath-rate of adults are the occupations
they pursue, and the food and drink they consume. The knife and
fork grinders of Sheffield suffer from the minute particles of steel-
filings which are breathed into the lungs ; the brass-finishers are
affected in a similar way by the brass-filings ; the stone-masons
from the dust of stone ; the coal-miners from the powder of coal ;
the painters, lead-smelters, and plumbers, from lead-poisoning : the
artincial flower-makers, the makers of paper-hangings, and the ayers
and cloth-printers from arsenical poisoning; and amongst others,
the makers of lucifer matches, from the inhalation of the vapours of
phosphorus.

The general causes which affect the mortality, are bad house
accommodation, impure air, and filthy water. The inferior house
accommodation generally leads to confined and restricted air, and
in many instances also to bad water.

The amount of air which an adult vitiates in the course of the

VOL. X.— NO. VI.

3x

624 DB 8TETBN80N UAGADAM'S IKTBODUGTOBT LECTUB& [dBC

eight hours he is asleep, is about 300 cubic feet ; and as this large
proportion is rendered unfit for respiration, it is reasonable to con-
sider that double the amount, or about 600 cubic feet of air for each
adult) is the smallest quantity which ought to be present in a sleep-
ing apartment Sanitary inquirers, and the Koyal Commission
which was appointed to inyestigate the causes which influence the
sanitary condition of the army, agree in considering that the air in
an apartment or barracks should be sufficient to allow every man
his full allowance of 600 cubic feet, and that the quantity of air
should be suj^lied in a good locality, where the y^tilation of ihe
apartment can be conveniently carried out»

Now, the Boyal Commission, in their inquiries into the amount
of space allowea to each soldier in the barracks at home, found that

1,335 men were living ai^d sleeping ia less than 250 enhic feet.
15,196 . . . . . . 350 „

34,882 . . . . . . 400 „

65,271 600 „

only 4,656 ... . with more than 660 „

but 2,003 . . . ... . 600 „

So that only 2000 men had the full {nroportion of air to breathe,
and there was altogether a deficient of fully 30 per cent, in the
proper quantity, or 600 cubic feet. The Boyal Commission ruled,
tiiat 600 cubic feet should be the lowest proportion of air allowed
to every soldier, and by Lord Herbert's exertions, improvements
were carried out which yielded most satisfactory results.

The influence of the improvements in the sanitary condition of
the barracks, was marked m the decided decrease in the death-rate
of the troops in the United Kingdom, before and after the improved
sanitary measures.

IIOBTAUTT OB DBATH^BATB.

ATwage of 10 Yoaro.

1837-184«. In 1859l
Infantry Begiments, . . 17-9 to 7*6 in 1000

Foot Guards, . . . 5K)"4 to 9*1 „

Royal Artillery, . . . 18-9 to 8*0 „

Dragoon Regiments, . « 13*6 to 8*0 „

The Royal Commissioners also extended their kibours to the ex-
amination of the condition of the military hospitals, and considering
that a man occupies the ward during the day as well as the night,
they very wisely adopted the increased amount of 1000 cubic feet
of air as the smallest allowance compatible with health in a sick-
room. The conditions of the military hospitals were found to '

362 beds had under 400 cubic feet of air.

959 „ from 400 to 600 „

820 „ „ 500 to 600 „

1927 „ „ 600 to 700 ^

1707 „ „ 700 to 800 „

705 ^ „ 800 to 900 „

423 „ „ 900 to 1000 „

240 „ „ 1000 to 1100 „

18 ,, „ 1100 to 1200 ,,

6 „ over 1200 „

1864.] BB 8T£Y£NS0N MACADAM'S INTfiODUCTOBT LECTUBB. 525

So that out of 7165 beds in the military hospitals^ onlj 264 had a
proper allowance of air ; and there was a total deficiency in hospital
space of 42^ per cent. The new medical regalations demand, that
for the Axtore 1200 cubic feet of air shall be allowed each patient
in the hospitals in temperate regions^ and 1500 cubic feet in the
hospitals m hot regions.

It is more difficult to trace the benefits of fresh air on the sick,
but there can be no doubt that the statistics of the improved hos-
pitals, as contrasted with the comparatiyely confined wards, will
show a more rapid improyement in the health of the conyalescents^
Mid a diminution in the proportion of deaths.

The importance of fresh water need not be insisted upon, but the
fact ought to be widely known, that the mere appearance of a water,
and eyen its taste and odour, are not safe indications of purity.
Many waters which are clear, sparkling, odourless, and tasteless,
are highly contaminated with organic impurities.

One 01 the most satisfactory results of medical supervision in
sanitary matters was obseryed m the case of the London postmen,
who number about 2935 on town seryice. Before official medical
duperyision was carried out, as in the three years 1851, 1852, and
1853, the average mortality was 15 in 1000 ; whilst, after m^cal
attendance had been provided, and even the medicines free, as
during the three years 1856, 1857, and 1858. the average mortality
decreased to 11 in 1000; and in the next tnree years, viz., 1859,
1860, and 1861, the death-rate fell to 6-3 in 1000. The improve-
ment in the health of the postmen is ascribed mainly to greater
attention being paid to the ventilation of the rooms, to the introduce
tion of filtered water, and to the more ready attention to small
ailments ; though, to some extent, the results are affected by a more
careful selection of men applying for vacancies.

In concluding these remarks upon sanitary matters, I need hardly
xemind you, that the constant wear and tear of the animal frame
not only renders the air foul, but tends to fill up the pores of the
skin ; and that attention should specially be directed to cleanliness
of person through frequent use of baths. No statistics have been
specially obtains to show the benefits of public baths in the general
community ; but ample testimony of the ^ood accruing from the
frec[uent use of the bath is affor<^ by individual experience ; and
it is only right and proper that part of the great sanitary improve^
ments in the health of the inhabitants of Liverfjool and other of our
larger towns, should be ascribed to the institution of public baths.
Many people have a strange repugnance to ablutions in general, and
this appears to be exhibited by all nations. Livingstone speaks of a
native who followed his party in spite of sll remonstrances, xmtil the
Makololo threatened to take him to a river and wash him, and then
he decamped, doubtless fearing that his garment of castor-oil and
dirt woula be lost, and he would then be cold and uncomfortable.

The great question of the disposal of the sewage of towns, is one

526 DE STEVENSON MACADAM'S INTBODUCTORT LECTURE. [DEC,

I do not wish to eater upon here, as I have only recently discussed
the matter at association meetings in Bath and in York ; and I am
desirous of avoiding the appearance of constantly referring to the
same topic ; but I am anxious to say this much^ that whatever is
ultimately done with the sewage of a town, it is right and projwr
that that sewage should be conveyed awa^ from the city and its
inhabitants. The cesspool system, as carried out in our smaller
towns and villages, is an abomination, and leads to the contamina*
tion of the well-waters with foul matters of a disgusting and highly
pernicious nature.

The benefits derivable from the improved drainage of towns may
be learned from the following statistics : —

In 19 towns in England which were improved under the Public
Health Act, the average mortality before the drainage operations
was 28 in 1000, whilst, after drainage, the death-rate decreased to
21 in 1000 ; and this, in a population of 468,000 people, gives an
annual saving of 3200 lives. In Liverpool, in 1846, the mortality
was 39 in 1000 ; whilst the improvements carried out in drainage,
improved water-supply, etc., decreased the mortality, till in 1860, it
was only 24-2 in 1000, with a saving of about 5000 lives annually.
Macclesfield, on the average of five years before sanitary improve-
ments, had a death-rate of 33 in 1000, and on the average of five
years after the drainage operations 26 in 1000 ; or the average dura-
tion of life in the whole population was increased from 24 years to
27 years. By similar improvements in drainag^e and other sanitary
operations, the mortality of Gloucester fell &om 27*60 to 19'71 ;
of Bradford, from 28^ to 22 ; of Croydon, from 28-16 to 22-9 ; and
of Berwick, from 28'5 to 21-7.

Had vour time permitted, I would have desired to refer to other
topics of interest at the present time, such as the indestructibility of
matter and of force, leading to the conservation of force, and its
relations to the animal structure^ and how the food of the animal not
only ministers to the growth and sustainment of the bodily frame,
but also supplies the force which is exerted by each of us in oar
daily work, whether that be the work of the hand or of the head.
But I trust I have said sufficient, on subjects collateral with strict
medicine and surgery, to show you that there are various topics of
vast interest to the public in general, of which the medical prac-
titioner ou^ht to be cognizant. He ought to remember always, that
his professional vocation is next to that of the clergyman, the most
noble and sacred of all professions, and that his position in life
demands that he possess an enlightened knowledge of even every-
day and common-sense subjects. True science should be studied
for its own sake, — for the Imowledge it gives us of the workings of
the great world around us, and the insight it afibrds us of the fene-
ficent plans and designs of the great Creator and Upholder of the
Universe.

1864.] DR T. Keith's case of oyabiotomt. 527

Article Yl.— Case of Ovariotomy. By T. Keith, F.R.C.S.E.

In the coarse of last summer, there appeared for several months, in
the pages of the Lancet^ a correspondence as to the possibility of
making an accurate diagnosis in cases of ovarian tumour. It was
maintained by some who had great experience of the disease, and
who had frequently performed ovariotomy, as well as by others who
had not been known to have completed the operation in a single
instance, that we have as yet nothing to go upon but blind chance,
and that a correct diagnosis cannot he mMe without an exploratory
incision. I have reason to know that this discussion, left as it was,
has done no good to the profession, and has unsettled the minds of
not a few sufferers from ovarian disease; and I am induced to
publish the history of the following case thus early, because it
seems to me to be an answer to those who maintain that a correct
diagnosis is impossible.

It was my twenty-first case of ovariotomy. The relations
between the uterus and tumour were known to be very intimate.
The operation of ovariotomy was thus, under any circumstances,
an unusually hazardous one; and the question that had to be
decided was this : whether this connexion was so close as to render
ovariotomy impracticable or almost deadly, or whether there was
sufficient space between the uterus and the tumour to allow of the
operation being completed in a satisfactory manner? Could it be
recommended to the patient and her friends with a reasonable
prospect of success? To the patient the question was of vital im-
portance, for, from the semi-solid nature of the greater part of the
tumour, her case was not one in which much time was to be gained
by tapping. Was this patient, then, to have the chance of escape
from a painful and inevitable death, or was her case beyond tne
reach ot surgery ? The question of operation or of no operation
was thus entirely one of dia^osis.

In the beginning of March last, I saw, with Professor Maclagan,
a married lady, thirty-four years of age, who had suffered from
ovarian disease for upwards of two years. She was first made
aware of the formidable nature of her complaint towards the end of
1862, about ten months after her marriage, when she came into
town for her supposed confinement. For a whole year after this
little or no perceptible increase of size took place : she lived quietly
and enjoyea life, inconvenienced only by tne bulk of the tumour.
A few months before I saw her, it had commenced to grow with
considerable rapidity.

The tumour reached to near the ensiform cartilage. The abdo-
minal portion consisted of three large cysts above and laterally,
and of a semi-solid mass below and centrally. It was unattached
to the parietes. A considerable part came below the brim of the
pelvis, and its connexions with the uterus were evidently very

628 BB T. KErra^s case of otjuuotomt. [dec.

close^ even the cervix felt quite fixed. The nteros itself was drawn
up oa the tumour. It was anti-flexed^ and its fundus was easilj
fdt, as if incorporated with the tumour, through the integuments in
the right iliac region.

I saw her again two months afterwards. The upper central
cyst had become much larger and more prominent, but the lateial
cjsts had not increased in proportion. There was now yenr little
of the tumour to be felt below the brim of the pelvis, and I was
satisfied that it was unconnected with the rectum, and probablj
also with the bladder. The relations, however, with the nterus
were still unsatisfactory, being very much as before, only that the
cervix was slightly movable, and the sound, when passed into it —
for I failed to pass it into the body of the uterus — scarcely moved
the uterus.

Though inclined to think that there was just bare room to isolate
and secure the pedicle, I requested her to see Mr Wells. This she
did in the beginning' of May. In a letter I had from Mr Wells,
after describing his impressions of the very close connection that
existed between the tumour and the uterus, he added: ^^It has
occuired to me that it might be a good plan to gain time by tapping
the upper cysts — fiilly explaining that the only object would be to
gain time — and that we could do no farther eood by tapping;
although by gaining time it is possible that the lower part of the
tumour, as it grows and rises upwards, may so elongate its con-
nexions with l£e uterus that what is now a very intmiate union,
may become a more or less distinct pedicle. I am convinced that
this change does occur during the progress and growth of ovarian
tumours, and explains the frequencnr of long pedicles in large
tumours, and short ones in tumours of small or moderate size«"

She was afterwards seen by Mr Fergusson and Dr West ; and at
this time it was believed that there was naif an inch of space between
the uterus and tumour. It was agreed that she should return home,
and that some time should be gained by one or two tappings^ as
suggested by Mr Wells, in hope that elongation of the pedicle
woiud take place as the solid part of the tumour increased and
grew upwards. Some symptoms of peritoneal irritation, however,
appeared about this time, and tapping became necessary towards
the end of May, when Mr Wells removed eleven pints of thick

Seen fluid from the upper central cyst From examination after
e tapping, Mr Wells was now satisfied that there was nearly an
inch of space between the uterus and tumour. Much relieved, she
returned to Scotland in the beginning of June.

By the beginning of September she was hurger than before the
tapping. The upper cyst was now very prominent, and she mea-
sured thirty-nine inches at the end of the sternum. The general con-
dition was still fairly good, though she had got very^ thin about the
shoulders and arms, and the weary nights were be^inniuff. On the
13th of September I removed fifteen pints of exoeedmgly Uiick viscid

1864.] DR T. KEITH'S CASE OF OTASIOTOHT. 529

fluid iiom the central cjaty hj tapping it about tbree inches above
the umbilicus. The uterus was now distinctly, separable from the
tumour, and I felt quite sure that there was room to secure the
pedicle.

The cjst refilled with the utmost rapidity, and in the couxse of a
week her girth was only two inches less than it had been beibre the
tapping. It seemed to me that nothing more was to be gained by
a repetition of the tapping, should this become necessary eveiy few
weeu, as now seemea most likely, while it was evident that tha
general condition of the patient would certainly suffer ; I therefore
recommended the removal of the tumour without delay.

This was done at her own home in the country, on the 21st
of September last ; Professor Maclagan, Dr Keith, and Dr Bogie of
Annan, were present. After exposing the surface of the tumour^
the hand was passed downwards to ascertain the condition of the
pedicle ; and it was found that there was sufficient space to place
the fore-finger under its lower edge. Anteriorly the tumour was
unattached; several c^rsts were emptied through a large canula
without much diminishing the size of the semi-solid mass, and it
was necessary to open some of the cr)fst8, pass in the huid, and
break down the smaller cysts of which it was composed. The
incision was then extended three inches above the umbilicus, in
order to bring into view some firm omental adhesion to the posterior
surface of the tumour. Several vessels were tied ; the silk ligatures
were cut off short and left behind. Lower down there was pretty
firm adhesion to the head of the colon and iliac fossa as far as the
brim of the pelvis. There were also some long adhesions running
in the direction of the right sacro-iliac synchondrosis ; all these were
carefully separated. The mass was then turned out, and the whole
of the pedicle brought into view j it was broad, short, and thick.
In its lower third it was almost an mch in length : scarcely so much
in its middle third, for here a portion of adenoid tissue ran in near
to the uterus. The upper part was nearly two inches in length, and
I intended to put a clamp upon this, and to surround the remainder
with one Of more ligatures, and hxmg it as near the line of incision
as possible. The pedicle was then tied in five separate portions, but
the strangulation was so imperfect, owing to the thickness and elas-
ticity of the parts embraced by the ligatures, that free heemorrhage
at once took place on cutting away the tmnour. Fortunately, a
Urge piece had been left beyond the ligatures ; the whole of this
was embraced in two larse clamps, and retained outside, the line
of incision being occupied by the semi-strangulated portion of the
tumour between the ligatures and clamp. The uterus was brought
up close to the wall, but from its previous great elevation upon the
tumour, there was not so much strain as might have been expected.
The pelvis was freed from every particle of clot^ and carefully
cleansed by perfectlv new soft sponges. The operation was finished
in the usual way, by bringing the wound together by deep and

630 DB T. Keith's case op ovariotomy. [dec.

superficial silk satores ; she was under chloroform for an hour and
a half.

Nature and intelligent nursing did the rest, and the patient was
able to walk into the drawing-room six weeks after the operation.

In conclusion, I would take the liberty of recommenaing those
who say they cannot make a correct diagnosis of ovarian tumour,
without an exploratory incision, to follow the advice given by
Bichard Wiseman, the father of English Surgery, in his introduc-
tion to his Surgical Treatises, and which was adopted by myself in
the present case, when, though almost certahi that the operation
was practicable and a justifiable one, I was yet unwilling, on my
own responsibility, to recommend a proceeding so unusually i

hazardous. '^ Thou toilt also learn one necessary piece of Humility — |

viz. : not to trust too much on thy own judgment^ esvedally in difficuU
eases ; hut to think jit to seek the advice of other Physicians or j

ChirurffeonSy whose long experience hath enabled them to assist thee in
preventing the aocidentSy ana encourage thee to go on in the work or fore- I

warn thee of the danger, A/ier thou hast thus defended thysdf from '

the censure of rashness j proceed holdty^ and let thy sincerity in thy
acting be thy warrant to hope for Ooas blessing on thy endeavours^

^avt Seconlr.

REVIEWS.

The Principles and Practice of Obstetrics. By H. L. HoDGE, M.D.,
etc., Philadelphia: 1864.

There are two epochs in a physician's life in which it is said that
he is specially prone to booxmaking ; in the former, he is youn?
and araent. desirous to exhibit his learning and acuteness, and
showing, if not the fruits of experience, yet his anxiety to acquire
them ; m the latter, he is cool and cautious and wise, all from his
fulness, of experience. It is with the second of these that Dr
Hod^ is naturally classed : he passed a long life practisiftg^
teaching in Philadelphia, before the voice of Meigs called him to
a prophet to all the world by condescending to " print it." Obedient
to the call, he is now a substantial author of portly volumes on the
diseases ot women and on obstetrics. His work on female diseases
was not of a kind to demand high praise. On the same subject
there were even better American works. His present imposing
volume is of a much higher stamp. It is very large, profusely and
elegantly illustrated, and is fitted to take its place near the works

1864.] DB HODGE's PRINCIPLBS AND PRACTICE OF OBSTETRICS. 631

of great obstetricians. Of the American works on the subject it is
decidedly the best.

Although Dr Hodge is a man of age and experience and reputa-
tion, his appearance as an author does not thereto correspond. We
cannot but think it would have been wiser in him to write more of
what he has seen and therefore thinks. He prefers to enter, in the
preliminary chapters of his book, on a great many scientific topics, of
which imperfect knowledge ana preconceiyed notions have caused
him to give obscure or incorrect accounts ; while in the practical
parts he is not only o^inionative, but goes the len^h of enjoining

Elans of treatment which he has never tried, and for trying which
e must have had plenty of opportunities. Dr Hod^ evidently
retains the ardour of youth, its ambition and its nopefcdness.
Were it otherwise, we should probably not have had to thank him
for this large contribution to medical literature. The combina-
tion of the qualities of youth and of age might, had we time, be
very aptly illustrated by the peculiarities of the work before us.

We may here name a few of the special views of our author on
subjects of high practical importance, but we shall scarcely criti-
cise them. Dr Hodge, repeating the old wordy talk about the
imaginary plethora of pregnancy, and adducing not a single new or
substantial armmient m its support, strives to reject as impertinent
novelties all the researches of modem science which have illustrated
the true state of the blood in pregnant women. Likewise he enters
upon the eclampsia parturientium as if plethora and bleeding were
evenrthing, uraemia and the restoration of the healthy condition of
the kidneys and of the blood being weak suggestions of men who
would be wise above their fellows. We fear we are putting too
much feeling into this antithesis, but we do feel that here it is just
to entertain a ''nobilem iram. ' More advanced pathology may
possibly throw into the shadowy regions of things past the present
ursemic views regarding puerperal eclampsia, by introducing others,
the result of more extendea and finer investigations, but it will
always point to uraemia as the road by which the higher position
has been reached. Plethora and all the old-fashioned notions con-
nected with it belong to a time when there was mere dogmatism on
the subject, and no dawning of true science. On this topic, then,
Dr Hoage shows himself certainly as an old author, but it is in an
unfavourable light. On one therapeutic aspect ot eclampsia Dr
Hodge seems to have some support, and he clutches at it knowingly
enough. He finds that in Europe the old treatment by bleeding,
which is so consistent with his plethoric pathology, is undergoing a
revival at the expense of the treatment by chloroform and other
novel methods. And he is, in appearance at least, justified in sup-
posing that the ursemic theories are proving weak when applied m
{>ractice, and that the plethoric is gradually being recallea to its
brmer place of honour. But here he mistakes appearances for
substance. In our busy and energetic, especially in the weaker

VOL. X. — ^NO. VI. 3 Y

532 ML HODOB'S PEINCIPLES AKD PBACnCE OF OBSTETRICS. [dBC.

and more versatile obatetrical circles, new and cmde plans of treat-
ment are, on the most miserably deficient grounds, proposed with
all pomp and weight of words, as if they were the result of the
grand conjunction of true theory supported by well-<iigested experi-
ence. It was in this unsatisfactory way that many suddenly and
thoughtlessly threw away bleeding, the old sheet-anchor, without
having provided a new one, and the natural result has followed — a
recoil to old plans. Besides, Dr Hodge must not suppose that the
return to bleeding is a return to the old method of using this remedy.
That is gone for ever. Truth is, that there is nothing to boast of
whatever in the way of treating pueipend convulsions, and that
advanced knowledge, of which we are justly proud, has yet to pro-
duce a substantial advance in our methods ol treatment We are
still eclectics ; now bleeding, now using diuretics, now chloroform,
now opiates, and not very rarely finding it wisest to do nothing.
But in whatever way we treat, we are not foolish enough to forget
the triumphs of science in making us better acquainted with the
disease treated.

In contrast with what we have just been describing in Dr
Hodge's theoretic views, we now adduce his proposal in certain
oases to use the fillet 1 Although the fillet may be called an
ancient and almost forgotten instrument, we look on Dr Hodse's
reintroduction or proposed reintroduction of it as an entire novelty.
We do not look on this as an adhesion to old obsolete notions,
rather regarding it as a juvenile efiiorescence of his inventiveness,
out of character with much of the rest of the work. Yorkshire,
the Boeotia of Great Britain, still possesses many antique fashions,
and among others the use of a whalebone fillet, which is still
manufactured and sold there. But Dr Hodge is not from York-
shire : he is a citizen of a young empire in which there are probably
no remains of the use of the antique fillet ; and his recommendation
of its use has thus a claim to entire novelty. Since the mechanism
of parturition has been greatly advanced, the fillet has now for the
first time been seriously proposed for restoration to the obstetric
armamentarium. We have not ourselves tried it, and we may say
we do not intend to do so; we shall therefore say little on the
subiect. Only we must add, that though Dr Hodge has proposed,*
he has not tried it, and this is a grave consideration, if not a grave
£fiult. An old and experienced practitioner writing a ponderous
and really valuable book, defaces its pages by definitiveiy recom-
mending measures which he has not tried. It is not unusual for
young pamphleteering doctors, with obvious objects and temptations,
to recommend a new remedy m a journal as a great cure, and the
failure of it in every sense may only stimulate to a repetition of the
adventure : but such conduct was not to be expected in our Pennsyl-
vanian autnor. Dr Hodge suggests a certain kind of fillet or lacque,
but if he takes the trouble to dip into the literature of the matter, he
will find there is nothing original in his instrument, and nearly as

1864.] DB HODGE's PRINCIPLES AND PRACTICE OF OBSTETRICS* 033

little in his way of using it From this statement^ howeyer, we
must except his use of a modification of Bellocq's navel-string con-
ductor in its application, a proposal which is perhaps ingenious.

It will be interesting to European obstetricians, engaged as thej
are in slowly and laboriously settling the categories of cases in
which version, long forceps, and craniotomy are to be used, to hear
Dr Hodge's views on this topic. Our transatlantic brother has had
much experience in the general class of cases to which these opera^
tions are applicable ; he speaks of them in a highly intelligent and
satisfactory way, and he is an advocate for the use of the long
forceps. This is a vague statement on our part^ but our practiced
brethren will have no difficulty in vaguely acquiring our meaning,
and that is all we wish. Dr Hodge is extremely long and tedious
on many less important subjects than this, and we wish he had
explained his views on it more fully. As it is, we have a valuable
opinion. With us there can be no doubt that the swing of the
pendulum has latterly been rather from the forceps towards version,
but we are strongly of opinion that the real progress of the topic is
Very slow, and tliat the pendulum will have many swings before
equilibrium and rest, ends so desirable, are reachea. It is to this
that obstetricians should strive ; and Dr Hodge's opinion and dis'-
cussion of the question contribute somewhat to its attainment.

There are many other attractive specialties in Dr Hodge's work }
but we shall close this notice by some brief and more direct criticisms
of chapter fourth, on gestation ; a chap'ter that describes much funda-
mental science in obstetrics. Although our observations do not tend
to the exaltation of the estimate of the book, we yet deem it proper
to make them in order to a just appreciation of it. As a last general
remark, it may be added that the whole subject of the mechanism
of parturition is treated of in numerous chapters and parts of
chapters ; and that, although Dr Hodge enunciates various peculiar
views well worthy of disputation, yet he everywhere shows an in-
telligent appreciation of the subject, the result of zealous study.

We do not look for much transcendental anatomy in a midwifery
book, albeit there is a great deal of conceit of this kind in modem
works, yet we expect the ruder anatomy to be well-riven. In
regard to the cervix uteri, a topic of the latter kind, Dr Hodge
exhibits some confusion of ideas. " The cavity of the neck of the
uterus (he says) is greatly developed at its superior opening, so as
to augment that of the body of the uterus." This is an erroneous
but a distinct statement, it is entirely opposed to the modem
descriptions of some authors, Cazeaux among others ; yet after a
paragraph or two we find the following : — " We acknowledge that
our observation, in most instances, confirms the experience of M.
Cazeaux" ! Again, while the anatomical view of Stoltz, Cazeaux^
and others is held by many, it is admitted that the old notions of
shortening do not far mislead in practice ; yet we find Hodge, who
holds the old views, saying, — '^ The above account of the shortening

534 DR HODGE^S PRINCIPLES AND PRACTICE OF OBSTETRICS. [dEC.

of the neck of the aterns^ at succeasive stages of gestation, has been
generally received as true ; but certainly, in practice, it cannot be
depended upon as a means of diagnosis.

On another anatomical subject, Dr Hodge should be, but is not
clear. Speaking of that part of the uterus where the placenta is
attached, ne sajs: — ^^'Here the demand is so great that the veins
often obtain an enormous size, and appear to inosculate very fineely
with each other, forming apparently large cavities opposite to the
placenta, which have been termed venous sinuses, or cells. It has
been satisfactorily demonstrated that many of these large veins or
sinuses have patulous orifices on the internal surface of me uterus.

where they are closed by the membranes of the placenta. ''

On this remarkable passage we shall only make some remarks as
interrogations of Dr Hodge or of the reader. Do the sinuses of the
uterus only appecar to inosculate freely ? Is there any doubt about
it ? Do they form opparenAy lar^ cavities opposite to the placenta?
Are there, indeed, any large cavities other than the large sinuses?
No one, not even Dt Hodge, describes them. What anatomist
ever called these sinuses by the name of cells? These sinuses are
so, they are not veins; why, then, are they called "veins or
sinuses?" How can an author, writing in 1864, dare to sa^ that
patulous orifices are demonstrated satisfactorily in these smuses
opening on the internal surface of the uterus? What recent
anatomist gives his name to this view — ^not Dr Dalton ?

Further on in this chapter we find it said that, as gestation
advances, the uterus seems to extend between the laminsd of the
broad ligaments which are deployed or unfolded on the anterior
and posterior surfaces of the organ. This is nearly the opposite of
anatomical truth.

As we proceed, we find the following simple statement, with a
few more simple additions that do not supplement deficiencies or
correct errors. " The contractions of the uterine fibres are excito^
motory, and, like those of the hollow muscles of the heart, stomach,
and bowels, are involuntary 'MM

At page 56, the decidua is described as having pervious orifices
for some time after fecundation. At page 70, it is said that ^^ few
experimenters will acknowledge that any such openings exist in
the membrana decidua." There is a curious idea involved in the
word experimenters here. Who are they? Was M. Coste, who
demonstrated the pervious openings, an experimenter? or were the
seduced women who drowned themselves tne experimenters?

As we advance, we come to still more marvellous statements.
Our readers may amuse themselves with the sentence (p. 57) before
the one we quote regarding the site of insertion of the placenta.
'' At this spot, however, after delivery, a mucous membrane begins
to be generated, which will be perfected at the expiration of three
or four months"! What anatomist describes this delay? How
do the women manage who are already &r gone in pregnancy

1864.] DS HODGE's PRINCIPLES AND PRACTICE OF OBSTETRICS. 535

before the expiry of the three or four months? Dr Hodge makes
mountainous difficulties over which he shows us no way.

Take another statement. The liauor amnii^ after the membranes
are ruptured, ^' favours relaxation of the vagina and perineum, thus
facilitating the passage of the child, and the easy performance of
obstetric operations" !

But now we halt^ not from want of similar material^ but from
want of frurther inclmation to pursue this line of criticism. We
shall end by a piece of curious English (p. 67).

^' We have no hesitation in declaring that superfoetation, in its
strict definition, never occurs ; the exceptions, if any, are certainly
very rare " !

On Diaecma of the Throat and Windpwej as reflected by the Laryn^
goscope. with 116 Engravings. By George Duncan Gibb,
M.D., M.A., Assistant-Jrhysician, Westminster Hospital. Second
Edition. London: Churchills: 1864.

This volume, although entitled a second edition, is in reality a new
work, for the introduction of the laryngoscope has so completely
revolutionized the diagnosis, and even the treatment of various
laryngeal diseases, that the greater part of the volume has required
to be rewritten. I)r Gibb was one of the first to see the advantages
to be derived from the use of the larjiigoscope, and has published
various interesting papers regarding it in the periodical literature
of the day ; and tne present volume may be looked upon as a resum^
of his researches on this important subject.

The first chapter treats of diseases of the upper air-passages, and
commences with a section on follicular disease of tne throat, or
clergyman's sore throat, as it is commonly called. This very
annoying complaint consists essentialljr in an enlargement of the
follicular glands of the throat and air-passages, resulting from
chronic inflammation of the mucous membrane ; as a result of this,
their secretion is sometimes increased in quantity, but vitiated,
being converted into an acrid, viscid discharge, firmly adherent to
the membrane, and causing great irritation ; at other times it is
arrested, causing the membrane to have a dry^ uncomfortable feel-
ing. The most important result of this condition is ulceration of
the glands, which is treated of under the second section of this
chapter, under the heading of chronic disease of the windpipe. The
symptoms of clergyman's sore throat are those of chronic irritation
of the throat, evidenced by frequent hawking, but very generally
without any decided cough. There is hoarseness or roughness of
the voice much increased upon any exertion ; and in advanced cases
of the disease it mav be wholly gone. On examination, the mucous
follicles at the back of the pharynx are seen to be enlarged ; they

536 DB oibb's diseases of the throat and windpipe, [dec.

stand oat prominentlj on a raw*looking; granulated surface. By
means of the laryngoscope the mucous membrane of the larynx
and trachea is seen to be generally congested, while the membrane
on the laryngeal surface of the epiglottis may be of a scarlet redness.
As the disease advances, the folncles become indurated or ulcerated|
and the various symptoms become much aggravated in intensity.

Among the topical remedies for this troublesome condition, Dr
Oibb attaches much value to the direct application of a solution of
nitrate of silver, in the proportion of from 40 to 80 grains of the
salt to an ounce of distilled water. Instead of a piece of sponge
attached to a whalebone handle, Dr Gibb recommends a brusn and
bent whalebone, as producing much less irritation, and there being
no risk of its scraping and injuring the delicate membrane of the
larynx. Combined with topical medication, constitutional treat-
ment is necessary, and our author attaches most importance to the
preparations of iodine. " My favourite remedy," he says, " is the
loduretted iodide of {)Otassium, or a weak Lull's solution, com-
bined with some carminative and tonic, of whicn the hydrastin, the
active principle of Hydrastis CanadenstSy is one of the best • • « . .
When iodine and iodide of potassium are combined, the dose to
produce the desired efiect need not be large, unless there is some
other indication besides the throat-affection for its increased employ-
ment. The iodide of ammonium also is a reliable preparation in
small closes, and ma/ be substituted for the potassium salt in many
cases j or either may be replaced by the bromide of ammonium,
especially if there is much irritation of the fauces and larynx."
Judgmg from Dr Gibb's recorded cases, this treatment has proved
very successful.

Chronic disease of the windpipe, which is treated of in the second
section of the first chapter, is frequently a consequence of the above
described follicular inflammation, or it may be the result of various
other throat affections. It is a very important disease, as, if allowed
to go on without treatment, it may nnally become irremediable.
The symptoms are the same as those of the follicular disease, but in
a more aggravated form, and in particular, the constitutional signs
of rapid consumption may be present. There is no doubt that such
cases are often mistaken for tubercular phthisis, and that patients
have been given up as incurable, when very simple measures might
have affected a cure. On laryngoscopic examination, deep ragged
ulcers are often found on the mar^ns of the ventricles of the larynx,
and on the lingual surface of the epiglottis ; the larynx may be
irregular and deformed, and there may be destruction of the true
vocal cords, producing incurable aphonia. The treatment of this
affection is necessarily more tedious than that of the simple follicular
disease, but is founded upon the same principles, the topical appli-
cation of nitrate of silver, and the internal administration of alter-
atives and tonics. Quiet and rest are essential, and durine the
treatment the use of the voice should be strictly prohibited. If

1864.] PR GIBB's DIAEASBS OF THE THROAT AND WINDPIPE. 637

BpasTDS occur frequentlj, and there should seem to be any danger
of suffocation^ Dr Gibb strongly recommends that a fistulous open-
ing should be made into the trachea, and that it should be kept
patulous. ^' This proceeding will give the Tocal organs such an
amount of rest and quietude as shall permit of considerable comfort
to the patient, and will not prevent the employment of such topical
medication as is likely to neal up the ulcerated surfaces. This
would not cause nartial obliteration of the larynx, as has been sup*
posed, unless unaer certain circumstances, nor would there neces-
sarily be destruction of the voice, for the patient would merely
require to place his finger over the fistulous ^opening in the wind-
pipe, and the voice or a loud whisper is heard. This I saw verified
m January 1848, when- a pupil at the Meath Hospital, in Dublin :
a man, aged twenty-five years, with a permanent fistula of the
larynx, was shown to the pupils by Dr Stokes, and was the subject
of some interesting clinical remarks. When in battle, this man,
who had been a soldier, was wounded in the throat by a splinter,
which perforated the larynx ; it healed up afterwards, leaving this

Eermanent opening. When it was exposed the voice could not be
card ; but the finger placed over it at once restored speech. The
same phenomenon is generally noticed where a silver tube is worn
in the trachea."

The second chapter treats of " Diseases of the Vocal Cords, giving
rise to Hoarseness and Modifications of the Voice." From the
section on stuttering and stammering we make the following quo-
tation : —

<' I have examined cases of both stnttering and stammeringjfnth the laryngeal
mirror, with the sole view of observing the action of the vocal cords in the
utterance of sounds. As contrasted with the double voice already considered,
the action of the cords is very different. Constant and irregular contraction
and rapid approximation of the cords, with a tendency for the glottis to remain
shut, are the phenomena noticed in cases of stuttering before undergoing treat-
ment. These irregular spasmodic actions are decidedly less in degree in cases
of stammering. When the person inspires and utters a continuous humming
noise, the vocal cords resemble in their action a couple of strings being
alteniately and rapidly pulled towards one another, and striking their free
borders with such apparently spastic rigidity as to produce a distinct flapj^ing
noise. AH the lai^ngeal muscles are no doubt in a condition that might
almost be compared to St Vitus' dance, involuntarily contracting and relaxmg
under the influences at work. Several times this action has extended to the
aryteno -epiglottic muscular fibres, and the epiglottis has been suddenly pulled
downwaras and backwards. But the action of the thvro-arytenoid muscles is
sometimes so energetic as to cause their projection in tne middle of the larynx^
and actually to conceal the true vocal cords beneath. If a long or full breath
is taken, to see the expansion of the glottis, the view is only momentary, for
the tendency is so strong to irregular contraction of the muscles, that it is
almost instantly closed. In persons who have undergone some amount of
treatment, there is more control over the laryngeal muscles, although the
tendency to irregular contraction, I believe, long remains, which really proves
that the means to effect a cure must be persevenngly and energetically carried
out. As to the pathology of stuttering and stammering, and the causes which
^ve rise to them, I do not propose to enter into, considering it sufficient in
this pUce to point out what may be observed with the laryngoscope.'*

538 DB gibb's diseases of the tuboat and windpipe. [DEa

The third chapter treats of acute inflammatorj diseases of the
throaty from which we extract the following important remarks
regarding the treatment of oedema of the larynx : —

" Most writers concur in the opinion that the onljr remedy which holds oat
any grounds for hope in the extremity of danger is tracheotomy-^which, to
prove efficacious, must be done at such an early period as shall afford the best
chance for the patient. Before this operation is resorted to, scarifications
should be practised with proper. instruments, with the aid of the laryngeal
mirror, upon the oedematous false cords, the edges of the epiglottis, and the
aryteno-epifflottidean folds. If carefnlly and judiciously managed, this will
afford abundant relief by the discharge of serum, and may be repeated every
four or five hours. Sometimes, however, obstacles will arise to prevent its
performance, especially if the patient lay exhausted and motionless in bed,
with an almost insurmountable difficulty in the opening of the mouth to permit
of the introduction of the mirror and scarificator together. Under such circum-
stances it is advisable not to delay opening the trachea.

** Before the laryngeal mirror was regularly employed, Lisfranc punctured
the oedematous swellings, guided by the sensation of the finger; and Mr Busk
treated two sailors thus affected by numerous minute punctures made with a
sharp-pointed bistourv into the back of the tongue, the uvula, and the pharynx,
every two or three nours. The relief is stated to have been sudden and
decisive, as a ereat quantity of serum was discharged. Warm-water gargles
were employed during the mtervals.

"In addition to L^yngoscopic scarifications, when practicable, if decided
and immediate relief is an object of the greatest moment, before time is afforded
for tracheotomy, catheterism of the larynx may be practised, with the aid of a
bougie half an inch in diameter, with a suitable curve. This squeezes oat the
serum through the punctures made, as if the oedema was a sponge, and clears
the larynx in a remarkable manner, as actual experience has proved in my
handa.

" It will be necessaiy afterwards to inhale the steam of boUing water, to
encourage the evacuation of serum ; and when all danger has passed away,
small doses of mercurials have been found useful, in the hands of some practi-
tioners, especially in the milder forms of oedema, so as gently and decidedly to
affect the system.'*

The fourth chapter treats of specific diseases, including Diph-
theria. Syphilis, Gout, Elephantiasis, and Cancer ; the fifth, of the
exantnematous afifections. Some of these subjects, especially the
sore throat of scarlet fever, measles, smallpox, and hooping-cough,
seem to us out of place in such a work as this, as these affections
are not local diseases, but merely parts of the general diseases.

" The sore throat from tobacco " is thus described in the sixth
chapter : —

" Now, what is the effect of tobacco upon the throat? If due reflection is
bestowed upon the matter, it will be remembered that the smoke of tobacco
almost constantly comes in contact with the soft palate, the tonsils, and the
pharynx ; if chewing is the preference, the iuice equally influences the same
parts, by lubrication during the act of swallowing; the result of this is an
irritation of all the secretins apparatus of the mucous membrane of the fauces,
which is at first preceded by slight heat and dryness, and then foUowed by
excessive secretion poured out by the mucous follicles, which, from their being
thus constantly stimulated, become hypertrophied, and elevated beyond the
surface of the membrane to which they belong. This condition may very well
bo seen on looking into the fauces, and wiU be found remarkably persistent in
severe cases, at the back of the tongue, and around the epiglottis.

1864.] DB QIBB'S DISEASES OF THE THBOAT AND WINDPIPE. 539

'* Moreover, in cases of excessive smoking I have seen with the laryngoscope
the mucous membrane of the larynx and of the trachea, very red, slightly
tumefied and dotted over with small red points indicating the irritation pro-
duced upon the follicles of these parts. This state of chronic congestion has
pervaded the membrane covering the vocal cords, and sometimes gives rise to
hoarseness and aphonia.

" The mouth and the bronchial tubes are occasionally affected by the smoke ;
but, as a rule, the intervening portions just mentioned are those chiefly involved.
Should throat disease exist, however, independently of smoking, it is much
aggravated by the latter, and sometimes causes very great misery and suffer-
ing, many examples of which I could relate.

*^ I should wish it to be understood, nevertheless, that by no means is the
moderate use of tobacco here condemned, which to so many seems a luxury
and enjoyment of no ordinary kind. For this chronic condition of the throat
is not produced, unless when its use is abused, and then its acrid nature soon
becomes apparent."

The concluding chapter ^treats of the laiyngoscope and rhino-
scope, and forms a complete treatise on the subject.

in conclusion, we can warmly recommend Dr Gibb'a book as a
thoroughly practical one, and as containing very clear directions for
the discovery and treatment of a' very important class of diseases.

IMnetples of Human Physiology. Bjr William Carpenter,
M.D., F.B.S., Registrar to the University of London, etc. Sixth
Edition. Edited by Henry Power, M.B. Lond., Assistant-
Surgeon to the Westminster Hospital, etc. London : Churchills :

" Carpenter's Physiology " has been for twenty years a standard
text-book of the science. Engaged in lecturing on the subject, the
author kept fully abreast with the progress of physiological know-
ledge, and successive editions represented the existing state of the
science at the time they appeared. The present edition, however,
appears under different circumstances. " Having," he informs us in
the preface, " long since relinquished, on his appointment to the
post ne at present occupies, the duties of a teacher of physiology,
and having consequently ceased to feel it incumbent upon him to
keep up with the progress of the science in detail, he found that the
mass of new material which had been accumulated by the industi^
of inquirers in every one of its departments was far greater than it
lay within his capacity to systematize ; the time and working power
left at his disposal by the requirements of his official position oeing
extremely limited." Li consequence of this the preparation of the
present edition was left entirely in the hands of Mr Power of the
Westminster Hospital.

Since the fifth edition of this work was published, great advances
have been made, and it became a question how these should be re-
corded without adding to the size of a volume already sufficiently
formidable. The difficulty was got over, we think judiciously, by

VOL. X.— HO. VI. 3 z

540 DB carpenter's principles of human PHTSiOLoaT.. [dec.

omitting the outline of Psycliologj which had appeared in the last
two editions under the title " Functions of the Cerebrum," and
occupied 140 pages. This omission does not at all interfere with
the completeness of the work as a Manual of Physiolo^ ; while,
to do the subject of psychology justice, or even to make it intelligible
to the student, a special treatise is required.

Mr Power has performed his duties as editor in an able and satis-
factory manner. To enunciate the changes which have been intro-
duced would be to write a history of the progress of physiology-
during the last nine ^ears ; it is sufficient to say that " Carpentear s
Physiology " will still doubtless maintain that place on the shelves
of the student and practitioner which it has so long and so deserv-
edly occupied.

A Manual of Physiology atkd of the Principles of Disease. Bj
Edward Dillon Mapother, M.D., Fellow, and Professor of
Hygiene, Royal College of Surgeons, Dublin. Second Edition.
Dublin : Fannin and Co. : 1864.

Lectures on Public Healthy delivered at the Royal College of Surgeons.
By E. D. Mapother, M.D. Dublin : Fannin and Co. : 1864.

Not long ago we introduced the first edition of Dr Mapother's
Manual of Physiology to the notice of our readers, and the favour-
able opinion we then expressed of it has been fully borne out by
the rapid sale of that impression. Considerable additions have
been made to the present eaition, and it forms altogether a very use-
ful elementary work on physiology. A somewhat peculiar feature
is the introduction of a series of questions .on the subject-matter at
the end of each chapter; while at the end of the volume are a number
of sets of questions of various examining Boards, including the
Dublin University, the Queen's University in Ireland, the London
University, the Koyal College of Surgeons of England, and the
Arm^ Medical Department. In the present age of competitive
examinations such selections cannot fail to be useful to students, by
showing them what they may have to expect.

The second volume mentioned at the head of this article consists
of twelve lectures on Public Health, delivered by Dr Mapother
before the Royal College of Surgeons in Ireland. They treat of
air, water, food, the functions of the skin, clothing, sanitary archi-
tecture, soil and climate, the prevention of zymotic and constitu-
tional diseases, and the vital statistics of Ireland. The lectures
contain a gooa deal of valuable information, and are rendered
additionally interesting by the local allusions we occasionally meet
with.

We make two quotations ; the first gives a slight sketch of the
fevers which have prevailed in Ireland during the last 130 years ;

1864.] DR MAPOTHER'S LECTURES ON PUBLIC HEALTH. 541

the second alludes briefly to the peculiarities of the climate of
Ireland.

"The plagae which produced over 100,000 deaths in London in 1665, and of
which we cannot read in the graphic pages of De Foe after such a lapse of time
without the strongest feelings of awe and pity, was the last epidemic of its
kind which visited Western Europe. Many outbreaks of it, however, have
occurred since then in the East, and during the late war a malignant fever arose
at Odessa, which, but for the prudence of the Russian government, desirous to
check alarm, should have received its true name, * the plague.* Scarcely in-
ferior in virulence, and more disastrous in the prolonged illness which it pro-
duces, is the epidemic fever which at closely recurring intervals has depopulated
our poor land. I shall mention a few of the most remarkable of these epide-
mics, the more especially as they convincingly show the very principal depend-
ence of fever upon an insufficiency of food-— an evil, I trust, we may consider,
at least to a great decree, preventible — and not on climatic conditions beyond
our control. 1729— Most severe epidemic, great distress, and want of food ;
weather not remarkable. 1740 — Dearth of provisions, almost amounting to
famine ; weather favourable ; 80,000 died, or, according to another authority,
Dr Rutty, one-fifth of the population. 1817-18 — Corn saved was green in the
husks ; potatoes scanty, wet, unripe. One million and a half of cases occurred
in this epidemic. Early in 1846, just when ^eat anxiety was being felt for the
safety or the potato crop, Dr Corrigan published his famous pamphlet, urging
the dependence of fever upon scarcity of food, and advising that all available
precautions should be adopted. His anticipations were, as most of my hearers
remember, awfully realized, for in the three terrible years following, 579,721
cases were treated in the hospitals alone. Tlie disease usually known as the
' ship fever ' which followed, destroyed thousands of the wretched emigrants,
scarcely a vessel escaped ; and to show its malignity, I may mention that in
one, the Loosthanky 329 out of 349 passengers caught the contagion, and of
these 117 died. The influx of destitute and fever-stricken Irishmen into Liver-
pool was so enormous that its death-rate was raised to 70 per 1000, more than
double its average, and the highest mortality ever recorded in any modem city,
80 that it well deserved the name of the * hospital and cemetery of Ireland.' "

" Descriptions of the climate of Ireland are contained in the writings of the
Four Masters, and, concerning later periods, in those of Boate, Molyneux, and
Rutty, and all seem to indicate that it has undergone no remarkable change within
a period extending over many centuries. Now, as then, its principal features are
the general prevalence of westerly winds, of severe easterly gales in spring, which
have been complained of by almost every ancient writer, the comparative mild-
ness of winter and the coldness of summer, dampness at ail seasons, and a
generally equable temperature. The last-named condition, as I have observed,
is due to its beine surrounded by sea, and to the influence of the Gulf Stream,
for while parts of the Continent — Prussia, for example — ^are annually covered
with snow, and the Elbe is not unfrequentl^ frozen, our northern lakes are
scarcely ever frozen, and the myrtle blooms m the open air at Glenarm in the
same latitude — ^namely, 55° N. Few parts of this country are more than 300
feet above sea level, so that but about one degree of temperature is thus lost by
elevation.

" The superficial features of Ireland account to a great degree for the mild-
ness and dampness of its climate, and foremost among such features must be
noted the abundance of lakes, rivers, and bogs, which so plentifully yield water
to the clouds by their evaporation. The vastness of the Shannon, ^ spreading
like a sea,* as the poet Spenser has it, would, in so small an island, alone account
for its humidity, which, however, is not so excessive as to deserve Lord
Macaulay*s description—' Ireland is a marsh, saturated with the vapours of the
Atlantic' The geological substrata are mainly limestone, granite, quartz, and
sandstone, and they are clothed with soils of more than average fertility, except
where bog, or vegetal matter carbonized by moisture, not by heat, as coal is,
prevaUs.

542 DB mapother's lectures on public health. [dec.

*^ The mean annual temperature may be set down at 50°, the winter ayerage
at Dublin being 41**, and the summer 61"*. In Belfast I find the Bommer
average is 64°, the winter 40*, or the annual mean 62*. The severitjr of our
winter rarely sets in till after Christmas, and the amount of frost is below that
of England. If our climate depended only on its latitude, and was not warmed
by the Gulf Stream, the winter mean would fall to 10^.

** The mean annual height of the barometer, the instrument which measores
the pressure of the air, was for six consecutiye jears 30*55, 29*31, 30*13, 30*58,
30-64, 29*27, and one of the highest degrees it has attained is 31*5, and the
lowest 27*5

'* The amount of rain varies in different parts of the island, being greatest
along the Atlantic shores, owinff to the influence of the ocean and to the
mountainous ranges which run close to the sea ; there was, for instance, at
Collooney, near Sligo, 42 inches of rainfall, while it was but 21 in the central
district, Armagh. At Belfast the annual average isuibout 35 inches, at Dublin
30, greatest in October, least in February, according to that learned meteoro-
logist, the Vice-Provost of Trinity College. The number of wet days is much
greater in this country than in Kngland, as is also the rainfall, which at Lon-
don averages but 21 inches, and these circumstances have originated the pre-
vailing, though to a certain extent exaggerated, impression of the humidity of
our atmosphere. That it does not shorten life appears from the fact that the
number of persons over 100 years of a^e is, in proportion to the populationa,
five time as gteat in Ireland as England, and the greatest longevity has been
observed in Connaught, the wettest of the provinces. If 100 be allowed to re-
present the utmost saturation of the air, 86 is the avenge for Ireland, and on
the 14th and 16th of last January it attained the enormous percentage of 94*."

Transactiona of the Obstetrical Society cf London^ Vol. V. For the
Year 1863. London : Longmans : 1864.

The Obstetrical is one of the most thriving of the medical societies
in the metropolis. Its list of Fellows contains the names of the
most distinguished obstetricians at home and abroad; while its
transactions annuaUy laj before the profession a large amount of
valuable matter. The present volume is in no respects inferior to
its predecessors, and contains a considerable numoer of valuable
communications. Among the more important of these the following
papers may be mentioned : Vaginal Lithotomy ^ by Dr Aveling of
SheflSeld; Vmco-vaginal Fistuhy by Mr Baker Brown; Obser-
vations on Ovariotonwj by Dr Clay; Cases of Amaurosis after
Parturition, by Dr Eastlake; Case of Ccesarean Section^ by Ih
Swayne ; Medical History of the Women in Southern India, by Dr
Shortt ; Mechanical Dysmenorrhcea and Sterility, by Dr Greenhalgh ;
Combined Kvtemal and Internal Version, by Dr Hicks ; Pertussis, by
Mr Marley. We make no quotations here from any of these papers,
as under the head of Periscope we have made several extracts from
the Transactions of the Society.

1864.] MEDICAL JURIBFBUDENCE. 5i3

PERISCOPE.

MEDICAL JURISPRUDENCE.

CASE OF POIBONI|(0 BY STRTGHMIA. BY PROFESSOR GEORGE BARKER,

PENNSYLVANIA.

On the 15th of June 1863, Daniel E. SaUsbory was tried at Cortlandville,
N. Y., for the marder of his wife by poisoning with strychnia. It aDpeared
that the defendant, when only eighteen years of age, had married Miss rsewton
on the 2d June 1861, ^eatly against the wishes of his parents, who, howeyeri
in time became reconciled to it. The defendant seems to have speedily become
tired of his wife, and in February 1862, endeavoured to induce a midwife to
brin^ about abortion. This the midwife refused to do, and in the following
April the deceased was safely confined. She recovered without any untoward
symptoms. At this time the prisoner and his wife lived with the parents of
tne former. In the early part of June the prisoner went to a druggist^s, and
purchased two shillings worth of strychnia, with the professed object of poison-
mg crows, which were doing much mischief by uprooting the com. The quan-
tity he obtained seems to have been about 18 grains, but none of it appears to
have been used for poisoning the crows. On the evening of the 30th of June,
when the prisoner and his wife had retired to their bedroom, the parents were
alarmed by hearing a loud scream from the prisoner's room. Mrs Salisbury in-
stantly took a candle and started to go there. While crossing the dining-room,
she heard deceased say, " Don't, Dan, don't I " or something similar. When she
reached the door, she called her husband. He came, and went into the room
with her. There was no light there. Deceased lay on the bed, near the front
side, towards which her right arm, upon which her child was lying, was ex-
tended. She was upon her back, and her body was straight. The defendant,
who was undressed, was on his knees on the back side of the bed, endeavouring
to hold her on the bed. The mother spoke, and said, " What in the world la
the matter, Frank?" Deceased looked at her, opening her eyes and partly
raising her head, being perfectly conscious, and said, ^'Oh, mother, mother I''
The father, upon his entrance, placed one of his hands under each shoulder, for
the purpose of raising her up. Her muscles were rigid, and her body stiffened.
She appeared to be in a " spasmodic fit," as he termed it. There was a twitch-
ing of the muscles of her shoulders under his hands. Her hands, arms, and legs,
as well as her body, were stiff, and her head was thrown back. Her breathing
was very hard, as though it was veiy difficult, her breath beine forced through
her teeth, making a shrill noise. Mr Salisbury could not raise ner, so he waited
until the spasm had passed. In a few moments the muscles relaxed, and she
was raised into a sittmg position. Some camphor was put on her lips, and they
attempted to give her some internally ; but she carried her head back, as though
it was offensive to her. Water was then given her, and she drank two or three
swallows of it. The father said, ^' Frank, do you feel any better ? " She
opened her eyes, and made an effort as if to speak, but was unable to articulate
anything. Defendant had said nothing on the entrance of his parents, or in
reply to their inquiries, nor did he do anything for his wife, but seemed like
one half-paralyzed with fright. His mother said, " Daniel, she is in a fit ; get
up and help rub her." He said he would as soon as he could dress himself.
He did not, however, wait to dress, but got up and assisted to rub her hands
and arms. When her hands were released, sne seized her abdomen violently,

544 PERISCOPE. [dec

T

to

as if to tear it, snch was the intense pain there. His father then told him to get
np, dress himself, and go for the doctor, while the hired man went across the way
for Orlando (brother of the prisoner) and his wife. Mrs Salisbury rubbed her &ce
and stomach with camphor. She said in presence of the defendant, who had not
^et gone, " Tm afraid she has been eating or drinking something that is poison,
br I saw roots steeping on her stove two or three weeks before this." Some one
then spoke of their neighbours, the Staffords, and defendant said he would go for
them. After an interval of about five minutes she went into another spasm.
Her lips were slightly parted, the teeth closed tight, the breath forced through
with considerable exertion, and she groaned as if her suffering was intense.
About this time, Orlando and his wife, who had been sent for, came in. Mrs
Salisbury said, " What in the world is the matter ? is she poisoned, or what is
the matter?" Orlando replied, ^'If there is any poison about her, give her
some lard." Some was melted and brought, but her teeth were so firmly set,
that it could not be given. Then came another intermission, during which
Orlando was sent for the doctor. Her head returned to its natural position,
and she was easily held up. She was spoken to, called by name, and asked if
she felt any better ; but she seemed to taVe no notice of it. It lasted about ten
minutes ; when she had a third spasm, not quite so long or so hard as the others,
though similar. Water was thrown on her face and head, which seemed to
convulse her, but slightly. A mustard poultice was prepared and applied to the
stomach. During the next intermission hot water was prepared, to put her feet
in. She was moved down in the bed, so that her feet hung off and could be
immersed. Almost immediately she went into the fourth spasm. The defend-
ant, who had gone for the Staffords, met his brother Orlando, and told him she
was dead. When he arrived at the neighbour's house, he said to Mr Stafford,
who opened the door, ** Eli, I want you to come up to our house immediately.
Frank is dead ; she has poisoned herself." Passing in, he repeated the same
words to those inside, and then went up stairs to the room of a hired man,
where he made the same statement. The man asked him how that could be.
He replied that she had been taking medicine of Dr Bolles, and had been dig-
ging roots round the yard, and might have got hold of some root that poisoned
her. He then went down stairs. In a few moments they all left for his father's.
On their way thev met the elder brother going for the doctor, who told them
she was not yet dead. Defendant was then asked what the matter was. He
replied substantially as before, adding that she had noKbeen well for a long
time. When they reached the house, she was sitting up in bed, supported by
Mr Salisbury and the hired man, with her feet in the water. Her eyes were
open, and were very bright and natural Mrs Stafford, who was quite intimate
with deceased, approached the foot of the bed, when she looked at her and ap-
peared to recognise her. Her limbs were rigid, her hands half-clenched, and
she was frothing at the mouth. The mother said, much excited, "Is she eoin^
to die here on our hands ?" The father replied, " If she does, we must do aS
that we can to save her, and keep quiet." This last spasm was the most severe
of all. It lasted till her death, which took place in about iave minutes from
the commencement of the last spasm, and thirty mmutes from the first attack.
During the whole time she neither vomited nor pureed. When defendant came
in with the Staffords, he did not approach the bed, but sat down in a chair in
the opposite comer of the room. When she was in the last spasm, he asked if
she was dead. His father replied that she was not then dead, but probably
would die. He made no reply to this, but in a few moments asked the same
question again. Upon being told that she was dead, he remarked that he hoped
'* she had gone home to glory, to a better world than this." When she died,
Mr Salisbury straightened her back in bed, until the family physician, Dr
Hyde^ who had been sent for, should arrive. The family then went into the
kitchen, and conversed with the neighbours about the facts already narrated.
Defendant's mother asked him if his wife had been taking poison or anything
of the kind. He said, ** Not as I know of." She then asked him if there was
any poison about the house that she could get hold of. He said there was

1864.] MEDICAL JURISPRUDENCE. 545

none. She then said to him that he was not well, and had better go to bed ;
but he remained in the kitchen, sitting by the stove. Dr Hyde now arrived,
about half an hour after her death. He states that he saw the body only as it
lay ; placed his hand on the heart and on the wrist ; did not further touch it,
but observed nothing which was unusual in its appearance, except its rigidity.
The neighbours then assisted in laying the corpse out. Ab one of them went
to the kitchen for some water, she noticed the defendant shutting the door
leading from that room to the wood-house, apparently coming in. The body
was found quite rigid, so much so that the assistance of two men was required
to straighten the limbs sufficiently to remove the clothes. The fingers were not
entirely closed, but partially bent, and so stiff that it was impossible to straighten
them. Several discolorations were noticed upon her neck. There were three
spots on the left side, which looked like bruises, commencing under the ear, and
running down under the jaw. On the right side there was one, about opposite
the others. They were about the size of the end of one's finger.

Information having been given to the coroner, a post-mortem examination
was made by two Eclectics, who then commenced to make the post-mortem
examination in the presence of twelve or fifteen persons who were m the room.
The cutting was mainly done by Dr BoUes, who opened the body, placed
ligatures upon the orifices of the stomach, and removed it. On examinme its
exterior, a slit was found where it had been cut, which was large enough to
admit the finger. Dr B. called for a bowl, enlarged this opening, and without
waiting to ascertain whether this bowl was clean, emptied the contents of the
stomach into it. There was perhaps half a pint, containing bread, mixed with
leaves resembling lettuce. Water was sent for, and these doctors proceeded
coolly to rinse off the inside of the stomach, by dipping it entire in the pail of
water and rubbing it with the hand, to see if they could discover arsenic, which
Mr Newton^s fiimily and the coroner supposed had been administered. The
stomach was found entirely normal in its appearance, with the exception of a
few patches, which were slightly congested. A tin wash dish being at hand,
the stomach was thrown into it, without examining its cleanliness. Meanwhile
a jury had been organized, and now came in to view the corpse. Dr BoUes
showed it to them and stated that he saw no evidence of arsenic in the stomach.
They then retired to another room, and Dr B. commenced sewing up the body.
This finished, he washed his hands, and went into the jury room. Here he
remained five minutes, at least, leaving the two bowls in the room with the
corpse. The one containing the stomach was on the floor, the other containing
its contents was on a table, not far from an open window. The foreman of the
jury questioned the propriety of leaving the stomach and cootents where they
were so easily acceflsible, and requested Dr B. to bring them into the jury
room. The aishes were found apparently as they were left. They were
brought into the jury room, where they remained until the close of the day's
examination. After placing them under the eye of the coroner, Dr Bolles
went down to the village, and obtained two self-sealing jars, closing air tight
by a band of India rubber. These he took up to the house, and, after the
a(youmment, he and the coroner placed the stomach in one and its contents
in the other. These jars were then taken by them down to Dr Bolles' house
and given by the coroner to the hired girl, who put them in the cellar. During
Uie autopsy Drs Hyde and Goodyear called, but told Mr Salisbury they would
not stay, as they had not been summoned.

Next day, Dr Hyde, Professor of Surgery in Geneva Medical College, the
family phy»ician, was summoned at the instance of the coroner's jury to make
an examination of the brain. It appeared normal, but somewhat congested ;
the left lateral ventricle contained an ounce and a half of bloody serum. There
was a large quantity of serum at the base of the skull ; and there was con-
siderable congestion of the base. of the brain and the spinal cord.

After the adjournment of the jury, the coroner took the jars containing the
stomach and its contents to Dr Manlius Smith, for analysis. The facts were
briefly narrated to him, and the jars, which were left in his possession, were

546 PERISCOPE. [l>EC.

placed under lock and key. The next morning a small portion, about half an
ounce, of the contents of the stomach, which was found to be rery acid, was
examined with a view to the detection of strychnia. One-third of the solution
which was obtained from this small quantity gave unequiyocal evidence of the
presence of this alkaloid. This solution left an exceedingly bitter taste in the
mouth, lasting for half an hour. A few days after this, another portion of the
contents of the stomach was examined by a different process, but with the same
result. Strychnia was certainly detected. Deeming it of much importance
that a careful examination should be made of the other organs of the body,
particularly as the stomach and its contents had been so carelessly protected
from outside interference, Dr Smith suggested to the coroner the examination
of the body. On Thursday, the 17th of July, this examination took place in
presence of the pury, the examination being conducted by Dr Smith. The
Dody was still qmte rigid, and the limbs stiff. The heart was entirely empty,
with not a trace of blood about it. The bladder was also entirely empty. The
uterus was of its natural size, and contained nothing. Dr Smith remoTed a
portion of the oesophagus, duodendum, and liver, with the heart, and about
four fluid ounces of bloody serum from the cavity of the chest. These he
placed in clean jars, and retained in his possession until he reached home.
After the body mid been reinterred, Dr Smith gave his evidence as to the ex-
istence of strychnia to the jury. They then retired, and rendered a verdict
^' that the said Frances E. Salisbury came to her death by poison ; . . . that
the poison was strychnine, the same being swallowed ; ana that the testimony
and circumstances of the case point very strong to Daniel Salisbury, the
husband of the deceased, as the guilty person."

In consequence of this verdict, Daniel £. Salisbury was arrested and tAken
before the justice, where an examination was had, fasting four days, and he
was committed to await the action of the grand jurr. He was indicted October
15, 1862, and the case was called at a Court of Oyer and Terminer, January
6, 1863. The prisoner was arraigned, pleaded not guilty, and demanded a
trial. As the defence was not prepared to try the case, the judge granted a
postponement to the next term.

. When Dr Smith arrived home with the parts he had removed from the body,
he set about making the final analysis. He had obtained from the coroner the
vial fotmd near the hog-house, the contents of which the defendant had pur-
chased for strychnia. The processes followed in this analysis Dr Smith has
kindly frunished me, and I am therefore enabled to give them in his own words.

^^ Method of Analysis, — ^As a preliminary experiment, about a. tablespoonful
of the contents of the stomach was placed on a small filter. The filtrate, which
had a marked acid reaction, was neutralized with a little potassa, and then
ahaken with some chloroform. After subsidence, a portion of the chloroform
was removed with a pipette, and evaporated on a white porcelain slab. Hie
residue from the evaporation of the chloroform was tested with sulphuric acid
and bichromate of potassa, and yielded an intense and beautiful blue colora-
tion, passing through purple into red. Another small portion of the chloro-
form, on evaporation, gave a. residue having a decidedly bitter taste, which
remained perceptible about half an hour.

'* Subsequently, the remainder of the contents of the stomach was placed in
a small dialyser of parchment paper, supported by a gutta-percha rim, and
floated on the surface of about two quarts of rain water, in a glass jar about
six inches deep. After the lapse of three days, the diffusate was evaporated in
a porcelain capsule over a water bath. Meanwhile, the dialyser was placed on
the surface of a fresh quantity of water. This, after the lapse of two or three
days, was added to the residue of the previous evaporation, and reduced to a
•mall bulk, about four fluid ounces. Tne concentrated liquid was neutralized
with ammonia, shaken with about an ounce of chloroform in successive portions,
the chloroform evaporated and the residue tested. It gave the proper colours
of strychnia; and m their due order, when treated with sulphuric acid and
bichromate of potassa, or peroxide of lead, or peroxide of manganese. A por-

1864.] MEDICAL JURISPBUDENCE. 547

tion of colouring matter that obstinately adhered to this residue prevented,
apparently, the production of good crystalline forms for inspection under the
microscope. For the same reason, the weight of the strychnia obtained from
the contents of the stomach was not determmed.

" From the stomach itself, treated in the main as hereafter described for other
portions of the body — ^but several months after it came into my possession —
slight traces of strychnia were thought to be indicated by the colour tests, but
so nndeddedly as not to be considered of any weight.

"The general plan of operating on the blood, oesophagus, duodendum, and
heart, was to digest them with dilute chlorohydric — ^in some cases dilute acetic
— acid, in a covered glass vessel, in a water bath, for several hours, till the
tissues were a good deal disintegrated. The resulting pulp was then placed on
a filter, and, after draining, washed with water. The nitrate was concentrated,
its acidity neutralized with ammonia or potassa, and chloroform agitated with
it. The residue from the evaporation of the chloroform gave no decisive re^^
sponse to the colour tests for strychnia. These residues were, however, con-
siderably coloured, nor did I succeed in satisfactorily ridding them of the
colour. The plan recommended by some experimenters of heating gently the
residues in contact with a snoall quantity of sulphuric acid to char the colour-
ing matter, etc., did not succeed in my hands in disposing of the colouring matter.
" With the liver a somewhat different course was pursued. Alr^y con>
siderably softened bv decomposition, it was cut up as finely as possible with
scissors, and digested with dilute chlorohydric acid m a glass vessel, in a water
bath at near the boiling temperature, during the daytime for several days. The
pulpy mass resulting remained four or five months longer in the jar, before fur-
ther operations were commenced ^n it. It was then transferred to a dialyser of
parchment paper, and dialysis made with about two gallons of water, in two
successive operations, each of about three days. The mixed diffusates were
evaporated to near dryness on a water bath. The residue was treated with
strong alcohol, which left behind a considerable quantity of chloride of ammo-
nium, and but little else apparently. The residue from the evaporation of the
alcohol was treated with successive small portions of water, till nothing more
was taken up. The watery solutions were mixed, evaporated to the bulk of
half a pint, and, after neutralissation, shaken with an ounce of chloroform. The
chloro»>rm did not separate well, but formed a persistent emulsion. Several
ounces of ether were then added, and, after agitation and repose, poured off and
evaporated by a gentle heat. The residue was coloured highly of a yellowish-
brown hue. A portion of it, treated with sulphuric acid and bichromate of
potassa, gave a change of colour, but bo masked oy the brown colouring matter
present as to give no satisfactory indications. The residue had a bitter, mixed
with a nauseous fotty taste. Some very dilute acetic acid was now added to the
residue from the etner, and left, after proper agitation, a considerable amount
of a brownish greasy substance adhering to tne sides of the capsule. The
acetic solution was neutralized and treated with ether, and the process repeated
several times. At length a solution was obtained which, when neutralized and
shaken with chloroform, gave on evaporation of the chloroform a residue not
much coloured, which, treated with sulphuric acid contaming a small amount
of bichromate of potassa, gave a distinct though fiiint puiple coloration, passing
into equally distinct though faint red. A friend was called upon to observe
some of these tests, and, without being told what colours were expected, named
them as above, purplish passing into red.

'* It should be said that after each repetition of evaporating the ether, as
before mentioned, a portion of the residue was tested with the sulphuric acid
and bichromate of potassa. A change of colour was produced in every case.
At first, its character was obscured by the brown colouring matter from the
tissues ; but at each successive evaporation, as this brown matter became less,
the character of the colours became less and less obscure, till, on the evapora-
tion of the final chloroform solution, there was no hesitancy in deciding as to
the shades of colour produced and their changes.

VOL. X.— NO. vi. 4 A

548 PERISCOPE. [dec.

*' That the coloara obtained in the experiments with the liver were due to the

Eresence of minute portions of strychnia, and not to colouring matter deriTod
'om the tissues, may be inferred from the fact that they became more and more
distinct as the colouring matter was more and more eliminated by the repetition
of the evaporating processes.

" I believe none of the final residue was tested, it beins all consumed in the
colour testings/* (Signed) " Wm. mamlius Smith.'*

Dr Barker received a summons to attend the trial on the 6th of June. The
following is his own statement : — ** I was then lecturing at the Albany Medical
College, and on Friday, the twelfth, left Albany for Syracuse. The next day,
Saturday, I went over to Manlius, visited Dr Smith's laboratory, and, with a
residue which he stated was obtained from the contents of the stomach, con-
firmed his opinion of the presence of strychnia, both from the colour tests and
the exceedingly bitter taste. I observed traces of a crystalline character, but the
form could not be determined. As a further confirmation of the evidence, we
agreed to try the physiolo^cal test of Dr Marshall Hall. Three active frogs,
of equal size, were procured. To the first was given a solution of nux vomica,
computed to contain one-twentieth of a grain of strychnia. This was injected
into the cavity of the abdomen, the frog placed in a dish of water and watched.
The main purpose of this experiment was to ascertain exactly the action of this
alkaloid, and thus to get control of the phenomena. In twelve or fifteen
minutes, the frog became convulsed, the spasm bein^ quite eneigetic. In a
few minutes more, he lost all power over the lower hmbs, and they renuuned
extended. To a second frog, a third of the solution obtained by dissolving the
residue from the contents of the stomach in water containing a little acetic acid,
was siven by injection, and the time noted. In eight minutes the spasms came
on, the convulsions being much more severe than in the case of the first (tog.
In twelve minutes he turned over on his back, and was dead in three-quarters
of an hour. An acetic solution of One-twentieth of a grain of the white powder
found in the vial on the prisoner was prepared, and injected, as in the other
cases, into the third frog. Ue became tetanized in nearly the same time with
the last, and expired in about forty-five minutes. The first frog did not die,
tut recovered. From these experiments, it was conjectured by Dr Smith, though
roughly, it must be confessed, that the strychnia which remained from previous
colour testings, at the commencement of the ph3r8iological experiments, was at
least one-tenth of a grain. Thus there seemed not only no doubt of the pre-
sence of strychnia, but even its quantity was estimated.'*

On the evidence adduced at the trial, the prisoner was found guilty, and was
sentenced to be hanged.

We give, in conclusion, Dr Barker's remarks regarding the chemical evidence.

** In the analysis, strychnia was suspected, from the fact that some of this
alkaloid had been purchased by the defendant; and, in a single half-ounce
of the contents of the stomach, Dr Smith was able to detect it. The evidence
which he obtained in the final analysis, confirmed as it was by my own
observations, leaves no reasonable doubt of its existence there, and, therefore,
of the possibility of detecting it while yet unabsorbed. But there was quite
as certain evidence of the existence of strychnia in the liver, though, of course,
the quantity was much smaller. The colours were faint, but distinct. Hence
we may conclude that strychnia is absorbed in quantity sufficient to be readily
detected by chemical means. The methods employed are not open to the
slightest objection. Dialysis, the method of Graham, and afterwards separa-
tion by chloroform, as proposed by Rogers and Girdwood, leave nothine to
be desired. Hence we cannot agree with Dr Taylor, when he says : ' Strychnia
is one of the alkaloids which in some cases is either speedily eliminated, or, if
deposited in the tissues, is so altered in its nature, or difinsed in so small a
quantity, that the most refined chemical processes at present known cannot
separate it.' And again he says that, up to May 1866, ' in no one instance
had strychnia been obtained from the tissues of a person poisoned by it, and
in the greater number of instances it had not even been found in the stomach

1864.] MEDICAL JURIBPKUDENCE. 549

in an nnabsorbed state.* 'No chemist has jet succeeded in separating the
alkaloid strychnia in an absorbed state from the blood, tissues, or soft organs
of the body.* In consequence of which, he concludes that, ' although it may
be detectea in the stomach (if carefully presenred), it cannot be detected in the
absorbed state in the blood and tissues.'

" On the 17th of March 1864, 1 received a letter from Dr Smith, in which he
says : ' I enclose in this a small package in which are two fragments of porcelain,
on each of which is a residue from the evaporation of some chloroform that
had been shaken up with the preparation of the liver from Mrs Salisbury.'
He describes the nreparation of these specimens as follows : ' The experiments
already mentionea were finished in the winter of 1862-3. The pulpy mass
from the liver remained undisturbed in the dialyser, with no water beneath,
till June 1863. It was then found moist, but not at all mouldy, and not
particularly disagreeable in odour. It was removed from the dialyser, and,
after being thinned with water, was placed in a glass funnel, the throat of
which was obstructed by a mass of flax fibres. Th^ liquid very slowly passed
through. Occasionally fresh portions of water were added to the contents
of the funnel, and after several weeks about a pint of brownish liquid had
collected in the bottle beneath. The whole remained in the same situation
till the setting in of winter, at which time the liquid had been reduced by
spontaneous evaporation to a little over four fluid ounces. About the last of
February 1864, this liquid was neutralized with ammonia, shaken with chloro-
form, the chloroform evaporated, the residue treated with acidulated water,
again neutralized, and shaken with chloroform. A repetition or two of this
process gave a residue showing clearly the purplish colour passing into red,
when treated with the appropriate reagents. It had also a slight, though
plainly perceptible, bitter taste.' On testing the residues which Dr Smith
sent me, I obtained very distinct colorations, purple ))assing into red ; confirm-
ing his statement that strychnia existed in the liver. In view of these facts,
Dr S. goes on to say : ' If there is no mistake, this experiment settles the fact
that liver, removed from a body poisoned with strychnia, after a fortnight's
burial, in hot weather, and left a week or two more in a jar, then cut up and
treated with chlorohydric acid and water in a water-bath, left standing three
or four months in a jar, then placed in a dialyser over five auarts of water for
three days, and then over five quarts of fresh water for another two days, still
may retain enough strychnia to give the appropriate colours with sulphuric
acid and bichromate of potassa. Two points of considerable interest are
established by this statement : First, that strychnia resists in a good degree
the putrefactive and other changes of the tissue in which it is stored ; and
second, that the process of dialysine does not fully separate strychnia from
the disintegrated tissues of the body; for quite as decided, and Dr Smith
thinks more decided, traces of strychnia were obtained from the pulpy mass
of disorganized liver from the dialyser than were obtained from the dinusate.
If this latter point shall be proved true for other poisons, this process cannot
be relied upon to discover them when very small in quantity." — American
Journal of the Medical Sdenees. October^ 18^.

MIDWIFERY.

CIBCUMSCBIBED PHLEBITIS OF THE LOVyER EXTREMITIES AFTER LABOUR.
BY DR HATDEN.

The two following cases of circumscribed adhesive phlebitis of the lower
extremities, occumng after labour— one attributable, at least in some measure,
to a local cause, but both apparently traceable to a constitutional origin, or
blood-crasis — possess some interest in reference to prognosis and treatment,
and suggest profitable reflection in regard to the pathology of blood- coagula-
tion in the hying body, and the changes which the clot may subsequently
undergo.
Case I. — Mr& K., aged about thirty-six years, nervous and anemic, and

550 PEKI800PE. [DBC.

Buffering from yaricose enlmmmeiit of the soperficial v«iib of the left leg and
thigh, WM confined of her fifth child in March 1863; kbonr was at the M
. term, and natural ; recoyer^ progressed satisfaciorily till the fifth day, when
sharp febrile symptoms set in, and the patient complained of pain and tendec-
ness in the left thigh. On examination this part was found swollen, and the
internal saphena, from the knee to the groin, hard and tender, and its course
indicated on the siurface by a faint pink streak. Leeches were applied, fol-
lowed by stupes; the limb was swathed in flannel; mercmry with daSk
administered in three^grain doses every third hour, till the gnms became sUghtiy
affected ; anodynes were necessary to procure sleep ; subsequently turpentine
stupes and tight bandaging were had reoonrse to. At the end of a week the
limb had resumed its natural condition, and conyalescenee was established.

Case II. — Margaret G-., aged twenty-one, married one year, and confined of
her first child on the 5th of Inst January, was admitted into the Mater Miseri-
cordiss Hospital on the S5th of that month. Labour was natural ; the child,
though at the full period, was unnsoally small, and died a fortnight after birth
The patient's health had been generally delicate, and for seyen months before
confinement her appetite greatly impaired. A fortnight before being admitted
into hospital, and a week after connneroent, she was attacked with acnte pain
in the left leff, which rendered her unable to put it to the sround. CEdema of
the foot and leg followed in a day or two. When admitted she waa anemic in
a high degree; pupils dilated, eyen in strong light; pulse 126, sharp and
irritable ; skin hot and dry; and acute pain and tenderness complained of in
the left leg, which rendered movement ot any kind all but impossiUe ; the lefi
posterior saphena vein, from the ankle to its termination in the popliteal space,
was hard, knotty, and acutely sensitive ; the heart's action was quicky and iti
sounds normal, but there waa yenous murmur in the neck. On the dOth of
January, inflammation had extended to the lower two-thirds of the thigh; and
on the dlst, quite to the groin. The femoral vein now felt like a hard eylmder,
and was acutely tender to the touch, the thigh much swollen, and the patient
in a state of high febrile excitement.

Under the treatment employed, which consisted in leechee to the groin,
warm poultices, aperients, and anodynes, pain waa alleviated, and the patient
obtained some repose. Mereury with chalk, and Doyer's powder were admin-
istered in small doses ; and on the 9th of February, the leg and foot having
become greatly swollen, hot not sensitive to pressure, camphorated mercorial
ointment was rubbed in in the course of the veins, and the entire limb, front
the toe to the groin, was tightly swathe'd in a flannel roUer.

Diarrhoea having now set in, the further use of mercury was suspended;
opiate astringents were given, and, subsequently, iron and quinine in moderate
doses. The patient's condition underwent a marked improvement ; the pulse
had come down to 102, appetite and sleep much improved, and oedema had
disappeared ; when, on the 21st of February, the right leg and diigfa were
simultaneously attacked, and went through the same course in all particulars
as the left. The same treatment was likewise employed, with the exoeption of
mercury, which on this occasion was studiously avoided.

When the inflammatory symptoma had been subdued, liquor potassse was
given in ten-drop doses every third hour, and a stimulating embrocation applied
to the limb. On the Ist of March was free from pain; pulse ninety^ix; urine
alkaline ; and oedema rapidly disappearing. March 10th, oedema of the limb
and rigidity in the course of the vems having entirely disappeared, compound
iron mixture was substituted for the alkali, porter and nutritions diet were
given, and the patient was allowed to sit up. At the present time her condi-
tion is nndergomg rapid improvement ; she is gaining flesh and colour, vid
able to take moderate exercise in the ward.

The first of these cases furnishes a good example of phlebitis, dependent, at
least proximately, upon previous varicose distention of the veins affected ; but
that this circumstance aoes not afford a full explanation of the attack will
probably be admitted, when it is borne in mind that an interval of five days had

1864.] MIDWIFCST. 551

elapsed between deliverj and the first mazdfiestation of aymptome of phlebitisi
daring which the enlaif;ed veuu had resnmed their normiu duneneionii, and the
patient been confined to the recumbent posture, and a low diet. Varicose
Teins, under other cirenmstances, are by no means commonly the sobject
of infiammation ; on the contrary, they appear to enjoy a certain immonity
firom it, as witnessed in the application of styptics and caustics with impunity
to a ruptured varicose vein.

Daring the last weeks of pregnancy, and for some time after parturition, the
blood contains an excess of fibrin, which must predispose to vascniar obstruction.
Dr Simpson sa^s, ** during the puerperal condition, the Uood is more loaded
with new materials, intenoed, some for excretion, and some for secretion, than
at any other term of life, and, hence, is specially liable to diseased changes
under the superaddition of anjr exciting or septic causes ; for the uterus, durmg
the first weeks after delivery, is becoming involved and absorbed by a kind of
retrograde metamorphosis, and the e&te materials resulting from its disin*
tegration necessarily first pass into the blood before they are ultimately dis-
charged and depurated from the system ; there is an excretory action going on
in its interior in the form of the lochial discharge, and the elements for the
formation of a new and important secretion, Uie milk, are present in the
oircolation." In both the cases, but more markedly in the second, there were
likewise anemia and feeble action of the heart, which, by weakening the vis a
tergo, would fiKvour stasis and coagulation of the blood, especially in the distant
subcutaneous veins, which derive no aid to their circulation firom muscular
pressure or adjacent arterial pulsation. Thus, perhaps, may be exjdained the
occurrence of coagulation and its consequence, mflammation, primarily in the
saphena veins in both cases ; otherwise, assuming with Dr Lee that postpartum
phlebitis of tHe lower extremities, or phlegmasia dolens, originates in th«
uterine veins, and extends by continuity downwards, we should be at a loss to
account for the immonitv enjoyed by the femoral rein at the onset of the
attack ; and in the second case given, fi>r a period of five days after the occur-
rence of inflammation in the sapnena.

It will be perceired that I look upon coagulation of the blood as oonstitntinff
in these cases the first step in the series of morbid changea observed, and
inflammation of the contamii^ vessels only as the second. I shoidd be
disposed to add, that inflammation of the vessels was, in both cases, the direct
eonsequenee of coagulation of the blood within them, fiivonred by the predis-
posine causes previously adverted to.

K tnis view oe correct, it would follow that the indications for treatment are
two, namely, whilst combating the local inflammation by strictly local means,
to quicken excretion through the bowels, the kidneys and the skin, and to
correct the tendene;^ to blood coagulation by administering alkaliea. This
latter class of remedies should be given in sufficient quantity to render the
urine alkalim^ and continued for some time after the appearance of improve-
ment.

I would esdiew merenry, except as a local deobstmesBt, in all similar caaes,
as being pre-eminently an impoverisher of the blood, br disintegrating or
fi»ronring disintegration of the red corpuscles. — Dublin (tuartorl^ Jowmd qf
Medical Sdenos.

CASE IN WHICH AI1AUR08I8 WAS OBSERVED EIGHT TIMES IK SUCCESSION AFTER
rARTURITION. BY DR H. £. BASTLAKE.

EuzA TxBBBT, sst 34. married ; the wife of a painter. The patient states that
she has had nine children at the full time, and no miscarriages. She has
always enjoyed good health. In three of her confinements she was attended
by medical practitioners, in the other six she was delivered by midwives. As
fiir as I can learn, all her labours have been natural. She has never lost m(Nre
than the normal amount of blood, and after the birth of her last child (which
took place on the 28th of hist January), the hssmorrhage was peculiarly slight,
accwding to the acoooat of the jnidwife who attended her.

552 PERISCOPE. [dec.

On the occasion of her first lying-in, she tells me that she made a quid^
recovery and nothing peculiar happened, her sight being then perfectly good ;
bat on the second or third day after the birth of her second child, and after
all her seven sabsequent labours, she has suddenly become totally blind in
both eyes, and also partially unconscious ; but when her senses returned, the
amaurotic condition remained, and on an average has lasted from three to
five weeks.

I saw her for the first time on the dlst of last January, three days after
her confinement. Her pulse was rather weak, but there was no marked
pallor, nor did she exhibit any great signs of debility. Her intellect wu
certainly clear at that time, though I believe that she had been somewhst
incoherent the day before. She assured me that she appeared to be in
absolute darkness, and after a few experiments to satisfy my own mind on
that point, I was thoroughly convinced that she could neither distinguish
any object, nor had she even the perception of light.

I should perhaps mention that she had never taken any ergot ; there was
no suppression of the milk or lochia, and I carefully ascertained that she
had not been subject to anv periodical or long-contmued discharge which
had suddenly dried up. There was no albuminuria. She compUined of
nothing but her want of vision, and all her other functions appeared normal.
Beinff a patient from the St Marylebone General Dispensary, 1 arranged that
she should be seen by my colleague, Mr Zachariah Laurence, whose reputation
as an ophthalmic surgeon must be well known to Fellows of this Society.
Having first well dilated the pupils by the application of atropine, he proceeded
to institute a most careful and complete ophthalmoscopic examination, but the
evidence adduced from it appears to be entirely negative, except that it
demonstrated the existence of a somewhat contracted state of the retinal
arteries ; this latter fact, however, being in all cases a question of degree,
may be considered comparatively unimportant.

I may add that no strabismus existed, and that no peculiarity either in
point of colour, form, size, or consistence, was noticeable in the eyebali. As
the patient was by no means a robust or plethoric woman, and, as I hare
stated, her pulse being rather weak, I allowed her a liberal diet, and since
her getting up she has been taking bark, with mineral acids, wine, Stc.y with
improvement.

The most remarkable feature in this case seems to be its apparently utter
isolation from the various forms of amaurosis attributable to other causes.
In the rejection of these we might infer, by a negative process of reasoning,
that this phenomenon was necessarily dependent in some way upon the
puerperal condition of the patient. I confess that I should have l)een induced
to incline to this opinion, had I succeeded in discovering a parallel case either
in the history of oostetrics or in the modem practice of midwifery. But I
have failed to establish a precedent. Dr M^Chntock, the late master of the
great Lying-in Hospital, in Dublin, whose experience as an accoucheur, I need
scarcely say, fairlv represents the probabilities of such an occurrence in our
day, assures me that he has never met with a similar example ; and Mr Wilde,
whose experience as an oculist must be very considerable, also states that he
has never seen a case of this kind.

The only authors, as far as I have been able to ascertain, who record
anything at all relating to this subject are Beer, in the year 1817, and very
recently Dr Ramsbotham. The former, in the second volume of his '^ Lehre
der Augenkrankheiten,** describes a form of amaurosis which occurs at the
commencement of pregnancy and disappears after parturition, but which is
always connected with nausea and uncontrollable vomiting ; he adds that we
must be careful to distinguish this kind of amaurosis from that which arises
sometimes during the last months of pregnancy, and is due to the violent
and continued congestion of the head, particularly if there is much fecal
accumulation in the intestines with constipation. This form of amaurosis
generally lasts until the birth of the child, or if the labour is much prolonged,

1864.] MIDWIFERT. 553

and accompanied with great ezhaostion, the blindness he stated is likely to
continue. He also relates a case of a young Jewess, who in her first three
pregnancies began to grow blind always immediately at the commencement
of utero-gestation, and in the third or fourth month she became completely
amaurotic, but, on the first two occasions, remained so only until after parturi-
tion, but lost her sight entirely after the third confinement.

Dr Ramsbotham describes a case somewhat similar, under the head of
cerebral affections in pregnancy, in the '* Medical Times and (Gazette," of
March 7th. I wiU quote that portion of it which has any interest connected
with the one I have brought before your notice.

Dr Ramsbotham first saw the patient on the 14th of June 1842 ; she was
then in the last month of her pregnancy.

He says : " The earlier montlu haa passed oyer yery well ; but, about six
weeks before, she began to lose the sight of both eyes simultaneously, and
continued to get worse by degrees until my yisit, when she was so completely
blind that she could only just point out the situation of the window.

She had not suffered any pain in the head, nor any unusual drowsiness ; her
recollection was perfect, and she was quite sensible. The pupils were much
dilated, the right more so than the left. The pulse was quick and small. She
was cupped, leeched, blistered, and slightly saliyated, without relief, and
continued getting worse until she could not distinguish the brightest sunshine.
On the 2da, she began to feel a tingling and numbness in the right anli and
leg, without any loss of power, and, on the 24th, Dr Blundell met us in con-
sultation. He feared, as I did, that convulsions or apoplexy would occur
during her labour.

He recommended that more blood should be taken by leeches to the temples,
and that the mercury should be continued . . . ohe went into labour at
midday of the 28th, and was delivered ultimately the next day by craniotomy,
owing to the pelvis being below the average size — the child being putrid —no
convulsions occurred ....

He concludes by saying : " As far as her labour was concerned, she went
on exceedingly well; but the blindness, numbness, and tingling remained
without dimmution for ten days. After that, she gradually began to mend ;
in a month she could distinguish objects ; in six weeks she told me the hour
of my watch, and, on the 24th of August, she went out of town very weak,
but able to stand and walk with assistance, and she had completely recovered
her sight . . . She had one child afterwards, without any return of the
symptoms ; but as she left that part of the town, I am not aware whether she
ever bore another."

The details of these cases, it will be observed, do not completely coincide
with those which have come under my notice. Whether there may be any
analogy between them, and how either or all may be connected, however remotely,
with parturition, are points upon wliich at present I do not venture to theorize ;
I haveonerely stated the facts as I observed them, and I shall willingly await
the opinions of any of the Fellows of this Society who, through their research
or experience, are enabled to throw any light upon this very interesting
subject. — TranaacUons of the ObtMrical Soday of London,

MOVABLE KIDNEYS GIVING RISE TO SYMPTOMS OF PREGNANCY.
BY EDWIN E. DAY, ESQ.

The fact tliat kidneys are sometimes movable is one on which some scepti-
cism exists. On the Continent this condition has been well described by Pro-
fessor Oppolzer, M. BAyei^i and others, and in this country Dr Hare has pub-
lished in the Medical Times and Gazette (first vol. for 1858) some good lectures
upon the subject.

To the general remark, " Has it been found after death ? '* Mr Durham has
fliven a satisfactory answer by producing to the members of the Medico-
ChirurKical Society the parts ot a body in which the kidneys were abnormally
situated and movable. Professor Simpson mentions a case in which the kid-

554 PEsisoopE. [dec.

ney was sarronnded by a special mesentery, Urns giTen it ooosideraUe noge of
motion.

There are three or four things with which they could be confoondad.

l$if Fecal masses in the colon.

2df Movable spleen.

Sdj Tumoars of the omentum or mesentery.

And, lastly, some women have the power of throwing their psoas muscle into
partial contraction, thus simulating this state of kidney.

Purgatives would decide the first point. The spleen would be larger thao
any kidnev, and would, of course, be found on the lett side, while it is commonly
the right kidney which is movable. Tumours of the mesentery or omentnra
would probably be confined to one side, and they would be anterior to the poa-
tion of the kidnev. The absence of the hilum would be a good assistance in
determining the cnaracter of the tumour.

Dr Priestlev, m the Medical Timet and GaseUe, 1857, voL i., p. 262, said, he
was convinced that some of the cases of spurious pregnancy which had coma
under his notice were cases of movable kidney, but he did not give any cases;
the following one may, therefore, be of interest in bearing out that opinion :—

Mrs W., aged 37, applied at King^s College Hospital on June 3, 1864, under
the following circumstances : — She was married, and had had one child fire
years before. Since that time she had menstruated regularly till September
last, when she was much frightened by the ceiling of her room udling in. After
that she missed two periods and supposed herself pregnant, and waa therefore
surprised at finding that at the third period the catamenia returned, and hsTe
continued regular since. She still thought herself in the family way, as, to use
her own words, " she had felt the movements of the child ; " but the nine
months having passed without any change in her condition, she waa anxious to
have my opinion as to her state.

On makmg an abdominal examination, I found that the abdomen was tym-
panitic, and that there was no uterine tumour whatever ; but in the right ilise
fossa I felt a tumour, which slipped readily away, from my hand, and upon
closer examination was determined to be the right kidney. The hilum was
readily felt, and the space over which the kidney could be moved was about
three or four inches. On examining the left side, that kidney was also found
movable, but it was not so low down as the right. It was situated just below
the level of the ribs, and could be moved over an area of two or three inches.

The movements which she had considered foetal were thus clearly to be
attributed to these movable kidneys.

In order to make the diagnosis more sure, I sent her into the Hospital under
the care of Dr Q. Johnson, who agreed in the opinion I had expressed. — Medi-
eal Timeeand QaztUe,

MEDICAL HI8T0BY OF WOMEN IN SOUTHERN INDIA. BY DR SUORTT.

When the wonum is taken with labour pains her relations and intimate female
fiiends come in and crowd around the sufferer, interfering with the ventilation,
which is already limited. She is directed to relieve herself by walking about,
and the midwife is sent for, although usually an experienced old woman of
the family acts as such. She rubs her with oil and bathes her back, loins,
and lower extremities in warm water ; if the pains are false, the woman may
partake of food, but after the commencement of labour nothing is given. She
IS made to sit with her legs extended, and her back supported by a woman
tilting behind, whibt the nurse shampoos her back and loins, and her friends
keep up a continual noise by talking.

Prior to the rupture of the membranes the nurse places a bag filled with
ashes under the perinseum as a support, and to prevent her dothes being
stained.

The pelvis and abdomen are well nibbed with lamp-oil, and shaken seversl
times to promote speedy delivery. The membranes are not ruptured ; this is
left to nature without regard to time. When the head protrudes, the nurse

1864.] MIDWIFEBT. 555

supports it with her hands, and directs the woman to lie on her back. Afler
the birth of the child, one end of the patient's cloth is tied as a binder round
the abdomen and pelvis.

Should the placenta not be expelled, they direct the woman to chew a lock
of her hair, which induces sickness and thereby brings on uterine action ; if
this is not euccessful, they draw on the placenta by the funis to detach it
from the uterus. The soiled clothes are now removed, and clean ones
substituted.

The child is placed on paddy, varying in quantity according to circumstances
(usoaUy about six pounds). A piece of rag is tied on the funis about four
inches from the umbilicus ; the cord is divided on the placental side with a
com sickle, and the cut end covered with burnt rags, or olack paper, or with
a paste made of ashes and water. The paddy, with two and a-half annas, are
given to the nurse, who also receives oil and betel nut every momins imtil
the twelfth day, when two pounds of rice, half a pound of dholl, chillies,
curry stuffs, and old cloth, and a rupee are given her. She is supplied with
food during the time of her attendance by some. The cloth the woman wore
during labour is given to the washerman.

TrBcUmento/the n&vhom CAsZe^. -^Immediately after the funis is cut the child is
washed in tepid water, and until the third day is fed on boiled honey, as until
that time the mother is not allowed to suckle it ; and if the external parts are
cold, five drops of the milk hed^e (Euphorbia Ttrucalli) are given it. On the
third day it is rubbed all over with sweet oil ; bathed in warm water and half
a pie weight of garlic ; one quarter pie weight of black pepper, heated in a kin
weight of castor oil, is given, and the dose is continued every second day.
Some give castor oil night and morning for the first, once a-day for the second,
and every other day for the third month. From the third day the mother is
allowed to suckle her child ; if she is not able to do so, it is brought up on
goats, cows, or asses' milk.

There are no particuUr rules about lactation ; but it is considered very
prejudicial to the infant for the mother to suckle it during her next pregnancy,
but this is not much attended to. The child receives its name on the twelfth
day after birth. The parents sit down, the mother holding the child in her
arms, while the assembled Brahmins stand around them. Some uncooked
rice is now spread on the ground, on which the father writes the date of birth,
the planet under which the child was bom, and the name that he intends to
sive it ; the PurohUa offers up some prayers, the father calls the child thrice
by its name, and the Brahmins are fed and presented with betel, etc., which
terminates the ceremony. At six months the child receives solid food, when
the ceremony called " Araii^^ is performed. It consists of burning a piece of
camphor on a brass plate, and moving it in circle around the parties ; some
substitute turmeric and lime water which become red when mixed for the
camphor. This ceremony is performed to blight the " evU eye"

The shaving of the child's head, piercing its ears to receive jewels, etc., and
investing it with the sacred card, are all performed with numerous ceremonies.

If a first bora child dies at birth or is stillborn, it is usual to place the body
in a chatty or earthen vessel, and bury it in the house, and after three months
have elapsed it is buried elsewhere, as the skulls, finger-nails, etc., are in
great requisition b;^ magicians to perform their charms. Children are never
burned. — Transactions ofiht Obstdrical Society.

ON DTSMENORRHCEA. BY DR GREENHALGH.

Of the three forms — mechanical, congestive, and neuralgic— considerable ex-
perience has convinced me that the first is by far the most frequent, and I am
anxious to impress this fact upon the attention of the Society, as somewhat
severe comments have been made by a recent author upon the mechanical
treatment of this affection. Many cases which 1 formerly regarded as of the
latter two varieties, and have treated upon the principles ordinarily advocated
VOL. X. — NO. VI. 4 B

556 ' PERI800PB. [dec.

withont BQCcess, have readily yielded to diviBion of the os and cerrix atari;
still, I have OBually been in tne habit, and would strongly urge a similar oonne,
of relieving any prominent symptom or symptoms by appropriate remedies be-
fore proceeding to operative interference. 1 have invariably noticed that cs«ea
so treated progress more satisfactorily. Again, it is roost important to bear in
mind that where dysmenorrhoea has been of long standmg, no matter what its
causes, more or less congestion or duration of the uterine tissues, or enlarge-
ment of the cavity of the uterus, is frequently induced, which will requin
treatment after the operation, especially in those cases of a metritic origin, be-
fore the case can be fairly said to be cured. A neglect of this precaution msy
lead to a redevelopment of the dysmenorrhoea.

The plan I generally pursue in such cases is as follows. In addition to the
ordinary hygienic measures, I give a combination of bichloride of mercurj,
quinine, and belladonna, m pills, one night and morning. If there be much
local tenderness, I order from four to six leeches to-be applied to the cervix;
if there be but little pain, suppositories of atropine and cocoa-nnt butter; if
much induration, the addition of strong mercurial ointment. The suppository
should be used every night, and oftener if necessary.

I have seen the best results from douches, at first of tepid, and subsequently
of cold water, to the uterus, which may be used night and morning with an
appropriate apparatus, the ordinary female syrin^ being worse tlum useless.
In some cases sedative, in others astringent, injections wm be found usefuL

In conclusion, a word or two upon sterility.

Experience has convinced roe that women are most prone to conceive im-
mediately after, more rarely before, the menstrual flow, and I have frequently
met with cases, especially in feeble women, where coitus early in the morning,
after the invigorating influence of a night's rest, has appeared to produce the
happiest results.

Again, the female discharges may be so acrid, especially where she is in in*
difllerent health, as to destroy the spermatozoa ; in such cases, the injection of
warm water into the vagina, so as simply to remove all secretion, or the use of
a very weak solution of either the carbonates of soda or ammonia in milk or
any bland fluid, will be found most useful, if had recourse to shortly before
connexion. — Tramactums of the Obgtebical Society,

ON A VARIETY OP CHRONIC PAIN IN THE BACK. BY DR HENRY OERYIS.

The malady which for a few minutes this evening I venture to bring before
your notice is one which, though perhaps more surgical than obstetric in its
pathological character, yet from its having occasionally been thought to be de-
pendent upon uterine disease, and treated as such, is, I think, not unworthy of
our consideration as obstetricians ; particularly as its recognition when present
enables us with certainty to direct our treatment to its cure, and so relieve the
patient from a complaint apt, when overlooked, to be both chronic in duration
and distressing in character. The following case was the first which drew my
attention to the subject, and as the disease itself is no novelty, and as one case

Srettv much resembles another, I will not trespass on your time by giving the
etails of others which have subsequently come under my notice.
In April 1860, Mrs D— , set. 30, came under my care as an out-patient ot
St Thomases Hospital ; she had a somewhat worn aspect, but did not appear
otherwise unhealthy ; her particular complaint was of a constant pain in the
lower part of the back, which she stated that she had suffered frofn, with bat
little intermission, since the year 1854, the date of her last confinement. She
had been treated for it by both private and hospital physicians, and they all
had spoken of it as a " weakness,'* connected with uterine disease ; thinking it,
I presume, that sympathetic '^ dolor dorsi " which constitutes so frequent a
symptom in the history of uterme afiections. She had, however, never suffered
from any other symptom of such disease, excepting an occasional catamenial
irregularity and an occasional slight leucorrhoea ; but at the time I first saw her

1864.] MIDWTFERT. 557

the catamenU was rmilar, and she had no abnormal discharge, and yet the
pain in the back was Both constant and severe.

On a vaginal examination, digital and specular, the uterus was found some-
what large but without tenderness, and otherwise healthy. No disease, in fact,
was detectible to which this chronic pain could in any way be ascribed. On a
careful examination of the back, I found that she defined the pain as being
especially connected with the 1^ sacro*iliac synchondrosis ; on percussion or
pressure upon this articulation there was a marked amount of tenderness, and
on taking hold of the ala of the corresponding ilium, and pressing it backwards
and forwards, she experienced a considerable increase of tne pain. On further
questioning her, I found that the pain was least when she was lyins at rest ;
worse when she walked, and greatly aggravated by a false step, a sudden twist,
or any other unexpected movement which affected the articulation, as in slip-
ping over the kerb, missing a stair, treading upon a loose stone, etc. Her
general symptoms approximated to those of slight hectic; there was some
variable febnlity, some loss of flesh and appetite, and a sense of weariness,
induced b^ the constancy of the pain. I could detect no local external fulness
or thickening, but the tenderness was considerable, and limited to the synchon-
drosis. She was not a rheumatic subject, and though never very robust, had
previously to the occurrence of this pain enjoyed fair health. I looked, there-
fore, upon the case as one of a chronic congestive, or subinflammatory condition
ot one or more of the tissues of the synchondrosis, following indeed her con-
finement, but unconnected with existing uterine disease. It was treated upon
ordinary principles, by rest, the local application of blisters in narrow strips,
of about two inches lon^ and one broad (within a limit I defined by the pen) ;
and as an internal medicme she took the bichloride of mercury in decoction of
cinchona three times a-day, and at night some extract of henbape and Dover's
powder, with an occasional aperient. She soon be^n to improve, and within
eight weeks was completely relieved from a pain which had previously scarcely
left her for six years. Her general health became also re-established. I, of
course, should not have ventured to bring such an ordinary surgical case before
the notice of this Society had it not happened that by several practitioners this
pain had been considered wholly dependent upon an associated uterine dis-
ease, and that since the occurrence of this case, I had seen others in which a
similar affection of one or other synchondrosis constituted their most important
element.

Of the post-mortem pathology of these cases I am unable to speak, as,
fortunately for the (jatient, they rarely permit the scalpel or the microscope to
aid in their elucidation.

In some cases there is a pain in the back, apparently of a rheumatic charac-
ter, affecting the ligamentous and fibrous tissues about the articulation,
and in some the periosteum is evidently affected. In these the iodide of
potassium in combination with alkalies and other antirheumatic remedies
IS of especial service; but in others, as in the case detailed, the affec-
tion is certainly of the deeper-seated tissues, the cartilage and fibro-cartilage,
vis., which connect the bony surfaces. In four cases which I observed^ the
piin came on after parturition, and in two the child was said to be an unusually
large one. Possibly, in these, this was the direct mechanical cause of the sub-
sequent condition of the articulation, the undue strain upon it originating that
condition of its tissues to which the chronic pain which followed was referable.
The patient whose case is detailed had borne no other child since the first occur-
rence of the pain, but another patient, in a labour subsequent to the one from
which she dated the commencement of the pain, suffered much from it during
her labour, and from its aggravation afterwards. I need scarcely refer to the
opinion founded upon what is said to occur in quadrupeds, that the human
pelvis during labour undergoes some enlargement of capacity by a slight yield-
mg of its articulation, as I believe it has been pretty generally abandoned, but
even if it were so, in those cases in which the condition under consideration
appears to originate in a mechanical pressure or tension during parturition, the

558 PERisooPB. f [dec.

ordinary pressure must have been more than usual, or the capacity to jield lest.
But in otner cases, with an equsJly defined affection of the synchondrosia, no
such origin was assigned, but it was variously ascribed to a cold, a strain,
'* weakness*' from some womb affection, etc. 1 have never met with it in the
nullipara. Sometimes there is some varying increase of pain during the cata-
menial period, and this might easily suggest the idea that some uterine mischief
was the cause of the backache ; but as this variety of pain in the back may
certainly coexist with a healthy uterus, the increase of pain at the monthly
period is probably'due to that customary amount of lumbar uneasiness which
often accompanies the periodic congestions of the uterus, and which, in these
cases, appears to the patient to amalgamate with her more constant pain ;
though really, as regaras its cause, distinct. I presume, then, these cases to be
mild forms of an affection whose severe form would be represented by abscess,
and I think that the cases which occasionally occur of subacute or chronic in-
flammation, and of threatened or actual suppuration of the symphysis pubis
occurring generally after a severe labour from large size of the child, and whose
diagnosis is unmistakable, are confirmatory of the view I would suggest of the
cause of an occasional form of chronic ^' pain in the back.*^ — TratiMcUotu of
ike OhsUtncal Soddy.

ON THE TREATMENT OF PERTU88IS. BT RICHARD ILARLEY, H.R.C.S.

Conclusion.— Although a prolonged practical observation has induced me,
thus forcibly, to expatiate upon the advantages of a free employment of chlo-
roform in pertussis, still I do not lay down, as a rule, the arbitrary administra-
tion of this a^ent, to the exclusion of all others. Hooping-cough presents no
special facilities in its treatment, and any one who bases this treatment upon
a blind speciality will be disappointed over and over again. In all diseases we
must modify our course by the special features of each case, and this rule
applies to hooping-cough, as well as to other complaints. In chloroform we
have a remedy that either at once prevents the paroxysm, or greatly lessens its
severity, frequency, and duration. But nevertheless an indiscriminate pre-
judice in its favour, to the entire exclusion of all other therapeutical agents,
would be injudicious.

By the employment of chloroform, belladonna, chlorodjme, and prussic acid
(but more especially the first two), pertussis will sJways yield, and by the
rapidity of cure the numerous and fatal complications will be prevented. Of
course, the bowels must be well looked to, and the diet properly regulated.
The food should not be solid; a hearty meal may immediately bring on a
severe paroxysm, or induce a relapse. Thick farinaceous, or thickened animal
broths, will be found to be of the easiest assimilation. Ventilation, good air,
and gentle exercise must not be neglected. A popular opinion and error is,
that a change of air of itself will effect a cure when the disease has reached a
certain stage, and in these words, ** a certain stage," lie all the gist of the re-
mark. When the first and second stages have abated, change of air, doubtless,
is beneficial, provided it be a chance that removes the patient from a badly-
ventilated room, in a close and smoky town, to the health-giving breezes of an
open country. But even this must depend upon the season of the year. I
would deprecate the removal of a patient from a warm and well-ventilated
room to the piercing winds of March, or the damp, cold, and fog of November.

From the setting in of the premonitory stage, the room used by the child
should be of a uniform temperature. He must be warmly clothed, and aU the
measures of hygiene strictly and carefully attended to. — TransacUana of Ote
Obstetrical Society,

1864.] INVESTIGATION IN THE CASE OF AN INSANE PRISONER. 669

MEDICAL NEWS.

REPORT OP INVESTIGATION IN THE CASE OF J. S. LOVE,
AN INSANE PRISONER.

At last Autumn Circuit in Glasgow, James Strang Love, residing in Rutherglen,
was placed at the bar charged with the murder of his brother Robert Love.
Both brothers resided in family with their father, John Love, a labourer. The
indictment charged the pannel with murdering his brother by cutting his throat
with a razor, on the night of Saturday the 28th or morning of Sunday the
29th May 1864. It was reported, that before the family went to bed on the
28th, the deceased had found fault with the pannel for not paying a sufficient
sum as board to his mother, and had also spoken to him about a razor which
the pannel had borrowed from a barber about two weeks previously, and which
he had not returned. The pannel had made no answer on being so spoken to,
but there was no quarrel, and they all went to bed quietly — the pannel and
his nephew in one room, the deceased and his father in another. About two
o'clock on Sunday morning, the pannePs mother was awakened by something
trickling on the floor. She got up, woke the father, and Robert was found
to be lying on his back dead, and blood was dropping from the bed to the
floor. The pannel was then in his own bed, and seemed asleep. Two policemen
-^ho were passing were brought in, and he was charged with the act ; but he
merely replied, " No, no." He showed where the razor was lying on a shelf
in his room. These facts, it will be understood, were not brought out in the
proceedings which we are about to report, and they are merely mentioned
in order that the nature of the act charged may be understood. The prisoner
having been brought before Lord Ardmillan on 22d September 1864, it was
stated, on his behalf, that he was not then a fit object for trial, in respect he
was insane. In support of this plea in bar of trial, his counsel (Messrs Orr,
Paterson, and R. Vary Campbell) adduced the following evidence, which we
report from notes taken by a member of the bar at the time. Mr Thoms,
advocate-depute, conducted the case for the Crown. The prisoner presented
a neglecttd and dull appearance, and he seemed to' take no interest in the
proceedings. It will be observed that legally, and immediately, the oidy
question raised by the prisoner's plea was, whether he was insane at the date
of his appearance in Court — ^not at the date of the act charged.

Mary Love. — My son James, the pannel, is thirty-one years past. His trade
is that of a dyer. He hasna wrougnt a third of his time during the last seven
years. He worked regularly before that time. During that time he was
not capable of work ; his mmd has been wrong. A change occurred in him
seven years ago. Before that time he was a particularly well-behaved hard>
working lad. He then began to get thoughtful and moody. About that time
a girl Mid a child to him, and she went wrong in her mind. This took place
in our own house. It was after that he ^ot moody and thoughtful. Light-
hearted lad before that — quite good-spirited. One day not kng after that

560 MEDICAL NEWS. [DEC,

he came home for his breakfast, and wanted me to fill three bowls with water.
I refused, and he went to his grandmother and she did it for him. He then took
a large needle and jagged his arm, and let blood fall into each bowl. He kept
doinff that a whole hour. I tried to stop him. I remember two men bringing
him home He had put lime in his eyes, and they were running with water.
He was then in a very outrageous state. I had to send for his father. He
beean to say his grandfather was a Jew and an Israelite. He said heayeo
and earth would be turned upside down. He was never quite right after the
occurrence referred to, but sometimes not so bad. He has gone three days—
near to four — ^without food when he could have got it. He would not take
it when offered him. He would then sit for weeks and months at the fire with
nothing but his shirt on, and his trousers hanging about his feet, though it was
never so cold. He was formerly tidy in his dress, but during the last seren
years he has become slovenly. He very often walked up and down all night.
He would do this bareheaded and barefooted. I remember one night in partic-
ular in which lie did this. He walked about this way in all weathers out of doort^
whiles looking up— whiles looking on the grotmd. He would stand stariD£
at the skies. He has stood so for several hours at a time. About a year ana
a-half ago, when his sister was lying in bed a-dying, he took a hanmier aod
broke the mantelpiece of the room in which she was. One time he lifted a
stool, and threatened to kill his father. His dying sister cried out when she
saw him do this. He made a drive at her. He Kad then no quarrel or apparent
anger with any of the family. He was then sober. He was of sober habits.
He was sober when the two men brought him in, as already noticed. He has
been taking some drink since he went wrong by times. He did not take
liquor often. I cannot say the quantity he mi^t take. I applied about 26th
or 27th March, a year past, to Inspector Wallace, to put him in the asylum.
A neighbour woman had brought the inspector of poor in to see this vunHj
in distress. My husband was then confined to bed and unable to work. I
then wished the Board to take charge of the pannel as insane. The inspector
replied that he could not take the pannel because he worked. I thought him
dangerous. My daughter Robina and my husband were present when I so
applied to the inspector. I never applied again for the pannel, but my husband
dia. The pannel used to go to church regularly seven years ago. After the
change in nim above noticed, I refused to go with him to church, because I
was afraid he would speak to himself. He cried aloud to himself by night
He spoke out on such occasions like speiring the questions and answers
(Church Catechism). I could hear him say such as, " Toots, man." — " That's
all riglft.** He spoke sometimes words wluch I could not make out, but when
I did make out nis words, I did not know what he meant. My son Robert
used to sleepwith pannel. But for some time back Robert has reftised to sleep
with him. Why did he reftise to sleep with him ? Because he was so trouble-
some he could not get sleep ; and he was afraid of Mm. The pannel was fond
of getting razors. I remember his having a razor before his sister died. One
day he went round about the table all day. I hid the razor from him. He found
it where I hid it. Robert charged him with having the razor. Pannel took it
out from his sleeve, gave it up, and wept. Dr Gorman was our doctor. On
one occasion, when he saw the pannel, he said he had the worst kind of it. Ha
said it might come on like that — clapping his hands. I don^t know whether
it was old Dr Gorman or the young one who said this. My son was getting
worse before he was taken to prison. Three weeks before that he was very
bad. He had not been drinking much. On the Monday morning before he
was taken away, he put on a clean shirt above his dirty one. He gave me a
push— ;-nearly made me fall— for wishing him to take off his dirty shirt. He
told me on one occasion to take down ray breast. I asked, Are you going
to murder me? I went direct to Mrs McMillan and told her. She then went
into my house. He was working at the fire with a carving-knife, riping the
ribs. She took the knife from him. The neighbours were afraid of him.
Bfr Monro, minister of the Free Church, Ruthei^en, in particular, was afinaid

1864.] INVESTIGATION IN THE CASE OF AN INSANE PRISONEB. 561

to enter the house on aocoant of him. Some boys I know hare turned back
on the road on account of him. People have spoken to me about him, — ^boys
one day, I remember, crying — ** Daft man " to him. This was about three
weeks before the act. [Prisoner's counsel here intimated his intention to ask
witness whether she had been in the asylum. The Advocate-depute objected,
on the ground that insanity of relations is not lepal evidence, but, on the
recommendation of the Court, the objection was withdrawn.] I was in the
asylum about fifteen years ago. I was there as a patient, sent by medical
directions. I was there four months. I was not in good health. My mental
alienation arose from troubles I had in regard to money matters. A brother
of mine has four children idiots. Andrew Strang is his name. He had four
more children right enough. Three of these children are still alive. Oom-
exanuned, — My son James was working on the Saturday before this act
happened. lie had been at work on the Friday before. He had not been
at work for a whole fortnight before. He whiles wasted his wages. He was
regular in paying his board seven years ago. Since that time ne was some*
times regular, at other times not. He paid me 14s. on the Saturday before
the act. I went to meet him coming home from his work to get the
money from him. He seemed to know it was right to go to church. He
did not sing when he went, but just looked at the book-board. Did he
know right from wrong? ** Whiles he did not know right from wrong." " I
think he did." " Sometimes I think he did not." I have told him to do things
because they were right, but he would not do anything but what he liked
himself. He would not let on he heard me. Short sentences generally, which
he talked to himself, ** Toots man," and " That's all right," and things of that
kind. He never spoke his mind to any of us. He used to get a razor to
shave himself from the barber. I did not want him to get a razor. Sometimes
I told him barber would not lend it. Were you afraid? I preferred him to go
to the barber and get shaved. He got me to buy tobacco for him. He was not
particular about its kind . He could make a bargain . H e was very fond of smok-
ing. He had his pipe with him when wandering about at night in the manner
already noticed. When he stayed at home, he smoked a good aeal. Strang's wife
was no connexion of his own. She was a very healthy person, and so was he
till he died. I spoke to the Provost of Rutherglen about the pannel. I said
he would be better away. By the Court, — Before your son was taken away,
had he been drinkmg more than usual ? "I don't think it." I have often
seen him in a state which 1 considered dangerous when I knew he had not
been drinking. Is it your opinion, as his mother, that he is of unsound mind ?
It is. It has been my solemn opinion before the occurrence and now.

John Love. — ^I am father of pannel. Remember son bringing home a girl
with child by him. The woman killed the child. She became insane, and was
sent to asyfum. A good while after this he went wrong. He was a fine
well-doing young man before this. He dressed just like a gentleman. After
the death of his child he did not care for anything. He just lost heart
entirely. He became dull and slovenly in his dress. I remember his getting
three bowls from his grandmother. [Corroborates previous witness as to
prisoner's behaviour on this occasion.] He was then sober. He was ill for
a long time after that. His mind was wrong. Dr Gorman, senior, was sent
for once to see James. The younger Dr Qorman saw him also two different
times after that. He would come home from his work at irregular times. No
matter what weather ; — ^though pouring rain, he would walk up and down the
ffarden by night or day. He spoke to himself, but just nonsense : I did not
know what he was saying. He did this very often. He stood seven hours
one night looking at ground. Sometimes better and worse. I was afraid
of him. He once threatened to knock out my brains with tongs. This was one
time when I wanted him to go to his work. He was then quite sober. Many
a night when he stayed at home he never went to bed, but cried to himseu
and smoked tobacco. Very often stood staring up to sky. He was often
seized with a shaking fit — his mouth shaking e^ the time. I remember his

562 MEDICAL NEWS. [DEC.

threatening to kill me with a stool when my daughter was on deathbed. He
gave her a drive in bed. He was sober at that time. Both I and my wife
wished they wonld take him away. In my own house, I asked Inroector
Wallace to take him away. He replied, *' I can^t take a man who is working."
He has not worked for Half of last seven years. I have seen him sit at the
fire with his shirt on, and trousers about his knees. Never at such times said
he was cold. 1 spoke to inspector twice before about James. He was a ^reat
deal worse about the time of the act. He was beginning to take a little drink
about three weeks before the act. He had not had drink when taken up.
Not long before he was taken to prison, he had been staying out at night in sll
weathers. I believed my son to oe insane all this time. " (Mas-examined. — On
the Saturday before the act he was at his work. I think he was at work on
the Friday, but can't say. Some days he went away with his can and never
went near his work. His weekly wages were 16s. or 17s. a- week. He just
paid his board as he liked. He used to know the value of money. " Terrible
teen of smoking.** Been him rise five or six times a-night to smoke. I told
him not to do this as it was hurtful, but he did not mind me. He might under-
stand that a thing was hurtful, but he did not heed mv reroarka. He knew
it was right to go to church. The witness added, " lie used to know that,
but he wasna sae minding about it now." I don*t know whether he knew
right from wrone. I never found out he had any delusions. After he dropped
working, he had not so much money to spend on clothes. I often could not
make sense of what he said. He would read for two or three hours at a time.
He read mostly in Revelations. He read very loud. He read some chapters in
particular over and over again, and said, ^' Heaps of blethers," while reading.
He was not drunk. By the Court. — My wife was in asylum for four months.
She was there as a patient by doctor's directions. I know brother of my wife,
who has four idiot children.

Bobina Love, sister of prisoner. — Corroborated generally the previous evi-
dence. About five years ago, the pannel put a Bible on the coals and burnt it.
He got the Bible from the woman that killed the child. When sister ill, mj
mother spoke to inspector to take him away. He was very incommimicative
and silent. Dr Gorman, when sister badly, thought he should be away.

Thorruu M^MiUan. — Live at Rutherglen, not far from J«hn Love s house.
Known the family four or five years. I have seen James standing at fire with
his breeches about his feet. Seen him shaking like a man in a fit— all in a
movement — his hands and all. First time I saw him I was afraid of him. I
thought him insane. I told his mother about two years ago that she should
get him confined. I thought it would make him better or worse. She said
they could not afford to put him in themselves, and the town would not.
Before this happened I had heard the people of Rutherglen saying he was
insane.

Mrs McMillan, wife of preceding witness. — Noticed something strange
about pannel. At different times his mother cried to me in her distress from
his behaviour. I was never afraid of hinL I thought him insane. I have
seen him lying naked on the grass with his trousers about his feet, shaking as
if in a fit. I had a particular way of coaxing him which made me never afraid
of him. I have seen him nights and days widking up and down garden with his
head and feet bare; no matter what weather. Cross-examined. — In managing
him, I spoke to him of things as right or wrong. I said 1 would give him this
or that, as, for instance, a piece of tobacco. He was very fond of tobacco.

Christina Brown, neighbour of the Loves. — ^I have seen pannel often walking
by night with his clothes hanging about him. He wouid walk in this way
by end of my house to piece of back-ground. He ^went quite solitary, and
talked to himself. Stared at sky as if he saw something. He would cry in
this attitude, ^' Katie, Katie T* Saw him walking up and down this way in all
weathers. One night I saw him begin to walk at seven o^clock p.m. ; saw him
walking still at six a.m. next morning. He was then bareheaded, but had
clogs on'. There had been rain during the night and he was very wet. I

IfiW.] INVESTIGA1I0N IN THE CASE OP AN INSANE PRISONER. 563

asked him, Was he not wet and wearied. He said, " No." On Wednesday
before he was taken avay, I saw nannel and his mother sitting near their hoase.
I was carrying water, and put aown my stoup between them. He stared at
his mother and me wildly. I was afraid, and went away thinking I was long
enough there. I then thought he was keeping his eye on his mother. When
his sister was a-dying he was sitting making a noise. I said, " Now*s the time
to put him away." His mother replied, that she could not pay for him and
the town would not. For three years past I have thought pannel insane.
OroBs-examined, — I had no conversation with him. Got only short replies.
When I spoke to him, I thought he understood me. Some weeks he worked
well, others not.

Robert Brawn, son of last witness. — ^I have seen prisoner lying naked on green.
I have heard young men and children crying, "There^s daft Jamie Love."
I have seen him wauung till twelve o'clock at night in garden. This occurred
" every night maistly."

WilUam Wallace^ Inspector of Poor, Rutherglen. — I knew father and one
or two of the Love family. I don*t recollect of beine spoken to about pannel.
I remember when father badly being in the house, but I do not remember of
being applied to to remove pannel to asylum. Certainly they never came to
my office about him. Dr Gorman, parish medical man, was attending father
at time. In October 18r5, I sent notice to Board of Supervision about a
Jean Weir's chUd. She wi^ot wrong in the mind, and took the life of the child.
She was tried and sent to asylum.

Thomas Johnston, — I am hcentiate of Royal College of Surgeons, Edinburgh,
twenty-five years in practice. I went to jail at request of agents for prisoner,
and I have seen him five times, about an hour each visit. I am decidedly of
opinion that the pannel is a man of unsound mind. I have satisfied myself of
that. I noticed no attempt to feign on his part. On my last visit, I saw him
for half an hour without his being aware of it. He was during that time stand-
ing listlessly with his back to the wall and making wry faces. My opinion
is very much confirmed by what I have heard to-day. The pannel is mcapable
of instructing counsel and agents for his defence. I have had charge of insane
patients. I think that the prisoner's illness began in mania, but that it has
now ended in dementia. He may be better or worse, but there are no lucid
intervals in his disease. Cross-examined. — I attempted to enter into conversa-
tion with the prisoner, but failed. He answered questions which I put. He
showed intelligence, but very much clouded. I consider him possessed of a
low intellect at present, but I cannot say what he was earlier. I asked him if
he knew the difference between a good man and a bad one. He said that there
was not much, if any. He did not converse with me, but only answered
questions. I asked him what county did Moses belong to? He said that
Moses was probably an Irishman. " Why?" I asked. He replied, " Because
his folks put him mto an ark of bulrushes." I asked him what would he do
if he saw his brother Robert. He said, He would be kind to him. Would he give
him a share of his dinner? He said, Yes. I thought then that he knew his
brother was dead. No delusions were discovered by me in pannel's mind, unless
I am to regard him as under the influence of delusions when talking to himself.
No s]^mptoms were observed by me in him consistent with palsy. Dates of
iSi^e visits were — ^Tuesday, Weanesday, Thursday, and twice on Saturday last
week. By the Court. — May a man be insane without a particular delusion
being discovered ? Yes ; such is quite consistent with my experience. There
seemed a gleam of intellect in him when talking to him about his wages ; but,
ajuirt from that subject, he is quite at sea. This gleam does not affect his
general incapacity.

David Walker, licentiate of the Faculty of Physicians and Surgeons in
Glas^w, thirty- four years in practice. I am one of the medical officers of
the city parish. I see many cases of insanity, and am familiar with the treat-
ment of lunatics. I observe from my note-book that I have had already during
the present year thirty-four such cases, besides four or five more belonging to

VOL, X.— NO. VI. 4 c

564 MEDICAL NEWS. [DYC

a pmate aBylnm. I have taken charge of the private asjlnm at €ktni|acl]ull
Glasgow, for six months. I visited the prisoner in thej&il on Saturday. I
came decidedly to be of opinion that he is a man of insane mind. I would
have no hesitation in signing a certificate to send him to "an asylum. He has
quite the cast of a lunatic of suicidal character. I found him incapable of
carrying on a conversation. I had no reason for suspicion that he was feigning.
He seemed occasionaUy to make an effort to collect his mind. Persons feigning
insanity ^nerally overdo it. I directed my attention cpeciallv to watch any
signs of his attempting to feign insanity. After what 1 have beard to-day, I
have no doubt that he is insane. Croas-^axxmined, — ^I visited him twice on
Saturday. I was alone with him fully half an hour. I asked him about his
religion — what church he belonged to. He stared at me, and muttered. He
did not seem to know the difference between Free Church and Established.
I asked him how much was twice 10— what half 10. He answered these
questions correctly. I asked him what was the third of a pound. He did not
know. I su^ested 6s. 8d., and he said that waa it. He said he was a dy^.
His most pomted answers were about his work. He stood with his back to
the widl. I can't say I got evasive answers from him, but rather, unconnected
answers. I got ** Aye, or "Yes," or "No," only from him^ reply to my
questions in general. By the Court, — His coxidnct as reported by the witnesses
to-day is just what I would have expected. It quit' confirms my opinion.

The proof for the defence was here closed, and he Advocate-depute called
for the Crown the following witnesses : —

JameB Gofrman^ junior. — ^I am a,surgeon, and practise in Rutherglen. Know
family of the Loves. I have seen pannel on the streets for several years. I
was Drought in contact with him in February 1863. I have spoken once to
him before the act. I saw the prisoner at the police-station after the act. I
had there some conversation with prisoner. He answered *the questions put

2uite intelligently, but quite unconcernedly, although thev were very important,
[is demeanour and manner were then those of a derangea man. I am parochial
surgeon in Rutherglen. No proper application that I know of was ever made
for the confinement of pannel as a pauper lunatic. When I saw him in February
1863, he had a general tremor. I was in doubt whether it was disease or a
custom he had got into. I did not then think hiip ixigtoe. Cross-examinad. —
He was, in February 1863, dirty and wild-looking-^4ike a deranged man. I
have seem him going about streets with a wild look,, and every one going oat
of his way. Bv the Uourt. — If an application had b^en made to vou, uom what
you saw, would vou have recommended his removid to an asylum ? I would
not have signed his certificate without farther investigation.

William Leiekman, Physician, Glasgow. — I am sureeon in the prison, and
lecturer on medical iurisprudence. After examining tne prisoner, I prepared
a report, dated 23d August 1864. Report read. It expresses my opinion that
the prisoner is sane. It is a true report. I prepared second report, along with
Dr Morton, dated 3l8t August 1864, to the same effect. It also is a true
report. Report read. I have heard the evidence to-day. What I have
heard does not shake my opinion as to his present mental condition. By the
Court. — I think it extremely possible, and even probable, that some time for-
merly the prisoner was insane. I think on several occasions when I asked
him questions he seemed to answer stupidly. I think he was feigning stupidity,
but not insanity. I have had cases of feigned insanity. If insanity were
feigned by a sane man, it would have been much more violent than in the
present case. If the evidence which you heard to-day be true, does it not go
to show a continued or frequently recurring insanity ? It does. I observed
no nervous tremor.

Jamet Morton^ Physician, Glasgow. — I have had some experience in insanity.
I made a number of visits to the prisoner between 23d and 31st August. I
concurred in the report which I signed alons with Dr Leishman. I have
heard nothing in the evidence to-day to shake the opinion which I then formed

1864.] INVESTIGATION IN THE CASE OF AN INSANE PBISONEB. 565

as to his saoitj. By the Court, — On one occasion I thought he was feigning.
He did not assume any great extravagance of manner. I draw inference from
the evidence to-day that ne is predisposed to insanity, but no evidence has been
adduced to lead me to think that he is now insane. Is his predisposition to
insanity a predisposition to a daneerons form of insanity? Assuming the
hciB stated to be true, I should think they indicate danger to himself or others.
I would require further evidence of insanity before giving a certificate for his
confinement. I observed no material alteration on him since he came into prison .

Lord ArdmiUan observed, that the objection to the trial on behalf of the
prisoner had been supported by a great deal of evidence. In regard to the
part of the evidence which is not purely medical, his Lordship said, I use my
own judgment, and the result is that, to my mind, it is not ^uite clear that
the prisoner ought now to be put on his trial. Farther experience will show
which medical men are right. If he should turn out not to be insane, he may
yet be tried. The result might be unsatisfiictory, if I should rule that he
ought now to be tried ; but, on the other hand, by finding that he is not a fit
subject for trial at present, no such result will follow. With regard to the
medical evidence, I think that the best course is to treat this as a case of divided
opinion ; and this view leads to the same result at which I arrive upon the non-
medical evidence. His Lordship therefore found, that the prisoner was not
then a fit subject for trial, and in terms of the statute, 20 and 21 Vict. c. 71,
ordered the prisoner to be confined till Her Majesty's pleasure should be known.

We have given a full report of the non-medical testimony, because in it are
to be found the materials for judging of the result at which the Court arrived.
And looking solely at this part of the case, we do not think that much difference
of opinion will arise among our readers as to the true view of the case. The
change of character seven years before the deed, the gradual sinking of the
pannel into a moody and listless state, with the particulars of his irrational
behaviour, seem to point irresistibly to the conclusion that he was labouring
under dementia. The only wonder is, why the prisoner was not put into confine-
ment long before the date of the alleged act. And it is truly melancholy to
reflect, that it is to negligence, either on the part of the prisoner's friends or of
. the public officials of Rutherglen, that the deplorable result is due. But the
singular part of the case is the conflict of medical evidence to which it gave
rise. The medical men for both parties were present, by leave of the Court,
during the whole investigation ; and we can only explain the opinions of the
medical witnesses for the Crown by the fact, that they were committed to a
view against the prisoner's sanity by written reports in the hands of the Crown.
We observe with pleasure, that evidence regarding the mental state of the
prisoner's maternal relatives, as bearing on the question of the prisoner's sanity,
was received with the concurrence of the Court. We trust that this is an
indication of an intention to relax the absurd rule of law which rejects such
evidence absolutely ; and that we have now heard the last of this rule being
pleaded as an obstruction to the evidence naturally sought in such difficult
inquiries.

INDIAN MEDICAL DEPARTMENT.

We have been requested to insert the following letter addressed to the Editor
of the Madras Times : —

Sib, — The grievances of the Army Medical Officers are but slightly amel-
iorated by the latest concessions. The department still labours under many
of the disadvantages whic^ existed prior to and during the late war with

666 MEDICAL NEWS. [DEC

Russia. Before the Army becomes popolAr enough to mduce the best men of
the medicAl profession to enter the service, And when in it to keep in it, the
Government mnst offer higher inducements thAn exist At present, And mitigAte
or, still better, remove altogether the cAuses which hAve induced mAnj to
leave the service, which keep up the discontent of those in the service, And
prevent our civil brethren from joining the nuiks. It is useless for the Govern-
ment to pretend to be blind to the wron^ of the department. One need not
come to IndiA to see them. They Are universAl, And urgently call for redresa.
The sufferings Are increAsine from the diminution of our number, but there
is no decrease of duties. At home the regimental work formerly done by
three medical officers is achieved bv two, but the difficulty of getting leave u

ffreat. When a lieutenant applies tor leave he has not to say Major will

discharge my duties should the request be granted. If an assistant-surgeon
Applying for leave is not able to guarantee that Surgeon-major will per-
form his duties, he stands a very poor chance of getting it. In India the
authorities Are trying the experiment of working a Queen^s regiment with three
medicAl officers instead of four, as heretofore. The experiment has &iled wher-
ever tried. I shall purposely avoid sayine anything About the IocaI me^&a]
service, at least in this letter. Were I to do so now, I should increase its aize
twofold, as the Indian medical officers (the few left of the most brilliant and
tried military medical service in the world), have peculiar hardships in addition
to those common to the two services. I shall enumerAte twelve reasons to
Account for the unpopularity of the Army Medical Service.

1. The " bad faith^' of our Government since the Warrant of October 1858.

2. Vacancies occurring in the department not being filled up, thus inflicting
injury upon the juniors of the service.

3. The great amount of foreign service and its unequal distribution.

4. The difficalty of obtaining leave of absence.

6. Being called upon to be present on occasions derogatory to the poaitioa
of a professional man.

6. The want of a General Medical Staff, possessing its head-quarters, band,
metis, and library, where every effort should be made to cultivate a professional
feeling and more equality than is occasioiuilly witnessed now between suz^gecms
and assistant-surgeons.

7. The snubbing to which medical officers are occasionally exposed by their
combatant brethren refusing to acknowledge their relative rank at the mesa-
table, both as regards the entertaining of guests and authority at the table.
There Are occasions when a medical officer should be vested with authority to
secure him respect. Without it he is held in contempt by the merest tyro in
the army.

8. Erroneously considered a " civil ^* depArtment of the Army. The dntiea of
A medicAl officer, especially on active service, entitle him to be considered more
" military " than '* civil." There are other officers than doctors who have
just as little of the purely fighting work to do. Aide-de-camps to wit. They
are exposed to all the dangers of a military life. So are doctors. They
sometimes die by the hands of their enemy, and thus terminates the " honour-
able and glorious career of a soldier.^* Many a doctor has thus suffered for
his country's cause. Acts of bravery are achieved bv the aide occasionally.
There is a very fair sprinkling of Y. C.s decorating the breasts of officers of
the medical department. Why, then, should our combatant friends so jealously
withhold the appellation of "'military " not " combatant."

9. Being placed last in the Army List in their respective corps, without
indicating their regimental or army position.

10. The want of an independent power at the head of the depa];tment. One
having, not only the interest of the army medical officers at heart, but the
honour of the profession.

11. Want 01 uniformity in the dress of medical officers.

12. The great want in the department of a legAl Adviser. One to whom
questions effecting pAy And retrenchments could be referred as to their legal

1864.] INDIAN MEDICAL DEPABTMENT. 667

bearing. Many consider that arrears are due to every royal assistant'snrgeon
who has served in India since October 1858, and other examples are not
wantine where apparent injostice has been experienced by officers of the Army
Medical Department.

Having given twelve causes, I shall enumerate the same number of proposals
to remedy them.

1. That " relative rank " shall carry with it aU precedence and advantages
attaching to the rank with which it corresponds, courts-tnartial only excepted.

2. That a purely seniority system be adopted in the medical department
of the army, and as soon as a vacancy occurs in the administrative grades
the senior medical officer be immediately appointed.

3. That medical officers have an equal share of home and foreign serviesL
there shall be a ^^ roster of service " kept for the two (proposed) grades, and
that the period of forei^ service be limited to five vears. Tluit medical
officers shall not be permitted to serve a second perioa of five years except
by exchanging duties. As at present the period of service at certain unhealtiny
stations shoukl be less than five years.

4. No officer requires more urgently than a medical officer a complete
release from the anxieties of his profession. Every medical officer should be
puranteed two months* leave in the year, by Government sending a substitotei
if his services, or their equivalent, cannot be dispensed with.

5. That a medical officer shall be called upon to witness the carrying out of
capital punishment, branding and flogging only when " all ** officers have to
attend.

6. To simplify the department, there should be two grades only, inspectocs
or administrative and surgeons or executive officers. The surgeon should on
first appointment receive, as now, 10s. a-day, and have his pay increased every
five years 58. a-day, carrying with it increased relative rank. Thus a surgeon
with twei^ty years service would receive £1, lOs. a-day with the relative rank
of colonel (and no higher rank should be held by an executive medical officer).
An inspector shoula receive £2, 5s. a-day with the relative rank of major-
general, and after five years' service as such £2, 10s. a-day, without increased
relative rank. Retirement after thirty years* service should be compulsory.
The hflJf-pay should be two thirds of full pay. Retirement should be voluntary
after twenty years' full pay service, and voluntarv, on full pay, after twenty-
five years' full pay service. An inspector should be allowed to retire on full
pay after five years' full pay service as such, and on two-thirds of his full pay
with less than five years' full pay service. For the maintenance of a band
and mess at the head-quarters at the Army Medical Stafil the usual donation
of fifty days' pay (thirty to mess, twenty to band) should be given to the
funds, and the annual subscription of twelve days' pay to the band at head*
quarters, and eight days' pay to the head-quarters' mess (payable quarterly)
while doing duty there, or if doing duty with a corps, to be subscribed to the
mess of that corps.

7. Medical officers should on all social occasions of ceremonv have the
defined relative position of the combatant officer. This ought to be included
in the first remedy, if anything is meant by relative rank.

8. In lieu of including the medical department under the general head of
civil departments, the following should be substituted at page 5 of the Queen's
Regulations, and elsewhere — *' Re^mental staff officers, officers of the medical
department, and officers of the civil departments attached to the army."

9. Under the head of Army Medical Staff should be given name, date of
first commission, relative rank, professional titles, period of half-pay servicer,
and how employed.

10. Instead of a director-general, there should be a cotmcil composed of
a Queen's medical officer, an officer of the Indian medical service, and a civil
member of the profession. The latter should be chosen every five years by
one of the colleges of physicians.

11. The dress of the medical officer should be the same with whatev€r corps
he be doing duty.

568 MEDICAX NEWS. [DEC

The following alterations in the present medical staff oniform shoold be
adopted : —

Iroosers, undress as present undress trousers of inspector-general, for all
ranks. Instead of cocked hat the present chaco of infantry of the line, with
hlack cock^s tail instead of worsted ball tuft, and medical staff plate instead
of regimental plate. Sword belt, dress the same as the present inspector-
general, for all ranks. Sword belt undress, as present surgeons, for all nutks.
Shoulder belt, dress, as present inspector-general, for all ranks. Shoidder
belt, undress, as present surgeons, for all rank. Instead of existing double-
breasted blue coat, a jacket of Rifles' pattern but blue cloth and coILur and
cuffs of black yelvet. Forage cap, as present inspector-generaL Greatcoat,
as present coat of infantry of the Ime. Shell jacket, as present medical staff
with black silk lining. Waistcoat, present staff pattern, with black silk lining.

12. The officers of the medical department of the army should devote a
portion of their means to ensure at all times a legal opinion from the highest
source attainable upon any question affecting their interest in the service.

I shall dose my letter with an extract from a periodical which till now has
been more incredulous of the injustice suffered by the officers of the army
medical department than the press generally. The Army and Navy GazetU
says, — *^ The army sureeon is an officer and an educated gentleman, and it is
unwise to ask him to submit to badses which he copsiders degrading. Far more
unwise is it to substitute for qusJifled men an inferior cL^ who are content
with their new position because it elevates them in society. The best men
we can ^et for the anny medical department are sure to be the cheapest.^* —
Yours faithfully, Anon.

LETTERS TO THE EDITOR.

THE COMPULSORY VACCINATION ACT.

Sir, — In the last (November) number of your Journal there was a paper
from Dr Lyell of Newburgh, in which he complained of the amount of unre-
mimerated work exacted under the Vaccination (Scotland) Act from those hold-
ing the appointment of vaccinators. In the course of his remarks, he stated that
he doubted whether the Act really required this extra work. As this was pre-
cisely the view which I myself held, I suggested that he, being a vaccinator,
should put the question categorically to the Board of Supervision, which, under
Sections v. and xxvii., is charged with the general superintendence of the work-
ing of this Act. Dr Lyell did so ; and at his request I send you the official re-
plies given by the Board, which are extremely satisfactory, and will probably
relieve the minds as well as the pens of many distressed vaccinators.

In regard to the other points raised by Dr Lyell as affecting the general
utility of the Act, I would merely suggest, that it is premature to speculate re-
garding the working of an Act which has not as yet been fairly tried ; and that,
before entering upon the question of how the provisions of the Act can be best
made to fulfil its general intention, it would be wise to wait, at least imtil we
have the Registrar-General's Report as to how far the present mode of work-
ing the Act has been successful in attaining that end. Meanwhile, medical
men are so far gainera by the Act, that the State now pays them for the for-
merly gratuitous work of yaccinating paupers, while they are no longer forced,
from considerations of the public weaJ, to press their gratuitous services upon
thol^e above pauperism, but are enabled to state, that for a trifling fee they are

1864.] THE COMPULSOBY VACCINATION ACT. 569

prepared to save their* clieDts from a very much heavier fine ; and should, tinder
any circomstances, this trifling fee be found to be burdensome, I do not doubt
but that the paternal goyemment will find some means of at once protecting
itself— that is, the whole body of the people — while relieving those who feel
themselves unduly burdened ; but I think it questionable policy for medical
men, as such, to interfere in this matter. I may add, that the solution of this
question is unnecessarily delayed by the unwise practice of gratuitous vaccina-
tion whether by private or dispensary physicians. — I am, yours, &c.,

F.R.C.P.E.

Query. — " Am I required to keep books, enter cases of vaccination, and
make returns to Board of Supervision, as per Sec. zxi., of such cases as I vac-
cinate as medUxd practitioner ^ as well as of such as I vaccinate as vaccinator f "

Answer. — " I have to inform you in reply, that the returns required by the
Board of Supervision are intended to include only the cases of paupers and
others, vaccinated by the vaccinator in his official capacity, by the instructions
or orders of the Parochial Board."

Query. — *^ Am I, in terms of the Vaccination Act, Sec. zxiii., bound to
transmit, within forty-eight hours, to the Registrar the particulars of any vac-
cination certificate which I may grant in my capacity of private medical prac-
titioner ; or is this only requisite in thoae cases which I vaccinate as vaccina-
tor?"

Answer.—" I have to state in reply, that in my view of the interpretation
of the Statute, the provisions of the twenty-third Section do not apply to your
private practice. — ^I am, &c, (Signed) " Jos. Walker, SecyJ"

ARMY MEDICAL DEPARTMENT.

Sir, — I forward you a few lines which I have hastily jotted down after read-
ing the Article on the Army Medical Department in the Edinburgh Medical
Journal for this month ; if you consider them worthy of publication in your
next number, they are very much at your service. — ^Your obedient servant,

CONSTANS.

Commercial people say that the demand, as a rule, always governs the supply
— but no rule is without an exception; and a ruder shock, or one more
disastrous in its immediate consequences, was never received by the commercial
world of England, than when the importation of cotton from America ceased.
Nevertheless, so vigorous is the spirit of trade and enterprise in the English
breast, that as soon as it was evident that the usual source of supply was
likely to be cut off for an indefinite period, efforts were made in all directions
to encourage the growth of this valuable commodity; and we may not
altogether be accused of romancing, if we state, that the hard trial our manu-
facturing districts have undergone will result in the spread of our influence
throughout the world, and tend to increase the value of our Indian possessions,
and strengthen our hold on a country which has heretofore cost us so much to
retain. Some years back it would never have been thought possible that the
question of supply and demand would have affected the public seihrices, yet
so it is; and little do the authorities emulate the example set by the
merchant princes to meet the emergencies of the situation. So great has
been our increasing prosperity as a nation, — ^so many are the opportuniticyi to

670 MEDICAL NEWS. [DEC.

men of all classef and conditions to raise themselTefl to positionB of ireilth
and independence by dint of industry, perseverence, and hard work, — so hig^y
is the skilled man esteemed in the labour market, that the money valne of
the very commonest labourer is double what it was thirty years ago; that
at this moment, should England be called on suddenly to maintain her proud
position by force of arms, she would be most seriously embarrassed for want
of two most important classes of men— namely, doctors and stokers. We are
not about to advocate the claims of the last-named individuals. The Firat Lord
of the Admiralty, if he desires to see his pet iron-clads crossing the Bay of
Biscay in a creditable manner, must look to them. But our desire is to drsw
public attention to the lamentable state of the Army Medical Department.
It is now generally understood that several energetic Members of Parliament
have promised to ventilate the subject thoroughly at an early period of the
next session. We have no wish here to establish the grievances or r^terste
the complaints of the medical officers. These we 'take as granted. Our
desire is simply to point out that the present organization and system, if
allowed to have fair play, is better adapted to carry out the end required than
the thousand-and-one theoretical systems and plans which have been devised
by hidden enemies or harebramed enthusiasts : and, considering the vast import-
ance of the subject, and how many influential persons may be misled by whst
appears so feasible in print, we intend to direct our remarks speciaDy m
reference to an article which appeared in this Journal last month.

It would be quite beyond the limits prescribed for articles in this Jomnal
to enter minutely into all the propositions and suggestions brought forward
in that article. We must content ourselves with a rapid and general review
of the whole subject. Had the army medical officer merely to admit a man
into hospital when ill, and discharge hun when well, and when required to
declare principles of sanitation, a great many difficulties would be smoothed
away; but unfortunately the army medical officer has a variety of other
duties — some, I might say, totally unconnected with his profession : he has to
attend parades, marches, rifle practice, field days, boards of all kinds, conrta
of inquiry, courts-martial (if necessary), examine recruits, to discharge and
invalid men ; and in the field he has to do duty in the trenches, visit outposts,
etc. etc. A complete knowledge of all these duties, with the endless
questions arising therefrom, is not acquired in the dissecting-room or in the
hospital wards ; nor does Netley, with all its careful detail of instruction, sent)
forth its alumni in that experienced condition which is only realized by a few
years' hard knocking about, and even that fails sometimes ; for it is no an-
common remark to hear that such a one is a very good professional man, bat
a very indifferent medical officer. It is for immediate special reference in ail
cases of doubt that the value of an able administration is soon perceived.

Who does the Secretary of State for War consult on all health q^e8tion8
concerning the army? Why, the Director-general — call him adviser if yoa
will, it is merely a quibble about a title— the old story of Caesar and Pompey.
Then, again, if all professional returns, statements, letters, etc., are forwarded
through the commanding officer, what is the result ? you remove the admin-
istrative at out^stations and increase it at the War Office. Independently of
that, you deprive the so-called adviser of the power of obtaining from a
professional authority (whose capabilities are most probably perfectly appreci-
ated at head-quarters) his own views of the point at issue.

1864.] THE ABMY MEDICAL SEBYICE 571

Ab it is, all the orders and directions issued by the Director-general emanate
from instructions received from the Secretary of State or the Commander-in-
Chief.

Beyond the annual report which accompanies the annual return, and
which may be regarded more in the light of a professional test of the medical
officer's diligence and acquirements — and which report is not seen by the
commanding officer — the officer in command is kept perfectly au oauratU with
everything that transpires in the hospital attached to his command.

What the Director-general has to do with the 800 War-Office clerks wo
cannot imagine. By abolishing the administrative branches, yon entirely de-
stroy the few prizes — ^if we may be allowed so to dignify them — which act as
incentives to the army medical officer ; and that these positions are regarded
as prizes is proved by the number of men who, having completed their twenty-
five years' service, still hang on in hope of promotion ; by the bitter feelings
of anger and mortification which have been displayed by those who, for some
reasons best known to the authorities, have been passed over ; and by the still
more conclusive fact, that very few of the deputy-inspectors or inspectors-
general agitate for anything more than increase of pay or allowance. We
are aware that a large body of the department, especially men of about
eighteen years* service and under, utterly deny these statements. They say
these positions are not prizes, that promotion in some instances is a positive
loss, that it necessitates immediate foreign service, and that, according to the
present system, there is as much prospect of every beneficed clergyman be-
coming a bishop, as of every medical officer becoming a deputy-inspector. With
regard to this last argument, it is merely necessary to refer to actual numbers
to show its absurdity : There are 34 inspectors and deputies to 800 medical
officers ; and, with regard to the church, there are between 30 and 40 bishoprics
to 8000 clergy. We have not the clergy list at our elbow, but we know we
are not very far out.

It is utterly impossible to graft a civil practice on a military stock, and so
long as, and such must ever be, military power exists, the Army Medical De-
partment must adapt itself to the peculiarities of the service.

The movements, etc., of the medical officers are guided by orders emanating
from the Adjutant-General. The opinion, or recommendation, or advice, call
it what you will, of the head of the Medical Department is asked on these
matters, because he naturally is supposed to know the medical officer most
fitted to carry out the wishes of the Adjutant-General ; as well might an
engineer or an artillery officer object to being governed by the head of his own
special branch of the service. The Adjutant-General must necessarily be an
officer of considerable experience, but he is not omniscient, and he falls back
for information in special departments on the heads thereof. A code of sani-
tary regulations would be a great boon, no doubt ; but that it would lessen the
administrative work, or put a stop to the constant representations of defects
by medical officers, is much to be questioned. Exigencies of all kinds are
constantly occurring, and a discretionary power must be left in somebody's
hands. The Queen's Regulations, although a very perfect work in its way, and
deprived of which we much fear the executive would soon collapse, still does
not and cannot meet every new question that is constantly presenting itself.
If any doubt exists on this point, we recommend the sceptic to visit the office
of a Brigade-Major in a large garrison for a few hours daily, and to con the

VOL. X. — NO. VI. 4 D

572 MEDICAL NEWS. [DEO

correspondence. As to uniform, patting aside all idea that the red cloth affieets
mackerel and men in a very similar way, it is absolutely necessary that it should
be worn. The recent order which exempted the class called acting-assistants
from appearing in military costume, has given rise to mistakes not only st
Aldershot but elsewhere, which are painfully ludicrous, and which, in a sterner
field, might be of very serious moment. We can recall an instance where a
most worthy medical officer, and one now holding a very high appointment in
this country, was made a prisoner by an artillery sentry in the Crimea, in
consequence of his being over zealous in the sanitary inspection of his neigh-
bourhood, and investigating the construction of the gunner^s cookhouae and
latrines in plain clothes. The unfortunate gentleman was suspected for many
hours of being a Russian spy. The only question in this matter is, whether or
not all medical officers should be dressed alike. We are inclined to think, that
if a dress could be devised, sufficiently handsome to obviate invidious com-
parisons, yet plain, serviceable, and adapted for all duties, mounted and dis-
mounted, it would be advantageous for all to wear the same uniform. Might
not the compulsory mess membership be compromised by medical officers being
honorary members only. If the mess is a parade, the medical officer ought to
attend it ; if it is regarded as a social gathering, endless heartburnings are caused
by excluding the doctor. The cause of discontent existing is this : the meis
is regarded as a parade, and the doctor is expected to pay, and pay heavily, for
the honour of attending that parade ; and he finds that everybody save himself
has a voice in the arrangements of that parade. _ Independently of this, he may
be moved at any moment from one corps to another, when he is again expected
to pay mess and band subscription de novo. This arrangement, we are aware,
has been recently cancelled, as far as India is concerned. And now, with re-
gard to the vexata quesUo of retirement ; having destroyed the administrative
branches, it is proposed to allow medical men to retire at any intermediate
period' between 10 and 20 years' service. Can any reasonable man doubt the
result— the good men would soon perceive, that ISs. 6d. a-day was, after all,
not such a very alluring bait to induce them to sacrifice 20 of the very be^t
years of their life. The indifferent men would probably take the earliest retire-
ment obtainable, and with that rub along in provincial practice, or as heum
teneniesy and the bad would consider it itn easy way of getting an annuity of a
little more than £300 a-year, and would consequently put in their 20 years
with the greatest ease to themselves. The peculiarity of medical practice
utterly prescribes that interchange of civil and military life to which aUnsion
is made, no respectable practitioner having once established a connexion,
would ever dream of throwing it up. How often we see this very point Ulw^
trated in the instances of navy surgeons, who, having been on half-pay for a
considerable time, when called upon to serve again, prefer throwing up their
half-pay, to withdrawing from the practice which they have acquired during
their sojourn on shore.

That there exists a clique of men in the department whom no changes or
improvements will satisfy, we are very much inclined to believe ; and we are
the more disposed to consider our opinion well founded, when we read over the
intemperate and utterly absurd productions that are constantly brought before
our notice. But that a just and universal discontent exists at this moment
there is no denying, and that this discontent extends so considerably into tlie
profession generally, as to cause the authorities of the War-Office to look I6r>

J864.] THR ABMT MEDICAL SEBYICE. 578

krard to each examination with fear and trembling lest the number of eandi-
^ates be insufficient, is a fait accompU. That this lamentable state of affiiirs
;}oald be removed without venturing on any wild experiments no man who has
isarefullj and dispassionately studied the question can for a moment doubt*
£^ery year that passes only renders the present difficulty greater ; every year's
^^lay will enable the profession to demand for its service a higher rate of re-
2^uneration ; every year of the present system retards the rapidity of promo-
tion among the assistants, and the knowledge of all the circumstances which
render the service so distasteful, becomes more widely diffused throughout the
various medical schools. But a very short time since, we can recall to mind
l^t a thorough and complete carrying out of the warrant of 1858 would havt
jiuieted every angry breast. We doubt very much now if that expedient would
^raw ; a silver lining of earlier- retirement, and some increase of pay, both
present and prospective, must be seen reflecting its rays behind the dark cloud
which now hangs over the department, before a steady and regular increase of
medical cadets for Netley can be counted on. We have various schemes for
earlier retirement, etc., possibly we may venture on a future occasion to bring
them before the notice of our readers. .

UNIVERSITY OF EDINBURGH— NUMBER OP STUDENTS-

The Winter Session of the University of Edinburgh commenced on Tuesday the
1st November. The introductory address was delivered by Principal Sir
David Brewster on Monday the 14th.

The number of students matriculated at this date (2dd November) is 1559.
They are distributed as follows among the different Faculties : — ^Arts, 627 ;
Medicine, 426 ; Law, 244 ; Divinity, 62. Last year at the corresponding date
pie total number of matriculated students was 1376, distributed as follows : —
Arts, 627 ; Medicine, 446 ; Law, 272 ; Divmity, 60.

MEDICAL SCHOOL, SURGEONS' HALL.

Thb Medical School, Surgeons' Hall, was publicly opened on Tuesday the 1st
of November, when an address was delivered by Dr Stevenson Macadam.
This address will be found at page 514 of the present Number of this Journal.

THE MORISON LECTURESHIP ON MENTAL DISEASES.

Sir Alexander Morison, Father of the Royal CoU^p of Physicians of Edm-
burgh, late Physician to Bethlehem Hospital, has funded and endowed a
Lectureship on Mental Diseases in connexion with the College of Physicians.
Six Lectures on some department of the subject will be delivered annually.
Dr William Seller, F.R.S.E., Fellow of the Royal College of Physicians of
Edinburgh, has been appointed Lecturer, and will deliver the first course in
the Physicians' Hall in the summer of 1865.

THE FACULTY OF MEDICINE OF PARIS.

The opening meeting of the Faculty of Medicine of Parb took place on Thurs-
day the M of November, under the presidence of M. Tardieu, Dean of the
Faculty. M. Duruy, Minister of Public Instruction, honoured the meeting

572 MEDICAL NEWS. [DEC*

correapondeiice. As to uniform, putting aside all idea that the red cloth afiects
mackerel and men in a very similar way, it is absolutely necessary that it should
be worn. The recent order which exempted the class called acting-assistanU
from appearing in military costume, has ^ven rise to mistakes not only at
Aldershot but elsewhere, which are painfully ludicrous, and which, in a sterner
field, might be of very serious moment. We can recall an instance where a
most worthy medical officer, and one now holding a very high appointment in
this country, was made a prisoner by an artillery sentry in the Crimea, in
consequence of his being over zealous in the sanitary inspection of his neigh-
bourhood, and investigating the construction of the gnnner^s cookhouse and
latrines in plain clothes. The unfortunate gentleman was suspected for many
hours of being a Russian spy. The only question in this matter is, whether or
not all medical officers should be dressed alike. We are inclined to think, that
if a dress could be derised, sufficiently handsome to obviate invidiona com-
parisons, yet plain, serviceable, and adapted for all duties, mounted and dis-
mounted, it would be advantageous for all to wear the same uniform. Might
not the compulsory mess membership be compromised by medical officen being
honorary members only. If the mess is a parade, the medical officer ought to
attend it ; if it is regarded as a social gathering, endless heartburnings are caused
by excluding the doctor. The cause of discontent existing is this : the mess
is regarded as a parade, and the doctor is expected to pay, and pay heavily, for
the honour of attending that parade ; and he finds that everybody save himself
has a voice in the arrangements of that parade. , Independently of this, he may
be moved at any moment from one corps to another, when he is again expected
to pay mess and band subscription de novo. This arrangement, we are aware,
has been recently cancelled, as far as India is concerned. And now, with re-
gard to the vexata quesHo of retirement ; having destroyed the administrative
branches, it is proposed to allow medical men to retire at any intermediate
period between 10 and 20 years* service. Can any reasonable man doubt the
result— the good men would soon perceive, that 18s. 6d. a-day was, after all,
not such a very alluring bait to induce them to sacrifice 20 of the very betrt
years of their life. The indifierent men would probably take the earliest retire-
ment obtainable, and with that rub along in provincial practice, or as houm
teneniesj and the bad would consider it itn easy way of getting an annuity of a
little more than £300 a-year, and would consequently put in their 20 yean
with the greatest ease to themselves. The peculiarity of medical practice
utterly prescribes that interchange of civil and military life to which allusion
is made, no respectable practitioner having once established a connexion,
would ever dream of throwing it up. How often we see this very point illaa-
trated in the instances of navy surgeons, who, having been on half-pay for a
considerable time, when called upon to serve again, prefer throwing up their
half-pay, to withdrawing from the practice which they have acquired during
their sojourn on shore.

That there exists a clique of men in the department whom no changes or
improvements will satisfy, we are very much inclined to believe ; and we are
the more disposed to consider our opinion well fonnded, when we read over the
intemperate and utterly absurd productions that are constantly brought before
our notice. But that a Just and universal discontent exists at this moment
there is no denying, and that this discontent extends so considerably into the
profession generally, as to cause the authorities of the War-Office to look for-

674

MEDICAL NEWS.

[dec. 1864

with his presence. The customary address was delivered bj the yoangest oi
the professors, M. Baiilon, whose duty it was to pronouce a eulogy upon his
master and predecessor Moquin Tandon.

At the end of the speech, the Minister of Public Instruction delivered at
address to the students, in which he felicitated them on their progress, an<^
encoura£;ed them to render themselves more and more worthy of the degr*
which should crown their studies. He reminded them that, thanks to tl
eminent masters who instructed them, they had in their own hands the pow4
and the means of sustaining the glory of French Medicine. " Much is said a
present,'* said his Excellency, " ofthe merits of the English and German Schools,
renowned, the first for the skill of its practicians, the second for the brilliancy
of its theories. Lict the pupils of our schools attach themselves more dosel^
to their masters ; let them follow more assiduously the courses delivered in this
amphitheatre, without neglecting clinical studies in the hospitals; and they
will put themselves in a position to preserve their traditional advantages ove;
foreign schools."

PUBLICATIONS RECEIVED.

Bnult and Ptfnean,— Do la Gndrison des

FigTres. Par MM. N. Braolt et E.

Pdnean. Bonrges, 1864.
Brinton,— Lectures on the Diseases of the

Stomach, with an Introduction on its

Anatomy and Phjaiology. By William

Brinton,M.D. 2d Edition. London, 1864.
Coryisart, — Collection de M^moires sor une

fonotion mtfconnne dn Pancr^. Par

Lncien Conrisart. 1857-63.
Dn Baisson,— Quelques Mots anr TAdde

lactiqne. Par M. Borin da Bnisson.

Paris, 1863.
Frazer,— Elements of Materia Medica. By

DrW.Frazer. 2d Edition. London, 1864.
Holmest—Svstem of Sorge^. Edited by T.

Holmes, M.A.Cantab. Vol. 4. London,

1864.
KoeberM, — Operations d^Ovariotomie, par

Professeur E. KoBberl^. Paris, 1865.
KceberM, — DerOvariotomie, par Professeur

£.£(BberW. Paris, 1865.

Mapother,— A Manual of Physiology, and of
the Principles of Disease. By Edward
D. Mapother, M.D., etc. Second Edition.
Dublin, 1864.

Noad,— A Manual of Chemical Analysis,
Qualitative and Quantitative, for the Use
of Students. By Henry M. Noad, Ph. D.,
etc. London, 1864.

Parliamentary Paper,— Health of the Navy
for the Tear 1861.

Pathological Society of London, Trans-
actions of the. Vol. XV. London,
1864.

P^trequin,~De l^mploi Th^rapeutique der
Lactates Alcalins dans les Maladies fone
tionelles de I'Appareil digestif. Ptt
Professeur J. £. P^trequin de Lyon.
Denxibme Edition. Paris, 1864.

Smith,— Handbook of Dental Anatomy and
Sorgery for the Use of Students and
Practitioners. By John Smith, M.D., etc
London, 1864.

PERIODICALS RECEIVED.

American Journal ofthe Medical Sdenoes,—

October. Phikdelphia, 1864
Berliner klinisohe Woohenschrift, Nos. 40

to 43.
Births, Deaths, and Marriages, Monthly Ke-

tams of, for October, and Quarterly Be-

turn, ending September 1864.
British Medical Journal,— Oct 29, to Nov.

26, 1864.
Dublin Medical Press,— Oct 26 to Nov.

23, 1864.
Dublin Quarterly Journal of Medical Science,

November 1864.
Gazette des Hdpitaux, — Nos. 124 to 135.

Paris, 1864.

Oazette Hebdomadaire de M^dedne, etc —

Oct 28 to Nov. 25. Paris, 1864.
Gazette M^dicale de Paris,— Nos. 43 to 47,

1864.
Journal de M^decine et de Chimrgie, —

Nov. Paris, 1864.
Journal fiir Kinderkrankheiten,— July and

August Erlangen, 1864.
Medical Times and Gazette,— Oct 29 to

Nov. 26, 1864.
Bevue de Th^rapeutique Medico-Chirurgi-

cale,— Oct 1, 15; Nov. 15. Pans,

1864.
Virchow's Archiv,— Vol. 30, Nos. 5 and 6.

Berlin, 1864.

SrrahaL—la the last number of thia Journal, in the last line of page 432, the word '^raooesBftillj"
• * Boooeflslvelj."

572 MEDICAL NEWS. [dEO-

correapondence. As to uniform, putting aside all idea that the red cloth affeeti
mackerel and men in a very similar way, it is absolutely necessary that it shodd
be worn. The recent order which exempted the class called acting-assistaDts
from appearing in military costume, has given rise to mistakes not only it
Aldershot but elsewhere, which are painfully ludicrous, and which, in a sterner
field, might be of very serious moment. We can recall an instance where a
most worthy medical officer, and one now holding a very high appointment in
this country, was made a prisoner by an artillery sentry in the Crimea, in
consequence of his being over zealous in the sanitary inspection of his neigh-
bourhood, and investigating the construction of the gunner^s cookhouse and
latrines in plain clothes. The unfortunate gentleman was suspected for many
hours of being a Russian spy. The only question in this matter is, whether or
not all medical officers should be dressed alike. We are inclined to think, that
if a dress could be devised, sufficiently handsome to obviate invidions com-
parisons, yet plain, serviceable, and adapted for all duties, mounted and dis-
mounted, it would be advantageous for all to wear the same uniform. Miglit
not the compulsory mess membership be compromised by medical officers being
honorary members only. If the mess is a parade, the medical officer ought to
attend it ; if it is regarded as a social gathering, endless heartburnings are caused
by excluding the doctor. The cause of discontent existing is this : the mess
is regarded as a parade, and the doctor is expected to pay, and pay heavily, for
the honour of attending that parade ; and he finds that everybody save himself
has a voice in the arrangements of that parade. _ Independently of this, he may
be moved at any moment from one corps to another, when he is again expected
to pay mess and band subscription de novo. This arrangement, we are aware,
has been recently cancelled, as far as India is concerned. And now, with re-
gard to the vexata queaUo of retirement ; having destroyed the administradve
branches, it is proposed to allow medical men to retire at any intermediate
period- between 10 and 20 years* service. Can any reasonable man doubt the
result— the good men would soon perceive, that 18s. 6d. a-day was, after all,
not such a very alluring bait to induce them to sacrifice 20 of the very beft
years of their life. The indifferent men would probably take the earliest retire-
ment obtainable, and with that rub along in provmcial practice, or as heum
tenentes, and the bad would consider it ta easy way of getting an annuity of a
little more than £300 a-year, and would consequently put in their 20 years
with the greatest ease to themselves. The peculiarity of medical practice
utterly prescribes that interchange of civil and military life to which allusion
is made, no respectable practitioner having once established a connexion,
would ever dream of throwing it up. How often we see this very point illn8>
trated in the instances of navy surgeons, who, having been on half-pay for a
considerable time, when called upon to serve again, prefer throwing up their
half-pay, to withdrawing from the practice which they have acquired during
their sojourn on shore.

That there exists a clique of men in the department whom no changes or
improvements will satisfy, we are very much inclined to believe ; and we are
the more disposed to consider our opinion well founded, when we read over the
intemperate and utterly absurd productions that are constantly brought before
our notice. But that a just and universal discontent exists at this moment
there is no denying, and that this discontent extends so considerably into the
profession generally, as to cause the authorities of the War-Office to look lor-

2044 103 053 7;

\