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THE

BRITISH AND FOREIGN

MEDICO-CHIEURGHCAL
REVIEW

OB

QUARTERLY JOURNAL

PRACTICAL MEDICINE AND SURGERY.

YOL. XLI.

JANUAET— APEIL, 1868.

A

'i

/

LONDON :
JOHN CHURCHILL AND SONS, NEW BURLINGTON STREET.

MDCCCLXVni.

PKINTED Bl

J. E. ADLAED, BAETHOIOMEW CLOSE.

THE

BRITISH AND FOREIGN

MEDICO-CHIRURGICAL REVIEW.

JANUARY, 1868.

PART FIRST,
^nalgtical anti (Etitical i^ebietois.

Review I.

1. On the Injuries of the Eye, Orbit, and Eyelids : their immedi-

ate and remote Effects. By George Lawson, F.R.C.S.,
Assistant-Surgeon to the Royal London Ophthalmic Hos-
pital, and to the Middlesex Hospital. Svo, pp. 430.
London- 1867.

2. Die Verletzungen des Auges. Von Dr. Adolf Zander und

Dr. Arthur Geissler. Svo, pp. 537. Leipzig und
Heidelberg: 1864.
The Injuries of the Eye. By Dr. Adolf Zander and Dr.
Arthur Geissler.

3. Jaarlijksche Verslagen betrekkelijk de verpleging en het

onderwijs in het Nederlandsch Gasthuis voor Ooglijders.
Door F. C. DoNDERs. 1863—6. Utrecht : P. W. van de
Weijer.
Annual Reports of the Netherlands Ophthalmic Hospital. By
F. C. DoNDERs. 1863—6.

4. Ophthalmiatrische Beobachtungen. Von Dr. Albert Mooren,

dirigirendem Arzt der stadtischen Augen-Klinik zu Diissel-
dorf. 8vo, pp. 345. Berlin : Hirschwald, 1867.
Ophthalmiatric Observations. By Dr. Albert Mooren, Chief
Surgeon to the City Ophthalmic Hospital at Diisseldorf.

5. Illustrations of some of the principal Diseases of the Eye,

with a brief Account of their Symptoms, Pathology, and
Treatment. By Henry Power, F.R.C.S., M.B. Lond.,
Surgeon to the Westminster Ophthalmic Hospital; Assistant
Surgeon to, and Lecturer on Physiology at, the Westminster
Hospital. 8vo, Twelve Coloured Plates, pp. 631. London:
1867.

81— XLI. 1

2 Reviews. [Jan.,

6. The Royal London Ophthalmic Hospital Reports, and Journal

of Ophthalmic Medicine and Surgery. Edited by J. C.
Wordsworth, J. W. Hulke, and J. Hutchinson. Vol. V.
1866. 8vo, pp. 399. London.

7. Recent Advances in Ophthalmic Science. The Boylston

Prize Essay for 1865. By Henry W. Williams, M.D.,
Ophthalmic Surgeon to the City Hospital, Boston (U.S.),
&c. &c. Small 8vo, pp. 166. Boston : 1866.

8. Tension of the Eyeball; Glaucoma, &^c. Some Account of

the Operations practised in the Nineteenth Century for
their relief. By James Vose Solomon, E.R.C.S., Surgeon
to the Birmingham and Midland Eye Hospital. 8vo,
pp. 80. London : 1865.

9. The Radical Cure of extreme divergent Strabismus. By the

same. 8vo, pp. 16. London : 1864.

10. Lectures on Diseases of the Eye. By N. C. Macnamara,

Surgeon to the Calcutta Ophthalmic Hospital. 8vo, pp.
286. London: 1866.

Of the various -works on ophthalmic surgery that are con-
tained in the foregoing list, the first four possess one important
character in common. Difiering in their scope and objects,
and thus requiring brief separate notices at our hands, they are
alike in containing materials for a clinical history of one of
the most serious diseases which the ophthalmic surgeon is called
upon to treat — the so-called sympathetic ophthalmia. We pur-
pose, therefore, in a few words to describe their separate aims
and their respective merits ; and then, at somewhat greater
length, to analyse and compare their teaching upon the im-
portant subject to which we have referred.

Giving the first place to our own countryman, we hail
with much pleasure Mr. Lawson^s valuable contribution to me-
dical literature. He has been fortunate in selecting a sub-
ject hitherto scarcely approached by writers, and he has
treated it with great care, learning, and ability. The injuries of
the eye must necessarily often fall into the hands of the
nearest surgeon ; and they are matters about which a full and
explicit book of reference is especially required. The first
attempt to supply this want was made by Mr. White Cooper ;
who, however, confined himself to the injuries of the eyeball,
excluding those of the orbit and ocular appendages. Dr.
Zander, of Chemnitz, and Dr. Geissler, of Meerane, both re-
cognised the great utility of such a treatise, and both com-
menced to translate it into German. Their intentions became

1868.] Recent Works on Ophthalmic Surgery, 8

known to each other, and led to a conference, which resulted
in their determination to abandon their original project, and to
write a new work on a more extended basis. Their ' Verlet-
zungen des Auges/ delayed by the illness and death of Dr.
Zander, was at length completed by his fellow-labourer, and
was published, in two parts, in 1863 and 1864.

Mr. Lawson's treatise comes next in chronological order;
and these three books form the whole of the systematic litera-
ture upon the subject.

The work of Mr. White Cooper, which appeared in 1859,
and which was at the time fully noticed in this ' Review,' was
unfortunate in being contemporaneous with a period of great
change and active development in ophthalmic surgery; inso-
much that, in some respects, it has become a record of the
past rather than a trustworthy guide in the present. Drs.
Zander and Geissler had the advantage of seeing the first-fruits
of this period, before , their labours were completed ; and of
writing when the uses of iridectomy were already established by
abundant observation. Mr. Lawson, in his turn, has had time
on his side ; so that (for example) he has been able to intro-
duce, into his section on traumatic cataract, a graphic descrip-
tion of the recent improvements in the methods of extracting
the crystalline lens. Between works thus separated by their
dates no comparison can be fairly instituted. It is enough to
state that Mr. Lawson's treatise represents the most advanced
oplithalmic surgery of the day ; and that it is sufiiciently full
to meet all the probable requirements of practice. As a book
of reference it is admirable ; clear, concise, and properly dog-
matic in its teaching. With its assistance, a surgeon not spe-
cially skilled in ophthalmology would treat, without misgiving,
any accident to the eye that might be brought to him ; and we
trust that many of our readers will provide themselves with an
ally so likely to be useful in emergencies. Those who are
familiar with German, and who choose to have within reach
facts and references about everything that has ever been done
or written on the subject, will find their desires fulfilled by the
^ Verletzungen des Auges.' Of the two works, the German is
(almost as a matter of course) the most comprehensive in its
plan, and the most copious in its details ; and, if we were at all
disposed to find fault with Mr. Lawson, we might complain
that his book is too strictly a record of what is done at Moor-
fields. The wide and judicious eclecticism of that great hospi-
tal may almost justify a member of its stafi" in maintaining
that its practice embraces the whole of ophthalmic surgery;
but still, as a matter of fact, there are active minds at work
elsewhere.

4) Reviews. [Jan.,

Mr. Lawson has written an excellent chapter on staphyloma ;
but in it he has not even mentioned Borelli's treatment by
ligature, although this method, especially in partial cases, is
described as yielding excellent results. This omission, and one
or two others of less importance, scarcely detract from the
general value of the book ; and we only mention them for the
sake of indicating the direction in which we shall look for im-
provement in a second edition.

The annual report of the Netherlands Ophthalmic Hospital
may be regarded, we are informed, as the deliverance of Pro-
fessor Bonders upon the various points that his practice has
brought prominently before him during the year. Many of the
articles bear his name, and the rest are said to be written
under his immediate influence and inspiration.

One of these, by Dr. J. J. Maats, on sympathetic ophthal-
mia, we select for further examination ; and, in the meanwhile,
we cannot but express our regret that matter so valuable should
be published in the Dutch language. In the four reports lying
before us, we find also, besides statistical records of great value,
learned papers on a variety of abstruse questions connected
with the optics and the physiology of vision ; on the distribu-
tion of the ocular blood-vessels, by van Woerden and Donders ;
on visual disturbance in albuminuria, by van der Laan; on
tumours within the eye, by Greve ; and on the anatomical
examination of extirpated eyes, by Rosow. All this wealth of
scientific and important matter is printed in a dialect that bears
about the same relation to German that Lowland Scotch does
to English. We cannot but feel that this, even if it be
patriotic, is inconvenient ; and we trust that Professor Donders
will in time take pity upon his readers all over the world, and
will be content to write in some one of the languages that are
commonly known to educated men. We presume that all Dutch
practitioners must understand German; and that they could
not be injured by that tongue being made the vehicle of future
reports.

The ophthalmiatric observations of Dr. Mooren contain an
account of the result of his experience as an ophthalmic sur-
geon, at Oedt and Diisseldorf, during the ten years ending in
October, 1866. During this time, 32,425 persons came under
his treatment for eye disease, and 5932 operations were per-
formed upon them. He divides his book into twelve chapters,
the first containing statistical tables, and the rest being de-
voted respectively to diseases of the orbit, of the eyelids, of
the conjunctiva, of the lacrymal organs, of the cornea,
of the sclera, of the choroid and iris, of the vitreous, of the
lens, of the retina and optic nerves, and of the muscles and the

1868.] Recent Works on Ophthalmic Surrjery. 5

accommodation. On each of these subjects, Dr. Mooren writes
from the fulness of his mind, and expresses the conclusions to
which he has been guided by his wide experience. He is
already too favorably known, as an observer and writer, to
require from us any further commendation than that which is
implied in the mere statement of the plan of his work ; and we
only regret that our space must limit our citations from it to a
single subject. From the chapter on diseases of the choroid
and iris we select the section on sympathetic affections, as an
example of the author's teaching, and for the purpose of com-
paring it with that of others.

The fact that disease occasionally extended itself from one
eye to the other has long been known to careful observers, and
was distinctly recognised by Beer, and still earlier by Himly.
Mackenzie was, however, the first to bring the subject promi-
nently before the profession, and to assign to the secondary
disease the name of sympathetic ophthalmia, by which it has
ever since been known. There seems reason to believe that
this name has been employed to describe disorders very different
in their nature, and in some of Avhicli the origin in sympathy
Avas, at least, doubtful. In 1863 Mr. Critchett brought the
subject before the Ophthalmological Congress at Heidelberg;
and the discussion upon his paper, in which Donders, v. Graefe,
Arlt, and others took part, has proved an important step towards
the attainment of more exact knowledge.

Mr. Lawson says —

" There are two forms of sympathetic ophthalmia. The first, from
being the slighter of the two, may be called sympathetic irritation.
The second is the severe disease now so well known by the name of
sympathetic ophthalmia."

With regard to the distinction between these two forms, Mr.
Lawson is not clear. In one place he says that '' sympathetic
irritation seems to differ from sympathetic ophthalmia only in
degree," and almost immediately afterwards that, in sympa-
thetic irritation, "although the eye may be subjected to
frequent recurrences of the attacks, yet no fibrinous effusions
nor disorganizing changes of its different tissues take place."
On the other hand, sympathetic ophthalmia " is essentially an
adhesive or fibrinous inflammation. . . . Its tendency is
to rapid plastic effusions, which soon become organized and
incapable of absorption — blending the different tissues together,
impairing their textures, and destroying their functions."
Surely the difference here is not so much in degree as in kind.

Dr. Maats recognises at least three kinds of sympathetic
disease of the eye, namely, sympathetic irido-cyclitis, sympa-
thetic serous iritis, and sympathetic neurosis. He attributes at

6 Reviews. [Jan.^

least some of the discrepancies to be found in authors to a
want of discrimination between these several forms.

Sympathetic irido-cyclitis corresponds to Mr. Lawson^s
second form^ " the severe disease now so well known as sympa-
thetic ophthalmia." The following case, condensed from Dr.
MaatSj furnishes a typical example :

" Herr H — , in August, 1863, suffered an extensive burn of his
face from the bursting of a Papin's digester. The cornea of the
right eye sustained a great loss of substance ; and there was a small
ulcer on the left also, but ,this healed perfectly without impairment
of vision. In Feb. 1864 there was a very large staphyloma of the
right eye, the left being normal in appearance and function. In the
following April the staphyloma was removed by abscission in the
ordinary way, and the perfectly clear lens escaped spontaneously.
"Within ten days the wound was so far closed that he was able to
return home. At the end of April he came again, complaining of
continuous pain in the stump of the eye operated upon. The stump
was about two thirds of the normal size, very soft, painful, and the
middle of the cicatrix presented a small suppurating spot. The left
eye was not painful, and its vision was normal, but the vessels
around the cornea were more than commonly injected. Counter-
irritation was prescribed, and the patient was directed to return in
two days. He remained away four days, and then came with irido-
cyclitis, nearly total synechia posterior, vision about -^^q. The
stump of the right eye was at once enucleated, and iridectomy was
performed upon the left. ISTotwithstanding this, and an active anti-
phlogistic treatment, the irido-cyclitis continued, increased, and
spread to the choroid, with acute supra-orbital pain, photopsia, and
continually diminishing vision. By the end of June he scarcely
saw the movement of a hand at one foot distance, and the aqueoiis
humour was very turbid. In this state the patient (who had pre-
viously been under Dr. Moll, of the Hague) came to Prof. Donders
at Utrecht.

" Professor Donders thought that he perceived swelling of the
lens, and therefore resorted to iridectomy and extraction. The
operation was done by a small flap, and without much trouble, but
was attended by some loss of vitreous. The pain immediately
decreased, the healing of the corneal wound proceeded favorably,
but the eye remained a little too soft, and the opening in the iris
closed. Nevertheless, the movements of a hand were seen at three
feet distance, and colours were distinguished. Two months later
the globe was still softer. An iridectomy was attempted ; but the
iris was very fragile, so that the piece seized by forceps tore away,
and it could not be held by a hook. The eye wasted more and
more, and became deeply grooved by the muscles. The perception
of light continued good, and it may be hoped that it will remain."

"With regard to the second form, the serous iritis, Dr. Maats
writes as follows :

1868.]

Recent Works on Ophthalmic Surgery.

" "We have yet to mention that, according to von G-raefe, a less
dangerous, simple serous iritis may be developed as a sympathetic
ophthalmia ; and Critchett coincides with this observation.

" There are also cases among those recorded by Pagenstecher that
do not answer to the" description of irido-cyclitis. It is evident that
when a disease is common the proof of its sympathetic origin in any
case is difficult to be given ; and doubly so, when there is no deter-
minate form of disease, in the eye first attacked, that can be assumed
as the first step to the sympathetic ophthalmia. The indication
assigned, by Pagenstecher, that exertion of the yet comparatively
normal eye increases the suffering of the diseased one, and that
increase of the symptoms in the latter increases also the sympathetic
symptoms, appears to us not entirely decisive. In cases of undoubted
sympathetic irido-cyclitis there may be rather an alternation of
disease between the two eyes than a simultaneous increase in both ;
and even improvement in the eye secondarily attacked, after enu-
cleation of the other, is not positively proved. The most conclusive
evidence would be, when between the seat of the inflammation in
the two eyes a determinate link of union could be shown, as is the
case in the typical form of sympathetic ophthalmia."

The third form of Dr. Maats, the sympathetic neurosis,
corresponds to the sympathetic irritation of Mr. Lawson. Dr.
Maats, however, recognises the most entire difference in kind
between this affection and the sympathetic inflammation ;
although he admits the difficulty or impossibility of distinguish-
ing in all cases the symptoms of developed sympathetic irritation
from those premonitory of inflammation. Still, he would
attribute this difficulty to the imperfection of diagnosis, not to
any tendency on the part of one aflection to glide into the
other. Of his sympathetic neurosis he says that, while it may,
for the time, entirely disable the eye, it has no tendency, how-
ever long continued, to produce any structural change ; and that
it is cured, immediately and perfectly, by the removal of the
eye causing the irritation. The folloAving case is an example :

" A blacksmith received a wound of the right eye from a piece
of iron, causing laceration of the retina. Inflammation followed,
and vision was lost. After a short time, and while the eye was still
painful, he returned to his work. A few days later the left eye
also was struck by a piece of iron, and the man was obliged to leave
his work again. The eye became red, painful, sensitive to light, and
was continually weeping. The man thought it was as certainly lost
as the other. Por two years he remained in the same condition, the
pain continuing day and night, and his face deformed by photo-
phobia. He could not readily distinguish large objects."

" Examination discovered that the right eye was atrophied, irri-
tated, and painful. The left" eye was opened with difficulty, and
displayed a clear cornea, a normal iris, and a small clear pupil. In
the belief that the left eye was suffering only from sympathetic

8 Revieivs. [Jan.,

irritation, the right eyeball was removed. As soon as the patient
recovered from the chloroform he said that all pain was gone from
the left eye. Two hours afterwards he opened the eye as well as he
had ever done, and Professor Donders found that the acuity of
vision was normal. Ten days later he was supplied with an artificial
eye, and discharged perfectly cured. His bowed-down head had
become erect, his contorted face had recovered its natural expression,
and he could scarcely have been recognised by those who had only
seen him during his time of suffering.

"The case teaches that sympathetic neurosis may continue for two
years in its most acute form without producing organic change. How
far the blow from the piece of iron on the left eye had contributed to
excite the irritation is hard to determine, but it is certain that the
left eye showed no trace of any former injury, and that it sufiered
from no independent affection."

Dr. Maats is inclined to think that the cases described by
writers, in which sympathetic ophthalmia, actually established,
is said to have been arrested by the removal of the eye first
affected, were really examples of irritation only. His expe-
rience teaches him that established sympathetic irido-cyclitis
possesses an obstinate vitality of its own, quite independently
of the cause in which it originated.

Besides these three forms, he calls attention to and briefly
discusses cases of " doubtful sympathy ;" and the question how
far, apart from injury, the occurrence of sympathetic ophthal-
mia may be occasioned by internal inflammation, glaucomatous
processes, &c. &c. On these points he arrives at no very
definite conclusions, quotes von Graefe to the effect that the
hypothesis of sympathetic influence should be accepted with
great reservation, but not AvhoUy excluded; calls attention to
the probable existence of some common (e. g. constitutional)
cause for the affection in both eyes; and, after citing some
cases of probable sympathy, admits that, after all, proof of
sympathy is wanting. He also quotes von Graefe, in order
absolutely to exclude the idea of sympathy in glaucoma, and
points out that in some diseases, such as recurrent iritis and
suppurative panophthalmitis, the attack in one eye seems to
exert an almost protective influence over the other — possibly
on the principle of counter-irritation. He does not mention
what seems to us a cogent point in the case, namely, the well-
known fact that many diseases of clearly constitutional origin
are almost always manifested first in one eye, and subsequently
in the other. Inherited syphilitic keratitis, nerve atrophy,
glaucoma, and senile cataract, all pursue a course on which a
hypothesis of sympathy might be based, if it were not excluded
by other considerations.

1868.]

Recent Works on Ophthalmic Surgery. 9

The following, recorded by v. Graefe, may be taken as an
example of " doubtful sympathy :"

"The blind left eye of a man thirty-seven years old was soft,
painful, with turbid aqueous humour, the iris vascular, chiefly at
the margins of a previously made artificial pupil, swollen, and pro-
jected forwards ; the lens turbid. Prom time to time there was
slight ciliary neuralgia; the globe was generally painful when
touched, and acutely so in the ciliary region. There was scarcely
any perception of light. In the right eye the conjunctival vessels
were somewhat prominent, the acuity of vision had sunk one third
within a week ; there was an appearance of cloudiness, with sub-
jective sensations of light and colour. On careful examination,
many hundreds of excessively fine points were found dotted over
the posterior surface of the cornea, and visible by focal illumination
(spots of iritis serosa). The commencement of the disorder by an
increase of the symptoms in the left eye, the acute pain in the
ciliary region, and the knowledge that, after injuries, such a serous
iritis may be excited by sympathy, were the grounds for supposing
this affection to be sympathetic. After enucleation the case pro-
gressed favorably. The points on Descemet's membrane became
larger and more evident, but much less numerous, and at last
entirely disappeared ; the vascular injection and the subjective
sensations disappeared also, and vision gradually returned, but all
with the slowness peculiar to the affection. The examination of the
extirpated eye, by Dr. Schweigger, tended to confirm the diagnosis.
He found suppurative irido-choroiditis, pus in the vitreous body,
atrophy with pigment deposit of the anterior half of the retina, and
detachment of the posterior half"

If we now turn to Dr. Mooren, we find that he recognises
many of the '^doubtful" cases as instances of true sympathy.
We shall perhaps treat him most fairly by placing an abstract
of the whole of his remarks upon the subject before our readers.
He says : —

"There were 37 cases of complete blindness from sympathetic
disease, occasioned in the following manner :

Twelve times by wound of the sclerotica, with injury of the ciliary
body at the same time.

Six times by phthisis bulbi of traumatic origin. Direct injury to
the ciliary body could no longer be proved when the cases
were seen ; but was highly probable.

Seven times by reclination.

Four times by the formation of staphyloma.

Once by prolapsus iridis.

Once by choroiditis ectatica.

Three times by phthisis bulbi after irido-choroiditis, without injury.

Three times by detachment of the retina with subsequent irido-
cyclitis.

" These 37 cases of blindness were in addition to another series of

10

Reviews.

[Jan.,

^mpathetic affections, which did not go on to an incurable stage.
The causes of the disease, and the nature of the secondary maladies,
are set forth in the folloAving table :

Secondary Disease.

Nine times, arrested irido-cyclitia.
Twice, acute irido-cyclitis.

Twice, irido-ehoroiditis.

Once, iritis.

Once, cataracta accreta.

Once, irido- choroiditis.

Once, irido-choroiditis.
Once, irido-choroiditis.

Twice, irido-choroiditis.

Primary Disease.

Nine times, reclination.

Twice, injury to tlie ciliary body by
iris hook, in the dilaceration of cap-
sular cataract.

Twice, phthisis bulbi traumatica.

Once, staphyloma formation.

Once, cretaceous lens deposit after
choroiditis.

Once, action of an artificial eye upon a
phthisical eyeball.

Once, cyclitis spontanea.

Once, glaucomatous choroiditis after
teleangiectasia iridis.

Twice, irido-choroiditis with participa-
tion of the ciliary body.

" In the nine first cases the reclination had been followed more or
less quickly by irido-cyclitis, producing blindness of the eye operated
upon. The previously and subsequently occurring absorption of the
irritating lens, together with the antiphlogistic treatment that we
may assume to have been employed,^ had arrested the primary inflam-
mation before the secondary had gained suflicient ground to possess
the power of independent development. From two cases in which
I slightly wounded the ciliary body with an iris hook, I infer that a
certain persistence of the inflammation in the first eye is necessary
to the production of destructive consequences in the second. In
both cases, in operating for the dilaceration of capsule, the sharp
point of the iris hook scratched the ciliary body. In consequence
there occurred cyclitis, with severe ciliary neuralgia and slight
hypopyon. Although the course of events in the eye injured Avas
favorable, yet on the fourth day a slight iritis appeared in the other,
and required the instillation of atropine. This secondary iritis first
began to decline together with the primary cyclitis. That in
neither of the two cases it proceeded to a profound sympathetic
ophthalmia, I attribute entirely to the fact that the injury to the
ciliary body was of a transient character, and too superficial to lead
to a localisation of the resulting inflammation. The same passing
influence in the production of sympathetic iritis was displayed by a
staphylomatous eye. The morbid process was arrested by removal
of the cretaceous lens through a transverse corneal section. Some
have tried to convince me tliat the iritis of the second eye was
possibly accidental and not sympathetic. This cannot be said in
the last-mentioned case, in which the ciliary body of the staphy-
lomatous eye was sensitive under pressure."

" There were thus twelve cases in which the primary cyclitis was

1 It is hardly necessary to mention that Dr. Mooren would not himself perform
reclination ; and that these cases coiild only have been seen by him at a period
subsequent to that operation. — Ed.

1868.] Recent Works on Ophthalmic Surgery. 11

arrested (either by the removal or by the transitory character of its
exciting cause) before its disturbing influence had been felt by the
second eye in a suflicient degree to establish a sympathetic disease
of independent character, capable of further spontaneous develop-
ment,

" Of the remaining eight cases, there were six in which enucleation
of the eye first diseased was performed, before an iridectomy to save
the second eye could be thought of. Portunately, considerable im-
provement of sight occurred in all of them, so much so that its
preservation for the future, so far as human foresight extends, may
be considered certain. I entertain no doubt whatever that, without
enucleation of the eye first afiected, and without iridectomy of the
second, absolute blindness would have been the issue.

" In the other two cases, in which the primary disease appeared
to be entirely arrested, enucleation was not performed, but only an
iridectomy upon the second eye, to arrest the further development
of the irido-choroiditis. The first case was one of teleangiectasia
iridis ; the second was in an old peasant woman, who, after being
blind for years, recovered sufiicient vision to count fingers across a
room. These two cases are the only ones in which a spontaneous
arrest of the primary disease occurred. Can we say that such an
apparent arrest involves no further dangers for the second eye ? As
far as a single observation can decide, I think the question must be
answered in the negative.

"A strong student, eighteen years of age, applied to me on
account of long-standing impairment of vision of his left eye. As
a little child he had been wounded in the ciliary body of the right
eye by a sharp bit of iron. The injury attracted little notice, and
the sight of the right eye was gradually destroyed by irido-cyclitia.
Slight pain continued for some years, and at last entirely ceased.
When I first saw the patient there was a slight concentric phthisis
bulbi, the cornea was turbid from interlamellar deposit, there was
no perception of light, and no tenderness on pressure. Eor about
six years the left eye had been gradually losing ground ; but, as the
patient did not read or write much, the failure of sight attracted
little notice. During the last six months it became so marked as to
induce him to come to me. At that time No. 9 of Jaeger's types
could only be read with great difliculty. The originally blue, but
then green iris was united to the anterior capsule. Epithelial
changes, chiefly in a stripe invading the transverse diameter of the
cornea, had a fatty aspect. There could be no doubt about the
existence of a sympathetic irido-cyclitis. As eleven years had
elapsed since the original injury, and as the injured eye was insen-
sitive to pressure, I thought that the primary inflammation had
entirely ceased, and that enucleation was superfluous. An iri-
dectomy of the second eye appeared to be sufiicient. The firm
adhesion of the iris, and the atrophy of its tissue, caused the
operation to leave only an irregular opening. A^ision was not im-
proved, and in a few weeks the new pupil closed again. After this
there was increased hyperemia of the iris, with effusions of blood

12 Reviews. [J

an.

into tlie anterior chamber. In spite of treatment the vision con-
tinued to fail. A second iridectomy, which at first made a good
opening, produced no improvement ; and at last the patient could
only distinguish light from darkness.

" I never forgot that the sympathetic irido-cyclitis had proceeded
so far, when I first saw the patient, as to possess the power of self-
continuance. But notwithstanding this, and the absence of any
evidence of the existence of the primary inflammation, I have often
regretted that I did not perform enucleation. Although the
prospect of thus saving vision was very remote, who can say but
that it might have been realised ? Besides the above case, I have
seen three others in which, notwithstanding enucleation, the disease
went on to blindness.

" The first of these cases was one of cyclitis of the left eye, that
resisted iridectomy. The immediate effects were very good; but
after a few weeks, without known cause, fresh signs of irritation
appeared. The patient was a boy of thirteen; and I proposed to
him another operation, without saying that I intended enucleation.
Unfortunately he did not return, and I was not acquainted with hia
address. Ten days later I met him in the street, and was shocked
to see that his previously sound eye was attacked by sympathetic
irido-choroiditis. His father, who lived at a distance, was instantly
summoned by telegraph ; but, on account of the objection of the
child, thi'ce more days were lost before enucleation could be per-
formed. Neither this nor the subsequent iridectomy availed to
arrest the progress of the disease. The eye became phthisical, and
only perception of the movements of a hand remained,

" The second case, also in a boy, arose from a punctured wound of
the ciliary body. The surgeon in attendance, who watched the case
with extreme care, proceeded to immediate enucleation as soon as
the commencement of sympathetic irido-choroiditis appeared in the
sound eye. The inflammation went on ; and, when I first saw the
child, some weeks after the operation, vision was reduced to the
difiicult recognition of single letters of No. 19. The circular
synechia resisted atropine ; the vitreous was generally turbid. An
iridectomy was performed, producing a wide opening, and appearing
to promise a good result. After a few days the aqueous again
became turbid, the coloboma smaller, the iris pushed forward, and
the lens seemingly increased in size by intra- capsular cell prolifera-
tion. By the advice of Prof. v. Graefe, who was then in Dusseldorf,
I applied warm compresses, under which the aqueous humour
recovered its clearness, and the iris its position. Some months
later a very large iridectomy was made, and the lens, which had
become contracted, was at the same time removed. Notwithstanding
the free pupil, vision was limited to the perception of the movements
of a hand ; and after a few weeks the pupil was again closed.

" The third case, with a similar unfortunate ending, occurred in a
boy of thirteen, after a wound of the eyeball from a steel splinter.
Notwithstanding early enucleation, irido-cyclitis attacked the other
eye. At first the disease seemed to be checked, but after the lapse

1868.]

Recent Works on Ophthalmic Surgery. 13

of six montlis the pupil was again closed. A second iridectomy
produced no improvement.

"Recapitulating these facts, we have, besides the thirty-seven
cases first mentioned, four in which sympathetic disease, once esta-
blished, went on to blindness notwithstanding enucleation. There
were, therefore, twenty cases of arrest of sympathetic inflammation,
against forty-one in which it terminated in absolute loss of sight.

" This is the dark side of the picture, and I turn from it to the
results of treatment when the patient is seen sufficiently early.
Fifty-five enucleations, performed under such circumstances, were in
every case followed by perfectly favorable results. All patients to
whom I explained their danger underwent the operation willingly,
except two, who left to consult another surgeon, or at least not to
return. In one of these cases I saw the patient again, totally blind,
seven years after I had in vain warned him of the fate that awaited
him. The tears of the poor fellow could not recall the past !

" The circumstances that rendered enucleation necessary were as
follows :

Twenty-tLree times, wound of the anterior part of the sclerotic, or
of the ciliary body.

Once, traumatic dislocation of the lens Vithout rupture of the
sclerotic.

Twice, cretaceous lenses.

Five times, staphyloma.

Once, irido-cyclitis after out-scooping of cataract.

Eleven times, non-traumatic irido-cyclitis.

Once, prolapsus iridis.

Once, detachment of the retina with consecutive irido-cyclitis.

Twice, glaucomatous choroiditis with frequently recurring effu-
sions of blood into the anterior chamber.

Seven times, partial choroiditis ectatica.

Once, choroiditis purulenta.

** The causes of sympathetic disease may be referred, as far as my
observations extend, to three wholly distinct groups :

" 1. To direct wounding of the ciliary region.

" 2. To some mechanical irritation of the ciliary body, either
from the presence of a foreign substance — e.g. an artifi-
cial eye — or from a lens displaced, either by reclination,
luxation, or staphyloma, &c. <fec.

" 3. To any inflammation of a part of the uveal tract when this
reaches its culminating point in cyclitis.

" In all the cases observed, tenderness of the ciliary 'body under
pressure loas the unfailing symptom that pointed out the danger of
sympathetic disease.

" The mere impairment or limitation of the accommodation of the
sound eye when taken alone has no significance as regards the risk of
sympathetic disease; and first acquires an important significance when
it occurs together with pain of the ciliary region.

14 Reviews. [J

an.

" In the presence of the latter symptom the enucleation of the eye
first diseased affords the only possibility of saninq the second one.

"I say 'possibility,' not 'probability,' since in all the fifty-five
cases in wbich the conditions of sympathetic disease were present,
and in which enucleation was performed in time, no outbreak of
destructive inflammation occurred ; while in thirty-seven cases in
which enucleation was not performed, and in four cases in which it
was performed too late, incurable blindness closed the scene.
Although in some cases of reclination the sympathetic inflammation
was arrested by the absorption of the lens, and in some cases of
staphyloma by its removal, yet such a result is too uncertain for any
expectation of it to be permitted to influence treatment, or to
produce neglect of enucleation. Even in six cited cases of apparent
arrest of inflammation there was no improvement of vision until
enucleation was performed ; and there remain only two cases in
which arrest without enucleation occurred. This result is altogether
outweighed by the cases of the young men in whom blindness was
produced, although no symptom of any permanent influence of the
original cyclitis could be discovered.

" When once the conditions for a destructive action upon the
second eye are present the greatest care is necessary, in order not
to make the sudden discovery that treatment will be 'too late.'

" A boy six years old was brought to me last year with the history
that he had been playing near his father's anvil, and was struck on
the ciliary region and slightly wounded by a flying particle of iron.
The symptoms were so slight that the child was still running about;
notwithstanding some intolerance of light and lacrymation that were
ascribed to commencing strumous ophthalmia. The child came to
me for the first time seven weeks after the accident, and the impend-
ing blindness from acute irido- cyclitis of both eyes was then
imminent. An iridectomy was performed; but, as might have
been expected, with no useful result. Three months only elapsed
between the injury and total blindness ; and it would seem from
this and other cases that iridectomy can do very little, or even
nothing, to check the course of an established sympathetic inflam-
mation. It should, however, be performed while any glimmer of
hope remains.

" Among the 116 cases observed there were 48 in which a wound of
the ciliary body was either evident or probable from the direction
and the history of the injury.

"Although sympathetic inflammation was less common after
staphyloma than the frequency of that afiection would have allowed
us to expect, yet this is probably to be explained by the fact that,
in by far the greater number of staphylomata, the new formation is
removed before the lens has set up cyclitis. Since I have observed
sympathetic ophthalmia, excited by the pressure of an artificial eye
upon a wasted globe, I have never applied an artificial eye without
first removing the lens. It appears that its presence is necessary to
the setting up of chronic cyclitis, except in cases where the contrac-
tion of the cicatrix, after an injury, is itself a sufficient source of

1868.] Recent Works on Ophthalmic Surffery. 15

permanent irritation. The occurrence of irido-cyclitis, after the out-
scooping of cataract, was the result of bruising of the ciliary body
by the use of traction instruments that were uusuited to the length
of the section and the size of the lens.

" It is very remarkable that many observers deny the power of
non-traumatic cyclitis, whether primary or arising as a complication,
to excite sympathetic ophthahnia. My own opinion is entirely
different from theirs. I am convinced that there are an infinite
number of cases of amaurosis, after irido-cboroiditis, referred to the
operation of some supposed common cause, in which the second eye
is attacked only through the influence of the first. If it were
possible to watch the development of the disease in such cases from
the beginning, it would be easy to obtain proof of such an opinion ;
but, for me, the small number of cases that I have seen afford
evidence enough.

" The same applies to detachment of the retina. This condition
is not of itself a cause of sympathetic ophthalmia, but only through
the intermediation of cyclitis. In the summer of 1860 I was con-
sulted b}'' a gentleman with detachment of the retina of the left eye,
and who had suffered during the year past from the most acute
irido-cyclitis as a complication. The pain was so severe that the
patient for many months was unable to lie down at night. All
remedies had been fruitless, and the pain was seated in the upper
and inner part of the ciliary body. Every attempt to use the
accommodation of the right eye, which was myopic = ^, with a high
degree of sclerotico-choroiditis posterior, was followed by conjunc-
tival hyper£emia and lacrymation. My proposal to perform enu-
cleation was instantly accepted. The sympathetic phenomena were
immediately relieved, and the patient was soon enabled to resume
his office as a counsellor in a court of justice. Only a few months
ago I saw him again, and the vision and power of work of his right
eye had increased beyond all expectation.

"The cases of choroiditis ectatica that produced or rendered
possible a sympathetic disease are so far especially remarkable that
the disorganization was generally only partial. It seems as if the
protrusion of the anterior segment of the eyeball by mechanical
disturbance of the circulation was favorable to the development of
cyclitis.

" Whether, as von Graefe supposes, the general increase of intra-
ocular tension diminishes the probability of sympathetic disease, by
diminishing the conducting power of the ciliary nerves, I am not in
a position to say. Such an action is not unlikely ; but it seems to
be going too far to say that the outbreak of acute glaucoma in the
second eye, immediately after an operation on the first, is not of a
sympathetic character. If I may be allowed to form any conclusion
from the small number of my observations, I must say that von
Graefe's opinion has contributed to strengthen my assumption of a
sympathetic influence. The four cases on which my observations
rest were all remarkable for relative integrity of vision. "With cor-
rection of the existing presbyopia JS'o. 1 was read fluently ; the field

16 Reviews. [Jan.,

of vision was not contracted, tbe sensibility of the cornea not
diminislied, and there was no coloured vision.

" When the tendency to glaucoma is present, there may yet have
been no single symptom which has indicated the rapid, or unexpect-
edly speedy, outbreak of the disease in the second eye. As far as
I am informed, all observers mention the unexpected outbreak of
the second glaucoma, showing that the general conditions were such
as to render this outbreak improbable. If, therefore, an attack of
sympathetic glaucoma (admitting the expression) is observed in
slight degrees of the malady, and only seldom in its higher degrees,
there must be some connection between the phenomena by which
the occurrence of the outbreak in the one case and its absence in
the other may be explained. Von Graefe's opinion is in complete
harmony with this, if we assume that the development of a sympa-
thetic glaucoma can only take place when the diminution of the
sensibility of the ciliary nerves is yet not very cousiderable, and
when, under considerable increase of tension, these nerves retain
their conducting power.

" That a certain degree of distension of the ciliary body, such as
obtains in the early stage of increased intra-ocular tension, favours
the development of sympathetic disease, is shown, I think, by the
two following observations, in both of which a degenerated lens was
removed from one eye. In both cases the original irido-choroiditis
had been arrested by an iridectomy upwards and inwards ; in one
case four years, in the other two years, prior to the cataract opera-
tion; in both cases all appearance of inflammation had entirely
ceased. Extraction of the cataracts by a superior corneal section
required, in both cases, an enlargement of the opening left by the
original iridectomy. The healing process was not interrupted until
the fourth day, when in both cases iritis set in, pursuing by no
means a violent course, but producing in a few days an outbreak of
irido-cyclitis with hypopyon in the second eye, the one not operated
upon. This secondary inflammation was first checked when the
primary was arrested by treatment. I do not hesitate for an instant
to ascribe this to a sympathetic influence. But such an efi"ect would
only be possible if tbe predisposing conditions for the development
of sympathetic disease were already present in the second eye. It
may seem a paradox, but is the expression of my own conviction, to
say that the cause of this influence must be sought in the iridec-
tomy, since the slight dragging upon the ligamentum pectinatum by
the iris forceps produces a temporary, yet for the time actual, in-
creased sensitiveness of the ciliary body. More cannot be said than
that this effect of the operation, under favorable circumstances, is too
slight to exert an influence upon the other eye ; but I am in no way
convinced that iridectomy can never pjoduce any unworthy reaction."

" Be this as it may, the sympathetic influence of the ciliary body
upon the second eye must in no way be underrated. Since I have
observed that, in cases of purulent choroiditis, the greatest sensitive-
ness of the ciliary body to pressure may continue after the sup-
purationjs completed, and may thus keep up the conditions necessary

1868.] Recent Works on Ophthalmic Surgery. 17

for sympathetic ophthalmia, I have thought it prudent in such cases
to proceed to the most speedy possible enucleation.

" It is scarcely necessary to mention that among the eyes removed
on account of the presence of morbid growths, there were some in
whicli the co-existence of active irido-cyclitis involved the possibility
of sympathetic ophthalmia. These are not included in the fore-
going numbers, since the primary condition for which removal was
required was the morbid growtl], and not the cyclitis.

"In 1859 I saw a case that simulated all the phenomena of
cyclitis. An aged landowner of Westphalia had been operated upon for
cataract of the left eye, by reclination, by a surgeon of his own
locality. Vision was obtained for a week or two, and then failed,
with continuous pain. When I first saw the patient the blindness
was complete ; at the lower part of the eye the lens was visible,
shrunken, and calcareous. It was partly adherent to the posterior
surface of the iris, but still freely moveable in the fluid vitreous.
Since the operation the neuralgia had continued day and night, and
in spite of all remedies. The pain was greatly increased by pressure
upon the front half of the globe. All exertion of the other eye (in
which there was no cataract) was rendered impossible, since abun-
dant lacrymation and headache followed all employment of its
accommodation.

" I did not doubt that I had to deal with a cyclitis favorable to
the development of sympathetic disease, and therefore advised
enucleation. The patient consented, with the reservation that an
endeavour to remove the displaced lens should first be made. This
was done, after a large iridectomy, by iris forceps. At the moment
of extraction the pain was experienced in its greatest severity, a cold
sweat covered the forehead of the patient, and his whole frame shook
under the influence of the neuralgia.

" The pain gradually subsided, and after an opiate at night ceased,
and did not return. From that time dated the perfect recovery of
the patient ; and in a few days all tenderness of the ciliary body
had disappeared.

" Althougli all the symptoms, the presence of the displaced lens,
the increased tenderness of the ciliary region under pressure, and,
lastly, the hindered accommodation of the second eye, seemed to
support my diagnosis of a cyclitis likely to produce sympathetic
disease, yet the result proved this diagnosis to be erroneous. There
was only a neuralgia, that might, perhaps, in course of time, have
led to inflammation, but that did not actually amount to that con-
dition. I have not seen any other case so remarkable.

" In most instances the sympathetic disease assumed the form of
irido-cyclitis ; and only once have I seen amaurosis produced by
sympathetic serous choroiditis.

"It is well known that in former times sympathetic blindness was
ascribed, not to the influence of the ciliary body, but to an extension
of disease through the intermediation of the optic nerve. Upon the
action of the ciliary body there is now no doubt, but is the action
of the optic nerve excluded ? Upon this question I have only the

81— xLi. 2

]8 Reviews. [Jan.,

light of a single observation, but this seems to me so convincing
that it hardly requires a second.

" In the spring of 1860 I saw a poor weaver, who had just before
lacerated the cornea and sclera of one eye with the brass-tipped
point of a shuttle- Cataplasms were applied, and, two days later,
on account of great pain about the wound, the eyeball was removed
under chloroform. It unfortunately happened that, in dividing the
optic nerve, the blades of the Cooper's scissors waddled a little, and
contused the nerve trunk. The accident attracted no notice, and the
patient was discharged as cured in a few days. In a few weeks he
returned, complaining of increasing weakness of vision, photopsy,
and weight over the brow. Although nothing was shown by the
ophthalmoscope, yet I thought of the influence of the contused
nerve-trunk, {and, suspecting neuritis, ordered a seton to the neck
and sublimate internally. The symptoms were not checked by
this treatment, and vision had declined to No. 14. Since enucleation
of the wounded eyeball had been performed two days after the
original injury, I thought a sympathetic ophthalmia scarcely pos-
sible ; but in order to meet the possibility betimes, before any trace
of iritis could be seen, and more for my own satisfaction than from
the presence of any necessity, I made an iridectomy. Intolerance
of light continued after the wound had healed ; and in November
the patient could only decipher letters of No. 16. At the same time
the optic disc presented a somewhat whitish aspect ; and all doubt as
to the presence of structural disease of the nerve was thus removed.
Until May, 1862, I saw the patient from time to time ; and the
pallor of the disc increased until the lamina cribrosa became visible
in patches. Since then the morbid process has been arrested, and
vision has so far improved that the patient can read No. 12.

" In this case the disease was manifestly not produced by the first
injury, but only by the contusion of the nerve-substance itself. The
facts show, at least, that sympathetic amaurosis from disease of the
optic nerve must not be ranked among impossibilities or improba-
bilities."

Mr. Lawson sums up his account of sympathetic ophthalmia
in the following general conclusions :

" 1. That it is a peculiar inflammation of one eye, originating
solely from an irritation in the other.

*' 2. That the most frequent causes of sympathetic ophthalmia are —

" a. Penetrating wounds of the eye, and especially those which
involve the ciliary region.

" j3. Foreign bodies within the eye.

" 7. The irritation excited in the sound eye by degenerative
changes taking place in the one already lost.

" 3. That one of the great pecuHarities of sympathetic inflammation
is its tendency to the rapid eff'usion of lymph into all the tissues of
the eye which it invades, capable of speedy organization.

" 4. That the disease once started is very difficult to arrest j that it

1868.] Recent Works on Ophthalmic Surgery. 19

is recurrent in its nature ; and that, even if the first attack be
arrested, a recurrence is almost certain to take place.

" 5. That it is seldom, if ever, excited by a suppurative inflammation
of the wounded eye.

" 6. That the removal of the injured eye affords the best chance of
arresting the disease; and if this operation is resorted to in its
very early stage, there is a good prospect of its doing so.

" 7. That if the symptoms of sympathetic ophthalmia are fully
developed, the removal of the injured eye (the source of the irrita-
tion) may fail to arrest the disease, though it will afford a chance
that should not be neglected.

" 8. That in no instance have I ever seen sympathetic ophthalmia
originate in an eye after the other had been removed on account of
an injury. I have frequently seen it continue its course after the
removal of the injured eye, but in each case sympathetic symptoms
were manifested before the eye was removed. Hence the importance
of diagnosing in what cases of injury sympathetic ophthalmia is likely
to follow ; and the necessity of at once excising such injured eyes as
are prone to produce it, and especially if they are already lost for all
visual purposes.

"9. That in the treatment of sympathetic ophthalmia, any opera-
tion on the eye whilst it is inflamed is positively prejudicial ; but
that when all the activity of the disease has subsided, much may
often be done by some operative procedure to regain for the patient
some of the sight he has lost, and also at the same time to prevent a
recurrence of the attacks.

" 10. That in the early stage of the disease the tension of the globe
is often increased to T + 1 or + 2 ; but that in the later stage the
eye becomes soft from atrophy of the vitreous, causing a diminution
in its consistence and bulk, and that this state is often followed by
detachment of the retina."

We find, therefore, that our authors are in general agreement
with regard to the character and the severity of sympathetic
ophthalmia, and that they differ only in the extent to which
they recognise its existence. Looking at much the same facts,
they classify them somewhat differently. Dr. Mooren is dis-
posed to push the doctrine of sympathy farther than more
cautious men will follow him, and to receive it as a sufficient
explanation of phenomena that most observers would refer to
other causes. He seems, moreover, to be impatient of the nice
distinctions made by others, and to put together, without suffi-
cient notice of their differences, all the forms of sympathetic
disease. His cases on page 15 and page 17 clearly belong to the
same order as that reported by Dr. Maats at p. 7, and are very
different from genuine sympathetic irido-cyclitis. He assumes,
without evidence, that they would or might have terminated in
it ; although the experience of Prof. Donders seems to show the
contrary. On the whole, we cannot acquit Dr. Mooren of a

20 Reviews. [Jan.^

tendency to push a hypothesis beyond its proper limits^ and to
overstep the bounds of philosophic caution in his conclusions.
We are by no means sure that in this he may not do good
service to the public. Time and careful observation are needed
in order to assign the exact limits of the danger from sympathy;
and in order to discover any trustworthy symptoms by which
this danger may be discerned while still distant, and while still
within the power of preventive treatment. At present we seem
only to know for certain that sympathetic irido-cyclitis never
commences after the eye causing the irritation has been removed.
In dealing with intelligent patients, or with patients who are in
a hospital and under constant observation, it may often be per-
missible to wait and watch, especially for observers who have a
well-grounded confidence in their own power to detect the be-
ginning of mischief. But when we read the history already
quoted from Dr. Maats, of the gentleman who was told to
return on the second day, and who returned on the fourth day
with irremediable disease, we cannot but feel that those who
wait and watch assume a very grave responsibility, and incur a
risk which ought to be clearly understood and consented to by
the patient. There can be no doubt that we know enough to
justify us in saying that the rule of treatment for sightless,
shrunken, and irritable eyes, should be early removal ; and that
we do not know enough to enable us to say when and under
what circumstances this rule may be departed from with safety.
The latter knowledge will ultimately be gained by men
having special opportunities ; the former should be the present
guide in practice of those from whom such opportunities are
withheld.

It is manifest that Dr. Mooren, writing in the strain of the
passage we have cited, will do little or nothing to clear up the
difficulty by which the question is surrounded. Professor
Donders, however, has approached this difficulty in a spirit of
philosophical inquiry, and has made attempts to discover the
exciting cause, the course, and the exact nature of the so-called
sympathetic influence. Dr. Maats enters at some length into
this part of the subject, commencing as follows :

" When Manni sought for the cause of the periodicity of certain
diseases, he knew that the general periodicity of nature was ex-
pressed very clearly in the lives of mankind ; and he came to the con-
clusion that we might legitimately wonder that so many diseases
are not periodic.

" The same kind of reasoning has been used in seeking for an
explanation of sympathetic ophthalmia. It is well known that the
impressions of the two retinae coincide, so that we do not know with
which of the two eyes we perceive any object ; that in both eyes the

1868.1 Recent Works on Ophthalmic Surgery. 21

accommodation eftbrt is equal and simultaneous, that in certain
mental emotions the tears flow from both eyes ; that the actions of
many muscles are united together in both eyes ; that the reflex
phenomena, such as contraction of the pupil (even when only one
retina is exposed to the light), the closure of the eyelids, the spas-
modic closure and the lacrymation in irritation of one eye, take
place at once in both ; and that by the use of one eye both are fatigued.
We know also that in strong closure of one eye the field of vision
of the other is from time to time confused ; and that a number of
organic defects, such as anomalies of refraction, which are congenital,
occur in both eyes at once. Hence we might wonder that inflam-
mation of one eye should not always entail inflammation of the
other. But here, as in general, the proverb applies, ' Those who know
too much know nothing.' We may say with humility that the occur-
rence of sympathetic ophthalmia is as yet in no way explained.

" Mackenzie and others were at first inclined to attribute to the
optic nerve an important part in its production. They had a dim
perception that the key to the phenomena would be found in the
chiasma nervorum opticorum ; and the more, since they believed
that the sympathetic inflammation commenced in the retina. Mac-
kenzie was, however, already inclined to call in the intervention of
the ciliary nerves and of the vaso-motor ganglia ; and gradually the
optic nerve was pushed into the background. It was felt that the
part assigned to it was unphysiological ; and cases were observed in
which the nerve was wholly useless, or even ossified, and yet no
symptoms of sympathetic ophthalmia appeared. Many observers
thus came naturally to the conclusion that the sympathy arose
through the intervention of the ciliary nerves ; and among these
Arlt holds the first place. Y. Graefe, Heinrich, Miiller, Bowman,
and Pagenstecher, expressed the same opinion. When it is con-
sidered that a persistent irritation of the ciliary region, in which the
ciliary nerves chiefly ramify and are distributed, is the starting-point
for sympathetic ophthalmia, and that this is first manifested in the
ciliary region of the other eye, it is scarcely possible to question the
intervention of the ciliary nerves in what H. Miiller calls * this
fatal sympathy.' Bowman insists chiefly on the intervention of the
vaso-motor nerves that reach the eye with the vessels themselves ;
and he mentions instances in which the inflammation of the sympa-
thetically afl'ected eye corresponded accurately to the seat of injury
in the other. He records the following remarkable case :

" A little boy, five years old, was wounded by a penknife in the
ciliary region, just behind and parallel with the cornea on the nasal
side. The knife had passed through the ciliary muscle and the base
of the iris, but had not wounded the lens. There was a small pro-
lapsus of the iris, which, however, did not project beyond the wound,
and occasioned no irritation ; there was no pain, and only a slight
photophobia. On account of the absence of unfavorable symptoms,
and the clean edges of the wound, a very favorable prognosis was
given. The ordinary precautions and treatment were used, and in a
week the wound had healed and the sight was good. The pupil re-

23 Reviews. [Jan.,

mained drawn towards the wound. It appeared that, with ordinary
care, no farther danger was to be feared. Of care there was no
want ; and some weeks after, when the child had ceased to suffer,
the wound was entirely forgotten. Eive months later the patient
was brought to me again, it having been remarked that his sight had
gradually become impaired. He had felt no pain. On examining
the wounded eye, I found the pupil pressed against the cornea, espe-
cially in the neighbourhood of the wound, and the iris firmly adhe-
rent to the lens. In the other eye a similar condition existed, but
in a less degree. In the precisely corresponding part of the eye, on
the temporal side, the iris was swollen and adherent to the lens, and
in the ciliary region the vessels were conspicuous, showing the pre-
sence of a deep-seated chronic inflammation. The right eye was
wounded below and in the nasal angle, the left now displayed these
limited changes below and on the temporal side. The case exhibited
in a remarkable way the symmetry of these sympathetic affections.

" After great care this patient recovered very good vision in six
weeks ; but the iris is still prominent, and I fear that he is not
secure from further changes."

" But in what way can the inflammation be propagated to the
other eye, either through the ciliary or the vaso-motor nerves ?

" We read in Stellwag von Carion, ' Also in calcification of the
lens and in bony deposits on the inner side of the choroid, we may
remark a tendency to sympathetic affections of the other eye, and
may explain this on the ground that the tissue hypertrophy often
aflfects the sheaths of the ciliary nerves, extends gradually to their
trunks, and so involves the nerves themselves in conditions of morbid
irritation.' The propagation of inflammatory morbid conditions
along the nerves is well known; but whether earlier writers had
used this explanation of the cases in question we do not know.
Only in H. Miiller do we find, in the examination of an extirpated
eye that had set up sympathetic ophthalmia, special reference to the
ciliary nerves. The eye was the subject of sclerectasia, irido- cho-
roiditis, solutio retinae, and capsular cataract. We read that the ciliary
nerves were atrophied in front of a certain point ; the fibrillae had
not undergone decomposition, and were still visible in section, but were
pale from medullary atrophy. Miiller found all the altered fibrillae
furnished with dark sheaths, in such a manner that they resembled
bare axial cylinders, but without being much increased in thickness.
* It is not too much to say,' he observes in a note, ' that to the ciliary
nerves must be ascribed the origin of many deep-seated disorders.
On the other hand, it is obvious that the secondary afiections of the
ciliary nerves, which follow from choroiditis and similar diseases,
are of great importance with regard to the further course of such
diseases, and with regard to relapses in the same eye.

" In order to know in what manner inflammation of the one eye
may be sympathetically carried over to the other, there are, as
Professor Donders has pointed out, two ways open. The first is by
comparative anatomical observation of enucleated eyes, whether or
not they have excited sympathetic ophthalmia. The second is, to

1868.] Recent Worhs on Ophthalmic Surgery. 23

produce artificial injuries in the eyes of animals, of the same cha-
racter as those that produce liability to sympathetic ophthalmia in
man. If we could in this way succeed in producing sympathetic
ophthalmia in animals, we should have opportunity, not only to ex-
amine the lesions in both eyes, but also to ascertain the state of the
nerves outside of the eyes. We have instituted such experiments with
nine rabbits and two dogs, but, to our regret, with negative results.

" In some rabbits a puncture with a scalpel was made in the ciliary
region ; in others a foreign body, a piece out of a grain of shot, was
introduced into the eye ; in others, threads were passed by a curved
needle through a part of the ciliary region, and were tied outside of
the eye. In all of them more or less acute inflammation speedily
followed the injury, with softening of the eyeball, injection of the
vessels, discoloration of the iris, contraction of the pupil, deposit of
exudation in the pupillary space, &c. In some of them, after a few
days, these appearances had vanished, and the eyes had regained
their normal aspect. In others, there were circumscribed exuda-
tions in the vitreous body, that slowly increased and involved a great
deal of the vitreous, lastly occasioning some turbidity of the lens.
In two, in which threads were passed through the ciliary region,
phthisis bulbi was produced. In those in which the eye recovered a
normal aspect, a second wound was made, through the sclerotic from
above, at a small distance from the cornea, over a length of three or
four millimetres, so as to let the ciliary processes project outwards.
This wound was daily touched with acetate of potash ; but, notwith-
standing, the symptoms of inflammation were not acute, and the
wound soon healed over. In two dogs, by a wound of the sclerotic,
the ciliary muscle and processes were laid bare and for a certain
distance drawn out of the eye. In one of them slight inflammation
and speedy recovery followed ; in the other acute iritis with turbidity
of the cornea, exudation in and closure of the pupil, and hardening
of the eye. By none of these injuries did we succeed in producing
sympathetic ophthalmia of the other eye. During ten weeks the
animals were kept under close observation, and in all of them the
unwounded eyes remained perfectly healthy ; and no morbid state
could be observed in any of them with the ophthalmoscope."

Dr. Maats proceeds to the next part of the inquiry, to the
actual condition of enucleated eyes, at greater length than we
can follow him, and Avith the aid of lithographic illustrations
that should be reproduced in order to do full justice to his de-
scriptions. He gives an account of the dissection of eighteen
enucleated eyes. Of these the first two had actually excited
destructive irido-cyclitis of their fellows, which had gone on, in
spite of treatment, to complete blindness. The cases are fully
detailed in an earlier part of the paper, and the mischief arose
in both from injury. This, in the first case, was a blow from a
flail upon a previously healthy eye ; and, in the second, a thrust
received by an eye that had already been blind for nineteen
years. In both cases one of the ciliary nerves was found actually

24 Reviews. [Jan.^

engaged iu the cicatrix at the seat of injury, and more or less
adherent to the coats of the eye and to the etfused lymph.

The remaining sixteen eyes were all removed because they
were useless and painful ; but none of them had excited sym-
pathetic ophthalmia, and only a few a small degree of sym-
pathetic irritation, which was immediately relieved by the
operation. Of the sixteen —

Three had been destroyed by common inflammation and

its results.
One by syphilitic inflammation.
Two by glaucoma.
One by staphyloma cornese.
Two by wounds from splinters of metal.
Four by wounds from percussion caps.
One by an umbrella thrust.
Two by '^injury,'' nature not specified.

The morbid appearances were, of course, various ; but in none
of them was there any special implication of any ciliary nerve in
a cicatrix or an inflammatory deposit. The ciliary nerves were
in many cases more or less changed or degenerated in structure,
charged with oil-globules and the like, but not in any decided
way involved in the disease. Dr. Maats sums up the cases in
the following general conclusions :

" We give these cases as simple facts. They are enough to prove,
1st, that indications for enucleation often exist ; 2nd, that the opera-
tion presents no difficulty, and is easily recovered from ; 3rd, that in
many diseased conditions of the one eye the other remains free. A
severe sympathetic ophthalmia was only developed in the lirst two
cases. Had they any peculiarity ? Doubtless. They both com-
menced by a woiuid of the ciliary region, with subsequent prolapsus
and adhesion of the inner parts to the adventitious tissue formed in
and about the wound. In both the choroid was involved, and one
of the ciliary nerves. In both irido-cyclitis had existed. In none of
the remainder had the same kind of injury been sustained, or was
the same kind of adhesion present. In none was sympathetic oph-
thalmia produced. The ciliary region was often implicated in the
morbid process, shrivelled together, adherent to other parts, &c. ;
but this seemed insufficient to produce sympathetic ophthalmia. Is
tension or traction of normal ciliary nerves requisite ? However
this may be, the cases cited afford a basis for the belief that the inter-
vention of definite nerves is necessary to the production of sym-
pathetic ophthalmia. From a physiological, or even from a patho-
logical point of view, this conclusion is not without importance.
That nerve-paralysis of nutrition is not sufficient to cause inflamma-
tion is well known. But the influence of irritation, or of morbid
processes arising iu the nerves, iu producing inflammation, is quite
another matter ; and although the experimental evidence of this by

1868.1 Recent Works on Ophthalmic Surgery. 25

Samuel lias not been confirmed by Meiasner and others, and tlie in-
fluence is not clearly declared in experiments, yet pathology fur-
nishes the necessary proof. It is, in our opinion, postulated by
sympathetic ophthalmia, and so far this is of pathological import-
ance ; but it follows also from those inflammatory processes that
occupy a determinate nerve limit, especially such as are bounded by
the middle line, like herpes zoster; and this last is not isolated. We
sometimes see cases of acute skin disease affecting the cheek and
forehead, bounded exactly by the median line, and even complicated
by ophthalmia. Two such cases occurred here last year ; in one of
them together with obstinate cyclitis, that continued long after the
pustules were cicatrized; in the other with keratitis and iritis. In
both of them the skin and the eye on the other side remained
entirely unaff"ected."

The belief that the ciliary nerves^ or one of them, must be
the ordinary source of the irritation from which sympathetic
ophthalmia springs, is strengthened by a case reported by Mr.
Vose Solomon, in the ' Dublin Quarterly JournaP for 1863. A
man received an injury to his left eye from molten iron, which
destroyed the sight, and produced symblepharon of the lower
lid. Two months after the accident he suffered from sympathetic
irritation of the right eye, evinced by pain, a feeling of internal
compression, and by a floating cobweb in the field of vision.
There was no photophobia, but the pain and dimness of sight
increased so much that the disorganised globe was removed by
enucleation, in the usual way, between eight and nine months
after the accident. Relief was felt within three hours after the
operation. The band to the lower eyelid soon reunited, and
opposed an obstacle to the introduction of an artificial eye. The
band was divided, and a glass mash introduced. The mash
excited a good deal of local pain, and reproduced sympathetic
ocular disturbance of the same degree and kind as that which
existed prior to enucleation. Removal of the mash relieved the
symptoms ; its re-introduction at the end of a fortnight restored
them, and its final abandonment was followed by permanent
improvement, although the eye continued to be irritable at
times. Upon this case, and others somewhat similar, Mr.
Solomon long ago founded the opinion that the fifth pair fur-
nished the channels of irritation in sympathetic, or, as he called
it, reflex ophthalmia. It seems difficult, if the ciliary nerves
furnish the ordinary channels, to assign any reason why other
branches of the fifth should not sometimes exert a similar in-
fluence. We have ourselves seen a case in which slight iritis
seemed to be produced by the irritation of an old and roughened
artificial eye, worn over a globe that had dwindled after internal
suppuration, and in which excision of this globe at once checked
the inflammation. Neither in this case nor in Mr. Solomon^s,

26 Reviews. [Jan.,

however, was there any appearance of irido-cyclitis ; and it may
fairly be considered probable that the form assumed by sympa-
thetic ophthalmia may vary with the nerve filament by Avhich
the primary irritation is conveyed. The probability that the
fifth pair may exert an influence in causing sympathetic dis-
ease is further heightened by the recent researches of Wegner
upon the influence of these nerves on the production of glau-
coma.

On the all-important subject of treatment we learn but little,
and that chiefly of a negative character. Dr. Mooren only refers
to it incidentally, and displays a belief in the utility of iridec-
tomy. He would resort to this operation as an expedient not
to be neglected, even where he expected but little good from it.
Dr. Maats passes in review the history of the treatment. He
relates that, when the present method of enucleating the eye
had been suggested by O^Ferrall and carried into practice by
Bonnet, and had been performed in this country by Mr.
Critchett, it was tried by Mr. Pritchard, of Bristol, as a remedy
for sympathetic ophthalmia. For a time much was expected
from it. Experience, however, has proved that sympathetic
irido-cyclitis so soon acquires an independent vitality, and a
power of running its course unchecked, that enucleation of the
first eye, when the disease is actually present in the other, is of
rare or questionable utility. It appears probable that the cases
described by writers, in which enucleation arrested the esta-
blished disease, were examples either of sympathetic irrita-
tion only, or at most of sympathetic serous iritis. Dr. Maats
concludes that enucleation, as a curative measure, should not be
neglected, but that very little must be expected from it. He
follows Mr. Critchett in believing that iridectomy is seldom
useful during the acute stage of the secondary disease. The
operation is very difiicult of performance; on account of the
friability of the iris, and the firm adhesions of its posterior
surface to the capsule of the lens. The opening that is made
is soon closed by fresh eff'usion. Both in this country and in
Holland experience seems to show that the inflammation should
be guided and controlled by careful antiphlogistic treatment of
the ordinary kind, in the hope that it may be exhausted without
destruction of the retina, and that at some future time an iri-
dectomy, with or without extraction of the lens, may restore a
certain amount of vision. Excessive tension may be relieved by
paracentesis, and the precise character of the general treatment
must be adapted to the power and constitutional state of the
patient.

As regards the prevention of sympathetic ophthalmia, there
is but one opinion among our authors, or among men conversant

1868.] Recent Works on Ophthalmic Surgery. 27

with this terribly destructive malady. Dr. Maats appears to
consider it possible that there may be a time before the sym-
pathetic disease has shown itself, but in which the morbid in-
fluence has travelled along the ciliary nerves far enough to
obtain an independent existence, and in which enucleation may
be too late. The existence of such a period must be problemati-
calj and its duration would probably be short. Putting it out of
the question, we may say that timely enucleation certainly takes
away one of the essential conditions of sympathetic ophthalmia,
and destroys the risk of its occurrence. It may sometimes
arrest its progress or mitigate its severity when actually present.
It cures sympathetic irritation absolutely and at once, and may
thus restore a patient who is practically blind to all the advan-
tages of sight. For the patient it is no loss, but rather a gain,
to be relieved of a blind and painful eye. The opefation, per-
formed after the method of Bonnet and Arlt, is simple, free
from danger, and followed by speedy and complete recovery.
The diseased eye is usually of uncomely aspect, and the sub-
stitution for it of a well-fitting artificial one will be a gain in
point of appearance. In the striking words of v. Graefe, " We
must not forget the importance of the issue. The danger of double
blindness is so alarming as to outweigh all other considerations ;
and even if we enucleate ten times uselessly for once that we set
aside an actual peril, the operation, in my judgment, would still
remain advisable."

The work of Mr. Power is remarkable for the number and
beauty of the plates by which it is illustrated, and for the marked
influence of German ophthalmology upon the mind of the author.

The plates are referred to in the Preface as being themselves
the cause of the book; and they deserve, therefore, the first
consideration. They contain fifty-four coloured representations
of the surface, and eighteen of the fundus of the eye, all from
Mr. Power's original drawings, reproduced by chromo-litho-
graphy. In saying that these figures are somewhat coarse and
hard as compared with nature, and therefore more or less inac-
curate, we only express the deficiency of the art, and re-echo
the judgment of the author. We read in the Preface that
" chromo-lithography was scarcely capable, without an expendi-
ture totally disproportioned to the end in view, of expressing the
fine shadings of colour which enable the practised eye to distin-
guish various yet similar forms of disease ;'' and we cannot
look at these, or at any other plates of ordinary varieties of eye
disease, without some feeling of regret for the expense incurred
upon them.

In the letter-press Mr. Power travels over a wide range of
subjects, and treats them with much care and perspicuity. The

28 Reviews, [Jan.,

few books upon ophthalmic surgery recently published in this
country have been remarkable for their neglect of the German
literature of the subject; and there are many matters which
have been discussed, and many results obtained at Utrecht or
Berlin, with which the English reader has hitherto had no oppor-
tunity of acquainting himself. The ' Ophthalmic Review,' and
recently the 'Ophthalmic Hospital Reports,' have done some-
thing towards publishing abstracts of important foreign papers ;
but they have done little or nothing to supply a general view or
digest of continental teaching. In this respect we attach especial
value to the work of Mr. Power. On every subject of which he
treats he appears to be familiar with its German aspect ; and
he reproduces this aspect in language of his own, checked by
the teaching of his own experience. For the English reader
Mr. Powei*'s book contains much that is valuable and much that
will be new. We would point to the chapter on strabismus as
one of great excellence, and one to which our remarks especially
apply.

On the question of cataract extraction, and on that only, Mr.
Power, although perfectly familiar with German writings, seems
to lag a little in the rear of German practice. He dwells rather
fondly upon flap extraction, and bestows the faintest possible
praise upon the modified linear method of von Graefe ; saying of
it, indeed, " The chief objection to the operation appeared to
me to be the difficulty of seizing the iris for the performance of
iridectomy, and the almost certain escape of a large amount of
vitreous.'" We believe that the difficulties inseparable from a
new operation will disappear with practice ; and in this par-
ticular case we think they may be due to the section adopted.
Mr. Power gives a woodcut, said to be copied from S tell wag
von Carion — the original of which is unknown to us — which
professes to represent "the section of the cornea made by von
Graefe.'' Anything less like the reality it would be difficult to
conceive.

Mr. Power's volume reached us only when this article was
already in type, and when it was impossible to arrange for a
more extended notice. We are therefore compelled to take
leave of it, and we do so with a full conviction that it will be
of great utility to the profession.

We have left oiu'selves little space in which to notice the
remaining books on our list. Fortunately, but little is required.

The lectures of Dr. Macnamara, in their Indian edition, we
have already mentioned with approval. The present work is the
English edition, revised and freed from most of the blemishes
by which the former was disfigured. Still, it is essentially the
same work, and does not require any further description.

1868.] Recent Works on Ophthalmic Surgery. 29

Dr. Williams was tlie successful competitor for the Boylston
Prize, offered by Harvard University, for the best dissertation
on " Recent Advances in Ophthalmic Science/^ The author
modestly states that " it is not devoid of the faults incident to
such a treatise ;" but he hopes that it may assist the student
and busy practitioner. We apprehend that the chief business
of a student or of a practitioner should be to make himself
thoroughly master of the knowledge required for the discharge
of the duties of his calling. A surgeon desiring to treat eye
disease ought to know a great deal more than this little book
can teach him, and one who had no such desire might without
inconvenience know less. We much doubt whether such a
volume can be of any real utility, or can serve any other purpose
than to enable its readers to gain a smattering of its subject-
matter. As far as it goes, it is well done; and the parts
relating to the ophthalmoscope and to refraction are illustrated
by numerous original diagrams, of remarkable clearness and
ingenuity, designed and drawn by Dr. John Green.

The Reports of the Royal London Ophthalmic Hospital
assume, year by year, a more general character, and thus
acquire an increasing value. The present volume contains
many contributions from members of the hospital staff, chiefly
from Messrs. Bowman, Hutchinson, Hulke, Lawson, and Streat-
feild. Of the value of their labours, and of those of Dr. Hugh-
lings Jackson, it is almost superfluous to speak. There are a
variety of minor papers, by men of repute who are unconnected
with the hospital; and a periscope, containing a large number
of abstracts from foreign ophthalmic journals.

Mr. Vose Solomon^s work on ' Tension of the EyebalP is an
attempt to revive a forgotten controversy, on a subject that we
think is not worth disputing about. The various endeavours that
have been made to cure glaucoma by incisions in the ciliary re-
gion have, as a rule, signally failed of success ; and every oph-
thalmic surgeon must have met with blind patients bearing the
scars of such operations, and remaining melancholy monuments
of surgical perversity. It would be better to throw a veil over
the past history of this painful question, than to spend time in
discussing the respective no-merits of straight and oblique
punctures. The events with which Mr. Solomon deals occurred
in a period when ophthalmic surgeons were gradually working
up to the present state of knowledge about intra-ocular ten-
sion; and the proceedings that were justifiable then could
no longer be justified now. Even setting aside the known
efficacy of iridectomy, it may be doubted whether the ciliary
region should not be scrupulously avoided by operators, as
being the chief source and centre of sympathetic irritation.

80 Reviews. [Jan .,

The little pamphlet on the cure of extreme divergent strabis-
mus, by the same author, contains an account of an ingenious
operation for this purpose. How far it would fulfil its objects,
and whether it possesses any advantages over the better known
method with which the name of Mr. Critchett is commonly
associated, are questions to which we are unable to reply. For-
tunately the cases of divergent strabismus due to excessive teno-
tomy of the internal rectus are now extremely rare ; and the
paralytic cases frequently admit of cure by the continuous
galvanic current.^

Review II.

Essai sur la Pellagre observes ct Corfou. Par C. Pretenderis
Typaldos, Professeur de Clinque Medicale k TUniversite
d'Athenes, Medecin de S. M. le Roi des Heleenes, etc.
Athenes. 1866.

Essay on Pellagra observed at Corfu. By C. Pretenderis
Typaldos, Professor of Clinical Medicine in the University
of Athens, etc. Athens. 1866.

One of the most striking features of the present age is the
great attention paid in all civilised countries to the promotion
of the public health. At home our tables are covered with
reports of commissions and parliamentary committees on sana-
tory matters — the state of the mining population, the in-
fluence of various trades and occupations on the health of the
persons employed in them, the conditions of the dwelliugs of
the poor, and the prevalence of different epidemic diseases. On

' Since the foregoing article was in type, an original paper on sympathetic
ophthalmia, by Dr. E. Meyer, has appeared in the ' Annales d'Oculistique.' The
author records three cases in which he carried out, with perfectly satisfactory
results, the suggestion of v. Graefe to divide the ciliary nerves behind the seat of
the original injury, as a substitute for enucleation of the globe. The first case
was one of pronounced sympathetic irritation, and was cured. The other two are
not described. The operation was performed by pinching up and incising the
conjunctiva, as if for a strabismus operation, and by freely separating it from its
attachments by scissors. A strabismus hook was next passed under the nearest
rectus muscle, so as to fix the globe. V. Graefe's linear knife was then made to
puncture the sclerotic, to emerge, and to cut its way out, in such a manner as to
make a subconjunctival linear wound, parallel with the corneal margin, and of
sufficient length to divide any nerves passing back from the seat of injury. Care
was taken to avoid the lens. Vitreous humour protruded through the wound, and
in one case required to be cut away. The incision in the conjunctiva was closed
by suture, and a compressive bandage applied. The method seems worthy of
trial, because an artificial eye always moves imperfectly upon the muscular stump
left after enucleation. In cases where the injured eye was much disfigured, and an
artificial one was required for cosmetic reasons, it would still be prudent, when all
irritation had subsided, to remove the ciliary circle by abscission, rather than to
run the risk of mischief being set up by the regions of which the nerves had
been left undivided.

1.868.] Typaldos on Pellagra at Corfu. ^

the continent, and especially in France^ the most elaborate
investigations are undertaken in all branches of hygiene; and
the United States set a noble example, during the late war,
of attention to the wants of the soldiers in the field and the
wounded in hospital, and are now making an energetic effort
to check the high rate of mortality which prevails in some of
their large cities. In Northern Italy the attention of the
Government has long been devoted to the great prevalence
of pellagra among the peasantry in certain districts and the
social evils which it entails, in the hope of detecting some
means by which its ravages may be arrested. More recently
the attention of the French Government has been directed to
the existence of a similar disease in certain parts of the south
of France ; and the work of Dr. Typaldos shows that pellagra
also occurs in the Island of Corfu.

After a brief notice of the medical topography of the island,
the author states that the knowledge of the occurrence of
pellagra, and probably, indeed, its existence at all in this locality,
is of quite recent origin. In 1839 a case, which it was thought
might be an instance of the disease, was seen by one of the local
practitioners, and in 1858 the occasional occurrence of pellagra
in the island was brought under the notice of Dr. Typaldos,
and induced him to enter upon an investigation of the subject
with a view to ascertain to what extent the disease prevailed,
and what were the circumstances under which it occurred. In
pursuance of this investigation he collected forty-eight cases in
1859, 1860, and 1861. The particulars of these cases he has
detailed in his work, and he shows that the disease prevails
in 27 villages out of 117 inhabited by the peasantry. These
37 villages contain a total population of 15,458 persons, and in
them the disease occurs in the proportion of from 1 in 1218 to
19 in 480 of the population. The reports are followed by an
analysis of the information obtained and a discussion of the
causes giving rise to the endemic, and the pamphlet altogether
throws much light upon the symptomatology and etiology of
pellagra ; and, as being the first medical work we have seen
from the press of Athens, afibrds a very favorable indication
of the state of science among the higher branches of the pro-
fession in the Hellenic Kingdom.

To the description of the disease given by Dr. Typaldos, it is
not necessary to allude, for it corresponds in general with that
of others which have been recently published. We shall, there-
fore, confine ourselves to his observations upon the causes which
apparently conduce to the prevalence of the endemic in Corfu.
Under this head the author passes in review the atmospheric
influences to which the population are exposed, the character

32 Reviews. [Jan.;

of the soil and the habitations and habits of the peasantry^
and the facts which he collected as to the effect of age^ sex,
hereditary predisposition and contagion on the spread of the
disease ; but his remarks upon the latter points referring only
to a small number of cases, and to a district in which the
disease has probably only recently made its appearance, possess
very inferior interest and importance to the elaborate reports
which have been published upon the disease in the Milanese
and other parts of Northern Italy. As in those localities so in
the Island of Corfu, the subjects of the disease are almost always
the peasantry in the rural districts ; but exceptions occur to this
rule sufl&cient to show that working in the fields and in the open
air cannot be accepted as the essential cause upon which it
depends ; though doubtless the cutaneous affections on the ex-
posed parts of the body are due to the influence of the sun^s
rays. So, also, although the circumstances of the persons who
suffer from pellagra in Corfu are always very depressed, and
fully warrant the term which has been applied to the disease
in France, of " mal de misere -," this equally does not explain
its specific nature, for the population, in other parts, are equally
exposed to want and its attendant evils without suffering from
any similar affection. The author, therefore, concludes that the
alimentary regimen can alone be regarded as being the specific
cause of the disease, and he dismisses the idea that the drinking
water is at all concerned in its production. The general food of
the peasants during the winter and spring, he states, to consist
chiefly of bread and legumes, with oil, seasoned with onions,
leeks, and garlic. The only animal food they take is salt fish
and cheese and occasionally fresh fish. In the summer they get
in addition, if the crop of oil has been abundant, a supply of
wine, and are apt to indulge too freely in its use. Their staple
diet is composed of bread, prepared with maize or Indian corn
flour, which is called " barbarella.'"' This, after being kneaded,
is baked in the oven in the form of flat cakes, and is eaten either
fresh or dry, the supply being often prepared for a week. When
fresh cooked it is soft and pleasant to the taste, but when dry
it is very heavy and indigestible. Of the persons whom Dr.
Typaldos found to be labouring under pellagra, all without ex-
ception had lived upon this diet, either almost entirely or in
chief part ; and he ascertained that the prevalence of the disease
corresponded in the different villages with the extent to which
maize constituted the food of the peasants. Thus, in some
localities they entirely live upon or have in addition to maize,
bread made with sorgho [Holcus sorghum), rye, rice, or wheat,
and he found that, when such grains are used, the people wholly
escape or suffer only slightly from pellagra. The observations

1868.] Typaldos on Pellagra at Corfu. 33

of Dr. Typaldos show, therefore, that the disease occurs in Corfu
under very similar circumstances to those which, since the time
of Thouvenel, have been found to attend its prevalence in the
north of Italy, and they indicate that its occurrence is in some
way connected with the use of maize as the chief article of diet.
The author further contends that it cannot be in consequence
of the small proportion of the azotized elements in Indian corn
that the grain is injurious; for it has been shown that when
rye, rice, or sorgho are used the population do not suffer from
pellagra, though those grains are still more deficient in azote
than maize. He finally arrives at the conclusion that the essen-
tial cause of the disease is the consumption of maize which has
been imperfectly ripened, or has undergone changes after being
gathered ; thus adopting the views of Ballardini, as advocated
in the thesis of M. Roussel and described by Dr. Peacock in a
paper in a former article of the review.' It has hitherto been
maintained by the advocates of this view, that it is only when
the grain is grown in too cold and wet a climate for it to be
properly ripened, that it undergoes the changes which give rise
to pellagra, the exil especially appearing in maize grown between
the latitudes of 42 and 47 in France and Italy. The discovery
that the disease prevails in Corfu between the latitudes 39° 20'
and 39° 50' N. appears to be opposed to the former observa-
tions ; but the author fully explains the apparent discrepancy.
He states that the climate of Corfu is well adapted to the
growth of maize ; that the harvest generally takes place
during dry and warm weather in from July to September,
that the grain is well ripened, and that the peasants take
great care in its preservation, drying it in the sun after re-
moving the husks; and generally keeping the stock in their
cottages. In ordinary seasons, therefore, the native grown
corn is good and wholesome, and when the population con-
sumes only that; they are free from pellagra. But within
the last thirty years the cultivation of the vine has greatly
extended in Corfu, and has, to a considerable extent, and espe-
cially in some localities, almost replaced the growth of maize ;
so that the supply of the latter grain is very insufficient for the
wants of the population; and considerable quantities are im-
ported from the neighbouring countries and from the Danubian
provinces. The maize, which is the produce of Albania,
Romagna, and Naples, is probably as good as that of home
growth ; but that from the Danube, having to be brought by a
long sea voyage, is very often seriously altered and mildewed ;
and Dr. Typaldos has found that this constitutes the largest
portion of the maize consumed in most parts of the island, and

1 ' British and Foreign Medico-Chirurgical Revi<!w,' for January, 1863.
81— XLi. 3

34 Reviews. [Jan.,

that much of the grain exposed for sale in the markets is
seriously diseased. Occasionally, also, he states that in ex-
ceptionally bad seasons, as in 1857, when the summer in Corfu
was very wet, the grain grown in the island is also not good.
After a full investigation the author appears to have esta-
blished the opinion, that in Corfu the essential cause of the
prevalence of pellagra is the consumption of maize which
has undergone changes which render it unfit for food ; though
he at the same time fully admits that other circumstances
conduce to the production of the disease, and that it is pre-
disposed to by the various evils which attend poverty and
wretchedness. So far as the Island of Corfu is concerned, we
adopt Dr. Typaldos' conclusion, but we cannot admit it as
applicable to all the localities in which pellagra is known to
prevail ; for in some, as in certain districts of France, the disease
exists where maize is not at all eaten by the people. It is
possible that exceptional instances of this kind may admit of
explanation ; for though diseased maize may not be taken, some
other diseased grain may, and similar effects may so be pro-
duced. It is, however, stated that pellagra is occasionally met with
among people whose food presents nothing peculiar or different
from that of others who do not suffer from the disease ; and,
though the facts of this kind which have as yet been recorded
admit of some doubt, they should at least make us hesitate before
we adopt any theory, which, though it may apparently explain the
appearance of the disease in certain localities, may be opposed
to the circumstances under which it occurs in others.

Review III.

Climatologie des Stations Hivernales du Midi de la France.
{Pau, Amelie-les-Bains, Hyeres, Cannes, Nice, Menton.) Par
Jules Edmond Theophile de Valcourt.

The Climatology of the Winter Stations of the South of France,
&c. By Dr. Jules E. T. de Valcourt.

This work on climatology, by a young physician, commends
itself to our attention by a certain air of novelty and freshness.

Although appearing in the modest garb of a thesis, it contains
a considerable amount of information, and this in a form so
condensed as to render it the more valuable as an addition to
the particular branch of medical literature on which it treats.
Among other advantages, it posessses the very material one of
being exempt from any extreme views consequent on strong local

1868.] Valcourt on the Climatology of France. 35

attachments. Dr. de Valcourt tells us he passed four consecutive
winter seasons in the medical stations of the south of France.
This he evidently did in the character of a dispassionate
observer. The result of his experience thus gained, as well
as that of a laborious and honest investigation of the sub-
jectj is given to us in some two hundred small quarto pages,
which will well repay a perusal by those acquainted with the
French language. We are by no means sure that a trans-
lation would not be acceptable to other readers. For our own
part, want of space will compel us to pass over much that is
really interesting ; but we will endeavour to follow the author
in a rapid glance at the six stations in southern France which
form the subject of his book. If we do not first pause to con-
sider the introductory chapter on climate in general, and on
that of France in particular, it is by no means because this is
devoid of interest ; to those indeed who have not already made
themselves acquainted with the subject, it would perhaps prove
as useful and interesting as any portion of the work.

Following our author in the order in which he writes, we
begin with Pau.

This ancient capital of Beam, of high historic interest, pecu-
liar in its situation, lying between a sandy desert and snow-
capped mountains, possessing a soil in some places retentive of
moisture, but which for the most part permits the rapid perco-
lation of every shower, whose inhabitants are scarcely less
Spanish than French, besides what is physically good, affords
ample materials of interest to every cultivated mind. Of late
years the whole town has undergone a marked change; its
streets are now clean, and open to the sunshine, so that its
3000 or 4000 visitors (as well as its 15,000 fixed inhabitants)^
including those settled in the immediate neighbourhood, possess
many advantages over the frequenters of Pau in former times.
With regard to actual temperature, Pau differs but little from
Paris, as the following table shows :

Whole year. Winter. Spring. Summer. Autumn.

Pau . . . 12.5° . 5.33° . 11.57° . 18.63° . 13.03°

Paris . . 10.8° . 3.3° . 10.4° . 18,1° . 11.2°

Difference. 1.7° . 2.03° . 1.17° . 0.53° . 2.41°

Or in Fahrenheit degrees :

Whole year. Winter. Spring. Summer. Autumn

Pau. . . 53.69° . 41.59° . 52.82° . 65.53° . 55.45°

Paris . . 50.14° . 37.44° . 50.7° . 54.4° . 51.83°

Difference. 3.55° . 4.15° . 2.75° . 1.12° . 3.62°

The Pau temperature given is the result of ten years^ careful
observation made by Dr. Ottley, and does not essentially differ

36 Reviews. [Jan.,

from that derived from other sources. The night temperature
is occasionally severe, but in the daytime the thermometer but
rarely falls to 32° Fahr., as shown by another observer. In the
winter of 1864, however, the mercury stood below this point on
four consecutive days in January, whilst in February, at nine
a.m., it was as low, or lower, on thirteen occasions. With
regard to variations of temperature, it is a happy circumstance
that these, for the most part, are inconsiderable during the
hours of exercise, viz. from noon till three p.m.

In five years (from 1837 to 1841) snow fell on 55 days, and
frost occurred on 111.

Regarding the indications afforded by the vegetation of the
district. Dr. de Valcourt's remarks are so much to the purpose,
that we quote them without abbreviation :

" The vegetation of a country affords tbe best proof of the accuracy
of what has been written of the severity of its winters. Foreigners
who have visited the shores of the Mediterranean are astonished, on
arriving at Pau, at not finding in the environs of a town so celebrated
for the mildness of its climate those plants which in other winter
stations abound to such a degree as to constitute a principal element
of the agricultural prosperity of the country.

" Orange, lemon, and palm trees are unable to endure the winter
of Beam ; even the olive, though much less delicate, is unknown.
The absence of this southern vegetation is a clear proof of the infe-
riority of the temperature of Pau to that of all other winter stations ;
and although the splendour and heat of the sunshine sometimes
remind the visitor of more favoured spots, the leafless trees and the
general sleep of vegetation afford unequivocal indications of a climate
occasionally, at least, severe. It should not, however, be forgotten
that if to a Parisian the temperature of Pau has only the advantage
of one or two degrees (centigrade) over that of his native city, the
difference to a German, and still more to a Russian, is very consi-
derable indeed. As to the English, not only do they find a climate
a little more temperate than their own, but they are enabled to
enjoy many a sunny day which, in their native land, would be one
of mist or fog ; and this is an advantage fully appreciated by the
generality of invalids."

Having thus referred to the sunshine of Pau, Dr. de Valcourt
justly points out that the superiority of the town, in a sanitary
point of viev\, lies rather in the nature of its soil and atmosphere
— the latter so peculiarly calm — than in actual temperature.
With regard to rain, Pau offers no exception to that extensive
district whose shores are washed by the Atlantic Ocean ; the
annual average of rainy days being 122, and that of rainfall
1091*0 millimetres (nearly 43 inches). The soil, however, being
for the most part sandy, and having the advantage of a good
deal of sunshine, soon dries, even after heavy rains; so that

1868.] Valcoubt on the Climatology of France 37

invalids are not deprived of outdoor exercise to the extent that
might be supposed. The absence, too, of free moisture in the
air is a noticeable fact.

Referring to the rarity of fogs at Pau, our author may well
be pardoned a feeling of exultation in the superiority of a
French town, when he declares that in a -visit paid not long
since to Scotland, during the three weeks of his stay, although
it was in the month of August, " un brouillard presque permanent
transpergait nos vetements."

The prevailing winds are the west, north-west, and south-
west, which, coming from the Atlantic Ocean, accounts for the
considerable amount of rain which falls.

We will conclude this brief epitome in Dr. de Valcourt's
own words :

" The sedative climate of Pau exercises a manifest influence on
the physical and intellectual condition of its inhabitants — a people
phlegmatic and slow of speech. Strangers coming from more
rigorous climates experience, after a little while, a change of tem-
perament ; their nervous irritability diminishes, their pulse becomes
considerably slower, and so continues. An analogous change takes
place in their morale, activity gives place to indecision and irresolu-
tion, idle musing succeeds to intellectual energy and the habit of
continuous exertion.

" This is a very important result of the calm condition of the atmo-
sphere. It explains the sanitary influence of the climate of Pau in cer-
tain cases, and its deleterious effect in others ; it is suitable to invalids
of a nervo-sanguine temperament, who still possess a fair amount of
strength, but who are suffering exhaustion from febrile excitement.
Phthisical patients belonging to this class are more numerous than
people think; to these, tranquillity, both physical and moral, is
indispensable ; without it hygiene and therapeutics are powerless to
arrest the progress of their disease. To such patients there are few
winter stations capable of affording so much benefit as Pau.

"Nervous affections, including hysteria, are benefited by the
climate of Pau, which, on the other hand, is detrimental to those
who require to be stimulated. Phthisis of a scrofulous character
demands a more bracing climate ; and for all patients suftering
from cachexia, from whatever cause arising, whether accompanied
by tubercles or not, this is likewise indicated. People of a nervous
constitution even find it difficult to endure so soft an air when
nervous excitement has ceased to be a predominant symptom, and
has given place to general debility. Pinally, those who are of a
rheumatic diathesis should avoid this climate, or that disease will
not be long in developing itself. "We are acquainted with many
persons who, having accompanied sick relations to Pau, have suffered
intensely from rheumatism, which it was impossible to attribute to
any other cause than the influence of the climate. This disease,
moreover, is very common among the inhabitants.

" Prom these facts we arrive at the following conclusions : Pau,

38 , Reviews. [Jan.,

situated in a lovely country, offers to the stranger many and various
advantages ; the mean temperature is two degrees higher tlian that
of Paris ; and although the thermometer falls in winter as low as in
the capital, severe frosts are of brief duration ; snow and fogs are
rare, and quickly disappear ; there are many rainy days ; the air is
somewhat damp and soft, the atmosphere almost invariably calm ;
the daily variations of the thermometer and barometer are sometimes
sudden, but confined within moderate limits ; these variations greater
in the months of February and March than at any other time exer-
cise an unfavorable influence on invalids at that period of the year.
To sum up : The climate is sedative, and manifestly beneficial to
invalids whose nervous system is over-excited, or whose pulse is
accelerated from feverishness, whilst it is prejudicial to the lymphatic,
the rheumatic, and the debilitated."

Amelie-les-Bains (Arles-les- Bains, Arles-sur-Tech),
although its sulphurous waters vrere known and valued in ancient
times, is still but a village of some 800 inhabitants. From
Paris the railroad conveys the invalid to Perpignau easily enough;
but from that point the journey, though not a long one (some
two-and-twenty miles), is sufficiently fatiguing from the frequent
change of carriages. The crowd of bathers who flock to this
favourite spot are a sufficient proof of the estimation in which
it is held, notwithstanding its imperfect shelter from some of
the colder winds, and its being cut off from much early and late
sunshine by the adjacent mountains. It is, however, proposed
to take advantage of a more favorable position on the other
side of the river, where a larger amount of sunshine will be
enjoyed; the village of Palalda appears to be the spot decided
on. After a rapid glance at the geology of the neighbourhood
and the exercise-ground — not too extensive — the author touches
lightly on the bathing establishments, and proceeds to tlie
consideration of temperature. On this subject it seems that
" doctors disagree ;" the annual mean, however, appears to be
15.28° (59.30° Fahr.) ; that of the winter, 7.96° (46.30° Fahr.) ;
of the spring, 14-9 °(57.36° Fahr.) ; summer, 23° (73.43° Fahr.) ;
autumn, 15.96° (56.72° Fahr.)

In the severe winter of 1864, during the night of January
5th-6th the mercury fell to 10° below zero (14° Fahr.), and on
the 19th-20th February an immense quantity of snow inter-
cepted all ordinary communications. This severity, however, is
no doubt exceptional, since the olive-tree, though it does not
attain any great size, yet flourishes in the district. In regard
to temperature and vegetation, no less than to rain and wind.
Dr. de Valcourt considers Amelie-les-Bains may fairly find a
place between Pau and the Mediterranean stations. The rainfall
cannot, it would seem, as yet, be given with perfect accuracy, but
the following tabic may be regarded as approximatively correct :

1868.] Valcourt on the Climatology of France. 39

Mean in Seasons <

C Spring
Summer
Autumn

[_ Winter

Fiue days.

Cloudy.

Rainj

. 40

20

32

. 59

17

16

. 53

26

12

. 58

21

11

Total . 210 . 84 . 71

To this moderate number of rainy days may be added as
among the agremens of Amelie-les-Bains, to many invalids at
least, a dry atmosphere and a general exemption from fogs.
In the first ten months of the year 1864, the wind blew from
the east 57 times ; south-west, 54 ; south, 49 ; south-east, 36 ;
north-west, 34; north, 34; west, 33; north-west, 11. The
prejudicial winds are the dry, cold, and violent north-west
(mistral), the north-east, and the east. Dr. de Valcourt^s
opinion of the climate of this station may be summed up in his
own words :

" During the six months of the cold season it is tonic, without
being too stimulating. In the month of September it is still too
hot and dry for those who suffer from chest affections ; all that
could be desired in November ; it becomes a little cold in December
and January. During the remainder of the season it is variable ;
the days sometimes splendid and hot, sometimes rainy and tem-
pestuous. The winds, however, are much less violent than at
Montpellier or Perpignan, and are not continuous in March and
April."

A summary, given by Dr. Bowyer, of cases in which the
mineral waters of Amelie-les-Bains are likely to be beneficial,
concludes the notice of this place.

Hyeres — after Amelie-les-Bains, the most southern winter
station in France, is the first place in which, travelling from
west to east, the cultivation of orange-trees in the open ground
strikes the attention. The town built on the southern slope of
a hill upwards of 760 feet in height, is well protected by its
neighbouring granite mountains from north and north-east
winds, but not from the mistral. The vast marshes of the
vicinity, so injurious to health in former times, have been
drained to a great extent, and converted into fertile plantations ;
but still to the south-east of the town an extensive growth of
reeds points out too plainly that much yet remains to be done
ere the sanitary advantages of the district are fully developed.
In a locality so charming in other respects, the existence of
salt-pits in full operation is to be regretted, since so many other
favorable and unobjectionable situations are to be found. In
the winter season, however. Dr. de Valcourt remarks, these
exercise no deleterious influence on the public health. Whilst

40 Reviews. [Jan.,

the town of Hyeres itself, as we have already said, is exposed
to the mistral, the adjacent hamlet of Carqueiranne and the
charming valleys of Costa-Bella and Saint-Pierre-des-Horts,
sprinkled with elegant villas, are sheltered from this noxious
wind by protecting mountains. The writings of M. Denis, that
accurate observer, are quoted, who, wishing honestly to show
that Hyeres is not the absolute paradise which some people
have declared, assures us that a perpetual spring does not reign
in this valley. The winter is not without its days of cold and
rain ; violent and even devastating winds are not unknown ; in
summer there is no lack of dust, and the heat is apt to last
longer than could be wished ; sudden and terrific storms also
will sometimes pour down hailstones or torrents of rain upon
the land. But,

" After all, and in spite of all, this is the valley beyond dispute
most favoured of heaven in the whole of France ; for the frosts,
which are but momentary, are followed by a succession of days
beautiful and warm, and the summer heat is tempered by those
refreshing breezes from the sea which regularly blow during a por-
tion of the day."

M. Denis divides the district into three zones, differing in
temperature and in other respects, which, says Dr. de Valcourt
appears perfectly justifiable in a medical point of view ; in fact,
the town (included in the first zone), which lies fully open to
the south, and is protected from north and north-east winds, is
insufficiently sheltered from the mistral. The littoral zone,
nearer to the sea than the preceding, lies open both to the sea-
breeze and the east wind, but escapes the mistral. This is
especially the case as regards the valleys of Saint Pierre-des-
Horts and of Costebelle ; lastly, the third, naturally less warm
on account of its northern aspect, is unsuitable to invalids.
Notwithstanding the usual mildness of its climate, Hyeres is
subject to occasional frosts. In January, 1820, the thermometer
(centigrade) was many degrees below zero for several days suc-
cessively ; all the orange-trees were frozen, a disaster which had
not occurred since 1789. Having pointed out certain difficulties
in arriving at an accurate knowledge of the temperature at
different seasons. Dr. De Valcourt gives us the following as the
result of his investigations, but " sous toutes reserves.'' Mean
winter, 8°.5 (46°.49 Fahr.) ; spring, 15° (59° Fahr.) ; summer,
23.4° (74° Fahr.) j autumn, 15.5° (59.9° Fahr.) ; whole year,
15.6° (59.10° Fahr.).

Even during the exceptional days of coldness (from noon till
three p.m.), invalids can take their daily exercise; in the
unusually severe winter of 1863-64, in which more snow fell at

1868.] Valcourt on the Climatology of France. 41

Hyeres than had been observed by M. Denis in any winter for
forty years^ the mean temperature in January at one p.m. was
as high as 11*6° (nearly 52° Fahr.). The richness and variety
of vegetation excite the admiration of travellers, and numerous
are the evergreen trees which afford a pleasing shade at every
season of the year ; an interesting list of the more delicate of
these forms of vegetable life is given, which will serve to show
how much there is at Hyeres to delight the eye of a botanist,
or of a simple admirer of nature. Orange-trees, however, no
longer abound, as in former days, but, as is shown, their dis-
appearance from especial cultivation is attributable to other
causes than change of climate.

" Now-a-days the trees, which more particularly contribute to the
preservation of the southern character of the place, are the mag-
nificent palms ; these for the most part display their majestic heads
in the open country, but they are also to be seen in the town : of
the seven existing in the ' Place des Palmiers ' two are of surprising
vigour."

A portion of the sea-shore enjoys also the grateful shade of
magnificent pine-trees. An investigation of the register of Dr.
Battaille from 1816 to 1829 enables our author to give the fol-
lowing account of the ordinary number of rainy days in tlie
year :

Jan. feb. March. AprQ. May. June. July. Aug. Sept. Oct. Nov. Dec.
5-5 4-8 4-9 6-6 4-7 3-4 2 1-8 5-5 8 85 7

Winter. Spring. Summer. Autumn. Whole Year.

17-3 . 16-2 . 6-9 . 22 , 624

These numbers include every rainy day, even that in which a
simple shower may have fallen. Snow is seen every two or
three years, but during the present century it has not been
known to remain at any time more than twenty-four hours
upon the ground. Heavy dews fall during the hot season, to
the great advantage of vegetation. Another and less agreeable
form of moisture is thus referred to :

" "We have been surprised at finding, according to the observations
of M. Bataille, that fogs are not very uncommon in the mornings of
spring and autumn, not even omitting those of summer : in the
month of April, 1829, they were noticed seven times ; they are,
however, seldom so frequent as this. They come up from the sea-
coast and the salt-pits at about nine a.m., become dense, and spread ;
proceeding slowly from south to north, they reach the mountains,
and end their course by diffusion, and falling back into the valleys ;
they destroy the buds of the fig and oUve, and even of the vine.
Since the marshes have been drained these fogs have lessened ; they

42 Reviews. [Jan,

would, perhaps, altogether disappear if that vast extent of land now
occupied by the salt-pits and Tetang des Pasquiers were reclaimed."

The mean annual rainfall according to observations of M. de
Beauregard carefully conducted for twenty-five years (from
1824 to 1849), is 746 millimetres (29 inches), October and
November alone afibrd a mean of 225 millimetres, whilst the
three winter months give but 257 millimetres. The only wind
that blows with violence is the cold and dry north-west, which will
sometimes in a few moments lower the centigrade thermometer
by four or five degrees (nine or ten degrees Fahr.) ; the north
wind need be little dreaded, as the adjacent mountains cause it
to pass above the town ; the east winds are cold and wet ;
those from the south, hot and salutary in winter, are apt to be
scorching in the summer. The advantage of sea breezes is
experienced much more sensibly at Costa-Bella than in the
town of Hyeres itself. The north-west wind blows rather fre-
quently in winter, but not with much violence, consequently at
that season it is far less dreaded than in the spring — its time
of strength. Sudden exposure to this wind, hazardous even
to the healthy, is in the highest degree dangerous to the
invalid.

" Finally, it may be stated that sixty-two rainy days, and not
many more cloudy ones, are to be reckoned on, with some few morn-
ing fogs. Two fine days out of three are the usual proportion, even
in the winter season." . . . " A residence at Hyeres is suitable
to those who require a dry, mild, yet bracing climate, and who are
unable to endure the damp cold of northern countries ; it is bene-
ficial in asthma, pulmonary emphysema, chronic affections of the
respiratory passages, and pulmonary consumption, unattended by
excessive feverislmess. Patients of a nervous temperament find
Hyeres suit them better than Coste-Belle, which agrees well with
children of a lymphatic temperament. Let us again impress upon
the invalid, which cannot be done too forcibly, the importance of
exercising every possible care in avoiding the mistral, that single
drawback to the excellency of this charming winter station."

Cannes. — It is a remarkable instance of the efffect of routine,
that Nice for so long a period should have enjoyed a sanitary
reputation, whilst the superior advantages of a place so near to
it as Cannes remained almost unknown till they attracted the
attention of Lord Brougham, in 1834. Even so late as 1853,
says Dr. de Valcourt, who first visited Cannes in the winter of
that year, the number of invalids frequenting it was small.
Since then, however, the annual influx has steadily increased,
and now no place in France enjoys a higher reputation, as every
English practitioner engaged to any extent in the treatment of
chest diseases must be well aware. This favorable opinion

1868.] Valcourt on the Climatology of France. 43

appears to be fully deserved ; for though, like Hy^res, it is not
an absolute paradise, yet few of our patients return from a
winter sojourn there who do not bring back a good report of
Cannes.

The topography of the district, as given by our author, shows
how favorably situated is the town : its protection from the
mistral is especially pointed out, and its superiority over cer-
tain portions of the neighbouring country briefly, but well
described. The mean annual temperature does not appear, as
yet, to be fixed with absolute certainty ; partly in consequence
of the limited number of continuous observations made of late
years : the following may, however, probably be accepted as
sufficiently correct. Whole year 16.7° (60.92° Fahr.), winter
9° (48.1° Fahr.), spring 15.8° (59.14° Fahr.), summer 24.3°
(75.23° Fahr.), autumn 18° (64° Fahr.). The lovely vegetation
of the district depends as much on the varying character of its
soil (whose interesting peculiarities are pretty fully noticed) , as
upon the mildness of its winters. A long list of the Flora is
given, in which the orange-tree, chiefly cultivated for its
flowers, still maintains an important place, whilst palm-trees
are not unknown. After specifying the beautiful plants which
charm the eye, even in the depth of winter. Dr. de Valcourt
says, with enthusiasm in which it is easy to participate,

" This rich enumeration amply shows how great is the vital power
of this favoured land. How can the invalid refrain from seeking
the renewal of his health in such a climate ! A climate where the
soil seems to require no rest, where frost is almost unknown,^ and
where the ground, even during the least favorable portion of the
year, is covered with a very harvest of flowers."

The east wind is the most prevalent, then the west ; the north,
as well as the south, is extremely rare; the latter, indeed, is almost
unknown, a happy circumstance since the inhabitants of. Cannes
thus escape the " burning dryness " which accompanies this
wind from the African Desert. Another point favorable to Cannes
is the absence of any streams of water beyond mere rivulets,
generally tortuous in their course, and free from those violent
currents of air which such streams as the Var and the Paillon
give rise to. The summer heat is tempered by refreshing sea-
breezes, which habitually blow from sunrise to sunset. From
the east and north-west winds, so trying to invalids in the
winter season, the village of Cannet, situate a mile and three
quarters from the sea-shore, is that portion of the district which
has the good fortune to enjoy the most perfect shelter, this is

^ The author's expression is, " Un pays dont la terre semble ne jamais con-
naitre ni la langueur ni les frimas."

44 Reviews. [Jan.,

shown in the luxuriant growth of its orange and other tender
trees.

Dr. de Valcourt passed a winter near this village, and was
struck with the absence of high winds during the entire period ;
and this, even when the mistral in the distance displayed its
presence by clouds of dust sweeping over the roads.

The annual amount of rain falling at Cannes, according to
Dr. Seve, is 677 millimetres (twenty-two inches) ; the number
of rainy days fifty-two. Snow is seen occasionally, but rapidly
disappears. Of fogs, it is sufficient to say, they are extremely
rare.

Our author^s views of Cannes may be considered pretty fully
summed up in the following conclusions :

" The climate is bracing, the winter temperature is remarkably
mild, as shown by the character of the vegetation ; the country is
healthy, and highly picturesque ; raiu seldom falls, the sky is usually
unclouded ; the winds, which are moderately strong on the sea-
shore, may be altogether avoided in certain portions of the territory.
The sea-breeze with its saline constituents, the east and north-west
wind, sufficiently cold and somewhat strong, do not prevent a sojourn
on the borders of the sea being quite suitable to the lymphatic and
scrofulous, as well as to those suffering from rheumatism, or simply
weakened by age or excessive labour ; it agrees also with patients
suffering from certain affections of the respiratory organs, chronic
bronchitis, for example. On the other hand, those who are subject
to haemoptysis, to febrile attacks, and individuals of a nervous tem-
perament, should avoid the sea-shore, and avail themselves of the
admirable positions to be found within a few minutes walk of this,
where they may enjoy a residence perfectly sheltered. With regard
to exercise ground, the eminences, not too steep, the Isle Sainte-
Marguerite and the Esterel, afford shade and ever-varying walks,
whilst the sandy shore with its uniform and gentle slope is superior
even to the far-famed strand at Trouville."

Nice. — Although no longer holding the proud position she
once enjoyed, when, with Pisa and Montpellier, she wellnigh
monopolised those invalids who sought a southern climate for
their winter residence, is still admired by many. " Her newer
rivals,'^ as Dr. de Valcourt well observes, have " acquired in
their turn a just and great celebrity ;" nevertheless, a city of
50,000 inhabitants, beautifully built, on the shore of the Medi-
terranean, with wide streets full of life, and no lack of magni-
ficent edifices, not to speak, at present, of those advantages of
climate which it really does enjoy, is not likely to be without a
heavy influx of winter visitors.

Nice is protected from the winds which blow over the conti-
nent, by mountains of various heights. From the configu-

1868.] Valcourt on the Climatology of France. 45

ration of the ground on which its houses stand, it may be said,
like our own Torquay, to possess different climates within its
own especial one. The Paillon, and other streams, often nearly
dry watercourses, when swollen by heavy rains, bring down
vast quantities of pebbles, which, accumulating on the sea-shore,
render the bathing at Nice far less agreeable than that at
Cannes or Mentone. The geology of the district, in which Dr.
de Valcourt tells us primitive rocks find no place, is more favor-
able to the fossil lover and botanist than to the simple seeker
after health. The plain of Nice is composed of alluvion rest-
ing often on beds of clay, so that water is found very near the
surface ; this sometimes proves an inconvenience to builders
who have to drive in piles to form their foundations; fortu-
nately, however, the inclination of the land seawards allows its
ready escape.

As the mean temperature obtained from various sources, and
taken at sunrise, at two p.m., and at sunset, we have the fol-
lowing figures :

Winter. Spring. Summer. Autumn.

8.33° (4.99°, F.) . 13.7° (55.52°, F.) . 22.9° (71 .69°, F.) . 16.17° (61.10°, F.)

Whole Year .... 15.27° (59.48°, F.)

During fifteen years, according to one observer, the mercury
never rose higher than 32.5° (90.5° Fahr.), although there are
exceptions, it does not usually fall lower than 3° below Zero
(26.8° Fahr.) ; and sometimes there is not a single frost during
the whole winter.

" Nice, then, enjoys a very mild climate, but those who live there
are nevertheless exposed to sudden transitions from hot weather to
cold ; between north and south aspects, between sheltered and
exposed positions, there is in winter a difference of from 10° to 15°
and in the spring cold winds will in a moment chill the atmo-
sphere."

The fertile plain produces magnificent olive-trees in great
abundance ; it is rich also in orange-trees, and so various and
abundant are its flowers, that our author abstains from enume-
rating them; nevertheless, there are fewer plants in bloom
here, in the month of January, than at Cannes. Observers
differ as to the number of rainy days ; the annual mean of
fifty-six being given hy two meteorologists, whilst M. Teysseire
considers that, ordinarily, as many as seventy days of rain may
be looked for : these he thus divides (adding also the amount
of rainfall from observations made by M. Roubaudi) —

46 Reviews. [Jan.,

Seasons. Winter. Spring. Summer. Autumn. Whole Vear.

Number of days . . 166 . 22-9 . 21-8 . 10.5 . 71-3

m.m. m.m. m.m. m.m. m.m.

Amount 179-3 . 189-7 . 71-6 . 267-4 . 707-9

nearly twenty-eight inches.

May, October, and November, are more especially the rainy
months. Observations made with Saussure^s hygrometer gave
ninety as the maximum humidity of the air, and fifteen as
the minimum ; the greatest oscillations occur in January. Snow
is rarely seen, but in February, 1853, it fell to the amount of
20 centimetres (nearly eight inches), to the extreme surprise
of the inhabitants. Trifling fogs, occurring in the morning, are
sometimes, but very rarely, seen. Storms are not very fre-
quent, although in summer-time the air is charged with elec-
tricity ; occasionally, however, terrific hurricanes occur.

M. Teysseire considers the yearly average to be one day and
four tenths of snow, and six days of fog. Nice is much more
blowy than the neighbouring towns; there are eighty-eight
days of violent wind in the year, much of this comes from
unfavorable quarters. The broad Paillon, whose bed is for the
most part dry, may be regarded as the principal, though not
the sole cause of this unquiet state of atmosphere. The mistral
though not a frequent visitor is formidable when it comes,
falling on the town with a force only partly broken by inter-
vening and too distant heights. The dust of Nice is pro-
verbial.

Dr. de Valcourt concludes his notice in tjie following words :

" What we have already said leads us naturally to sum up the
advantages and inconveniences of this winter station. A pure air,
a healthy district, a mild temperature, a luxurious vegetation ; the
resources of a large city — all these are well calculated to attract a
multitude of strangers every year. But, nevertheless, the wellnigh
constant atmospheric disturbance, the ever-penetrating dust, and
the general and sometimes excessive dryness of the air, render the
climate far too exciting for irritable constitutions."

"The sea-shore and the banks of the Paillon are especially
hazardous to patients of a sanguine temperament, with hurried cir-
culation, and a dry and painful cough, as well as to those subject or
predisposed to haemoptysis. The rheumatic, the gouty, the scro-
fulous, and all who stand in need of powerful stimulation, or of a
dry atmosphere, find themselves wonderfully benefited by a residence
at Nice. The eminences of Cimies afibrd some sheltered and highly
favorable situations where invalids may escape the nervous excite-
ment consequent on a residence close to the sea. The climato-
logical distinction between the city and the hills is highly important,
as we shall show in our last chapter."

1867.J Valcourt on the Climatology of France. 47

Mentone, built on the slope of a hill, with the sea to the
south-east, and the maritime Alps on the north, enjoys a
beautiful and sheltered situation, the advantages which are
accurately described at some length in an interesting quotation
from ' Le Chevalier Ardoino/ Lemon, orange, and olive trees
declare the mildness of a climate which is at the same time
refreshed by streams of water. A long avenue of plane-trees
bordering the right bank of one of these, the Carrei, affords, in
addition to the sea-shore, a level and very charming walk to
those who are unable to mount the hills; whilst these latter,
clothed with evergreen oaks, chestnuts, and pines, afford a
charming climb to the stronger relatives or friends of invalids
whose self-devotion entitles them to more consideration than
they are apt to get. The geological formation of the district
has no especial interest ; the valleys are covered with a rich
alluvial bed formed of sand, of the debris of rocks, and of
vegetable mould, affording ample nourishment to the many
trees of southern growth. Thirty million lemons of excellent
quality, according to M. Abel Rendu, are annually gathered in
the communes of Mentone, Roquebrune, and Monaco.

"In Sicily," says this writer, ''there is only one lemon season in
the year, viz. from September to March ; in spring and summer a
trifling amount only of fruit remains upon the trees, whilst at Men-
tone, where the heat is more moderate, these are constantly loaded
with flowers and fruit, blossoming four or even five times a year."

Although those plants which especially belong to a soil of
primary formation are not to be found at Mentone, the flora is
nevertheless extremely rich.

Supplementary to notices extending over a longer period
(but less recent), by other meteorologists we have a table,
placed at our author's disposal by Dr. Farina, of that gentle-
man's observations taken three times a day, of temperature in
1863 and 1864. We extract the mean of each month :

January. February. March. April.

8.8° (46.54° F.) . 10.2° (50.3° F.) . 13° (55.2° F.) .' 16.1° (60.9° F.)

May. June. July. August.

19.4° (66.9° F.) . 23.3° (73.9° F.) . 25.1° (77.1° F.) . 25.4° (77.7° F.)

September. October. November. December.

21.2° (70° F.) . 18.9° (66° F.) . 13.4° (52.1° F.) . 9.6° (49.2° F.)

There can be no doubt about the mildness of Mentone.

Rain falls on seventy -eight days in the year, and is more
equally distributed among the different months than is the case
elsewhere : subject to exceptions, the wet month j9«r excellence
appears to be November, and the dry one July. The annual

48 Reviews. [Jan.,

rainfall amounts to about 700 or 720 millimetres (a little
under and a little over twenty-eight inches) . The air, without
being too moist, is free from excessive dryness. With regard
to the relative frequency of winds. Dr. de Valcourt declares
himself unable to arrive at any accurate conclusion, so greatly
have observers thus far differed in their estimates. There are,
however, two points on which writers agree ; the frequency of
east winds, and the rarity of the mistral. From the latter, as
well as from the north and north-east winds, Mentone is well
sheltered by protecting mountains, but less so from those which
blow from the south-east and south-west. The annual aver-
age of windy days — more or less violent — may be set down as
about eighty.

Dr. de Valcourt considers in regard to mildness of climate,
that Mentone possesses a slight advantage over Nice, and even
over Cannes ; that the steepness of its hills is somewhat to be
regretted, but that nevertheless the locality is admirably suited
to scrofulous and rheumatic patients, and to phthisical ones
able to endure the proximity of the sea.

From the concluding chapter, "On the Sanitary Influence of
Climate and on the Curability of Consumption,""^ we must
limit ourselves to a single extract, viz. a quotation from a
memoir by M. Rochard, which was " crowned " by the Aca-
demy in 1855.

"In the north of France," says this able writer, "the unhappy
sufferer from phthisis, at the beginning of our long winter, and from
his first bronchial attack, finds himself confined to his chamber,
deprived of all society and of every external source of interest,
compelled to pass his time between the fireside and his bed ; the
observance of medical prescriptions, a little reading, and perhaps
some small amount of conversation, alone break the melancholy
current of his thoughts. Let him, on the other hand, determine on
a change of climate, a series of new impressions exhilarate, a higher
and more equable temperature enable him to take continual exercise
either in a carriage or on foot. His digestion is thus improved, his
nights are more tranquil, his strength increases, and his bronchial
attacks becoming less frequent, he escapes a material source of
acceleration of his disease."

A table of thermometrical observations, extendiag over two
winters (December, January, and February) . and embracing all
the stations treated of, is appended, and forms an appropriate
termination to this highly creditable thesis.

1868.1 Diseases of Women. 49

Review IV.

Diseases of Women. Bernutz and Goupil. New Sydenham
Society, 1866. Vol. II. Pp. 270.

M. BernutZj in his essay on ' Pelvi-Peritonitis/ aims at show-
ing— Firstly, that it has been very frequently confounded with
diseases having a totally different origin and involving different
tissues, that the group of symptoms called variously engorge-
ments of the uterus, partial chronic metritis, ovaritis, peri-uterine
phlegmons, is referable to intra-peritoneal inflammation, that
the terms pelvic abscess, pelvic cellulitis, peri-metritis, peri-
hysteritis, have been often used without due regard to the
tissues really affected.

Secondly, that this morbid condition is of frequent occur-
rence in women, is generally symptomatic of inflammation of
the ovaries or fallopian tubes, and homologous with orchitis in
the male, the extent of the female tunica vaginalis, viz. the
peritoneum in relation with the genital organs, giving rise to
the more extended lesion. He is not, however, strictly correct
in calling the fimbriated extremity of the fallopian tube the
homologue of the epididymis, as this is represented by the
parovarium,! or Rosenmuller^s body; "Muller's duct in the
embryo being developed into the fallopian tube of the female,
but becoming atrophied in the male " (Farre) .

Thirdly, that secondary symptoms have been allowed to
obscure the primary disease, and consequently errors in treat-
ment have been committed.

Setting on one side inflammation of, and abscesses in, the
broad ligament, or involving the perirectal cellular tissue which
he considers as varieties of phlegmon of the iliac fossse, true
pelvic cellulitis, and confining his observations to those phleg-
mons which have been supposed to be limited to, or chiefly
seated in, the uterine cellular tissue, M. Bernutz asserts that
it is an anatomical impossibility for the peri-uterine swellings
called retro-, ante-, latero-uterine inflammatory tumours to be
located in the cellular tissue between the uterus and perito-
neum. " For the cellular tissue separable is only a small band
situate at the junction of the neck with the body of the uterus
and at the sides at f of an inch from the lateral borders of the
uterus. The peri-uterine swellings under consideration are
certainly not formed by the inflammation of this thin ring of

' ' Der Neben-Eierstock des Weibes.' Kobelt. Heidelberg. 1847.
81— XLi. 4

50 Reviews. [Jan.,

cellular tissue, which when involved but very slightly augments
the swelling due to pelvi-peritonitis" Farre,i in his essay on
the uterus, says, — " The peritoneum, after covering the fundus
uteri and a portion of the posterior surface of the bladder, is
suddenly arrested in its descent at a point very nearly opposite
to, but sometimes a little below, the internal os uteri, and
therefore about the seat of the junction of the body with the
neck of the uterus, and here the bladder becomes attached to
the cervix. On the posterior surface of the uterus the peri-
toneum is closely adherent to the tissues beneath, until it
reaches the level of the anterior point of reflection. At this
point the peritoneum becomes much more loosely connected with
the uterus by the interposition of a quantity of lax connective
tissue which intervenes between it and the posterior cervical wall.
Loose connective tissue separates the peritoneum from the pos-
terior cervical wall to a great extent. Acute or chronic iaflam-
mation of this tissue {perimetritis) causes deep congestion of the
vessels accompanied by serous and occasionally by sanguineous
and possibly fibrinous infiltration. The extreme laxity of the
tissue readily admits of a great degree of distension. In this
way is rapidly formed a tumour which almost invariably occupies
the space between the peritoneum and the posterior wall of the
uterus at the point where the body joins the cervix {retro-uterine
tumour.)" The contradiction between this description and that
by M. Bernutz can only be reconciled on the supposition, that
the subjects severally dissected varied as to the amount of cel-
lular tissue at this place, or perhaps we ought to say is irrecon-
cilable.

M. Bernutz takes a strong position against those who describe
the tumours in question as cellulitic, when he asserts that only
two cases, where at the autopsy proof of inflammation in this
cellular tissue was found, have occurred in France during the
three years since his essay first appeared in the ' Archives de
Medecine,' one^ of which is very imperfectly recorded, while the
other^ is a case of critical abscess occurring in the course of
smallpox. The post-mortem record is, unquestionably, the
only true guide, and we have here nine cases very elaborately
detailed with autopsies. In eight the symptoms were those
usually ascribed to perimetritis, while at the autopsy no lesion
of the peri-uterine cellular tissue could be found, but adhesions
and depots of pus, formed amongst the pelvic viscera, corre-
sponded with the tumour felt per vaginam.

1 ' Cyclop. Anat. and Phys.' vol. v, § Art. " Uterus," p. 626, 630, 631.
' * Gazette des Hopitaux,' Av. 17ine, 1858.

3 Simon. ' Bulletins de la Societe Anatomique de Paris,' xxxiii annee, 1 serie,
t. iii, Juin, 1858, No. 10, p. 234.

1868.] Diseases of Women. 51

M. Bernutz met with 99 cases at the hospitals La Pitie and
Lourcine, which he thus classifies :

Class I —43 Duemeral / ^^ ^^*®^ childbirth.
l.lass l.—4iJ puerperal I s after abortion.

II. — 28 blennorhagic. ^

III. — 20 menstrual.

3 venereal excess.
jy „ , , . J 2 with chancres on the cervix.

2 after the use of the uterine sound.

[_ 1 after the use of the vaginal douche.

The first class, as might be expected, is the most numerous,
and under it he discusses the causality of puerperal fever.
Briefly, he thinks that there exists a specific disease " la puer-
peralite," and that the various lesions met with are sympto-
matic secondary afifections. The puerperal entity may be either
mali moris or boni moris. The modifications of the malignant
kind originate ab interno, as in an epidemic constitution, mental
emotion anti-hygienic conditions. The pelvi-peritonitis under
consideration belongs to the benignant form, is, so to say, acci-
dental, and generally lighted up by some external cause, which,
in the majority of instances, is " the getting up '' too soon after
a '' confinement.^'

The causation of pelvi-peritonitis, after abortion, is far more
difficult to trace ; it belongs to the class puerperal. It is often
impossible to decide whether the cause of the abortion may not
be also the cause of the serous inflammation. It seems pro-
bable, though proof is not obtainable, that it occurs more
frequently without perceptible cause after abortion, than after
labour at term.

The third class, menstrual pelvi-peritonitis, is allied to the
first, inasmuch as the inflammation may be looked upon as the
reflection on the peritoneum of the general condition caused by
the puerperal or menstrual disturbance. Of the twenty cases
observed, in three of them the only assignable cause for men-
strual retention was syphilis and a mercurial course. In two
dysmenorrhoea had previously existed. In the others the cata-
menia ceased abruptly after the application of cold water, or
on mental emotion or local irritation of the uterus.

The analogy between male and female orchitis is most
apparent in the blennorrhagic variety. The inflammation spreads
by continuity of tissue from the vagina, along the uterine cavity
and fallopian tubes to the peritoneum, as from the urethra, along
the vas deferens to the epididymis and tunica vaginalis. The
pelvic inflammation often appears first on the left and then on
the right side, like the form of orchitis, called by Bicord orchite

B2 Reviews. [J

an.

a bascule. The vaginal discharge ceases on the development of
the peritonitis, as is seen in the male subject when the gonor-
rhoea dries up on the establishment of orchitis.

The fourth class is illustrated by four cases detailed in the
text, and sundry others are referred to in the notes according
to the sub-varieties mentioned above.

The symptoms of pelvi-peritonitis are modified by the con-
stitution and the idiosyncrasy of the patient, the exciting cause,
and the form of the attack. In the acute form, where the well
known signs of peritonitis have been present, or if that silent
variety has occurred where, though pain and high fever are not
marked, large quantities of corpuscular lymph are thrown out,
and there is a general impression of a typhoid character, should
the patient survive the first impulse, the fever abates and ex-
treme prostration follows, often accompanied by a rigor or
evening chilliness. The abdomen becomes less painful and ex-
amination is possible. The uterus is found at first in the posi-
tion it had before the attack ; but after some days a tumour,
the exact shape and position of which should be made out by
bimanual exploration, is felt in one or more of the vaginal
culs-de-sac, by election in the left latero-posterior. The uterus
is now more or less displaced, especially when the tumour is
retro-uterine, the cervix uteri being projected against the pubes,
and drawn upwards in the vagina, exactly as in the case of
haematocele. The tumour, at first presenting only a sense of
resistance, becomes gradually more tense and prominent, semi-
elastic, and then hard. If the morbid process continues, the
tumour becomes easily perceptible abdominally, yielding a fibro-
cartilaginous sensation between the hand on the belly and the
finger in the vagina. It rarely rises above the pelvic brim, is
separated by a space from the horizontal ramus of the pubes,
and is free of the abdominal wall, an important diagnostic sign
between it and phlegmon of the broad ligament. Exacerbations
are frequently brought on by the menstrual molimen, or by
too active treatment, or free examination. The tumour then
increases, and often also appears in the opposite iliac fossa, the
uterus being correspondingly displaced. These conditions may
be repeated until a chronic state is set up, which brings on a
general debility and almost defies cure ; and in its train follows
uterine irritability or neuralgia, so often the subject of empiric
and quack treatment. Ulceration of the cervix often co-exists
with the peritonitis, but it is only a coincidence and an index
of the morbid condition of the cervico-uterine mucous mem-
brane. Metrorrhagia is a special symptom in the acute form
of female orchitis, and often appears as a critical discharge
before resolution. It is most marked in the menstrual and

1868.]

Diseases of Women. 53

blennorrhagic classes^ but, in the latter, is perhaps attributable
to the mercurial course. The inflammation may terminate,
though this is rare, by resolution, most frequently false mem-
branes form binding down the uterus, and sometimes pus is
formed. This latter occurs in the early stage of severe puru-
lent peritonitis. Here the ordinary termination is by escape
of pus per rectum. M. Bernutz knows of no case where a
spontaneous opening has happened into the vagina, and only of
one into the bladder. Should the pus burst into the abdominal
peritoneum death is almost certain, and usually comes on
rapidly. Sometimes the inflammation spreads from the pelvic
to the abdominal serous membrane by simple continuity. A
very fatal sequela is purulent consumption, the deposit of
tubercle being quite secondary, and may not be found in the
lungs, though the symptoms simulate pulmonary phthisis, but
are relieved by escape of pus per rectum. Chronic pelvi-
peritonitis is really a chronically morbid condition of the
genital organs, which, from time to time, lights up fresh
peritonitis, and it is remarkable that the serous membrane,
once diseased, takes on inflammation more slowly, and the
peritoneal symptoms, as pain and swelling, appear later and
less marked than in the acute form. The false membranes
may contort the intestines, and even cause strangulation, may
induce sterility, but if impregnation takes place they will pro-
bably not interfere with gestation more than giving rise to
hypogastric pains, and sometimes obstinate vomiting. The
particular form of peritonitis depends much on the patient^s
diathesis.

Tubercular disease of the ovary, the analogue of male tuber-
cular orchitis is not uncommon. The deposit invades also the
rest of the genital organs, though it may be absent from the
lungs, but it gives rise to no external symptoms, except per-
haps leucorrhcea, unless inflammation occurs.

Tubercle is found primarily in the genital organs, and second-
arily in the lungs, and vice versa.

The affections with which acute sero-adhesive pelvi-perito-
nitis are most easily confounded are hsematocele, inflammation
of an ovarian cyst, and phlegmons of the iliac fossae, especially
the first and last. Pelvi-peritonitis,'like haematocele, may occur
in connection with amenorrhoea or with menorrhagia. That
the mere fact of a peri-uterine tumour appearing coincidently
with menstrual retention, is not sufficient of itself to determine
it to be a haematocele, is shown by case No. 26, most minutely
detailed in the original, when the symptoms, on first examina-
tion, were those of hsematocele, but the antecedent history
pointed to peritonitis, and the subsequent copious evacuation

54 Reviews. [Jan.,

of pus per rectum^ without any trace of blood, followed by re-
covery to health, with fixidity of the uterus, proved the existence
of purulent inflammation. In addition to the general history,
with absence of dysmenorrhoea, we shall find that the tumour,
examined from time to time, always presents the sensation of
a purulent deposit, and not the varying one of extravasated
blood.

Pelvi-peritonitis with metrorrhagia, and especially the puru-
lent form presents many points of resemblance with hsemato-
cele. The difl'ereutial points are the history, the tendency to
recur, the absence of anaemia, the abscess-like character of the
tumour, all which are contrary to hsematocele. The diagnosis
between pelvi-peritonitis and phlegmons of the iliac fossse is not
diflicult to an unprejudiced observer. In the non-puerpera,
the former is always to be suspected, as the latter is of rare
occurrence. In the former, the tumour is readily felt per
vaginam, and seldom rises above the pelvic brim ; in the latter,
it is first felt abdominally, and takes its course according as
the abdominal or psoas muscles are involved. The former, when
of the sero-adhesive kind, usually resolves without suppuration,
the tendency of phlegmon is to form pus. In the puerpera the
diagnosis is more difficult. The serous inflammation begins
very soon after labour, and with a rigor. We have the charac-
teristic pain and countenance, and the digestive functions are
much interfered with. The reverse is usually the case with
phlegmon when, also, free extension of the thigh is interfered
with. Per vaginam, the tumour is readily perceptible, but in
inflammation of the broad ligament nothing can be felt unless
the muscular cellular tissue also becomes involved. The fre-
quent relighting up of the inflammation, and consequent in-
crease of the tumour is peculiar to the serous membrane. The
diagnosis between pelvi-peritonitis engorgements of the uterus,
uterine deviations, fibrous tumours, and hysteralgia, can be
made out by a careful attention to the history and repeated
vaginal examinations.

We shall only notice a few points in the treatment. In the
acute stage M. Bernutz gives opium in small hourly doses to
narcotism, and then covers the abdomen with a camphorated
blister ; no calomel, nor any purgatives, diete absolue.

In this, and in the subacute stage, puncture is only to be
made when the presence of pus is a certainty ; but then M.
Bernutz is in favour of an artificial opening, as also in the more
chronic purulent form.

Dr. West thinking " it safer to leave the emptying the abscess
entirely to nature^^ is certainly mistaken in quoting Bernutz as
in agreement with him. Injections into the cyst are highly

1868.]

Diseases of Women.

55

dangerous. Leeches to the cervix, when the use of a speculum
is not forbidden by excessive inflammatory tenderness, relieve
pain far better than by their outward application, or than scari-
fication does. Rest for the genital organs is best obtained by
the couch and abdominal belt. The scrofulous diathesis requires
special treatment. An hysterical condition often prevails after
the inflammatory etages have quite subsided, this must be
treated on general principles : hydropathy, medicated waters,
and a country life may be of great benefit.

We append an analysis of the eight^ cases detailed by M.
Bernutz, to illustrate his description of the varieties of pelvi-
peritonitis. The numbers to the cases correspond with those
afiixed in the book. We have arranged them in three tables.
Table I is '' the Pre-history,^^ or general condition of the patient
previous to the invasion of the special aficction. Table II con-
tains {a) " the History," or account given by the patient of the
commencement of the attack ; and {b) " the Examination " by
the physician, with the general and local symptoms. Table III
gives the progress, termination, and autopsy. The cases should
be read continuously, according to the number affixed to each
stage.

I'able I.

1

The Pee-histoey.

Case.

Constitution.

General health.

Menstruation.

Preg-
nancies.

Age on
admission.

1

Lymphatic

Fair

Irregular

None

18

2,

Good

Good

Regular

One

19

3

Good

Good

Regular

None

22

5

Lymphatic, scrofu-

Hyteria, epilepsy,

Irregular, Dysme-

One

lous

dyspepsia

norrhcsa, leucor-
rhcea

6

Lymphatic

Weak lumbar
pains

Irregular, leucor-
rhoea.

One

33

7

Feeble, delicate

Hy steria, dyspepsia

Irregular

None

23

8

Strong

Good

Regular

Now
pregnant

19

y

...

Good

Regular

Three

33

1 There are nine cases detailed, but Case 4 is here omitted, as it is a report of
an operation performed for ovariotomy, but the supposed tumour turned out to be
the intestinea matted together by old pelvi-peritonitis.

56

Reviews.

[Jan.,

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Diseases of Women.

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1868.] Diseases of Women. 59

Versions, Flexions, Prolapse. — No condition of the uterus
has attracted more attention, and been the subject of a
greater variety of treatment, than when it is found out of
its supposed normal position. A woman comes for advice,
complaining of general malaise, dyspepsia, intestinal irregu-
larity, usually constipation, with, perhaps, frequent desire to
micturate, uneasy sensations referred to the womb and adjacent
parts, bearing down, pain in the back and lower belly, cata-
menia irregular and perhaps dysmenorrhceal, leucorrhcea, &c.
On examination the uterus is found retroverted or retroflected,
or both, or in the opposite position of version or flexion, without
any marked disease. The question arises, are the morbid uterine
symptoms caused by its apparent abnormal position? By many
the answer has been given in the affirmative, and a mechanical
treatment been adopted with a view to remedy the " deviation.^'
The conclusion arrived at by M. Goupil is, " that deviations of
the uterus, when simple, with the exception of prolapsus and
providentia, do not cause any functional disturbance.^^ To
prove this he first gives the result of statistical investigations by
Huschke, BouUard, Depaul, Cusco, Aran, Richet, and himself,
as to the normal position of the uterus, which show that this
in the fcetus is ante-flexion, in girls before menstruation the rule
continues but exceptions increase ; after puberty, ante-flexion
and ante-curvature exist in rather more than one half. After
pregnancy the axis of the uterus corresponds with that of the
pelvic brim.

He then, in order to fix a standard of normal position and
proportion, gives a number of measurements of* the cervix as to
its size and distance from the ostium vaginae, the depth of the
vaginal culs-de-sac, &c. &c. : and, lastly, examines in detail the
various versions, flexions, and descents of the uterus, and their
connection with the train of morbid symptoms frequently
ascribed to their influence.

One great source of error is our ignorance of the occurrence
of deviation without uterine distress ; for vaginal examination
is rarely made until the patient's symptoms openly demand it.
M. Goupil, taking advantage of his position at the Lourcine
(a "Lock" hospital), examined, by "the touch," every patient
that was admitted (229), and thus was led to the conclusion
above mentioned.

A retroversion was found in fifty-one cases, of which fourteen
were nulliparae. Of the latter only three presented any morbid
symptoms attributable to the version; of these, two had suf-
fered from pelvic peritonitis, and the other came into the hospital
for vaginitis, being then free from uterine distress. The uterus,
on December 10th, was ante-verted and movable. On Decern-

60 "Reviews, [Jan.,

ber 27th the catamenia appeared, and stopped abruptly in the
evening. The next day she complained of uterine disturbance,
and pain in the lower belly and groins. The uterus was found
in the same position as before, but somewhat larger and heavier.
The morbid symptoms gradually abated under appropriate treat-
ment. Ante-version, in some cases, is caused by cicatricial ad-
hesion between the cervix and floor of the vagina ; in some by
peritoneal utero-vesical adhesions ; in many cases the cause is
undemonstrable.

TV e see that this version occurs more frequently in multiparse,
and in them the uterus is also more frequently excessively
mobile, changing its position as the patient is in the recumbent
or erect posture. When no important lesion is discoverable, as
old pelvi-pei'itonitis, we can easily understand how the uterus
which has suffered pregnancy is liable to congestion, shown by
uterine catarrh and excessive sensibility; and mobility here
provokes pain and distress, which is relieved by external or in-
ternal appliances to steady and fix the uterus. It is probable,
too, that varices of the broad ligaments and ovarian varicoceles
often exist in the class of women [e. g. washerwomen) who are
subject to venous congestion, suffering from haemorrhoids, and
varicose legs. In some cases the pains complained of must be
attributed to neuralgia and hysteria.

Retroversion, says M.Goupil, when uncomplicated, gives rise
to neither pain nor any other symptom. It usually occurs after
a confinement, and there is almost always some falling of the
womb. When it is found accompanied by uterine distress, this
is due to some dffection of the tissues ; and if this be cured the
position of the uterus is of no consequence. M. Goupil, how-
ever, passes over without notice an important class of cases,
where the position of the uterus helps to keep up the affection
of its tissue, just as in the case of many inflamed structures, as
the breast and testicle, or in oedema of dependent parts, when
the position has a tendency to impede circulation, or to constrict
the affected part. It is the want of nice discrimination between
the case that is benefited by a mechanical support and the case
where a foreign body increases the morbid condition of the
affected organ, or acts injuriously on the contiguous tissues, that
has given rise to the unqualified condemnation of mechanical
apparatus, on the one hand, and the malap plication of it on the
other. The pessary, as M. Goupil rightly observes when treat-
ing of prolapsus, is a mere palliative ; but even an intra-uterine
stem may, we think, be beneficial by acting as an irritant to the
cervix, and causing an increased discharge, thereby unloading
the vascular rete and lessening congestion, while it keeps tlie
canal open ; and a vaginal pessary that gives indirect support to

1868,] Diseases of Women. 61

the uterus by distending the walls of the vagina, and so drawing
on the cervix and tending to elevate the fundus, or directly sup-
ports the fundus, may be of much service. But we quite agree
with M. Goupil that the forcible redressment of the uterus, and
the endeavour to keep the organ in its supposed normal position
by mechanism, as though the deviation was the cause and its
removal the remedy, is an unscientific treatment, and likely to
cause more mischief than the existing disease.

The chapter on latero-versions and flexions contains some
ingenious observations on their congenital origin. Practically,
they are not of consequence, as they do not of themselves cause
morbid symptoms, nor influence existing disease. For this
reason, and because the examination of the patient is usually
in England only made in the accouchement position, this class of
deviations has not been so prominently brought under notice as
others.

Simple ante-flexion, like the other flexions, is of itself not
productive of morbid symptoms; but inasmuch as the cervical
canal is readily diminished in capacity when the mucous mem-
brane is afl'ected, the uterus is more liable to menstrual or leu-
corrhoeal retention, and thus this special conformation pre-
disposes to obstructive dysmenorrhoea. M. Goupil shows, by
illustrative cases, that though the flexion is not infrequent, as
he found it in 34*78 per cent, of nulliparae examined, yet in
every case in which uterine distress was complained of uterine
catarrh or congestion was also present ; and when these were
cured the uterine symptoms disappeared, although the ante-
flexion remained. M. Goupil regards pelvi-peritonitis as the
chief cause of uterine disturbance, and urges that there is a
special relation between flexion and serous inflammation. He
rejects "the purely mechanical theory of constriction, and with
it the treatment of incising or dilating the cervix;" but his
colleague, M. Bernutz, when treating of menstrual retention,
admits that division of the cervix may be of service in some
cases of dysmenorrhoea.

M. Goupil does not appear to have dissected any flexed uteri,
and makes no mention of the pathological wasting of tissue re-
ferred to by Virchow and others. He does not think that
flexion is caused by adhesions in the vesico-vaginal cul-de-sac,
but that the flexion must have existed previous to the in-
flammation.

While we think that the limited field in which M. Goupil
worked has been utilized by him to great advantage, and that
he has proved his point, viz. that simple flexions are not morbid
conditions demanding of themselves a cure, but that, where
uterine disturbance is coexistent, the cause must be looked for

6% ~ Reviews. [Jan.,

more deeply than the prominent flexion ; more extended observa-
tions would have led him to consider how far the original de-
velopment, frequently an arrested one, may influence disease, and
that in some cases operative measures may facilitate the recovery
to health, as in the case of congenital phimosis, &c.

Retroflexion, like its converse, is sometimes congenital, and
often exists without inducing uterine disturbance ; indeed, it is
of less consequence than ante-flexion, as dysmenorrhcea is less fre-
quently associated with it. M. Goupil notices that elongation
of the cervix is not infrequent, and may give rise to an apparent
but not real prolapse. When it occurs in puerperae, the flexion
may have been caused by post-partum inflammation. Constipa-
tion, which is an ordinary coincident symptom, is referred by
him to adhesions interfering with the action of the gut ; for he
says that the touch per rectum demonstrates that no sufficient
pressure is made by the uterus. It does not seem to us unlikely
that both in retro-version and -flexion constipation may act very
powerfully, both directly mechanically, and also by the con-
gestion of the hsemorrhoidal vessels consequent on the loaded
state of the bowel. Of the important complication with preg-
nancy M. Goupil does not treat.

Prolapse of the womb is divided by M. Goupil into three
forms when it occurs simply, when it is accompanied by elonga-
tion of the supra-vaginal or of the infra-vaginal portions of the
cervix. The first variety is that usually found in aged women,
and it is often consequent on repeated labours.

M. Goupil passes over without much discussion the disputed
subject of the mechanism by which prolapse is caused. He
cites a case of vesical calculi, which were deposited, after the
womb had fallen, in the pouch of the prolapsed bladder, and
thinks that sometimes the calculi may be the cause of the vesical
prolapse. In the description of the other two varieties of pro-
lapsus, M. Huguier's treatise on elongation of the cervix (Paris,
1860) has been largely drawn upon, and his opinions generally
acquiesced in. Hypertrophy of the cervix, when there is no
other aflfection and no real prolapse, is not a cause of functional
distress, though this may be readily set up by coitus, &c. ; and
so the congenital development become a cause of disease, even
ending in fatal peritonitis.

M. Goupil brings evidence of elongation of the supra- vaginal
cervix in five sisters, all of whom were sterile. He is greatly
averse to the use of the sound, and recommends a gum-elastic
catheter, the stylet being withdrawn for an inch, if absolutely
required to diagnose between elongation of the cervix and
prolapse of the fundus.

In the chapter on diagnosis M. Goupil again reiterates his

1868.] Diseases of Women. 63

opinion that the distress accompanying uterine deviations ori-
ginates in pelvi-peritonitis, or metritis, or congestion, aug-
mented by abnormal mobility of the organ. The abdominal
belt and pessaries act by limiting the movements of the womb,
the former by pressing down the viscera, the latter by distend-
ing the vagina or imparting a new direction to the uterus. He
reminds us that the latter must be used with great caution and
only after all acute inflammation has subsided, quoting cases
where fatal peritonitis has been relighted on the application of
a pessary when chronic pelvi-peritonitis was only dormant.

Sundry pessaries are described as Kilian^s, Zwanck's, Boser's^
&c. ; and an apparatus, designed by himself, consisting of an
abdominal belt carrying a jointed swan-necked rod, having at
the other end an intravaginal cupped stem for the support of
the prolapsed uterus. Those interested in this subject should
refer to the published description of instruments exhibited by
the Obstetrical Society last year (1866). The various opera-
tions put in use for contracting the vulva or vagina, or both,
episioraphy, perineoraphy, M. Goupil thinks have not proved
ultimately successful. The last-named operation, when rupture
has occurred at labour, he would perform from the fifth to the
eighth day, as, previously, the woman may suffer from the
exposure of her person, and later the edges of the wound will
require more extensive parings to get a sufficient raw surface.

The ablation of the cervix with the knife for elongation,
practised by M. Huguier, is warmly recommended. At the
same time, M. Goupil believes that the ascent of the uterus de-
pends chiefly on inflammation of the diminished cervix, together
with that of the upper portion of the vagina and the neigh-
bouring parts, morbid adhesions, and general nodular contrac-
tion taking place. He details two cases where he found removal
of the infra- vaginal portion of the cervix with the ecraseur give
great relief, if not absolute cure, and thinks that, when practi-
cable, this mode is preferable to the more extensive operation
of Hugnier, being simpler and less dangerous to the patient.

We have to thank Dr. Meadows for the careful arrangement
of excellent indices to the subjects treated, and to the biblio-
graphy, which add much to the value of the work. The text
has been well translated, and though considerably abridged
from the original, the material facts and arguments are
throughout fairly brought forward ; and we think the members
of the Sydenham Society will be well satisfied with these
volumes.

6i

Reviews. [Jan.,

Review V,

Clinical Surgery in India. By J. Fayrer, M.D., F.R.C.S., and
F.R.S. Edin. ; Surgeon, Bengal Army ; Professor of Surgery
in the Medical College; First Surgeon to the Medical
College Hospital, Calcutta, &c. London. 1866. 8vo,
pp. 774.

Clinical Surgery in India is a title which recommends
itself to us, and we welcome with pleasure the book which bears
such a name. We know pretty well what is the state of clinical
surgery here in our (own country ; but it is a fi'csh interest to
us to learn what is the state of clinical surgery in our Indian
empire. The various classes of our home population, the con-
ditions under which they live, and the diseases that affect
them, are all subjects which are tolerably familiar to us; but
when we travel to the far East we meet with different conditions
of life, different races of people, different forms of disease from
those that we are accustomed to ; and these cannot fail to arouse
our attention and to excite our interest, in the hope that they
may throw some light upon the phenomena of disease, and
assist us in solving the difficult problems which life and death
present.

In this country the field is comparatively small, and well
supplied with husbandmen. There is hardly a village or a
hamlet which does not come under the observation of an intel-
ligent medical man. If a case is allowed to go on getting
worse, until it has reached formidable dimensions before it is
submitted to a medical man, it is not because there is no advice
to be had, but because the patient neglects to avail himself of
it. But in India the case must be very different. There the
number of regularly qualified medical men is very small com-
pared with the area of the country and the amount of the
population ; and it may easily happen that a patient is so far
removed from advice that he cannot obtain it if he would, and
thus it comes to pass that diseases are allowed to run a long
course, and morbid growths attain a gigantic size before they are
brought under the notice of the medical men. Something of
the same kind used to occur in this country up to a recent
period ; in fact, until the facilities for communication increased
on the introduction of steam power. We are often told that
the present generation does not see such examples of disease as
the last generation had to deal with; and the records of surgery cer-
tainly seem to bear out this remark. Now, why is this ? No doubt
because maladies are brought earlier under the care of a medical

1868. J Clinical Surgery in India. 65

man, aud under the regular rules of treatment ; and what used
to occur in this country until thirty or forty years ago takes
place at the present day, and on a much larger scale, in our
eastern possessions. But this is not the only feature which
gives clinical surgery in India a special interest ; not only are
the cases of a more neglected and aggravated character than the
ones which we see in this country, but in some instances it
happens that diseases which are rarely seen at home are quite
common in the east, and that our brethren of the Indian medical
service are able to give us most important information respect-
ing them. For these reasons Dr. Fayrer's ' Record of Clinical
Surgery in India ' presents many interesting features, and can
hardly fail to be read with pleasure by the profession at
home.

Dr. Fayrer opens his volume with an address delivered before
the Bengal Branch of the British Medical Association, and
closes it with an introductory address to the students of the
Calcutta Medical College.

Let us first of all, before we proceed to notice any of
the surgical cases detailed, take a glance at these two ad-
dresses, for they belong to the same class, and may well be
grouped together. They were delivered, we observe, before
mixed audiences of Europeans and natives ; and they afford a
most satisfactory proof of the progress which medical study has
made in our eastern possessions ; and surely the spread of sound
surgical and medical knowledge in a country where nothing but
empiricism existed before must be an unmixed good. We are
sometimes taunted with our conduct towards the semi-civilized
and uncivilized communities, and certainly such taunts are not
altogether without foundation. The means by which the Eu-
ropean has gained a footing in foreign countries have sometimes
been of the most discreditable kind ; and the way in which he
has introduced his vices, to the manifest injury of the inferior
races, has been disgraceful to his morality.. No thought-
ful man, who reflects upon the way in which we have obtained
an entrance into India, to China, or to Japan, can help admit-
ting that such is the case. It is tlierefore very refreshing to
turn to the opposite aspect of the subject, and to contemplate
the medical science which we have introduced, and the medical
schools which we have planted, and to remember that here at
least we have conferred a real blessing upon the native popula-
tions with which we have been brought in contact. A better
illustration of this could hardly be given than the fact men-
tioned by Dr. Fayrer, that in the year 1864 no less than 1200
bodies were dissected in the medical school of Calcutta, whereas
thirty years before dissection was entirely unknown. This one

81— XLi. 6

G6 Reviews. [Jan.,

fact speaks volumes. It tells us of prejudices that have been
broken down, of the flourishing medical school which exists at
Calcutta, and of the qualified native doctors who are every year
sent forth to carry the blessings of scientific medicine and
surgery throughout the length and breadth of our Indian
empire.

If we turn now to the body of Dr. Fayrer's volumes, with
which we are more immediately concerned, we find that he
deals with many of the most important topics in surgery. A
glance at the table of contents shows us that we shall here find
osteo-myelitis, perineal section, aneurysm, fractures, lithotomy,
abscess, elephantiasis, hernia, amputations, tetanus, and a
number of other interesting subjects, viewed from an Indian
standing-point : and this enumeration of subjects gives but a
feeble idea of the contents of the volume before us ; for there are
many short chapters in it which only occupy a few pages, but
which contain cases of great professional interest, and which are
very suggestive to the surgeon. Many of these cases have been
recorded by the native dressers to the Calcutta Hospital, and it
would be difficult to find cases better reported anywhere. The
way in which they have been observed and noted would be a
credit to any of our metropolitan hospitals ; and these reports
have been amplified and their value enhanced by Dr. Fayrer's
clinical remarks. The subjects which are considered at the
greatest length are, osteo-myelitis, hernia and its radical cure,
elephantiasis, tetanus, and amputation at the liip-joint; but,
besides these, atresia oris, " naevoid elephantiasis," melanosis,
and a variety of other subjects are briefly discussed. We have
observed that the malignant diseases find but a very small place
in this volume. How is this? Is it a mere accident? or is it
a significant fact, tending to confirm the opinion which has been
expressed by some writers that cancerous diseases are of much
less frequent occurrence in the east than they are in the west ?

With reference to osteo-myelitis Dr. Fayrer is of opinion that
this subject has not received the attention which it deserves, and
he deals with it at some length. He points out how frequently
a suppurative inflammation of the bone and the medulla follows
amputations and other operations — how often this seems to give
rise to pysemia ; and he advocates, as the only rational and
effective plan of treatment, amputation at the joint above the
seat of disease. These views and this plan of treatment are
illustrated by some well-chosen cases, and there can be very
little doubt that, as far as it goes, it is a sound and reasonable
method of practice. But we cannot help thinking that osteo-
myelitis must be a more frequent and a more severe complica-
tion of operations in India than it is in this country ; and per-

1868.] Clinical Surgery in India. 67

haps this may be the reason why it has not received a larger
share of attention from European writers. It is possible
that the climate of the East, the hygienic conditions of the lios-
pitals, or the constitutional differences between Asiatics and
Europeans, may account in some degree for this. But, how-
ever this may be, it is certain that in this and in other portions
of Dr. Fayrer's work, we have noticed that the inflammatory
process, once kindled, seems to run on with great rapidity and
vehemence in the class of patients who were the subjects of his
operations.

In endeavouring to produce a radical cure in cases of hernia.
Dr. Fayrer has used Wiitzer's method, and a modification of it
devised by himself. The modification is very slight, and consists
chiefly of an alteration in the shape of the wooden plug which
is employed to retain the invaginated skin ; so that the principle
of the operation is the same as that of the German one. Both
of these methods seem to have yielded very fair results ; and, as
Dr. Fayrer subjected his patients to severe tests before he re-
ported his cases, we are bound to give due weight and con-
sideration to his statistics. By Wiitzer^s method he reports 12
cured and 7 benefited, out of 22 patients, who were operated on.
By his own method he reports 24 cured and 6 benefited, out of
38 patients who were submitted to operation. In no case was
there any serious symptom, still less any fatal issue, arising
from the attempt to bring about a radical cure of the disease.
These figures must be considered satisfactory, as far as they go.
They are probably as favorable as those which can be quoted in
support of any operation of this class ; for it seems tolerably
certain that we have not yet found means (if, indeed, we ever
shall find means) of effecting a radical cure in all cases of this
formidable disease.

One of the most interesting chapters in the volume before us
is that which relates to elephantiasis. This is a disease which
is rarely seen in this country. An hospital surgeon may, perhaps,
meet with two or three cases in the course of a long professional
life; but in tropical climates it is endemic, and by no means
uncommon. Sometimes the disease attacks the genital organs,
sometimes the extremities ; but it is seldom that both parts are
affected in the same individual. Women are subject to it as
well as men ; but it appears to have a preference for the latter.
The aetiology of it is extremely obscure, and the pathology
cannot be said to be thoroughly known and understood. It
seems to consist of an hypertrophy of the true skin and the sub-
cutaneous areolar tissue, and even the bones undergo an increase
in their size and weight. The elements of the skin become ex-
aggerated, forming a coarse fibrous stroma, the interstices of

68 Reviews. [Jan.,

which are filled with a gelatinous substance ; and this increase
of size may go on apparently almost to an unlimited extent,
until it kills the patient mechanically by the enormous weight
which he has to drag about with him. When the disease affects
the scrotum, the fibres of the dartos partake of the hypertrophy
to a notable degree. The disease is accompanied by attacks of
periodic fever, at which times the tumour is painful, and appears
to undergo some increase of bulk, so that the more frequent
these febrile attacks are the more rapidly it grows.

" Dr. Allan "Webb, who has had much experience of this disease,
is of opinion that there are two varieties of it ; one due to a pecuh'ar
intermitting fever occurring twice in the month, at the lunar
changes, called by the natives moon-fever. The other variety has
for its origin the syphilitic poison, and appears from two months to
two years after infection. The first or simple elephantiasis, gene-
rally invades the scrotum in men, the labia in women ; and the second,
or venereal variety, jrenerally begins in the prepuce in men, and the
nymphse in women. The tumour of simple elephantiasis is commonly
smooth : the venereal variety, tuberculated on its outer aspect. The
advent of the simple variety is often ushered in with considerable
fever, pain, and swelling. The venereal variety is slow, chronic, and
more free from pain and fever. In the advanced stages, when the
tumours have acquired great size, they appear to increase alike
without pain or fever, by simple growth, or increase of their proper
substance." — p. 307.

Dr. Fayrer then gives an account of the way in which he has
been accustomed to operate upon the tumours formed by scrotal
elephantiasis^ and states what have been the results of his own
operations : — ,

" Of twenty-eight cases, six have proved fatal ; five from pyaemia,
and one from exhaustion. In the case of a very large tumour, the
operation caused great depression, and, being followed by slight hae-
morrhage, death occurred from asthenia within six hours. In all
these cases the genital organs were preserved, and so far as I am
informed, this is alwavs done here, however large the tumour may
be."— p. 320.

The aortic tourniquet, which has lately been found of so much
assistance in performing large operations about the lower part
of the body^ does not seem to have been used by Dr. Fayrer in
any of his cases. We should think it would be found a very
valuable means of controlling the hsemorrhage, which is often
one of the most alarming complications in operating upon these
large scrotal tumours.

Another chapter in Dr. Fayrer^s work is occupied with the
subject of elephantiasis of the leg, and its treatment by ligature

1868.1 Clinical Surgery in India. . 69

of the femoral artery. This is a plan which has been recom-
mended by some surgeons, and it is worth trying any remedy to
cure so fearful a disorder. But the results which it has yielded
in Dr, Fayrer^s hands are not encouraging. He has only tried
it twice ; and in the first case death occurred from pyaenia, while
in the second the relief obtained was very trifling. When cases
of this kind are seen early, a good deal may be done by the use
of astringent lotions, bandages, and constitutional treatment ;
but when they have reached an advanced stage they appear to
be very hopeless.

Dr. Fayrer has seen several examples of a peculiar kind of
elephantiasis of the scrotum, which he believes has not been
described before, and which he proposes to call " nsevoid
elephantiasis." In these cases the ordinary appearances of
elephantiasis are supplemented by a use void condition of the
vessels, giving the tumour a purple hue and a highly congested
aspect. Perhaps this may depend upon purely mechanical
causes — upon an obstruction to the venous circulation, leading
to a retardation of blood and to a varicose state of the vessels.

Three cases of traumatic tetanus are reported by Dr. Fayrer,
all of which recovered. The first was treated by section of the
median nerve, as well as by drugs — the second and third were
treated by opium-smoking, but also by drugs and ice to the
spine. Though, therefore, the results were very satisfactory,
they do not enable us to argue much as to the curative treat-
ment of this most formidable disease, for, in each instance, a
variety of remedies were employed, and there was nothing very
decided in the histories of the cases to show to which of them
the recovery of the patient was to be attributed.

We have now noted a sufficient number of points to give our
readers an idea of the comprehensive character of this work,
and of its clinical value. Surgeons at home will peruse it with
pleasure ; and those who are in practice abroad ought to admit
it to a place on their shelves, for they will often find it of great
use to refer to, more particularly in relation to those oriental
maladies which are seldom seen by English surgeons, and which
are only briefly handled in our treatises on surgery.

We cannot help thinking that the form of Dr. Fayrer^s book
is unnecessarily bulky. The type is so large, and there is so
little of it on each page, that the size of the volume is out of
proportion to the matter which it contains ; and in these days,
when our shelves are already crowded, there is no occasion to
add needlessly to the thickness of books. This volume is not
the product of an Indian printing-press. It would be more
interesting in some respects if it were. It has been printed at
home by one of our first publishers, and the illustrations with

70 Revietvs. [Jan.,

which it is adorned are woodcuts made in this country from
photographs taken in Calcutta.

Review VI.

Die Krankhaften Geschwiilste. Dreissig Vorlesungen gehalten
wdhrend des Wintersemesters, 1862, 1863, an der Untversitdt
zu Berlin. Von Rudolph Virchow. III. Band ; I. Halfte.

On Tumours. Thirty Lectures delivered during the Winter Session
of 1862, 1863, in the University of Berlin. By Rudolph
Virchow. Vol. Ill, Part I, pp. 496. Berlin, 1867.

The unexpected publication of the third volume of this book
in two separate parts, of which the first has only as yet appeared,
renders expedient a separate notice of each of the two parts.
For, first, the material contained in this first part is so rich and
extends over so wide a field as to supply of itself ample food for
study : secondly, the subject of the cancers, which will, we doubt
not, be most fully dealt with by the great cellular pathologist,
will be more satisfactorily treated of in a separate review : and,
thirdly, it would be impossible to do justice to both parts in one
paper without trespassing too much on the space allotted to our
subject. There is, certainly, nothing that Virchow touches which
he does not adorn ; and it is difficult to say whether in reading
his writings one admires most his great diligence, his rare gift
of pathological observation, or his power of inductive reasoning.
The only fault that can be found with his writing in the book
before us is, that he is too often apt to repeat himself. This,
which in the original delivery of the lectures would be an
advantage, becomes a fault in the book.

Lecture XXII treats of Struma ; — a word used in Germany
in quite a difi'erent sense to that which attaches to it in Eng-
land; being there applied generally to what we designate as
bronchocele, or the French as goitre, and not being in any
sense employed as a synonym for scrofula. The plan adopted
in the classification of the different varieties of bronchocele is
one which Virchow loves to employ in dealing with the morbid
anatomy of the organs of the body generally — that, naniely, of
taking the several component tissues of the organ in question,
and classifying the diseases of the organ according to the tissue
which is principally involved. Thus, regarding the thyroid
gland as made up of follicles partitioned off by connective tissue
and everywhere permeated by blood-vessels, we have, basing

1868.] ViRCHOw on Tumours. 71

our classification on an anatomical standpoint, a follicular, a
fibrous, and a vascular bronchocele.

A. The Follicular Struma or Bronchocele. — The healthy thy-
roid gland is mapped out by fibrous partitions of three different
sizes — large septa, which divide the gland into lobules ; medium-
sized septa, which subdivide these lobules into lobulets ; and
very fine septa, which encompass the ultimate follicles. The
follicles are not to be considered as isolated or independent sacs,
but communicate one with another ; so that a lobulet is a cluster
of branching and inter- communicating follicles, not an aggrega-
tion of separate sacs. Further, the follicles are not lined, as is
supposed, by epithelium, but are filled out with round nucleated
cells, very like those of lymphatic glands. Now, the bronchocele
in question, the commonest form of all, is a follicular hyperplasia,
and is not, as many think, constituted by a new and distinct
formation of gland-substance in the stroma or connective tissue
of the organ. Its construction is the result of the following
sequence of changes. The pre-existing cells of the follicles
become irritated, undergo division, and multiply. Thus multi-
plying, they push their way in the form of little tap-shaped off-
shoots (zapfen) from the follicles into the surrounding soft
tissue, and form there, by a process reminding us of gemmation
in the lower animals, fresh follicles, which may at a later period
be cut off by growth of connective tissue round them and sepa-
rated from their parent, but which, as he has satisfied himself
by repeated microscopical observation, are never distinct new
formations. Seeing that this follicular increase may go on
indefinitely, the size and rapid enlargement of the gland in
certain cases are thus well accounted for. At the same time
that this cell-increase progresses, a fluid is being formed, which,
by its greater or less consistence, gives more or less firmness to
the tumour. The form in which this fluid most often appears
is that which has been denominated as colloid. It is the opinion
of Forster and others that this colloid substance is made out ot
cells by a process of transformation or metamorphosis which the
cells undergo : but this is not exactly the case. Its first origin
is, Virchow believes, in a clear hyaline fluid, which is albu-
minous, akin to the protoplasma, and escapes or transudes from
the cells of the follicles. Its subsequent conversion into colloid is
effected by a combination of this simple albuminous fluid with soda
and salt. In this way is formed an amorphous, homogeneous or
finely granular substance, sometimes enclosing cellular or nuclear
forms, and chemically composed of albumen, alkali, and salt — a
substance which can be artificially made in the laboratory by
mixing the serum of blood with dry salt, filtering, and then
dropping into the mixture a concentrated solution of soda. It

72 Reviews. [Jan.,

is met with in two forms, the one soluble in water, the other
insoluble in water, hardly soluble in boiling acetic or hydro-
chloric acid, and becoming hard on the addition of alcohol ; this
difference in solubility depending on the different proportions of
soda and salt which the substance contains. There can, he
thinks, be little doubt that, bearing in mind the natural presence
in the gland of a fluid rich in albumen, soda, and salt, it is by
the meeting of these that colloid is formed in the body just as
in the laboratory. It must, however, be remembered that the
presence of colloid does not necessarily constitute a bronchocele.
Colloid bodies may be found in considerable number in the
thyroid gland, both of men and beasts, without any noticeable
enlargement of the gland. That which causes the enlargement,
the tumour, is the follicular hyperplasia : nor are the contents
of these multiplying follicles in all cases colloid : they may
be quite fluid, constituting the softer variety of bronchocele
("struma follicularis mollis'^). But the typical bronchocele
and that which reaches the largest size is the colloid bronchocele.
The cysts of various sizes, sometimes colossal (Riesenkropf,
gigantic bronchocele), that are met with in bronchoceles,
are formed by atrophy of the walls of the follicles, from the
increasing pressure of their contents, and by the subsequent
confluence of many follicles into one. At the same time the
colloid softens and is converted into a sticky fluid, rich in albu-
men, which fills the cyst and which may present various shades
of colour from an admixture of blood, a consequence of haemor-
rhage into the cyst. This pressure, atrophy, and consequent
fusion may thus go on indefinitely till cysts of the largest and
most formidable kind show themselves. Such thyroid cysts will
sometimes seriously endanger life from the rapidity and extent
of the haemorrhage to which they are liable. They will also,
occasionally, inflame and suppurate, thus placing life in jeopardy
by bursting into the trachea or pharynx.^

B. The Fibrous Bronchocele, or " Struma fibrosa, ^^ is that in
which the connective tissue of the gland is more especially the
seat of irritative hyperplastic increase. The follicles here play
a most unimportant part, being reduced to mere atrophied
remains (as the livef -lobules in cirrhosis), or, in extreme cases,
entirely destroyed. This is essentially a chronic variety, often
a later change in what has been a follicidar bronchocele. The
fibrous thickening affects, as a rule, parts only of the gland,
giving rise to the presence of very hard knobs or lumps, and is
at times of cartilaginous density. As a still later change, lime

' See a very interesting case of the kind reported by Mr. Savory in the ' Lancet'
ol' November 24.th, 1866.

1868.]

ViRCHOW on Tumours. 73

may be deposited in the connective tissue, and the " struma
ossea^'' results.

C. The Vascular Bronchocele, or " Struma vascularis," is
that in which the blood-vessels increase in size and number.
The thyroid gland, which is naturally very vascular, and subject
to considerable variations in its supply of blood, is sometimes
the seat of intense vascular hypertrophy; the increase being
predominant either in the arteries, large and tortuous clusters
of which are seen ramifying over its surface, or in the veins,
which, in the form of great varices, permeate the interior of the
tumour. Such tumours as these will occasionally prove rapidly
fatal by a sudden swelling up of the gland (much in the way
that the erectile tumours, to be afterwards described, swell up)
and consequent suffocation.^

To the above varieties must be added one of extreme rarity,
the Amyloid Bronchocele, which is, however, occasionally met
with. In this, as in other organs affected with amyloid dege-
neration, the small blood-vessels are the first and principal seat
of the change.

The causes of bronchocele and of its close ally, Cretinism —
for in all districts where cretinism is endemic, goitre is likewise
endemic, though the converse does not hold — are the subject of
a lengthy discussion, having been specially studied by Virchow
in Lower Franconia, in Bavaria, And first, the influence of
climate and place as exciting causes being accepted as indisput-
able, the question follows — Is there anything in the air or water
common and peculiar to all districts where goitre is endemic,

' The writer of this review was witness of a singular case of this kind that
occurred two years ago. A girl, aged 18, presented herself as an hospital out-
patient with a large bronchocele, in which both lobes of the gland and the isthmus
were involved, and which was very vascular, as indicated by the heaving of the
tumour at each pulsation of the arteries. There was no cardiac affection and no
prominence of the eyes. She complained of some difficulty of breathing, increased
on exertion ; but there was no ground for suspecting the danger which was, as the
event proved, imminent. One evening, a week after she was first seen, on the
occasion of her going out to a dance, she was running up-stairs considerably
excited to prepare for the entertainment, when her breathing suddenly became
embarrassed, and the tumour began to throb with unusual violence. She was
brought down and laid on a sofa by her mother, but the dyspnoea increased, and
she died suffocated in about two hours afterwards. The autopsy showed a large
and very vascular colloid bronchocele, covering the larynx, extending down the
trachea nearly to the arch of the aorta, and lapping round on both sides poste-
riorly so as almost to embrace the oesophagus. The trachea was flattened by
pressure in such a way that its calibre was reduced to less than half its natural
size. All the other organs of the body were healthy. It seems quite reasonable to
attribute death in this case to swelling up of the vascular tumour, in consequence
of excitement, and the complete closure of the already flattened trachea. The
case ofl'ers a good illustration of the kind of tumour under discussion, and of the
way in which life is endangered thereby.

74 Revieivs. [Jan.,

widely scattered as they are ? He cau return no better answer
to this question than Inglis and M'Clelland long ago returned
— that the prevalence of limestone formations in goitrous dis-
tricts is an ascertained fact. Still, Virchew is not satisfied with
the opinion expressed by McClelland, that the presence of
endemic goitre is directly dependent on the use of water impreg-
nated with lime-salts. Lime or magnesia taken into the body
in the drinking water can hardly be a direct cause of goitre,
because the latter prevails in districts where neither of these
substances is present in the water in any but a very small
quantity. He hazards a hypothesis, that there is something
contained in the water, and, possibly, in the vapour of the water
dispersed through the air, which acts as a miasma : but what
that something is has not yet been discovered. Sojourners in
a goitrous district may and do become goitrous while there, and
lose their goitres on leaving the district. Many such cases are
recorded. Equally undeniable is the influence of local causes
in the production of cretinism : and, although cretinism is
undoubtedly hereditary, yet the territorial and local influences
are much more powerful to prodvice it than are the hereditary :
for Virchow has seen a perfectly well-formed and healthy child
born of a cretin ; and, again, the same which has been said of
goitre may be said of cretinism, that settlers in a cretinous dis-
trict who have previously borne healthy childj-en will, from the
date of their arrival, produce cretins. If to this fact be added
another, that cretinism is congenital and never acquired post
natum, we are driven to seek the active cause of cretinism at
some period of intra-uterine life : and what is more natural
than to suppose that the same something, the miasma, which is
operative in the production of goitre, acts through the blood of
the mother on the foetus in utero, and brings about the series
of defects which constitute cretinism. The most important of
these defects — that in the conformation of the skull — was first
thoroughly investigated by Virchow, and explained in an elabo-
rate memoir' some years ago. In this he showed that the
primary seat of faulty development in the cretin skull is in the
base, which is shortened unnaturally from premature synostosis
of the occipital with the basi-sphenoid and of the basi- with the
pre-sphenoid. The same early synostosis might, he found, be
present in other sutures, but the typical defect was in the base.
It is to be regarded as the efl^ect of some intra-uterine irritation
acting on the sutures ; and, seeing that congenital bronchocele
is often coincident with congenital cretinism, it is hard to resist
the conclusion that the same irritant is active in the production

1 ' Untersuchungen iiber die Entwickelung des Schadelgrundes,' &c. Berlin,
1857.

1868.] ViRCHOw on Tumours. 75

of both abnormities. The " reiz" or irritant, Virchow^s darling,
is thus worked in here as elsewhere. Whether the imperfect
cerebral development in the cretin is a secondary effect of the
cranial malformation cannot be asserted ; the two, at any rate,
constantly coexist. Although a full meed of praise must be
awarded to Gruggenbiihl for his disinterested philanthropy; his
scheme for curing cretinism is called a " noble dream.'^ The
true cretin cannot be improved ; he can only be taken care of.
Hence all efforts must be directed towards prevention by im-
proving the sanitary condition of those places where cretinism
is endemic.

The singular combination of symptoms which go to make up
the disease known everywhere in Germany as '' Morbus Base-
dowii," and to the honour of whose discovery both Basedow and
our own Graves may fairly and independently lay claim, is fully
entered into. The enlargement of the thyroid gland, the first
among the trio of symptoms, is not as a rule so remarkable as
in ordinary goitre, the most salient feature being the great size
of the blood-vessels, especially the veins, and the rapid changes
of size to which the gland is consequently subjected. Neither
is there any one special kind of enlargement ; for the gland may
be simply swollen, or it may be so enlarged as to constitute a
bronchocele in any of its varied phases and aspects — colloid,
cystic, &c. The heart, as the second of the trio, is generally
hypertrophied and dilated, especially in its left ventricle, even
though the valves are healthy. Lastly, the prominence of the
eyes, or exophthalmia, is pathologically accounted for in several
ways — by hypertrophy of the intra-orbital fat, by dilatation of
the intra-orbital veins, and by fatty degeneration of the recti
muscles (v. Recklinghausen) . No one of the trio can be called
primary or essential, for any one may be absent; but all the
three seem to be rather the common effects of one cause. The
presumption that this cause is to be sought for somewhere in
the nervous system becomes stronger as pathological investiga-
tion progresses ; and that Avhich was at first a clever hypothesis,
that the sympathetic nerve is at the root of all the mischief, is
in a fair way to be confirmed by observation as a fact. In a
well-marked case of the kind, recently examined at Berlin, in
which hypertrophy of the heart, bronchocele, and exophthalmia
were present, Virchow found " very decided enlargement and
interstitial thickening of the cervical sympathetic,^^ Hence,
although the phenomena of exophthalmic goitre correspond in
part only with what paralysis, in part with what irritation of the
sympathetic might cause, it is highly probable that disease of
this nerve is the cause of all the symptoms.

Hypertrophy of the pituitary body, though, comparatively

76 Reviews. [J

an.

speaking, unimportant, deserves a passing mention, from the
close structural resemblance which the anterior and larger half
of the body bears to the thyroid, and from their similarity of
development ; the former being an offset from the pharynx, the
latter from the cesophagus. The former, like the latter, is
subject to hypertrophy {'' struma pituitaria'^), and is occasion-
ally found filled with colloid, exactly recalling, and chemically
identical with, the colloid in bronchocele ; the only difference
being that its cells are more prone to fatty degeneration than
those of the thyroid gland under the same circumstances. In
like manner is recognised a " struma supra-renalis," or hyper-
trophy of the cortical layer of the supra-renal capsules, which
closely resembles in structure the thyroid and pituitary body,
and which must be regarded as glandular.

Lecture XXIII. — Turning now from the contemplation of the
great group which plays by far the largest part in the history
of tumours, and on which our attention has hitherto been ex-
clusively fixed — the group of connective tissue and lymphatic
tumours — we come to the consideration of those tumours whose
principle and essential structure is of a kind which physiologi-
cally ranks highest among the tissues of the body, and which has
received the name of " tissue of animal life" — the tumours,
namely, which are made up of muscular, fibre or "myomata,''
those composed of nerve-tissue, or "neuromata," and those
constructed of blood-vessels, or "angiomata."

Myomata or muscular tumours. — A few rare instances where
the striated muscular fibre plays the principal part in the forma-
tion of the myoma are alluded to; as, for instance, myomata
of the heart, of which he has three specimens in his museum,
and cases of hypertrophy of the tongue, which are with
some hesitation included among tumours, being for the
most part congenital defects, but occasionally acquired, and
consisting of connective tissue in excess, together with a
superabundance of muscular substance not displaced by the
hyperplastic connective tissue. In like manner, instances of
myomata occurring in muscles of the trunk and limbs have
been recorded ; but none are well authenticated. The myoma
proper is composed of smooth, inorganic, muscular fibre, held
together and compacted by a vascular connective tissue ; the
blood-vessels being sometimes so large and prominent that the
tumour has almost a cavernous aspect, and is capable, like the
cavernous tumours, of undergoing rapid changes in size. This
change of size is aided, too, by the muscular fibre in the tumour
which possesses active properties, like those of the organ in-
fested, and will contract from time to time, making the tumour
hard, small, and pale. The myoma is the result of an irritant

1868.] ViRCHow on Tumours. 77

acting upon some part, more especially the mucous membrane, of
the organ in which the tumour is seated, and is at first always an
outgrowth from the tissue of the organ. Thus, for instance, in the
uterus, where the tumour has often the appearance of discon-
tinuity, and is, in fact, discontinuous, so that Paget speats of
" continuous uterine outgrowths,'^ as distinguished from " dis-
continuous uterine tumours," careful observation shows that
every myoma is alike an outgrowth in its first development ; the
isolation by means of connective tissue which it may subse-
quently undergo being always a later change in the course of
its life. This will be presently again referred to. Beginning
with the least important of the myomata, those of the skin may
be enumerated, especially of the scrotum, where muscular fibres
abound ; of the oesophagus, cardiac end of the stomach, and
upper end of the small intestine, in which localities they grow
from the muscular coat, and either push before them, polypus-
like, a layer of mucous membrane, so as to project out into the
calibre of the tube, or, in the case of the stomach, tend inwards
into the peritoneal cavity as well as outwards. In the prostate,
Virchow recognises with Thompson two forms of enlargement. —
a. The muscular enlargement, or myoma, which here especially
concerns us, is always partial, in nodules or lobules, never in-
volving the whole of the gland ; it has its favourite seat in the
posterior and upper part of the gland, whence it sprouts, push-
ing before it the posterior wall, and projecting into the cavity of
the bladder, at whose neck it lies like a great valve, constituting
what is wrongly termed the '^middle lobe of the gland ;" it is also
met with in the lateral lobes, where it lies imbedded, single or
multiple, and enlarges the lobes by its increase backwards
towards the rectum, or inwards towards the prostatic portion of
the urethra ; it is, lastly, joar excellence, a disease of old age. b.
The glandular hypertrophy is, as Pauli has shown, more par-
ticularly a disease of earlier life, but does not here concern us.
In the uterus, a partial hyperplasia of the cervix is met with,
which sometimes reaches a considerable size, so as to put on all
the external appearances of prolapsus. The body of the uterus,
however, maintains its natural position, or only slightly sinks,
while the great cervix projects beyond the orifice of the vagina.
A hypertrophied cervix of this kind, amputated by Mayer, was
examined by Virchow, and found to be made up of soft, hyper-
plastic, vascular uterine tissue. But the true myoma infests, by
preference, the fundus of the organ, where muscular fibres are
naturally most abundant, and is here met with in three forms,
according to the relations which it holds to the uterine walls : —
first, the polypus, which projects into the cavity of the uterus ;
secondly, the subserous myoma, which projects into the cavity of

78 Reviews. [Jan.,

the peritoneum ; thirdly, the intra-parietal or interstitial myoma.
The supposition that certain of these tumours are independent
formations in, but not of, the uterine tissue, and originate in a
cytoblastema deposited among the proper uterine elements, is
quite erroneous, and results from a want of proper attention to
the study of their first development. The very first trace of a
uterine myoma that can be seen is a slight swelling and hyper-
plastic increase in one of the closely-interwoven bundles of the
uterine muscular fibre, which in a short time becomes so de-
cidedly hypertrophied, that it looks like a small knot in the
substance of the uterus. This little knot then pushes its way,
gradually increasing, into the surrounding tissue, and soon be-
comes large enough to be dignified by the name of myoma.
Now, many such myomata never lose this connection with the
uterus, however large they may grow. The continuity of tissue
is clearly traceable with the naked eye. Some, on the contrary,
have unmistakably the appearance of distinct tumours, being so
isolated by investing capsule from the surrounding uterine sub-
stance, that they may be clean shelled out, or else lianging from
the uterus by nothing but a fibrous pedicle, in which all traces
of muscular continuity with the uterus are lost. In these, Virchow
strongly maintains that the isolation or separation of the tumour
is in all cases an after-change, dependent on excessive formation
of connective tissue, and consequent displacement of muscular
fibre round and about the growing myoma. In like manner the
blood-vessels which enter abundantly into the continuous
myoma become in great part cut oft' from the discontinuous :
and thus are explained the discrepancies so noticeable in the
statements of different authors, some of whom have found that
the tumours are readily injected from the uterine vessels, others
of whom have failed in their attempts at injection. Similarly,
as regards operation, it makes all the diff'erence whether a poly-
pus be discontinuous or continuous : and the way in which one
obstetrician ignores all danger of hseraorrhage in excising
polypi, while another goes to work more warily, may be thus
accounted for. The description of the first and second varieties
contains nothing particularly worthy of notice. The third, or
intra-parietal, is not only completely surrounded by muscular
substance, but appears as a very part of the uterine wall. The
various elongations, contractions, and twistings, which the cavity
of the uterus may undergo from the presence of this form of
tumour, as well as the different flexions of the uterus itself, are
enumerated at length. A remarkable phenomenon is seen in
the occasional birth or spontaneous expulsion of the intra-
parietal myoma and the polypus. In the case of the former,
separation from the uterine wall takes place by a process of sup-

1868.]

ViBCHOw on Tumours. 79

puration or sloughing round the tumour, or by the action of the
tumour itself in wearing away the muscular and mucous layers
which cover it, and is followed by expulsion with regular labour-
pains.^

There is no doubt that the myoma may become much smaller
by undergoing a sort of fatty degeneration and shrinking of its
substance ; but he doubts if, as some assert, it is ever com-
pletely absorbed. Such a statement has never been confirmed
anatomically, and is based only on clinical observation. In like
manner the tumour will sometimes become indurated, of car-
tilaginous hardness, or even calcified, and so remain stationary.
Such a calcified myoma, when intra-parietal, is sometimes a
source of great pain and inconvenience, and has even been known
to cause death. It has hence been sometimes found necessary
to remove the mass, either whole or in fragments, by an opera-
tion. Many other peculiar forms or appearances are also
assumed by the myoma, according to the predominance of one
or other of its component structures, or as a result of par-
ticular changes to which it is subject. Thus there is sometimes
met with a soft variety, in which an abundant interstitial
tissue, containing mucine, is present, so as to give the tumour
somewhat of the appearance of a myxoma ; or, again, when the
muscular fibre is in excess to the exclusion of the connective
tissue, we see a red fleshy mass instead of the paler myoma
proper; or, again, an unwonted development of blood-vessels,

' A very interesting specimen in illustration of this is one that was prepared by
Van-der-Kolk, and that is now in the Oxford Pathological Museum. The follow-
ing is the abbreviated translation of Van-der-Kolk's MS. : — " Ei-om a woman,
aged 50, who had long suffered from the presence of an abdominal tumour. After
she was admitted into the Amsterdam Hospital, I examined her abdomen and
found the uterus of such a size that I should have suspected pregnancy, had it not
been for the age of the woman and the length of time that she had noticed her tu-
mour (more than a year before admission). I therefore concluded that she had some
disease of the uterus, probably a fibrous tumour. After a time she was seized with
violent pains, as of labour, and with profiise haemorrhage from the vagina, which
ceased and then shortly recurred again and again, till she died exhausted. An
immense fibrous tumour is seen filling out the uterus, whose walls closely encom-
pass the tumour, and are as thick as those of the pregnant uterus at the full
period of gestation. The lower half of the tumour is partially separated from the
uterine walls : and the haemorrhages which caused death are thus easily accounted
for by the rupture of blood-vessels during the act of separation." The great
thickness of the uterine walls is then commented on as the probable cause of the
attempt at expulsion ; and a comparison is made between this preparation and a
similar one which adjoins it, but in which the uterine walls are thin and there has
been, consequently, no attempt at separation or expulsion. The writer of this re-
view watched another case in the Necker Hospital, at Paris ; that of a woman, who,
having been some time under observation with a large tumour in the hypogastric
region, the nature of whicVi was doubtful, and having suffered from repeated
attacks of haemorrhage, was one day seized with regular labour-pains and profuse
haemorrhage, and slowly gave birth to a great, soft, vascular myoma. Other
cases of the kind are related by Cruveilhier, in his 'Anat. Path.' vol. i, Livrai-
son xi.

80 Reviews. [Jan.,

especially in the large intra-parietal kind of tumour, will cause
the growth to assume a cavernous aspect {" myoma cavernosum^')
— a form remarkable for the rapid changes of size that it will
undergo, and for the difficulties that it will often thus throw in
the way of diagnosis ; or, lastly, a process of softening and dis-
integration, starting from the connective tissue, may fill the
tumour with what look like cysts filled with fluid contents
(" myoma cysticum"). This latter has been denominated '' fibro-
cystic tumour of the uterus," and has been often mistaken for
an ovarian cyst, and punctured. The sacs or cysts are always
found to have more or less uterine tissue around them ; they
sometimes reach an enormous size, and are, like many ovarian
cysts, often multilocular. Myomata are occasionally formed
between the layers of the broad ligament. In this situation they
are, in the large majority of cases, dislocated uterine myomata ;
and though in some instances no connection whatever between
them and the uterus or any surrounding organ can be traced,
yet, seeing that the ovary and the round ligament are, as well
as the uterus, centres from which they may be developed, it is
probable that they have had at some period of their lives a con-
nection with one of these three parts. Finally, that which is
called ''fibrous tumour of the ovary" has a near relation with
the myoma, in that it often contains muscular fibres small and
imperfectly developed. This tumour should, therefore, occupy
a place between the fibrous tumour and the myoma, and be
called " fibro-myoma." Its intimate structure corresponds
exactly with that of the hard uterine myoma, the fibres vastly
preponderating over the muscular tissue, and blood-vessels being
few. Affecting, as a rule, the free end of the ovary, with which
it is continuous, it leaves, for the most part, the remainder of the
organ uninvolved and recognisable in connection with the tumour.
It is seldom of very large size, ranging from that of a hen's
egg to that of a foetal head. Like the uterine myoma, it will
sometimes become cystoid, or will put on some of the characters
of a sarcoma, growing to a much larger size, and resulting in
what must be called a mixed tumour — " myo-sarcoma.'^

Lecture XXIV deals with Neuromata or nerve-tumours. All
that has been previously written on this subject has received at
Virchow's hands a thorough sifting and rearranging ; for, on the
one hand, a large number of the tumours that have been in-
cluded by authors in this group are no neuromata at all, but
either cancerous tumours in connection with nerves, or myxo-
mata, or gliomata, which spring from and are seated in the peri-
neurium or neurilemma, and have no trace of nerve-tissue in
their composition. On the other hand, owing to the extraordi-
nary difficulties which beset the microscopical examination of

1868.]

ViRCHow on Tumours. 81

these tumours^ many real neuromata have been confounded
with fibrous and fibro-nucleated tumours. The true criterion,
however, is to be sought in the relative quantity of nerve-
elements that a given tumour contains. Whenever these are
found in a state of hyperplasia, the tumour is a neuroma, and
no glioma or myxoma. A neuroma is, then, a tumour composed
essentially of hyperplastic nerve-elements, with the addition of a
certain quantity of connective tissue containing blood-vessels.
The word nerve-elements is here used advisedly, in that nerve-
cells as well as nerve-fibres may enter into its composition, and we
may have a cellular ov ganglionic as well as a fascicular or fibrous
neuroma. Its first formation is in most instances exactly iden-
tical with the first formation of new nerve-tissue in the repair
of a nerve after section, not by simple division of or outgrowth
from pre-existing nerve-tissue, but by means of a young, newly-
formed granulation-tissue (which, as we have seen in the previous
reviews of this book, plays so conspicuous a part in the develop-
ment of tumours generally), allied to the connective tissue, whose
elements are afterwards developed into nerve-tissue. The close-
ness of the link which connects the tumour under consideration
with regenerating nerve-substance is seen in the " amputation
neuroma," as good a type as can be brought forward of the
fibrous neuroma in general. This bane of surgeons, the painful
swelling of the nerves in stumps, was only at a comparatively
late period found to contain an abundant supply of nerve-fibres
in a dense, close-meshed network, prolonged into it from the
trunk of the affected nerve. A continuity of the nerve with
the tumour is evident in all cases : nowhere is the tumour set
or imbedded in the nerve-end as the myoma in the uterus. Both
kinds of nerve-fibre, the gelatinous or grey, as well as the tubular
or white, are found in the fibrous neuroma — one of the many
discoveries in pathology to the credit of which Virchow is justly
entitled. Many of the so-called " painful subcutaneous tumours"
are to be included among the neuromata, especially those which
are remarkable for their hardness, which lie loose in the sub-
cutaneous tissue, and vary from the size of a pea to that of a
bean. One such tumour examined by Virchow was found to
consist almost exclusively of nerve-fibres. They are generally
met with on the extremities, are connected with the finest ter-
minal branches of the nerves that ramify there, and are far more
common in women than men. They are easily and success-
fully extirpated. At the same time it must be remembered
that all the painful subcutaneous tumours described cannot be
regarded as neuromata; for small subcutaneous tumours of any
kind, muscular, vascular, &c., will, provided they involve in
their growth some one or more nervous branches — and it is
Sl^XLi. 6

82 Reviews. [Jan.,

the small, sensitive, cutaneous branches which are particularly
open to such impressions — give rise to the same painful symp-
toms as the true neuromata. As regards the origin of the
amputation neuroma, there can be no doubt that the tumour
is a direct consequence of irritation. In like manner many of
the subcutaneous neuromata can be traced to blows or other
injuries, so that the " Reiz" holds sway here as elsewhere.
Other kinds there are, however, which are not so readily
accounted for, but have a more decidedly constitutional charac-
ter. Such are the " multiple neuromata," where a single nerve
is, throughout the whole of its course, beset with little strings
of tumours, like the beads on a rosary, or where many nerves
throughout the body are similarly affected. This disease is not
only hereditary, but often, also, congenital. It seems to bear
some peculiar relation to idiocy and cretinism, in connection
with which it is often found present. So general is it in some
cases, that even the sympathetic does not escape, but is, like
the spinal nerves, swollen with tumours. The above neuro-
mata, the greater part of which are accessible to the surgeon,
and of which the amputation neuroma is, speaking generally,
the type, resemble on section fibromata or fibro-myomata, being
white or yellowish- white, lobular, with a compact fibrous grain,
and having occasionally their outer layers superimposed one
upon the other in a concentric form like an onion. Before ex-
amining them microscopically it is well to adopt ReiFs plan of
maceration in dilute nitric acid, which clears the nerve-fibres,
as it does the muscular fibres in the myomata, of their connec-
tive tissue. The nerve-fibres are then seen lying in very tortuous
bundles, and forming a dense-meshed, closely interlacing net-
work. Where, as sometimes happens, the tumour is composed
entirely of the grey or gelatinous fibres, it is extremely difficult
to recognise its real nature, for it appears to be made up of
groups of long nuclei imbedded in a firm, fibrillated basis-sub-
stance, and bears the closest resemblance to the fibro-nucleated
tumour, with which it is almost always confounded. But careful
examination shows that these nuclei neither form part of cells
nor lie irregularly clustered in a basis substance, but have a
regular plan of arrangement in the fibres of which the tumour
is composed. Dichotomous division of the primitive nerve-
fibres in neuromata is very commonly seen : this, coupled with
the manifold divisions of the bundles of fibres, which break up
into tufts and interlace in every direction, makes a very Gordian
knot of the whole mass. The nerves of common sense are much
less often the seat of tumours than the spinal nerves ; but the
auditory is sometimes so affected. There is, however, no recorded
instance of neuroma in the olfactory or optic nerves. Neuro-

18G8.] ViRCHow on Tumours. 83

mata are, as a rule, local and benign tumours ; they behave in
their manner of life more like some natural structure of the
body than tumours, being small, of very slow growth, and but
little subject to degeneration or other changes ; nor do they ever
manifest infectious properties.

The cellular or ganglionic neuroma has a soft consistence, a
grey or greyish-white, in parts reddish, colour, and thus closely
resembles the grey or white substance of the brain or spinal
cord. It is met with generally in the central nerve organs, where
it has very much the character of a simple hypertrophy. Vir-
chow^s attention was first called to a formation of the kind in
the brain of an idiot, where he noticed small masses of grey
substance, from the size of a hemp-seed to that of half a cherry,
in the midst of the white substance of the brain, outside and
above the corpus striatum and on the floor of the anterior horn
of the lateral ventricle. Since then he has met Avith many
similar specimens, generally in the neighbourhood of the lateral
ventricles, and more particularly in the brains of lunatics.
These little tumours are manifestly congenital, but are never-
theless capable of increase after birth. Their study seems to
be as yet in its infancy, but is full of interest. Again, some of
the cases of ''hernia cerebri congenitalis,^' or encephalocele,
have strong claims to be placed in this category, as being mon-
strous partial hyperplasise of the brain, which, enclosed in their
dura and pia mater, are pushed through a hole in the skull. In
like manner, some of the sacral and coccygeal tumours are com-
posed of a luxuriant grey nerve-substance. Virchow describes
such a case at length, where the mass was continuous with the
filum terminal e of the cord and contained well-marked grey and
white nerve-tissue.

Lecture XXV gives a very full and perfect account of An-
giomata or Vascular Tumours. — Under this heading are
comprised only such tumours as are composed principally
or mainly of newly-formed blood-vessels, or of blood-vessels
with newly-formed elements in their walls. Hence, no place
is here assigned either to tumours composed of extravasated
blood, which have already been spoken of under the title of
haematomata, or to the many kinds of tumour which, at certain
periods of their life, become abnormally vascular and show by
the side of their proper structure an excessive development of
blood-vessels, or to simple dilatations of pre-existing blood-
vessels, as aneurisms and varices. At the same time, the diffi-
culty of drawing a line between the angioma proper and the
angiectasis, or dilatation of vessels, is at times very great ; and
the more is this the case the larger the vessels involved. Thus,
when a vascular mass occupies a place where capillaries are
abundantly present, and where in the place of capillaries we see

84 Reviews. [Jan.^

groups of spaces containing blood just as in the normal cavern-
ous tissue, we have no hesitation in calling it a vascular tumour :
but where it lies among, or near, large trunks, either of arteries
or veins, we are often in great doubt whether to regard it simply
as a cluster of dilated blood-vessels or to dignify it with the
name of angioma. That which he takes as the criterion is the
presence of newly-formed tissue in and around the walls of the
blood-vessels. Where this is present, the name of angioma may
be unhesitatingly given to the growth.

The Cavernous angioma is the type of the tumour in question.
It is seen on section to be made up of numerous cavities or
spaces holding blood and intercommunicating, so that any
injected fluid passes from one space to another, and finally flows
out into veins for the most part tortuous and dilated. These
blood-spaces are seldom round, but rather angular, and are
limited by partition-walls (Balken) of very various sizes ; some
large and thick, being composed of a compact connective
tissue with elastic fibres, and, most interesting but not constant,
smooth muscular fibres arranged in concentric form round the
spaces, containing, also, vasa vasorum that empty themselves,
in part at least, into the spaces ; others smaller, finer, and more
decidedly muscular than the large ones, but like them lined by
a tesselated epithelium. Here, then, is a pathological structure
which has a perfect physiological prototype in the cavernous tissue
of the penis and clitoris, and which, like that tissue, is endowed,
though in an inferior degree, with erectile properties. The doctrine
of Rokitansky concerning the cavernous tumour — that it is an
independent formation, having no communication with the
blood-vessels of the body, and manifesting in its relations an
exact analogy with ordinary alveolar tumours (as alveolar cancer)
in all respects save this, that in its spaces blood- cells are deve-
loped instead of cancer-cells — is rudely attacked by Virchow.
For, first, he says, injection of these tumours shows unmistak-
ably their connection with the blood-vessels of the body. Very
true, answers Rokitansky ; but this connection is only established
at a later period of their life. But, returns Virchow, this cannot
be ; for blood corpuscles in a state of early development, that is
nucleated, are never found in them, as they would be if inde-
pendently developed there ; and, again, were the blood stagnant
in the spaces, one would expect to find something unnatural in
its consistence and characters, which is never the case. The
truth is, that the cavernous angioma can, from the earliest
period of its existence, be injected artificially from the neigh-
bouring arteries, so that the circulation m it is identical with that
in the ordinary cavernous tissue. Even in those tumours which
have a direct and large communication with veins, small arteries

1868.] ViRCHow on Tumours. 85

can, if carefully sought for, be found entering at the periphery.
Hence, the blood is conveyed to all cavernous tumours by means
of arteries, circulates through the blood-spaces, and from thence
passes out into veins. The cavernous angioma may be divided
into two kinds : — a. The circumscribed is small, as a rule,
seldom larger than a walnut ; round or oval in shape ; sur-
rounded by a capsule of greater or less consistence, which is a
later formation in the life of the tumour, being a result of irrita-
tion, and continuous with the surrounding connective tissue
proper to the part. Through this capsule pass the blood-vessels
of the tumour, and from it proceed the septa or trabeculse which
bound the blood- spaces, b. 7%e rfi^w^e has no limiting capsule,
but merges into the surrounding parts, so that it is often hard
to say where it begins; it is also naturally larger, and may,
indeed, reach a very great size ; it is more flattened than the
preceding, so as to have less of the appearance of a tumour ; it
is a spreading, and, in a certain sense, an eating (fressende)
tumour. The history of the origin of the cavernous angioma
is among the most difficult questions of pathology, and is closely
linked with a physiological problem equally difficult to solve,
the new formation of blood-vessels in general. And first, speak-
ing only pathologically, he cannot endorse the opinion which
has, since John Hunter, been generally accepted, — that both
blood and blood-vessels are created anew : but he maintains that
the vessels only are new formed, and that the blood gradually
forces its way into them from pre-existing ones. How then
are the new vessels formed? That they originate somehow or
other in cells there can be no doubt : but Virchow cannot agree
with Neumann and others who think that it is by a series of
cells joined by anastomosing processes, into which blood gradually
flows. Their development rather commences in this way : — The
cells of the connective tissue round and about the vessels become
irritated, and undergo the usual hyperplastic increase, so as to
form the granulation-tissue, with which we are now so well
acquainted. Lying thus closely packed together, they next
group themselves so as to form little cylindrical tubes, which
are gradually converted into new vessels, and into which the
blood from the surrounding vessels forces a passage, distending
them, and throwing them into sharp curves and convolutions.
As a second stage in the process, wherever the curves of a con-
voluted cluster of new vessels come in contact with each other,
atrophy and breaking down of their walls ensue, and a conse-
quent fusion or blending of many small blood-vessels into one
large cavity or blood-space results. A blood-space in an angioma
is, therefore, not a mere passive dilatation of the walls of one pre-
existing blood-vessel, but is formed by fusion of many. Lastly,

86 Reviews. [Jan.,

the irritant continuing its action, there follows an active hyper-
plasia and thickening of the walls of the spaces as well as of
the veins and arteries in the circumference of the tumour.
The cavernous angioma, though believed to be often a con-
genital defect, is not so in reality. The true nsevus, which is
congenital, is not a cavernous tumour, but a telangiectasis, or
simple dilatation of blood-vessels, and often constitutes the basis
out of which the cavernous tumour is afterwards formed by pro-
gressive development. The change by which this is effected is
often very rapid, a few months even sufficing for its fulfilment :
but it may also be slow, not commencing for some years after
birth, when a blow or some such mechanical irritant starts the
cavernous metamorphosis. The first external evidence of this
transformation is seen in the greater prominence of the simple
usevus, which is naturally flat, and scarcely projects beyond the
surface-level : its colour now becomes brighter, and the forma-
tion of the cavernous blood-spaces is indicated by numerous
small red points, with which the tumour is dotted over. The
surface next becomes uneven, like that of a mulberry, and the
whole grows more and more prominent, till it may come to
stand out in well-marked relief from the surface. Cases are,
however, occasionally met with where, even in advanced periods
of life, this same cavernous angioma, in consequence of some
irritant acting from without, is formed de novo without any
congenital naevus to serve as a starting-point.

Cavernous angiomata are either external or internal. The
external are sometimes superficial, sometimes deep-seated.
The superficial form takes origin in the skin, and may
thence extend to the deeper parts : it afffects by preference
the head and face and adjacent parts of the neck and throat;
all those parts, more especially where in the early develop-
ment of the embryo fissures existed, and have subsequently,
in the course of development, become closed.^ Virchow
maintains that it is along the borders of these fissures, where
there is a very rich distribution of blood-vessels, that angio-
mata are wont to form ; a very slight irritant here sufficing for
their production. Most common and most important among
them stands the auricular angioma, which involves the outer
ear, and may thence extend into the temporal region, and down
to the angle of the jaw. Next comes the labial, which is often
erectile. The so-called Leopold's lip^ was, according to Grafe,

' For a full account of the branchial or visceral fissures and arches, and the part
played by them in the development of the face and external ear, see KoUiker,
' Entwicklungs-Geschichte,' Lect. 24 ; and Carpenter's ' Human Physiology,' ed. 6,
p. 819.

* The Emperor Leopold is said to have had a pendulous lip, which, whenever
he was in a passion, used to swell up like a turkey-cock's comb in such a manner
as to bang down on his chin.

1868.] ViRCHOW on Tumours. 87

caused by an erectile labial angioma. The naso-frontal^ palpebral,
buccalj are all to be noted ; likewise the angioma of the scalp,
which finds its seat of preference alongside of the sutures
or about the fontanelles, and which is particularly interesting
from the fact that its vessels are often directly continuous
with those of the bone, or even with the interior of the cranium,
and that its removal is hence not unattended with danger.
The deep-seated angioma has a deeper, subcutaneous origin ;
is either ''lipogenous,^^ i. e. developed in the subcutaneous
fat of the head and trunk, where it is generally diffuse and of
large size, often spreads to the skin, and is, perhaps, the com-
monest kind of angioma ; or " phlebogenous,^^ i. e. in direct or
open communication with large venous trunks. But even here
the rule already laid down — that the blood enters the tumour
by arteries and leaves it by veins — is not violated. The phlebo-
genous angioma is more often met with on the extremities than
on the face, is generally multiple, and has, unlike the lipogenous,
a tough limiting capsule. The most important of the deep-
seated angiomata are those of the cheeks and orbits. In the
latter situation they have often been met with, but the recorded
cases require to be carefully sifted, inasmuch as real orbital
aneurisms — of the ophthalmic artery and arteria centi'alis retince
— are often confounded with these tumours. A true muscular
angioma is of very rare occurrence, for the muscles when at-
tacked are most often secondarily attacked by the extension of
a subcutaneous angioma. Osseous forms of this tumour affect
by preference the periphery of bones immediately beneath the
periosteum, but are sometimes met with deep-seated in the
cancellous tissue. Their history is likewise very difficult to
clear up, from the way in which they are confounded with
pulsating cancerous and sarcomatous tumours of bone. The
natural tendency of the external angiomata is to spread ; but
they will often remain stationary, and occasionally, though
rarely, atrophy spontaneously. The various plans of treatment —
by caustic, especially Nussbaum's plan of introducing a fine-
pointed, red-hot needle into the body of the tumour, and the
galvano- caustic needle ; by ligature ; by ligature of the main
artery that feeds the tumour, now much in disfavour ; by
excision, or by Chassaignac's " ecrasement lineaii'e ;" and,
lastly, by the injection of coagulating fluids — are next dis-
cussed, and the conclusion formed that no plan can be recom-
mended for all cases alike.

The internal angioma has only within a comparatively recent
time been made a subject of investigation. That in the liver is
by far the most common, and may be taken as the type of the
tumour in question. It is here met with lying generally just

88 Reviews. Jan.,

beneath the capsule, from the size of a cherry to that of a
walnutj both diffuse and circumscribed, looking like a dark-blue
nodule in the liver-tissue, as if some blood had been extra-
vasated into the part. A closer examination, however, shows
that it is composed of a real cavernous tissue, whose spaces are
filled with blood ; and that it is not an intermediate or adven-
titious deposit, but is substituted for, and takes the place of,
the liver-tissue, beginning in an acinus, and thence gradually
extending. It can be injected from the hepatic artery, so that
the blood circulates in it according to the law, from the artery
through the tumour to the vein, not, as Rokitansky supposes,
from the portal vein through the intercalated tumour to the
hepatic vein. Its development is identically the same as that
of the external angioma, in the hepatic connective tissue, where
it forms its blood-spaces in the manner already described. It
grows slowly ; nor does it in any way interfere with the func-
tions of the organ ; and it has not, as Rokitansky believes, any
affinities with cancer of the liver. The kidneys and the spleen
are similarly, but more rarely, diseased.

The Angioma simplex, or Telangiectasis, to which allusion
has already been made in speaking of the development of the
cavernous angioma, is best studied, in the common congenital
nsevus. This, which is diffuse, to a certain extent erectile, and
has for its seat the skin and subjacent tissues, being either
superficial or subcutaneous, has scarcely a claim to be ranked
among tumours, so flat is it, and so slightly salient. From
the very puzzling appearances which microscopical sections of
the nsevus present, — appearances as of little club-like processes
or bladders filled with nuclei, a result of the corkscrew-like
twisting of the blood-vessels and the different ways in which
they are cut in the section, — the wildest theories have been
hazarded as to its true character. It is really made up of a
congeries of tortuous blood-vessels, whose walls are hyperplastic
and very thick for their size, and which take the place of the
capillaries of the part affected. Between the blood-vessels is
some interstitial connective tissue, with, occasionally, a rem-
nant of fat, hairs, glands, &c., varying in quantity according to
the amount of pressure exercised by the blood-vessels and con-
sequent atrophy of the surrounding tissues. The vessels of the
cutaneous papillae will likewise take part in the dilatation and
hyperplasia when the tumour is cutaneous, and often become
the seat of little saccular enlargements that can be seen with
the naked eye, and are apt to bleed as their walls get thinner.
An interesting variety of the telangiectasis, in which the venous
radicles are involved rather than the capillaries, is the varicose,
or venous angioma. The part of the skin thus affected has to

1868.] ViRCHow on Tumours. 89

the naked eye a red punctate appearance, as if spattered with
blood, and is found when slightly magnified to be made up of
veins, some smaller, some larger, whose walls are thickened
and irregularly dilated into a series of saccular pouches. On
making a vertical section through the tumour, it is observed
that, at a certain depth beneath the surface, these pouches are
separated one from the other by some little interval ; but nearer
the surface, as the rete Malpighii is approached, they become
so approximated as to form an almost continuous layer, with
nothing but the hair-follicles and sweat-glands, and here and
there a thin strip of connective tissue, to keep them apart.
This tumour is either congenital, or appears soon after birth as
a small red spot, which in some instances spreads rapidly, in
others remains stationary or disappears spontaneously. Seeing,
however, that this spontaneous cure is not the rule, and that
there is a frequent tendency in the simple angioma to become
cavernous in the way and manner indicated, Virchow insists
on operative interference being necessary in every naevus that
shows any signs of increase; for there are no marks by which
the tendency to spontaneous disappearance can be prognos-
ticated. After detailing the different plans of treatment in
vogue, he concludes by recommending extirpation for the sub-
cutaneous forms, and for those superficial ones of moderate size
which are seated on the face and neck : but for the deep-
spreading ones, for those which are diffuse, and lie near large
blood-vessels, he recommends caustic acupuncture, either with
Nussbaum's red-hot needle or with the galvano-caustic appa-
ratus.

In connection with that variety of the simple angioma which
infests internal organs, and which is comparatively rare, he
takes occasion to give an elaborate history and description of
haemorrhoids generally, — those, namely, of the anus, as also
the not uncommon venous dilatations about the neck of the
bladder and cervix uteri, sometimes spoken of as vesical and
uterine haemorrhoids. The true internal angioma simplex is
seen most often in the central nervous system, more particularly
in the neighbourhood of the fourth ventricle, in the pons Varolii
and medulla oblongata. Van-der-Kolk's observations on the
frequency of this affection in the medulla of epileptics are
criticised by Virchow, who asserts that he has often detected
telangiectasis in the medulla oblongata of people who have
never had epilepsy, while he has failed, as a rule, to find the
change in real epileptic cases. It has, he thinks, no positive
pathological significance, except that it may in certain cases
serve as a starting-point for haemorrhages. Sections of the
medulla or pons affected with the disease show either the veins

90 Reviews. [Jan.,

or the capillaries dilated in just the same curious varicose way
as in the external angiomata.

Certain vascular abnormities are, lastly, appended to the
group of vascular tumours and called " spurious angiomata/'
Thus, all tumours of the softer kind will at times undergo so
marked a vascular development, that their blood-vessels usurp
the place of the proper tumour elements. This has been seen in
the bronchocele and uterine myoma, and is still more prominent
in some cerebral gliomata and myxomata. In the same class
must be included the vascular excrescence of the female urethra,
or " vascular tumour of the origin of the meatus urinarius '' of
Ch. Clarke. This springs from the little prominence which
naturally surrounds the orifice of the urethra as a small, bright-
red, somewhat granular, very tender tumour which readily
bleeds. It has but a very loose, more or less peduncular, at-
tachment to the mucous membrane, and has this analogy with
the telangiectasis proper, that a very large number of vessels
enter into its composition, which are prolonged up into the
tender papillae of its surface; while it differs from the telan-
giectasis in this, — that the walls of its vessels are not dilated
or thickened. Its basis-substance is a soft mucous or con-
nective tissue, and it is covered over with a layer of tesselated
epithelium. It is a truly local disease, and requires a truly
local treatment, — ligature, excision, or caustic.

The lecture closes with an account of the Lymphangioma
racemosum, which is to the lymphatics what angioma is to the
blood-vessels, — a tumour composed of dilated and tortuous
lymphatics grouped and rolled up together. It is rare, and is
at times remarkable from the periodic discharges of lymph which
will flow from it.

The last part of this book is now in the press, and is promised
to the public in the course of this year, when we shall hope to
give a similar analysis of its contents to our readers, and so
bring the whole to a conclusion.

1868.] Recent Observations upon the Contractile Tissues. 91

Review VII.

1. Memoir on the Contractile Tissues and on Contractility. By
M. Charles Rouget. M. Brown-Sequard's ' Journal de la
Physiologie/ t. vi. Pp. 647—697.

2. On the Structure and Formation of the Sarcolemma of Striped
Muscles in Insects, ^c. By Lionel S. Beale. (*^ Trans-
actions of the Microscopical Society/ vol. xii.)

3. On the Development of Striated Muscular Tissue. By
Wilson Fox, M.D. ('Philosophical Transactions/ 1866.
P. 101.)

4. On the Developmental History of the Muscular Tissue of the
Heart. By C. Eckhard. {' Zeitschrift f. rat. Med./ Bd.
xxix, heft i, p. 55, and Henle and Pfeiffer's ' Bericht/ 1866,
pp. 50.)

5. On the Elements of Transversely Striated Muscle. By
C. J. Eberth. ('Archiv. f. Path. Anat. v. Phys./ Bd.
xxxvi, pp. 100.)

The structure of muscular tissue has long been a fertile
source of discussion. !Nor is this surprising when it is remem-
bered that in all probability the greater part of the appearances
presented in a dissected specimen are factitious, or the result of
post-mortem changes; and that, in the few cases where the
delicacy of the investing membrane of the body in the lower
animals permits the muscular tissue to be examined with high
microscopic powers during life, it appears almost perfectly trans-
parent, with very faint, if any, traces of transverse or longitudinal
striation ; so transparent, indeed, that some inquirers have with
Kiihne contended that the fibres are in their living and active
state filled with a homogeneous fluid or semi-fluid substance.
One of the last numbers of M. Brown-Sequard^s ' Journal of
Physiology^ contains an important essay on this subject from
the pen of the well-known anatomist M. Rouget, which, besides
adding several points of interest to our knowledge of the minute
structure of muscular tissue, is remarkable, as in some respects
returning to the old view of the nature of the fibre advocated by
Muys, Raspail, Barry, and others, that it consists of a flattened
spiral band, wound in a close spire upon itself, and hence
resolving muscular action in great measure into a play of
elasticity.

M. Rouget states that, for upwards of ten years past, he has
bestowed much labour in the investigation of this subject, and
that his attention was first directed to it by the imperfection at

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the commencement of that period of our information relative to
the distinctive characters of the different forms of the contractile
elements. Kolliker's discovery, that the bands of involuntary-
muscular fibre were essentially constructed of long fusiform
cells with staff-shaped nuclei, constituted a great step in advance.
Nevertheless, such nuclei are not always demonstrable in
tissue presenting evident signs of contractility ; and M. Rouget
was himself led to the discovery of certain muscles, as those
surrounding the vesiculEe seminales, the ovario-tubar muscles,
and the proper muscles of the testis by other evidence.

Now, it is a matter of great importance to the physiologist to
determine the nature and the mode of organization of the true
contractile substance, and it is obvious that the essential attri-
butes of all muscular tissue ought to be met with in those con-
stitutional parts in which-the proper activity of this tissue — con-
tractility— resides. The German observers, relying upon external
forms, and preoccupied with the cellular theory, have been
unable to discover any other analogy between the elements of
striated and those of smooth muscular fibre than that resulting
from a supposed cellular origin common to both, whilst thoy
have not sought to explain the cause of any of their numerous
points of difference; and in particular in reply to the question,
with what condition of organization is contractility combined,
they appear to have been satisfied with having found some
transversely striated fibre-cells, constituting an intermediate
form bridging over the interval between the other two. Is
contractility, then, M. Rouget asks, to be considered as neces-
sarily associated with transverse striation? Such cannot be
regarded as the solution of the problem, since it is universally
admitted that a great number of tissues possessing contractile
power are destitute of transverse strise.

M. Rouget proceeds to describe the general structure of a
muscle in the higher animals, its perimysium of connective
tissue, from the internal surface of which septa proceed, that,
penetrating its substance, divide it into fasciculi, and finally
into fibres, details with which every reader is sufficiently fami-
liar. As regards the fibres, he observes that the greater number
of histologists (Rollett, Herzig, Bisiadecki) have believed that
they could demonstrate their cellular nature and origin, and
their entire analogy with the fusiform fibre-cells of involuntary
muscular tissue. In the usual mode of describing the structure
of muscular tissue, the fibres are always considered as essen-
tially differing from even the smallest fasciculi in the circum-
stance of possessing a proper investing membrane — the sar-
colemma — quite separate and distinct from the connective tissue
surrounding and dipping into the substance of the muscle.

1868.1 Recent Observations upon the Contractile Tissues. 93

Nevertheless, it is well to remember that the sarcolemma is not
constantly present. It is therefore not essential to the consti-
tution of muscle, nor to the appropriate performance of its
functions. According to the observations of Dr. Beale, it is
impossible to demonstrate it in the muscular fibres of the heart
or of the tongue. In the case of the frog, there are several
localities in which very distinct and narrow elementary fibres
may be observed, in which no tubular sarcolemma can be
detected; for example, in the small muscles of the eyelids and
eyeball, in parts of the mylohyoid of the green tree-frog, and in
young muscles of the limbs. Perhaps the same statement may
be made of the remarkable rod-like muscles described by
Dr. Carpenter in his late researches on the Crinoidea. But to
proceed with M. Rouget's statement.

In the interior of the tube of sarcolemma, which might repre-
sent the membrane of a cell, or several such membranes
coalesced, is found the contractile substance, respecting the
nature of which opinions vary so widely, the majority, however,
regarding it as formed either of fibrillse or of discs, decomposable
into one or two species of contractile particles (sarcous elements) .
Within the sarcolemma also are found disseminated, cellular ele-
ments termed muscle-corpuscles, or nuclei of muscles, which are
situated sometimes near the centre, sometimes at the periphery
of the contractile substance.

The difficulty that is experienced in many instances in sepa-
rating fibres into fibrillae has caused the greater number of
observers to consider the latter as artificial products ; and
amongst the few who do admit their real existence, they are not
considered to be true anatomical elements, but intra-cellular
formations. It nevertheless may be readily shown, by making
transverse sections, that this description is not accurate, and that
the fibres are really composed of more delicate elementary parts;
and further, that in order to arrive at the true primitive elements
of the muscular substance, two orders of constituent groups
must be successively set free or detached from one another
beyond the artificial limit of the fibre. The best mode of exhi-
biting this is by softening thin sections of muscles by mace-
ration in caustic ammonia, and then submitting them to
examination with a power of 350 diameters. The interior of a
primitive fibre is then found to present segments which are
again subdivided into polyhedral masses by delicate septa, the
whole of which are connected with the internal face of the
sarcolemma in the manner represented in the adjoining
figure.

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Transverse section of two primitive fasciculi from one of the muscles of the thigh
of a frog. 5, sarcolemma ; s', septa, emanating from the sarcolemma, and
dividing the mass of a fasciculus into segments, whose dimensions are
similar to those of the fibres of the higher vertebrata ; /, still smaller septa
dividing the fibres into fibrillae ; n, nuclei of the muscle or muscle-corpuscles ;
g, section of the plasmatic canalieuli, which occupy the angles of intersection
of the septa, separating the primitive cylinders from one another ; v, section
of capillary vessels.

The surface of the primitive fasciculi (fibres) of voluntary
muscle, especially in various articulata, fishes and batrachia, pre-
sents obscure longitudinal lines intermediate to the so-called
striae longitudinales when these are present. These lines, which
are distant from one another about ^^'^rrrth of an inch, and in the
thickness of which fatty granules are often visible for a variable
extent of their length, correspond exactly to the septa which
segment the primitive fasciculi into prisms or cylinders con-
tained within the common envelope of the sarcolemma. Accord-
ing to Leydig, every such primitive cylinder represents a
metamorphosed primordial muscular cell. They are well marked
in the muscles of the lateral line of fishes, where we may easily
recognise the primitive fasciculi thus divided into a number of
polyhedric or prismatic columns, the fatty deposit in the septa of
which confers a peculiar aspect on these muscles, causing them
to differ from those of the trunk muscles generally.

The observations made by M. Rouget on the muscles of
the lateral line of fishes of the genera perca, salmo, scomber
sardella, thynnus, &c,, confirm the existence of the primitive
cylinders of Leydig, but show that they are more numerous
and much smaller than those described by him in the perch ;
and M. Rouget has not been able to perceive the large lacunar

1868.1 Recent Observations upon the Contractile Tissues. 95

cavities represented by Leydig in the centre of the primitive
cylinders. He has noticed only at the angles of junction of
the primitive cylinders obscure starred spots, which correspond
to the sections of canaliculi coursing in the interstices of the
septa of the primitive cylinders. He has, moreover, observed
the same differences of colour, a similar amount of fatty deposit,
and a like capacity of disintegration into primitive cylinders in
the primitive fasciculi of many other muscles than those of the
lateral line; and, what is of still greater importance, he has
ascertained that this division of primitive fasciculi into
cylinders, or rather into primitive prisms, occurs in all the
muscles of animal life in all vertebrata, in a manner iden-
tical with that which has been described as existing in
the muscles of the lateral line of fishes ; whilst in the inverte-
brata the muscular segments, corresponding to the primitive
cylinders, present the most varied forms and most diverse
modes of aggregation. The conclusion at which M, Rouget
has arrived in regard to the intimate constitution of these
primitive cylinders differs completely from that of M. Leydig.
In lieu of the superimposed disks which, according to this
observer, form the primitive cylinders, M. Rouget has every-
where ascertained the presence of fibrillae grouped to form the
primitive cylinders. A primitive fasciculus of the pectoral
muscle of a pigeon, for example, examined when perfectly fresh,
and without the aid of any reagent, presents, independently
of its transverse, a more or less marked longitudinal stria-
tion, according to the degree of contraction of the muscle ; some
fibres always exhibiting it with great distinctness. The longi-
tudinal striae are of two orders, one («') separated by intervals
of about ^-yVo^^i of an inch and more or less well marked, are
especially characterised by the presence of a series of obscure
granules, apparently of the nature of fat, between which may
be distinguished the second set, much finer, separated from one
another by intervals not exceeding ij— oTriith of an inch (/). When
oblique transverse sections are made, it is easy to show — 1st,
That the longitudinal striae of the first order correspond to the
lines which circumscribe the triangles or polygons seen on
transverse sections, and which are sections of the primitive
cylinders j 2ndly, that the series of granules correspond to the
more dull or obscure points of transverse sections, and to the
angles of junction of the prisms or primitive cylinders; and
3rdly, that the fine longitudinal striae of the second order corre-
spond to the interstices of separation of the several pieces con-
stituting the very fine mosaic which covers the surface of the
section of the cylinders, that is to say, to the interstices of the
constituent fibrillae of the contractile substance.

96 Reviews. [Jan.,

Thus the primitive cylhiders are composed of a reunion of still
finer fibrillae into a common group, separated from the neigh-
bouring groups by a line of demarcation corresponding to a proper
envelope. This envelope may not, indeed, be always isolable, in
consequence of its slight consistence ; but its independent exist-
ence is sometimes capable of being demonstrated on longitudinal
section, and is always indicated on transverse section by a well-
defined, dull line. In the fresh state, on transverse section,
there may be seen, at the points of intersection of the septa,
the orifices of lacunae of considerable size, the prolongations of
which penetrate to a greater or less extent into their inter-
stices.

Each primitive cylinder is bounded in this way at a part of
its periphery by canals full of a liquid which doubtless plays an
important part in the acts of nutrition. These canals have no
other wall than a species of semi-solid plasma, which consti-
tutes the septa of separation of the primitive cylinders. (See gi,
fig., p. 94).

If we now proceed to build up a muscle by synthesis we see,
as the first and fundamental constituent, the fibrillse, forming,
by their juxtaposition, the first group — the primitive cylinder.
The cylinders, united in one envelope — the sarcolemma — form
the primitive fasciculus, or fibre. A number of fibres, included
in one and the same sheet of the perimysium internum, represents
a secondary fasciculus, from whence the transition is obvious to
the binary and quaternary divisions and the entire muscle.

Thus, the same type of organization may be seen perpetually
repeating itself in a series of divisions, continually becoming
more delicate ; and the fibre, or primitive fasciculus, the sup-
posed anatomical element of muscle, is constituted exactly on
the same plan as the entire muscle, without other difi'erence
than that which results from the delicacy and tenuity of the
several parts.

In the next place, M. Rouget proceeds to consider the cha-
racters of unstriped muscular tissue, and somewhat sharply
criticises the observations of KoUiker, who, he says, no sooner
discovers in any organ elongated and fusiform cells with a staff"-
shaped nucleus near their centre, than the whole question is
considered to be settled, and the muscular nature of the organ
to be established. No inquiry is made as to the composition
or intimate nature of the supposed cell, whether it is homoge-
nous throughout, whether its envelope is distinct from the
contained material, or whether the contractile power belongs to
the contents or to the envelope. Upon all these questions no
interest is felt, nor is any trouble taken to reply to them.

He then refers to the general arrangement of the fibres of

1868.] Recent Observations upon the Contractile Tissues. 97

smooth muscular tissue, showing how they form membranes
enclosing cavities by interlacing and anastomosing with one
another, and being at the same time mingled with much con-
nective tissue rich in elastic fibres. Apart from these pecu-
liarities, the smooth dififer from the striated muscular fibres
much more in their outward appearance than in their intimate
striation. Both forms of contractile substance, in fact, possess
this essential feature in common : that they are formed by a
group of contractile fibrillae enclosed in one and the same enve-
lope of connective tissue, into the interior of which the vascular
canals never penetrate. The nutrition of the elements contained
in the sheath of the primitive fibres (sarcolemma) and in that
of the smooth fibres, really depends on a system of canaliculi,
of lacunae, and of nuclei, analogous to that seen in osseous,
fibrous, and in other tissues.

The muscular fibres of the heart appear to occupy an inter-
mediate position between the striated and smooth forms. They
present the striking peculiarity of interlacing and anastomosing
with one another, and although they present well-marked
transverse striae, M. Rouget considers that, upon the whole, they
have more affinity with the smooth than with the striated type
of muscular tissue ; and this opinion is supported by the obser-
vations of Weissmann and Gastaldi, who have found that in
fishes and reptiles the fibres of the heart can be broken up into
fragments, containing nuclei identical with the fibre-cells of
organic muscles, without the aid of any reagent. Even in adult
birds similar cylindrical fusiform fragments can be detached,
which, however, are not to be regarded as fibre-cells, or as
proper cellular elements, since they contain numerous nuclei,
and may even be further broken up into true fibres.

M. Rouget is of opinion that the balance of evidence is deci-
dedly in favour of the view which holds that the natural ten-
dency of muscular tissue is to split up longitudinally into
fibrilhe rather than into discs. The appearance of the latter
(he observes) is always associated with marks of violence, or is
the result of chemical action, as of hydrochloric acid, whilst
that of the former is perfectly natural, their size constant, their
outline always defined, and they may be well observed in
the muscles of insects when the sarcolemma is deficient, each
fibrilla being surrounded by a somewhat thick layer of connec-
tive tissue.

The longitudinal striation indicative of the presence of fibrillee
may, indeed, sometimes be imperceptible ; but this is only when,
in consequence of vigorous contraction, the transverse striae are
brought into strong relief. This is well shown by comparing
fibres acted on by weak hydrochloric acid (t-oVo ) } ^^^ by strong

81— XLI. 7

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solution of common salt : iu the former case the fibre swelling,
and the longitudinal striations being very evident ; in the latter,
the tissue undergoing contraction, and the transverse striation
comiug clearly into view and masking the longitudinal. He
believes, therefore, from these and other considerations, that the
existence of fibrillse may be shown without the intervention of
any manipulation to which the artificial development of these
elements can be attributed.

M. E-ouget then proceeds to consider the existence of fibrillse
in smooth muscular tissue, a point to which (he remarks) no
attention has hitherto been directed. Many of the muscles of
the invertebrata, as the adductor muscles of the lamellibran-
chiata, present the characters of the striated form of muscular
tissue in a very well-marked manner ; but in many, perhaps
even in the greater number, the muscles of animal life present
close analogies to the smooth muscular fibres of vertebrata — the
fibres being destitute of transverse striation, smooth, homoge-
neous, and highly refractile. But even here, with high micro-
scopic powers, and in the fresh state, they may clearly be seen to
be invested by a delicate, transparent, and elastic membrane,
occupying the position of a sarcolemma, and to present finely
granular longitudinal strise, and occasionally an obscure trans-
verse striation, the former being very distinctly brought out by
immersion of the fibre for a few hours in water. Such fibres
maybe obtained from the earthworm.

The smooth muscles of vertebrata may, even with low magni-
fying powers, be seen to be composed of anastomosing and
decussating fibres, accompanied, in a part at least of their
course, by nerves and vessels. The finely granular appearance
which they present may, with high powers ( x 600), be resolved
into undulating longitudinal striae, which are, in fact, fibrillse
analogous to those of voluntary muscular fibre, from which they
differ only in their smaller diameter and in their transverse
markings, being less regular. When the fasciculus is intact,
the direction of the fibrillse is everywhere parallel to its axis,
and they appear continuous throughout its whole length.
Besides these striae, however, oblique lines may be seen tra-
versing the fasciculus, and indicating the boundary of two
adjoining muscular fibre-cells, each of which contains in its
interior a rounded or elongated staff-shaped nucleus. Never-
theless, a few days^ maceration in dilute hydrochloric acid shows
that the fibrillse are perfectly continuous, not only throughout
the whole length of the fusiform fibre-cell, but across the
boundary line dividing the cells from one another, and there-
fore throughout the whole length of a muscular band or fasci-
culus, which thus comes to be equivalent to a primary fasci-
culus, or fibre, of striated muscle.

1868.] Recent Observations upon the Contractile Tissues. 99

Additional evidence of the uninterrupted continuity of these
fibres is aflPorded by the presence of a sarcolemma investing
their whole lengthy by the destruction of which alone it occurs
that the fusiform elements — the so-called fibre-cells — separate
from one another. It may be urged that the presence of a
sarcolemma cannot be demonstrated in the fusiform elements
that may sometimes be detached even in the perfectly fresh
state, nor in those set at liberty by maceration in alkaline or
acid fluids ; but in truth such fusiform elements are quite
deprived of sarcolemma, in the former case because they have
escaped from the sarcolemma, and in the latter (viz. when
chemical agents have been employed) because the sheath has
been destroyed by the reagent. Thus, though it exists, it is
difficult to exhibit the sarcolemma of smooth muscular fibre in
the muscles of vertebrated animals, except by indirect means,
as by dissolving the sarcolemma, and setting the fusiform
elements free, or by dissolving the contractile substance and
leaving the investing sheath.

In the invertebrata, on the contrary, it is a comparatively
easy task, but in both classes the intimate structure is identical.
It is easy to substantiate all the statements made by M. Kouget
in the muscular bundles of the snail or of the leech, in which
may be seen the mode of union of the fusiform bodies, their
obliquely cut surfaces interdigitating with one another by very
distinct dentations which establish a complete continuity

Figure shomng the interpenetration and fusion of the extremities of two fusiform
fibres from the common leech. At several points the contractile substance
appears to pass without interruption from one fibre into the other.

between them, their exact adaptation to one another to form
muscular bands, of which the calibre and the form (generally
cylindrical) are perfectly uniform throughout the whole length
of the muscle; and lastly, the uninterrupted passage of the
sarcolemma over the surfaces of union of the fusiform bodies, so
as to enclose in a common cavity all the segments of one and
the same muscular cylinder.

Addressing himself, then, to the subject of the corpuscles,
which are found distributed through the substance of muscle.

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M. Rouget denies emphatically that the striated muscles belong
to the class of cellular formations. Not only, he says, is
the true mode of development of muscle contrary to this view,
but it is impossible to conceive a cell which possesses in its inte-
rior quite a system of cell formations (muscle-corpuscles)
identical in their nature with the connective-tissue-corpuscles.
The fibres of striated muscle, with their internal framework of
connective tissue, and their proper circulatory system, which he
believes to be constituted by the lacunae, the plasmatic canals,
and the muscle corpuscles situated in the thickness of the septa,
cannot be connected with a primitive cellular formation except
by those who are blinded by preconceived opinion. If this be
true for striated, it is also true for unstriped muscular fibre. In
these fibres also we find a framework of connective tissue, viz,
the sarcolemma investing the bands formed by the smooth fibre
and fibrillse; two systems difiering from one another in their
origin, as well as in their nature, and never having been consti-
tuent together of the same cell.

The great argument in favour of the cell-theory of develop-
ment in muscle is the presence of nuclei, each of which may be
supposed to correspond to a primary cell : but if it be asked,
does this nucleus belong properly to the contractile substance of
the fibrillae, the reply is unquestionably that it does not. For
if we examine the muscles of the trunk of a leech or snail, it is
easy to isolate with the aid of hydrochloric acid muscular cords
formed of four or five fusiform segments soldered together. In
the interior of each of these segments is a cavity which occupies
its whole length, and which is filled by a granular plasma. It is
in the centre of this substance that the nucleus is found, and it
is to this that it really belongs. This granular mass, with its
nucleus, is the apparatus of nutrition of the cell, which is as
entirely distinct from the group of fibrillse surrounding it as the
fundamental substance of bone is from the osseous cells and
their ramifying canaliculi. The central nucleus of the fusiform
cells, and the cavity which contains them, represents exactly in
the smooth muscle the nuclei and the plasmatic canaliculi of the
primitive fibres of the muscles of animal life.

From the consideration of the structure of the muscles of
these and other animals, M. Rouget believes that the fusiform
segments of the smooth muscular fibres are nothing else than
the divisions of these fibres, a peculiar mode of grouping of the
fibrillse. In the fibres of the striated muscles the fibrillse are
grouped into cylinders, whose length equals that of the muscular
cord, and which can be separated laterally from one another.
In the smooth muscles the fibrillse are grouped into segments
separable more or less obliquely from one another, and pos-

1868.] Recent Observations upon the Contractile Tissues. 101

sessing at their centre plasmatic lacunae and nuclei, which
ordinarily correspond to those at the periphery of the fibres of
striated muscles.

Lastly, in reference to the transverse striae of muscular tissue,
he observes that in articulata two sets may be distinctly observed,
one of which is much coarser than the other. The coarser and
thicker striae are the expressions of undulations on the surface
of the fibre, whilst the more delicate correspond to the striations
of the fibrillae ; that is, to the so-called sarcous elements. That
the coarser striae are not the collective expressions of the
fibrillar markings is shown by the fact that, in the vertebrata,
they are two or three times larger than the sarcous elements
themselves. He entirely disbelieves the doctrine of Briicke,
Rollett, and others, by whom the muscles are supposed to be
constructed of disdiaclasts of variable length corresponding to
the distance between the adjoining striae; and he is equally
opposed to another view generally entertained, to the effect that
the fibrillae are composed of alternate layers of doubly and
singly refracting material, since, were this the case, the appear-
ances presented should always be identical; whereas, as
M. Rouget has himself shown, when muscle is examined by
means of polarized light, those striae which present a dark
appearance may, with the slightest alteration of the focussing,
be instantaneously converted into the transparent striae, and can
undergo identical changes of colour in chromatic polarisation,
showing that, in point of fact, there is no difference between the
dark and the transparent striae. He recommends strongly the
stereoscopic examination of photographs of muscular fibres, as
showing that the transverse striation is entirely owing to
wrinklings or undulations of the surface of the fibre, which fre-
quently, by the strong play of their light and shadow, obscure
the longitudinal striation that is always revealed on close
inspection.

Fibril from a muscle of the wing of an Ateuchus, strongly stretched, whilst still
contractile X 700. At the lower part the fibrillar striaj present their normal
regularity, but as the fibril is followed to its extremity, broken by the forcible
extension to which it has been subjected, the turns of the spire arranged at
first vertically are seen to become more and more oblique, and more and
more separated from one another, till the helicoid arrangement is very dis-
tinctly shown.

102 Revieivs. [Jan.,

Careful examination has convinced him that the contractile
fibrillae of striated muscle is really an elastic helix, of which
the spiral turns, separating from or approximating one another
during life, determine the state of contraction or repose of the
muscular mass.

Mechanical extension can produce an elongation in the living
fibre, a partial unrolling of the helix, to which the various forms
presented by the fibrillae are due. After death and the esta-
blishment of cadaveric rigidity, the fibrillae become very fragile
and inextensible, maintaining without alteration the approxima-
tion of the turns of the spire which existed at the moment of
the accession of the rigor mortis.

The fibrillae of smooth muscle, in lieu of presenting this
regular spiral arrangement characteristic of striated fibre, are
simply undulating bands; the undulations, however, not
extending through the whole thickness of a fibre.

Striated fibres (he concludes his observations by remarking)
are elastic apparatuses, resembling spiral springs, whilst smooth
muscular fibres are simply elastic, like the fibres of wool or of
twisted hair.

Having devoted so much space to the consideration of M.
Rouget's observations, we can only here glance at the results
obtained by the other able writers whose names appear at the
head of this article, and who have been for the most part occu-
pied with the subject of the development of muscle. The
investigations of Dr. Beale on the structure and formation of
the sarcolemma were chiefly made on insects, and especially on
the larva of the silkworm. " In considering,^^ he says, " the
development of muscular tissue and other structures connected
with it, it must be borne in mind that several tissues of very
different nature are undergoing development at the same time,
and in very close relation with one another, and that the appa-
rent confusion often observed in specimens is in great measure
due to the number of nxiclei which take part in the formation
of these different textures. Even at a very early period of
development of muscular tissue, nuclei of more than one kind
can be clearly recognised, and have been figured by some
observers. There are at this early period nuclei which take
part in the formation of muscular fibres, nuclei concerned in the
development of vessels, and nuclei concerned in the development
of nerves ; and at a later period, in fully formed muscle, other
nuclei are found, which lie imbedded in the substance of the,
sarcolemma, others again belonging to the connective tissue
upon its external surface, and, finally, others which lie upon the
surface of the contractile tissue, just beneath the surface of the
sarcolemma. Hence there can be little doubt that, as Dr. Beale

1868,] Recent Observations upon the Contractile Tissues. 103

believes, many of the nuclei seen in connection with the sarco-
lemma of striped muscle are really the nuclei of vessels and
nerves ramifying upon its external surface. He shows that in
some instances these vascular and nervous nuclei may be
stripped off from the surface of the neurilemma, leaving this
membranous tube clear and almost destitute of any nuclei
whatever. He observes that the sarcolemma is imperceptible
in young muscles ; distinct, but thin, in fully formed muscles ;
thick, and comparatively firm, in old muscles ; that it certainly
does not result from changes taking place in an expansion of
flattened cells covering the surface of the muscle — an undoubted
mode of origin of some delicate membranous structures — for no
such cells are to be demonstrated during the development of the
muscle in any case ; and he appears to coincide with the state-
ments of Rouget above given in thinking that the sarcolemma,
especially in many of the old muscles of insects, is continuous
with the intermuscular connective tissue. His description of
the sarcolemma of insects, as seen in the larva of the blowfly, is
very remarkable, and his observations as here detailed corrobo-
rate his former statements in reference to the /io/i-penetration
of the sarcolemma by nervous fibres — a point in which it is well
known he is at issue with some of the leading German microsco-
pists. The sarcolemma in this insect presents a number of
transverse lines, which are situated in the membrane itself, and
which, being at nearly the same distance as the transverse
striae of the muscular tissue beneath, has caused them to be
overlooked. These transverse markings really consist of the
ramifications of fine branches of the trachaese, and crossing the
fibre in all directions are numerous fine nerve fibres, which, with
very high powers, may be shown to form an anastomosing
plexus, or network, over the surface of the sarcolemma, and so
intimately adherent to it as to form a part of its substance.
He regards the appearance termed by Kiihne a '' Doyereschen
nervenhugel,^^ or nerve heap of Doyere, and regarded by this
anatomist as the point where the nerve-fibre penetrates the
sarcolemma, as in reality only the profile view of that part of
the muscle-fibre where it is joined by a bundle of nerves, and
where a portion of the sarcolemma is drawn out as it were into
a cone, though far from terminating here, as Kiihne maintains
they may, with sufficient care and high magnifying powers
(jL-th or Tirth), be seen to form the anastomosing plexus above
described.

Dr. Fox, whose observations were conducted upon the tadpole,
chick, sheep, and human embryos at various stages of growth,
though he regards the muscles of the tail of the tadpole as
offering by far the best material for investigations of this nature,

104< Reviews. [Jan.,

obtains the following results by the use of high power (tV*^
and ijVthj Powell and Lealand, magnifying from 900 — 1850
lin. diam.). The earliest forms (he remarks) which indicate
any differentiation from the round cells of the embryo are
indicated by the appearance of oval bodies^ measuring about
-j5-^th of an inch in their long diameter, and about -To-oth in
their short, containing a clear oval nucleus, which is surrounded
by pigment granules and glistening scales. He is disposed to
regard these bodies as cells, on account of their sharply defined
outline, stability, and distinctness, notwithstanding his inability
to distinguish an investing membrane surrounding them at the
earlier period of their development ; and he considers that this
view of their nature is supported by the appearance of a cell-
wall at a somewhat later period, and also because upon re-
examining some of his preparations after a period of twelve
months, he has found that in some of the early cells the con-
tents have shrunk, and the outline of a membrane has become
quite distinct.

Whether these bodies in their earliest development be cells
or not, as they advance they elongate, the nuclei sometimes
remaining stationary, at others multiplying by division, and
having attained a certain length a change in their structure
becomes apparent. " Usually at one side a part appears lighter
than the rest, and in this position sometimes a longitudinal,
sometimes a transverse striation, makes its appearance;" or
both may occur simultaneously. There is no sharp line of
demarcation between the altered and unaltered portions, and
over the former grains of pigment are seen sparsely scattered.
The pigment then gradually diminishes, and at this stage a
distinct membrane may be seen bounding the granular portion,
and soon after on the clearer side where the striae are percep-
tible, conditions of which Dr. Fox gives numerous drawings.
As development progresses, the amount of space occupied
relatively by the granular portion of the contents of the mem-
branous envelope diminishes, and its place becomes gradually
occupied by striated matter. A membrane may still be traced
over the whole structure, and the nuclei, which are sometimes
numerous, sometimes solitary, are uniformly situated between
the membrane and the striated portion, surrounded by a little
dimly granular material. Dr. Fox's account of the process of
development, both in the tadpole, as shortly given above, and
in the chick, which is closely similar, is exceedingly clear and
intelligible. He considers that the cell-wall becomes gradually
converted into the sarcolemma of the fully formed muscle, and
attributes the absence of this membrane in the fibres of the

1868.] Recent Observations upon the Contractile Tissues. 105

heart rather to its extreme tenuity rendering it invisible than
to its absolute deficiency.

Finally, Dr. Fox is disposed to consider each fibre as a
structure representing a series of many potential cells which
have never become detached from one another, their division
after the multiplication of their nuclei having been prevented
by the longitudinal fibrillation, as shown by striation of a
portion of their contents, while the sarcolemma would thus
represent the united membranes of many cells which have been
engaged in the formation of the fibre.

We consider this to be a very fair statement of the case, and,
as Dr. Fox himself remarks, it is a view essentially different
from that of Schwann, by whom the fibre was represented as
formed by the fusion of a series of pre-existent and independent
cell structures.

M. Eckhard, from the results of his observations, some of
which were, like those of Dr. Fox, made upon the dorsal muscles
of the tadpole, is disposed to believe that, in its earliest stages,
muscular tissue consists of nuclei surrounded by protoplasm ;
after a short space of time the nuclei arrange themselves in
series or rows, and the contractile striated substance is deve-
loped in and from the protoplasm. The protoplasm of the
several nuclei, he says, is so intimately blended and continuous
throughout, that the arrangement may be rendered perhaps
more intelligible, by saying that, in the first instance, there are
cords or long masses of protoplasm in which the nuclei lie
imbedded. If some of these masses possess a contour line
resembling a cell- wall, it appears to him to be rather a con-
densation of the external portion of the protoplasm, than a
separate structure. The further progress of the protoplasm
cylinders containing nuclei, is described by Eckhard in terms
essentially similar to those of other observers, only he admits
the possibility of the spontaneous origin of the nuclei in the
protoplasm without division of previously existing ones. In the
case of the walls of the heart in the chick during the second and
third days of incubation, they consist of clear vesicular nuclei
with one or two well-defined nucleoli which lie imbedded in a
finely granular protoplasm. He has never been able to discern
any indications of a division of this protoplasm in accordance
with Schwann^s cell theory, either at this or at a later period.
At the end of the third day, however, there appears in the pro-
toplasma a number of fine irregularly coursing and anasto-
mosing fibres. They are usually in close relation with the
nuclei, and seem as if they had been formed under their influ-
ence. The fibres, when examined in the recent state, are quite
soft and compressible, but they can be rendered firm by a short

106 Reviews. [J

an.,

immersion in a weak solution of bichromate of potash. At this
period of development, structures may easily be isolated, bearing
considerable resemblance to stellate cells, though it is impos-
sible to demonstrate any investing membrane, whilst an addi-
tional circumstance rendering their nature doubtful, is found in
their easy destructibility. As soon as the fibres make their
appearance, the nuclei begin to degenerate ; they become fewer
in number and smaller in size in proportion to the increase of
the intervening substance and fibres. Whether, in the further
development of the muscle, new nuclei are formed or no, has not
been ascertained. With the consolidation of the fibres the
formation of transverse striae commences.

Eberth's observations were made upon the muscles of the
palps of embryo spiders, and he describes the muscles as con-
sisting of fusiform, uninuclear cells, equalling yV^h of an
inch in length, and containing a finely granular protoplasm.
On these immense cells transverse striation becomes per-
ceptible, if their apparent magnitude be only doubled. Each
cell fills the entire space between the origin and the insertion of
the muscle. All increase in the thickness of the muscle results
from simple growth of the cells, and not from their coalescence;
the nuclei multiply by division, which is preceded by an increase
in the number of the nuclear corpuscles. In the earlier periods
of development the nuclei are arranged in a single row in the
axis of the fibre-cell, but at a later period they pass towards the
surface.

It will be seen from these observations, as well as those of
Forel on the Najadae, and of Mecznikow on the Planariae, as
compared with those of Lockhart Clarke, Savory, and others,
that two opinions are held amongst physiologists respecting the
earliest condition in which the contractile tissue exists, some
considering that the individual fibres proceed from one or from
a group of cells, in the contents of which striation both in the
transverse and longitudinal direction soon appears, whilst others
maintain that nuclei only are in the first instance present,
each of which accumulates around itself a quantity of granular
protoplasm matter and pigment matter, in which striation
occurs, but which may or may not be invested by a proper cell-
wall. It is possible that diff'erences may exist in different
species, and it may fairly be stated that, before any definite
conclusion can be arrived at, it will be requisite that careful
inquiry should be made in a much larger series of animals than
have hitherto been under observation.

1868.] Hospital Reports. 107

Review VIII.

Saint Bartholomew's Hospital Reports. Vol. II. Edited by Dr.
Edwards and Mr. Callendbr. 1866. Pp. 264.

Clinical Lectures and Reports by the Medical and Surgical Staff
of the London Hospital. With an Appendix on the Recent
Epidemic of Cholera. Vol. III. 1866. Pp. 499.

The volume of St. Bartholomew's Hospital Reports' contains
twenty-six papers, of which the following are abstracts :

I. — Pathological Anatomy of the Kidney. By Reginald
Southey, M.D. Oxon. — In this paper Dr. Southey treats of
the diseases of the kidney as they originate in the primary
structures of which the organ is composed, namely, the stroma
of areolar tissue, the tubular gland system, the blood-vessels, &c.
He divides interstitial disease into hypertrophy, or simple in-
crease in quantity of the intercellular elements or substances ;
cellular hyperplasy , or the changes which take their origin from
the cells of the connective tissue, the cells multiplying by rapid
division of nuclei at an early stage of their development ; and
simple fatty degeneration. The pathological changes commenc-
ing in the vascular apparatus are thickening of the walls, which
may be simple or amyloid; dilatation of the vessels, which may
be simple or degenerative ; and obstructions of vessels, such as
embolism of arteries, and thrombosis of veins. In reference to
the changes in the glandular elements of the kidney. Dr. Southey
considers that the urinary tubes do not usually become affected
by what is called catarrh, as a primary disturbance, but that a
gonorrhoeal catarrh of the urethra, or prostatitis, or a vesical
catarrh is by far the most common cause of catarrhal changes
in the tubuli uriniferi ; but he admits that this affection may
commence in the glandular tubes proper, when they are exposed
to the direct excitation of poisoned blood or too highly stimu-
lating diuretics. An instance of catarrhal change in the kidney
beginning in the Malpighian bodies is afforded in fatal cases of
cholera. In this disease the blood becomes so thick that it
circulates with great difficulty through all the capillaries of the
body, and its stagnation in the Malpighian bodies gives rise to
the venous congestion observed in the cortical portion of the
kidney, and to the ecchymoses which may be observed occa-
sionally in that structure.

108 Reviews. [Jan.,

II. — On Congenital Cystic Tumour. By Thomas Smith. —
The disease thus named by Mr. Smith is defined by him as a
tumour formed of an admixture of cystic and solid substance
in varying proportions^ the cystic element consisting of one or
more circumscribed cavities^ with thin walls, and containing
serous fluid. Such tumours are liable to be mistaken for fatty
growths, for subcutaneous nsevi, and even for spina bifida, but
in the last case the skin over the tumour is in a discoloured
state, and in the others the diagnosis may be made by the intro-
duction of a grooved needle. The disease does not appear to be
a fatal one, and is not very serious except from the great bulk
which the tumour sometimes attains, and a spontaneous cure
has not unfrequently happened. Of all the remedial mea-
sures recommended for the treatment of this affection, Mr.
Smith prefers the employment of the seton, and he gives the
particulars of five cases in which this plan was successfully
adopted. He admits that in the hands of other surgeons the
treatment by seton has not always been successful, but he
thinks that where fatal results have ensued, the setons were
too large, and that fatal inflammation or suppuration super-
vened.

III. — Practical Observations on Diphtheria. By W. Newman,
M.D. Lond. — The author of this paper believes, in common
with most modern physicians, that diphtheria is not so much a
local as a constitutional disease, depending on some morbid
condition of the blood. He combats the views of those who
once believed that diphtheria was an exanthem like scarlet fever,
and he points out the diagnostic marks by which the two
diseases may be distinguished. He regards diphtheria as a
disease in which some morbid material is received into the
blood, causing general constitutional disturbance, and being
specially marked by what Dr. Newman somewhat erroneously
designates the exudation of lymph about the mucous membrane
lining the throat, pharynx, and upper part of the air passages.
This local state, however, like the eruption in scarlatina, is not
a constant or necessary attendant of the affection, which may
consist only of the constitutional disturbance. Dr. Newman
divides diphtheritic affections into the simple and the malignant,
the former comprising the laryngeal disease, and the latter the
nasal complication, but it is rather questionable whether the
malignant form described by Dr. Newman is not to be regarded
as scarlatina. The rules of treatment laid down are in accord-
ance with those generally adopted by modern physicians, and
consist in the local application of the strong hydrochloric acid
■with an equal bulk of honey or water, in the internal administra-

1868. J Hospital Reports. 109

tion of wine, and in the use of a stimulating and supporting
diet.

IV. — Onthe Relation of Phlebitis and Thrombosis to Pyamia.
By William S. Savory, F.R.S. — After briefly alluding to the
exploded idea that pyaemia is due to the absorption of pus from
distant parts, and its subsequent deposition in the localities where
it is found, Mr. Savory examines the connection existing between
pyaemia and phlebitis, a combination which he believes to be
rarely observed, as the worst forms of phlebitis often exist
without producing pyaemia. The supposed existence of pus in
the canal of a vein, the lining membrane of which has poured
out lymph, has been shown to be caused by the disintegration of
coagula in the veins, such disintegration giving rise to a granu-
lar and oily matter which appears puriform to the naked eye.
As the result of his inquiries Mr. Savory concludes that throm-
bosis may exist without any evidence of phlebitis, and that it
very often occurs without being followed by pyaemia; that
phlebitis may occasionally exist without thrombosis, and often
occurs without being followed by pyaemia ; that pyaemia often
exists without any evidence of thrombosis or phlebitis; and
that, therefore, it has not been satisfactorily shown that either
phlebitis or thrombosis stands in any special or peculiar manner
in relation to pyaemia as cause and effect.

V. — Case of Intra-cranial Cyst containing Hair ; also a Case
illustrating the Physiological Action of Iodine. By William
Turner, M.B. Lond., F.R.S. E. — The first case was observed
in the cranium of a male child, aged twenty-three months,
whose body was being dissected in a medical school. The tumour
was of about the size of a French bean, and was situated between
the dura mater and the occipital bone. The cyst appeared to
belong to the group of tumours designated by Mr. Paget as
cutaneous proliferous cysts. The second case was one of local
iodism, and occurred in a laboratory where an experimental
chemist had been exposed for several hours on two successive
days to the vapours of iodine and hydriodic acid. The symp-
toms were irritation of the mucous membrane of the eyes and
nose, and occasional frontal pain, but there was no salivation
or soreness of the gums. The effects passed off without the
adoption of any treatment.

VI. — Remarks on the Use of the Thermometer in Disease.
By John Southey Warter, M.D. Edin. — In this paper Dr.
Warter shows the value of thermometrical observation in the
diagnosis of disease, the instrument giving information which

110 Reviews. [J

an.

cannot be obtained by other means. The paper is illustrated
by a diagram showing the curves of temperature in different
diseases, the range being from 94° to 105°. In the diagnosis
of typhoid and typhus fevers from other diseases, the thermo-
meter affords valuable aid, and the elevation of temperature in
what appears a simple diarrhoea, may announce an attack of
typhoid ; and, again, the maintenance of a low temperature in a
case exhibiting symptoms resembling fever may prove the ab-
sence of typhus. Dr. Warter also thinks that the difference of
thermometric indications is one of the proofs of the non-identity
of typhus and typhoid fevers. In active tuberculosis there
is always some elevation of temperature, and the same is the
case in pneumonia and acute bronchitis, but in abdominal dis-
eases the thermometer gives no special information. In hysteria
the temperature is not raised above the natural standard, and
from this circumstance Dr. Warter thinks that valuable infor-
mation may be obtained in distinguishing that affection from
several inflammatory and feverish maladies which in some
respects resemble it.

VII. — On the Treatment of Enlarged Bursa over the Patella.
By William S. Savory, F.R.S. — In this short communication
Mr. Savory recommends a mode of treatment which he believes
to be the most efficacious yet adopted, namely, to puncture the
enlarged bursa with a lancet, to press out all the contents, and
then to subject it to firm pressure by a pad of lint, strapping,
and bandage, so that the walls of the cavity may be everywhere
kept in contact, and the sac thus obliterated.

VIII. — On Gouty and some other Forms of Phlebitis. By
James Paget, F.R.S. — Mr. Paget, in this paper, gives an account
of some cases of phlebitis, different from any he has found on
record. They are all examples of the so-called adhesive phle-
bitis, in which inflammation of the coats of a vein is associated
with clotting of blood in its canal, but not with suppuration or
pyaemia. The disease to which Mr. Paget gives the name of
gouty phlebitis is that condition in which phlebitis is associated
with ordinary gouty inflammation in the foot or joints, and
occurs in persons of marked gouty constitution. It is found
more usually in the lower limbs, and affects the superficial
rather than the deep veins. Mr. Paget does not consider that
active treatment is necessary in the management of gouty phle-
bitis, the best agent being rest, with the trunk and limbs level.
Other forms of phlebitis are described in the paper, one case
described being of a very rare kind, in which the disease

1868.] Hospital Reports. Ill

extended through large portions of the branches of both the
superior and inferior venae cava.

IX. — Case of Congenital Myopia, with a faulty perception of
Colours, limited to a small portion of one Retina, of recent
origin. By Bowater J. Vernon. — The subject of this case had
always been short-sighted ; but after examining the spots on the
sun with the aid of a powerful telescope, about four years ago, it
would appear that some injury was done to one retina, for after
a time he found that he could not distinguish colours so accu-
rately as he had done before. Examination with the ophthal-
moscope showed considerable choroidal changes in the fundus of
the right eye, and Mr. Vernon considers that a small portion of
the retina on that side has lost the power of appreciating tints,
while its functional power does not seem to be otherwise
impaired.

X. — Respecting Rupture of the Axillary Artery in reducing
Dislocation of the Shoulder -joint. By George W. Callender.
— In this paper Mr. Callender relates some cases in which the
axillary artery was accidentally torn, the first case being one
which occurred in his own practice at St. Bartholomew's Hos-
pital. The patient was a man, aged 61, who had a dislocation of
the head of the humerus. It had been reduced when the accident
first happened, but had recurred in consequence of injudicious
movements made on the part of the patient and his friends.
When he came to the hospital the dislocation was reduced only
with very great trouble ; and as simple extension had failed, the
object was at last obtained by circumduction of the humerus ;
but immediately after the reduction a swelling was perceived
beneath the pectoral muscle, and it resisted all the ordinary
means used for its dispersion, till at last it was determined to per-
form an operation both for the removal of eff'used blood, which,
it was conjectured, had flowed from the rupture of the axillary
artery, and for the ligature of the artery itself. The axillary
space was accordingly opened, and the coagula and the effused
blood were removed, after which the artery was tied in two
places and divided between the ligatures. The patient did well
for a few days ; but he subsequently died suddenly, with symp-
toms of pulmonary embolism. After relating this case, Mr.
Callender refers to other cases of the same accident, thirty-one
in number, which are arranged into classes according to the
general characters they present. The conclusions drawn from
the consideration of all the cases are generally that the axillary-
artery has been known occasionally to give way from accidental
causes ; that this rupture is a rare accident ; that it has usually
occurred during extreme extension, when the head of the bone

113 Reviews. [Jan.j

has been twisted round in effecting the reduction ; that the
accident has happened to persons above fifty years of age^ the
dislocations being old or the artery being diseased ; and that,
although the occasional occurrence of the accident does not
contraindicate the attempt to reduce old dislocations, yet that
caution should be observed so as not to overstretch the vessel by
circumduction and extreme extension.

XI . — Remarks on the Rectangular Talipes Eguinus ofOrthopcedic
Surgery. By Holmes Coote. — The condition here described is
when the patient walks on the sole of the foot, but cannot raise the
foot beyond the right angle to the leg, in consequence of the tense
condition of the tendo-Achillis. The inconvenience is not very
great in persons who are not obliged to work ; but in those who
are, treatment becomes absolutely necessary. Mr. Holmes
Coote does not believe that the affection is congenital. The
treatment consists in removing any cause of excentric irritation,
as decayed teeth, irregularities of the menstrual functions, &c. ;
in giving alterative medicine and employing stimulating lini-
ments; in using steady and continued extension by Scarpa^s
shoe ; but in most cases the division of the tendo- Achilles
becomes ultimately necessary.

XII. — On the Treatment of Irreducible Hernia. By John
Langton. — In opposition to the views of those surgeons who
advise that an irreducible hernia should be left in a great
measure to itself, or that its reduction should be attempted by
absolute rest, abstinence, and the use of evacuants, Mr. Lang-
ton advises that certain mechanical means should be used, having
for their object the gradual return of the hernia into the ab-
dominal cavity, and that the patient should continue his usual
avocation. He divides irreducible hernia into epiplocele, en-
terocele, and entero- epiplocele, the second being the most rare.
He describes the apparatus by which pressure of the tumour is
effected, and he states that at the Truss Society the cases are
successfully treated in the manner he describes.

XIII. — Case of Wound of the Right Lumbar Region, involving
and laying bare the Kidney ; complete Recovery. By Bowater
J. Vernon. — The patient was a boy, aged 14, who was brought
to the hospital after having fallen from the wall of a house, at a
distance of forty feet, upon a heap of rubbish. On examination
a wound was found extending across the spine from above the
right iliac crest, and on the right side the erector spinse was torn
through, and in the gap thus formed the lower end of the right
kidney protruded, a portion of it as large as a walnut being

1868.] Hospital Reports. 113

fairly exposed. Mr. Paget secured a portion of the integument
over the wound, so as to protect the exposed kidney, and the
wound was lightly dressed with oiled silk, and frequent but
small doses of opium were administered. Urine was discharged
from the wound for several weeks ; but eventually the wound
healed over, and the lad was discharged apparently in perfect
health.

XIV. The Inheritance of Cancer and its relations to Questions
concerning the Local or Constitutional origin of the Disease. By
W. MoRRANT Baker. — In support of the constitutional origin
of cancer, Mr. Baker adduces some statistics collected by Mr.
Paget, which show that of 103 cases there were forty-five in-
stances (in forty-one families) of direct inheritance from father
or mother. As to the results of operation, they seem, on the
whole, to confirm the views of those who argue for the con-
stitutional origin of cancer, the number of cures being at present
insufficient to support the notion of the local nature of the
disease.

XV. Observations on the Pathology and Treatment of Joint
Disease. By Holmes Coote. — After describing the details of
two cases, Mr. Coote observes that of all the structures comprising
a joint two only are the subjects of primary inflammation,
namely, the synovial membrane and the cancellous tissue of the
bone, and the knee is most commonly the seat of the disease ;
but atrophy of cartilage, elongation of ligaments, or gradual
distension of the capsule, Mr. Coote regards as errors of nutri-
tion, not necessarily of inflammatory origin. In one of his
cases the disease of the joint appeared to be in an early stage ;
but in the other it was more advanced, and was complicated
with general paralysis. The chief remedial measure to be
adopted in such cases is rest, long continued, and unremitting,
until the healthy nutrition of the parts has been restored ; and
among the wealthier classes of society this plan can in most cases
be effectually carried out, and when combined with change of
air and all necessary accessories it usually suffices to effect an
early cure.

XVI. On the Prejudicial Effect of Inter-articular Pressure in
Joint Disease, and the application of continuous Extension by
means of a Weight, as a remedy for this condition. By F.
Howard Marsh. — After pointing out the injurious effect of
pressure of the surfaces of the bones in cases of diseased joint,
Mr. Marsh dwells more especially on the pressure caused by
abnormal muscular action ; and he shows by a simple experi-

81— XLI. 8

114 Reviews. \J

an.

nient which he performed at the Hospital for Sick Children, that
when this pressure is removed or lessened a proportionate relief
of the severity of the symptoms is obtained. In the case of a
child suffering from acute articular disease of the leg, and who
was treated only by suspending a weight from the foot of the
affected limb, Mr. Marsh found that whenthe weight was raised,
and the muscles were thus allowed to contract on the joint, im-
mediate pain was caused, but was removed on the replacement
of the weight. The progress of joint disease being thus proved
to be so much influenced by the pressure of the articular sur-
faces on one another and by muscular action, it follows that one
of the great objects of treatment should be to keep the surfaces
at all times free from contact and to control the muscles. Mr.
Marsh then proceeds to examine the ordinary treatment of
diseased joint by splints and bandages; but he argues that the
application of the weight possesses all the advantages without
the drawbacks of the other plans. The amount of weight which
it is proper to apply must depend upon circumstances ; but it
may be stated generally, that for children between six and nine
years old four pounds are appropriate. Mr. Marsh concludes
his paper by giving the history of some cases successfully treated
by the method which he recommends.

XVII. Notes on Oxaluria. By Dyce Duckworth, M.D. —

Dr. Duckworth thinks there is suflicient evidence to prove that
oxalic acid is a natural constituent of the blood, probably in
combination with protein matters. He has lately made some
experiments with a view to induce temporary oxaluzia by
the ingestion or administration, sometimes of lime-water, and
sometimes of oxalic acid. The results showed that by taking
from half a grain to two grains of lime with four of liquor
calcis, or by taking a grain of oxalic acid in solution, oxalate of
lime can be produced in the urine, and detected by its well-
known crystals under the microscope. Dr. Duckworth has
found (as others have done) that the oxalate of lime occurs very
frequently in the urine of hospital patients, and, indeed, he
found it to be the rule that convalescents from most acute diseases
had oxaluzia for a few days before the various secretions returned
to the natural condition. This was especially the case after
scarlatina and typhus, typhoid and rheumatic fevers.

XVIII. On the Treatment of Acute Pericarditis with Opium.
By Fhederic J. Faure, M.D. — During the last three years Dr.
Farre has treated in the hospital eleven cases of rheumatic
pericarditis, in all of which nearly the same plan was adopted,
although in a few the complications which occurred required

1868.] Hospital Reports. 115

the use of some additional remedies. Dr. Farre^s practice
differs from that of some others, in the omission of mercury in
pericarditis, for although he still believes that this metal gene-
rally has the power of arresting the effusion of fibrine and of
promoting its absorption, he considers that the peculiar nature
of pericardial inflammation interferes with this action. But
opium tranquillises the heart, and by procuring rest for that
organ, it promotes the cure of pericarditis, just as it promotes
the cure of peritonitis by trauquillising the intestines, and
diminishing their peristaltic action. Dr. Farre employs blis-
ters in pericarditis, not only when effusion has taken place, but
in every case as soon as pain is felt in the heart, and he gene-
rally finds that they afford the same relief as leeches or cup-
ping. In all the eleven cases recorded by Dr. Farre except
one the results were satisfactory. The exception was that of a
boy who, during the treatment, died suddenly " in a fit.''

XIX. Surgical Cases, Devon and Exeter Hospital. By
Philip Chilwell Delagarde. — These cases are miscellaneous,
having no connection with one another except from their occur-
rence in the same hospital. They include an example of
restoration of the upper eyelid after a burn ; restoration of the
upper lip after smallpox ; resection of the head of the femur
for unreduced dislocation into the ischiatic notch ; two cases of
removal of the breast, and a case (successfully treated) of
traumatic tetanus.

XX. Case of Profuse Venous HoBmorrhage from the left Meatus
Auditorius Externus, consequent on [a fall upon the back of the
head. By Luther Holden. — The subject of this case, while
intoxicated, struck his head with considerable force against a
lamp-post, and bled profusely from the left ear, which was con-
sequently plugged with cotton wool by the surgeon who first
was called to him. When he was brought to the hospital, the
house-surgeon could find no external injury, but on removing
the plug, a stream of blood flowed from the ear, and the plug
was accordingly re-applied. After a quiet sleep, he was much
better, and suffered from no very marked symptoms, except
those which might be expected from the loss of blood ; and on
the twelfth day the plug was removed, when about half an
ounce of bloody fluid spurted out. The man remained in the
hospital sixty-four days, when he was discharged, apparently
well, and he was seen on several subsequent occasions, but
suffered no relapse. Mr. Holden considers the case to be
without precedent, and he regards the haemorrhage as being
caused by a fracture of the mastoid process of the temporal bone>

116 Reviews. [Jan.,

laceration of the lateral sinus passage of the blood through the
mastoid cells into the tympanum, and its escape through the
lacerated membrana tympani,

XXI. Case of Aneurism of the lower part of the Common
Iliac, of the External Iliac and Femoral Arteries, successfully
treated by Pressure of the Abdominal Aorta. By Vincent F.
EcK. — The subject of this case was an Irishman, who had been
treated for aneurism by compression in Dublin and Tralee, but
who subsequently came to London, and was admitted into St.
Bartholomew's Hospital. It was determined to try again the
effect of pressure high up on the common iliac artery and a
tourniquet was accordingly placed over the bifurcation of the
aorta, in such a manner as to control only the passage of
blood through the right common iliac, leaving the left, as far
as possible, free. By this plan the pulsation in the tumour
was arrested, and although the progress of the cure was delayed
by several unfavorable symptoms, the treatment was even-
tually successful, the size of the swelling being diminished by
more than one half, and the pulsation being greatly diminished.

XXII. Medical and Surgical Landmarks. By Luther
HoLDEN. — In this paper, which, however, does not admit
either of analysis or abbreviation, Mr. Holden points out the
various lines, eminences, or depressions, on the surface of
the body, which indicate the position, course, and relations of
the more deeply-seated structures and organs. He remarks
that many students, and even those who are good anatomists,
sometimes find themselves at a loss to describe on the living
body the parts with which they are familiar by dissection, and
the present paper is written in order to induce in students the
habit of looking at the living body with anatomical eyes, and
with eyes, as it were, in their fingers'* ends. Mr. Holden suc-
cessively describes the head, the face, the neck, the chest, and
the back, with especial reference to the connection between the
external appearances and the relations of the subjacent parts,
and his paper is announced to be continued in a subsequent
number of the ' Reports.'

XXIII. Note on the Termination of the Second Case of
Poisoning by Mercuric Methide. By George N. Edwards,
M.D. — This case has already been partially published in a
former number of the ' Reports,' and the present paper
describes the post-mortem examination, the principal appear-
ances observed being effusion of lymph on the left pleural sur-
face, and pneumonic consolidation of the left lung.

1868.] Hospital Reports. 117

XXIV. On an Operation for the Relief of a Stricture of the
Urethra. By George W. Callender. — The case described
was that of a man who had suffered from narrowing of the
urethra, and as all attempts to pass a catheter, although aided
by the use of a hot bath and opium, had failed, and the symp-
toms were becoming most severe, the bladder was punctured
above the pubes. This operation gave great relief, but sub-
sequently diffuse inflammation of the scrotum supervened, with
formation of matter, and requiring free incisions. This treat-
ment had been adopted in Cornwall, where the man lived, but
he was eventually sent to St. Bartholomew's Hospital, when
three sinuses were seen in the perinseum leading to the urethra,
and the opening above the pubes was occupied by a canula,
through which the urine was drawn off, Mr. Callender deter-
mined to adopt a plan recommended, but not practised, by John
Hunter, for the relief of such a condition, and consisting of the
passage of the curved extremity of a canula, from the bladder
into the urethra, and then passing another straight canula from
the glans down the urethra, so that the two may nearly meet,
having the stricture only between them, which is then to be
divided by a piercer. Mr. Callender accordingly performed the
operation in the manner just indicated, and the result was
quite successful, the fistulse gradually closing, and the urethra
admitting the passage of a number eight catheter. Before
leaving the hospital, however, it was necessary to relieve the
bladder of two calculi, which were removed by the supra-pubic
opening, and after this was done, the opening closed.

XXV. On the Value of Palpation in the Diagnosis of Tuber-
cular Disease of the Lungs. By George N. Edwards, M.D.
— Dr. Edwards, feeling confident that the value of palpation
in the diagnosis of tubercular disease of the lungs is not duly
estimated, determined to institute a series of observations in
which his own diagnosis, arrived at from palpation, was cor-
roborated by other observers, from auscultation and percussion.
Dr. Edwards states that it is almost impossible to express in
words the difference between the sensation conveyed to the
fingers by the portion of the chest over tubercular and that
over healthy lung, but perhaps it may be described rather as a
want of elasticity than anything else. He then gives a table
of fifty cases in which he adopted this method of diagnosis,
and in all of them the position of the tubercles was confirmed
by the auscultatory phenomena.

XXVI. Extracts from the Statistical Report of the Hospital
for the year 1865. — The tables here given have been selected for

118

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an.

republication from the ' Annual Report of the Registrars of
the Hospital, Dr. Edwards and Dr. Willett.' Attention is par-
ticularly requested by the reporters to the tables, which show
the cases of disease bred within the wards of the hospital during
the year. All the contagious cases, however, are not to be
credited to the wards of the hospital, for many cases are
admitted, ready charged with fever or erysipelas, which breaks
out while the patients are recovering from some comparatively
trivial injury.

The Clinical Lectures and Reports by the Medical and Sur-
gical Staff of the London Hospital occupy a volume of 499
pages, and although the articles are not numbered, the following
is an analysis of the contents, which are illustrated by several
well-executed engravings.

A Case of Ligature of the External Iliac Artery for Femoral
Aneurism, with Clinical Remarks. By John Adams. — The
subject of this case was a fat woman of intemperate habits,
who attributed the disease to a kick she had received in the
groin. The aneurismal swelling appears to have begun in the
femoral artery, where the vessel passes under Poupart's liga-
ments, but it extended upwards beneath the abdominal walls
in the course of the external iliac artery.. The ligature
was placed round the external iliac artery after an incision
had been made in the abdomen from the umbilicus to the
middle of Poupart's ligament. The pulsation in the tumour
was at once arrested, and in about two months she appeared to
be nearly well ; but after leaving the hospital she died, after
two or three attacks of arterial haemorrhage. No post-mortem
examination was allowed. In his remarks on the case, Mr.
Adams points out that the fatal haemorrhage most probably
proceeded from the artery below the ligature, and that if such
a case were to present itself again, and the patient were likely
to die of haemorrhage, the only plan promising to be successful
would be to lay open the tumour, insert the finger into the
lower orifice of the artery, and direct an assistant to pass an
armed aneurismal needle around the blood-vessel below the finger.

On the Spectrum Analysis in Relation to Chemistry, Patho-
logy, and Medical Jurisprudence. By A. Letheby, M.B.,
M.A., Ph.D., &c. In this paper Dr. Letheby describes the
history of spectrum analysis and the different kinds of apparatus
by which its phenomena may be exhibited ; he also indicates
the applications of this discovery to many branches of practical
science. Dr. Letheby especially alludes to the use of spectrum

1868.] Hospital Reports. 119

analysis in testing for blood-stains, and as an example of the
delicacy of the test and of the time which may elapse after the
blood has been drawn before it loses its properties, he states
that some blood-stains upon linen which were examined in 1849
had been again examined recently by Mr. Sorby and himself.
The blood was altered in character, being changed from cruorin
into hsematin, but on applying appropriate tests the presence
of blood was manifested.

A Lecture, with Cases, on Diabetes. By Dr. Eraser. In
this lecture Dr. Fraser lirst gives a summary of the principal
points in the pathology of diabetes, then he indicates the chief
methods of treatment which have been recommended, and he
concludes by relating the history of some cases occurring in the
practice of the London Hospital. Most of the cases were re-
lieved, though not cured, by the treatment adopted, and Dr.
Fraser admits that no remedy hitherto employed, and no plan
of diet hitherto suggested, has been uniformly successful.

A Clinical Lecture on Unilateral Herpes. By Jonathan
Hutchinson. In introducing the subject of herpes zoster,
or common shingles, Mr. Hutchinson remarks that this
disease is not a skin- affection in the correct sense of the
word, but rather a symptom, displayed by the skin, of irrita-
tion of the nerve. In confirmation of this view, he adduces
some cases in which the eruption followed the course of
cutaneous nerves. Mr. Hutchinson also endorses the opinion of
Bateman that shingles commonly follows the regular course of
fever, in its eruption, maturation, and decline, within a limited
period, like the eruptive fevers. It appears also that the disease
very rarely occurs twice in the same person, that it is never
contagious, and that it very seldom exists on both sides at once.
The dorsal nerves, and especially the third or forth dorsal, are
much more frequently affected than any others, the forearm and
tlie legs are rarely affected, but the two sides are liable to the
disease almost in an equal proportion, and all ages suffer nearly
alike, except early infancy; Mr. Hutchinson^s paper is illus-
trated by a table containing the records of sixty-three cases of
herpes zoster.

Three Clinical Lectures delivered during the Session, 1865-66.
By C. F. Maunder. These lectures were founded on cases
treated in the hospital, the first being an organic stricture, with
retention and extravasation of urine ; the second on retention of
urine ; and the third on cases of strangulated hernia.

120 Reviews. [Jan.,

Notes of Unsuccessful and Successful Cases of Saline Alceholic
Injections into the Veins for Relief of Collapse of Malignant
Cholera, treated during the Epidemic of 1848-9. By Dr. Little,
late Senior Physician to the London Hospital. — This paper
was evidently written some years ago, for at the commence-
ment Dr. Little observes that the subject of malignant or
Asiatic cholera is at the present moment a matter of no great
importance in Great Britain — a remark which could not be ap-
plicable to the year 1866. The experiment of injecting saline
alcoholic fluids into the veins was adopted by Dr. Little in
1848-9, in consequence of the want of success which had
attended all therapeutical measures in cholera during the cholera
epidemic of 1832. In resorting to the use of these injections.
Dr. Little did not expect to cure cholera, but to save some lives
which were struggling into reaction, and the cases he adduces
appear to prove that in a certain number of instances the intro-
duction of saline and stimulating fluids into the blood was
attended with beneficial results. Dr. Little entirely condemns
the use of purgatives in cholera, and he warns the profession
against their use, but he considers that the operation of injec-
tion or transfusion into the veins if performed with due precau-
tion is not of itself dangerous, and that the injection of saline
and alcoholic fluids into the circulating system is a powerful
means of exciting the heart and the nervous system under cir-
cumstances of great depression, such as that seen in the collapse
of malignant cholera.

Case of Poisoning by the external use of Belladonna. By R.
GossET Brown, M.D. In this case an embrocation containing
two drachms of liquor belladonnse had been employed externally
for the relief of hooping-cough, and its use was followed by
symptoms of poisoning, including the existence of delusions.
On the discontinuance of the use of the belladonna, the delusions
disappeared and the hooping-cough in course of time dis-
appeared likewise.

Case of Poisoning by the external use of Belladonna. Under
the care of Dr. Eraser. — This case was somewhat similar to
the last, but the fact of poisoning by belladonna was only sus-
pected by the symptoms, although it was afterwards fully
proved by the production of a bottle labelled as containing
extract of belladonna mixed with water, and to be used as a
lotion. The patient was a servant, who had applied the lotion
to relieve a pain in the breast, and who afterwards exhibited the
constitutional symptoms of poisoning. It was suspected that
she might have swallowed some of the fluid, but this she strenu-
ously denied.

1868.] Hospital Reports. 321

Two Cases of Acute Suppuration in the Knee-Joint, in which
recovery, with free motion, ensued. By Robert B. Carter.
— The first of these cases was that of a coal-miner who
had received a severe blow upon the knee : the second was that
of a young woman, in whom the inflammation of the knee-
joint supervened upon child-bearing. In both cases the pus
was removed by puncturing the joint, and in both the result was
favorable, but the writer of the paper lays great stress upon the
necessity of mechanical support, strapping, and bandaging, in
the treatment of such cases.

Case in which the Symptoms of a Large Abdominal Aneurism
were present and cure resulted. By Frederick H. Daly, M.D.
— In this case the existence of an aneurism was inferred from the
pulsation of the tumour and the existence of a bruit, and the
diagnosis was confirmed by Mr. Hutchinson. The treatment
consisted in absolute rest, the application of ice, and the admi-
nistration of acetate of lead iuternallv. After a rather Ions
course of treatment, it was found that the aneurism had disap-
peared, and Dr. Daly attributed the cure in a great measure to
the action of the acetate of lead.

Cases selected from those sent in by Students in Competition for
the Hospital Gold Medals of 1865. These cases are, of course,
miscellaneous, comprising both diseases and injuries, and they
afford a favorable specimen of clinical reporting in the
hospital.

A Lithotrity Syringe. By C. F. Maunder, F.R.C.S.— The

construction of this instrument is figured in an illustration, and
it is so formed as to serve the purpose of injecting fluid into the
bladder, and at the same time to remove the fragments of the
stone which has been crushed. The fluid is injected from an
elastic bottle, and the fragments of the stone are received into
the fenestrated end of a catheter attached to the bottle.

A Case in which Gastrotomy was performed for Stricture of
the (Esophagus. Under the care of Mr. Curling. — The patient
was a sailor, set, 57, who was treated ineffectually by all ordinary
means, and at last Mr. Curling, after consultation with his col-
leagues, performed the operation of gastrotomy, and the cavity
of the stomach was made to communicate with the external
wound. Food was introduced by this aperture, and from that
time the urgent symptoms were relieved, but the man died
thirty-two hours after the operation. On a post-mortem ex-
amination, a tight constrictiou of the oesophagus was discovered

132 Reviews. [Jan.,

about four inches and a half from the stomach. There was also
extensive ulceration of the oesophagus.

Marriages of Consanguinity in Relation to Degeneration of
Race. By J. Langdon H. Down, M.D. — The object of this
paper is to prove by reference to actual results that marriages of
consanguinity are not so productive of deterioration of race as is
generally believed. Dr. Down gives the history of 20 marriages
of cousins producing 138 children, and of these 25, or only a
little more than 18 per cent., were idiots, and he contrasts these
results with those of 20 marriages in which there was no con-
sanguinity, and from which alone were produced 145 children,
26 of whom, or 18 per cent., were idiots. Dr. Down attributes
many cases of idiocy to injury sustained by the infant at birth
in diflficult labours, and he thinks that instrumental interference
in labour is a cause of idiocy. With regard to consanguinity,
he does not attach very much importance to it as a cause of
degeneration of race, unless hereditary disease is superadded.

A Lecture on Cases of Cerebral Hemorrhage. By J. Hugh-
LiNGs Jackson, M.D. — This lecture is founded upon and illus-
trated by some cases of cerebral haemorrhage, but it also enters
generally into the causes, symptoms, and diagnosis of that affec-
tion. Paralysis is a common symptom of cerebral haemorrhage,
but the amount of paralysis depends upon the damage done to
the motor tract; and if this part of the brain is but little in-
jured there will be very little paralysis, or it may even pass oif.
But when the corpus striatum is the seat of the haemorrhage, as
is often the case, there will be marked paralysis, the corpus
striatum, thalamus opticus, and crus cerebri, being all parts of
the motor tract ; while if the mass of the hemisphere above the
ventricle is the seat of the effusion, there need be no paralysis
at all. Dr. Jackson contends, however, that cerebral haemor-
rhage ought not to be regarded as only a local affection, but
that it should be considered in connection with the general
disease of the arteries throughout the body, and with pre-
existing or concomitant morbid conditions in other organs, as
the kidneys, liver, heart, &c. Even the examination of the
retina by means of the ophthalmoscope affords valuable informa-
tion in reference to cerebral haemorrhage, because the condition
of the retinal vessels enables the observer to detect tissue
changes which may be generally present throughout the system.
As cerebral haemorrhage is not so much a local disease as a
local manifestation of a general morbid condition, it follows
that special medication of the brain is not likely to be beneficial,
and that when recovery from paralysis ensues the result is rather

1868.] Hospital Reports, 123

due to the patient^s general condition than to the treatment
adopted. When the system is not mueh impaired recovery
may be hoped for; but when there is considerable disease in
other viscera the prognosis must be unfavorable.

Observations on an Ethnic Classification of Idiots. By J. Lang-
don Down, M.D. — In this short paper Dr. Down suggests that a
classification of idiots may'perhapsbe formed by referring them
to groups resembling the different varieties of the human race.
Thus among the idiots and imbeciles under his own care, at the
Earlswood Asylum, and in the out-patient department of the
London Hospital, he finds that, together with numerous repre-
sentations of the great Caucasian family, there are well-marked
examples of the Ethiopian, the Malay, and the Mongolian varie-
ties. Dr. Down appears to regard idiocy as a kind of degenera-
tion from the normal standard of physical and intellectual man,
and he thinks that this degeneracy furnishes some arguments in
favour of the unity of the human species.

Cases of Delirium Tremens, with Clinical Remarks. By Dr.
Fraseb. — In this article Dr. Eraser relates the particulars of
several cases of delirium tremens occurring in the London
Hospital, and he makes some practical remarks upon the treat-
ment which he has found most efficacious. He appears to rely
chiefly on the use of stimulants and the administration of opium,
his own experience showing that the greatest success followed
that mode of treatment. He, however, tried the effects of
digitalis ; but all the cases witnessed by him, in which that drug
was tried in the treatment of delirium tremens, were unsuccess-
ful. In reference to the treatment of the disease without
stimulants, he has witnessed only a tolerable amount of success,
and he gives the number of cases so treated, which have fallen
under his own observation, and their results, showing that those
cases did best in which a moderate amount of stimulation
was resorted to.

A Statistical Report of the Deaths occurring during the year
1865 amongst Mr. Hutchinson's Patients. Compiled by Mr.
Hutchinson and Mr. Waren Tay. — During the year eighty-
one deaths occurred out of 1212 cases, and they are arranged in
tables, according to the nature of the diseases or injuries under
which the patient was suffering. It appears that " hospital
diseases" were very rare during the year, with the exception of
pyaemia, of which seventeen persons died. Two died of trau-
matic tetanus, five of erysipelas, and three of traumatic
gangrene.

124 Reviews. [Jan.,

A fatal Case of Operation for Jiemoval of an Extra-uterine
Foetus. Communicated by Mr. McCarthy. — The patient was a
married woman, the mother of four children. The operation
was not performed, in consequence of the patient's refusal to
undergo it^ until the last extremity, and death followed in an
hour.

A Case of Acute Symmetrical Carcinoma. Under the care of
Dr. Fraser. — The patient was a girl, aged 20, and the carcino-
matous deposit was very extensive, consisting of tumours on
both sides of the body, with enlargement of nearly all the lym-
phatic glands. The two mammae were exactly alike, being
enlarged and indurated in all parts. The post-mortem examina-
tion confirmed the diagnosis of general cancer.

Observations on the Results which follow the Section of Nerve-
trunks, as observed in Surgical Practice. By Jonathan Hutch-
inson.— These observations are intended to show the results
■which follow division of the nerves, as regards the nutrition of
the part affected and the maintenance of animal heat. Next to
loss of sensation, the chief result of section of a nerve is a dimi-
nution of temperature, and another result is inflammation, which,
however, Mr. Hutchinson thinks is rather permitted than caused
by the state of nutrition induced by the section. None of Mr.
Hutchinson's cases lend any material support to the com-
monly received opinion^that nerve-trunks, when cut, are rapidly
repaired.

Clinical and Pathological Facts in reference to Injuries of the
Spinal Column and its Contents. — This section contains a series
of nineteen cases illustrative of injury to the spine, together
with a descriptive list of the specimens relating to injuries of the
spine in the museum of the London Hospital. The cases of re-
covery have especially been collected in order to illustrate the
important fact that, even in severe cases with permanent local
displacement and with paraplegia lasting for some weeks,
complete recovery may ensue.

A Clinical Lecture on Dislocations and Fractures of the Spine.
By Jonathan Hutchinson. — One of the chief objects which
Mr. Hutchinson has in view in this lecture is to furnish con-
clusive arguments against operative interference in injuries of
the spine. He asserts that many cases recover if placed under
favorable circumstances and let alone, and that in the fatal cases
it has by no means been proved that any benefit would have re-
sulted from operation. The effect, therefore, of such a measure

1868.] Hospital Reports. 125

would have "been to increase the patient's sufferings and aggra-
vate the danger. Mr. Hutchinson thinks that permanent com-
pression of the cord or of any part of it is a very rare event,
and that although the vertebral column is sometimes suddenly
crushed by violence, the bones spring back by their own elas-
ticity, and thus restore the column to its original position.
From a consideration of many other circumstances Mr. Hutch-
inson strongly condemns the practice of operating on the spine
with a view of elevating depressed fractures of bone, and among
the strong objections to this proceeding are the conversion of a
simple into a compound fracture, and the risks of pysemia and
of spinal meningitis.

Note on the Functions of the Optic Thalamus. By J. Hugh-
lings Jackson, M.D. — This short note is written by Dr.
Jackson, to correct a statement which he formerly made in
reference to the absence of loss of sensation as a symptom of
hemiplegia. From a more extended observation he now thinks
that sensation is more often and more considerably affected in
hemiplegia than we formerly thought it to be.

Notes on Syphilis. By Jonathan Hutchinson. — These
notes are founded on several interesting cases of syphilis which
■ have occurred in Mr. Hutchinson's practice. The cases are of
a miscellaneons character, some of them showing the resem-
blance existing between syphilitic induration and cancer, and
the mode of making the diagnosis. Mr. Hutchinson adduces
some remarkable instances of the beneficial eflFect of the iodide
of potassium in syphilitic indurations, and he observes that in
doubtful cases the administration of this salt will generally
assist materially in revealing the true nature of the disease.

Detached Notes on Symptoms, Definitions, and Diagnosis.
By Jonathan Hutchinson. — These notes are entirely of a
miscellaneous character, but they contain some very useful
practical suggestions.

The rest of the volume contains a descriptive list of the more
important specimens, casts, &c., added to the museum of the
London Hospital during the past year (1865), and is arranged
by Mr. L. S. Little, the curator of the museum, and illustrated
by several wood engravings; a report on the medical cases
under treatment in the London Hospital during the year 1865,
drawn up by Mr. J. E. Adams, the Medical Registrar; and an
appendix containing notes on the Cholera Epidemic of 1866.
It is well known that during the late outbreak of cholera in the
eastern districts of the metropolis the London Hospital re-

126 Reviews. [Jan.,

ceived a large number of patients sufiFering from that disease,
and its report on the subject will necessarily attract much
professional attention. But it is stated that the notes in the
present volume are not intended to interfere with or to super-
sede the more complete history of the epidemic in the hospital,
and which will be published in the next volume of the ' Hospital
Reports/ The present notes, however, contain much valuable
information, both of a statistical and practical character, and
are drawn up by individual members of the hospital staff.

Review IX.

1. De V Amaurose lies a la degeneration des Nerfs Optiques dans

les cas d^ alterations des Hemispheres Cerebraux. Par M.
Lancereaux. Paris, 1864.
On Amaurosis in connection with Degeneration of the Optic
Nerves in cases of Alteration in the Cerebral Hemispheres.
By M. Lancereaux. Paris.

2. Etude Ophthalmoscopique sur les Alterations du Nerf Optique

et sur les Maladies Cerebrates dont elles dependent. Par X.
GrALEZowsKi, Docteur en Medecine, &c.

3. Ditto. By the same. ' L'Union Medicale,' Nos. 102, 105 ;
et 'Gaz. des Hopit.,' No. 6. Paris, 1866.

Ophthalmic Study of the Alterations of the Optic Nerve and of
the Cerebral Diseases on which they depend. By X. Gale-
zowsKi, M.D., &c.

4. Du Diagnostic des Maladies du Systeme Nerveux par V Oph-

thalmoscope. Par E. BoucHUT, Professeur agrege de la
Faculte de Medecine, &c. Avec un Atlas de Vingt-quatre
Planches. Paris, 1866.
On Diagnosis of the Maladies of the Nervous System by the aid
of the Ophthalmoscope. By E. Bouchut, Professor of the
Faculty of Medicine. With an Atlas of Twenty-four Plates.
Paris, 1866.

5. On the Use of the Ophthalmoscope in Cerebral Diseases. By
Dr. J. W. Ogle, 'Med. Times and Gazette/ June 9,
1860.

6. Cases, mainly of Disease of the Nervous System, in which the
Ophthalmoscope was used. By the same, ' Medical Times and
Gazette,-* September 28 and following dates, 1867.

7. Papers on the Value of the Ophthalmoscope to the Physician.
By Dr. J. Hughlings Jackson, * Royal Loud. Ophth. Hosp.
Reports,' ' Med. Times and Gazette/ ' London Hosp.
Reoorts.' Various dates.

1868.] Medical Ophthalmoscopy. 127

8. Right Hemiplegia : Loss of Speech and Amaurosis. Paper
by Dr. Russell, ' Brit. Med. Journal/ Sept. 8, 1866.

9. On the Use of the Ophthalmoscope at the Leeds Infirmary.
By Dr. Allbutt and Mr. Pridgin Teale, * Med. Times
and Gazette/ May 11, 1867.

The books and essays whose titles are quoted above have, we
think, an interest beyond the results with which they are more
immediately concerned. We cannot hide from ourselves that
our knowledge of the diseases of the central nervous system has
until quite recently been of a very meagre sort, and we may add
that our method has been unworthy even of our knowledge. It
was naturally to be expected that the diseases of the most com-
plex and inaccessible parts of the body should be the last to
benefit by the more vigorous and more philosophical mode of
investigation which within the last few years may be said to
have changed the face of the medical art. On the other baud,
we may well be cheered if we see that by active inquiry and a
progressive method we are beginning to make way into the
most secret places. It is in the description of the functions and
of the disorders of the brain that what has been called the meta-
physical habit of thought most tenaciously holds its ground.
Where the order of phenomena is most complex and observa-
tion most difficult, there our theories most readily escape the
test of experiment. Unchecked by direct reference to nature,
theories which have a fair aspect, and which are symmetrical
and definite, there continue to command assent although else-
where discredited. No one would indeed now dream of refer-
ring the functions of the liver or of the heart to an immaterial
principle residing in or about these organs, yet many persons
still cling to the opinion that the functions of the brain are
something more than the movements and the relations of the
cerebral tissues. Hence, they not unnaturally refer diseases of
the bruin to something more than the abnormal movements of
these tissues.

We are tempted, for instance, to give a reality to such a dis-
ease as epilepsy apart from the phenomena in which we say that
it is seen. We are led to forget that molecular equilibrium
may be disturbed to a greater or less degree in the brain as in
any other aggregate ; and instead of tracing out deviations from
health, we satisfy ourselves Avith naming the morbid state as we
see it in its fullest development, and having named it we try to
hope that it is explained. We thus begin more or less con-
sciously to use such a word as epilepsy in the sense of a principle
of causation, and to forget that it is merely a name given to a
more or less uncertain group of irregular movements. Even in

128 Reviews. ["J

an.

the writings of those who take a clearer view of the value of
such names as epilepsy, chorea, and the like, we may often de-
tect a tendency to use such words, too much in a pictorial sense.
A brilliant sketch of an epileptic state, for instance, is set before
the reader, and is presented to him as a " type" or standard, by
which he is to regulate his conceptions of all similar states. Cer-
tain marked features are held to be necessary to the proper con-
stitution of the " type^^ and all modes of irregularity of function
not presenting such features are held to be what they please,
but certainly not epilepsy. They must group themselves after
a given fashion, and present certain given characters on pain
of being neglected or, at best, recorded as '' curiosities." Yet
it is in these slighter deviations from the normal order, in spas-
modic neuralgias, local tremors, transient suspensions of the
senses, and such minor indications of lessened tension, that we
shall ultimately find the explanation of the more "typical"
forms of disorder. It is not by setting up opposition standards
to the standard of health that we shall learn the modes of initi-
ation of morbid changes, but rather by watching the outskirts
of health itself.

Before we can comprehend extensive changes, we must
familiarise ourselves with slighter ones, and so take with us the
clue to the larger mystery. We shall, no doubt, continue to de-
pict the extreme and complete manifestations of disease for
clinical ends, yet if we are to discover their origin, we shall
have to desert this kind of synthesis for analysis. We must un-
ravel groups of phenomena, and trace each element to its
source. We must learn to have a less exclusive admiration
for brilliant displays of disease, and to cultivate rather a percep-
tion of those many little various errors from healthy order by
which nature chiefly seeks to betray herself. A straw may
show the way of the wind better than a falling tower. A habit
of thus wakefuUy regarding the minutest variations of the nor-
mal state, and of verifying them accurately, is of inestimable
value. It is quite the opposite of that other habit of setting
up certain morbid standards or lay-figures to which all changes
are to be referred. It cannot be too earnestly impressed upon
our students that any new facts, however small, if well observed,
may lead up, and probably will lead up, to some wider truth
of scientific or even of immediately practical importance. But
to compare individual instances of disease with conventional
standards, is directly to discourage the observation of those
lesser phenomena and to teach the student rather to pare them
off as far as possible until he can produce his case in trim with
accepted models. The baneful influence of this method of case-
taking is but too plain in all medical schools. Students are

1868.] Medical Ophthalmoscopy . 129

led to think that facts which seem to them to be acces-
sory are not only unworthy of verification, but are even in-
trusive, and rather spoil the elegance of their case than
otherwise.

We much doubt indeed whether such terms as epilepsy,
chorea, &c., will prove ultimately to be valuable as names.
Their signification will be found so indefinite as the study of
temporary failures of function advances, that we fully expect to
see the groups Avhich they profess to designate altogether
broken up, and their elements grouped again under higher
and more philosophical names having reference to other and
wider affinities. We see this process in other names, indeed,
already going on. The name '' apoplexy,'^ for example, is re-
tained in our nomenclature rather from habit than from any
belief in its value ; and the term " inflammation," again, hangs
on our lips by a very precarious tenure.

The way which is open to us for the discovery of the laws of
change in nervous organs must be, to a great extent, therefore,
a way of destruction. Nothing is so conducive to a right
appreciation of the truth as a right appreciation of the
error by which it is surroimded. The successful investi-
gator must bring to test statements and conceptions which
have been too long accepted on faith, habit, or good nature.
He must look boldly behind certain large words which
are now too often the shelter of ignorance, and he must
satisfy himself whether they have any definite value or not.
When it is seen how much our current language really signifies,
and when all technicalities, which took their rise in old and
false methods, have been swept out of sight, we shall feel,
perhaps, a little bare, but at any rate we shall have open field
for new researches. When we have stripped oS" all our over-
growth of heavy verbiage, we shall see that there is no lack of
facts. In our endeavour to verify those which we think we
have, we shall continually come across others which no
ingenuity of our own could have led us to seek for, but which
may turn out to be of the greatest practical value.

Moreover, the steady pursuit of such a method strengthens
in the observer a spirit of open-eyed sincerity which answers in
the man of science to the catholic sympathy of the greatest
artists, and is the true magistery. We have constantly found
that the cultivation of such a temper as this is accompanied by
the discovery and the use of instruments of greater precision.
Both in the history of medicine and of other sciences the intro-
duction of such instruments has always coincided with periods
of genuine progress. We are led, therefore, to regard the
application of the ophthalmoscope to the diagnosis of nervous
SI— xLi. 9

130 Reviews. [Jan.,

disorders as of very happy augury. Our readers well know the
marvellous change which this instrument has produced in the
knowledge and method of the oculist. Not only has it cleared
up for him many doubts^ and has enabled him to recognise
certain pathological states which before were beyond his reach,
but it has encouraged new habits of accuracy, which are, as it
seems to us, also very evident in recent work in those departments
of ophthalmic practice where the ophthalmoscope is less needed.
Recent inquiries, for example, into the disorders of accommo-
dation, and of the muscular action of the orbit, appear to us to
have been conducted in a genuinely scientific spirit, and have
led to results whose bearing upon more general laws of nervo-
muscular life may turn out to be most important.^ Whatever,
then, may prove to be the practical value of the ophthalmoscope
in detecting disease of the brain or spinal cord, it has for us
this great charm — that its use must favour a spirit of indus-
trious and accurate observation, and must favour also that whole-
some disposition of mind which welcomes any facts, however far
away they may seem to be from traditional doctrines or digni-
fied theories. We can scarcely hope that the ophthalmoscope
will, in the hands of the physician, ever rank in usefulness with
the stethoscope. We confidently believe, however, that as the
invention of the stethoscope has been of incalculable advan-
tage to us, not directly only, by revealing changes of tissue
during life, which previously could be but roughly guessed at,
but also indirectly, by encouraging the study of diseases of the
chest; so the ophthalmoscope will help us, not only by the
facts it directly reveals, but by stimulating work in the direc-
tion of nervous diseases. Nor must it be forgotten that by
means of the ophthalmoscope we are for the first time per-
mitted to see the commencement and progress of change in
the life of nervous tissue, and to ascertain the modes and
times of such change. '

This is no slight matter, and if to all these considerations we
add, as we shall presently show, that the ophthalmoscope is even
already of some use in diagnosis, we shall have made it clear
that this instrument must be in the hands of every physician
who wishes to speak with authority on the subject of diseases of
the nervous system. The great drawback to the rapid intro-
duction of new instruments is the labour required in learning
their use. Thus it is that many useful aids to diagnosis — the
laryngoscope, the endoscope, the sphygmograph — have a kind of
alacrity in sinking out of notice. Every medical school is now
bound to teach its students the use of the ophthalmoscope as

1 Cf. e.g. Grafe, ' Klinische Analyse' der Motilitats-storuagen d. Auges,' and
the many treatises which hare followed it.

1868.] Medical Ophthalmoscopy. 131

carefully as the use of the stethoscope is taught. But it is not
easy for physicians who have left the schools, and are engaged
in practice, to take up a new instrument which requires much
skill in the using. We can assure our readers, however, that a
few hours spared for this work are very well spent. We, who
have given some little time to familiarise ourselves with the
ophthalmoscope, can speak confidently on this point. The new
glimpse thus gained of a number of obscure and difficult
diseases adds greatly to the interest of study, and we hope to
show that the ophthalmic signs of intracranial disease are by no
means few or unimportant.

When we have reviewed the results at which MM. Galezow-
ski, Bouchut and Jackson have arrived, the reader will probably
agree with us that no records of nervous diseases can hence-
forth be called complete which do not contain an account of the
ophthalmoscopic appearances. It has long been known that
indications of changes in the nervous system were to be found
in the eye. Motor aberrations, such as contraction or dilata-
tion of one or both pupils, squints, ataxy of the ocular muscles,
and imperfect accommodation; disorders of vision, such as
photophobia, diplopia, hemiopia, and even amaurosis, have all
been recognised as occurring in connection with central disease.
It was not possible, however, until the discovery of the ophthal-
moscope by Helmholtz to attach any other than a very loose
meaning to the word " amaurosis.^^^ Suspension of the visual
functions is often due to other causes than to disease of the
optic nerve or retina, and it is likely that many cases of so-
called amaurosis are actually due rather to troubles of accom-
modation than to any deficient power in the nerve of sight.^
A minute study of the disorders of motility in and about the
eye is quite as important as a study of the variations of the
optic nerve itself. A slight droop of the upper eyelid, and an
equally slight deviation of the axis of the eye, will reveal the
existence of a meningitis to the physician who had previously
hoped that he was dealing only with a fever. We are unwil-
lingly obliged, however, now wholly to pass by other sympto-
matic affections of the eye, in order to give our exclusive atten-
tion to the alterations of the optic nerve and retina, considered
mainly in their relation to cerebro-spinal disease. It is but very
recently that the profession has been made aware that the
interior of the eye presents any visible indications of the dis-

^ Witness the often ill-quoted epigram of Walter, "Amaurosis seijener Zustaiid,
wo der Kranke nichts sicht, und auch der Arzt nichts."

' We are bound to say, however, that M. Bouchut denies that the impairment
of vision which may follow diphtheria, for instance, is a disorder of accommodation.
He continues to attribute it to defective nutrition of the optic nerve (p. 35G)i

182 Reviews. [Jan.^

orders of the nervous system, nor can we say even yet that the
great importance of these indications is generally understood.

One very great drawback to the full appreciation of such facts
is the unlucky division of cases between the physician and the
ophthalmic surgeon. If the disturbance of sight be that which
most affects the patient, he goes the round of the ophthalmic
hospitals ; if, on the contrary, the disturbance of the nervo-
muscular functions be uppermost, he falls under the care of
physicians, who are naturally prone to overlook any changes of
the inner eye. As marked changes may occur at the back of the
eye with slight disorder of the visual function, it is not sur-
prising that the physician should overlook one half of the facts,
and it as naturally happens, on the other side, that the surgeon's
attention is equally limited. While the present absurd division
of the profession into operators and non-operators continues, we
must be content to urge upon those physicians who take an
interest in nervous diseases to frequent the ophthalmic hos-
pitals, where a wealth of material awaits them, of which they
have little conception. We are able to assure our medical
brethren that they will receive a warm welcome from their
surgical allies, who, in their turn, are much interested in the
relations of eye affections to more general diseases. Indeed,
physicians have little idea how " medical " are the ' Ophthalmic
Hospital Reports' and the ' Ophthalmic Review ;' and to the
medical work of ophthalmic surgeons like Mr. Hart, Mr.
Hutchinson, or Mr. Bader in England, and like Grafe,
Liebreich, or Desmarres abroad, physicians are already deeply
indebted. We wish we could say that the physicians showed a
greater sense of their obligations. The number of physicians
who are working with the ophthalmoscope in England may, we
believe, be counted upon the fingers of one hand. If 'we may
judge from the elaborate works of Galezowski and Bouchut, it
would seem that the same reproach cannot attach to our Conti-
nental neighbours, who will, therefore, unless we bestir ourselves,
make this large field of observation more especially their own.

If we rightly remember. Dr. John Ogle was the first, or one
of the first, physicians to call the attention of the profession in
England to the probable results of ophthalmoscopic examination
in cases of cerebral disease.

We have referred above to his paper on that subject pub-
lished about seven years ago in the ' Medical Times.' He then
impressed upon our. notice the very close relations which exist
between the cerebral and the intra-ocular circulation, and he
urged that the beautiful vascular structure of the posterior parts
of the eye might serve in its variations as an index to the vascu-
lar condition of the intracranial organs. Dr. Ogle's remarks,

1868.] Medical Ophihalmoscoptj . 133

as he himself said, were more in the nature of anticipations
than of conclusions drawn from wide experience; but we think
that, in looking rather to the vascular than to the nervous con-
nections of the optic disc and retina, he was right.

To this question we must return. We must now proceed by
opening the books before us to give a sketch, necessarily very
brief, of the changes in the eye which are known to accompany
certain diseases of the brain and of the spinal cord, and certain
other diseases of organs more remote. We shall do this most
clearly by dividing our matter into two parts. First, we shall
point out what symptomatic changes are known to occur in
the inner eye. Secondly, we shall endeavour to show with
what central or other diseases these changes are found to
coincide.

The parts which we have to watch are the optic disc, the retina,
the choroid, and the blood-vessels. The optic disc is liable to
simple congestion, and to congestion with effusion within or
around it, to inflammation of its sheath, to inflammation in its
substance, to anaemia, and, lastly, to atrophy. The retina is liable
to fibrinous and fatty exudations or patches, more especially in
the course of the vessels, also to haemorrhages. The choroid is
liable to loss or disturbance of its pigment, also to haemorrhages.
The blood-vessels are liable to many characteristic changes — to
diminutions or obliterations, to dilatations, to tortuosities, to
pulsations, to varicosities, to blood stases, embolism, and throm-
boses, and to rupture. The reader will scarcely expect us to
enter into minute descriptions of these very various states. We
must refer rather to the invaluable atlas of Liebreich and to the
excellent chromolithographs attached to the volumes of MM.
Galezowski and Bouchut. We shall make a few remarks only
on the meaning and causation of these deviations from the nor-
mal condition. The great variation which is found even in
healthy nerves is one of the chief difiiculties experienced by be-
ginners in ophthalmoscopy. Many peculiarities which to the
unwary observer appear to be marks of disease are in no way of
evil meaning. Not only do we find from time to time such
peculiarities as large white patches upon the retina, and white
rings or rings of pigment^ upon the margin of the disc, which varie-
ties maybe congenital or may be mere harmless changes, having
no special meaning; but we find variations also in the colour and
vascularity of the optic nerve, which at times may be puzzling
even to a practised observer. There is sometimes room for
doubt whether a deeply coloured disc is due only to the com-
plexion of the patient or whether it be due to congestion. A

' An excess of pigment is common in old people, but not common in children
unless in morbid conditions.

134 Reviews, [Jan.,

pale disc, again, may be pale from general anssmia or its pallor
may be the mark of commencing atrophic change; or in one per-
son some largeness of the vessels and distinctness of the capil-
laries is a physiological condition, in another it may be due to
pathological conditions. To determine the presence of slight
congestions in the papillae is, therefore, not easy, and can be
done only by carefully considering all the circumstances of the
case, by watching its progress, and by comparing one eye with
the other. In the normal state both eyes are, of covirse, alike,
but in morbid states it is rare for both eyes to advance by quite
equal degrees. On the other hand, we may take this occasion
to say that, if we except embolism of the arteria centralis retinse,
all other symptomatic changes of the optic nerve and its vessels
are found more or less equally in both eyes.^ The diagnosis
of the severer congestions is not a matter of much difficulty.
Here the changes are too evident for misapprehension, and the
differences between the two eyes are generally decided. In these
we find the papilla scarcely distinguishable in colour from the
retina, and, perhaps, to be traced only by the convergence of the
vessels. The veins also tend to become swollen and tortuous,
sometimes varicose. The name peri-papillary congestion has been
given by Bouchut to that condition in which the centre of the
disc remains white, and he justly observes that this peri-papillary
congestion is often seen to be wholly or partially confined to
one part of the circumference of the disc,^ with the correspond-
ing district of the retina. As regards the vessels, it will be
readily understood that the retardation of the blood in the veins
produces in them every degree of change from simple enlarge-
ment to varicosity and even to rupture. Ruptures are most
frequent in cases of albuminuria, and the blood thus effused de-
generates more or less quickly, so that these hsemorrhages
appear also as whitish blotches or streaks in the course of the
vessels, and are very characteristic of that state of the system in
which the small rough kidney is found. There are three morbid

^ In some rare cases simple atrophy may advance as far as the destruction of
sight in one eye hefore the other eye begins to fail. We have now two such
cases under our care. Vide also Mr. Hutchinson, ' Ophth. Hosp. Rep.' iv, 235.

' We may take this opportunity of saying that these and like changes at the
back of the eye are often far better seen with a lens of lower power than those
commonly sold with the mirror. A lens of three and a half or four inches focal
length acquires a little more skill in the use, but gives a far finer picture of the
parts. For daylight examinations the ray from a lamp must be thrown down a
blackened tube, the further end of which is padded and fitted to the orbit.
Within this tube and at its proper focus point the lens must be fixed, or it may
be made to travel upon a second tube within the first. There is no reason why
the mirror should be fixed in the upper end of the tube, as is the case in Gala-
zowski's and other daylight ophthalmoscopes. Moreover, the mirrors in these
instruments are very inferior to those sold by Weiss and other English makers.

1868.] Medical Ophthalmoscopy. 185

states of the optic nerve whicli have attracted much attention as
being generally connected with central disease. These are
known as — 1 {a), optic neuritis; 1 {b), consecutive atrophy; 2,
primary, or progressive, atrophy. We shall venture to discuss
a little in detail Avhat is meant by optic neuritis, as we conceive
that a knowledge of the true nature of this disorder is of the
greatest importance to the physician. Unless we know the
origin as well as the aspect of the condition called optic neuritis,
we cannot rightly know the significance of it. All observers,
perhaps, are agreed on the description of that particular change
known as optic neuritis, and recognise its coexistence with me-
ningitis of the base of the brain, with tumours, and with large
haemorrhages. The causes of optic neuritis and the conditions
of brain Avith which it occurs have been very carefully studied
by Dr. Jackson. In many very readable and instructive
essays he has drawn attention to the value of optic neu-
ritis as a symptom, and has repeatedly pointed out how
constantly the cerebral diseases which cause it are " coarse"
diseases. To this statement we shall have to return. A
good description of the appearances in optic neuritis is to be
found in a series of papers by Mr. Hutchinson in the fifth
volume of the ' Ophthalmic Hospital Reports.' Optic neuritis
must, of course, be distinguished from the retino-neuritis of
albuminuric patients, and from the retino- choroiditis of syphilis.
The history of the case and the limitation of the affection for the
most part to the papilla and the converging vessels will be suffi-
cient to settle the diagnosis. Grafe says optic neuritis is ''a
condition marked by serous infiltration and prominence of the
papilla, and is most commonly due to extra-ocular causes, whe-
ther orbitar or cerebral." The disc becomes larger than usual,
its edges indistinct,^ irregular, and puffy, and the infiltration
casts a veil over it so as to change its colour into a lilac-grey,
and more or less to conceal the vessels as they pass within its
margin. The veins increase in size, become tortuous, or even
varicose ; they darken in colour, and are seen to be gorged with
blood ; the capillaries also, which in the natural state should be
invisible, become evident, and give a mossy or, as Mr. Hutchin-
son says, a woolly look to the disc. As the walls of the vessels
are mostly healthy, the extravasations which we may see in albu-
minuric cases do not very frequently occur in optic neuritis.
Unless the neuritis depend upon orbitar disease, it is always to
be seen in both eyes. The pupils are generally dilated, whereas
in the earlier stages of simple atrophy they are for the most part
contracted. M. Galezowski, who has treated this subject with great
accuracy and ability, describes another form, slightly differing
> Liebreich, 'Atlas,' fol. xi, figs.. 6, 8, and 9.

136 Reviews. [Jan.,

from the above, which he calls optic peri-neuritis. The papilla
is still prominent, but the exudation is confined to its borders, so
that its edge is concealed under a veil, the central part appear-
ing more like health. The capillaries in peri-neuritis are deve-
loped at the periphery. "We are able ourselves to testify to the
truth of this distinction. Some investigations of value have
been made into the pathology of the nerve in optic neuritis.
During the congestive stage it has been found that the optic
nerve for more or less of its length is of diminished consistence,
and of a reddish or yellowish-grey colour. The sheath is
thickened, and Yirchow states that this thickening is of an " in-
flammatory uature.^^^ Sometimes the contents of the sheath
are seen to be pultaceous ; if so, this softening generally extends
to the chiasma. It has indeed been more than once seen by
Galezowski to extend far beyond the tracts, as far even as the
central peduncles. M. Tiirck''^ states that he has traced the
softening up to the corpora geniculata. In one case the corpora
quadrigemina were themselves swollen and soft.

The next stage iir optic neuritis is marked by a gradual sub-
sidence of the intense vascularity in and about the disc, the
infiltrations are absorbed, the nerve whitens, and the capillaries
slowly shrivel and vanish. In most cases the central vessels
themselves undergo some diminution. The edges of the disc are
now distinct, but are deformed, and patches of organized lymph
are to be seen about or upon them. This consecutive atrophy
is to be clearly distinguished from the primary atrophy which
we shall describe hereafter. The present form seldom reaches
the pearly whiteness of the other, which shows also even and
clean-cut edges, and destroys sight more certainly. Indeed, it
is remarkable, in some cases, how little optic neuritis and its
results interfere with vision.^ In them the disorder of the eye
is constantly overlooked. Sometimes patients who were more or
less blind during the acute stage recover some sight in the sub-
sequent stage. On examination of the injured nerve we find
that all tumefaction has disappeared, the nervous fibres are
mostly broken up, and there is considerable hypertrophy of the
connective tissue. Now, what is it that this so-called optic
neuritis means ? "What is the reason or mode of these somewhat
rude changes? It is clearly necessary to know this precisely,
if we are to reason from them to the nature of coincident dis-

* ' Annales d'Oculistique,' t, liv, Juillet et Aout, 18G5.

" ' Zeitschr. der k. k. Gesellsch, der Aerzte zu Wien,' 1852, p. 118.

^ We have under our notice two cases of \iniliiteral epileptiform seizures, ia
both of which there is distinct optic neuritis of hoth eyes. Both patients can
read No. 1 Jiiger. Loss of siglit is an oculist's, not a physician's, symptom. It
may suddenly occur in an eye already under observation, but without auy accom-
panying change in the appearances.

1868.]

Medical Ophthalmoscopy. 137

turbances going on in the brain. Is the term " optic neuritis,"
in short, a correct term ; and are we right in calling these phe-
nomena evidences of iniiammation ? By evidences of inflamma-
tion we mean evidences of lesion of the proper structure of the
nerve, followed by more or less tumultuous and unsuccessful
efforts at repair. If we hold this view we look upon the vascu-
lar turgescence as secondary, and consequent upon a demand
for the materials of repair. The congestion is not in such case
a destructive process, but, in endeavour at least, is constructive.
Again, if we hold this view we regard the origin of the mischief
to be some lesion of continuity in the nerve-filaments within
the skull — a lesion caused by mechanical pressure, or by the
propagation of a destructive process from neighbouring
tissues. Such a lesion might be established by the encroach-
ment, say, of a tumour upon optic filaments in some part of
their length, and in some region of their distribution ; or, again,
by the propagation, say, of a meningitis to the neurilemma of
the optic nerves — an inflammation which would readily penetrate
their substance.

Mr. Hutchinson, for instance, considers that —

" The neurilemma is first involved in neuritis, and that its nuclei pro-
liferate. Into its meshes the effusions, solid or fluid, of inflamma-
tion take place ; and it is owing to the continuity of their structure
that the inflammatory process travels from one end of the nerve to
the other. Thus, also, the nerve-tubules are subjected to pressure,
and their function is suspended" (loc. cit.).

Dr. Jackson, we believe, gives substantially the same inter-
pretation of the phenomena called " optic neuritis.^^ On the
Continent a like view is also prevalent, and much pains have
been taken to show that the frequency of optic neuritis in con-
nection with tumours of very various position is due to the ex-
tensive relations of the optic filaments, and to the connections
of the optic centres with other ganglia.^

This, which we may call the physiological explanation, has
long appeared to us to present great difficulties. Dr. Jackson
has shown that optic neuritis occurs with disease in any part of
the brain, the only condition being that the disease must be
" coarse,^^ that is, a tumour, say, or a large hajmorrhage. We
presume, for example, that he would not expect, in such a case, to
find limited softening; but if the cause be the ''descent" of an

^ We have recently received some most interesting researches of Grafe's upon
neuro- retinitis, published in the • Arch, f, Ophth.' xii. 2, s. 114 — 119. We can
now only commend the papers to our readers. The great disadvantage under
which oculists work is that eyes do not come under their observation until the
late and accidental symptom of amblyopia comes on.

138 Reviews. [Jan.,

inflammation along tlie course of optic filaments, wliat disease
would seem more likely than inflammatory softening to initiate
such a process ? We do, indeed, find that inflammations of the
membranes of the base are a common cause of optic neuritis ;
but is this to be explained by the supposition of a travelling
process ? "We have had under our own care more than one case
of cerebral disease in which conditions of the optic disc, not to
be distinguished from the slighter forms of so-called " optic
neuritis," have remained stationary for many months, giving
rise to little disorder of vision. It seems unlikely that molecu-
lar disintegration of the optic fibrils sufficient to make an obvious
demand upon the vascular supply for repair, or to cause such a
degree of stasis, should remain stationary or advance so leisurely.
Nor, after comparison of a number of affections of the optic
disc, could we be satisfied that in any of these cases the struc-
ture of the nerve was primarily in fault. We failed to draw any
line between simple dilatation of the veins, evidently due to
impeded circulation, and other disorders, which, in addition to
stasis, presented small or large eff'usions. We conclude that
''optic neuritis" depends not at all upon the nature of the in-
tracranial disease, but upon the amount of resistance which it
offers to the circulation. Finally, M. Bouchut likewise concludes
that meningitis does not disturb the optic nerve by exciting in-
flammation in the course of the neurilemma, but by throwing up
a dam in the way of the venous blood. We will give his own
words (p. 17) :

" The blood from the interior parts of the eye, which has served
for their nutrition, returns to the venous torrent by the choroido-
retinian branches of the ophthalmic vein, which pass over the disc up
to its centre, and which they cross to penetrate into the nerve. Once
in the optic nerve, the venous blood enters the cavernous sinus, thence
into the petrous or lateral sinus to gain the jugular vein, which it
does easily so long as no obstacle arises to choke the sinuses for
more or less of their extent. If such an obstacle arises, which fre-
quently happens in inflammation of the brain or membranes, in
tumours, phlebitis, haemorrhages, chronic hydrocephalus, cerebral
congestions, &c., there results a stasis in the veins and capillaries of
the disc, retina, or choroid, which causes various changes at the back
of the eye."

These changes he then enumerates, including " fibrinous
exudations," and he adds that there are " difflerences of degree
only" between all and any of these ; also (p. 29) that " such
troubles of the circulation sooner or later cause degenerations
of the retina and choroid and atrophy of the optic nerve and
disc."

1868.] Medical Ophthalmoscopy. 139

The reader will not fail to see that much depends upon the
apparently minute question whether the origin of optio neuritis is
to be taken as a sign of molecular instability in the nerve-tracts^ or
of interference with the cerebral circulation. Shall we continue
to talk of " optic neuritis/' and please ourselves wdth calculating
the amount of " irritation " " set up " in the brain, or shall we
calculate, from optic congestions and effusions, the degree of
obstruction which exists to the ebb of the blood? If we are to
reason from the eye to the brain, it is well to discover which
of the two tracks our minds are to follow.

That the retinal circulation may be a most delicate test of the
cerebral, is a hope already, indeed, entertained by several
observers. Dr. Jackson has published an important paper upon
the retinal circulation as seen during sleep. ^ He desired to
find in that '^ outpost of the cerebral circulation''^ some evi-
dence of the variations of vascular tension in both health
and disease. He has also examined the eyes of patients in
epileptic fits. He reports that in one case, at least, the disc
paled, the vessels at times even vanishing outright. Curiously
enough, they seemed to sympathise with the breath, filling with
expiration, and emptying on inspiration. He compares this
with the pallor of the face seen at the outset of a fit. Many
observations, however, will be needed before we can have any
certainty on this matter. Unluckily, M. Bouchut seems to
speak of a tumidity of the retinal vessels in epilepsy, which he
says persists some days. If, however, he examined any patients
during the paroxysm, he has not been careful to say so. That
a relaxation of the vessels should follow the spasmodic contrac-
tion spoken of by Dr. Jackson is likely enough, and this would
seem to support the recent conjecture that an epileptic fit depends
upon a spasmodic contraction of the cerebral vessels.^ The sub-
sequent relaxation would correspond with the period of coma.
The difficulty of catching a patient in a fit, and the greater
difficulty of then examining his eyes, has prevented us from
coming to any conclusion on the subject. That the retinal
vessels are very heavily congested during states of sopor and
coma is, we think, made clear. M. Bouchut has a most strik-
ing chapter upon the retinal phenomena which follow the
administration of chloroform. In many cases he watched the
effect of the inhalation of this drug upon the retina, and in all
he found a very marked injection of the back of the eye, with
increase in the number and size of the veins. In some cases he
noticed a capillary congestion and effusion, masking the whole
of the papilla, and throwing a veil over it. In one case the

1 'Royal Lond. Ophthal. Hosp. Reports/ vol. iv, pt. i.

- We have ourselves observed in many cases of violent mania that a persistent
blush of the disc and neighbouring retina remains for several days.

140 Reviews. [Jan.,

eSects were so marked thatM. Cmnier, an experienced observer,
could scarcely believe in the reality of what he saw. These
congestions interfere little with vision, and last some time after
recovery. Effects of the same order were seen also to follow
the administration of belladonna and opium.

In these latter cases the capillary circulation is little affected,
the papilla seeming unchanged, while the veins are distended.
This is curiously in accordance with Dr. Jackson's observations
on the state of the eye in natural sleep. He ''found the
optic disc was whiter, the arteries a little smaller, and the veins
thicker than in waking. The veins were thick and almost plum
coloured'^ (loc. cit.). All this is very interesting, and deserves
continued attenion. M. Bouchut has succeeded in producing a
well-marked "contre-coup^' in the optic nerve by purposely
wounding the brain. He has sacrificed dogs and rabbits with
an assiduity that must be very flattering to those animals, and
he gives two drawings of optic mischief successfully induced by
causing commotions within their skulls. i

Lastly, this industrious physician has determined that at the
instant of death the choroid pales and loses all colour, the central
artery vanishes, and the veins soon cease to be appreciable.

We must now pass on to consider the second form of
atrophy. 2. Simple primary or progressive atrophy is to the
oculist the most hopeless of all diseases. Consecutive atrophy
is merely the result of the weight of a previous congestion which
has crushed the nerve and interfered with its nutrition. In
this form the nerve may not be quite killed ; it generally is not,
and if released it has some chance of recovery. But progres-
sive atrophy is a deliberate death — a process of degeneration
from within, mostly ending in utter blindness. This disease
must be distinguished from the atrophy with glaucomatous exca-
vation, or with posterior staphyloma, and from the changes in
the disc which may accompany pigmentary retinitis and choroi-
ditis. The appearance of this atrophy is very characteristic.
The fine capillaries which give the rosy tint of the healthy disc
slowly wane, and a dead or pearly white is left. With the
failure of nutrition vision also is lost, passing steadily and
surely away. The central artery and vein do not necessarily
shrink. In consecutive atrophy we do not so often see this
dead white, and the edges are not so sharp. The border of the
nerve in progressive atrophy is flat and even, the disc being
strongly contrasted with the red tissues surrounding it, while
the border of a nerve which has been merely crushed uneven. In
tion and effusion is, on the contrary, badly defined and by conges-

' Dr. Richardson has promised us to try the effects upon the optic-nerve and
retina of freezing the various parts of the brain.

1868.]

Medical Ophthalmoscopy. 141

the latter case there are often, too, blotches and stains about it,
the remains of former effusions, which lessen, to some extent, the
contrast between the disc and the retina. It is doubtful
whether any active stage is seen at the beginning of this degene-
ration. Our own impression, from one or two cases, is that a
transient flush of congestion — a faint show of resistance, as it
were — may be seen at the outset. It is seldom that attention
is given to the eye at this time. Progressive atrophy depends
nearly always upon some disease of the brain, cerebellum, or
spinal cord. Little is known of any chances of recovery
from it.^

The forms of organic change in the eye which occur with
Bright^s disease and with syphilis we shall briefly consider here-
after. We are obliged also, from want of space, to omit all
discussion of the functional changes of the eye. This we
regret, as the phenomena of colour-blindness, and of coloured
vision, are very interesting. Dr. Jackson has related some
instances of epilepsy with coloured vision, in the 'Medical
Times' of June 6th, 1863. We must say a few words,
however, on the importance of testing the field of vision.
The extent of vision may be registered from time to time by
having on slips reduced diagrams of the test-board.'-^ To these
^e outlines found on the board are rapidly transferred, and the
slips are then filed with the other records of the case. In pro-
gressive cerebro-spinal atrophy w^e constantly find a diminution
of the visual field, which begins at the outer circle, and advances
more or less concentrically, mostly preferring, however, the
inner and outer sides. Hemiopia, again, which has been so well
described by Grafe, is a most interesting affection; lateral
hemiopia is constantly due to cerebral disease, and is curiously
accordant with what we know of the decussation of fibres at the
chiasma. But the limits of our space, which we may take also
to be the exact limit of the reader's patience, compel us to
hasten on to the intra-cranial diseases which may cause any of
these ocular disturbances. We shall enquire what symptomatic
changes in the optic nerve and retina, if any, are found to

' Since the above was written we have investigated this question in a large
number of cases. In many the atrophy is of a mixed kind ; there may be slight
effusion in essentially degenerative atrophy. Some few cases, especially in old
people, appear to begin by a gradual paling of the disc. By far the greater
niamber begin with a pinkness and vascularity of the disc (red softening). This
pinkness after some time yields, first on the inner edge of the reversed image,
which whitens, leaving pinkness and vascularity about the opposite edge and
neighbouring retina. This part is the last to whiten. It is not until the stage
of white-softening is reached that sight begins really to fail. In the red stage
the pupils are generally contracted. We are disposed to call this process the real
optic neuritis.

- Vide Mr. Pridgin Teale, ' Med. Times and Gazette,' May 11, 1867.

143 Reviews. [J

an.

accompany meningitis, cerebral lisemorrhage, encephalitis, senile
softening, hydrocephalus, tumours, epilepsy, insanity, myelitis,
locomotor ataxy, fevers, Bright's disease, and syphilis. Of many
of these cases we shall be obliged to speak very briefly.

The effects of meningitis upon the optic nerve are undoubted,
though their frequency and their origin is a matter of some
controversy. The statements of MM. Galezowski and Bouchut
are curiously at variance. M. Galezowski, who attributes the
changes in the optic disc to the inflammatory action which is
propagated along the course of the nerve, declares that the discs
are unaffected in all cases where the inflammation of the mem-
branes is remote from the optic nerves.^

In meningitis of the base he says that these nerves must be
almost always involved in the process, wherefore we find in
tuberculous meningitis that optic neuritis generally exists. Not
so in meningitis confined to the fissure of Sylvius, or upon the
convex surface of the brain. In such cases, however severe
they may be, he is convinced that the discs preserve their
normal aspect. M. Bouchut asserts almost the very contrary of
this. He gives a table of fifty-nine cases of meningitis, some
tuberculous and some not, and states that obvious changes in
the eye were seen in all but two. Of these two, one was of
doubtful diagnosis, and the other was only examined once, and
that four days before death. He finds in the first period dilata-
tion of the veins of the retina, peri-papillary congestion, and
often effusion; in the second period, tortuous veins, stasis,
thrombosis, and even rupture of the vessels. These, he says,
appear more or less quickly, according to the amount of obstruc-
tion to the circulation in the sinuses occasioned by the me-
ningitis, so that in a case where a meningitis was diagnosed M.
Bouchut did not find ocular changes on one day, but found
them on the next. After death the meningeal veins are seen to
be full of liquid or clotted blood, and the sinuses of blood mixed
with free or adherent clots. In some cases he has found " a
veritable phlebitis '' of the sinuses of the dura mater, with
obliterations of the passages. The other sinuses of the dura
mater are seen sometimes to press upon the cavernous sinus,
and so to close it. Thus he fully explains the engorgement of
the back of the eye, and the exudation of serosity. M.
Bouchut considers, then, that meningitis, wherever found, must
always tend mechanically to oppress the venous circulation. He
notices that the eye corresponding to the side of the more
intense inflammation presents more marked disturbance.

Another proof that these disturbances are due to mechanical

' A curiously negative case, of universal meningitis without change in the eye,
was recorded by Dr. Jackson in the ' Medical Times ' two or three weeks ago.

1868.] Medical Ophthalmoscopy, 143

obstruction he finds in the fact that a dropsical enlargement of
the eyeball may sometimes also be ascertained by palpation.
This result has been likewise seen to follow a large cerebral
haemorrhage. It is probable that the different views held by
MM. Galezowski and Bouchut of the origin of the aflFections
of the optic nerve seen in meningitis may have given a bias to
their observing faculties. It is probable^ too, that M. Bouchut,
being eminent as a children's physician, sees for the most part
cases of tubercular meningitis, that is, meningitis of the base.
Our own experience is not large enough to enable us to judge
between these conflicting statements ; but it is large enough to
have given us a strong opinion, which leans to the side of M.
Bouchut. With his explanation of the cause and mode of this
kind of optic trouble, indeed, we entirely agree, as we have said
above. M. Bouchut thinks that the changes in the eye often
occur early enough to be the first certain signs of the disease.i

We ourselves have found great help from them in diagnosing
the existence of chronic meningitis. In chronic cases the
nutrition of the nerve often sufiers severely from the effects of the
congestion j primary atrophy is not seldom seen in this disease.

In cerebral haemorrhage,^ although the disorders of motility
in the eye are very important, yet in ordinary cases the optic
nerves present few indications of value. When the haemorrhage,
however, is a large one, it tends, by obstruction, to cause
stasis and infiltration in and about the discs. This effect is
always more complete in the eye corresponding to the side of
the clot. Those observers who call it '' optic neuritis'^ attri-
bute it to irritation of optic filaments by the clot, or by the
excited tissues around the clot. M. Galezowski goes farther,
and makes the astounding statement, founded, seemingly, on a
single case, that " where amaurosis supervenes, the apoplexy is
always situated in or near the optic ganglia '' (p. 126).

Dr. Jackson expressed an opinion some little time ago that
when amaurosis occurred with hemiplegia, the hemiplegia would
be found on the left side. This is certainly not borne out
by our own observations. When a cerebral haemorrhage has
caused a great obstruction to the venous circulation, rupture and
haemorrhage into the retina is sometimes seen. Of course the
connection between the two haemorrhages is accidental. This

^ This is no doubt true, and its . results upon the interpretation of treatment
are very cheering. We have notes of several cases of meningitis (suspected from
other symptoms, ascertained by the ophthalmoscope) which have entirely re-
covered. The treatment in these was by cod oil and iodide of iron, not by purg-
ing and calomel.

' If there be such a thing as " apoplectiform congestion, " it is possible that
a study of the circulation of the eye may be of great value in such cases. This
subject is scarcely ripe enough for discussion.

144 Reviews. [Jan.,

coexistence of retinal and cerebral apoplexy is often seen in
company with the small rough kidney. In these cases the two
apoplexies are of like causation, and probably depend upon like
degenerations of the walls of the blood-vessels, their concurrence
in time being probably quite accidental.

Under the head of encephalitis we include those obscure intra-
cranial diseases which depend upon local degenerations of cere-
bral tissue, are generally chronic in their course, and give rise
to partial paralyses and to perversions and loss of general or
special sensations. Every physician knows but too well the
difficulty of getting complete histories with autopsies in such
cases. These partial inflammations not infrequently follow a
blow upon the head, or they may depend upon atheromatous
disease of the vessels, embolism, or syphilis.^ We now omit
those cases in which the encephalitis is secondary to a haemor-
rhage or tumour, and we also omit senile softening and pro-
gressive general paralysis. Of course we include those frequent
cases in which one or more clots are found in the diseased
patch, and which are not causes of the degeneration, but
consequences of it. Amaurosis is a not uncommon feature in
this disease, as M. Lancereaux has shown. A constant headache,
vomiting, or nausea, strabismus, and deafness, are also among
its symptoms. The amaurosis probably depends upon the descent
of the nervous degeneration along the optic nerves, the atrophy
being of the hopeless progressive form, with even edges." Some-
times, when the softening is limited, the amaurosis may for years
be the only symptom. It is stated that local encephalitis may
be set up about the corpora striata, the thalami, and the corpora
geniculata, by the ascent of neuritis from the terminations of
the optic nerves, the mischief being established first of all in the
eye. If the statement be proved, these facts would support the
explanation, which is given of the origin of some other diseases
of the centres, such, for instance, as the peripheric origin of
certain spinal diseases or the encephalitis said to follow some
wounds of the frontal nerve. It seems likely, from some ob-
servations, that a further study of afi'ections of the eye may
enable us to infer from them something of the position of these
localized patches of disease.

In senile softening there is for the most part an absence of
symptomatic changes in the eye; but of course it will be remem-
bered that old persons are very liable to atrophic changes at the
back of the eye, independently of any central mischief. At the

1 Or struma, as Dr. Little has suggested. ' Med. Times and Gaz.,' Oct. 12,
1867.

■^ It would be interesting to know how far the analogy of the white optic-nerve
atrophy can be applied .to certain forms of deafness — aural auiaurosis.

1868. 1 Medical Ophthalmoscopy, 145

same time all chronic cerebral disease tends more or less to
lower the nutrition of the optic centres and nerves, and the
arterial disease which leads to senile gangrene of the brain may-
exist in the optic nerve and retina also.

In the diagnosis of chronic hydrocephalus M. Bouchut has
pointed out that ophthalmoscopic examination may be of great
value. The somewhat large and soft heads of rachitic cliildren
do, as we all know, often simulate commencing hydrocephalus.
Even so experienced an observer of children's diseases as M.
Bouchut states that without the ophthalmoscope the diagnosis
may be almost impossible. In rachitis repeated scrutiny has
convinced him that the back of the eye remains normal, while
in commencing hydrocephalus he always finds there enlarged
and numerous vessels and a prominent and suffused disc. As
the intracranial pressure increases, the disturbance becomes
greater, and ends in destruction of the nerve. It so happened
that on the morning of the day on which we now write we were
requested to see a case of hydrocephalus. The child, by
anxious nursing, had been kept alive until its head had gained
an enormous size, and the question of surgical interference
arose. We found both discs completely destroyed by consecu-
tive atrophy and large patches of old effusion upon both retinae.
The mother thought her baby was blind, or nearly blind.

The occurrence of amaurosis as a symptom of tumours within
the cranium has long been known, and many interesting papers
have been written upon this subject. Grafe was one of the
first to treat in detail of this amaurosis, and he attributed it ex-
clusively to the pressure of the tumour upon the cavernous sinus.
Lancereaux has published several cases, and arrives at the very
opposite conclusion to Grafe, saying that the mischief is due to
compression of the nervous matter. It is^ indeed, the old story of
the gold and silver shield — both authors are right, and both wrong.
When the tumour is so placed as to interfere with the ebb of tlie
blood, we find stasis and infiltration in and about the optic disc.
In other cases the affection of the optic nerve is due, not to the
tumour, but to the encephalitis which surrounds the tumour;
then we find that the destructive process passes along the ner-
vous connections, and so leads to atrophy of the disc. Thirdly,
atrophy of the discs may be caused by the direct pressure of
the tumour upon the optic nerves or centres.^ It might be
expected that in a large proportion of fractures of the base of
the skull the optic nerves would suffer from the presence either
of some dislocated part or of sanguineous effusion. Such in-
stances are recorded, but are found to be rare. M. Galezowski
examined fifty-seven cases of fracture without meeting with

1 In the two latter cases the atrophy would be of the " simple " kind.
81— XLi. 10

146 Reviews. [J

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such a symptom. So the ophthalmoscope, unfortunately, can-
not help us in obscure cases of this kind. M. Galezowski de-
votes many pages to a careful discussion of the relations betif een
optic affections and cerebral tumours, and he draws many
valuable conclusions from which the position of these latter
within the skull may be determined. For these details we must
refer the reader to the book itself.

The occurrence of amaurosis in connection with epilepsy
may be treated at great length or with the brevity which
we fear must chiefly distinguish our own treatment of it. If
we were to begin by looking upon epilepsy as a symptom,
and upon optic disease as a symptom, and were then to dis-
cuss the value and meaning of these two symptoms, taken
together, as we might discuss the meaning of amaurosis and
vomiting, or amaurosis and headache taken together, we
should be led into a long discussion. It must be enough for
us in this place to say that epilepsy may be a symptom,
(1) of some obvious disease of the cerebral organs, of tu-
mour, say, or of meningitis ; or (2) it may be what is badly
called, " essential epilepsy," that is to say, a manifestation of
some periodical change in the function of the cerebral tissues,
whether nervous or vascular, not connected with marked
static change. Now, it is with epilepsy of the first kind that
amaurosis is usually associated. We perhaps never find optic
atrophy in connection with " essential epilepsy^" while on the
other hand it is as common in symptomatic epilepsy, as we
have shown, when speaking of amaurosis in connection with
tumours, meningitis, haemorrhages, &c. Those epilepsies which
depend upon organic disease are, of course, more or less
unilateral according to the position of the diseased tissues, aud
Dr. Jackson has repeatedly called our attention to the frequency
of optic atrophies in unilateral epilepsy. It seems probable that
slight disturbances of the vascularity of the retina occur in ordi-
nary uncomplicated epilepsy, especially if violent or long con-
tinued, and these, if carefully observed, may throw some light
upon the pathology of this disease.^ Competent observers still
assure us that venous dilatations are to be found in the central
ganglia in severe epilepsy.^

Under the vague name of insanity are comprehended
such a number and variety of tissue changes, functional and
organic, that we have almost to apologise for the use of
such a term. Our readers may, however, wish to know whe-
ther the ophthalmoscope is likely to prove of much value to
the alienist physician in dealing with so vast a collection of ob-

1 A simple and ready means of photographing the back of the eye would be an
immense help to observers.

2 Which are, no doubt, vessels in which the frequent repetition of spasm has
been succeeded by paralytic dilatation.

1868.] Medical Ophthalmoscopy. 147

scure aflfections. Upon this point we find that alienists and
oculists alike are silent. We shall be glad if, by our own
remarks, the attention of both classes of observers may be drawn
more particularly to this branch of the subject. If the ophthal-
moscope can help forward the study of mental disease, it will be
the means of increasing the knowledge of the physician in the
highest branch of his high profession. It is not possible for us
to give any complete account of the results to which we have
been led by a tolerably large experience of the state of the eye
in the various classes of the insane. When the reader remem-
bers that a large assemblage of lunatics means a large assemblage
of cases of severe cerebral disease^ he will be prepared to hear
that symptomatic affections of the eye are very frequent in
lunatic asylums, and that the ophthalmoscope will no doubt
throw much light upon the diagnosis and pathology of the various
causes of insanity. Perhaps its value is most evident in the
distinction between organic and functional disease. There are
very few cases of organic disease, sufiicient to disturb the mental
functions, which do not cause also changes in the optic disc or
retina.^ Of a large number of cases of mania, for example, of
which we have notes, we find that about two thirds present un-
mistakable aff"ections of the optic nerve. If doubtful cases were
taken, the proportion would be still larger. Now, when we
compare the cases which present marked eye mischief with those
which do not, we find that in almost all of the former there are
other symptoms which lead us to suspect organic disease ; the
rest of the cases being functional disorders, such as hysterical
mania, erotomania, and the like. In melancholic patients
again, and monomaniacs, where obvious organic disease of the
brain is not frequently found, we find in like manner, from our
notes, that if we exclude retinal ansemia, which in melancholic
patients is often well marked, a small proportion only present
any symptoms in the eye. It would take us very long to
unravel all our cases of dementia, but, speaking generally, we
find in them also that organic disease and eye affections go to-
gether. As dementia is often a sign of profound changes in
nervous nutrition, so we find that sympathetic affection of the
optic nerve is not uncommon in that disease. Simple atrophy
of the nerve occurs also in a considerable number of congenital
idiots.^ In general paralysis atrophy of the discs is, we had
almost said, invariable. Unluckily, it is not a very early symp-

^ We need scarcely say that such changes may and do exist without causing
much derangement of vision. Indeed it is not possible to estimate degrees of
vision in the insane with any accuracy.

- Dr. Langdon Down is kind enough to inform us that our experience agrees
with his own in this matter, as he has often noticed that amaurosis occurs in a
considerable number of idiots.

148 Revieivs, [Jan.,

torn. It becomes unmistakable about the end of the first stage
or the beginning of the second, and in a certain number of cases
it progresses to complete amaurosis before death. We see here
another mark of the nervous waste in which general paralysis
consists, though we have not detected in the vessels of the retina
any signs of that tortuosity which has been seen in the grey
matter in that disease. In spinal disease, atrophy of the optic
nerve is not uncommon, and it is frequent in that form
of it known as Locomotor ataxy. It is also observed in some cases
of chronic myelitis not attended with shooting pains, &c. The
causation of atrophy in these cases, which is of the simple pro-
gressive kind, is very interesting, and wholly diiferent from its
causation in cerebral disease. The atrophy in spinal disease
probably depends upon an affection of the great sympathetic,
through its communications with the anterior roots of the
spinal nerves. These cases must be very interesting to M.
Claude Bernard. Amblyopia is often mentioned in connection
with lead poisoning, but without recorded change in the
optic nerve. We therefore call attention to a case of
Dr. Hirschler, of Pesth (quoted in Virchow's ' Jahresbe-
richt^ for 1867, p. 447), where he noted "Eine mattgraue
Verfarbung und verringerte Transparenz der Papille." The
affections of the optic disc and retina, which occur in
convalescence from fevers, diphtheria, and other profoundly
debilitating diseases, need not delay us. They are not very
common events, and probably depend only upon profound anaemia
of the base of the brain and optic nerves, attended at times,
perhaps, with some effusion of serosity. They are generally,
but, unfortunately, not always, cured by generous diet and
tonics. The mental feebleness which sometimes persists in such
convalescents is no doubt a phenomenon of the same order.
We are disposed to think that some degree of meningitis
has probably existed in the course of fevers which are
followed by affections of the optic nerves to any extent.
The disorders of the back of the eye seen in Bright's disease and
syphilis now only remain to be noticed. We shall not detain
the reader by carefully describing these, but we rather refer to
the papers of Mr. Bader on these subjects published by him in
the ' Ophthalmic Hospital Reports' and in the ' Reports of
Guy's Hospital.' In syphilis the choroid seems to be chiefly in
fault, and we see patches of many colours at the back of the eye,
some being of a brilliant white, others of darker tints, such as
red or brown. In Bright's disease the nutrition of the optic
nerve as well as of the retina is profoundly altered. Galezowski
has found in these cases atrophic change of the nerves as high
as the corpora quadrigemina, and he frequently notes fatty

1868.]

Medical Ophthalmoscopy. 149

patches in and about the chiasma. Upon the retina we find
extravasations in the course of the vessels, which are slowly
effused and pass into degenerative states forming white patches
or striations along the margins of the veins. Other patches are
probably due to degeneration of the retina itself. The hsemoi-
rhages in such retinae are very different to the ruder retinal
apoplexies of cerebral disease. These latter occur more brusquely,
are preceded and accompanied by great vascular dilatations and
distortions, and do not congregate along the course of the ves-
sels. In cerebral disease, moreover, the disc is generally the
first to show signs of change, while in Bright's disease retinal
degenerations are first in order : finally, in cerebral disease, we
do not see the fatty patches of degenerated retina.^ A question
has arisen whether these retinal affections are found in all kinds
of albumina, or only, as is generally supposed, in connection
with that state of tissue of which the small rough kidney is a
symptom. A case is reported from the Leeds Infirmary where
marked retinal degeneration coexisted with symptoms of the
large, smooth kidney, the diagnosis being verified by an autopsy.
We understand also that the physicians of that institution have
a second case of the same kind under observation.

We have now said enough to show that various and most im-
portant indications of disease are to be found in the eye. The
remarks which we have made, however, chiefly bear upon the
disorders of the optic nerve and retina ; when we add to these the
disorders of the ciliary region, the lens, the cornea, the conjunc-
tiva, and the orbital apparatus, which we have been obliged to
pass by, we shall see that physicians must now be in possession
of a vast number of facts which help in the diagnosis of many
obscure diseases and morbid states of tissue. As the import-
ance of these facts bears no proportion to their prominence, it is
clear that they can no longer be neglected on the score of
their minuteness, and that instruction in ophthalmic practice
should be given to both medical and surgical students. We
have gone at some length into the question of the symptomatic
value of disorders of the eye, for we believe, that few
physicians are really aware of what has been done for them
almost entirely by their surgical brethren. We have necessa-
rily spoken briefly, but not, we hope, vaguely, and we have said,
perhaps, enough.^ Sir Thomas Watson, with great sagacity,

' M. Liebreich's Atlas contains admirable plates of Bright's retina. Similar
changes have been recorded as occurring (very rarely) in diabetes.

2 Our wish has been to deal wholly with ascertained facts, and not with specu-
lations. The state of the retina, &c., ought, however, to be carefully noted in all
so-called cases of " shock " in railway accidents. One or two suggestive cases
have come under our notice. It must be borne in mind that symptomatic
changes in the optic nerve are often very slow.

150 Reviews. [J

an.

begins his course of lectures on medicine with four lectures on
diseases of the eye, his —

' Only motive, however, for beginning with a few of the numerous
morbid states to which this little part is liable being this — that we
find in the eye more satisfactory and plain illustrations of the general

facts and doctrines of pathology than in any other single part

of the body. ' Here' (to use the words of Dr. Latham), ' here you
see almost all diseases in miniature ; and, from the peculiar structure
of the ey e, you see them as through a glass ; and you learn many of
the little wonderful details in nature of the morbid processes, which
but for the observation of them in the eye would not have been known
at all."

The words of Sir Thomas Watson and Dr. Latham are daily
gaining a weight and a meaning which could be no more than
guessed at by their distinguished authors. It would not^ indeed,
serve any good purpose to exaggerate the value of ophthalmo-
scopic work to the physician. It would be absurd to pretend
that the eye is a window through which the states of the brain
may be seen as the workings of the soul might be seen
through windows in our bosoms. It is enough to say that mis-
chief or change of state in the eye is not uncommonly coincident
with nervous and other diseases. Between these concurrent
events there must lie a chain of causation which may turn out
to be a series of phenomena of infinite value, and which is
already known in many cases to be of high interest. In a word,
to end as we began, wherever there are facts to be observed, and
wherever we can hope to strengthen inference into certainty,
there must we work. No thorough knowledge of the signifi-
cance of optic changes in cerebral disease, &c., can be attained
until we are familiar with their modes. We have just obtained
a very interesting and valuable paper on optic neuro-retinitis,
by Grafe ('Arch. f. Ophth.,' xii, 2, s. 114—149) to which we
would call the attention of our readers.

151
PART SECOND.

Art. I. — Lectures on Clinical Medicine, delivered at the Hotel
Dieu, Paris. By A. Trousseau, Professor of Clinical
Medicine, &c. &c. Translated and Edited, with Notes and
Appendices, by F. Victor Bazire, M.D. 8vo. London,
1867. Parts II and III, completing Vol. I.

The past year has witnessed the death both of the dis-
tinguished author and of the able translator of these most
lucid lectures on clinical medicine, which were briefly noticed
in this Review for 1866. The science of medicine has, indeed,
lost a most conscientious and clear-sighted exponent in Pro-
fessor Trousseau, whose example and labours have done much
in France in the way of introducing and commending to
attention the teachings of English pathologists and practi-
tioners, and particularly those of the eminent Dublin physician,
the late Dr. Graves. The death of Dr. Bazire is equally to be
mourned in the interests of medical science. He had but
lately entered on an active professional career, yet what he
had already effected augured well for his own prospects, and
also for the progress of medicine. The translating and annotat-
ing these lectures was his principal undertaking, and the mode
in which he executed it is a monument of his care and
industry, and of the extent of knowledge he possessed and
could bring to bear upon it.

The contents of Part I were remarkable for their com-
parative novelty, and for illustrating the philosophical and
practical acumen of Professor Trousseau.^ Those of the second
and third parts, now before us, though they may have to yield
the palm in respect of novelty, are not the less interesting and
important to the practitioner. To enumerate them they are —
Progressive muscular atrophy ; facial paralysis ; cross paralysis ;
infantile convulsions; eclampsia of pregnant and of parturient
women; tetanus; chorea; senile trembling and paralysis
agitans ; cerebral fever and chronic hydrocephalus, and neu-
ralgia in Part II; whilst in Part III are — Cerebral rheu-
matism; exophthalmic goitre, or Graves's disease; angina
pectoris; asthma; hooping-cough, and hydrophobia.

Dr. Bazire's notes and appendices were very copious and of

1 This Part was noticed in our April number for 1866, p. 111.

152 Bibliographical Record. [J

an.

great value in the first part; but in the two following, under
notice, they are much more sparse and brief. We do not refer
to this by way of indicating a defect, for both the subjects of
the lectures and Dr. Bazire's special studies afford explanation
of their absence. Indeed, annotations to lectures so compre-
hensive as are those of Trousseau would be only incumbrances,
except so far as they could convey original information calcu-
lated to give completeness to the subject discussed, or could
elucidate obscurities, or otherwise could correct any misappre-
hension or ignorance of English doctrines or practice displayed
by a foreign physician. As an example of notes of the first
class referred to, in the shape of addenda of original matter,
" the Appendix by the Editor '' to the lecture on " Progressive
Muscular Atrophy'' may be cited. For Trousseau, at the date
when his lecture was delivered, appears to have been ignorant
of Mr. Lockhart Clarke's important minute researches into the
morbid anatomy of the disease; consequently, without the
appended review of those researches, the lecture might have
been pronounced incomplete.

An examination of the doctrines and teachings of Trousseau
cannot here be undertaken ; but it may be said of him that he
was a very admirable and cautious teacher of pathology, most
carefully criticising hypotheses, testing them by the light of his
immense practical experience, and, where found valid, illus-
trating them by cases in language of great fluency and of much
grace and clearness. He must also be regarded as a safe
practical physician, well versed in British therapeutics;
although, indeed, the attention given to the symptomatology
and morbid anatomy of the diseases discoursed upon vastly
preponderates over that bestowed upon treatment. This may
be deemed to have been Trousseau's misfortune rather than his
fault, particularly when regard is had to many of the lesions
described in the lectures as yet published ; for, unluckily, too
many of them are of such a nature that, with respect to them,
we may well entertain misgivings whether medicines ever can
be of much avail. Progressive muscular atrophy seems to belong
to this class of maladies, and Trousseau sums up his instruction
on its treatment as follows : — "Treatment is unfortunately power-
less against this complaint ; and if localised Faradisation has, in
some cases, been able to arrest its development, the disease has
made further progress after a more or less prolonged inter-
mission." On the other hand, however, in the foot-notes
Dr. Bazire expressed himself more hopefully of treatment, and
could quote other physicians who agreed with him.

In conclusion, we desire strongly to recommend these lectures
by Trousseau to all who desire to obtain a satisfactory acquaint-

1868.] Medical History, 6fc., of the American War. 153

ance with modern medicine; and we are glad to learn that
arrangements have been made to continue their publication in
English. We have only to hope that the translation and
editing of the remaining lectures will be as satisfactorily
carried out as they have hitherto been.

Art. II. — Circular No. Q, War Department. Surgeon-GeneraVs

Office, Washington, November 1, 1865.
Reports on the Extent and Nature of the Materials available

for the Preparation of a Medical and Surgical History of the

Rebellion, 1865.

This work is valuable chiefly in a statistical point of view,
and mainly in consequence of the very large number of cases of
injury which the terrible experience of the great conflict en-
ables the American surgeons to bring together. It is a work
which does great credit to the Surgeon-General's Office from
which it has emanated ; and although itself only a specimen and
a kind of preface to the general medical history of the war
which we hope is in preparation, it will itself long form an
authentic book of reference both to the military and civil sur-
geon. Besides the statistical collections, there are many very
interesting individual cases, and the book is exceedingly well
and very profusely illustrated. We would call especial atten-
tion to the photograph of a patient after recovery from a bullet
wound which passed from the right side of the front of the belly
to the spine (opposite p. 26), and where, with American inge-
nuity, both the back and the front are shown by photographic
lines in front of a large mirror. There are also beautiful illus-
trations of the various forms which gunshot fractures of the
bones assume. But the most important and valuable portions
of the report we believe to be the statistical tables of the various
operations necessitated by injuries in battle, comprising as they
do numbers never before approached, and operations (excision
resection, &c.) never before tried on any large scale in military
surgery. The medical part of the report, though less novel and
we think less valuable (from the circumstances of the case),
appears done with the same conscientious care ; and the chap-
ters on hospital construction and on the arrangements for the
transport and care of wounded soldiers are well worthy of study.
It would be useless, we feel, to ofi'er extracts from a work of this
kind. We can only conclude by expressing the thanks of the
profession in England to the American department, not merely
for this laborious and expensive work, but for the great liber-
ality Avith which the copies have been circulated. We trust
that the 'General History,' for which such extensive materials

154 Bibliographical Record. fJan.,

are 'proved to exist, is steadily progressing under competent
superintendence.

Art. III. — Del Guanara, Nuovo Alimento Nervoso. Ricerche
Sperimentali del Professore Paolo Mantegazza (^Dagli
Annali Univ. de Medicina/ April, 1865). Milano, 1865.
Pp. 56.

On the Guanara, as Alimentary Substance and Nervous Excitant.
Experiments by Professor Paolo Mantegazza. Milan, 1865,

The author refers guanara to the class of coffee plants, or
those containing caffeine, such as tea, coffee, mate. Of these,
according to Stenhouse, mate contains the least amount of
caffeine, and guanara more than twice as much as the best tea.
The convenience which attaches to it from cold water being
employed in its use, and its superior power of excitation, will
probably recommend it to notice in proportion as intellectual
effort becomes a more general and indispensable ingredient in
the business of human life. The plant which yields guanara is
the Paullinia sorbilis of the genus Paullinia, in the family of
Sapindaceee, Jussieu. The fruit is worked up into cylinders of
the colour of chocolate, and somewhat of the consistence of
pudding, of about 200 grammes in weight ; when sweetened and
lowered with water, it constitutes an agreeable beverage of
pleasant favour.

At Uio Janeiro guanara costs twenty-four francs a kilogramme,
and half as much at the place of manufacture, the price being
enormously increased in Bolivia and elsewhere at a distance
from this centre. In the province of Mato Groso, in Brazil, it
the common beverage; but in general it is too expensive for
any to enjoy but the well-to-do classes, with whom it is con-
sidered excellent as tonic, aphrodisiac, and intellectual exci-
tant. According to a saying in vogue its use is the most costly of
all the vices. Used as a medicine, it is considered to be as
somewhat astringent and serviceable in the diarrhoea of infants.
But, if taken after meals, it has a tendency to disturb digestion,
and it is grateful after fatigue, especially during great heats,
and peculiarly useful to prolong the midnight vigil.

Fournier introduced it to European notice with exaggerated
announcement of its virtues, and many others have bestowed
some attention to the subject. The author of this pamphlet
having spent a short time in South America, warns the inquirer
against any conclusions drawn from specimens not imported
direct. The effects of guanara in relieving neuralgia and hemi-
cramia, though unmistakeable, do not appear to be of a perma-
nent character.

1868,J Bonders on Psychical Processes. 155

Professor Mantegazza has undertaken a series of minute
experiments to ascertain the physiological character of this
drug. In frogs, like cofFee, it produces tetanus, its action being
opposed to that of coneine ; in the infusoria it does not diminish
ciliary movements ; in larger animals it seems to create restless-
ness, wakefulness, spasms, and muscular inability. It kills
frogs in a dose of from five centigrammes to half a gramme,
the latter proportion being a fourth part of what is used in
common beverage by man ; altogether its action on frogs is
very analogous to that of caffeine. In the human subject it
seems to produce, in larger dose, defect of appetite, constipation,
and sometimes a minor degree of strangury and urticaria. Its
effects on the nervous system, then, would seem to be of a dis-
turbing character, and in this it has some analogies to strych-
nine; but, like tea and coffee, opium, it may some day force
its way into common use and the same general favour which is
accorded to it in the western hemisphere.

Art. IV. — Description of two Instruments for Determining the
Time required for Psychical Processes. By Dr. F. C.
DoNDERS, r.R.S., Professor of Physiology and Ophthal-
mology in the University of Utrecht. Translated from the
' Nederlandsch Archief voor Genees en Natuurkunde.' Deel
III, Aflevering i, p. 105. By William Daniel Moore, M.D.
Dub. et Cantab., M.R.l.A.
These instruments were exhibited by me in the sectional
meeting of the Society of Utrecht, held on the 16th of October,
1866. The one, which I have called noematachograph, serves
to determine the duration of more or less complex operations of
the mind. The other, to be termed noematochometer, defines
the shortest possible time for a simple idea.^

The noematachograph consists of a cylinder, in many respects
similar to that of the phonautograph, on which the time is regis-
tered by a vibrating tuning-fork. According to the vibrations
of the latter is indicated 1° the moment when a stimulus acts,
and 2° when the token of perception, the signal, is given.

Various stimuli may be employed, as an opening induction-
shock, the opening or closing of a constant current, a spark or
a great flash of light, transparent signs illuminated from behind
by a strong induction-spark ; lastly, a sound, whether of a spring
struck by a pin projecting next the cylinder, or of a tuning-fork
suddenly set vibrating by a peculiar arrangement, and directly
registering these vibrations, or, finally, of the human voice, or
any other sound, registered by a phonautograph, or rather by a

* At first I named the instruments Noematachometer and Noematachoscope.
I prefer, however, Noematachograph and Noematachometer, which are here used.

156 Bibliographical Record. [J

an..

simplified apparatus, consisting of a modified Konig's stetho-
scope, covered with elastic membrane and connected by two
gum-elastic tubes with two mouth-pieces.

The stimulus can now be acted on according to different
signals : — The closing of a current by pressure on a so-called
key, whereby an electro-magnet sets a pin in motion (not so
suitable on account of the variable retardation) ; [b) the striking
of a tuning-fork or the projection of an accent in sonje experi-
ments, where of many stimuli it is necessarily required to dis-
tinguish one ; (c) the lateral pushing away of a horizontal piece
directly connected with a vertical wooden bar, to the upper part
of which a small horizontal spring is connected, writing on a
cylinder and indicating the moment when the wooden bar is
turned, by the lateral pushing away of the horizontal piece,
round its axis. If the said horizontal piece be held between two
fingers, it can, in connection with a dilemma to be solved, be
pushed at will to either left or right.

With the noematachograph we can now —

(«) Determine the physiological time in impressions on the
eye, the ear, and diflterent parts of the skin. The simplest and
most accurate signal to give is the vertical wooden bar. Deter-
mining the physiological time in irritation on different parts of
the skin, we obtain some knowledge of the rapidity of conduc-
tion in the nerves, in which we have, however, to take into
account both the strength of the stimulus and the route of con-
duction in the central organ.

{b) We can thus investigate how much time is necessary to
solve a dilemma, and in connection therewith to give a signal.
The signal may then be either conventional or natural ; by prac-
tice the conventional may approximate to the natural, and thus
the influence of practice is studied. As conventional signals
serve — 1st, turning the wooden bar to the left or to the right,
accordingly as the stimulus is received on symmetrical parts of
the left or right side, accordingly as red or white light is exhi-
bited, accordingly as the vowels a or o are seen or heard, &c. ;
2nd, closing of the current by pressure, either on the key held in
the right or on that in the left hand, such an arrangement being
made that when both keys are pressed the current is not closed
(Conf. de Jaager, ' De physiologische tijd van psychische pro-
cessen/ Diss, inaug. Utrecht, 1865). As a natural signal
the repetition of the sound of a letter heard is employed, a
vowel preceded or not by a blow-consonant. As practised signal
the calling out of the sound of a vocal sign suddenly exhibited
by an induction-spark. In connection herewith, the influence
of practice with the above-mentioned conventional signs may be
investigated.

1868.J DoNDERS on Psychical Processes. 157

It was proved that the solution of a dilemma and the reaction
corresponding thereto requires more time than the simple
reaction on a stimulus, and that the difference is much more
considerable with conventional than with natural signals, while
on the first the influence of practice is more rapidly felt. The
diff'erence in two experiments, the one withy the other without
the solution of a dilemma^ exhibits the time required for the
psychical process of distinguishing and distinctive manifestation
of the will.

We can, with the noematachograph, determine the time
required to distingish one out of more than two stimuli, and to
answer with a given signal. For this, the repetition of the sound
heard (natural signal) and of the announcement of the sound
of a suddenly illuminated vocal sign (practised conventional
sign) are particularly suitable. Experiments may also be made
with conventional signs, without practice, to be given on one of
more than two stimuli previously agreed upon.

{d) The instrument may be employed to determine what dif-
ference of time is necessary to decide which of two stimuli had the
priority. For this purpose two springs, with a fifth^s difference of
sound, are brought by turning, by two projecting pins, into a
state of vibration ; the distance of these pins can be modified,
and thereby the difference of time. In like manner two sparks
may be discharged at the side of the cylinder with a difference
of time which may be modified at will.

If by comparison of the experiments described under a and b
or c it be deduced, as difference of the time found in them, how
much time is required for the united double action of distin-
guishing a stimulus out of two or more and for reacting on the
distinction made, we can, from the experiments mentioned
under d, ascertain how much time an idea or thought alone
requires. A defect in these last experiments is, that the cylinder
is not every time turned with absolutely equal rapidity, and that
consequently, by the distance of the pins or of the breaks which
sparks give, we cannot absolutely regulate the difference of time
before the experiment, but only after the latter ascertain it from
the vibrations of the chronoscope between the two pins. Chiefly
for these reasons, and at the same time in order to be able to
compare the impressions on two different senses with respect to
their priority, I have constructed a second instrument, the
no'eraatachometer.

The noeraatachometer consists of a prism, which, loaded with
a horseshoe, is set free behind a vertical plank by burning a
thread, and in its fall, by displacing a cork lever without any
noise, opens a current, the spark of which is seen, and a moment
before or after loses its horseshoe on two copper bars, the sound

158 Bibliographical Record. [J

an.

of which blow is heard. As on the falling prism the place where
the horseshoe rests, and the pin which moves the lever, are
movable, we can, knowing the precise rapidity with which the
prism is falling opposite to the opening in the plank, regulate
with perfect accuracy how much the blow shall be produced
earlier or later than the spark. With the time required to dis-
tinguish the priority, I think I have found that necessary for a
simple idea. The difference of time required to recognise the
stimulus by hearing and by sight is found at the same time by
giving priority alternately to one and the other stimulus.

Art. V. — On the Mode of Action of Strychnia. By A.
Ingram Spence, M.D, Assistant-Physician, Royal Edinburgh
Asylum. Edinburgh, 1866. Pp. 16.

The author of this paper, which was read before the Medico-
Chirurgical Society of Edinburgh, gives an account of some
well devised and seemingly carefully conducted experiments
on frogs, — tending to prove,

1 . That the mode of action of strychnia is not through the
nerves, nor along the course of the blood-vessels, but through
the circulating blood; no effect, in any instance, having been
produced when the poison was injected into the abdominal
cavity, provided the circulation was arrested by the excision of
the auricles, or of a portion of the ventricle.

2. That there are nerve-cells possessed of different functions,
— some subservient to motion, some to reflex action, — differ-
ences seemingly indicated by the phenomena produced by the
application of strychnia to the cerebro-spinal axis drained as
much as possible of blood.

3. That the effects of the alkaloid are not in consequence of
its vitiating the blood so as to render it incapable of being
influenced by oxygen ;

4. Nor attributable to a state of hypersemia of the spinal
chord.

5. That little reliance is to be placed in any of the hitherto
proposed antidotes of the poison, especially woorara and tobacco,
recovery having taken place after chronic poisoning, seemingly
as readily, whether either of these or nothing was used.

6. That for medicinal purposes, the best mode of administer-
ing strychnia is by the mouth internally ; and " in those dis-
eases in which the reflex cells require stimulation, although
practically there may be some difficulty in determining the par-
ticular cases.''

1868.] DoNDERS on the Constituents of Food. 159

Art. VI. — On the Constituents of Food, and their Relation to
Muscular Work and Animal Heat. By. F. C. Bonders,
M.D., F.R.S., Professor of Physiology, &c., in the Univer-
sity of Utrecht. Dublin, 1866. Pp. 45.

We hardly need remind our readers of the questiones vexatce,
the disputed points involved in the subjects which constitute
the title of Professor Donders^s paper, as given above. The
manner in which he has engaged in their discussion is such as
might be expected from his well-earned reputation as an able
and careful inquirer.

Some of his conclusions we shall notice, and almost in his own
words, or rather those of his learned translator, Dr. W. D. Moore,
of Dublin. It is to be understood that the indestructibility of
force, the correlation of forces, is a matter taken for granted
by the author. Relative to the direct and indirect production
of heat. Professor Donders, after having made certain state-
ments, remarks, —

" We may, on the ground of all this, safely assume what may also
he more accurately proved by calculation, that the bodily heat is for
the most part developed in and through the muscles, principally, as
has been said, indirectly, but, as it appears, also directly from chemical
action. This last holds good, in fact, for all parts of the body.
Everywhere, where there is capillary circulation, is arterial blood
changed into venous, oxygen is chemically combined ; and if neither
elastic tension nor electro-motor action supervenes, we are justified
in inferring the direct origin of heat. Indeed, in the high tempera-
ture of the blood of the hepatic veins (Gr. von Liebig and G-avarret),
and of the saliva secreted under nervous irritation (Ludwig), we
have the direct proofs of development of heat in non-contractile
parts. And as in continued muscular work, the circulation of the
blood and respiration are more active, and evidently a great quantity
of blood is conducted through all the organs, we have to expect
everywhere an increase of the direct development of heat : in all
irritated parts this increased activity manifests itself, after continued
work, in the increase of irritation, in pain and swelling."

Where treating of mechanical work, work accomplished by
the muscles, he gives the following sketch of the phenomena
connected with their contraction, whilst admitting that the
peculiar change of the molecular condition which determines
their contraction is still involved in obscurity.

" In normal life the muscle contracts under the influence of the
nerves. The action here excited (voluntarily, automatically, or
by reflexion), manifestly itself a modification of the electrical phe-
nomena (Du Bois-Eeymond), is propagated with tolerably great
rapidity (amounting in frogs to nearly nine English feet in the

160 Bibliographical Record. [Jan.,

second — Helmlioltz), and, as it seems, with increasing intensity
(PflUger) to the so-called primitive bundles of the muscles, which
are to be considered as the terminal organs of the motor nerves.
In the condition of rest the muscles have, with very slight tone,
persistent elastic tension (Weber), and with consumption of che-
mical energy by oxidation, an electro-motor action is developed
(the cause of the ' resting muscular current' of Du Bois-Reymond),
and thus mediate, perhaps, also, immediate heat is produced ; the
muscular sound, too, appears to be present even in rest. The con-
traction (thickening with shortening), of the so-called primitive
bundles proceeds from points where the nerve fibres are attached
with flat expansion mediately or immediately to the muscular sub-
stance, and is then propagated to both sides in each fasciculus under
the form of nerves, so that a muscular fasciculus is not equally
shortened throughout its whole length — in cold-blooded animals with
the rapidity of about a metre in the second ; at the same time, too,
the tone of the muscular sound rises. The shortening does not
commence directly upon the arrival of the exalted nervous action ;
there is a latent period of about y^gth of a second (Helmholtz),
with the commencement of which (von Behold) an important phe-
nomenon coincides and announces the approaching contraction ; this
phenomenon is an instantaneous electrical discharge (Meissner), lasting
less than toVo^^ ^^ ^ second (von Bezold) comparatively weak, but
still, probably, equivalent to that of the electrical organ of fishes."

Relating to the question whether in exercise of the muscles
there is any increased expenditure of nitrogenous matter, the
conclusion at which the Professor arrives is affirmative, viz. that
there is a decided metamorphosis of matter in the organs them-
selves, an influence which seems to be supported by the results
of Dr. Parkes^ inquiry " on the elimination of nitrogen by the
kidneys and intestines during rest, and exercise on a diet without
nitrogen,^^ ^ though seemingly opposed by some interesting
observations of Dr. Verloren quoted by Dr. Donders on bees
and their larvae, the latter feeding on nitrogenous food in a
quiescent state, excreting much urine ; the former living chiefly
on non-nitrogenous food, leading a most active life, and excreting
little urine.

As to what food is essential to life in general, the author's
inference is that non-nitrogenous matters and nitrogenous are
both necessary, and equally necessary for muscular work, and
that for extra work a larger proportion of the former is needed.

''The food of man,'^ the subject of the eleventh and last
section, which Professor Donders calls " the great question," is
carefully considered. The final conclusion is this :

" Miiscular work and heat arise in the animal organism, both being
derived from the chemical energy as well of non-nitrogenous as of
' ' Proceedings of Royal Society,' Jan., 1867.

1868.] Heaton on the Function of the Blood. 161

nitrogenous matters. Of both kinds of food the animal system has
need. In the body there exists a certain relation between heat pro-
duced and muscular work. By exercise this relation becomes more
favorable for muscular work. A liberal supply of albuminous matter
tells favorably in the same. The reason of this is probably to be
found in the better nourished and firmer condition of the muscles
and of the whole body, which is obtained by means of a more highly
albuminous diet. The development of man in general appears to
attain the highest pitch under the use of a mixed diet."

This slight notice of and few extracts from Professor Donders's
j)aper will leadj we hope, many of our readers to peruse and
study it ; it will amply repay them. As an example of careful
physiological research, we do not know of any other which has
recently been brought forward more deserving of attention.

Art. VII. — 1. Physiology at the Farm j in Aid of Rearing and
Feeding the Live Stock. By William Salter, M.D.,
F.R.S.E., and Henry Stephens, F.R.S.E., &c. Edinburgh
and London, 1867. Pp. 634.

2. On Non-nitrogenised Food in a Physiological Point of View.
By the same Authors. 1867. Pp. 26.

Op 'Physiology at the Farm/ judging from those portions
of it which we have read, we have formed a very favourable
opinion : as a compilation from the best and most recent
sources of information, it appears to us well adapted to answer
the purpose for which it is designed, viz. to afford that amount
and kind of physiological knowledge to the farmer which may
enable him to conduct his business on scientific principles,
especially the rearing and feeding of live stock.

The value of the volume is enhanced by an ample index, a
full glossary, and a list of the works consulted.

Of the pamphlet, the title of which is given above, we have
merely to remark that it seems to us a successful reply to certain
objections which have been critically made, especially by an
anonymous writer in ' The Field,^ to Messrs. Salter and Ste-
phens's views of the parts performed in the economy by nitro-
genised and non-nitrogenised food.

Art. VIII. — On the Function of the Blood in Muscular Work.
By C. W. Heaton, F.C.S., &c.i
This is an ingenious paper in support of the opinion of
Mayer that all oxidation takes place in the blood; that there-
fore all, or nearly all, the force of the body is generated in
the blood; that muscle, quoting Mayer's words, '^ produces

' From tlio * Philosophical Magazine ' for May, 1867.
81— XLI. 11

162 Bibliographical Record. [Jan.,

mechanical effects at the expense of the chemical action ex-
pended in its capillary vessels ; and further, to use the words
of the author, " muscular disintegration, so far from being the
cause of muscular work, must rather be regarded as an effect
contingent on it."

Art. — IX. — On State Medicine in Great Britain and Ireland.
By Henry W.RuMSEY,F.R.C.S., &c. London,l867, Pp. 58.

This is a well-reasoned, argumentative paper, highly credit-
able to its author, and well adapted to answer the purpose for
which it was written, that, namely, of calling attention to the
very important subject of state medicine, a subject till recently
in a manner ignored and sometimes ridiculed, and even now
hardly sufficiently appreciated in its several and extensive bear-
ings.

Mr. Rumsey, taking a comprehensive view of this great sub-
ject, discusses it under the heads of — 1, etiological, comprising
registration of mortality and sickness ; 2, medico-legal ; 3, sani-
tary, including district organization and professional interests.
Under each he first points out the multifarious defects and
shortcomings in the existing state of things, and the manifest
evils resulting from them. Next, he suggests how they may be
corrected so as to accomplish the greatest practicable good,
judiciously supporting his statements by reference to high autho-
rities.

In an appendix the discussion is given that followed the read-
ing of his paper, which, we should mention, was delivered as an
address (in substance, since enlarged), at the Congress of the
British Medical Association, held at Dublin, on the 7th of Au-
gust, 1867, a discussion in which the speakers generally
supported his views, as was shown by the adoption of a series of
resolutions. These were the following, and they embody the
spirit of the address and the principles mainly advocated in it.

1. *' That the Association desires to express its decided approval
of the plan proposed by Dr. Farr, namely, the appointment of a re-
gistration medical officer in every registration district or group of
districts, with medico-legal and sanitary functions, and pledges itself
to support tbat measure as the initiative step to a national organiza-
tion for the purposes of State medicine."

2. " That the Committee of Council be instructed to direct their
early or special attention to the amendment of the sanitary laws, to
invite the co-operation for this end of the Council of the National
Association for the Promotion of Social Science, and to urge the
branches of this Association to promote tlie same important
object by local efforts, by representation to individual members of

1868.] RuMSEY on State Medicine. 163

Parliament, and, if need be, by deputations to Her Majesty's
Government."

3. " That a Committee beappointed^ to collect information,

in such a manner as they may think best, on the subjects brought
before the Association by Mr. Eumsey ; and that the Committee of
Council be empowered to make such pecuniary grant as the funds of
the Association will permit towards the expenses of this inquiry."

We must not conclude this our brief and imperfect notice of
Mr. Rumsey's paper without strongly recommending it to the at-
tention of our readers^ and at the same time exhorting them to
give as far as they may be able their support to the great objects
— national objects — which he has so ably advocated. Let it be
kept in mind that it is not reform that is needed, but a new
organization altogether, one founded on well-established prin-
ciples and as much as possible on exact science.

Aet. X. — Giornale Italiano delle Malattie Veneree e delle Malat-
tie delta Pelle. Compilato e diretto dal Dott. G. B. Soresina.
Anno 1866, Milam.
Italian Journal on Venereal and Cutaneous Diseases. Edited
by G. B. Soresina. 1866. Published monthly, Milan.
The editor is chief physician to the Sifilicomio at Milan,
and the promised staff of contributors comprises the names best
known in Italy as interested in syphilography and skin disease.
Such are the names of Galligo, Gamberini, Pellizzari, Sperino,
and others of no less weight. The journal is in continuation of
an appendix, which for some four years past has been advan-
tageously issued in connection with the ^ Gazetta Medica Lom-
barda,^ forming an extra sheet to the subscription. The first
number of this new issue contains axioms in syphilography by
Professor Gamberini, of Bologna, in which, without sacrifice to
individual bias, he has acquitted himself in such wise as all may
admire. We shall not linger on points disputable.

Professor Dubini, of Milan, describes a curious affection of the
scalp, which he terms " wasp nest" {vespajo) . He has observed
this in young country people of the lowest class. It forms one or
more round raised circumferences of the diameter of from five to
eight centimetres, which pours out pus from countless small fora-

1 COMMITTEE.

Dr. Acland, F.R.S., Chairman.
Dr. Burke. Dr. J. G. Morgan.

Dr. Falconer. Dr. G. H. Philipson.

Dr. Gairdner. Mr. Ransome, M.B.

Mr. Ernest Hart. Dr. Tindal Robertson.

T)r. Lankester, F.R.S. Dr. Rumsey.

Di-. Mapother. Dr. Symonds, F.R.S. Ed.

Dr. A. T. H. Waters.

Dr. A. P. Stewart, Hon. Secretari/i

164) Bibliograjjhical Record. [Jan.,

mina ; these lead to sacculi, wliich are not indepeiideut, but
forming in their ensemble a large focus of destruction inter-
sected by filaments of gangrenous cellular tissue, with no indu-
ration at its base ; all the anatomical elements participate in the
ravages of the disease, the cause of which is not known. An
extended monograph, by the hand of Dr. Guiseppe Profeta, of
Palermo, on constitutional syphilis and its cure, appears in the
opening numbers.

Art. XI. — 1. A Handy Book of Meteorology . By Alexander
BucHAN, M.A., Secretary to the Scottish Meteorological
Society. Edinburgh and London. 1867. Pp. 204.

2. Journal of the Scottish Meteorological Society. Nos. XIV.

and XVI.

3. Meteorological Observations on the Humidity of the Air of

Scarborough. With Chapters on Rain, Rain Gauges and
Rainfall Investigations, and on the Humidity of the Atmo-
sphere in Relation to Disease. By C. M. Fox, M.D., &c.
London, 1867. Pp. 41.

That which stands first in our heading is a comprehensive
little workj it contains a great amount of information, fully
warranting the title it bears, and we think it reliable gene-
rally for accuracy of statements. There is no part of me-
teorology that we find neglected in it. The illustrative wood-
cuts are numerous, and it has besides many diagrams, tables, and
a pretty extensive index.

We shall ofi'er only one extract, and that from the first chapter,
the " History and Scope of Meteorology." Adverting to a
great neglect in the teaching followed in the schools of this
country, the author remarks —

" In the schools of the United States of America metereological
observations and the keeping of meteorological registers form a part
of the common education of the people. Also in the higher scliools
of France and some other European countries systematic instruction
is communicated on this subject. But in this country few even of
the liberally educated classes are able to read from a vernier — are
ignoi'ant of the use of the movable cistern of a barometer — have
not the elementary knowledge to give an intelligible interpretation
of the fluctuations of the barometer as indicative of coming changes
of the weather — and when required to send their barometers to a
distance for repair, forward them by rail as ordinary parcels, thus
almost to a certainty securing their destruction."

The numbers of the ' Journal of the Scottish Meteorologjical
Society' before us contam, as usual, a great amount of valuable
observation relating to two quarters of the past year. Of the spe-
cial articles which it contains, we shall notice only one, that en-

18G8.] Meteorological Observations, ^c. 165

titled "A comparative view of the winter climates of Edinburgh,
Jersey, and Mentone ;" from which it appears that Mentone is
deserving of preference in relation to health, in several particu-
lars; chiefly, however, as warmer, drier, and as having fewer rainy
days, — not, however, for uniformity of its winter dim ate, inasmuch
as comparing one year with another, so far as temperature is con-
cerned, it differs but little from Jersey or Edinburgh. One great
advantage of Mentone described is that the thermometer there
rarely indeed falls to the freezing point ; and, next to that, its
comparatively small number of rainy days and its large amount
of sunshine.

What we have thus stated generally any of our readers
specially interested in the subject will find in detail in the pages
of this Journal, with tabular statements relative to the monthly
range of temperature, the daily range, rainfall, number of days
in which rainfalls, and humidity of the air : the last, as indi-
cated by the dry bulb thermometer during three months, being,
at Mentone, between 75° and 67°; at Edinburgh, between 9S°
and 87° ; and at Jersey, between 89 and 79°.

In the sixteenth number the article " On the Climate of
Jerusalem'^ is specially interesting, both on account of the
locality discussed and the valuable information which it conveys.
Dr. Fox^s little work contains a good deal of useful meteoro-
logical information, both general and particular ; the author is
much in favour of the climate of Scarborough, the chief excel-
lence of which appears to be its cool, bracing, summer climate,
with a prevalency of westerly and north-westerly winds.

In estimating the hygrometrical state of the atmosphere the
author expresses an opinion, which we would suggest his re-
considering, viz. that it accords with the rainfall, without
taking into account other conditions — such as have a de-
cidedly modifying effect; for example, the'nature of the locality,
whether level or hilly, — the quality of the soil, whether clay or
gravel, the kind of rain and frequency, whether in heavy
showers or slight, whether numerically in excess or deficiency.
According to his mode of estimation, how damp ought to be
the climate of Sithwaite, in Browndale, where the average yearly
fall is about 133 inches ; we say about, for we speak from me-
mory ; yet we believe its average dryness of climate exceeds that
of many other parts of England, where the rainfall is vastly less.
We learn from Dr. Fox's preface that an institution has been
established at Scarborough of an humane kind — would that
there were more such — " a cottage or village hospital,'^ aftbrd-
ing accommodation for three male, and three female patients,
dependent on voluntary contributions : he adds that any
profits accruing from his publication will be devoted to it.

166 Bibliographical Record. [J

an.

Art. XII. — Companion to the New Edition of the British
Pharmacopoeia, 1867^ comparing the strength of the various
Preparations with those of the London, Edinburgh, and
Dublin, United States, and other Foreign Pharmacopoeias,
withPracticalHints on Prescribing. By Peter Squire, F.L.S.,
Chemist on the Establishment of the Queen, &c. Fifth
edition. 1867. Pp. 318.

The title of this volume sufficiently explains its object ; and
that the author was correct in supposing that such a work would
supply a want experienced by the medical profession and others
is proved by the fact of this the fifth edition having been sold
off within a fortnight of its publication. In this edition, the
recently published British Pharmacopoeia is compared not only
with the pharmacopoeia which previously had been in use in
Britain, but also with the principal continental ones, " in the
hope that some international spirit may be infused into future
editions, and that preparations bearing the same name may be
of the same strength in whatever country or language they may
be prescribed.'^ We find that the " non-officiaF' preparations
are increased in number, and that incompatibles and antidotes
to poisonous drugs are added. A very instructive table is pre-
fixed to the work, in which at a glance it can be seen what
preparations of the 1867 edition of the Pharmacopoeia are
new, what were used in the 1864 edition, and what are derived
from the London, Edinburgh, and Dublin Pharmacopoeias. A
second table is given, showing the changes made in the prepara-
tions of the three Pharmacopoeias.

Among the auxiliary practical information afforded by Mr.
Squire are included the weights and measures of the metrical
system ; the equivalents of English weights to French grammes ;
and a table of comparison of the Fahrenheit with the Centigrade
thermometer. An appendix contains a list and description of
articles employed in chemical testing ; directions for percolating
tinctures ; with an enumeration and description of various
recent preparations as well official as otherwise, such as the
various *' granulated preparations," suppositories, medicated
pessaries, and bougies.

That indispensable addition to all books of this kind, a
copious and accurate index, closes the volume.

We have no hesitation in saying that no medical practitioner
can well afford to be without this most helpful book. As it is
one of constant reference, we heartily wish that a smaller and
more portable edition could be published.

1868.J ' 167

PART THIED.
©tisittal ©'ommunications.

Art. I.

Notes on ilie Cholera Epidemic o/" 1865-66 in Europe and America.
By Gavin Milroy, M.D., P.E.C.P., Vice-president of the
Epidemiological Society, &c.

The geographical history of this epidemic visitation is note-
worthy on various grounds. The pestilence reached Europe this
time from the East by a new channel, On all prior occasions, the
northern regions of the Continent were infected for some time before
the southern countries or the shores of the Mediterranean came
under its influence ; now it reached the former from the south, and
primarily from Egypt. The transit of the disease, too, from east to
west, was certainly much more rapid than it had ever been before,
corresponding with the greater frequency and acceleration of inter-
course within the last fifteen or twenty years between different lands
and peoples. Hitherto, the want of anything like rehable data
respecting the chronology, as well as the geography, of the career of
this most migratory of pestilences had been much felt by epide-
miological students. No attempt had yet been made to form a
connected record of the movements and general march of the disease
by obtaining authentic information respecting the exact dates of its
appearance and spread in the different countries invaded, on the plan
that had for some years been carried out, with official governmental
aid too, in respect of other and somewhat kindred branches of
physical research. Fortunately, something was now done to supply
this much desiderated knowledge ; and the results obtained, although
far from being so accurate or complete as could be wished for, have
not been unfruitful of good to science, and will eventually prove of
service to the public welfare everywhere by the stimulus given to
more systematic observations of similar phenomena in future.

The French Government, generally the foremost in the promotion
of scientific inquiries, took steps in the course of the autumn, 1865,
to secure the co-operation of the principal European States for the
establishment of an international conference, to be held at Constan-
tinople, for the purpose of (a) collecting evidence respecting the

168 Original Communications. [Jan.,

history of the outbreak of the pestilence in the summer at Mecca
and Medina, and various places along the lied Sea coast of the
Arabian peninsula, and its subsequent extension to Egypt, and
thence to other lands; and {b) discussing the measures of State
medicine to be recommended for general adoption, with the view of
preventing the recurrence of the like disastrous consequences as had
befallen many countries in 1865. To the several reports of this
learned body I shall have frequent occasion to refer in the following
pages.^ Nor had the medical profession in this country been
behindhand in urging on the work of investigation. Prior, indeed,
to the step taken in France, the Epidemiological Society had memo-
rialised the Government to turn to useful account the widespread
machinery of the consulates of the British empire, scattered as these
are over every part of Europe, or rather of the world, for obtaining
the required information." The objects sought for by the Society
will be best explained by the following extract from their memorial
addressed to the Foreign Secretary in the early part of September :

" Hitherto, the information before the profession respecting the
exact course of the development of cholera in the several epidemics
which have traversed Europe has been far from being either so cor-
rect or so complete as the interests of science demand. A much
more full and accurate knowledge of the geographical history of the
disease — as it appears in different lands, and under the varying
conditions of climate, country, the habits and diet of peoples, &c. —
is greatly to be desired. Epidemiological inquiries have to be con-
ducted much in the same way as meteorological inquiries; to be
fruitful of good, both must equally rest on accurate data collected
in a wide area of observation, and over periods of time more or less
extended. What the Board of Trade now does to advance the pro-
gress of meteorological science may be done by other departments
of the Government to advance the interests of epidemiology.

" On no point is authentic information more needed than as to the
exact dates when the pestilence first appears in the different localities
attacked over the face of the Continent. Great Britain possesses
greater facilities in obtaining such information, from her widespread
relations and intercourse, than most other countries. It is respect-
fully submitted that the object in view might be efficiently attained,
through the co-operation of H.M. consuls, if the Secretary of State
for Foreign Affairs would be pleased to give instructions to those

1 The'Conference consisted of two diplomatos, and of twenty-one medical men,
delegates from France, Britain, Belgium, Holland, Denmark, Sweden, Russia,
Prussia, Austria, Spain, Portugal, Italy, Papal States, Greece, Turkey, Egypt,
and Persia. Their sittings continued for nearly twelve months, and the results of
their deliberations are contained in six separate reports, which were issued in the
course of last year.

* When it is known that the number of British consuls and vice-consuls con-
siderably exceeds 200, it will at once be seen how much good, in respect of such
inquiries, may be effected through so many centres of intelligent agency scattered
over the world.

1868.] Notes on the Cholera Epidemic in 18G5-66. 1(59

gentlemen to record and communicate the most reliable information
within their reach in respect of their consulates and the surrouudiug
districts, and if all such information were made available for the
benefit of medical science. To the following points the Council of
the Society would particularly invite attention :

" 1. The exact dates of the earliest recognised or ascertained cases
of the disease, whether the cases proved fatal or not.

" 2. Did these cases occur among strangers or persons recently
arrived in the place ? — or among residents who had not been recently
away from it ?

" 3. Had there been any unusual amount of bowel disorders, or
other form of sickness, prevalent among the inhabitants prior to the
occurrence of these cases ?

" 4. In what part of the town or village did the first cases occur ?
— and what part or district suffered most during the visitation ?

" 5. "What is the nearest place where the disease was known to
exist at the time of the occurrence of the first cases, or to have
existed shortly before such occm-rence ?

" 6. What precautionary measures have been taken by the autho-
rities to avert, or to meet, the visitation?"

Earl Eussell promptly gave effect to the recommendation; and
the result was that a very large amount of valuable intelligence was
procured through the Foreign Office, and to some extent also from
the Colonial Office. The admirable digest of this evidence, prepared
by the directions of Mr. Simon (all the official reports having been
transmitted to the Medical Department of the Privy Council), and
published in his annual report of last year, reflects the highest credit
on Mr. Radcliffe, the energetic Secretary of the Epidemiological
Society. Besides this fruitful source of intelligence, the annual
reports of our army and navy now afford much important informa-
tion respecting epidemic diseases among our soldiers and sailors in
various regions of the world, together with occasional notices of the
history of these diseases among the civil communities of the localities
where our regiments or ships of war happen to be stationed. Nor
are the more frequent and fuller memoranda on all epidemiological
matters that have, of recent years, been given in our weekly medical
journals to be omitted, as affording much assistance to the inquirer.
It would be a great boon to accurate research if still greater exten-
sion and more systematic precision were bestowed by all medical
periodicals on this important branch of professional intelligence.
Several of the foreign journals have doubtless been in the habit of
adding their quota of information on this head, and I can only plead
my want of favorable opportunity for reference to them for not having
availed myself of their aid in putting together the following details.

During the first and second quarters of 1865, cholera was widely
prevalent, in greater or less force, along the shores of the Indian
Ocean, and in many parts of southern Asia, from China to the Red

170 Original Communications. [J

an..

Sea. There is evidence to show that it existed at Hongkong, at
Manilla, and in the island of Borneo ; at Singapore and Penang, in
the Straits of Malacca ; at Bombay, as well as in numerous parts of
the Bombay presidency, extending northwards in the direction of
Gwalior, and in an easterly direction to Kurrachee; at several
points along the coast of Beloochistan and of the Persian Gulf, on
to Bassorah and the mouth of the Euphrates ; at Muscat on the
east coast, and at Makalla and at Aden on the south coast of
Arabia ; at some points on the southern shores of the Red Sea ; and
also on the adjacent coast of eastern Africa.

However incomplete our information is respecting the dates of
the commencement, and the duration or persistence, of the disease in
many of these places, it is nevertheless quite true, as Mr. Eadcliffe
justly remarks, that "the prevalence of epidemic cholera in the
Bombay presidency contemporaneously Avith the presence of the
disease in the south of Persia and Arabia, and its extension into
Egypt, and into Asia Minor and southern and western Europe, is
a fact of great interest.^' It is only by pursuing the method of
synchronous registration of epidemic diseases over extensive tracts
of the earth's surface, that we can reasonably hope ever to arrive at
any general truths respecting their mode or modes of development
and diffusion. The single fact, — if fact it be, and there appear to
be satisfactory grounds for admitting it, — that cholera ^.was cer-
tainly prevailing at several points of the Arabian coast to the south
and south-east of Jeddah simultaneously with, if not prior to, its
earliest appearance there, is obviously of great import in discussing
the question as to the origin of the disease in the ' II Hedjaz,'' or
land of pilgrimage, in the spring of that year.

That two ships, loaded with pilgrims, chiefly Javanese, suffered
severely from cholera shortly before reaching Jeddah in the early
part of March is indisputable. They had sailed originally from
Singapore, but had touched at Makalla, on the south coast of Arabia,
where cholera then existed, and one report stated that the outbreak
on board took place after leaving this port. Jeddah, it is said, was
free from the disease before the arrival of these pilgrim ships. In
the latter part of April, the mortality had acquired such dimensions
among the more than ordinarily great number of pilgrims congre-
gated there, that the Egyptian Government sent a medical com-
mission to report on the causes of the dreadful loss of life that had
occurred throughout the Hedjaz. Without entering into details,
it is sufficient to say that the whole district was festering with
putrescency in the midst of masses of human beings, filthy beyond
measure, half-starved, and exhausted from excessive excitement and
fatigue. Numbers of the pilgrims were infected with the disease
on their return from Mecca to Jeddah, when they re-embarked there

18G8.] Notes on the Cholera Epidemic in 1865-66. 171

on their return liome.^ It is from this point in the history of the
epidemic of 1865 that I propose to enter into a more detailed nar-
rative of its movements and geographical dispersion, for the appre-
ciation of which the reader will find a map of the countries visited,
lying before him, all but indispensable.

Egypt. — For a twelvemonth at least before the appearance of the
cholera, there had been an unusual amount of destitution and suffer-
ing among the labouring classes throughout Lower Egypt. The
terribly destructive murrain of 1863 and 1864, which had swept off
nearly half a million of the cattle, had occasioned almost famine
prices for food in every part of the land ; and such vast numbers of
the carcases had been thrown into the river — forming in some parts
a floating bridge from one side to the other — and there left to
putrefy, that the atmosphere as well as the water was corrupted for
miles around. In the early part of 1865 the misery of the people
was extreme, and much sickness, especially low typhoid fever, was
generally prevalent. The level of the Nile, too, this season, was
lower than it had been for many years, so that the water supply
was unusually scanty as well as impure. As the season advanced,
the heat set in with extraordinary force, even for Egypt. Nor was
the famine and its consequences confined to the land of the Pharaohs ;
for the whole of the south-eastern districts of the Arabian peninsula
were similarly affected from widespread disease among the cattle, as
well as from failure of the ordinary crops.

The earliest recognised cases of cholera occurred on May 21st, at
Suez, on board a ship (said to have been the first which arrived
from Jeddah) with pilgrims on board returning from Mecca. It
would seem, however, that no deaths from the disease took place on
shore at Suez till a full month later, although in the interval thou-
sands upon thousands of returning pilgrims were disembarked, and
had passed through the place on their way to Lower Egypt.

The first fatal case of the pestilence occurred, according to the
accounts given, on June 2nd, among some of these fugitives in a
crowded encampment on the banks of the Mahmoudie canal, in the
outskirts of Alexandria. The heat at the time was excessive, and
the waters of the canal were stagnant and off'ensive. Other attacks
and deaths soon followed ; but the ofiicers of the Sanitary Intendance

^ The Conference states, that since 1831, the date of the first known visitation
of epidemic cholera in the Hedjaz, the disease reappeared, during the time of the
annual pilgrimage, in 1835, 1846, 1847, 1848, 1859, and in each successive year
afterwards, although with comparatively little force, down to 1864 inclusive.
Whether the district suffered in 1854-55, when the city of Nejed in Central
Arabia is known to have been visited, does not appear. The affirmation that all
the above outbreaks of the disease followed upon infected arrivals from abroad, rests
on very impei-fect evidence ; and with respect to the epidemic of 1865, it is to
be noted that Dr. Goodeve, one of the British commissioners, was not satisfied
that its origin could be satisfactorily traced to importation from India.

172 Original Communications. [Jan.,

did uol, or would not, admit them to be cases of genuine cholera,
and reported them as cases of algide pernicious fever, or of sporadic
summer cholerine. Nor was it till the 11th of the month that the
true nature of the disease was officially recognised and admitted.
That was the date on which fool bills of health were first issued by
the foreign consuls in Alexandria.

Before the end of June, the disease had spread not only over
Alexandria, but also to numerous districts throughout Lower Egypt,
and had even invaded Middle Egypt. It broke out simultaneously,
it has Ibeen stated, in numerous places distant from each other,
and without much, if any, intercommunication ; but authentic data
on this, as on most other points relathig to the topography of the
pestilence, are far too defective to merit any confidence. In Alex-
andria, the epidemic reached its acme in the first week of July.
Upwards of 4000 of the poorer inhabitants (few were the victims
among the well-conditioned) perished in a population which had
been reduced by more than 30,000 fugitives, who fled in all direc-
tions from the place. The panic gave rise to many disastrous con-
sequences. Numbers were attacked who might otherwise have
escaped ; and troops of people flocked on board vessels, which then
became so crowded that disease broke out soon after their leaving
Alexandria, and were sometimes refused admission into the ports
which they sought to enter. Such results used to be common in
seasons of the plague, and now the same events are reproduced in
epidemics of cholera. The total mortality throughout Egypt, from
the beginning of June to the end of September, when the epidemic
had generally disappeared, has been set down at someM'hat above
61,000 out of an estimated population of 4,841,167. There seems
to have been no recondescence of the disease, either during the latter
months of 1865 or in 1866.^

Malta. — The history of the epidemic there is full of interest, and
fortunately the data respecting it are thoroughly reliable. The
account of it drawn up by Surgeons Adams and Welch, of the
22nd Eegiment,^ affords ample details, and is illustrated by excellent
sketch-plans and statistical tables ; altogether, it is a model for an
epidemiological report, and reflects great credit on the service.

For a fortnight at least before the appearance of the disease in
Alexandria was known to the authorities of Malta, numerous fugi-
tives from Egypt had arrived, and one, if not more, vessels with
returning pilgrims had coaled in the port on their Avay to Tunis.

1 Egypt suffered from epidemic cholera in 1831, and partially in 1835 and 1837 ;
in 1844 (?), in 1848, in 1850. and in 1855. It has been alleged that, in all these
visitations, Cairo was attacked befoi-e Alexandria ; but the evidence for this state-
ment is wanting. In 1831 the epidemic commenced in July, that of 1865 in June.

* ' Statistical, Sanitary, and Medical Reports of the Army Medical Depart-
ment,' vol. vi, 1866.

1868.] Notes on the Cholera Epidemic in 1865-66. 173

It was not till June 14tli that quarantine (at first) of seven days
was established, and that the lazaret, which had previously been
occupied by the military, was made ready for the reception of
detenus. No special medical officer was appointed to it till the
22nd. Between the 14th and July 5th, upwards of 1500 persons
from Alexandria were landed and confined in the lazaret, which, besides
being badly ventilated and infested with privy smells, was the scene
of " much crowding, discomfort, and wretchedness." The first cases
of actual cholera in this building occurred on June 28th, and w^ere
received from the " AVy vern," just arrived from Alexandria ; but,
prior to that date, several cases of choleraic diarrhoea had taken
place among the inmates. Already, however, the disease had broken
out unmistakably in the immediate neighbourhood, but outside, of
the lazaret, and about two hundred yards distant from it, in a
number of small houses that were formerly used as a plague hos-
pital, and were at the time inhabited by soldiers' wives and their
families. Being surrounded by a high wall considerably above the
roofs of the houses, and the privies and drains leading from them
being in a very foul condition, the atmosphere of this confined
locality was of course most offensive, and the people had frequently
complained of the great unwholesomeness of the place. The lazaret,
too, was no better; for there, as far back as May 20th, several of
the military, who then occupied the building, had been attacked
with severe diarrhcca, which the patients themselves attributed to
the disgusting effluvia from the latrines.

Diarrh(]ea had been prevalent for some time among the occupants
of the old plague hospital prior to June 20th, the day on which the
first fatal case of cholera occurred there. This was in a girl, set. 8,
who died within seven hours from the commencement of the attack.
No communication either with the lazaret, or with any of the vessels in
quarantine, could be traced. Within the next eight days, six other
children in the same locality were attacked, and five of the cases were
fatal. As most of the other inmates of the buildings were now suf-
fering from diarrhoea, or gastric malaise of some sort, they were all
promptly removed from the locality. It was high time; for five
cases of cholera occurred, within a few hours of their removal, among
the families of the artillery, who had unfortunately been transferred
to an unwholesome district on the opposite side of the quarantine
harbour, where the disease speedily spread to some extent; whereas
all sickness quickly subsided among the other families who were
more favorably located. The subsequent history of the epidemic
among the military showed in a most striking manner the influence
of the sanitary, or otherwise, condition of the accommodation on the
development and progress of the disease. In some barracks there
were but few and only scattered cases, or none at all ; while in others
the attacks were numerous and persistent. The cam])ing out of the

174 Original Communications. [Jan.,

men was invariably attended with good results. There is every reason
to believe that had this precaution been generally practised at an
earlier period^ as Dr. Anderson (the principal medical officer) recom-
mended, there would have been much less sickness and mortality
among the troops. The strength of the garrison was 5904. In this
force there were 120 men attacked, and of these 87 died. Among
the officers, numbering about 100, there was but one attack, and
that was fatal. Of 467 women, 50 were attacked, and 35 died;
and among 774 children, 26 were attacked, and 19 died.

Among the civil population, the Jirst undoubted case occurred on
July 1st, in a man living in the outskirts of Valetta; two days
before his death he had been at work in the lazaret, where the dis-
ease then existed. The case was returned as one of " gastro-enterite,"
to avoid creating alarm among the population. It does not seem
that other cases followed in the locality. The second case occurred
on the 3rd, in a woman residing in the city, at a distance from the
former ; the only assignable explanation of her attack was that '' she
had received, four days prior to her decease, some old clothes as
patterns from a merchant's family who had arrived a fortnight back
from Alexandria in a vessel with cholera on board.'' The members
of the family, however, seem to have been quite unaffected.

On the 1 0th it broke out in another direction, in a tavern that
was mnch frequented by the military ; and on the same day, in one
of the suburbs at a distance, where it was believed to have been
brought by persons who had been liberated from the lazaret, after
performing quarantine. After this date it spread more or less over
the whole capital, but always keeping chiefly to the low-lying and
dirty streets. As with the plague in former days, the ground floors,
in which the poor live, and which are almost invariably very un-
wholesome dwellings, suffered infinitely more than the upper stories
of houses. Some of the public institutions which had been ravaged
in former epidemics were again visited heavily ; whilst others, whose
site or condition had become improved, nearly or altogether escaped.
Three only out of the numerous staff of attendants in all the civil
establishments were attacked. Diarrhoea was universally prevalent
among all classes after the cholera had manifested itself in the city ;
and in many cases it was of a severe form, although not proving
fatal. Previoush^, however, there had been no unusual amount of
bowel disorders among either the mihtary or civil population during
the early summer months. The first half of 1865, as compared
with 1864, had a high temperature and a dry state of the air.
" While the state of the weather was such as to foster zymotic dis-
ease when jDresent, there was nothing in the meteorology in general,
nor in the health of the community, to warrant a supposition of the
outbreak which followed." The influence of the epidemic was
experienced throughout the entire island. Some of the casals or

1868.] Notes on the Cholei'a Epidemic in 1865-66. 175

villages suffered very severely ; e. g. Zeitun, where typhus fever had
been prevailing at the end of 1864 and beginning of 1865. The
adjacent small island of Gozo remained exempt till July 21st, when
the first case occurred in a man who had come over with the disease
upon him from Malta, and in whose family other attacks followed.
Prom this family, as from a centre, the disease, it is stated, spread
in different directions. The chief violence of the epidemic in Malta
was in August.

The total mortality among the civil population — estimated in
1861 at nearly 18,000 — between the beginning of July and the first
week in November, when the disease entirely ceased, amounted to
1479 deaths. In Gozo, with an estimated (1861) population of
15,459, there were 253 deaths.

In the Mediterranean fleet, consisting of twenty -three vessels, many
of which are always stationed at Malta, and where there is, moreover,
a large naval hospital, there were only 7 fatal cases of cholera
throughout the year out of a force of 6346 souls. Tour of these
cases occurred at Malta, and in three different ships. Many of the
workmen, however, in the dockyard, which is much hifested with
foul effluvia, fell victims. The three other cases in the fleet occurred
on board one ship when anchored at the mouth of the Danube.
Whether many passenger or merchant- ships at Malta, or after leaving
the port, suffered much, there is unfortunately no means of deter-
mining. This is a great want.^

1 1. The first visitation of cholera in Malta was not till 1837. The disease had
been prevailing throughout Italy in 1835-36, and Sicily had been visited in the
latter year, and again in 1837. Strict quarantine was at the time in force
against arrivals from Sicily. The earliest cases occurred on June 9tli among the
inmates of a crowded old poor-house, overlooking the quarantine harbour, and
which again suffered severely in 1865. Gozo was not attacked until twenty-seven
days after the disease appeared in Valetta. The deaths among the civil popu-
lation between June and October, when the disease ceased, were 3893 ; among
the garrison (including women and children), averaging 3070, the cases were 315,
and the deaths were 78. The Mediterranean fleet suffered considerably. Out of
a force of upwards of 7000 souls, there were 38 deaths from cholera, 26 on board
ship and 12 in Malta Naval Hospital. The first cases were in June. In some of
the ships, the earliest attacks are said to have occurred as they neared the coast,
and before entering the harbour or communicating with the shore {Bryson).

2. In June, 1850, suspicious endemic cases had occurred at the end of May and
beginning of June in some of the worst parts of Valetta. The first authenticated
fatal case was on June 9th, in a seaman recently arrived from Susa, on the
Tunisian coast, where the disease then existed. Some fugitives from Tunis had
landed, it was said, at the beginning of the month. The epidemic continued to
the beginning of October. Among the civil population in Malta and Gozo there
were 1629 deaths, and 133 among the garrison. In the Mediterranean fleet,
with a force of about 6750 souls, there were 118 deaths. In one ship, the "Queen,"
there were 80 cases, of which 46 were fatal between June 6th and the end of
September.

3. In ISS-l', the first year of the Crimean war, when cholera was so prevalent in
England and France, from both of which countries transports, &c., were con-

176 Original Communications. [Ji

an.

Gibraltar. — The circumstances connected with the development
of the disease there also are extremely interesting; they are fully
detailed in an excellent report by Deputy-Inspector Dr. Rutherford,
in the same volume of the 'Army Eeports/ which contains the
account of the Malta epidemic. The history of the Gibraltar visitation
affords a seeming proof of the possibihty of the pestilence being in-
troduced by a body of apparently healthy men, arriving from an
infected locaKty. The occurrence of the first case, thirteen days
after leaving that locality, and of the second case thirteen days after
the first, together with one or two similar instances of the same
sort, mentioned by Dr. Rutherford, well deserves consideration in
connection with the difficult subject of quarantine as a means of
defence or protection against its importation. " If the disease can
and does remain dormant for fourteen days and upwards, may not an
explanation be afforded," he remarks, " of the futility of quarantine
laws, which frequently impose three, four, six, or ten days' observa-
tion upon vessels having * health on board,' and which come from
so-called * infected ports.' "

On July 6th, the transport " Orontes,'' with the second battalion of
the 22nd regiment on board, left Malta for Gibraltar, en route for
Mauritius. The men had been very healthy in their barracks, and
were considered free from any choleraic tendency at the time of
going on board. Cholera had, however, broken out close to the
point of their embarkation, in the Marsa Muscet Harbour. On
the 1 0th they reached Gibraltar, without having had any sickness
whatever on board during the voyage, save one trifling case of
diarrhoea, which had speedily got well. The crew also had been
quite healthy. The troops were immediately camped out on the
Xeutral Ground. There was then no sickness either in Gibraltar
or its neighbourhood ; the general health of the garrison and civil
population had been, throughout the season, '^ exceptionally good."^
Between the 10th and 18th, the men of the battalion continued

tinually arriving, there was a partial outbreak in Valetta (to which city it was
confiued) ; about 300 deaths occurred between July and October. No details
have ever, I believe, been published.

4. In 1855, there were again several deaths from cholera among the native
population of Valetta ; no other part of the island suffered. Among the military,
there were throughout the year occasional cases of the disease in the hospitals, in
consequence of the constant arrival of infected troop-ships bound to or returning
from the Crimea.

The total number of deaths from cholera among the military in Malta during
the years 1854, 1855, and 1856, did not exceed 128 in all, out of a force which
cannot be estimated under 23,000, stationary or passing through. There were, of
course, no quarantine restrictions throughout the continuance of the Crimean war.
It is much to be regretted that no details are to be had respecting the public
health, civil and military, during those eventful years.

' There are no means of knowing with accuracy the state of the public health
in any part of the southern districts of Spain at this time. Cholera had already

1868,] Notes on the Cholera Epidemic in 1865-66. 177

healthy ; there had been but one case of diarrhcea^ so slight as not
to necessitate the man's admission into the hospital. At 9 p.m. of
the 18th a private, who had attended evening parade two houcs
previously, was attacked with vomiting and purging ; he died next
morning. The whole camp was at once broken up ; the men of the
right wing, to which the patient had belonged, were at once put on
board the " Star of India," which, after forty -eight hours^ proceeded
to sea, " all being apparently perfectly healthy."

The left wing (the transport for its conveyance having not
arrived) was encamped at a considerable distance from the original
site. With the exception of two cases of diarrhoea, the corps re-
mained healthy till the 31st, when a man, who had been ailing for a
couple of days, and also a woman of the detachment, were attacked ;
he died the same evening, and she the next day. The troops were
straightway embarked in the "Devouport," and, '^all being in
apparently good health," sailed, after sixty hours' detention, for
Mauritius. Both transports reached Mauritius in the first week of
October, without a single case of cholera having occurred in either
of them during the voyage, and the troops were landed in good
health.

On August 3rd, the day after the departure of the 22nd, two
cases of cholera occurred in a corporal of the 15th, and his child,
living in a cottage outside the fortress on the front facing the
Neutral Ground, about a quarter of a mile nearer the Rock than
that regiment's camp. Both cases proved fatal. On the 9th,
a woman of the Engineers, in a cottage in the same locality, was
attacked and died; and early on the 10th, a soldier in the casemate
barracks, just inside the walls of the fortress, and about 400 yards
from the above cottages, was seized; this case was followed by
seven other cases in the same barracks, in the course of that day.
The earliest cases among the civil population occurred on the 11th.
The epidemic reached its acme at the middle of September, and
ceased at the end of October.

The total mortality amounted to about 580. The convicts,
although " cut off in a great measure from all intercourse with the
other inhabitants," suffered most severely; 57 out of 700 died.
Among the military, estimated at 6000, there were 106 fatal cases;
and among the civil population, estimated at about 15,000, the
deaths were 416. The visitation was, therefore, more fatal than on
any former occasion.

appeared on the east coast of the peninsula at Valentia (and probably also at
Barcelona), although its existence there was not admitted by the Spanish au-
thorities until the beginning of August. "The utmost diflBculty," says Dr.
Rutherford, "was experienced in obtaining any information of a reliable nature
upon this and similar subjects."
81— XLI. 12

178 Original Communications. [J

an..

On August 24th, a military cordon was drawn right across the
Neutral Ground by Spain, so as to cut off all communication with
€ribraltar. Why this step was not taken sooner, does not appear
very obvious. It was continued till nearly the end of November.
The amount of distress it occasioned to the neighbouring Spanish
villages, as well as to Gibraltar, was very great ; and the destitution
that ensued, upon so many of the people being thrown out of em-
ployment, inevitably aggravated the severity of the visitation on
both sides of the cordon. On this as on former occasions, this
measure of rigour failed in its object. In the second or third week
of September, there was a sharp outbreak of cholera in St. Roque,
the first Spanish village past the Neutral Ground, and four or five
miles distant from the Rock. A.t this time, it was prevailing
severely in Seville, and probably in other places also between that
city and St. Roque.

A most interesting episode in the history of the Gibraltar epi-
demic requires to be noted here, relating to an outbreak in the
Atlantic, on board a transport ship which sailed from the bay after ,
the disease had fairly manifested itself on shore.

The 9th Regiment, which had formed part of the garrison during
the early period of the epidemic, but had continued quite healthy,
was replaced by the 78th Highlanders in the third week of August,
and ordered off to the Cape. The left wing embarked on the 19th
in the "Windsor Castle," and sailed immediately; she reached her
destination with all well. On the 21st, the right wing went on
board the "Renown." Next morning, 22nd, one of the men of
the regiment, of very intemperate habits, was attacked on board,
and quickly succumbed. The ship was at once hauled into the
stream; and, as no other case occurred, during the next thirty
hours, she then proceeded to sea, having on board 16 officers, 353
men, 28 women, and 65 children. On the 29th and 30th, two
children had diarrhcea ; both recovered in a few days. On September
3rd, a sergeant, his wife, and child were attacked with dysentery,
which lasted upwards of a fortnight. On the 5th, another child of
this family, and also a soldier were attacked with cholera; both
died, the former on the same day, and the latter on the 10th.
Fifteen other seizures, besides a good many cases of dysentery and
of diarrhcea, took place during the next ten days, and 12 were fatal.
There were three more deaths, two from diarrhoea and one from
dysentery. Of the crew, fifty-two in number, two (one being the
surgeon of the ship) were attacked with cholera, and died. After
September 20th, there was no fresh attack of sickness, and the ship
reached the Cape on October 9th, in a healthy state.

No information has appeared, as far as I know, as to the health
of the mercantile shipping at Gibraltar during the epidemic. Quaran-
tine against Alexandria and Malta seems to have been established

1868.] Notes on the Cholera Epidemic in 1865-66. 179

about the 25tli of June. After that date, vessels with foul bills
were not admitted. Passengers were detained on board a hulk in
the bay, for a week before receiving pratique. i

8j}ain, — It might have been expected that in a country where
the most systematic and rigorous quarantine poHce is maintained
throughout the kingdom, and which was duly represented at the
Constantinople Conference, as well as at the Paris Conference in
1851, authentic data would have been had respecting the first
appearance of the disease on its shores. Yet it seems altogether
doubtful whether the earliest cases occurred at Valentia or at Barce-
lona ; no authentic details have ever been published. The disease
had certainly appeared in both cities in July. It speedily spread
and soon extended to Carthagena and to Murcia, as well as to many
places inland.^ Thousands upon thousands of the inhabitants of
the infected places now, as on all former visitations, fled in all direc-
tions ; and again were cruel attempts made to exclude, by force,
the fugitives from towns and districts which the pestilence had not

^ The first visitation was in 1834. Cholera had prevailed during the spring in
the adjacent districts of Spain. The earliest case in Gibraltar was on 23rd of
May. During the next three weeks several other cases occurred. In the third
week of June the disease began to be epidemic, and it steadily increased till the
middle of July. No part of the Rock escaped, not even the Neutral Ground.
Several cases occurred among the shipping. The total deaths were 414, viz.
162 among the military, and 252 among the civilians. The strength of the
garrison was 3929 ; the population was then estimated at 17,000.

In 1849 there occurred 17 cases and 5 deaths from cholera among the garrison.

In 1854 there were 24 cases and 12 deaths ; and in 1855 there were 99 cases
and 62 deaths.

Unfortunately, no account has been published of the mortality in these several
years among the civil population.

In 1860 there was, between August 16th and December 14th, a partial preva-
lence of cholera; 68 cases and 41 deaths occurred among the military, and 126
cases and 49 among the civil population, including convicts. The former were
estimated at 6632, the latter at 18,344. Nothing seems to be known as to the
origin of this visitation.

^ According to the Constantinople Conference, the first case at Valencia was
on July 8th, in the person of a French trader who had come from Marseilles — ■
whether by sea or by land, it is not stated. The only explanation ofi'ered is that
" on est d'autant plus fonde h, supposer que c'est lui, ou ses bagages qui ont
importe le cholera, que les victimes frappes successivement habitaient la meme
maison." No details are given as to his previous condition, or to that of the
public health in the town. The mortality was excessive; 5000 deaths among a
population of— 107,000, but reduced by flight to— 70,000.

Respecting Barcelona, we are told that "la sante generale etait bonne lorsqu'
arrive I'escadre Anglaise venant de Malte, ou sevissait le cholera " (neither the date
nor the health of the fleet mentioned). " On lui en attribue par consequent
I'importation." The earliest cases are said to have occurred about July 22nd.
As to Carthagena and Murcia, " on suppose que le cholera a ete importe de
Valence, en suivant le cherain de fer. L' epidemic se montre d'abord sous forme
de cholerine." At Alicante, the disease was introduced by some baggage or
merchandise from Marseilles ; it first appeared in the house to which the articles
had been conveyed. This is the only information given.

180 Original Communications. [Jan.,

yet reached. Madrid in the centre of the kingdom, and Seville in
the south-west, were smitten, the one in August and the other in
September. Cadiz, the great seaport near Seville, seems to have
escaped the infection. At Madrid, diarrhoea, bilious colic, and
dysentery had been prevalent for some time previously to the first
cases of cholera ; the outbreak of the epidemic afterwards was like
"an explosion.''^ In three or four days as many as 3000 cases
occurred, of which 1000 at least were fatal.^ The disease, more-
over, broke out about the same time in various other places in
Castile. Besides the mainland of Spain, two of the Balearic islands
were infected. At Palma, in Majorca, the disease appeared in the
latter part of August. No explanation of the occurrence has been
given, nor has any account of the outbreak of the disease at Port
Mahon, in Minorca — the great quarantine station of Spain in the
Mediterranean — been made public, as far as I know.

At the end of 1865, the disease was raging in many places in the
northern and in the southern provinces of the peninsula. Santander
is one of the places mentioned on the one hand, and Seville on the
other. Altogether, no country suffered more severely in 1865 than
did Spain. Of its forty-nine provinces or departments, thirty-one
had suffered more or less severely. Whatever was the period of its
first appearance in different places or districts, the chief violence of
the visitation was experienced in most of them about the same time,
viz. during September .^ This was the case at Gibraltar also. Very
generally, tlie epidemic had ceased by the first or second week of
November. Notwithstanding, perhaps in consequence of, the flight
of thousands and tens of thousands from infected towns, the mor-
tality in most of these was very great. Seville lost between two
and three thousand, and Madrid upwards of 3000.^

Portugal. — It is stated by the Conference that, in the month of
July, the cholera was raging in Spain and progressively advancing
towards the frontiers of Portugal, which had hitherto remained
exempt. At length it appeared at Elvas, a frontier fortified town,

' The Conference state that " the origin of the outbreak at Seville has been
attributed to some foul linen brought by sailors from Valencia. Madrid received
the infection from the same city more directly."

' At Seville, the acme was not till the third week in October.

3 Spain was first visited by the pestilence in 1834; but no detailed history of
the visitation has ever, I believe, been published. The southern provinces seem
to have suffered before the northern. The loss of life in many of the large towns
was very great, and almost every part of the peninsula suffered. In 1848, there
was a partial and circumscribed outbreak near the port of Vigo on the north-
west coast. The epidemic of 1853-54 prevailed over the whole country, and was
of extreme virulence in most parts, cbiefly between Juue and October. The
Balearic islands did not entirely escape. In 1855 and in 1856, there was a
partial reappearance of the disease ; again in 1859, and also in 1860, especially
on the east coast.

1868.] Notes on the Cholera Epidemic in 1865-66. 181

about the beginning of October, and caused fifty deaths there. A
few cases also occurred on the north-west frontier of the kingdom,
at Preizo and Cinta Espada. Moreover, a woman and attendant,
who had gone from Elvas to Oporto, fell sick in the latter town,
and died there. Then a man, who lived on the first floor of the
same house was attacked and died ; and two children of a family,
who occupied the lower part of the dwelhng, also sickened, but
they recovered. These cases at Oporto were, we are told, rigorously
isolated, the effects of the sick were destroyed, and the house was
disinfected j and thereupon the danger was stopped.

It would, however, seem that " une influence cholerique^' was expe-
rienced not only in Lisbon, but in the country generally, — " influence
caracterisee par des vomissements et de la diarrhee, quelquefois risi-
formes, et dans quelques cas accompagnes de crampes, de refroid-
issement, &c. ; mais cMtait la, toute la manifestation epidemique et
sans mortalite.'' It was rumoured that three or four cases of cho-
lera occurred in Lisbon, but no authentic account has ever appeared.

It is strange, and much to be regretted, that the Portuguese com-
missioners have given such meager and incomplete information as
to the epidemic in their country. How is it that Portugal and
Spain are always so unwilling to make public full details of any
severe sickness among their people? No countries maintain so
vigilant a supervision at all their seaports, so as to be thoroughly
aware at all times of the introduction of epidemic diseases by the
arrival of shipping from abroad.^ But nothing is made known.

France. — Although the existence of cholera at Marseilles was not
officially admitted until the 23rd July, there can be no reasonable
doubt but that the disease had been introduced into the city several
weeks previously. As early as June 11th, a steamer which had left
Alexandria on the 1st of that month arrived, bringing many pas-
sengers, of whom sixty-five were Algerine pilgrims from Mecca.
Two of the latter had died on the voyage, and a third died soon
after landing, from what was termed dysentery, while others were
more or less indisposed. During their stay at Marseilles, these men
were lodged under canvas. On the evening of the same day, 11th
(the date, it will be remembered, of the official recognition of the
cholera at Alexandria), another steamer arrived from Alexandria,

1 The first cholera epidemic m Portugal occurred in 1833 ; it commenced in
the neighbourhood of Lisbon in April, and soon afterwards broke out in that city,
and lasted there till October. It reappeared in 1834, but with less severity. The
disease did not reinvade the country till 1855, although in 1853 it existed
in one or two of the conterminous provinces of Spain, and in 1854 there was
a partial outbreak in the southern province of Algarve. In 1855 the pesti-
lence seemed to have entered Portugal from the Spanish frontiers. Lisbon was
not attacked until October; for three months previously, intestinal disorders had
been more than usually prevalent. In the summer of 1856, the disease re-
appeared both in Lisbon and in numerous country districts.

183 Original Communications. [Jan.,

wliicli she had left on the 3rcl. During the next fortnight many
other steamers from the same port arrived, all landing passengers,
who rapidly dispersed at once in different directions. When the
disease became epidemic in Marseilles, the old part of the town
opposite the Johette quay seemed to be the chief focus of the in-
fection. In August it spread widely in the departments of the
Bouches-du-Ehone, Herault, and Vaucluse in the south. Almost
the whole of the Mediterranean coast of France, from Nice to Per-
pignan near the foot of the Pyrenees, appears to have been under
the influence of the epidemic.

Toulon was attacked about the end of August, and the deaths
there to the end of October amounted to nearly 1300. The earliest
fatal case near Paris occurred on September 18th at Puteaux, a
little village on the Seine, "where extensive dye-works occupy a
large number of workmen, and which, for filth and want of sanitary
arrangements, is a perfect disgrace to municipal administration."
The first deaths in Paris itself were on the 24th, by which time
other suburban villages around the metropolis, besides Puteaux, had
become infected. The chief violence of the epidemic in and around
Paris was in October ; the disease did not cease till the second week
in 1866. Upwards of 6000 had fallen victims to the scourge.

Besides the places and districts already mentioned, other parts of
Prance suffered in 1865. The two towns of liaon FEtape and
Rambervilliers in the department of the Vosges, and also several
places, in nearly the same latitude, in the western departments of
Pinisterre (particularly Brest), Morbihan, and Cotes du Nord were
visited in November or December ; or probably earlier, as the disease
would seem to have been at Havre in the first or second week of
October. Cases had also occurred among the labourers engaged in
the Mont Cenis Railway, at the village of Bardonecchio, at the
beginning of November. In 1865, as on most former visitations of
the pestilence in Prance, Lyons again remained intact. The com-
parative immunity of this populous city, situated as it is in the
direct line between Marseilles and Paris, is a notable event that has
never been satisfactorily accounted for.^

* Prance was first visited by the cholera in the spring of 1832. It began in
Paris about the middle of March, and prevailed with great severity in April and
May. The progress of the disease to the south was slow. Marseilles, Toulon, and
other places along the Mediterranean coast were not invaded in the first epidemic
until 1834. At Marseilles there was a reappearance of the disease in 1837. The
whole country from north to south, sufi'ered from the epidemic of 1849. Bordeaux
and some other places were revisited in 1850, Towards the end of 1853, Paris was
again invaded ; in the following year the epidemic was very widely diffused over
most of the departments, and in many places it was extremely fatal. Marseilles,
Bordeaux, &c., suffered again in 1855. The chief force of all the epidemics (except
of the first) was felt from July to September, and chiefiy in July. The island of
Corsica suffered severely in the autamn of 1854.

1868.] Notes on the Cholera Epidemic in 1865-66. ' 183

Italy. — It was at Ancona, which has of recent years been in most
direct and frequent communication with Alexandria, that the disease
first appeared. Quarantine against all arrivals from Egypt, had
been established there on the 19th of June, if not sooner. The
earliest known case of true cholera occurred in a woman who had
arrived from Alexandria on July 3, and had performed quarantine
in the lazaret till the 9th, when" she was discharged. On the
following day, while travelling to Pistoia, she was attacked and died
in that town next morning. Whether any cases of the disease had
been received into the lazaret prior to this woman leaving it, does
not appear.^ The disease subsequently spread through the city and
its outskirts, reaching its acme in the first and second weeks of
August, and occasioning upwards of 1300 deaths. What was the
condition of the public health in Ancona, prior to the appearance
of the cholera in her midst, is unfortunately not known. " Pro-
fessor Ghinozzi, who made an official investigation of the outbreak,
believes that it would have occurred, even if no communication with
Alexandria had taken place," Mr. Radcliffe states in his memoir.

In August and September the disease spread to many places, both
north and south of Ancona ; but with this remarkable peculiarity,
that while in Bologna, Modena, Acqui and other places in Pied-
mont, scattered cases or small groups of cases occurred, nowhere in
the northern provinces did the disease become fairly epidemic;
whereas in numerous towns in the provinces of Capitanata, Terra
di Bari, and Otranto, to the south, it raged with great violence;
although there was very much less intercourse with Ancona in this
direction, than towards the more busy and populous towns in the
north of the peninsula. Whether it extended into Calabria and
towards the straits of Messina, does not distinctly appear. ' The ex-
planation given by the Conference of the much greater diffusion and
severity of the epidemic in the southern than in the northern parts
of Italy is, that it was due, in respect of the latter, " aux mesures
prises pour etouffer les premiers germes.''^ Is this explanation
merely conjectural, or does it rest on any ascertained evidence ?

Naples was not invaded till the beginning of October; the
earliest case in that city was on the 7th. The last case in Naples
occurred towards the end of December.

Throughout 1865, Florence seems to have entirely escaped ; a few
cases, it was reported, had taken place in a village a few miles dis-
tant. Neither was Leghorn nor Genoa infected till a later period.

^ The Conference state that no one In the lazaret had been attacked, and that
it may be presumed that the disease was introduced into Ancona by the clothes
or effects of passengers who had arrived from Alexandria. The iirst case is
declared to have occurred in a washerwoman, who had taken a quantity of linen
belonging to persons who had come from Egypt. ' Le cholera s'est ensuite im-
mediatement repandu dans presque tous les quartiers." On what evidence these
statements rest, the reader is not told.

184 Original Communications. [Jan.,

Whether there was any truth in the rumours that cases had
occurred in November, at Civita Vecchia, it is impossible to say ; so
much concealment is invariably practised in the Papal and other
States where quarantine restrictions against foreign ports are most
rigorously enforced.

The immunity of Sicily, in 1865, is noteworthy on several
accounts, and especially in relation to the alleged efficacy of rigorous
quarantine for its exclusion from a country, as cited by the Con-
stantinople Conference, Sardinia and Corsica were equally intact.

There were repeatedly rumours, in the public journals at the time,
that cases of cholera had occurred in August of that year at
Messina, Catania, and Palermo j but there has been no official or
reliable statement one way or the other, nor does it appear that
any communication has been received from our consuls in these
places. The defensive measures, adopted by the authorities to ex-
clude the disease, amounted to all but a total suspension of direct
intercourse ; suspected vessels not being allowed even to approach
the shore, under threats of being fired into. Next year the tables
were turned, and Sicily had then to endure a similar embargo on
her commerce with Malta and other Mediterranean ports.^

I have thus tried to follow the progress of the pestilence along
the Mediterranean in a north-westerly direction, noting the prin-
cipal places and countries, in that course, which were invaded in the
summer of 1865. No mention, it will be observed, has been made
of any known extension of the disease from Egypt, due west, to any
part either in Barbary, Tunis, or in Morocco, although many of
the pilgrims from Mecca were bound for and returned to these
countries. Indeed, the only part of the north coast of Africa where
the disease occurred that year seems to have been the Prench pro-
vince of Algeria, into which it was introduced by direct arrivals
from Prance, but without it ever manifesting any tendency to
become epidemic.^ It will now be necessary to start once more
from Alexandria, and take a northerly course, so as to make out as

1 The northern provinces of Italy were visited for the first time in 1834-35 ;
the central, including the Papal States, in 1835-36 ; and the southern provinces,
including Sicily, in 1836-37. The outbreak in Palermo in 1837 — the same year
that Malta was first attacked — was of extraordinary severity. The epidemic of
1854 was spread over the whole peninsula ; and in 1855, and again in 1856, there
were partial recurrences of the pestilence. The island of Sardinia suffered in
1855 ; it seems to have previously escaped.

* In the latter part of 1849 the coast of Barbary, including the towns of
Tunis, Oran, and Algiers, suff"ered from cholera. Whether there had been an
earlier visitation, is not known. In 1850 there was again a wide prevalence of
the disease there, while it was raging in Egypt ; and in 1851 a partial recur-
rence of it in some parts of the North African coast. In 1854 Algiers was in-
fected, probably by arrivals from France ; and there were also that year numerous
sporadic cases in Tripoli. In 1856 the coast of Morocco was suff'ering from the
disease, at the time when Madeira and also one of the Cape de Verde islands
were first invaded by the pestilence.

1868.] Notes on the Cholera Epidemic itt 1865-66. 185

well as we can — after briefly noticing the visitations of the pesti-
lence at two or three of the principal places on the coasts of Syria
and Asia Minor — how it reached and spread through the eastern
and central parts of Europe.

Jaffa. — The earliest case here is said to have occurred on July 1st,
and the disease to have prevailed in greatest force in the third week
of that month. Some dismal disasters occurred on board one or
two vessels crowded with refugees from Alexandria, which sought
admission to the port, and, being refused leave to enter, were forced
to returu to Egypt.

Beyrout. — Erom June 17 to July 25, upwards of 3000 persons
from Alexandria were sent into the lazaret. The crowding was ex-
cessive, and the- consequence was that the detenus became violent,
and broke through tlie restraint. But the disease had already
appeared in the town, where the first case occurred,, in a man who had
had no communication with the lazaret or its inmates; and the second
case was, on July 3rd, in an abbe, who had just been liberated from
the lazaret after a quarantine there of ten days. The chief mortality
was in August and September. More than half of the inhabitants
fled to the mountains. The season was a very sickly one ; " such
has been the general unhealthiness," wrote the British Consul,
" of the present summer in Beyrout, that hardly a single person
Avho remained in town escaped a serious attack, either of cholera or
fever; and the latter disease is still (Oct. 21) prevailing to a great
extent. Even in the mountains, there is more than an ordinary
amount of sickness. ^^

Cyprus. — From June 24 to July 18, there were 1200 persons
detained in the lazaret at Lurnaca. The first case of cholera
occurred, on July 7, in a coffee-house keeper, in whose house
several persons after completing their quarantine were lodged.
Erom him, it is asserted, the disease spread to the town, and thence
over the island. No further information is given by the Conference.

Smyrna. — The first vessel with a foul bill from Alexandria
arrived on June 23, and she landed one cholera patient at the
lazaret; but several arrivals from Alexandria had already come in
and received pratique, having nothing suspected on board, and
having moreover completed their five days of voyage without any
sickness on board since leaving port. The earliest case of cholera
in the town occurred, on June 24, in an Armenian woman, who does
not appear to have had anything to do with the lazaret, and whose
sickness could not be traced. The second case occurred, on the
29th, in a woman who had nursed the former patient. The epi-
demic reached its acme in the last week of July and first week of

186 Original Communications. [J;

in.

August. Out of a population, reduced by fliglit, of 100,000, about
2500 perished. Prior to the arrival of the infected shipping, the
health of Smyrna is stated by the Conference to have been " parfaite."
The sufferings among the poorer inhabitants " were greatly aggra-
vated by extreme privation, in consequence of an almost entire
cessation of labour. Employers had fled from the town, and busi-
ness came to a standstill during the progress of the epidemic."^

Constantinople. — With respect to the public health of the city
prior to June 28, nothing had indicated, it is stated, the approach
of any epidemic sickness. In the want of all mortuary registra-
tion, this point, however, must always be more or less questionable.
On the day mentioned, a frigate, which had left Alexandria five
days previously, arrived, and landed at the Marine Hospital 12 of
her crew — 1 afflicted with confirmed cholera, and 11 with cholerine.
Two men had also died of cholera between the Dardanelles and Con-
stantinople, and their bodies had been buried at sea. There had
been much diarrhoea among her crew during the voyage from Egypt.
This government ship was at once admitted to pratique ; and this,
too, notwithstanding that it was perfectly well known that cholera
had broken out in the port of departure. Moreover, there must
have been several, probably many, arrivals from Alexandria prior to
this frigate. The Porte, it is to be remembered, professes to have
a regular quarantine code and system, in compliance with the re-
quirements of other countries. On the 30th, nine fresh cases were
landed from the frigate ; and then, having been furnished with a
fresh crew, she was sent to a quarantine station at the mouth of the
Black Sea ! Within three or four days, some of the workmen
engaged in a barrack immediately adjoining the Marine Hospital
were attacked, as well as other men on board a vessel which was
moored close alongside. At the beginning of the second week in
July, the disease had appeared outside of the arsenal, and soon after-
wards it had spread over the entire city. It subsequently extended
to the villages along both sides of the Bosj)horus and around the
Sea of Marmora. The greatest mortality in Constantinople was
during the first two weeks of August. The epidemic continued to
nearly the end of September. The mortality among a population
of 800,000 has been stated by some at 12,000, by others at 15,000.

In reference to the pestilence in Constantinople, the Conference
take occasion to remark that the most insanitary localities in a town
sometimes escape, comparatively or altogether, during an epidemic
visitation ; and they quote, in illustration, the case of the bagnio

1 Syria and Palestine seem to have been first visited by cholera in 1830 or
1831,. and to have suffered also in 1837, in 1847-48, and in 1854-55 ; but our in-
formation respecting the medical history of these countries is extremely imperfect
and uncertain.

1868.] Notes on the Cholera Epidemic in 1865-66. 187

(within the precincts of the arsenal) which suffered but h'ttle in
comparison with the adjacent barracks of the soldiers and sailors.
The worst hygienic conditions are said to exist in the bagnio, in
which were confined 700 galley slaves, of whom 500 Avere daily sent
out, two usually chained together, to be employed on the public
works. They remained exempt until near the end of the epidemic,
when, at length, one of the guards was attacked, and soon afterwards
15 of the prisoners. Of these cases, 7 were fatal. This was the
entire loss. On the other hand, among the soldiers and sailors in
the arsenal, the deaths amounted to 11 per cent, of their whole
force. No explanation of the marked difference is offered. It
would require to know all particulars as to the mode of life of these
two sets of men, and as to the site and condition of the buildings
they occupied, as well as respecting the frequency and amount of
their exposure to a morbific or infected atmosphere, before hazarding
any opinion. At Gibraltar it has been seen that the convicts suffered
more severely than any other section of the population.^

There were, of course, during the prevalence of cholera in Con-
stantinople, continual departures therefrom of vessels in different
directions — some through the Dardanelles for places in the jEgean
Sea or Mediterranean, and others by the Bosphorus for ports in the
Black Sea. Let us first take the latter course. At Therapia, on
the European shore of the Bosphorus, near the' entrance into the
]31ack: Sea, there was a sudden outbreak on the night of the 31st
July; it lasted for a week, and was very destructive. Notwith-
standing numerous infected arrivals from Constantinople at Bourgas
and at Varna, on the west shores of the Euxine, and a good many
sick persons were landed at their lazarets (the quarantine was
generally for three days only), the disease showed no tendency to
spread. One fatal case occurred at Bourgas in a sailor after being
discharged from the lazaret. It was at Sulina, situated near the
entrance to the delta of the Danube, that the earliest manifestation
of the disease in this region occurred ; this was at the beginning of
August.

According to Dr. Jellinck, the medical officer of the Navigation
Hospital there, the arrival of a steam transport, which had lost two
men on the voyage from Constantinople, w^as " the signal for the
outbreak of the epidemic '' in the place. Although the cholera was

1 Constaufcinople experienced its first visitation in 1831. The second visitation
commenced in the latter part of 1847, and continued for a great portion of 1848,
both in that city and throughout most parts of the Ottoman dominions. In 1854r-^
55, during the Crimean War, there were but few districts of Turkey in Europe
that remained altogether exempt. Constantinople, of course, suffered; but at no
time did the disease prevail there with epidemic violence, notwithstanding the
constant arrivals of sick transports and other infected vessels from the seat of war,
as well as from Marseilles and other ports in the Mediterranean where the disease
existed.

188 Original Communications. [J

an.

cliiefly confined to the poorer classes, "every one was more or less
attacked with a certain malaise, characterised by sensitiveness in the
region of the stomach, loss of appetite, and, above all, a sparing
secretion of reddish urine/' Within two or three days of its appear-
ance at Sulina, cases began to occur not only in several places along
the course of the Danube, but also on the west coast of the Black
Sea to the south of Sulina, and especially at Kustendjie, between
that town and Yarna, and memorable, it may be remembered, for
the terrible explosion of the pestilence among a French body of
troops in 1854.

Before proceeding westward along the course of the Danube, let
us see how the southern provinces of Russia bordering on the Black
Sea fared about this time. Notwithstanding that an official report
has been published by the Russian Government of the epidemic, it
is difficult, from the imperfect and confused data given, to trace its
development and progress. At the great commercial port of Odessa,
which has so much intercourse with Constantinople, cases of epidemic
cholera do not seem to have been received into, or to have occurred
in, the lazaret till the first or second week of August. The earliest
case among the townspeople took place in a customhouse officer on
the 17th of that month; most of the subsequent cases were limited
to one or two districts, the rest of the town suffering but little ; the
visitation was altogether very much less severe than in former
epidemics, although the general health previously was certainly un-
favorable. The mortality during the early months of the year had
been much above the average, and in the summer months it had
greatly increased, in consequence chiefly of inteitinal affections,
which caused between 600 and 700 deaths in June, July, and
August.

About the same time that cholera appeared at Odessa, it manifested
itself in the village of Borchi, in Podolia, upwards of seventy miles
to the north of Odessa. The persons first attacked there were some
German labourers, who, with their families, had arrived from Galatz,
which they left on August 4th, via Odessa. All appeared to be
quite healthy when they reached Borchi on the (July 26, 0. S.)
7th of August, except an infant which had diarrhoea, and died three
days afterwards. From this date cholera began to break out among
the inhabitants, attacking with especial violence the newly-arrived
strangers ; only one, out of eight of them who were seized, recovered.
The mother of the child first affected did not sicken until the 18th;
she died two days afterwards, or ten days after her child. The dis-
ease subsequently spread to different localities in the neighbourhood.
Great stress has been laid upon this outbreak at Borchi as affording
indubitable evidence of the introduction of the disease into a healthy
locality by the arrival of strangers from an infected place — that
place in the present instance being confidently asserted to have been

1868.] Notes on the dholefa Epidemic of 1865-66. 189

Galatz. Statements are conflicting as to the date of the earliest
manifestation of the disease at Galatz ; it is doubtful whether it
existed there so soon as August 4. But whether it did or not,
the strangers came last from Odessa, where the disease was certainly
present, at least in the lazaret, in the first week of that month.
Unfortunately, no authentic information has been given as to the
previous health of the districts intervening between that city and
the village of Borchi, or of Borchi itself.

During September, cholera appears to have been widely difl'used
throughout the province of Podolia. Subsequently it spread to
Kiev to the northward ; but, before this province became affected,
the disease appeared at Kerch on the eastern coast of the Crimea.^
In October it was at Taganrog, at the northern extremity of the Sea
of Azof ; and in November it was heard of in the province of Yol-
hynia, to the north of Kiev, and bordering on the southern provinces
of Poland. '^In almost every place," states the ojBficial Russian
account, "before the appearance of the cholera, the prodromata of
the disease, especially diarrhoea, were observed.''^ Towards the end
of 1865, the disease continued to exist in various places in the
south-west provinces of the empire, and also in the Caucasian pro-
vinces as far south as the frontiers of Persia. A few fatal cases
occurred, during December, in St. Petersburg ; but no decided out-
break occurred there till the following June.^

Returning now to the delta of the Danube, it is to be observed

1 From the report of the Conference, it would seem that the disease had
appeared at the eastern end of the Black Sea in the coast towns of Soukhum and
Poti, at the beginning of September, if not sooner, and that it had penetrated
inland to Kutais about the middle of last month. It was introduced, says the
report, into Tiflis, the capital of Georgia, by a Frenchman and his wife who had
arrived there, a week later, from Marseilles by the way of Poti and Kutais. They
both fell sick, but recovered ; still it was believed that they imported the disease,
" car les diarrhees qui y regnent habituellement en ete ont revetu depuis leur
arrivee la forme cholerique." At Sinope and Samsoun, on the south coast of the
Black Sea, although numerous infected arrivals from Constantinople entered these
ports, but very few eases occurred. Trebizond, on the same coast, but further
eastward, suffered more severely.

~ Odessa and other Russian ports in the Black Sea were first invaded by cholera
in the autumn of 1830, about the same as Moscow. Other parts of Russia in
Europe became the seats of the pestilence in the course of that and of the follow-
ing year. The next visitation was in the summer and early autumn of 1847 ; it
lasted in different parts of the empire through 1848. In 1852 there were many
irregular outbreaks in the northern provinces, and also in various parts of Poland.
Again, in 1853, there was a considerable prevalence of the disease in the northern
and central provinces. In the early part of 1854 it existed in Bessarabia and
other districts near the Danube, which were soon to become the theatre of war.
As the year advanced, Odessa, Varna, and other places on the Black Sea — Turkish
as well as Russian — appear to have been the seat of the choleraic infection before
the arrival of the allied fleets there. Throughout 1855, the disease existed in
almost every part where large bodies of traops were assembled. In 1858, and again
in 1859, some of the northern Russian ports, as Helsingfors, Riga, &c. suffered
more or less severely from cholera.

190 Original Communications. [J

an.,

that, after the outbreak at SuHna, many of the towns on the banks
of the river — as Tultcha, Galatz, Rutschuk, Widin, &c. — became
infected between the early part of August and the middle of
September. The disease had penetrated too into numerous places
in the surrounding districts, and among others to Bucharest, the
capital of Wallachia. All the attempts made to exclude the
scourge were. Dr. Jellinek remarks, fruitless, and the measures
resorted to for the purpose only served to increase the distresses of
the poor : — " At Sulina we were obhged to endure the inconvenience
of a complete exclusion, commerce was checked, the navigation
suffered enormously, every ship was taxed to no inconsiderable
extent for health-guards, &c. ; and the same thing was repeated,
with the same want of success, at Tultcha, Galatz, and Ibraila,
whilst the epidemic advanced constantly, and attacked places
situated in the interior of the river-bordering cauntries/'

From the following observations of Major Stokes, R.E., the
British Commissioner in the Danube, it seems that the disease did
not penetrate westward into Austria by this way ; or, at least, its
course in this direction could not be traced :

" At Orsova, the frontier town of Austria on the Danube, the
quarantine, established for a short time, was removed upon the
earnest remonstrance of my Austrian colleague on the Commission.
Although the cholera visited every Turkish town where the quaran-
tine was strictly enforced, to within a few miles of Orsova, that
place remained quite free from the disease. The passenger traffic
through Orsova, between the East and Yienna, is very conciderable,
and yet no instance occurred of cholera being imported from the
many pest-smitten towns."

Central 'Europe. — It has just been seen that the pestilence had,
in the month of August, spread up along the course of the Danube
from its mouth, and had penetrated into many places in the Danu-
bian principalities ; but, as far as our imperfect information goes, it
would seem that it had not extended in that direction into the
Austrian dominions. Orsova, the frontier town on the river, at
least remained unaffected; nor had any cases occurred in Pesth,
Buda, or Yienna. In the last week of August the disease, how'ever,
manifested itself in the town of Altenburg in Saxony, twenty-four
miles south of Leipzig, and the outbreak there is believed to have
been caused by direct importation either from the infected districts
of the Danube, or from the shores of the Black Sea. The circum-
stances were these. A woman, with her infant, twenty-one months
old, had left Odessa on August 15, and, [travelling by the Danube
steamer, had reached Altenburg on the 24th of that month, both
being then in apparently good health. It is not stated at what
towns on the Danube the steamer by which she came from Odessa

1868.] Notes on the Cholera Epidemic of 1865-66. 191

had touched, nor at what place on the river the woman had been
landed, to proceed on her way to Saxony. The other passengers
and the crew of the vessel are supposed to have been throughout
free from any sickness. The woman put up at her sister's house,
situated in a most unhealthy locality in Altenburg, and which was
itself very unwholesome and impure. The infant was seen by a
physician, in consequence of it suffering from diarrhoea, on the 27th,
three days after arrival. The mother at this time seemed to be
quite well ; but, in the course of that evening, she sickened, and
next day (28th) all the symptoms of mahgnant cholera appeared;
and she died on the 29th. On the evening of that day her sister
was attacked, and the attack proved fatal on the 30th. The infant
(who had been previously removed to another house) sank from
exhaustion on the 31st. None of the other inmates in the house
where the infant died were affected. It was from the other house
(No. 678 in the Kunstgasse) where the mother and her sister died
that the disease " manifestly spread " to other parts of the town.
In the course of September, it had extended to several of the
neighbouring villages, as Rasephas, Werdau, &c. The sanitary
condition of Altenburg is stated to be very bad ; the death-rate, in
ordinary years, is high for a town of its population, which amounts
to about 18,000. In 1864 it was higher than usual; and in 1865
it was higher still, independently of the deaths from cholera. In
1860-63, inclusive, the deaths averaged 27 per 1000 of the in-
habitants; in 1864 the ratio was 29 per 1000; and in 1865 it
rose to 35 per 1000, without taking into account the 91 deaths
from cholera between the end of August and beginning of December.
For three months prior to the occurrence of any cases. of that
disease, there had been very great mortality, — most probably from
intestinal diseases, as neither fever, nor other recognised epidemic
malady was prevalent. The part of the town where the Kunstgasse
is situated lies low, and had been inundated, in the spring, from the
overflowing of an adjacent pool; and, in front of No. 678, runs a
stagnant fetid ditch, into which all sorts of household impurities
were thrown. The heat in July and August was unusually great.^

The sanitary condition of the other places affected was also very
defective, and their ordinary death-rate high. In Werdau, with a
population of between ten and eleven thousand, where the death-
rate had for some years averaged 33 per 1000, 1865 was an un-
usually sickly year; the mortality, exclusive of 201 deaths from
cholera, between September 17 and December 11, largely exceeded
the ordinary ratio. In August " there was a tendency to diarrhoea
and cholerine." The first case of cholera there was in a person who
had come from Altenburg, A few cases occurred in Leipzig, but
the disease manifested no tendency to become epidemic, nor indeed
^ • Die indiaAe Cholera in Sachsen in 1865/ vou Dr. Guuther, 1866.

193 Original Communications. [J

an.,

in any other place in Germany, northward of Altenburg in latitude
51°, during 1865. In November it is believed to have existed to
a partial extent in some places on the frontiers of Saxony and
Bavaria ; and there was a rumour that several cases had occurred
at Nuremberg. Whetlier any choleraic manifestations had mani-
fested themselves in the lands intermediate between these frontiers
and the Yosges districts of Trance, w^hich, as has been already seen,
were partially infected in the autumn, I am unable to say. Besides
North Germany, Hanover, Holland, and Belgium seem to have
been unaffected by any distinct traces of the disease this year. We
shall, therefore, turn southward and endeavour to make out what had
been taking place in the southern provinces of Austria, and in
some adjacent regions which have not hitherto been noticed.

Austria. — Notwithstanding the very frequent intercourse of Trieste
■with Alexandria, it was not till the end of September that any cases
occurred there, and even then not in Trieste itself, but in an
adjacent village.

The Conference state that the first three cases occurred on
September 28; these were followed by two other cases in Prosecco,
a village about eight or nine thousand yards from Trieste. Thence
the disease seems to have advanced into the town ; the cases there
were almost all single and isolated, except in three houses where
several deaths took place under one roof. Of eighty-three attacks
in all, between September 28 and November 19, sixty were fatal.
Pive deaths occurred at the inland village of Optchina, near Trieste,
and a few cases also at the village of Maggia on the coast, only
about six or seven miles distant.

Although the earliest cases of cholera at or near Trieste were not
till the end of September, diarrhoea had been very prevalent in the
town during July, and several of the cases were of a decidedly
choleraic type; but none proved fatal. In August, and also in
September, diarrhosa continued to be common among the inhabi-
tants. The Conference, admitting that the development of the
cholera at the end of September could not be traced to any parti-
cular infected arrival or arrivals about that time, consider that the
previous diarrhoea and cliolerine prevailing in Trieste might be
owing to the admission of the many fugitives from Alexandria, who
flocked to Trieste and stayed there. "N'a-t-on pas le droit de
rapporter des phenomenes choleriques de Trieste a Temigration
venue dc TEgypte au mois de Juin ? Nous le j^ensons, mais nous
manquons de preuves suffisantes pour Taffirmer.''^ The difficulty is
to account for the non-occurrence of the fully-developed disease
during the very season that it almost invariably prevails through-
out Europe, and when all tlie adjuvant causes of its genesis and

1868.] Notes on the Cholera Epidemic of 1865-66. 193

growth are most active, and for the retardation of the event till
so advanced a period of the year.

The number of persons detained in quarantine at Trieste, between
June 18 and February 1, 1866, was no less than 11,108. A
woman, arrived from Alexandria on August 4, was attacked (in the
lazaret ?) four days afterwards ; and a man, arrived from Ancona on
August 24, was attacked within a few hours after landing. -It is
not stated whether either case was fatal. Between August 7 and
October 20, a death occurred in three different vessels while per-
forming quarantine in the harbour.

The disease does not seem, as far as we know, to have extended
from Trieste to any place, either on the Venitian or on the Dalmatian
coast. The only place on the Albanian coast of which any mention
has been made, in connection with the pestilence, is Vallona, nearly
opposite to Brindisi on the Italian coast, where an Austrian
steamer, which left Alexandria on August 7, arrived on the 12th,
and landed 406 passengers, 5 of whom were moribund from cholera.
The passengers were landed on an island in the harbour, and kept
in quarantine for ten days; only one death occurred among the
number, and the town remained perfectly healthy. The port of
Durazzo, thirty miles to the northward, also escaped, although
several svessels from infected places^ especially from Ancona, had
arrived there during the season.

The western coast of Turkey and the whole of Greece appear
to have remained exempt throughout 1865. But at one or two
points on the eastern coast, there was a partial development of the
disease, in consequence of their more direct and frequent com-
munication with Constantinople and* with the town of Dardanelles,
which had become infected about the middle of July, and at
which is one of the principal quarantine stations in the Turkish
dominions.^ At Salonica, upwards of 4000 persons, chiefly from
Constantinople and Smyrna, were, in the course of the season,
detained in the lazaret, which was often excessively crowded. The
total number of deaths from cholera among the detenus amounted
to 122. Very few cases occurred in the town itself; the first was
in a man, shortlyafter being quarantined for fourteen days. Two other
persons in the same house were attacked, but the disease did not
spread. Notwithstanding this immunity of Salonica itself, several
of the adjacent villages suffered considerably, in consequence, it was
believed, of persons, who had performed their quarantine, resorting
thither. Nearly the same thing happened at the port of Volo,
situated to the south of Salonica. Rather more than twenty fatal

1 The quarantine at tlie Dardanelles commenced on June 29th, the day after
the appearance of the disease at Constantinople. Within the next five weeks,
more than 2000 persons were sent into the lazaret, which was utterly insufficient
to accommodate them. Fifteen deaths occurred among the detenus,

81— XII. 13

J94 Original Communications, [Jan.,

cases occurred in the lazaret between July 26 and August 10 ; but
only two attacks, one being fatal, took place in the town ; both
occurred in officials of the lazaret. Several of the adjacent villages,
however, suffered more severely. Whether it was from one of these
villages that the inland town of Larissa, situated to the north of
Volo, contracted the infection at a later period of the year j and also
how and when the large town of Monastir, nearly in the centre
of the country, and intermediate between Salonica and Durazzo,
became first infected ; are points on which I fear we must be content
to remain in ignorance. AH the information which the Conference
appears to have been able to obtain is this : " Larissa, as well as
the whole of Thessaly had enjoyed perfect health until the end of
November. At that time there arrived from the neighbouring pro-
vince of Monastir, and notably from Fiorina, thirty miles distant,
where cholera existed, from three to four hundred Bulgarians to be
engaged in different occupations during the winter. It was then
that the disease appeared at Larissa. Most of the attacked were
among the Bulgarians who had come from an infected district ; the
rest of the cases were among persons living near to the immigrants.
The disease ceased with the flight of these strangers.''^^

From the shores of the Mediterranean and from the Continent,
we now pass to our own country, which supplies an interesting page,
or rather portion of a page, in the history of the epidemic.

Great Britain. — Notwithstanding the incessant intercourse, both
by sea and land, with all the countries ravaged by the pestilence,
and although no restrictive measures to bar the enemy out were
adopted at any part of the coast, the all but complete immunity it
enjoyed in 1865 is a very notable epidemiological event. Contrast
in this respect the fate of Spain, which is the great exclusionist
Power in the present day, and the fact becomes striking indeed.
The only point on our shores where the disease manifested itself
was at a port on the south coast, and that the very one which is
in most direct and rapid communication with Egypt, as well as with

1 As to previous visitations of cholera on the Dahnatian and Albanian coasts,
and on the opposite or Ji]gean coast of the Turkish peninsula, our information is
most scanty. Even in respect of Trieste and other Austrian ports in the Adriatic,
very little unfortunately is known. The first visitation at Trieste was in 1835,
when Lomhardy and Venetia were invaded. In the following year there appears
to have been a removal of the epidemic, and the Dalmatian coast was attacked.
Whether, and to what extent, it spread into the neighbouring provinces under
Turkish rule, we are quite ignorant. In 1848 and 1849 the southern parts of
the Austrian dominions appear to have suffered, and Trieste probably did not
escape. In 1854, and also in 1855, scarcely any part of the empire seems to have
escaped the wide-spread and most destructive visitation of these years. It is
known that, in 1855, the towns of Volo and Larissa were attacked by the pesti-
lence; beyond this, nothing can be said. {Vide ' Parliamentary Returns on Quaran-
tine/ August, 1860.)

1868.] Notes on the Cholera Epidemic of 1865-66. 195

Malta and Gibraltar, viz. Southampton j its latitude is nearly 51°.
This in itself is an important fact in the history of the present
epidemic, marking as it does a signal difference from the course of
the former visitations of the disease, which always first appeared at
some point on our eastern shores, those namely that are in most
frequent and direct intercommunication with the northern half of
Europe. During the summer months, two or three cases of
cholera had occurred among the passengers on board one or two
of the numerous fleet of the Peninsular and Oriental steamers on
the voyage from Alexandria to Malta ; and it is also beyond dispute
that in several of the vessels, on arriving at Southampton, some of
the crew were, or had been immediately before arrival, affected with
diarrhoea. On the whole, however, there was marvellously little
sickness in these fine and roomy vessels throughout the whole
season ; and it is also to be noted that not a single instance of any
thing like choleraic illness is known to have occurred among any
of the passengers, or among any of the crews or of their families,
after landing at Southampton. The earliest cases of cholera there
were certainly not among them ; but they occurred in individuals
who had had no direct or traceable communication — as far as a
strict examination by an accomplished inquirer could discover —
either with the steamers, or with any person or any thing that had
been on board of them. About the middle of August, a suspicious
attack took place in a Avoman engaged in one of the shops in South-
ampton; but, as she recovered, doubts were entertained as to the
real nature of the illness. It was not till about the end of the
third, or the beginning of the fourth, week in September that the
earliest undoubted cases of malignant cholera were met with ; and
they occurred nearly simultaneously in three distinct and separated
localities, and in persons unconnected, and having no communica-
tion, with each other. All these persons were in humble life, and
all were living under what must be considered to be unfavorable
if not decidedly unwholesome, household conditions. This was true
also of nearly all the subsequent cases which occurred in and
around Southampton, with the exception of two or three instances
at most, one of these latter being that of the medical officer of
health, in whom bodily exhaustion and mental anxiety seemed to
have had much to do in the induction of the fatal attack. Of thirty-
one cases, fifteen of Avhich were fatal, in Southampton proper, almost
all occurred " in the lowest, dampest, and most crowded parts " of
the district — a district which had been ravaged in the epidemic of
1849. With respect to the origin of the outbreak, Mr. Simon
most justly remarks that the report of Professor Parkes' "peculiarly
exact inquiry into all the circumstances connected with the begin-
nings of the epidemic, and into the relations of the cases to one
another" afibrds "a useful illustration of the extreme difficulty

196 Original Communications. [Jan.,

which in all such matters there is in proving or disproving con-
tagional relations."

With the exception of Southampton, none of the other com-
mercial ports of the kingdom," not even those which have much
intercourse with the Levant and the Mediterranean, as London and
Liverpool, appear to have manifested any indications of threatened
or actual choleraic sickness among their shipping, or on shore,
throughout the entire season. Neither did any case occur at any
of our great naval ports, or among any vessel of war which may
have arrived from the Mediterranean. Notwithstanding, too, the
incessant intercommunication with Paris and other infected places in
France, no evil consequences followed. The only other spot in
England, besides Southampton, where the pestilence manifested
itself in 1865 was in a farmhouse at the village of Theydon Bois,
in Essex. The circumstances connected with this circumscribed
little outbreak, as recorded by Mr. Eadcliffe in an official report to
the Privy Council, are certainly of extreme interest in the history
of this mysterious disease. The farmer and his wife had gone to
Weymouth on September 8, for change of air; he had for some
time been suffering at home from gastric disorder, which his medical
attendant considered was partly due to the impure quality of the
water used in the house. On the 23rd, he was seized with diarrhoea,
sickness, and cramps, which continued more or less the next day,
and left him still unwell on the 25th, when they both returned to
Theydon Bois, passing on their way through the railway station at
Southampton, but without going out of it. During the journey,
the wife began to be affected with intestinal disorder ; her symptoms
became aggravated soon after reaching home, the diarrhoea increas-
ing, and eventually lapsing into cholera, from the secondary fever
of which she died on October 11. But ere this, no fewer than
ten other persons, either members of the family or persons in
attendance upon them, had been attacked, and five or six of them
had died. Two were attacked on September 30 th, one on October
2nd, one on 3rd, two on 5th, three on 6th, one on 10th. Of these,
the farmer himself, who had suffered at Weymouth, and had ever
since had relaxed bowels, was attacked on October 6th, and died in
fifteen hours after seizure.

That the use of polluted drinking water — polluted by the
dangerous defilement of soakage from the water-closet — by the
household of this farmhouse had much to do with the production
and the virulent character of this formidable, although circum-
scribed, outbreak, in many at least of the persons attacked, is in
accord with other well-examined observations of a similar nature,
and cannot but be accepted. This conclusion obviously suggests a
most important practical lesson of hygienic and prophylactic medi-
cine. That there were other causal elements of mischief at work at

1868.] Notes on the Cholera Epidemic of 1865-66. 197

the same time, and other channels, besides the drinking water,
whereby the morbific poison was communicated to the attendants,
may also be fairly drawn from the history of this curious incident.
The really knotty point is how to account for the first case, that of
the wife. There had been no evidences or traces whatever of a
choleraic character or significance observed at Weymouth, either
before or during her sojourn there; nor were there any after she
left. Cholera had, indeed, just begun to manifest its presence in
Southampton, when they passed through the station on their way
to London ; but unless the atmosphere of that town be supposed to
have already become the vehicle of floating morbific germs, at a
distance, too, from the localities where the first cases of the disease
had occurred, it is difficult to imagine that the disease was contracted
there. Still, this supposition is far from being inadmissible ; nor
is the development of the disease in the first case in this history at
all so puzzling or so mysterious as in some other well-known in-
stances in which a solitary attack occurred in a district in which the
disease was not present at the time, and under circumstances, too,
which precluded the possibility of exposure, of even the slightest
kind, to infection. Tew, however, will be disposed to go so far, on
one point at least, as the Constantinople Conference, when they
assert that " it would be difficult to find a more conclusive example
of cholera contracted in one infected locality (Southampton), and
imported into a healthy spot where the disease spread exclusively to
persons who were in more or less direct relations with the sick."
With this case, the history of the visitation of the disease in
England, in 1865, comes to a close. We must now cross the
Atlantic, and foUow it to two points, far apart from each other, on
the shores of the New World .^

New YorJc. — The steamer "Atlantic" sailed from London on
October 10, with twenty-eight cabin and twelve steerage passen-

^ Great Britain was first invaded in October, 1831 ; the earliest cases occurred
on the east coast ; London was not infected until February, 1832. There was a
partial recandeseence in some parts of England in 1834 ; and in 1837 there were
two isolated outbreaks, one on board the " Dreadnought " Hospital Ship, in the
Thames, and the other in the House of Industry at Coventry, that town itself
remaining free. The second general visitation began in October, 1848, the first
cases again being observed on the east coast; the great prevalence of the
epidemic occurred in this country, as on the Continent, in 1849. In 1850 there
were some partial outbreaks in Ireland. The third visitation commenced in
August, 1853 ; some of the earliest cases occurred in London. Newcastle waa
visited with extreme violence in September. In 1854 the disease prevailed as
an epidemic. In the autumn of 1859 two or three partial and isolated outbreaks
occurred ; one at Wick, on the north-east of Scotland ; another at Glass Hough-
ton, a small village in the West Riding of Yorkshire ; and another, on a small
scale, at the coast-guard station on the Itchin river at Southampton, described
in Dr. Parkes' report in the * Eighth Report of the Medical OflScer of the Privy
Council.'

198 Original Communications. [J

an.

gers for Havre, where she remained one day and received twenty-four
additional cabin, and 540 steerage passengers. The latter came chiefly
from localities in South Germany and in Eastern i'rance. Almost
all of them had passed through Paris, which was then infected, on
their way to Havre. The presence of the disease in that port was
not known, and had, at least, not been recognised by the authorities,
at the time of the saiHng of this emigrant vessel. Later in the
year, various places on the coast of Normandy, including Havre,
were certainly infected. Some of the emigrants, while there, were
taken ill, and one woman died ; the cause of her death was not pub-
lished. The ship left the port with a clean bill of health, on the
12th, and reached New York on November 3rd. There had been
sixty cases of cholera, and fifteen deaths, during the passage. The
first death had been in a child on the very day after leaving Havre.
All the cases and deaths had occurred among the steerage passen-
gers ; not one of the cabin passengers or of the crew had suffered.
The Atlantic was kept in strict isolation at the quarantine station
below New York ; forty-two fresh cases and eight deaths, all among
the steerage passengers, occurred during the detention. The disease
did not extend beyond the infected ship. A quarantine of five days'
observation was thenceforth enforced at New York on all arrivals,
without exception, from London, Southampton, Havre, and all
Mediterranean ports; if any case of cholera had occurred during
the voyage, the vessel was, moreover, to be detained until all the
passengers were removed from her, and she was thoroughly venti-
lated and fumigated. The immunity of the City of New York, in
1865, is quoted by the Conference as a signal proof, among other
evidences, of the success of quarantine isolation as a safeguard
against the extension of the disease. The late season of the year
may probably have had something to do with the non-extension of
the disease at this time ; for next year, in spite of the same restric-
tive precautions, the enemy found its way into the city, and became
widely spread over the country. At no other point on the sea-
board of the United States, was there any manifestation of cholera
in 1865. We must go far south to one of the islands in the
Mexican Gulf to find the only other spot in the Western Hemisphere
where it found a lodgement in the course of that year.^

^ Epidemic cholera first reached the New World in 1832 j about midsummer of
that year it seems to have appeared at New York, as well as at Quebec and
Montreal. It spread over nearly the whole extent of the United States before
the end of the year : in 1833 Mexico was attacked. In 1834 there was a partial
reappearance in the United States and in Canada, Nova Scotia and New Bruns-
wick were visited for the first time in that year. In 1836 Mexico and Central
America were invaded. For the next twelve years the pestilence was absent
from the New World. In the latter part of 1848 occurred the singular event of
an outbreak on board two emigrant ships, last from Havre (which was said to be
unaffected at the time of their departure) ; in one on the sixth day, and in the

1868.] Notes on the Cholera Epidemic of 1865-66. 199

West Indies. — On the 22nd of October, 1865, cholera broke out
at Point-a-Pitre, the principal port of Guadaloupe, one of the two
West India Colonies of Prance, and situated in latitude 16° N.,
about the centre of the Windward Islands. It subsequently spread
to the town of Basseterre, and over the entire island, and proved
extremely fatal. The adjacent islet of Marie- Galante, a dependency
of Guadaloupe, also became infected. The origin of the disease has
been attributed to the arrival, on October 9tli, of a vessel, the
^'Virginie," from Marseilles, which, she left on September 3rd.
There had been no sickness, it is stated, among the crew, fifteen in
number, during the voyage of five weeks ; and tliere were no pas-
sengers on board. The first appearance of the disease in Guada-
loupe occurred fourteen days after the arrival of the ship, and
■when she had commenced to discharge her cargo, which consisted
of " matieres alimentaires.'^^ It was then regarded as a pernicious
algide fever ; " il regne a la Pointe-a-Pitre," writes the Governor,
on November 5, " une maladie qui a quelques apparences du cholera,
mais qui d\ipres tons les hommes competents est une fievre palu-
deenne, la fievre pernicieuse algide. Elle est attribuee exclusive-
ment aux miasmes qui se degagent des marais avoisinant la ville,
miasmes developpes extraordinairement par la persistance excep-
tionelle des pluies et la hauteur presente des marees." Ere long,

other on the twenty-seventh day, after leaving Europe. " The circumstances
attending the nearly simultaneous appearance of the disease in two vessels
traversing the Atlantic, and about a thousand miles apart, are among the most
curious on record in the history of epidemic cholera. The disease did not extend
beyond the quarantine station on Staten Island at New York, after the arrival
of the infected ship there ; but at New Orleans it seems to have spread not only
in the hospital, but also in the city generally, although it did not exist at the time
in any other part of the United States." (' British and Foreign Medico-Chirur-
gical Review,' October, 1865, p. 444.) The city of New York was not attacked
till the following midsummer, when the disease was already widely spread over
the country. In 1850 the disease was present in Mexico, and also in some of the
northern regions of South America ; in 1851, and again in 1852, there was a
partial reappearance of it in Canada and in the United States. Towards the end
of 1853 it was present in New York and in New Orleans, besides various other
places in the country ; and in 1854 it was more widely diffused over the whole
continent. The island of Newfoundland was affected for the first time that year.
In 1857 the disease prevailed in Central America, reaching in the course of that
year to the Pacific shores of that region.

* The Constantinople Conference state that it has been suspected that it was
not the "Virginie" from Marseilles, but a vessel, " Sainte Marie," which left
Bordeaux on September 15, and reached Guadaloupe on October 20, that im-
ported the disease. Cholera did not exist in Bordeaux at the date of departure ;
but it was alleged that some of the crew had come from Marseilles ; also, that the
earliest cases in Guadaloupe occurred in washerwomen, who had washed the
clothes of the crew of the " Sainte Marie." Both these statements were after-
wards disproved. •' Whatever may have been the channel of importation, it is
not the less true — and this is the capital fact — that the cholera broke out at Gua-
daloupe only after the arrival of a vessel from an infected country."

Several vessels from Marseilles had previously arrived at Martinique, St.
Thomas, and Cayenne ; but without any traces of cholera being imported into
any of those colonies.

200 Original Communications. [Jan.,

all doubts as to the nature of the malady ceased. The epidemic
continued in Guadaloupe till the following spring or early summer.
Upwards of 10,000 deaths, it has been said, occurred among a
population of 149,000.

In the second or third week of November, five men from Marie
Galante landed at Dominica ; two were ill with cholera at the time,
and one of these men died ten, and the other twenty, hours after
landing. A strict isolation of the place where the men abode was
maintained, and no other cases occurred. None of the other West
India islands, nor any place throughout the whole Mexican Gulf,
manifested any traces of infection in 1865. It was not till the
following year that any extension of the disease in this region of
the world occurred.^

In another article I hope to follow up the preceding narrative of
the leading events in 1865 by a sketch of the geographical history
of the epidemic in 1866-67. Without seeking at present to draw any
general conclusions respecting the apparent laws of the development
and spread of the disease in different lands, or as to the results of
those measures of medical police which are mainly trusted to in most
countries for its exclusion and arrest, I would only remark that all
must perceive, from what has been already stated, how scanty and
imperfect our authentic information really is in regard of the origin
and movements of the pestilence, in very many of the places where
it appeared in 1865. Often it is impossible to determine the date
of its first manifestations, and the steps of its early progress ; and
yet the accurate knowledge of these very points must be the foun-
dation of all sound etiological reasoning. There is more than one
cause for this common source of difficulty. Besides the general
indifference on the part of governing autliorities everywhere about
matters of public health, there is a universal unwillingness to
acknowledge the existence of any distemper, the open recognition

* The history of the course of epidemic cholera in the West Indian archipelago
presents many points of interest. Cuba was invaded as early as 1833, and it pro-
bably continued to be infested with the disease for two or three years subse-
quently. The next visitation there is supposed to have been in 1848-49. None
of the other West India islands suffered until the end of 1850, when Jamaica was
attacked for the first time. The rest of the group, including all the Windward
and Leeward Islands, and also the Bahamas, remained exempt for the next two
or three years, when (with the exception of Antigua and possibly of two or three
others) most of them were smitten. Cuba had for several years never been entirely
free. 1854 was the year of the widest extension of the epidemic; together with
many other islands, Guadaloupe suffered that year. In 1855 the Spanish island
of Porto Rico was attacked for the first time. The disease was also to some
extent in St. Kitt's and in Jamaica during the spring and summer. In 1856
Porto Kico continued to suffer; and the islands of St. Thomas andof Cura9oa, as
well as British Guiana, were attacked. The disease lingered in Guiana in 1857
and also in 1858. The West India Islands seem to have been exempt during
these years ; nor, as far as I am aware, was there any recurrence of the pesti-
lence in them until 1865. Our knowledge however of epidemiological phenomena
in that region is far too scanty to warrant any confident assertion on this head.

1868.] Stewart on Amyloid Degeneration. 201

of which carries with it many serious restraints^ inconveniences, and
losses to the aifected community. So notorious is this reluctance
in some countries of Europe — whatever be the motive or motives of
their conduct — that no one looks for any faithful intelKgence respect-
ing the first appearance of an unusual sickness in their midst ;
e. g. in Spain, Portugal, Papal States, &c. The readiness, too, with
which medical men are prone to accept and make use of evidence,
however loose and meagre, when it seems to accord with the views
which they have adopted, adds not a little to the other difficulties
encountered in exploring a confessedly obscure branch of scientific
inquiry ; and it is much to be regretted tliat so voluminous a public
document as the Eeport of the late International Conference is
anything but free from this blemish. Until the exercise of a far
stricter Mogic of facts' be our invariable rule of conduct in the
investigation of epidemiological problems, but little progress can be
expected to be made in their real solution.

Art. II.

On Hemorrhage from Waxy or Amyloul Degeneration. By T.
Grainger Stewart, M.D., P.E.S.E., Pathologist and Extra
Physician to the Eoyal Infirmary; Physician to the Royal
Hospital for Sick Children ; Lecturer on General Pathology,
Edinburgh.

EoR some years past I have noticed that haemorrhage from the
stomach and intestine occurs in cases of waxy or amyloid degenera-
tion, and that independently of ulceration of the mucous membrane.
I have thus been led to look into tlie literature of the subject, and
inquire among professional friends as to their observations. The
results of these inquiries are the following :

My colleague. Dr. Sanders,^ showed in 1852 that, "in a well-
marked example of waxy spleen with transparent Malpighian bodies,
a great number of these were found filled with blood recently extra-
vasated, giving the fresh section a peculiar dark-spotted appearance.
The effusion was limited to the Malpighian bodies, and preserved
their shape. No extravasation occurred elsewhere in the spleen or
other organs."

Dr. Wilson Pox^ recorded in this journal a case of purpura,
with waxy degeneration. The patient was a man aged 33, who, in

1 ' Proceedings of the Physiological Society of Edinburgh/ 1852.

' ' British and Foreign Medico-Chirurgical Review,' Oct., 1865, p. 480.

202 Original Communications. [Jan.,

November, 1864, contracted syphilis, which was followed by con-
stitutional symptoms, and was treated by means of mercury and
iodide of potassium. Early in May, 1865, a painful purple rash
appeared on the inside of the thighs, and in the middle of the month
a similar rash appeared on the face. On admission to University
College Hospital he was weak, feverish, irritable ; there were nu-
merous patches of extravasated blood on the skin of different parts
of the body. The gums were coated with a reddish sordes, and
the blood contained an excess of white corpuscles. A few days
later large vesicles filled with discoloured serum were seen in various
parts, and portions of skin assumed a dark purple hue. A soft
blowing murmur was heard over the heart, loudest at the base.
Although under appropriate treatment," the tendency to purpura
diminished, the strength gradually became exhausted, and he died a
week after admission. During this time the urine was acid, con-
tained no albumen nor any trace of blood. On post-mortem exami-
nation numerous points of extravasation were found in the skin, the
muscles, and the subserous and submucous tissues. Close to, but
not at those points, amyloid degeneration of the small vessels was
found, and the muscles themselves in certain parts presented the same
character. There were some other points not, however, essential
to this paper. In commenting upon this most interesting case.
Dr. Wilson Tox remarks, as to the question of the relationship of
the diseased capillaries and the haemorrhage, as follows : — " A
direct association of the two changes will probably be con-
sidered doubtful by many who know that lardaceous degeneration of
the tissues is rarely, if ever, associated with haemorrhage; and,
further, that the change in the parenchyma of organs thus affected,
and also in mucous membranes is often preceded by a similar change
in the small vessels. The evidence as it stands at present is
decidedly against such a theory of causation, and the following
hypotheses can only be stated as queries: — 1. May the larda-
ceous degeneration which we know chiefly as a chronic disease
occur occasionally in a more acute form ; and in this manner so
rapidly alter the elasticity of the vessels before their diminished
calibre can have retarded the flow of blood in the part that rupture
and haemorrhage ensue ?

" 2. Is it possible that this lardaceous or waxy change, occurring
only in tracts of tissue, may throw such a strain upon the collateral
capillary circulation of tissues around, that adjacent but comparatively
unaffected capillaries give way ?

"3. Is it possible that the waxy change in the capillaries may
pass, as it often does in other tissues (liver, kidney, muscles), into a
softer and more granular condition, which, when affecting the coats
of vessels, may lead to their rupture in the same manner as it causes
that of the voluntary muscles ?"

1868.] Stewart on Amyloid Degeneration. 203

M. Hayem,^ in an elaborate paper on the amyloVd degeneration
of the intestine, remarks that the principal symptoms produced are
diarrhoea and haemorrhage. After referring to the former, which, as
is well known, is generally present, he states that he has met with the
latter in two cases, both of which had reached the second stage, viz.
that of ulceration, or erosion of the mucous surface ; and he referred
the haemorrhage to rupture of the vessels surrounding the follicles.

Dr. Inches, of St. John's, N.B., informed me that, while acting
as resident-physician to the Charity Hospital in New York, he ob-
served in many cases of constitutional syphilis that dysenteric diarrhoea
appeared in the later stage of the disease, but unaccompanied by the
characteristics of inflammatory dysentery.

Dr. Warburton Begbie informed me that he has observed haemor-
rhage from the kidneys occur in a case of waxy degeneration of these
organs, and that he was inclined to ascribe the haemorrhage to the
degeneration, but had not been able to satisfy himself upon the
point.

It thus appears that haemorrhage has been observed accompanying
the waxy degeneration in the spleen, in the skin, in mucous and
serous membranes, in the suhstance of muscles, in the mucous mem-
brane of the intestine, and perhaps in the kidney.

With regard to the spleen, my own observations amply confirm
those of Dr. Sanders, and they show besides that haemorrhage more
extensive, and not confined to Malpighian bodies occasionally occurs
round affected vessels. Such hajmorrhages are met with both
recent and of old standing. I have seen them forming fawn-coloured
spots of a quarter of an inch in diameter, distributed in considerable
numbers throughout the organ.

With regard to haemorrhage from mucous and serous surfaces,
and into skin and muscle, Dr. Wilson Fox's observation remains, so
far as I know, unique, and it appears to me better not to attempt to
found much upon it at present.

The haemorrhage from the kidneys observed by Dr. Begbie I
have not seen during life, and only now and then have observed
traces of more or less altered blood in the renal tubules. I pass
by this subject also, merely commending it to the attention of the
pathologist and the physician, and proceed to consider the haemorrhage
from the stomach and intestine. In doing so I shall first narrate a
few illustrative examples, and afterwards indicate the conclusions to
which these and other cases have led me.

Case 1. — M. A. J — , aet. 30, was a wandering beggar, had
had syphihs, and said that she did not remember ever to have been
strong and healthy. She was admitted to the Eoyal Infirmary on

1 ' Comptes Rendus tie la Soc'iete de Biologie,' 1866. ' Gazette Medicale,' 6, 1866,
' Biennial Report of New Syd. Soc.'

204 Original Communications. [Jan.,

January 21, 1866. She had not menstruated for several years,
and her weakness had been increasing up to the time of her admis-
sion. She complained of cough. The physical signs in the chest
were not very distinct, but the symptoms of phthisis were well
marked. The urine was rather copious, of sp. gr. 1014, of a light
amber colour, and contained much albumen, with a few finely granular
tubecasts. She had much diarrhoea ; the motions, at first watery,
were ultimately of a black, tarry colour ; this was referred to the pre-
sence of blood in the fseces. She died exhausted on February 14th.

Autopsy. — The body was emaciated. There were traces of syphilitic
ulcers in the vagina. Both lungs contained a considerable amount
of tubercular (or perhaps syphilitic) deposit, little at base or apex,
much in the middle part. The pleurm were adherent. The heart
was natural. The liver was large and waxy ; both cells and vessels
affected. It contained no syphilitic cicatrices or deposits. There
were remnants of an hydatid cyst. The spleen was connected to
neighbouring organs by many fibrous adhesions. Its vessels, but not
its Malpighian bodies, were waxy. The kidneys were in the third
stage of the waxy degeneration. The uterus and bladder were
natural. The intestines were extremely waxy. The epithelium
remained firmly attached to the surface of the villi, was markedly
translucent, and on the application of iodine assumed the charac-
teristic reddish colour. The small arteries were also waxy. The
mucous membrane of the bowel was coated in many parts, both in the
small and large intestines, with a layer of brownish-red matter, which
adhered in some parts loosely, in some firmly, to the surface, and
which, though mostly on tlie free surface, was here and there to be
seen within the membrane, particularly in the villi. This matter
was ascertained in some parts to consist of altered blood, and
nowhere did it exhibit any reaction with iodine. There was no
ulcer, nor trace of ulceration in the bowel.

Commentary. — In this case there was along with the symptoms of
waxy kidney a copious diarrhoea, at length distinctly bloody. At
the post-mortem examination no explanation was found of the one
or the other, excepting the waxy degeneration, while the traces of
recent hsemorrhage from the degenerated surface and in its substance
were remarkably distinct.

Case 2. — T. B — , a^t. 33, a carter, was admitted to the Uoyal
Infirmary, under my own care, March 1, 1867. Had been a man
of intemperate habits, and afi'ected with syphilis. About two months
before admission had an attack of diarrhcea, which gradually sub-
sided. Prom increasing weakness he was obliged to give up work
in the middle of January.

On admission, he had considerable fever, passed large quantities
of slightly albuminous urine, often tinged with bile. He frequently

1868.] Stewart on Amylo'id Degeneration. 205

vomited coffee-ground matters, and had very severe diarrhoea, always
of a black, tarry colour, sometimes interspersed with blood, occa-
sionally even clots ; he had repeated attacks of aphthous ulceration
of mouth and throat which yielded to treatment, but the hsemorrhage
and diarrhoea gradually wore him out, and he died exhausted. May
22nd.

Autopsy. — The body was much emaciated. The heart was natural.
The pleurse were not adherent, but about the middle of the right
there was some recent lymph. Throughout both there were nodules
of various sizes, from that of a cherrystone to that of a walnut.
They were about eight in number, and most abundant in the upper
half, though not specially towards the apices. They were opaque and
cheesy in the centre, exhibited no traces of softening. The margins
were more translucent, and of a darker colour. Microscopically
they were found to consist of fatty and granular matter, with small
cells or nuclei. The bronchi were natural. There was no peri-
tonitis nor ascites. The liver was enlarged, and extremely waxy ;
it weighed 8 lbs. 11 oz. In the centre of the lobules there was a
good deal of yellow pigment in the cells. The greater part of the
lobule was waxy, and there was very little fatty degeneration.
The spleen was enlarged ; it weighed 1 lb. 6 oz. Its smaller arteries
and Malpighian bodies were waxy. Into many of them hsemorrhage
had taken place. Throughout its substance there were further
numerous white tubercle-like nodules, some single, smaller than a
millet-seed, others compound, and forming masses of the size of a
raisin. Successive stages were recognised, and the smaller were
found to be formed by the deposit of whitish matter within the mal-
pighian bodies. This matter was composed of cells or nuclei similar
to those seen in the lung. The Tcidneys were enlarged in the second
stage of the waxy form of Bright^s disease, with considerable fatty
degeneration of the epithelium of some of the tubules. The
stomach was waxy. The villi and arteries of the small intestine
were also waxy. The large intestine contained slight traces of old
ulcers, and was throughout in an extreme state of waxy degenera-
tion. The upper part of the large and some portion of the small
intestine were coated with a layer of reddish-brown or fawn-
coloured matter, which adhered at some parts firmly, at some
loosely to the surface. The brain was somewhat atrophied, other-
wise natural.

Commentary, — In this case the gastro-intestinal symptoms were
very severe, but at the post-mortem examination no lesion of the
tract was found, excepting the advanced waxy degeneration. The
recently effused blood forming a layer on the surface of the mem-
brane showed that the hsemorrhage had not taken place from any
individual point, but from a great part of the tract at once. There
were traces of old ulcers — but only traces — in no way fitted to account

206 Original Communications. [Jan.,

for the haemorrhage. One of the singular features of the case was
the marked fever which existed throughout.

Case 3. — E. H — , hawker, set. 26, was admitted to the Royal
Infirmary on the 15th December, 1866. Three weeks before ad-
mission he had had an attack of vomiting and purging ; the vomited
matter and motions were black. On examination there were signs
of pleurisy, with feeble respiration. Heart was natural. Urine
could not be obtained for examination. She complained of pain in
the epigastrium about ten minutes after taking food, occasionally
vomited blood, and passed dark blood and tarry matter by stool.
She had previously had one or two fits. These recurred occasionally
from December 16th to 18tli. Bloody vomiting and purging con-
tinued throughout. She died on December 21st.

Autopsy, — The body was emaciated. Tlie skull cap was natural.
The brain was somewhat cedematous. The heart was natural. The
lungs were partially adherent. At other parts the surface was
toughened with a thin layer of lymph. The lungs were cedematous.
The liver was waxy. The spleen was also waxy. Many of the
Malpighian bodies contained extravasated blood. The kidneys were
intensely waxy, small in size, the degeneration far advanced. There
was no trace of ulceration in the stomach or intestine, but through-
out their whole extent there was advanced waxy degeneration, and
the surface of the membrane was coated with reddish-brown matter,
apparently altered blood.

Commentary. — The vomiting and purging were in this case so
severe as to suggest to the physicians in attendance the idea of
irritant poisoning. The post-mortem examination fully cleared up
the case, and showed it to be identical with the others here recorded.
As her kidneys were in an advanced stage of the waxy form of
Bright's disease, it is apparent that the fits were ursemic. And
there was little doubt from the history that the poor girl had been
the subject of constitutional syphilis.

Case 4. — A. M — , a shoemaker, has been under my observation
as a case of waxy liver, spleen, and kidneys, since 1859. He has
at times been affected with diarrhoea and vomiting, occasionally
bloody. The first time that such an attack occurred was in February,
1861. During the year which followed he occasionally passed by
stool blood red and altered, and his bowels were very frequently loose.
After a time these symptoms disappeared, but in 1864 I find a note
that on several occasions he had intense diarrhoea, sometimes bloody,
and that he vomited bloody matters. On September 22, 1865, he was
seized with vomiting of bile and clotted blood, and he passed black
tarry matter by stool. Soon again his bowels became constipated,
and his general health improved. When I last saw him he was

1868.] Stewart on Amyloid Degeneration. 207

considerably better, bad not had haemorrhage from the bowels or
stomach for many months.

Commentary. — Of the existence of the waxy degeneration in this
man there can be no doubt ; but we cannot positively say that the
intestinal tract has been affected. The diarrhoea and haemorrhage,
hoAvever, so closely resembled that which occurred in association
with that lesion in other cases, that it appears to me very reasonable,
in the absence of evidence of any other cause, to ascribe it to this.

The conclusions which seem warranted by the facts I have ob-
served in connection with this subject are —

1. That haemorrhage is not a very infrequent consequence of the
waxy or amyloid degeneration of vessels.

2. That, next to the spleen, the intestinal tract is the most com-
mon seat of such haemorrhage.

3. That the haemorrhage occurs independently of any visible
ulcerative process.

4. That it probably depends upon rupture of the capillaries at
the affected parts.

5. That waxy or amyloid degeneration of the liver does not of
itself suffice to induce haemorrhage from the bowels.

6. That the haemorrhage occurs in cases in which the liver is free
from waxy degeneration. >

7. That the occurrence of haemorrhage increases the danger of
the patient. But,

8. That sometimes it comes and goes for years without markedly
depressing the vital powers.

In regard to treatment, I may add that, so far as I have yet seen,
the diarrhoea and haemorrhage appear to be better controlled by
sedative and astringent enemata than by any other means.

208 Original Communications. [Jan.,

Art. III.

Miscellaneous Contributions to the Study of TatTiology. By Joim
W. Ogle, M.D., Physician and Lecturer on Pathology, St.
George's Hospital.

Having from time to time during the last two or three years
collected material from our hospital books for clinical and patho-
logical lectures, I propose in this series to place on record some of
the cases from that source which have furnished me with a basis for
my lectures.^ I shall also incorporate with them a few other cases
which have come under my own notice bearing on the subject in
hand, and append allusions to any cases from other quarters which
may appear specially illustrative of it. The instances of chorea
which I have placed in Chapter the First I had already prepared and
intended to have supplied (now nearly a year ago) to this Eeview, but
postponed them on ascertaining that my friend Dr. Tuckwell, of
Oxford, was engaged upon the observations which, in connection
with the interesting case of fatal maniacal chorea, were published
in the number for October last.^ I propose to add, by way of
short notes upon the individual cases, such observations as each one
may suggest, and at the end of the chapter comment upon them
as a whole.

CHAPTER I.

Remarhs on Chorea Sancti Viti, including the History, Course, and
Termination of Sixteen Fatal Cases, and also certain details of
Out-patient and other Cases which tvere not fatal.

Case 1. — Chorea ; pregnancy ; fibrinous dejposits on the hearths

valves.

Anne G — , eet. 23, pregnant, was admitted July 21st, 1841, with
chorea, which had been brought on by a fright. She was confined.
No further particulars are recorded, except that she died August
30th.

Post-mortem exatnination. — Cranium. — Pia mater much congested,
especially over the cerebellum ; brain much congested ; its ventri-
cles of natural size, containing only a shght amount of fluid.

Spinal cord healthy ; intra-vertebral veins very congested.
Whole of brain and spinal cord rather softened, but this probably
owing to great heat of temperature.

^ The cases which I have prepared for this series are cases of chorea, of fatal
tetanus, and of fatal poisoning.

' I shall append to this chapter the details of a chronic but severe case of
maniacal chorea in a pregnant unmarried girl, which not long ago came under my
care at the hospital.

1868.] Ogle's Cases of Fatal Chorea. 209

Thorax. — Heart's walls softened ; the tricuspid valve had, on its
segments, several soft fibrinous granulations, easily removable.

Abdomen. — The right kidney was wanting, but the corresponding
supra-renal capsule was in its natural position ; the bladder had only
one urethral aperture ; the uterus was contracted to the size of a
foetus' head.

Remarks. — As points worthy of notice in the history of this case,
I would draw attention to the pregnant condition of the patient, and
to the fright which she experienced; both being circumstances gene-
rally acknowledged as frequently instrumental in the causation of
choreic affections. Amongst the anatomical characters presented
after death worthy of consideration were the congestion of the nerv-
ous centres, and the condition of the heart's valves. The softening
of the spinal cord need not be looked upon as other than a result
of post-mortem change. The absence of the right kidney, though
of course without any possible connection with the disease which
the patient suffered from, is a fact worthy of notice^ (149) .

Case 2. — Chorea ; congestion of the brain; unusual amount of faecal
accumulation in and adherent io the intestines.

Emma L — , a maid-servant, set. 17, was admitted November 16th,
1842, with violent chorea, which had been coming on gradually for
the previous fortnight. The catamenia had been absent since
August, but then was scanty. She had not been frightened and no
cause of the disease could be given. The pulse was quick and the
tongue coated, and thirst was complained of. She had had no me-
dicine excepting some purgative pills. Two three-grain doses of
calomel, followed by a dose of senna, were given, and a warm bath
ordered. As on the next day the bowels had not been opened, the
calomel and senna were repeated, also the warm bath. Two days
after admission the pulse was more feeble and quick. She was
quieter, though she had had no sleep, and been very violent in the
night. A large-sized evacuation had followed the enema. The
choreic movements rather quickly ceased, and she became coma-
tose, and died in the middle of the following night.

Post-mortem examination. — Cranium. — Great congestion of the
vessels of the brain existed ; there was slight serous effusion at the
base of the brain, and the outer parts of the brain were much darker
than usual ; the bloody puncta in the white parts were much more
numerous than natural ; ventricles of natural size. No other morbid
appearance.

Spinal canal. — Congestion of the posterior vertebral veins
existed ; and slight effusion of serum in the theca vertebralis ; the sub-
stance of the spinal cord was congested. No other morbid appearance.

Thorax. — The right side of the heart was gorged with blood, and

' We have the history of several cases in onr hospital records, in which ahsence
or malformation of a kidney existed.

81~XLI. 14

210 Original Communications. [Jan.

slight hypertrophy of the left ventricle existed ; the lungs were ad-
herent to the chest walls. No valvular disease.

Abdomen. — The small intestines from the jejunum to the ileo-csecal
valve were filled with faeces, very tenacious, and in many parts so ad-
herent to the bowel as only to be removed with much difficulty ; the
large bowel also was filled with faecal matter ; the lining of the caecum
and ascending colon very congested; the peritoneum everywhere
was very congested ; the uterus and ovaries were unusually large j^ the
former very congested, as also the vagina; the ovaria containing
several cysts.

Remarks. — In this case, which followed a very rapid course, there
appears to have been no history of fright or of rheumatism ; neither
were the heart's valves found after death to have been affected.
Amongst the noticeable post-mortem appearances are the congestion
of the brain and spinal cord ; the remarkable loading of the small
bowel with faecal matter, unusually adherent as it was to its walls ;
also the loading of the large bowel, which was congested ; also the
congestion of the peritoneum and of the uterine organs (75).

Case 3. — Chorea ; diseased clavicle ; fibrinous deposits on the hearths
valves ; fceces adherent to the colon.

Mary K — , aet. 15, was admitted. November 6th, 1844. She
had enjoyed good health until twelve years of age, when before one
of the catamenial periods she was attacked by chorea, commencing
gradually and becoming severe, at first affecting one side chiefly,
then becoming general. The movements ceased during the night.
She was often drowsy, and felt pain across the forehead. The ab-
dominal organs appeared to be natural. She got well in two
months by taking tonics, purgatives, and sedatives. About two
months afterwards she had a second severe attack, preceded by
drowsiness, and recovered under the same remedies. The catamenia
then appeared, were regular for eight months, and the girl enjoyed
good health. Afterwards menstruation became irregular, and finally
ceased ; and after tiiree months the involuntary movements returned.

She came into hospital with shght chorea, which increased, coming
on in paroxysms, leaving great exhaustion. She died, quite worn
out, November 24th. Before death she complained of pain like
rheumatism about the left wrist and the right side of the chest.

Post-mortem examination. — Cranium. — The brain was wet, other-
wise it was natural.

Spinal canal. — The veins of the cord were much congested, other-
wise the cord was quite natural.

Thorax. — The clavicle was denuded of periosteum, having an
abscess under the pectoral muscles in connection with it ; the lungs
were condensed ^osienorXy', fringes of fibrine-coagulum were found
on the auricular side of the initral valve curtains.

Abdomen. — Much light-coloured faeces were found adherent to

* Much larger than in those who have home children.

1868.] Oglt^'s Cases of Fatal Chorea. 211

the inner surface of the colon, otherwise the abdominal contents
were natural ; the generative organs were vascular.

Remarh. — In this case the recurrence of the maladj three times
(with distinct intervals) is to be noticed ; the two first attacks, at
any rate, appearing to have some definitive relation to the uterine
functions ; also the headache and tendency to drowsiness, and after
death the congestion of the spinal cord; also the condition of
the heart's valves. The abscess about the clavicle appears to have
been unnoticed during life (258).

Case. 4. — C/iorea ; congestion of the brain ; fibrinous deposits on
the hearths valves.

Mary H — , set 26, a married woman with two children, the
youngest being set. 4, was admitted January 8th, 1845. She had
complained of pains in the head since her last confinement ; shortly
afterwards she had twitchings and jactitations of the left side, gene-
rally not severe, but sometimes so sudden as " to take her off her
legs.'* The movements were worse when the headache was bad, and
also worse when recumbent. She had had rheumatic fever two months
previously and recovered, and about ten days afterwards she was
suddenly thrown down in the park by sudden jactitations on the
right side of her body. These then gradually affected the other
side of the body and increased.

Some days before admission she had had no sleep, and had
dysphagia. For a long period she had had hsemorrhage for a week
at a time every fortnight.

When admitted the face was flushed and hot ; jactitations were
violent all over the body equally, and she could hardly, speak or
swallow. She was quite sensible, and complained of pain in the
head ; the pupils acted readily ; the pulse was frequent, but almost
imperceptible. The tongue was coated ; the bowels open.

Fetid gums were ordered, and ordinary diet and porter given.

On the day following pain in the head was very bad. Calomel
and opium were given every four hours, and a turpentine enema
administered; the head was shaved and ice applied. The bowels acted
twice after the injection. She slept in the night a quarter of an
hour, and then the jactitations ceased; they again came on when
she awoke. The calomel and opium were repeated.

On the 10th the pulse was 140 ; she slept in the night, and on
the following morning (the 11th) she was noticed to be drowsy.
The calomel and opium were omitted ; she became exhausted, and
the pulse much slower and weak. She sank and died the same day.

Post-mortem examination. — Cranium. — The scalp vessels were
gorged with blood, as also the meningeal veins. The cerebral mem-
branes were healthy. The grey substance of the brain was dark,
and the puncta large and numerous. The pons Varolii and medulla
oblongata were very congested. Their substance was firm.

212 Original Commurdcations. [J

an.

Thorax. — The. lungs were congested posteriorly. Slight Jibrinous
deposit existed round the mitral orifice of the heart on the auricular
surface.

Abdomen. — The uterus was large and hard, and its cervix could
hardly be cut, but no scirrhous deposit was met with. The neck and
lips of the uterus were much, but superficially, ulcerated. Extra-
vasated blood existed in the ovaries, in cysts.

The other organs were healthy.

Remarks. — Notice in this case the pains in the head, to which
treatment was directed, the existence of dysphagia, and the previous
existence of rheumatic fever. After death the congestion of the
nervous centres (the spinal cord unfortunately being not examined),
the state of the hearths valves, and the condition of the uterine organs
are noticeable (10).

Case 5. — Chorea; areolar tissue inflammation and erysipelas;
abscess of the mediastinum, and empi/em.a.

Anne M — , aet. 17, was admitted October 15th, 1845. Six or seven
months previously she had had a fright, which deprived her of move-
ment or speech for a quarter of an hour, and afterwards she had
symptoms of chorea, with twitching of the muscles of the face and
upper limbs. Catamenia absent ever since. She had ascarides.
There had been no previous attack of chorea.

On admission the face was flushed, the movements very trouble-
some ; the hearths sounds were natural, but its action was quick ;
breathing natural but hurried.

Iron and purgatives were given, and morphia subsequently to
procure sleep.

A swelling existed on one of the wrist-joints from frequent move-
ments, and there was soreness of the back and limbs. The symp-
toms of chorea were almost instantly relieved by a water-bed follow-
ing a warm bath, but she complained of a " pricking pain" at the
heart, and a loud bruit came on with both cardiac sounds — at the
apex loudest with the first sound, loudest at the base and downwards
towards the aortic valves with the second sound.

Calomel and opium, and afterwards quinia and belladonna, were
administered.

October 31st. — It was noted that the chorea had almost ceased,
the chest symptoms increasing. Dyspnoea was oppressive; there
was short cough, and expectoration; the pulse was irregular and
quick; the fingers almost constantly flexed, thumbs drawn into
the palms.

November 3rd. — So weak as to require stimulants.

5th. — The hearths bruit had disappeared, but the left side of the
chest was dull, and not rising on inspiration. She became worse and
dyspnoea increased.

7 th. — ^Erysipelas of the ankle set in, and she became weaker until

i»68,J Ogle's Cases of Fatal Chorea, 213

she died ; a slight return of chorea came on two days before death,
which occurred November 12th.

Post-mortem examination. — Sloughs on the surface, and erysipelas.

Thorax. — An abscess was found in the anterior mediastinum, and
pus in the left pleural sac. The lungs were compressed, and without
air. The heart was healthy in all respects.

Cranium. — The brain was natural.

Spinal column. — Much fluid existed in the arachnoid cavity of
the spinal cord ; otherwise the cord was natural. A small abscess
existed in connection with an intervertebral cartilage just below the
diaphragm.

Remarks. — Notice in this case the fright as the assigned cause,
and absence of catamenia since the commencement of the attack.
The abscess of the mediastinum and the empyema were probably of
pysemic origin, and connected with the bed-sores. Unfortunately,
the wrist-joints were not examined after death. The disappearance
of the cardiac murmurs must not be disregarded (261).

Case 6. — Chorea; liability to rheumatic fever ; old pericarditis; fibri-
nous deposit on the heart's valves. Softening of the spinal cord.
George S — , set. 19, was admitted June 27th, 1850, unable to
stand or walk. It was stated that he returned from work on the
20th complaining of pains in the knees, which had since then
swelled. He had had several attacks of rheumatic fever since he
was twelve years old. On the 24th involuntary movements of the
hands and legs had begun, and had increased ever since. On ad-
mission the movements were very decided, but not very frequent
or severe, and there was a vacant and painful expression of face.
The heart's action was excited and its sounds nowhere very distinct ;
a well-marked bruit existed at the point where the apex was felt
beating. The urine was very loaded, bowels relaxed, tongue whitish.
He was ordered half a grain of tartar emetic every four hours, under
which the movements became much controlled. He put out his
tongue without much difficulty, but the painful, almost sardonic,
countenance continued. On the evening of the 30th he became
more restless, and at times delirious ; he answered questions with
more difficulty, and the choreic movements became more frequent.
He had to be placed on a water-bed to prevent the evil efi'e.cts of
friction. Calomel and opium were given, but he became worse, and
would at times almost jerk himself out of bed. For two days he
was passing his evacuations involuntarily. He quickly emaciated,
and sank and died July 4th.

Post-mortem examination. — Cranium. — The sinuses of the dura
mater and the cerebral and meningeal vessels were full of blood.
The brain was tolerably firm throughout, but very congested, the
^^puncta vasculosa" being very large and many. The ventricles
were nearly empty.

214 Original Communications. [Jan.,

Spinal canal. — The spinal veins were very distended with blood.
The whole spinal cord was rather softer and more moist than natural,
and opposite the third or fourth upper dorsal vertebrae it was com-
pletely broken down and almost diffluent.

Thorax. — The pericardium was universally and firmly adherent.
The left ventricle of the heart was firmly contracted ; its other cavi-
ties contained small coagula. The margin of the left auricido-
ventricular opening was fringed with a row of beads offirmfibrine.
The other valves were healthy. Both lungs were loaded with blood,
and their bases contained patches of haemorrhage.

Abdomen. — The various organs were natural.

Remarks. — Observe the tendency to rheumatic fever, and the ex-
istence of the cardiac bruit, also the delirium. Among after-death
appearances the softening of the spinal cord, the state of the heart's
valves and of the pericardium, and the hsemorrhage into the lung are
to be noticed (113).

Case 7. — Chorea ; apparent softening of portions of the spinal cord.

Mary W — , set. 17, was admitted with chorea November 24th,
1855. She was emaciated, and had never menstruated. She had
been quite well until five or six days previously, when she expe-
rienced slight jerkings of the limbs, which gradually increased in
frequency and severity. There was no history of any fright, and she
had never had any "fits.''' Her complexion was flushed. The
tongue was moist and fissured. The pulse was fuU and soft, and
the skin warm. At times the jerking was absent for a period of the
day, but returned at night. She was perfectly rational. Morphia
at night was prescribed, and four grains of sulphate of zinc every
six hours, which was subsequently increased. Two days after ad-
mission she was talking incoherently and in a hysterical manner, and
she refused to take medicines. She became exhausted by the constant
jactitations, and chloroform was exhibited, which speedily acted,
and for a time quieted her; but the movements again returned,
and the chloroform was again required.

At 10 a.m. on the 28th she became stertorous and the breathing
hurried ; absence of all movements ensued, and she sank and died in
two hours.

Post-mortem examination. — Cranium. — The bones were natural,
and the brain and its membranes were quite healthy.

Spinal column. — The bones were natural; the central parts of
the dorsal and the upper parts of the cervical portions of the cord
appeared to be somewhat softer than they ought to be ; otherwise
nothing of note was found.

Thorax. — The heart and lungs were healthy.

All the other parts of the body were natural.

Remarks. — In this case there is no mention of fright as a sup-
posed cause. The catamenia were defective. The case illustrates

1868.] Oqlti's Cases of Fatal Chorea. 216

the relationship of the affection to, or its coincidence with, hysteria,
and to a certain degree the periodicity which pertains in some instances.
The sudden stertor which came on, and after death the softening of
the spinal cord, are to be observed ; also that the brain was natural
(309).

Case 8. — Chorea ; abscesses beneath the integument.

Mary A. E — , set. 7, was admitted with chorea, October 10th,
1860. She was a delicate-looking child, and very irritable, and had
always been considered nervous and excitable.

Three weeks before admission she had been pushed into a ditch
and greatly frightened. She remained greatly excited, and ten days
afterwards she became affected by choreic movements in the limbs of
both sides ; the speech also became embarrassed. The bowels had been
confined. The tongue was furred. The sounds and impulse of the heart
were natural. An enema was administered, and antimonial wine with
nitrate of potash given in solution, and ordinary diet prescribed.

At the end of about a week nausea and vomiting were produced,
and the spasmodic movements were less violent. Sulphate of zinc
and valerian were subsequently given, but apparently without advan-
tage ; to this sulphate of iron was added. Friction of the hands
had been so great that the skin was to a great degree rubbed off,
and the hands had to be fastened down. Subsequently the choreic
movements were constant and no sleep was procured. Opium and
antimony were given every four hours; later on an abscess was
formed under the integuments of the chest, near the shoulder. This
was opened by means of poultices. Wine and bark were ordered.

At the beginning of November redness of one heel was observed,
and an abscess at that place eventually formed. The abscess on the
thorax also discharged blood, and she became very low, with sordes
on the lips. She sank and died November 6th, the choreic move-
ments having continued to the last.

Post-mortem examination. — Cranium and spinal column. — The
brain and its membranes, as also the spinal cord and its coverings,
were natural.

Thorax and abdomen. — There was a large cavity over the
pectoralis muscle, extending into the axilla from the clavicle to the
seventh rib. The lungs were very void of blood. The heart was
natural. The abdominal organs were natural.

An abscess also existed over the fibula, near the ankle-joint.

All the tissues of the body were very pale.

Remarks. — In this case a history of fright is given. The abscesses
under the integuments are to be noticed. The nervous centres were
natural (295).

Case 9. — Chorea ; death after coma and convulsions, following an
attack of scarlet {?) fever ; plugging of the carotid artery bi/\
fibrine.

Edith S — J set. 11, was admitted into the hospital October 23rd,

216' Original Communications. [J

an.

1861, with slight chorea, affecting chiefly the left side (of three
weeks' standing), which was said to have followed a quarrel in which
she was engaged. Her general health was good ; but her father had
been subject to epilepsy, and had died of aneurysm. The bowels
were much loaded, and she was purged and treated by generous
diet and stimulants. After a time fever and sore throat (? scarlet
fever) came on, but without any eruption on the surface, and was
attended by an albuminous state of the urine. An epileptic attack
came on, and death shortly followed (Nov. 29th).

Post-mortem examination. — Cranium. — The brain was anaemic;
there was no excess of ventricular fluid. The carotid artery in the
cavernous sinus, on the left side, as far as the origin of the oph-
thalmic artery, was full of firm fibrinous coagulum.

Neck and thorax. — The heart and other organs were natural,
except that the trachea was lined by soft, fibrinous exudation, the
heart's cavities being full of yellow blood-coagulum ; an abscess
existed in the neck about the cervical glands.

Abdomen. — The kidneys were large, congested, and dripping with
blood.

Remarks. — Whether the plugging of the carotid artery in this
case was the result of embolism is uncertain. Possibly some
fibrinous deposit may have existed on the heart's valves or lining,
and been overlooked ; or it may have once existed during life, and
been removed before death^ (288) .

Case 10. — Chorea following scarlet {^) fever ; congestion of the brain ;
fibrinous deposits on the heart's valves ; recent pericarditis.

Ann H — , set. 9, was admitted March 5th, 1862. She had had
chorea two years previously, following a fright, which quite yielded
to treatment ; and she went on well until November, in 1861, when she
had 'what was called scarlet fever, and since then had had pains in the
limbs and ankles, which had latterly been worse. Ten days before ad-
mission the chorea again came on, preventing sleep for several nights ;
when admitted the tongue was coated, and the pulse 76 ; urine turbid
and scanty ; a loud systolic bruit existed at the apex of the heart ;
the choreic movements were most severe, and she ground her teeth
loudly ; if the movements ceased at all she would often scream.

Purgatives, iod. of potass., bark, and morphia at night, were
ordered.

No improvement occurred, and on the 7th she passed no urine ;
on the 8th one sixteenth of a grain of strychnia was given every
six hours, and during that and the next day some diminution of
convulsions occurred, but bed-sores owing to friction began to form.
She became very low, and wine had to be given with quinine, in

' This case has been related in connection with the plugging of the carotid
vessel in the number of this Review for October, 1865 (see page 499).

1868.] Ogle's Cases of Fatal Chorea. 217

addition to morphia at night. The strychnia was omitted. The
movements became less as she became weaker, and she died March
14th.

Post-mortem examinntion. — Thorax. — The lower parts of one lung
were hepatized. The inner surface of the mitral valve flaps was
headed with recent blood-stained fihrine. Slight indications of
recent pericarditis existed.

Abdomen. — The kidneys were vascular; other organs natural.

Cranium. — The vessels on the surface and in the substance of the
brain were very full of blood ; the brain othewise natural.

Spinal cord. — Flakes of red coagulum were adherent to the side of
the spinal dura mater (supposed to be of post-mortem origin), and
the neighbouring veins very full of blood. The inside of the dura
mater was of a dull red colour, but quite smooth and shining ; the
pia mater and cord itself were natural.^ Numbers of small recent
blood clots were met with beneath the periosteum covering the
central parts of the bodies of all the dorsal vertebrse, and were seen
on removing the spinal cord.

Remarks. — •Notice the history of a previous attack of chorea from
fright, the existence of so-called scarlet fever (? rheumatic), followed
by pains in the limbs, preceding this, the second attack. Notice
also the cardiac bruit, and after death the condition of the heart's
valves, the fulness of the cerebral veins, the blood coagulum adherent
to the dura mater and beneath the periosteum of the vertebrse. The
spinal cord itself and brain were natural (71).

Case 11. — Maniacal chorea; epileptic attach. Fibrinous deposits
on hearts valves.

Mary A. M — , set. 20, and a married woman, was admitted
June 14th, 1862. She was a barmaid, and had had rheumatic fever
in the winter previous, and had been aihng subsequently. She had
also had two " fits'' since. Eor five days before admission she had had
chorea, and for three days but little sleep. When admitted she was
in an excited state, and in something like an hysterical condition, in
addition to the chorea. She was treated with zinc and valerian and
iron. These movements could for a time be partially controlled by
suitable stimulants. On the day following she became decidedly
maniacal; but after taking several quarter-grain doses of tartar
emetic, from which she vomited, she became quieter. On the next
day she was again sensible, but the choreic movements continued.
In the evening she had an epileptic attack, and again became violent.
She soon sank, and died June 17th.

Post-mortem examination. — Cranium. — The cerebral veins were
full of blood, and the grey matter of the brain very dark and con-
taining many puncta.

* This case has been related at length in the ' Lancet,' May 17th, 18G2 ; see
p. 515.

318 Original Communications. [Jan.,

Spinal column. — The cord was very vascular on its surface and in
the substance of its grey matter, but was otherwise natural.

Thorax. — Much recent fibrine existed, fringing the mitral valve
flaps of the heart, which were also much thickened. The other organs
were natural.

Abdomen. — In the ovaries were several cysts containing blood.
The cervix of the uterus was congested, and presented an appearance
thought to be from ulceration : Fallopian tubes containing pus-like
fluid.

JRemarks. — In the life history of this case notice the attacks of an
epileptic character which had existed previously, and which recurred
shortly before death ; also the hysteria-like condition in which at
one time she was. As points of pathological anatomy, the conges-
tion of the brain, the congestion of the uterus and cysts of the ovary,
as also the state of the heart's valves, are to be regarded (164).

Case 12. — Chorea ; nervous centres congested, fibrinous deposits
on the heart's valves.

Jane G — , set. 16, was admitted May 27th, 1864, having been
suffering from chorea three weeks, attributed to a fright. The
catamenia were absent two months, and during that time she had
complained of rheumatic pains and had some redness of the joints.
On admission she was very thin, having been but imperfectly fed,
owing to the chorea. Articulation Avas impossible ; respiration very
rapid, and loud rales existed in the bronchi. Wine and nourish-
ment, and morphia with tartar emetic, were ordered. The muscular
movements became more extreme, and she died in the evening of
the day of admission.

Post-mortem examination. — Cranium. — The veins on the surface of
the brain were full of blood, and the brain-substance very congested.

Spinal cord. — The vessels of the cord and its membranes were
very congested. On section the grey matter of the cord was darker
than usual, and covered with points of blood.

Thorax. — The right lung was partly hepatized. Recent fibrinous
heads existed on the mitral and aortic valve flaps of the heart, which
was otherwise natural.

Abdomen. — The spleen contained white specks of matter like
tubercles ; the kidneys were congested.

Remarks. — Notice the fright mentioned as the assignable cause,
and after death the congestion of the nervous centres, and the state
'of the heart's valves (132).

Case 13. — Chorea ; congestion of nervous centres.
Mary C — , a well-grown girl, set. 15, was admitted June 30th, 1863,
with violent choreic convulsions, affecting chiefly the upper limbs.
These movements could for a time be partially controlled by placing
the arms over the chest, and when she was steadfastly gazed at in
the eyes. The tongue was much affected, and she could only speak

1868.] Ogle's Cases of Fatal Chorea. 219

in a monosyllabic cry, which could not always be understood. The
power of swallowing was pretty good. Her expression was anxious,
and her eyes often suffused with tears. The pupils were natural;
the heart's sounds and movements were natural.

It appeared that, seven months previously/she had lived in a hard
place, and was awakened often by shouting into her ears. This had
much frightened her, and she left her situation, but had ever since
been subject to twitchings of the muscles, and was by others con-
sidered " very nervous." The catamenia had appeared seven months
back, and only once since, and then only very scantily.

No good arose from the use of sulphate of iron and zinc with
sulphuric acid, and she was then ordered half a grain of tartar
emetic in a morphia draught every four hours. Sleep came upon her
at times, but never lasted long. The urine passed freely. Wine
was given and the medicine continued.

On the 3rd a very restless night was reported, and the pulse was
150, and weak.

The movements only ceased a short time before death, July 4th.

Post-mortem examination. — The body and limbs were well
nourished and healthy looking; excoriations of the skin over the
gluteal regions and ankles existed.

Cranium. — The white substance of the brain contained many
puncta, and the large blood-vessels in the ventricles were very
distended ; the corpora striata and optic thalami were natural.

The pons Yarolii was very full of blood, giving a pink colour to
the tissue, chiefly the anterior parts. The medulla oblongata was of
a pink colour.

The cerebral dura mater was congested.

Spinal cord. — This was very vascular, and particularly the grey
matter, and the vessels of the pia mater were large and full of
blood.

Thorax. — The heart's cavities were uncontracted ; its walls blood-
stained, and the contained blood very fluid, otherwise nothing was
noticeable in connection with it.

Abdomen. — The os uteri and vagina were bathed vnth pus, and
showed evidences of mechanical irritation, the os uteri being also
very open. The uterus and appendages were very full of blood;
other organs natural.

Remarks. — Observe in this case the peculiar and exceptional
manner in which the chorea movements were under voluntary
control, as also that " fright " was the supposed cause of the attack ;
after death mark the congestion of the nervous centres, and the
extreme irritation of the urinary organs (167).

Case 14. — Chorea ; altered state of the spinal cord ; fibrinous

deposits on the heart's valves.
Leopold L — , set. 11, was admitted July 13th, 1864 ; he had been

220 Original Communications. [J

an.,

an in-patient with chorea, but was discharged, still suffering to some
degree. The symptoms never left him, and in three weeks he
returned (the disease having lasted three months, and no cause
having been ascertained for it). The whole body, which was well
nourished, was affected with the movements. After the use of
sulphate of zinc and iron the movements became less marked, the
appetite continuing fair. He subsequently relapsed, and strychnia
was given (gr. -rVth up to -r^th) along with iron ; still he became
worse, began to emaciate, and arsenic was substituted for the other
medicine. The surface of the body was frequently torn with the
boy's nails, and the tongue often bitten. The hps became very
parched and deeply and remarkably cracked and fissured, and the
motions passed involuntarily. The severity of the convulsions
prevented his being lifted out of bed, and in consequence a
" water-bed '^ was resorted to. There appeared to be also great ex-
citability and passionateness of temper, and to some degree the
paroxysms could be controlled by speaking sharply to him. He had
at last to be tied down, so great were the struggling and kicking ;
and the hair of the back of the head became worn off. The mouth
and tongue became deeply ulcerated. Belladonna and other reme-
dies were tried in vain. He sank and died from exhaustion, retain-
ing consciousness to the last.

Post-mortem examination. — Cranium and spinal column. — The
surface and also the other parts of the brain were generally injected.
The ventricles were natural. The veins within the spinal column
were very distended with blood, as well those lining the spinal cavity
as those of the dura mater and those covering the spinal cord itself.
On section the cord did not at first present any unnatural appearance ;
but on minute examination portions of the grey matter were of a
duller and more yellow colour than natural, and this was chiefly so
towards the upper part of the cord.

Thorax. — The right pleura contained a few adhesions. The left
ventricle of the heart was contracted. Upon the inner edge of the
mitral valve was a line of soft beads of fibrine, easily detached.

The kidneys were much congested; the other abdominal organs
were natural.^

Remarks. — The congestion of the brain, the diseased state of the
spinal cord, and the condition of the heart's valves are to be noticed
in this case (249) .

Case 15. — Maniacal chorea, pregnancy , intestinal worms, congestiony
and softening of nervous centres, fibrinous granulations on hearts

valves.

Harriet S — , set. 17, a general servant, was admitted under my care,
April 24th of the past year (1867), with well-marked but not severe

1 This case was related by myself in the ' Ti-ansactions of the Pathological So-
ciety,' vol. xvii, p. 421 : and the fissured state of the lips, illustrated by a woodcut.

1868.] Ogle's Cases of Fatal Chorea. 321

Saint Vitus's dance, affecting the whole body, which she had suffered
from since about Christinas. The catamenia had been absent three
months, but before that had been regular; she had never had
rheumatism. She had had measles the previous summer. She was
reported also to have vomited worms of the size and shape of earth
worms. She was very violent in temper, and whilst in the hospital
showed this considerably. The abdomen was very large, and evi-
dently contained a pregnant uterus ; this was confirmed by the ful-
ness of the mammae, and the well-marked dark colour of the areolae
of their nipples, which were found to exist. The face was rather flushed,
and the patient was evidently greatly distressed in mind about her preg-
nancy. The heart's action was quickened and irritable, and a systolic
bruit existed. The pulse was regular, but feeble. The urine was free
from albumen and sugar. Bowels confined ; the pupils were not quite
of equal size, but acted tolerably well to the light. Calomel and jalap
were at once given, and subsequently the mistura ferri co. with valerian
thrice daily, and one third of a grain of the extract of cannabis indica
ordered every night. In the course of the evening of the 29th it was
found requisite to give her morphia, as she had become more violent,
and as tliis increased, in the middle of the night she had a quarter of a
grain of acetate of morphia, and one sixtieth of a grain of sulphate of
atropine injected subcutaneously. She had to have the jacket applied.
The violence of the choreic movements continued unabated, and sordes
were formed on the lips and tongue ; she also screamed much and
was evidently highly delirious. The injection was repeated May 1st,
and at 4 p.m. the same day she vomited a lumbricus. She became
more furious and maniacal, and more exhausted, and died in the
evening, twenty-four hours after the disease had become so much worse.
Post-mortem examination. — The body generally was well noiirished,
the surface generally congested.

Cranium. — The cranial bones were natural ; the cerebral mem-
branes were much congested ; the brain itself was " wet,^' and pitted
on the surface ; the '' puncta vasculosa""^ being increased, and giving
to the brain generally a pink hue. No fluid existed in the ventricles,
and, moreover, the central parts of the brain were much softened, and
easily broken down by water falling upon it. The veins at the base
were much congested.

Spinal column. — The vertebrae were natural. The spinal cord was
hardened in chromic acid solution, and subsequently examined
microscopically by Mr. Lockhart Clarke, who reported upon it as
follows : — In the cervical and lumbar portions of the spinal cord no
appreciable alteration of structure was discovered; but in the lower
part of the dorsal region, at the ninth dorsal nerves, the anterior
columns were swollen, and formed a convex protuberance of con-
siderable size. In a transverse section of the cord carried through
this part, and examined under the microscope, it w^as very evident
that extensive morbid changes had been going on, the white sub-

222 Original Communications. [Jan.,

stance had been softened, and was now vctj friable under the action
of chromic acid. In two or three places there were circumscribed
effusions of blood, surrounded by granular exudations, which had
probably occurred before the effusions.j

Thorax. — The left lung was very greatly gorged with blood
in patches — it however floated in water. No tubercular deposit
existed. The bronchial tubes were congested, and contained much
mucus ; the lower lobe of the right lung was in the same state.
The left ventricle of the heart was contracted and empty, the
right one partially contracted, and containing a decolourised clot.
The structure of the heart was firm; the mitral valve-flaps were
slightly thickened, and on the auricular surface of the orifice some
heads of soft fibrinous deposits of recent origin and easily removeable
existed ; the other valves were natural.

Abdomen. — The liver was congested ; a small fibrinous deposit
existed in its right lobe, which was slightly fatty ; the spleen was
soft. Both kidneys were coarse, and congested, and mottled. The
intestines were natural with exceptfbn of containing one ascaris lum-
bricoides in the duodenum. The uterus contained a foetus of about
four months' period.

Remarks. — In this case we have the very unusual conjunction of four
conditions which are separately apt to be looked upon as having a
close connection with chorea, viz., the presence of intestinal worms,
the pregnant condition, the anxious state of mind consequent on the
concealed pregnancy, and fourthly, the heart- affection. The case
passed through a very rapid course, and its complication with
mania is worthy of note. The absence of rheumatic history is to be
regarded. Amongst the pathological conditions ascertained after
death the congestion of the nervous centres and the condition of
the heart's valves are particularly noticeable (118).

Case 16. — Chorea; sudden congestion of the lungs ; effusion into
the pericardium ; fibrinous granulations on the heart's valves.

Mary A. G — , set. 12, was admitted under my care, October 3rd
of the past year (1867), with slight chorea of about six weeks'
duration. She was pale and anaemic, but it was affirmed that she
had never been laid up with rheumatism. A very decided rather
loud and rough cardiac bruit existed, attending both the systole and
diastole, and heard both at the base and apex ; not particularly con-
ducted along the large vessels.

Auscultation showed nothing unnatural about the lungs.

She was at first treated by steel in various forms, and frequently
purged, and santonine was twice given in hopes of evacuating any
lumbrici. She was going on much the same, when dyspnoea came on
suddenly December 3rd, and the right lung became full of moist
sounds. She was confined to bed, and small doses of morphia and
antimony were given every four hours. On the day afterwards she

1868.] Ogle's Cases of Fatal Chorea. 223

had greatly improved, and was in all respects much better. The
antimony was continued.

She went on improving until the 20th, when vomiting came on,
and the dyspnoea and the heart's action and the pulse were greatly
increased, the cardiac bruit being much intensified. Congestion of
the lungs set in, and she suddenly died early on the 26th.

Post-mortem examination. — Cranium. — The bones were natural.
The cerebral membranes were natural, but the brain itself was
" wet " and anaemic ; otherwise it was natural. The large vessels
at its base contained much dark, only very slightly decolourised and
well-adherent blood-clot.

Spinal column. — The vertebrse were natural. The spinal cord was
placed in a solution of chromic acid for future examination. I have
later on to give the results.

Thorax. — The lungs were very loaded with serum and somewhat
solidified. The pericardium was quite full of clear serum. The left
ventricle of the heart was contracted and empty, the right one
dilated and full. Around the margin of the mitral valve orifice on
the auricular surface a number of beads of soft recent fibrine were
found adherent, forming a distinct ring round the edge of the
orifice. A similar ring of fibrinous beads was met with around the
fight auriculo-ventricular aperture. Similar deposits were also
found on the surface of the endocardium in several parts. The
structure of the heart was natural.

Abdomen. — The liver was fatty and nutmeggy, and greatly con-
gested ; the spleen was natural ; the kidneys congested.

Remarks. — In this case observe the absence of rheumatic history,
the condition of the heart as ascertained during life and after death,
the suddenness of attack of lung symptoms, the unexpected death.
It is noticeable that the brain showed no signs of congestion (305).

Eeviewing the above sixteen cases, I wiU now proceed to indicate
certain points, suggested by their consideration, connected with that
form of chorea ^ of which they are illustrations.

First of all as regards the sex of these cases. It is generally
acknowledged that chorea much more affects the female than the
male sex. ^ This will be amply exemplified by the details of the
cases of non-fatal chorea contained in the tables given later on ; but
among the above- detailed fatal cases this preponderance in favour of
the female sex is remarkable, inasmuch as, out of the sixteen cases,
we have no less than fourteen that were females. It is interesting to
find that the late Dr. Bright observed that the acute form more
affected females than males. Trousseau observes that the rare
instances of chorea affecting persons after the age of puberty have
almost exclusively occurred in women.

1 I shall have the opportunity of describing one or two cases later on of other forms
of chorea (not the St. Weit's dance proper) which have come under my notice.

2 In Dr. Bright's experience males were more afl'ected by chronic chorea than
e males.

234 Original Communications. [Jan.,

As to AGE, these fatal cases occurred in individuals presenting,
on an average, a greater advance of life than is generally given for
all cases (including fatal and non-fatal) of this variety of chorea, as
we shall see in connection with the table of my out-patient choreic
cases ; for out of the sixteen fatal ones only two were under the
age of ten (viz.. Cases 8 and 10, which were respectively
7 and 10 years of age), whilst three were of the age of 20 and
upwards (viz.. Cases 1, 4, and 11), the rest being intermediate — two
being aged 11, one aged VZ, two aged 15, one aged 16, three aged
17, and one aged 19. The extent to which age, sex, and other so-
termed predisposing causes may favour attacks of chorea, will be
more fully alluded to when my non-fatal cases of chorea shall have
been given in an ensuing Number.

As regards the length of time during which the patients had
suffered from the affection before it proved fatal, it will be found that
of those whose history contains information on this point, this period
was, on the whole, a short one; for though in the case of one (viz.,
No. 13) it was possibly seven months, in another (No. 5) six or seven
months, in two others (No. 14 and 15) three months, in another
(No. 8) six weeks, in another (No. 16) nine weeks, in two others
(Nos. 10 and 12) three weeks, in No. 2 two weeks; yet in No. 6
it was only ten days, in Nos. 7 and 10 only ten days, and in No. 11
only eight days.

As regards the fact of the patients having suffered from previous
ATTACKS of chorea or not, in only three cases have we mention of
this — viz., in Case 3, in which two previous attacks occurred; in
Case 10, in which one previous attack had existed; and in Case 14,
wherein a relapse was suffered while the patient was in the hospital.
Speaking of this well-known tendency to relapse, Romberg quotes a
case in which a girl aged 9 had nine relapses, with intervals of
about one year.

The details of my cases are not sufficiently explicit to show which
parts of the body were, in various instances, chiefly affected.

Respecting so-called important complications of the affection, it

will be seen that in Cases 3 and 4 headache and drowsiness had

been suffered. (Of course, I exclude in such complications the

headache, &c., which might attend the effects of opiates and other

remedies, and which might also result from exhaustion, pain, want

of sleep, &c.) In one case (No. 11) epileptic attacks had existed;

in one case (No. 9) chorea and convulsions followed an attack

of scarlet fever ; in two cases (7 and 11) hysteria-like symptoms ; and

in Case 6 delirium existed. In this latter case, also, the sphincters

were mentioned as having been affected.^ In Cases 11 and 15 (one

a married woman, aged 20 ; the other aged 15) mania existed. It

' Jules Simon observes that in chorea the sphincters may be also affected, or
rather that the faecal matter is propelled by the contractions of the abdominal and
visceral muscles. This would appear to be so at any rate in those cases in
which there is inability to retain the urine, a somewhat rare occurrence.

1868.] Oglb^s Cases of Fatal Chorea. ^U,^

may here be worthy of mention that authors speak of a connection
between chorea and other so-called neuroses. Tor example, Dr.
Theophilus Thompson,, in his article on this disease in ' Tweedies'
Library of Medicine/ alludes to chorea as beings at puberty, super-
seded by hysteria, and this by neuralgia, seeming to depend on
a similar condition of the nervous system ; he also refers to chorea
as inducing fatuity, epilepsy, or hemiplegia. Dr. Bright thought an
analogy could be traced between chorea and other diseases of the
nervous system, marked by general irritability, and remarks, " Thus,
I am induced to point out a connection in this respect be-
tween chorea, hysteria, and the delirium of drunkards." Again —
"In chorea that part of the nervous system which ministers to
voluntary motion is chiefly 'affected ; whilst in hysteria the nerves on
which organic life and involuntary matters depend are principally
irritated ; and in the delirium which takes place in drunkards those
portions of the brain which are particularly associated with the
manifestations of thought and reason are labouring under disease.^'
Thompson speaks of *' choreic movements being mistaken for
drunkenness.''^ It is interesting to find that Youatt speaks of
chorea in the dog as terminating in epilepsy, or palsy, or paralysis-
agitans. Todd closely associated chorea with certain epileptic phe-
nomena, for he was of opinion that the actual state of the nerves and
nervous centres, upon which choreic hemiplegia depends, was very
analogous to that which exists in the so-termed epileptic hemiplegia.

As regards the secondaey affections which supervened in the
fatal cases, we have two cases (viz., 5 and 8) in which so-termed
phlegmonous or erysipelatous inflammation existed. In one of these
there was empyema also.

With reference to the oft-mooted question as to what links may
be supposed to exist in the chain of causation of that perversion or
disorder of the muscles secondarily and of the nerves primarily, ^
which results in the condition termed chorea, it may be worth while
to consider how much light and instruction these fatal cases tend to
afford. The histories of many show that some disturbance of the
generative system existed, for in five cases (Nos. 3, 5, 7, 13, and 13)
the catamenia were defective, and in two cases (1 and 15) pregnancy
existed.^ Now, it is well known that irritation of the genito-urinary
system has been often looked upon as an exciting cause of the
malady. Out of the six cases which Dr. Bright had known to end
unfavorably, in one "the most unequivocal evidence of extreme
uterine irritation was found after death ;" in a second one (at the

^ Not of the MOTOE nerves alone, of course, as it is well known that the sensory
nerves are oft-times also affected, as proved by the anaesthesia and sometimes hy-
peraesthesia which exists.

* Later on I shall be able to quote one or two cases of non-fatal chorea, in which
pregnancy existed, one being that of a woman lately under Dr. Page's care at
the hospital.

81— xii. 15

226 Original Commmiications, [Jan.,

Manchester Infirmary) the patient was four mouths advanced in
pregnancy ; and in two others the patients were of an age " when
uterine irritation is most likely to exist." Bright assumed that it
was probable that the uterus was in many cases " the source of that
general irritation which so strongly marks chorea, inasmuch as many
cases were connected with irregularities in the menstrual discharge,
or with amennorhcea.^'

Eomberg says that "the occurrence of chorea before the first
supervention of the catamenia, or during amenorrhoea, or even
during pregnancy, proves that the uterine system may be the source
of the irritation ;" and quotes three cases of the kind which came
under his own notice, in all of which pregnancy existed. In one
case the woman became pregnant a second time, and again had
chorea. He observes that " the chorea generally commences at
about the third or fourth month of pregnancy; it rarely occurs
earlier, and then less frequently during the latter months.^' He
quotes cases bearing on the question from Dr. Lever's paper " On
Disorder of the Nervous System associated with Pregnancy and
Parturition."^ He remarks that it is quite exceptional to find
chorea occurring after delivery, whether at the full ])eriod or pre-
mature. I find, however, a case recorded by Spiegelberg in which
chorea came on in the latter half of pregnancy." Dr. Levick, of Ame-
rica, in 1862, recorded three cases of chorea associated with pregnancy,
and described uterine irritation as one of the causes of the disease.
Quite recently Gubler and Dumoni have recorded a very severe
case of chorea in a woman five months pregnant, who was cured in
eight days by large doses of bromide of potassium.^

Trousseau, speaking of pregnancy in connection with chorea,
states tliat the disease is owing merely to the chlorosis which so
frequently attends pregnancy.

Again, as regards mental emotion or alarm being influential in
exciting or determining the choreic state, it will be seen that out of the
sixteen cases there are eight in which fright or other emotion was
supposed to have contributed to its production (viz. Cases 1, 5, 8,
9, 10, 12, 13, and 15) ; in others, it was either denied or not ascer-
tained to have occurred. Some observers are inclined to protest
against the idea that fright is nearly so adequate a cause of the
affection as is generally imagined, but there can be no doubt of this
being frequently the case, and almost every author who writes on the
subject supports the supposition by authentic cases. One of the
most positive and remarkable cases of this kind is quoted bj
Dr. Bright. It was that of a child, aged 9, who, having got well of
an attack of chorea, was sleeping with his father. The father had an
attack of apoplexy, which so frightened the child that "feom

1 * Guy's Hospital Reports,' second series, vol. v and vol. vi.
' Quoted in the ' Sydenham Society's Year-Book,' 1859, p. 389.
a See 'Bulletin de Thera)).,' 1865-8, p. 178.

1868.] Ogle's Chases of Fatal Corea, 227

THAT TIME the cliorca returned/' Mayo, in his ' Outlines of
Human Physiology/ p. 170, relates the case of a woman who,
during pregnancy, was greatly frightened ; the alarm induced chorea
in the foetus. The child grew up, but always remained choreic.

As respects the history of rheumatism or rheumatic symptoms
having existed, we have mention of it doubtfully in Cases 3 and
10, but decidedly in Cases 4, 6, 11, and 12 ; in the last instance,
the rheumatic symptoms came on during the absence of the cata-
menia.^ Presumably also, in Cases 1, 9, 14, and 15, rheumatism
may have existed, as after death it was found (to be noticed here-
after) that cardiac affection existed. In Case 16 particular in-
quiry was made, and a complete denial of any previous rheumatism
given, although the heart was obviously recognised as being diseased
during life, and found to be so after death. At the present day we in
England almost unanimously connect chorea and rheumatism to-
gether (whatever may be the mode of connection) ; this, no doubt,
is mainly owing to the researches of Bright and Todd, following
those of Bouillaud ; still, there are those who have only found
them to be at times coincident. I shall speak of this again when
reviewing my series of non-fatal cases. In the mean time I may
state that Romberg, a high authority on all nervous diseases, says
that the rheumatic disposition was rarely traceable in the cases
which he has observed. He, however, noted cases of chorea as being
greatly affected by climate and weather, being always worse in
winter ; and mentions -that the disease occurs more frequently in
the southern than the northern climates. Peacock found that in
14 cases of chorea rheumatic or cardiac symptoms had existed in 5, but
states that this proportion is probably too large. Trousseau says,
that of all predisposing pathological states, rheumatism is the most
marked and the least questionable : and one of the most recent Prench
writers looks upon chorea as a manifestation in the rheumatic
diathesis.

As regards the pathological anatomy presented by the various
fatal cases, we find that congestion (more or less complete) of the
nervous centres (brain or spinal cord, or both), was met with in six
cases (viz. 3, 4, 10, 12, 14, and 15), whilst in Case 7 there was
actual softening of the spinal cord, and in Case 14 the spinal cord
was otherwise affected. In Case 15 there was softening of certain
parts of the brain .^

' It is interesting to find that Dr. Todd established a connection betwen rheu-
matic fever and deranged titerine secretion. He stated that some of the most severe
cases of rheumatic fever he had ever seen followed dysmenorrhoea. He observes, " It
would seem as if, in these cases, the uterus were but imperfectly evacuated, and its
contents becoming decomposed and getting into the circulation, produced a morbid
state of the blood, which gives rise to the symptoms under which the patient
labours, and requires for its cure the elimination of the unhealthy material by the
various emunctories — a state similar and analogous to pya;mia."

^ With reference to such lesions in connection with chorea and chorea-like symp-
toms, it will be not uninteresting briefly to quote such cases aa have been pre-

228 Ori(, mat Communications. [Jan.,

In Cases 2, 3, 4, 10, and 13, there were proofs of congestion and
other graver lesions of the genital system; in Cases 1 and 16 (as
before noticed) pregnancy existed. In Case 2 the peritoneum was
greatly congested, and in Cases 2 and 3 the condition of the intestines
was remarkable, inasmuch as they contained feecal matter which was in
a peculiar and exceptional manner adherent to the walls of the bowel.

Coming now to the state of the heart, it was found that out of
these sixteen cases in no less than ten cases there existed more or
less fibrinous deposit or granulations upon some portion of the heart's
valves or hning membrane, viz. in all Cases excepting 2, 5, 7, 8, and
13 ; in Case 6 old pericarditis existed, and in Case 10 we have decided
evidence of recent pericarditis having existed, although in this case we
have no mention of a cardiac ' to-and-fro' murmur having been ob-

sented to our London Pathological Society. Thus, at page 16 of vol. v is a case
of chorea following a fit, related by Dr. Hale, in which chronic disease of the
cerebral dura mater was found. In a second case, which came on immediately
after a fright, related by Dr. Goodfellow (see vol. xiii, p. 19), extensive softening
of the brain and spinal cord was met with. In a third case, related by Dr. Broad-
bent, at p. 246 of the same volume, a tumour was found arising from the centre
of the spinal cord. Romberg quotes seven fatal cases in which similar organic
lesions were met with after death. They are as follows : — Case 1 was quoted from
Dr. Hughes' digest of 100 cases of chorea (see 'Guy's Hospital Eeports,' 1846).
Here the fornix and the surface of the third cerebral ventricle were softened. An

OPAQUE GEANTJLAE DEPOSIT alsO existed OU One of the SEMILUNAR VALVES

of the heart. Case 2 was that of Dr. Bright's, already quoted. Case 3 was re-
lated by Frerichs. In this case the choreic movements existed during sleep.^
After death the medulla oblongata was found pr-essed upon by an enlarged odon-
toid process. Case 4 was from Cruveilhier, and was combined with paralysis.
Softening of the occipital cerebral convolutions and atrophy and degeneration of
the spinal cord were found. The remaining cases were from Romberg's own
practice. In one case, aged 76, chorea had existed since she was six years old.
Softening of the crura-cerebri and atrophy of the brain were met with. In Case 6
the central parts of the brain and corpora quadrigemina, and in Case 7 softening
of the spinal cord, were found. Dr. Peacock (see number of this Review for Oct.,
1863) records the fatal case of a boy, aged 11, who died in a comotose state six
days after admission into the hospital with chorea, which had been observed one
month. After death the arachnoid membrane, on the surface of the hemispheres,
was found opaque, and much serum existed beneath it and in the ventricles. The
spinal cord was not examined. The pericardium and heart were healthy, except
that two of the aortic valve folds were congenitally united. Recently Mr. Hine has
recorded, in the ' Medical Times and Gazette,' August 5, 1865, the case of a preg-
nant woman who had chorea, apparently caused by emotion, in whom softening of
the spinal cord was found. Dr. Aitken, in a case of chorea, found (* Glasgow
Med. Journal,' vol. i.) that the sp. gr. of the corpus striatum and optic thalamus
was decidedly greater on one side than on the other. Dr. Chambers, in his
' Lectures,' pp. 361 and 369, mentions that in three fatal cases of chorea he found
after death that the nervous system was perfectly healthy. In a fourth fatal case
tubercles were found in the spinal cord. Skoda, speaking of softening of the
septum lucidum and fornix, sometimes found in fatal cases of chorea, suggests that
an EXUDATION in the spinal cord or in the brain is the immediate cause of the
disease (' Canstatt's Jahrb.,' vol. iii, p. 57). I propose to examine the records of
all fatal choreic cases which I can find, to ascertain in what proportion organic
lesions exist.

1 Marshall Hall observed that sometimes the movements continued during sleep
if dreaming existed ; and Youatt noticed that in the dog if the sleep was disturbed
choreic movements might continue.

IS68.] Ogle's Cases of Fatal Chorea. 229

served during life.^ It is noticeable that in several of these cases in
which after death fibrinous deposit on the heart's valves existed, we
have no record of the occurrence of any valvular murmur whatever
during life. It is worthy of comment that in several of those cases
in which, after death, fibrinous deposits on the heart's valves, &c.,
were discovered, we have no record of the existence of any valvular
murmurs whatever before death ; indeed, only in Cases 9, 15, and 16,
does such a record exist. In Case 5 we have a distinct notice of a
double valvular bruit at the base of the heart having existed and having
subsequently disappeared y^ in this case we have no mention of any
fibrinous deposit on, or other afi^ection of, the heart's valves. In
Case 16 the pericardium Avas found to be distended with serum, and
possibly this caused the patient's death. This sequel in cases of
chorea is, of course, of uncommon occurrence. It is, however,
mentioned by Dr. T. Thompson, in his article above quoted, that in
chorea serous effusions into the arachnoid cavity and into the
PERiCAEDiuM may come on.

Concerning the presence of the fibrinous granulations or fringes
so often met with in the heart's valves in these cases, the readers of
the case of maniacal chorea described by Dr. Tuckwell in this
Review (to which I have alluded at page 208) will remember that that
gentleman drew marked and renewed attention to the probable exist-
ence of this phenomenon in the majority of cases of fatal chorea ; also
to the fact that softening of the brain or spinal cord frequently was
found in such cases, and will remember that he supposed that the soft-
ening of the nerve centres often resulted from the plugging up of the
cerebral and spinal arteries, and accounted — as would irritation of the
same parts from a similar cause — for the chorea. Dr. Kirkes had, in
1863, pointed out that when chorea and acute rheumatism are asso-
ciated the connection really was between chorea and valvular disease
of the heart ; and Dr. Tuckwell shows that Dr. Kirkes had been the
first to indicate that chorea " was the result of irritation produced
in the nerve centres by fine molecular particles of fibrine which are
set free from an inflamed endocardium, and washed by the blood-
current into the capillaries of those centres." Dr. Kirkes, with

* I lately had a most interesting instance of the rapid way in which peri-
cardial friction sounds may come on. The patient was brought into the hospital
for rheumatic fever, andwas examined very closely. The heart's action was increased,
but, though carefully listened for, no bruit, exo- or endo-cardial, could be detected.
In two hours afterwards a positive and distinct friction sound was heard all over
the base of the heart. That this suddenly occurring pericarditis may be swiftly
fatal also is shown by a case of chorea, related by Dr. T. K. Chambers in his
' Lectures,' p. 173, in which loud friction sound came on in the course of the day,
and the patient died of pericarditis in the evening.

2 Such disappearance of cardial murmurs [in chorea might take place if the
bruit was resulting from that condition called anaemic, or from some irregularity
(of choreic origin) of muscular or tendinous fibres controlling the movements of the
heart's valves or the exit of the apertures of valves, or even, in some cases, where
owing to recent fibrinous deposits connected with them, such bellies being liable to
be washed off by the blood stream. ^

230 Origwal Commimications. [Jan.,

other observers, had noticed the occurreuce of softening of the
uerve- centres in this affection, but erroneously thought that all such
were cases of pale or white softening, and did not attribute it to
embolism of large vessels, as does Tuckwell, but rather to " the im-
perfect nutrition of the nervous centres, or the unhealthy state of
blood which affords the development of the chorea."

It will be seen, on reading Dr. Kirkes^ paper, that he does not, in
forming this view, repudiate the influence assigned to supposed ex-
citing or outward causes ; for he remarks that, owing to this assumed
defective nutrition of nerve centres, they become unnaturally capable
of being affected and excited by what would, in a state of health, prove
to be but ordinary impressions ; and with this tendency they are liable
additionally to be affected by blood rendered irritating by rheumatic
affections or by disease of the heart's valves. With the above views
of Kirkes and Tuckwell in mind, the large proportion of cases which
I have recorded, in which the heart's valves are affected, will prove, I
think, of considerable interest. Still, for my own part, I am not at
present prepared to give adhesion to a necessary connection between
even the grave and fatal cases of chorea and embolism, whether the
embolism consist in plugging up of large, tangible vessels, or in the
circulation of minute atoms of fibrine within the minute capillaries
of the nervous structures giving rise to " iiieitation ;" although, on
the whole, I incUne to think the latter supposition is, perhaps, the
more tenable.

I venture to throw out some considerations, as a contribution to
the question, to which I have been led by thinking over the subject.

In the first place, either view necessitates the division of all true
choreic cases, not merely into those that are and those that are not
fatal, but into those that depend upon embolism and those which do
not; although in each kind of case the phenomena be not only
so alike, but so identical, that until death it would be impossible to
predicate of any one instance to Avhich category it pertained.

Dr. Todd had suggested that the choreic cases of adult life, and
more advanced ages, might not be due to the same morbid con-
dition " as that which gives rise to the ordinary choreic convulsions
of early life.'" Dr. Tuckwell suggests that, possibly, the causation
of the chorea in fatal cases may be different from that of the non-
fatal ones ; that, in fact, there may be a centric and an excentric
chorea ; but I think he seems inclined to suppose, though he leaves
it an open question,^ that in all kinds of chorea we have the de-

^ He says, " We have not as yet sufficient evidence to justify the conclusion that
embolism is a direct cause of severe chorea, but we have enough to warrant the
strong suspicion that such may be the case, and to fix the attention of medical
men on the heart and blood-vessels in the future examination of all fatal cases."
Dr. Tuckwell will, I hope, excuse my quoting from a letter which he wrote to me
some months ago on the subject. He observed :

" I was glad to find in the post-mortem you made in your fatal case of chorea
[the case referred to at foot-note of page 220] that the mitral valve was studded
with beads of soft fibrine. I have a notion that, if the valves of the heart aro

1868.] Ogle's Cases of Fatal Chorea. 231

position of fibriiie on the heart and valves, which, being removed
and transported, produces the cerebral or spinal embolism which is
the cause of the affection. Certainly, as both he and Kirkes sug-
gested,^ inquiry led to the finding of this deposit in a very large
per-centage of fatal cases, and very careful inquiry, instituted with
THE OBJECT OF FINDING SUCH, may lead to their discovery in a
still larger proportion. Still, even if they were met with in all
cases, something more, I would with deference submit, would be
required to warrant the inference being inevitable that the essential
cause of chorea was embolism ; and for the following reasons : —
Supposing that chorea were owing to the presence of molecular
fibrinous material in the blood, circulating in all directions and parts,
as fibrine would do in this form of mechanical subdivision, I would
ask how we could find an explanation of the fact that chorea (under
conditions operating so generally) is so frequently unsymmetrical and
one-sided as it is, or even confined, it may be, to certain muscles or
series of muscles. Should we not of necessity get other and graver
motor symptoms than merely defective harmony of associated move-
ments ? I suppose that the " one-sided'^ or mere local effect from such
a MECHANICAL cause would be considered as being not at all analo-
gous to those similarly partial effects produced by certain chemical
alterations of the blood (such as we have often in cases of uraemia, in
rheumatic, neuralgic, miasmatic, and other blood-poisons strictly so
called), in which the supposed materies morbi has what may be
termed an affinity for certain parts or tissues, or in which, so to say,
such tissues appear lo atteact the baneful elements.

Again, when by experiment fibrine, in a minutely divided state, or
any other finely powdered substance, is made to circulate iii the blood-
current, do we meet with results at all comparable with the symptoms

carefully examined in all fatal cases of chorea, similar, though sometimes very
delicate^ beads will be found. If you should open a body in wMch this appearance
is not present, will you kindly tell me ? I am sure that the appearance is some-
times ovei'looked in these cases in the eagerness of the pathologist to find some-
thing in the spinal cord. I think I told you of a case I saw in the H6tel Dieu,
•where the heart was opened as usual, and put aside as healthy ; and when the spinal
cord was sent to Robin for examination to supply Trousseau with material for a
clinical lecture, a German student, who was present and poking about among the
debris as only Germans who wear spectacles can poke, routed out the heart, and
found that, when examined minutely, the mitral valve was fringed on both flaps
with very fine and delicate beads of fibrine. This was shown to I'rousseau, but he
took no notice of it, dilating on a supposed enlargement of the capillaries of the
spinal cord which had been found. Again, a woman in the fourth month of preg-
nancy died with bad chorea in the Vienna Hospital, and was brought down to
Rokitansky, His assistant, who made the post-mortem, dilated on the pregnancy
as the cause of chorea, and took no notice of the condition of the cusps of the
aortic valve, which were covered zvith abundant, very delicate, beads of Jlbnne."
These are obviously the two cases which he quotes in his paper to which 1 allude.
' Kirkes had prophesied, as quoted by Tuckwell, " that future experience will
still more positively demonstrate that an affection of the left valves of the heart,
with the presence of granular vegetations upon them, is an almost an invariable
attendant upon chorea, under whatever circumstances the chorea may be develojaed,"
The italics are my own,

233 Original Communications. [Jan.

of chorea ? If, also, the chorea were the result of cerebral or spinal
capillary embolism, surely we ought always, in fatal cases, even when
such ulterior stages as suppuration and abscess are not arrived at, to
encounter lesions (stasis, congestion, or other appearances met with in
that condition which goes by the name of secondary deposit, the
result of mechanical impediment) which, if they existed in such
delicate tissues as those of brain or medulla, would be at once
apparent. Then, if they existed at all, they would most likely, ac-
cording to some, be in the neighbourhood of those parts which Dr.
Todd pointed out as probably constituting the centre of volition and the
centre of emotion. Where we have reason in other cases to suspect
capillary embolism, have we not rather the symptoms, and also the
post-mortem appearances, of pyaemia or of gangrene ? I cannot call to
mind a single instance of acknowledged capillary embolism attended
by phenomena which could even suggest chorea. Then, again, sup-
posing chorea to be caused by plugging of the larger cerebral or spinal
vessels, how rarely in those cases in which such a state is determined
to have existed, producing softening, did chorea-like symptoms arise ;
and how rarely have such symptoms been mentioned in cases of soften-
ing of nervous structures of any description or arising from any cause^
(though, ofjcourse, convulsive action may have existed) . How rarely,
again, do choreic symptoms accompany rheumatism, a condition in
which fibrinous deposits on the hearths valves so often exist. More-
over, under such a supposition as the above, how should we be able
to account for that sudden occurrence of the disease as a result of
mental emotion, which undoubtedly often exists, or, what is perhaps
more to the purpose, for its frequently sudden disappearance or
cessation,^ or for the good effects at times found to attend the use
of certain remedial measures ? Will it ever happen that watching
the effects of remedies of whose action physiologically we know
something will give a clue as to the part of the cerebro-spinal axis
affected in chorea, if, indeed, any one part is specially concerned in
chorea? The chorea ought (under the above supposition), taking
an average of cases, to be found mainly affecting one side in corre-
spondence with the frequency with which embolism occurs on one
side. Perhaps investigation may prove this to be so.

Again, it might be asked, if there was merely a mechanical cause

' Dr. Tuckwell quotes from Dr. Todd to show that cases of softening of the
brain are sometimes attended by movements so choreic as to be mistaken for real
chorea.

* Many cases might be quoted illustrating the rapid removal of the affection. A
remarkable instance is mentioned by Skoda of severe and general chorea being
cured in five days by tartar emetic and cold douches to the head. Dr. Guy, of
King's College, observes : — " One of the worst cases of chorea which I have seen,
and which combined constant restlessness and grotesque action of the muscles
with mental incoherence, was cured within ten days by aperient medicines only."
A very severe case of a form of chorea, of which I have notes — that of a young
man in Derbyshire — took its leave during the_time the patient was being carried
to the infirmary.

1868.]

Ogle^s Cases of Fatal Chorea. 233

(which, of course, would be constant in operation), such as embolism,
why should the movements be so decidedly and universally inter-
rupted during quiet sleep ? Or why should certain peculiarities as
to age or sex be considered as predisposing influences ? Eecognising
the frequent existence of these fibrinous deposits or 'granulations on
the hearths valves in chorea, I should be much inclined to look upon
these post-mortem appearances rather as results of some antecedent
general condition of the blood, common also to the choreic condition.
It is very freely recognised that this affection is frequently, in some
way or other, connected with that condition of blood which obtains
in what we call anaemia,^ or that existing in rheumatic constitutions.
In both of these states, we know that the fibrine of the blood is much in
excess- (as also it is in pregnancy, another condition looked upon
as obnoxious to chorea), and in these states we know that the fibrine
(with which the blood is surcharged) is very prone to be readily
precipitated, either owing to its superabundance or from other ob-
scure and acquired properties (possibly also from some interference
with the relation of the fibrine and the other constituents of the blood)
upon the hearths walls or valves.*"^ May not this hyperinosis be the
explanation of the coincidence alluded to ? In most cases the de-
posit is probably very slight, and in many cases so slight as to re-
quire search for it. May it not infrequently be that it is often only
formed in quite the dying state ? Speculation might suggest that
the fibrinous deposits arise from some interference with the degree
of solubility of the fibrine, induced by the presence of some un-
wonted elements within the blood (some result of tissue meta-
morphosis), produced by the excessive muscular action and other
functional disturbance which exists in the choreic state, thus being
not in any way related to this state as a cause, but as a consequence,
PosTCRiPT. — For the following notes of a highly interesting case
of chorea, successfully treated by the oil of male fern, I am in-
debted to my friend, Dr. Giles, of Deptford. It illustrates well
quick recovery under the use of remedies.

" Case of acute chorea, caused hy the presence of a tapeworm, and
successfully treated hy the oil of male fern,
"I was requested to see the following patient by one of the
surgeons of the Pimlico Dispensary, during his absence in the
country. He described it to me as a complication of rheumatism,
chorea, and worms, and said that the only remedy that seemed to do
any good was atropine, which he had given in gradually increasing
doses. She had been under his care for about a month.

* Some authofties look upon rheumatism as causing anajmia.

^ Andral, giving 3 as the average relative proportion of fibrine to 1000 parts of
healthy blood, states that the variation in disease ranges from 1 up to lOJ per
1000. In cases of ansemia he gives the proportion^ of fibrine as 3'5, and in rheu-
matism as 10 per 1000.

3 I do not speak of the condition of the heart's valves alluded to as being the
result of endocarditis.

234 Original Communicatiom . [Jan.,

" Ellen L — , set. 9, residing in Pimlico^ Avas first seen by me on
29th September, 1863. She M'as evidently suffering from acute
chorea ; had had no sleep for four days and nights; there was constant
irregular spasmodic action of the whole body and face; she was
never still for a moment (continually working). A bed-sore had
formed over the sacrum the size of the palm of the hands, and the
elbows were much chafed. She from time to time uttered a feeble
whine, and wore a pitiable look of distress ; her consciousness was
perfect. The tongue was dry and brown, and sordes had accumu-
lated on the lips. The pulse was exceedingly rapid and feeble.
The pupils were moderately dilated. She had taken no nourish-
ment, except a little wine and beef-tea, for some days. She seemed
rapidly sinking. The mother told me she had been in the habit of
passing portions of tapeworm for the last tljree months, and that
large pieces had come away while under treatment ; she had never
seen the head. I saw by the patient''s letter that scammony and
calomel had been the medicine used. Thinking all these nervous
symptoms might proceed from the intestinal irritation, I resolved to
try a full dose of male fern. The mother was at first unwilling to
have any change made in the medicine (morphia) which had last
been prescribed, thinking the case hopeless, but at length yielded. I
prescribed 01. Fihcis Maris Sj; ex Mistura Acacise ^iss, to be taken
immediately, and to be followed in six hours by 01. Eicini Bss.

" On visiting her the following morning, I found the child asleep,
quite free from any convulsive movement. The mother told me the
draught had acted freely four hours after taking, that the child
turned very pale and faint, and she thought she Avas dying. She
however gave her some wine, which revived her, and in the course of
a few minutes she Avas fast asleep and quite quiet, with the exception
of occasional twitching. She slept for two hours ; on Avaking she took
some beef tea, and then slept again. When she awoke the convulsive
movements commenced again, though in a greatly mitigated degree.
About seven yards of tapeworm were collected, and the head with
the four suctorial discs found. The castor oil had not been given.

" The subsequent history is simple. She continued to improve
daily, the mouth and hps cleaning. The bed-sore gradually healed
under the use of nitric acid lotion. In a few days all convulsive
movements had ceased, and in ten days she was able to leave her
bed. The medicine prescribed Avas bark and ammonia, generous
diet, and a little wine at first. On the 16th of September I took
my leave of her, she having been able on the previous day to leave
the house. During her convalescence I examined her heart several
times, and always found a distinct mitral murmur.

" I have lately seen her mother, and she tells me her daughter has
enjoyed good health ever since, and has seen no more tapeworms."

{To be continued.)

1868.]

235

PART FOURTH.
ar4)tonicIe of i$let(ical Science.

(CHIErLT rOEEIGN AND CONTEMPORAET.)

CHRONICLE OF PHYSIOLOGY.
By Henet Poweb, P.R.C.S., M.B. Lond.,

Assistant-Snrgeon to, and Lecturer on Physiology at, the Westminster Hospital.

Blood Cieculatioit.

1. Del Globulimetro, nuovo strumento per determinare rapidamente la

quantita deiglohetti rossi del sangue. P. Manteggazza (Milano,
1865, 8vo, 2 pi.)

2. Researches into the nature of Hcematoidin. P. Holm. (' Mole-

schott's XJntersuchungen,' Band x, 1867, p. 447.)

3. On the Movement of the Blood in the Veins. H. JacobsoN".

(' Reichert's Archiv,' 1867, p. 224.)

Mantegazza suggests a new kind of instrument to determine
quickly, with some approach to accuracy, the proportion of corpuscles
in a given specimen of blood. Ordinary human blood has remark-
able absorptive powers for light, and a very thin layer of it accord-
ingly, when held against the light, appears opaque. M. Mantegazza's
instrument consists of a small glass cell, the sides of which are sepa-
rated from one another to such a distance that when the blood,
diluted with a certain proportion of a solution of carbonate of soda,
is introduced into it, the flame of a candle placed behind it is just
rendered invisible. This is the 0 point, and corresponds to the
number 5,625,000 corpuscles in one cubic millimetre,^ which is the
highest proportion of corpuscles yet met with in plethora. Now,
it is obvious that the fewer the corpuscles the more transparent will
the blood become ; and the diminution in the number of the cor-
puscles can be approximately ascertained by placing between the
observer and the candle one or more plates of tinted glass, so that
the candle is still kept just invisible, the thickness of each plate cor-
responding to a known diminution. In proportion to the number of
plates which are required to be added will be the deficiency of cor-
puscles. The plates are so tinted that each one that is required to
be added to keep the candle invisible corresponds to a diminution of

' A millimetre corresponds to one twenty-fifth of an English inch.

236 Chronicle of Medical Science. [Jan.,

about 125,000 corpuscles in the same bulk of blood. About thirty
of these plates are supplied with the instrument, or, which is more
convenient for practical purposes, a disc with a series of five or more
holes, in each of which in succession additional plates are placed, is
made to revolve at will before the blood column, so that the number
can be read ofi" with tolerable facility. Mantegazza finds the mean
number of corpuscles to be for men about 5,000,000, and for women
4,500,000, the extremes being 5,625,000 in plethora, and only
225,000 in extreme ans3mia.

2. M. Holm observes that there are certain points of similarity
between hsematoidin and the principal colouring matter of the bile,
termed by Stadeln bilirubin, which have led some to think that they
are identical, though they are really two quite different substances.
In order to prove this he examined the colouring matter of several
specimens of human bile and of gall-stones, whilst he obtained hse-
matoidin, in the first instance, from the cicatrices left in apoplectic
haemorrhages of the brain, and subsequently from the corpora lutea
of the cow. In procuring it from the latter he rubbed down the
whole corpus luteum with ground glass into a pulp, and treated it
with chloroform. The fluid was filtered, and the golden-yellow
fluid left to evaporate spontaneously. The crystals of hsematoidin
appeared after a few days as microscopical tabular crystals with
three acute angles, one side of which was sometimes convex. By
the union of the bases of two of these deltoid crystals rhombic
tablets were formed, or by the union of four a star with four rays.
At other times, by the rounding off of the angles, elliptical or even
staff-shaped crystals were developed. The crystals are amongst the
most beautiful objects in organic chemistry. By transmitted light
they appeared red, by reflected they presented a metallic surface of
a cantharides-green colour. Haematoidin is very easily soluble in
chloroform, forming a golden-yellow solution. It is also readily
soluble in bisulphide of carbon and in absolute ether. It is insoluble
in alcohol and in water, in ammonia, solution of soda, diluted mineral
acids, and dilute acetic acids ; but it dissolves in warm acetic acid,
and if to this solution a little nitric acid be added it assumes a blue
colour. The differences between bilirubin and haematoidin are well
marked, and may be briefly here enumerated. Bilirubin possesses
the properties of a weak acid uniting with bases, whilst haematoidin
is apparently an indifferent substance. Bilirubin is insoluble in
ether, haematoidin easily soluble ; on the contrary, in the alkalies
bilirubin is easily soluble, whilst haematoidin is insoluble. Lastly,
if a solution of bilirubin in chloroform be shaken up with ammonia
or soda it will be entirely abstracted from the chloroform, which will
remain colourless, the alkaline fluid becoming yellow. Haematoidin,
on the contrary, is not withdrawn from the solution in chloroform
by alkalies, and the chloroform solution consequently remains
coloured.

In a paper which immediately succeeds the above, M. Stadeler
shows that the colouring matter of the yolk of the egg is closely
allied to hsematoidin in its nature.

1868.]

Chronicle of Physiology. 237

3. Jacobson has employed a peculiarly constructed nozzle adapted
to an ordinary manometer, and originally constructed by Ludwig and
Spendler. The animals experimented upon were sheep, and the in-
strument was introduced into the subclavian vein. The degree of
pressure found to be exerted in the veins during normal respiration,
and reduced to the mercurial column for more easy comparison with
other hsemodynamic researches, was as follows :

In the left innominate vein — 01 mm. of mercury.
„ right jugular
" Vt^ subclavian „ - 0-1 „ j ^oge to the

, 5, . , " r> 1 uiose to tne origin

eft jugular „ — O'l „ \ ^^ ^^^ innominata

left subclavian

+ 0-2

— 0-1

»

— 0-1

— 0-6

»

— 1

» /

+ 3

»

+ 5-2

>»

+ 4-1

„

+ 9

>»

+11-4

»

of the innominate
vein.

a brachial vein opening

into the last-named

In the external facial vein

„ internal facial „

„ brachial vein
In a branch of the same
In the crural vein

In a dog, in a state of narcosis from the administration of opium,
and who breathed with difficulty and unnatural frequency, the
pressure in the right innominate vein was found to be +1"5 mm. of
mercury. The pressure of the blood was always found to be ma-
terially increased on muscular exertion being made. No respiratory
influence when this was normal could be observed in veins lying at
some distance from the heart. Thus it was scarcely perceptible,
and not constant in the crural, brachial, and facial veins. It first
became apparent in the jugular and subclavian veins, when it
amounted in toto to about 0"9 per sq. mm. ; so that in inspiration the
pressure sank about 0'3 mm., whilst in expiration it rose about 06 mm.
With local compression the pressure diminished in the central part
of the vein, but remained positive in the extremities, whilst it was
negative in the cervical veins. Thus in the internal facial vein it fell
from + 5 per sq. mm. to + 3'6 — in the external vein from + to 1'9.
In the subclavian vein from 0 to — 5 per sq. mm. with quiet inspira-
tion, and rose to— 35 in expiration. In the jugular vein from 0 to — 3
mm. in inspiration, and — 1 per sq. mm. in expiration. Nearly equal
negative values occurred in forced respiration when the blood-current
was uninterrupted.

Digestion.

1. On the Active Participation of the Stomach in the act of Vomiting.
MouiTZ ScHiFF. (' Moleschott's Untersuchungen.' Band x.
1867. Pp. 353.)

2. On the Absorption of Food in the Small Intestine. LirDWia
Letzeeicu. ('Virchow's Archiv f Path. Med.' Band, xxxix.
1867. Pp. 435.)

3. On the so-called Vacuoles, or Cells resembling a Port Wine-glass, of
the Small Intestine. J. Sachs. ('Virchow's Archiv,' xxxix
Pp. 493.)

238 Chronicle of Medical Science. [Jan.,

1. M. Schiif commences his observations by an historical review
of the various opinions that have been held upon this subject. It
has, he says, been customary to make Majendie express himself
much more strongly in reference to his well-known experiment of
substituting a bladder for the stomach of a dog than any warrant
can be found for in his works. All that he really says is (1) That
the stomach does not appear in all instances to contract in the act
of vomiting; and (2) That the pressure of the abdominal walls
appears to be sufficient to effect vomiting.

M. Schiff has exhumed a review of a work by Tantini contained
in an early volume of Froriep's ' Notizen,' in which the important
observation was made by the Italian investigator that no vomiting
can be induced in Majendie's experiment unless the cardiac portion of
the oesophagus is also cut away ; for if this remains, its contraction ia
sufficient to prevent the evacuation of the contents of the stomach from
occurring, and that in such cases, besides the pressure of the abdominal
walls, some other agent must be in operation to effect vomiting. Budge,
in 184)0, maintained that the act of vomiting was effected partly by
the pressure of the diaphragm and abdominal parietes, and partly by
the active contraction of the stomach, which last may in some in-
stances act per se, the pyloric portion in particular acting with great
energy, and propelling the contents of the stomach with great force
towards the cardiac orifice, which last during the act of vomiting
remains patent.

Eiihle, in 1847, considered that the stomach should be examined
as far as possible in its natural position, and under these circum-
stances believed that the only movement observable in the stomach
during the act of vomiting was the drawing up of the cardiac ex-
tremity against the diaphragm, which was probably effected by the
contraction of the longitudinal fibres of the oesophagus.

He suggested and carried out an experiment with a view of
determining what the amount of force was with which the stomach
expelled its contents that was followed by remarkable results. It
consisted in fastening into the empty and exposed stomach a mano-
meter, and then injecting some emetic into the veins. "When he
examined the fluctuations of the manometer during the act of vomit-
ing, he met with the unexpected result that at the instant of the
ejection of the contents, the pressure, instead of rising, fell. Riihle
attributes this to the sudden yielding or opening of the previously
contracted cardiac orifice, permitting the passage of the contents which
had before been compressed by the gastric parietes, but he considers
that under ordinary circumstances the actual evacuation ia effected
by the pressure of the abdominal parietes, which from other experi-
ments he was led to conclude, is more than sufficient to overcome
the resistance of the cardia. Valentin thought it could better be
explained on the Bernouilli and Venturis theorem of the origination
of negative pressure in rapidly flowing fluids.

M. Schiff, from his experiments, has also arrived at the conclusion
in accordance with the observations of Eiihle, that an opening of the
cardiac orifice takes place in the act of vomiting, which is effected

1868.] Chronicle of Physiology. 289

by an active muscular contraction, and that such act is indispensable
for the performance of vomiting; and he dissents from Euhle's
opinions, believing that the pressure of the abdominal wall and of
the diaphragm is insufficient to overcome the resistance of the cardia
and of the lower part of the oesophagus. He admits that movements
even of an active kind are often visible in the muscular iibres of the
stomach just before and after vomiting, but considers that they are
wholly uninHuential in producing this act.

M. Schiff thus describes the constant appearances seen in dogs
which had been etherized, and to which, after the stomach had been
exposed by a crucial incision, tartar emetic and ipecacuanha had
been administered after recovery from the ether. After a few
deeper inspirations than usual, a very full respiration was taken ;
the diaphragm descended a little ; the lower ribs were forcibly drawn
in when the dog stretched its neck; the left half of the«stomach
was drawn up, its volume diminished a little, and this stood in
direct relation to the amount of gas present in the stomach, and a
noise like that of a strong eructation was produced in the throat.

Immediately after this eructation the left half of the stomach
again descended, and expiration followed. When movements of the
stomach were already present, they were generally intensified ; but
if the stomach was already quiescent before the period of vomiting
commenced, weak peristatic movements^occurred, though occasionally
it remained perfectly quiescent. During the act of vomiting, especially
soon after the ingestion of food, a considerably increased quantity
of bile is discharged, in dogs, into the duodenum ; but very little, if
any of the food is squeezed through the pyloric aperture.

It is not to be concluded that the movements of the stomach are
wholly unessential or inoperative in the act of vomiting, since there
are various circumstances under which violent efforts are made, the
diaphragm being fixed and the abdominal parietes strongly contract-
ing, yet in which no evacuation of the gastric contents occurs. In
such cases the obstacle to the discharge would seem to be in the main-
tenance of the closure of the cardia, and investigations are therefore
required to determine whether at the instant of vomiting the active
participation of the stomach does not consist in effecting that of
opening the cardia, which is essential to the act. Schiff proposed to
himself to determine this point, and in order to do so made gastric
fistulae on the left side of the abdomen in dogs, sufficiently large to
enable two fingers to be introduced. After recovery from the
operation had resulted for some weeks, M. Schiff began to introduce
the fingers for a few minutes several times a day. It was found that
the cardiac orifice was uniformly closed, and presented considerable
resistance to the entering finger, and that if it even penetrated, the
fibres tightly grasped it.

After accustoming the animals to these proceedings for some time
a moderate meal was allowed, and shortly after a few grains of
ipecacuanha, or of tartar emetic, or both, were administered to it,
and the fingers were quickly introduced through the fistulous orifice.
The usual swallowing movements which precede the act of vomiting

240 Chronicle of Medical Science. [Jan,,

were then felt to occur, and it was observed that any portions of meat
which the animal was made to swallow at this time were conveyed with
great rapidity through the cervical portion of the oesophagus, but only
slowly through the thoracic portion, at the lower part of which it
might even be brought to rest for a short time. When, however, it
had once entered, as it were, the grasp of the cardiac sphincter, its
motion was again accelerated after the swallowing movements
had continued for some time, one finger being still kept just in the
cardiac orifice, whilst the other touched the smaller curvature. The
usual full inspiration took place, which appeared to depress the
smaller curvature much more than the cardiac orifice, which, if any-
thing, rather rose in the opposite direction. Then an instant before
the contraction of the abdominal walls occurred, the contraction of
the cardiac sphincter was perceived to disappear suddenly and com-
pletely, and the finger passed without opposition into the lower
thoracic portion of the oesophagus. Immediately succeeding this
opening the abdominal parietes contracted, and the gases and solid
or fluid contents of the stomach rushed past the finger to be dis-
charged by the mouth. In cases where several acts of vomiting
rapidly succeeded one another the cardiac orifice remained perma-
nently dilated. It would hence appear that the opening of the
cardia is efi'ected by the contraction of a definite set of muscular
fibres, since it precedes the pressure of the abdominal walls. These
muscular fibres can only be the longitudinal fibres of the lower part
of the oesophagus, which, having arrived at the stomach, spread
themselves in all directions obliquely over its surface. But M. Schiff
considered it requisite to ascertain whether the act here described
was one of actual vigorous muscular contraction, or whether the
opening of the cardia were not the result of a negation of muscular
efibrt produced in a reflectorial manner.

In order to ascertain this point, three methods suggested them-
selves. First, direct section of the muscular fibres in question, though
there was here danger of too seriously damaging the structure
of the stomach, or even of perforating its walls. Secondly, of divid-
ing the nerves supplying the muscle, but for this a precise knowledge
of the nerves and their distribution was requisite. A third method
still remained, which consisted essentially in paralysing a portion of
the muscle without actual separation of the outer and inner coats of
the stomach. This was effected by drawing the cardiac extremity
of the stomach in dogs of from one to three months' old through an
opening in the abdominal walls. A piece of wood (Walze) was
placed in front, and a tight ligature tied around and just below the
cardia, so that the posterior fibres were smashed. This in no way
seriously affects the aninal, who again begins to eat and drink on
recovering from the chloroform. If now the emetic be administered,
efforts at vomiting are made, but no evacuation of the contents of the
stomach occurs. This experiment, then, may be regarded as the
converse of that performed by Majendie. In both experiments the
presence of the abdominal parietes and diaphragm was maintained,
but in the experiment of Majendie the whole stomach was removed

1868.] Chronicle of Physiology. 241

with the cardia, and vomiting occurred. In M. SchifTs experiment
the whole stomach was preserved, yet vomiting was rendered im-
possible. It is thus apparent that in the stomach there is an anta-
gonist to the active efforts of vomiting, not an agent assisting or
furthering those efforts, and it is evident that it must be the anta-
gonist of this antagonist which is destroyed by the ligature. It is
clear also that the cessation of the cardiac contraction during vomit-
ing is not due to a mere relaxation of the circular muscle induced
by any reflex nervous influence. It may, however, be said that
the ligature may have destroyed certain nerves distributed to the
lower part of the oesophagus and muscles around the cardiac orifice,
but a sufiicient answer to this is found in the fact that the whole of
the gastric portion of the sympathetic may be destroyed by the
ablation of the ganglion cceliacum without affecting the act of vomit-
ing, whilst as regards the vagus, in the mode in which the experi-
ment is performed by Schiff, these fibres are not interfered with.

M. Schiff now endeavoured to ascertain what were the effects of
division of the vagi in the neck, and also of division of the oesopha-
geal branches. He found that although during the first few hours
(seven or eight) the preponderating condition was one of contraction
of the cardiac orifice of the stomach, and the lower part of the oeso-
phagus immediately adjoining it, hindering the entrance of the morsel
of food swallowed into the stomach, yet that this alternated with
periods of partial or general relaxation of the sphincter, and that
after the lapse of some days the cardiac orifice remained moderately
or slightly contracted, easily yielding to the pressure of the finger
introduced through a gastric fistula. He remarked also that the
movements of the stomach were materially modified, becoming irre-
gular. Vomiting, though not common, may yet occur, under favour-
able circumstances, after division of the vagi, and is then essentially
accomplished by the contraction of the abdominal muscles aided by
the fixation of the diaphragm. From other experiments he is inclined
to believe that the accessory fibres contained in the vagus are those
which are the really potential ones in affecting the movements ob-
served. After the* ablation of the accessorius, however, imperfect
though violent efforts at vomiting were witnessed, showing as M.
Schiff observes, that one of the most important functions of the
nervous system is the co-ordination and harmonious adaptation of
numerous movements, each individually capable of being called into
play by other means.

2. In the thirty-seventh volume of Virchow's * Archiv ' (1866),
a paper appeared by M. Letzerich, in which he endeavoured to show
the mode in which the absorption of fats was effected. He believed
that he had been able to distinguish two kinds of cells on the free or
intestinal surface of the villi. One of these was the ordinary
columnar epithelial cell with closed extremities ; the other consisted
of a spherical, pear-, or spindle-like body, the free extremity of which
turned towards the cavity of the intestine, was wide open, whilst
the attached end was tapering, penetrated the basement membrane,
and he felt certain discharged its contents into a kind of plexus with

81— XLi. 16

242 Chronicle of Medical Science. [Jan.,

structureless vralls, the wide meshes of which lying in the connec-
tive tissue of the villus, surrounded, and was in direct continuity with
the central lacteal. These special absorbent organs appeared to be
much fewer in number than the proper epithelial cells between
which they were interspersed. He was able easily to discern fat
molecules in their interior, especially in hedgehogs ; but he ncA'er
found any oleaginous particles in the true epithelial cells, except
under abnormal conditions, as where an excessive quantity of fat was
forced into the animal's stomach. In the present paper, M. Let-
zerich states that he has substantiated his former observations, and
recommends the following proceeding to be adopted in order to show
the proper organs of absorption that he has described. A considerable
quantity of well-washed mutton or beef is given to a hedgehog for a
meal, two or three hours after which it is killed. A small portion
of the duodenum, after half an hour's exposure to the air of a warm
room, is immersed in a solution of two drops of concentrated solution
of chromic acid to one ounce of water, which prevents the contrac-
tion of the villi. After the lapse of from twenty-four to thirty
hours, fine sections may readily be made with a razor, and examined
with the aid of a little glycerine and water. In all cases the interior
of the resorptive organs may be seen filled with fat molecules which,
travelling through them, enter the plexus and may be traced to the
lacteals. But if lean meat or pure albumen have been administered
to the animal, then the resorptive organs appear as strongly refrac-
tile bodies, to which, when hardened, if a little solution of carmine
in ammonia be added, an instantaneous colouration of their contents
takes place, indicating the presence of albumen, whilst the surround-
ing cylindrical epithelial cells undergo no change. As regards
these micro- chemical relations, the resorptive organs resist the
action of alkalies for a much longer period than the cylinder-epithe-
lial cells, and whilst the latter soon disappear in a solution of bichro-
mate of potash, the former may be discerned after the lapse of several
months.

3. M. Sachs observes that under the superintendence of M.
Chrzonszczewsky he has long been engaged in the study of the
structural arrangements for absorption in the small intestine, and
has, therefore, had occasion carefully to test the truth of the above
statements of M. Letzerich. He gives them an unqualified opposi-
tion. He considers the beaker-cells or vacuolae to be altogether arti-
ficial products, resulting from the action of the chromic acid or nitrate
of silver, etc., on the delicate epithelial cells of the villi, for although
the vacuolae as described by Letzerich are, indeed, sometimes visible,
yet in such cases the surrounding epithelial cells are scarcely percep-
tible, are remarkably altered in form, and their nuclei have almost
entirely disappeared. The plexus into which the resorptive organs
were said by M. Letzerich to open was never discovered even with
the utmost care by M. Sachs.

1868.] Chronicle of Physiology. 243

Nervous System.

1. On the Sensitiveness of the Spinal Cord to Electrical excitation.
Hermann En&elken. (' Keichert und Dubois Eeymond's
Archiv,' 1867, p. 198.)

2. On the CiUo-spinal Centre described hy M. Budge. Db. E. Sal-
KOWSKi. (' Henle und PfeufFer's Zeit. f. rat. Med.,' bd. xxix,
1867, p. 167.)

3. On the Supposed Anastomosis between the Geniculate Swelling of
the Facial and the Lesser Superficial Petrosal Nerve. E. Bischoff.
('Henle und Pl'euffer's Zeits.,' xxix, p. 161.)

4. On Ciliary Movement. Alex. Stuabt. (Idem, p. 288.)

Engelken's experiments were undertaken in conjunction with
Prof. Pick to determine the truth of the assertion made by v. Deen
and others that the strands of the spinal cord were insensible to all
stimuli except those of a purely organic nature. Now, v. Deen
grounded his statements upon the circumstance that mechanical
irritation as well as electrical when applied to the anterior strands
of the spinal cord excited no muscular contraction. But it may be
remarked in opposition to this that mechanical irritation is not of a
measurable character, and it is conceivable that violent injury to
the nerve structure may prove only a feeble stimulus. As a proof
reference may be made to the well-known experiments of Pontana
who long ago showed that rapid division of tlie sciatic or instanta-
neous destruction of it with the blow of a hammer, frequently produced
little or no excitation of the nerve as indicated by muscular contrac-
tion. Moreover, it is quite intelligible that even weak irritation of
a mechanical nature applied to the anterior columns may not occa-
sion muscular contraction, since it is probable that such irritation
must traverse a large number of ganglion cells, and be thus diffused
through many fibres, whence its effects become almost imperceptible.
And it may be observed also that it is quite possible that inhibitory
fibres of the spinal cord may be simultaneously called into play with
the proper motor fibres. In order that decisive results should be
obtained Engelken considers that the electrical stimulus should
alone be employed since this only is (thanks to the modern improved
methods of research) exactly measurable, and can be applied with
all degrees of strength.

Engelken-then gives the details of various experiments made upon
frogs, one of them being a repetition of v. Deen's own experiment,
on which he chiefly relied for the establishment of his statement,
and from which it appears that the electrical currents employed by
V. Deen and Gruttmann were much too feeble to produce any effect.
The results at which Engelken has arrived are — 1, that the anterior
columns of the spinal cord are just as excitable as any other nerve
fibres ; and 2, that the same is true for the posterior columns.

As regards the grey substance of the spinal cord no experiments
could be made on account of the smallness of the spinal cord in frogs,
and therefore the question of its unexcitability by inorganic stimuli
must be conBidered as yet doubtful.

244 Chronicle of Medical Science. [Jan.,

2. We have only space to give the general result at wliich M.
Salkowski has arrived after performing numerous experiments upon
rabbits. He states as the result of his inquiries that the vaso-motor
nerves of the ear and the nerves that are subservient to the dilatation
of the pupil, take origin in rabbits above the level of the atlas, and
therefore in all probability from the medulla oblongata ; course back-
wards without decussating in the spinal cord, and emerge generally
through the anterior roots of the seventh and eight cervical, and
first and second dorsal nerves, in order to enter the cervical sympa-
thetic. He has been unable to determine whether a part of the
fibres issuing from the medulla oblongata, reach the sympathetic by
communicating with the hypoglossal, as stated by Bridge to occur in
rabbits and frogs.

3. Dr. Bischoff states that he has made thirty-six special dissec-
tions with a view of determining whether the lesser superficial
petrosal nerve communicates with the geniculate ganglion of the
portio dura, and that in no one instance has he been able to discover
any such connection. The small nerve forms a loop and comes into
close topographical relation with the seventh, but does not actually
combine with it. A small branch of communication sometimes passes
between the lesser and the great superficial petrosal nerves, and a
small artery sometimes runs between the lesser petrosal and the
seventh, which he believes may have been taken for the supposed
communication. A minute gangliform enlargement exists on the
most convex part of the loop formed by the lesser petrosal.

4. Stuart commences his paper by remarking that the general ten-
dency of recent observations upon the nature of ciliary movement,
has been to assimilate and identify it with ordinary muscular move-
ment. During a late sojourn in Naples, the opportunity occurred to
him of observing well-marked ciliary motion, in the case of the larvae of
various species of gasteropoda, as the eolis and flabellina, in which the
cells are of large size and cylindrical form, and contain one, two, or
more strongly-refractile nuclei. The number of cilia on each cell
varies from six to eight ; they are 0'014 millimetre in length, and
present a flattened form, and indications of transverse striation.
Besides the nuclei the cells contain a pale granular material, which
by careful adaptation of the light can be distinctly seen to present
strige running parallel with the longitudinal axis of the cell. The
striae he believes are certainly not due to foldings of the cell wall,
but appear as columns isolated from one another by a little fluid.
They are about forty to sixty in number in each cell. That these
elements are of a muscular nature, M. Stuart considers is rendered
evident by observing the movements of the nucleus, which may be
seen to be drawn hither and thither according to the action of the
different strands to the extent of one fourth of the whole length of
the cell. Moreover, the movements of the nucleus stand in close
relation with those of the cilia, ceasing when they cease, and recom-
mencing with their recurrence. The striae, like muscular tissue in
general, became much more distinctly defined on immersion in a solu-
tion of one per cent, of chromic acid. M. Stuart agrees with Dr.

1868.] Chronicle of Physiology. 245

Kistiakowsky (' Sitz. d. Wien. Acad.,' bd. 51, 1865, p. 263), that
both constant and interrupted electrical currents act as irritants to
ciliary movement ; the opposite results obtained by earlier experi-
menters being due to the employment of improperly-constructed
apparatus which occasioned the destruction of the cells. It is pro-
bable that in chemical composition the contents of the cells essen-
tially consist of an albuminate of soda, since all movement, as has
long been known, is stopped by the action of acids. Thus, a solution
of one per cent, of acetic acid arrests the ciliary movement entirely
in from one to two minutes ; a solution of one per cent, of nitric
acid, in from two to three minutes ; of phosphoric acid in from three
to four minutes ; and of oxalic in from four to five minutes. On the
other hand, if the acid have not been applied for too long a time,
the activity of the cell may be restored by the addition of an alkali.

The alkalis, and especially soda, act as strong stimulants to ciliary
motion. Concentrated solution of sugar stops all action as soon as
it has endosmosed through the cell wall, or rather, as soon as it has
withdrawn a certain proportion of water from the cell contents, con-
sequently, in about from four to eight minutes. In these researches,
therefore, M. Stuart believes he has been able to demonstrate that
the spontaneous ciliary movement of the cells of the larvae of the
opistho-branchiata is due to the presence of contractile threads in
their interior, which are probably in direct relation with the cilia.

Deglutition.

Dr. MouEA. — On the Act of Deglutition. (With three plates, in
Eobins' ' Journal de I'Anatom'ie.' 1867. P. 157.)
After describing the various organs implicated in the act of
deglutition as the velum palati, isthmus faucium, the tongue, pharynx,
and oesophagus, M. Moura gives the following account of the acts
of deglutition, which h6 divides into two parts as observed with the
laryngoscope : 1. 2%e disposition of the food on the floor of the
mouth. The food boluses prepared by mastication and impregnated with
saliva, are insensibly carried towards the base of the tongue into the
glosso-epiglottidean fossettes and over the whole extent of the ex-
ternal face of the epiglottis. They are maintained in this position
as though resting on a kind of floor or floating bridge, limited or
arther interrupted behind by the free border of the epiglottis, and
by the hyo- or pharyngeo-epiglottidean folds placed on each side of
the space in which they are contained. An urgent desire to swallow
is then experienced, and causes the act to be completed, but some-
times the desire can be restrained. If the aliment be very soft it
overflows the hyo-epiglottidean folds, and even the free border of the
epiglottis. Some portions can descend in the anterior part of the
pharyngeal channels, or float about the orifice of the cavity of the
larynx, in the fashion of gla9ons suspended from the ceilings of
houses. In exciting the act of deglutition gently and with great
precaution, the larynx begins to rise, the vocal cords approximate,
then meet and close the glottis. The summits of the arytenoid car-

246 Chronicle of Medical Science. [J;

an.

tilages follow the same movements, and are carried forwards and
upwards. The inferior part of the epiglottis undergoes an inflexion
behind and forms a projection (the bourrelet of Czermak), which
fills up anteriorly the interval comprised between the two sub-glottic
folds and the summits of the two arytenoids. In the meanwhile,
the velum palati raises itself and becomes applied against the pha-
rynx. The isthmus of the fauces is elongated and slightly retracted.
The uvula is directed forwards instead of being pendent and vertical.
The base of the tongue now commences its movement of ascent ; it
carries with it the free portion of the epiglottis with the aliments
which are brought successively into view. The second act now begins.

2. The disposition of the several parts of the pharyngo-epiglottic
orifice into which the alimentary substances, whether solid or fluid,
penetrate.

The pharynx contracts, becomes elevated, and retracts in its turn ;
it comes into contact with the borders of the epiglottis at the instant
that its contraction becomes energetic and anterior in point of time
to the period when the tongue swollen and raised towards the pa-
latal arch entirely conceals the bottom of the throat. There may
then be seen lying across the retracted isthmus, the middle of the
superior border of the epiglottis turned forwards, and taking the
form of a semicylindrical groove which is completed by the pharynx
and in which the bolus lies. Continuing its ascent the base of the
tongue now raises the uvula, applies itself to the pillars of the fauces,
and prevents further observation of the passage of the food.

As regards the deglutition of liquids, on using a black liquid such
as ink, he has observed that the parts tinted are the whole of
the mouth, the velum palati, uvula, the pillars of the fauces, the
external surface of the epiglottis, the pharynx, the posterior surfaces
of the cricoid and arytenoid cartilages. On the contrary, the vesti-
bule of the larynx to within a very small distance of the edge of the
epiglottis, and the whole extent of the anterior or laryngeal part of the
lateral grooves, preserved their natural colour. A slight noise accom-
panies the brisk cessation of the pharyngo-laryngeal contractions,
and coincides with the descent, or, more correctly, with the detach-
ment of these organs from one another. This noise proves that air
enters the pharynx with a certain degree of force to fill the vacuum
produced by the descent of the food, and by the energetic contrac-
tions of the posterior fauces.

Dr. Moura describes very minutely the difi'erent forms of epiglottis
which present themselves to laryngoscopic examination, of which he
makes no less than five, namely, 1, The omega form ; 2, The horse-
shoe ; 3, The semicircular ; 4, The arc ; and 5, The truncated cone.

1868.J

247

EEPOET ON MATERIA MEDICA AND THERAPEUTICS.
By RoBEBT HuNTEE Semple, M.D.,

Member of the Royal College of Physicians, Physician to the Eastern Dispensary, London.

I. On the Application of Iodoform to the Treatment of Cancer of
the Uterus, and Diseases of the Bladder and the Prostate. By M.
Demarquay. — After describing the properties and mode of prepara-
tion of iodoform, and referring to the therapeutical use of this sub-
stance in England, M. Demarquay gives ' the results of his own
experience of it as a local application. He has employed it in
cancer of the uterus and in diseases of the bladder and prostate.
He has applied it in the form of suppository with cacao butter,
which is to be placed in the rectum in the case of diseases
of the bladder or prostate, or in the vagina, in contact with the
diseased mass, in the case of carcinoma or epithelioma of the
uterus. A plug of cotton, placed at the entrance of the vagina,
will prevent the substance from running out. When the cancer has
foi'med a cavity, the remedy must be placed in the midst of it, in
order that the diseased structure may be well exposed to its action.
Patients affected with inflammation of the prostate and the neck of
the bladder reported themselves as somewhat improved by this plan
of treatment, but M. Demarquay does not consider the results as
altogether satisfactory. In cases, however, of ulcerated cancer of
the neck of the womb, the improvement has been more decided.
The application of iodoform has relieved pain, without disturbing
the organic functions, and the improvement has continued as long
as this agent was employed. The same improvement was observed
in some cases of ulcerated cancer of the rectum, but M. Demarquay
observes that, in certain instances of inflamed uterine cancer, the
suppositories produced so much pain that they were necessarily
discontinued. The iodoform is, therefore, not applicable in all cases,
but in suitable conditions it is very useful, being very superior to
opium as a local sedative, the iodine it contains producing its con-
stitutional effects, while the organic functions, and especially the
digestive, are undisturbed. — bulletin General de Th6rapeutique, May
15, 1867.

II. A Severe Case of the Hcemorrhagic Diathesis, treated hy large
Doses of Wine. — A woman who generally enjoyed good health had her
gums softened and ulcerated to such a degree that the teeth were
denuded to their whole extent. Prom the mouth there flowed in-
cessantly a thick sheet of saliva, quite red with blood, in the midst
of which there oozed out from time to time several semifluid and
blackish clots. The mouth was almost entirely filled with semi-
coagulated blood, which appeared under the form of divided streams
as soon as the jaws were separated. The tongue was covered with a
thick clot, and if it was wiped the blood was immediately seen to

248 Chronicle of Medical Science. [J

an.

flow from it in little drops. At intervals there was a well-marked
difl&culty of breathing, and some paroxysms of coughing supervened,
and the patient threw up mucus reddened with blood and even
mixed with blackish clots .Thej body and the limbs were dotted
with bluish spots, and the legs and thighs were sprinkled with spots
of purpura. This condition lasted a fortnight, during which a
variety of remedies had been employed in vain, and the patient was
in a state of great exhaustion. TJnder these circumstances, M,
Faure, recollecting what he knew of the eifects of intoxication in
animals which had been subjected, for experimental purposes, to
the action of alcohol, resolved to plunge the patient into a state
of drunkenness, and to keep her in it for a prolonged period. He,
therefore, ordered some old Bordeaux wine, and gave her several
glasses, one after another, and directed a glass to be given every
quarter of an hour. In the evening she was intoxicated, but, never-
theless, the treatment was continued all night. The next morning,
the hsemorrhage was entirely arrested, and it has never since
appeared ; and the cough, the oppression, and the sleeplessness,
which had so long distressed her, all ceased. It is also worthy of
remark, that from this time no more spots of ecchymosis were pro-
duced, and those which existed were absorbed in a few days. —
L' Evenement Medical, and Bulletin General de Therapeutique, March
30, 1867.

III. On the Distinctive Characters of the Bromide and Iodide of
Fotassium. By M. Bonnefon. — The price of the bromide of potassium
being rather high, this salt is often adulterated with iodide of
potassium, which is much cheaper, and hence it happens, as the
therapeutical powers of each are very diiferent, that failures in
treatment are sometimes erroneously attributed to the bromide,
although the want of success is really due to the faulty method of
preparing it. As the bromide and iodide of potassium are isomor-
phous, and are both white, it is impossible to distinguish them by
their appearance, and there is no easy test by which the presence of
iodide of potassium in the bromide may be at once detected. The
following, however, are the characters by which the two salts may
be distinguished : The bromide has a salt and rather acid taste, the
iodide an acid, pungent, and metallic taste. The action of air on
the bromide is but slight, but on the iodide it is more marked ; for,
by means of its oxygen, it displaces a portion of the iodine and
communicates to the salt a slightly yellowish tinge, and causes it
also to smell of iodine. The bromide is very soluble in water, but
sparingly so in alcohol, the iodide is very soluble in both. With
nitrate of silver the bromide of potassium gives a yellowish-white
precipitate, and with a salt of lead a white one ; but iodide of
potassium gives with nitrate of silver a white precipitate, and with
a salt of lead a yellow one. Corrosive sublimate produces no re-
sult with a solution of bromide of potassium, but it gives a red
precipitate with the iodide. Bromine decomposes the iodide of
potassium, but iodine produces no effect upon the bromide. In
order to ascertain whether the bromide of potassium contains any

1868.1 Report on Materia Medica and Therapeutics. 249

iodide of potassium, a small quantity of the suspected salt should
be dissolved in water to which some starch has been previously
added, and then a few drops of nitric acid should be employed,
when a blue colour will be produced owing to the formation of
iodide of starch. — Bulletin General de ThSrapeutique, Feb. 15, 1867.
IV. On the Therapeutic Effects of the Bromide of Potassium. By
James Begbie, M.D., Edinburgh. — Dr. Begbie does not refer, in
this paper, to the alterative, absorbent and deobstruent properties
of the bromide of potassium, which have all been recorded, but to
its efficacy in some forms of disease in which it has only recently
been employed. Dr. Begbie regards the bromide as a valuable
calmative and hypnotic, and has known it to procure repose in
cases where opium and other narcotics have failed, or where they
have succeeded only at the expense of sickness, vomiting, headache,
and other unpleasant consequences. In the sleeplessness occurring
during convalescence from fever, or at the termination of acute
diseases, or after the performance of surgical operations, the bromide
is a safe and efficacious remedy, given in doses of twenty to thirty
grains in water, every night and morning, for some days or weeks.
In nervous affections, arising from overtaxed brain, and characterised
by headache, want of sleep, breathlessness, giddiness, &c., the bromide
of potassium has been successfully employed. Dr. Begbie also con-
firms the opinion, now generally entertained, of the efficacy of the
bromide in the treatment of epilepsy ; and, although he does not
consider it an infallible remedy in this disease, he believes that the
paroxysms are often warded off, or their violence mitigated by its
use, which should, however, be continued for a prolonged period.
In the treatment of acute mania and delirium tremens, for which
opium, antimony, aconite, digitalis, and other powerful drugs have
been employed, Dr. Begbie proposes to substitute the bromide, which
he believes to be a safer and not less efficacious medicine, and he
gives a few cases in which it has proved beneficial. In several
affections of the larynx and bronchi, which are believed to be of
cerebral origin, or at least are connected with some derangement of
the nervous centres, such as hooping-cough, laryngismus stridulus,
and spasmodic asthma, the bromide of potassium has been found by
Dr. Begbie to possess powers not inferior to any of the narcotic
remedies in general use. In diabetes, which has been attributed,
with considerable force of argument, to derangement or irritation
of the nervous centres. Dr. Begbie believes that the use of the
bromide is fairly indicated, and that it may produce satisfactory re-
sults. He relates four cases, in three of which the bromide was
successfully employed, and he states that Sir James Simpson has also
treated a case with the same remedy and with entire success. Even in
cholera, Dr. Begbie recommends a trial of the bromide, on the ground
that the phenomena of this disease, in its early stages at least,
point to its intimate connection with derangement of the ganglionic
system of nerves. The remedy has been tried in the Leith Cholera
Hospital and the Edinburgh Cholera Hospital, and although it
cannot be considered as an antidote to the poison of cholera, Dr.

250 Chronicle of Medical Science. [Jan.,

Begbie states that it has certainly stripped the disease of some of
its terrors, especially by allaying irritation of the nervous system,
and relaxing spasm of the muscular fibres. Dr. Begbie concludes
his paper by suggesting the use of the bromide as a sedative in
certain stages of fever, and in exophthalmic goitre. — Edinburgh
Medical Journal, December, 1866.

V. On the Eucalyptus Globulus as a Febrifuge. By Dr. Ullers-
perger, of Munich. — The Eucalyptus globulus is a tree of considerable
size growing in New Holland, belonging to the order of Myrtacese, and
having a hard wood which is used in ship-building. It is stated that,
in Barcelona and the neighbourhood, an infusion of the leaves, used
like tea, has been given with the greatest success in fevers. Several
intermittents were also cured, among which was a double tertian, and
another case in which quinine had been given without effect. The
favourable results were manifested after the first dose ; and while
quinine, given in the increase of the fever, only aggravated the
symptoms, the eucalyptus on the other hand, taken under the same
circumstances, did not aggravate, but diminished its violence. Ac-
cording to Salarich, who describes the tree in the ' Espanna Medica,'
the eucalyptus grows in temperate as well as in hot climates, but not
in cold ones. Besides its use in intermittent fevers, Salarich recom-
mends it as the best anodyne in nervous headache and in other pains
of the head, which are not exactly of a periodical type. — Schmidt's
Jahrhilcher der Gesammten Medicin, December 10, 1866.

VI. On the Use of Permanganate of Potash in the Treatment of Car-
buncle. By Dr. T. L. Leavitt. — As the local use of permanganate of
potash was found very beneficial, during tlie last year of the American
war, in the treatment of sloughing ulcers, phlegmonous erysipelas,
and hospital gangrene. Dr. Leavitt conceived that its peculiar reme-
dial properties would prove equally successful in carbuncle, arising,
as it does, from a depressed vitality and a morbid condition of the
blood. He gives the history of three cases in which the perman-
ganate was successfully employed, and it would appear that this
remedy succeeded when other means had failed. In one of the
cases, after a crucial incision had been made into the carbuncle with-
out any relief, the application of a strong solution of the perman-
ganate (3 gr. to 5j) was followed by rapid relief of the symptoms —
true pus took the place of the previous sanious discharges, the pain
subsided, and the fever disappeared ; and after continuing this appli-
cation for a few days longer the slough separated and the wound
healed. In another of the cases the local application of the per-
manganate was almost the sole measure resorted to, as only a slight
incision was made into the tumour, and the carbuncle disappeared
entirely in three days, although on a previous occasion the patient
had suffered from a series of carbuncles which lasted a whole winter.
Dr. Leavitt has found the permanganate equally beneficial in the
treatment of chronic ulcers, and he relates a case, of many years'
duration, which yielded to the remedial powers of this preparation.
— American Journal of Medical Science, January, 1867.

1868.] Report on Materia Medica and Therapeutics. 251

VII. Successful Treatment of a Case of Traumatic Tetanus hy the
direct application of Infusion of Tohacco. By J. B. Junor, of Peebles.
— The case was that of a girl nine years old, whose leg had been
severely injured by a large cope-stone falling on it, and causing a
lacerated and contused wound of the calf of the leg, extending from
immediately below the knee to beyond the ankle, and laying bare
the posterior tibial artery in the whole of its length. During the
progress of the case symptoms of tetanus became manifest, and soon
became perfectly developed, the rigidity extending over the whole of
the body, and the paroxysms becoming very frequent and severe.
Chlorodyne was given internally, and a belladonna lotion was applied
to the wound ; but these measures produced only a temporary
alleviation of the symptoms, and on the sixth day after the appear-
ance of tetanus Mr. Junor applied to the wound stupes of an infusion
of Cavendish tobacco, half an ounce to a pint of water. Within two
or three hours after the application of the tobacco there was a great
improvement, all the rigid muscles became to a considerable extent
relaxed, the mouth could be opened about half an inch, the paroxysms
were less severe and frequent, and a good deal of sleep was obtained.
On leaving oS the tobacco lotions the paroxysms returned, but on
reapplying them relief again ensued, and the same result was
observed on a subsequent occasion when the use of the tobacco
was suspended. At last, about two months after the commence-
ment of the treatment, the wound healed, the tetanic symptoms
entirely ceased, and the patient recovered. — Edinburgh Medical
Journal, February, 1867.

VIII. On the Use of Sromide of Potassium in Acute and Chronic
Affections of the Testis. By Dr. Bedford Brown, of Washington. —
Bromine possesses remarkable sedative powers over the nervous system
without inducing the serious effects resulting from more powerful
narcotics, and therefore it is specially adapted to the treatment of
the diseases of organs having such varied and extensive nervous
communications as the testis. Dr. Brown states that an experience
of nearly ten years convinces him that it has a very decided specific
effect in diseases of the entire genito-urinary system. In affections
of the testis, and of the generative organs generally, there is a
remai-kable association of sympathy, not only between themselves
and their varied relationships, but with the entire spinal cord and
brain, and the prompt action of bromine on these two great nervous
centres accounts in some measure for its sedative influence when
used in disease of the generative organs. In urethral strictures
attended with undue irritation of the bladder and its neck and
enlargement of the prostate gland, bromine is a valuable remedy,
and in consequence of its success in these affections Dr. Brown
determined to test its powers in organic diseases of the testis.
It was employed in the three principal forms of serious disease of
this organ — namely, acute inflammation, chronic enlargement, and
scirrhous hardness. He gives the particulars of three cases as
illustrative of the efficacy of the bromide of potassium in the three
conditions alluded to the first case (which is the most remarkable)

252 Chronicle of Medical Science. [Jan.,

being one in which there was scirrhous hardness of both organs,
with great increase of size and weight, and in which a perfect cure
ensued after the use of the bromide for four months, in doses of ten
to twenty grains three times a day. — American Journal of the
Medical Sciences, July, 1867.

IX. On the Successful Employment of Bromide of Potassium in
Hooping -Cough. By Dr. de Beaufort. — Dr. de Beaufort has observed,
in the course of his practice, that the use of bromine was attended
with very good effect in the treatment of hooping-cough, and he
anticipated such a result. For, according to his view, the principal
symptomatic phenomenon which distinguishes hooping-cough from
a simple catarrh, is the exaltation of sensibility in the laryngeal
mucous membrane, especially towards the upper orifice of the
larynx. This hypersesthesia excites, by reflex action, the convulsive
cough and the contraction of the larynx, and consequently a medicine
like the bromide of potassium, which exerts such a remarkable
anaesthetic action ought to arrest the principal symptoms of hooping-
cough, and to reduce the disease to its catarrhal element. The
bromide, in the hands of Dr. de Beaufort, rapidly produced the
desired effect, and in twenty cases, taken at different periods of the
disease, laryngeal spasm was found to disappear in five days on the
average, and the disease was converted into a bronchial catarrh. The
patients, however, were not cured, but their condition was altered ;
there was no more anxiety or vomiting, the appetite was improved,
the nutrition was better, and the strength was increased. Such a
rapid result was very satisfactory, but Dr. de Beaufort desired to
complete the cure, and he therefore endeavoured to find some other
medicinal agent, which might effect, in combination with the
bromide, what the latter was insufficient to accomplish alone. The sub-
stances which he found most efficacious were aconite and the balsam
of Tolu,, and he publishes a formula in which the syrup of balsam of
Tolu, bromide of potassium, and an alcoholic preparation of aconite
are combined together. By the aid of these three remedies he has
seen hooping-cough cured in twelve days on the average. — Bulletin
General de Therapeulique, May 30, 1867.

X. On the Employment of Hydrochlorate of Ammonia in the Treat-
ment of Catarrhal Affections, as an Adjunct to the Sulphate of Quinia.
By Dr. Marrotte, Physician to the Hopital de le Pitie, Paris — By
the term catarrhal affections. Dr. Marrotte indicates a number of
epidemic complaints which have lately prevailed in Paris, and which
include several forms of fever and of pulmonary inflammation,
generally assuming a periodic type. These afiections were often of long
continuance, but they never assumed a malignant form, and their
habitual seat was the mucous membrane of the throat, the bronchi,
and the intestines. Pleurisy sometimes supervened, and also
neuralgia, which latter attacked most commonly the face, but oc-
casionally the trunk and the pelvis : and pneumonia and rheumatism
were also among the sequelae. Two characters appear to Dr.
Marrotte to belong to the epidemic he describes, namely, the
distinctness of the paroxysms, and the inflammatory excitement of

1868.] Report on Materia Medica and Therapeutics. 253

the mucous membrane. At the commencement of the epidemic, Dr.
Marrotte found mild remedies sufficient for the treatment, such as
rest in bed and warm drinks, to which he added, according to cir-
cumstances, some acetate of ammonia or Dover's powder, and even
pleurisy yielded to the same treatment. But when neuralgia super-
vened, he employed sulphate of quinia, in large doses, namely, from
one gramme (about fifteen grains) to a gramme and a half, as re-
commended by Trousseau. But when the cases were accompanied
by feverish symptoms of an acute character, the quinia often failed, and
Dr. Marrotte was induced to try the effect of hydrochlorate of am-
monia, in consequence of having witnessed its efficacy in marsh fevers.
When the cases were slight the paroxysms of fever, and especially the
neuralgic attacks, were arrested on the first or second day, though in
more severe cases, two, three, or four days were required for the
cure, but the improvement was considerable on the first, and
especially on the second day. The doses of the salt, which were
necessary to cut short the paroxysms, varied from two to four and
five grammes a day. It was administered in quantities of half a
gramme to a gramme, at intervals of three to four hours, in such a
manner that the last portion should be taken two or three hours
before the anticipated approach of the paroxysm. Dr. Marrotte
considers that the facts collected by him prove that, in the present
constitutional epidemic, the hydrochlorate of ammonia may become
a useful adjuvant to the sulphate of quinia in the treatment of the
affections he describes. — Bulletin General de Therapeutique, May 15,
1867.

XI. On the Treatment of Pulmonary Phthisis hy the Vapour Bath
(vaporarium). — -Professor Trousseau, during the latter years of his
attendance at the Hotel Dieu, as physician to that hospital, con-
ceived the idea of treating phthisical patients by making them live
permanently in a warm and moist atmosphere ; and he was led to
this idea by observing that in flax-spinning establishments, where a
warm and moist air is required, the number of phthisical patients is
relatively limited. An apparatus coutrived to carry out this mode
of treatment was fitted up in a ward of the Hotel Dieu ; but un-
fortunately the experiments were not continued for a sufficiently long
period to test its efficacy, and the ouly treatise bearing upon thia
mode of treatment has emanated from a provincial French physician,
Dr. Henrot, of Kheims. In the year 186i Dr. Trousseau was con-
sulted by a manufacturer of E-heims on the illness of his daughter,
who was suffering from a pulmonary affection. Dr. Trousseau sug-
gested that if the patient had a steam-engine, and could be placed
in a workshop full of a warm and moist air analogous to the atmo-
sphere in the flax-spinning establishments, she would experience
great relief He added that the small number of consumptive
patients in the flax-spinning factories had been observed, and that
he himself had seen benefit derived from this treatment in the case
of a spinner living near Paris. The advice of Dr. Trousseau was
carried out at Eheims by the patient's ordinary medical attendant,

254- Chronicle of Medical Science. [Jan.,

who constructed for her a room, into which steam was made to pass.
The result was so successful that the same means were employed in
other cases. The vaporarium is a room filled with steam, in which
the patient always remains. To obtain a moist and warm atmo-
sphere two methods are employed. In the one, used in establish-
ments where there is a steam-engine, a pipe conveying the steam is
passed into the room, and this pipe is plunged into the bottom of a
trough containing water, the trough being so -constructed that the
steam in traversing it may be mixed with a great quantity of water,
and that the evaporation may be considerable. The second plan
consists in arranging, in the patient's room, a pipe leading from a
gas-reservoir, and terminated by an apparatus like that employed in
kitchens where the stoves are heated by gas. Over this pipe a
metallic vessel is placed filled with water ; and by lighting the gas
the water is made to boil, and afterwards to disperse its steam into
the room. The latter arrangement is the less convenient, and the
more expensive of the two. Several cases are recorded by Dr.
Gallier and Dr. Henrot, in which this treatment was successfully
adopted for phthisical patients in whom the physical signs of pul-
monary disease were well marked. It is stated, as the results of the
treatment, that three confirmed cases of phthisis were cured, that
two cases of obstinate cough were improved, that one case of croup
was rapidly cured, and one of oedema of the glottis, which had
resisted all other means employed, was cured in a few hours. In
some cases, however, when the treatment was commenced too late,
the treatment was unsuccessful. Although the number of cases is
still too small to justify any positive conclusion, it may be understood
that the steam chamber may act beneficially in many cases, and may
be substituted, especially in the winter, for a residence in southern
countries and maritime regions. — Bulletin General de Therapeutique,
July 30, 1867.

EEPOET ON TOXICOLOGY, FORENSIC MEDICINE,
AND HYGIENE.
By Benjamin W. Richaedson, M.D., F.E.S.

I. — Toxicology.

Researches on Thallium. — The action of thallium has been care-
fully studied by Dr. William Marme. The author traces out the
effects of thallium on various classes of animals, as on reptiles, birds,
and mammals. He maintains that small doses of the various prepa-
rations can be tolerated for a short time, but the poison is cumulative
in its efiiects : the organism never accustoms itself to the poison.
In large doses after a time thallium takes efiect on the stomach and
intestines, as do also its salts, such as the iodide and sulphide, but in
the latter the efiiects are more sudden. "When the very soluble
preparations of thallium are introduced into the system of frogs

1868.] Report on Toxicology ^ Forensic Medicine, 6fC. 255

by subcutaneous injection, lethal symptoms are induced by 003
to 006 of a gramme; in birds, by 0"04 to 016 of a gramme;
in dogs, 0'15 of a gramme; in rabbits, 004 to 006. When
the same preparations are introduced by the stomach the doses
differ: then 05 to I'O of a gramme is required to produce
effects on dogs and cats, 0"5 for rabbits : for mice, 05 milli-
grammes. Por injection directly into the blood by the vessels doses
scarcely smaller are requ-'red than when the injection is simply sub-
cutaneous; for as the quantity of water for solution in the latter
case must be greater, the diffusion of the poison is relatively expe-
dited. Symptoms of poison are never so rapidly evinced from the
thallium compounds as from the active compounds of mercury.
After continued administration of small doses of the thallium salts
the appetite is impaired, there is pain in the bowels, vomiting,
diarrhoea and haemorrhage, free salivation and wasting. To these
symptoms may be added feebleness, difS^culty of respiration, and
weakness of the circulation. Anomalous muscular action has also
been observed, viz. tremor, and want of co-ordination of movement.
Animals thoroughly affected can neither walk nor stand with security :
they stretch out their fore limbs as if under chorea, i.e. without any
distinct object or intention. These latter symptoms often occur
even when the aniuial takes its ordinary quantity of food they do
not therefore necessarily depend on disturbance or interference with
the digestive power. As the poisoning becomes general, conjunc-
tivitis is a frequent symptom, attended W'ith a free secretion of mucus,
and probably also with disturbance of vision, although the ophthal-
moscope does not discover any peculiarity in the retina, the lens, or
the iris.

The further effects of the poison show themselves, according to the
post-mortem appearances, in the form of small effusions of blood and
pneumonic infiltration of the lungs ; to these are added an intense
congestion of the vessels of the intestines of the large and of the
small vessels alike, especially of the vessels of the mesentery and
of the stomach. In the pericardial cavity in the higher animals,
when the poison has been long continued, there is always a large
increase of the pericardial fluid, and upon the cardiac surface are often
found hsemorrhagic effusions of various degrees. Fatty degeneration
is rarely met with.

Thallium salts, which are soluble, seem to find their way into all
the organs, and their elimination out of the system is chiefly by
the excretion from the kidneys, although all the excretory surfaces
serve to some extent as outlets. Very much later the salts are
found in the contents of the intestinal canal.

As the salts are found in the urine and in biliary secretions equally
after the operation of subcutaneous injection, it must be inferred
that they are thrown into the intestines by the bile, to be reabsorbed
in the alimentary canal, and this especially as the salts are very
soluble in alkaline solutions. The rapidity of absorption of those
thallium compounds which act on the body is great ; the salts can
be detected in the urine in from three to five minutes. In the milk

256 Chronicle of Medical Science. [Jan.,

of the goat the poison was detected in seventeen hours, after the
subcutaneous injection of so small a dose as 0*050 of a gramme. In
the lachrymal, salival, buccal, tracheal, and stomach fluids, and in
vomited fluids, thallium has also been discovered after its subcu-
taneous introduction into the body. When metallic thallium is
given by the stomach, its elimination begins somewhat suddenly,
and when the administration is continued in small doses, for a time
the presence of the poison can be discovered in the urine so long as
three weeks after the last dose. The author does not appear to
have any antidote for the eifects of thallium. There is no known
eliminative agent ; alkaline solutions of soda may be taken if given
early, and may be followed by briskly-acting emetics and purgatives.
Marme concludes his paper by describing the mode of detecting
thallium by means of spectrum analysis, and suggests that certain
of&cinal metallic medicines may be bearers of the substance. — Nadir.
V. d. k. Oes. d. Wissensch. zu Gbttingen, Nr. 20, Aug. 14<th, 1867 ;
und ' Schmidt's Jahrhucher," Nr. 9, 1867.

Suhlimation of the Alkaloids. — Dr. Guy has continued his researches
on the sublimation of the alkaloids, and his papers now may be con-
sidered as completed for the first stage of his interesting researches.
Speaking of the vegetable alkaloids, Dr. Gruy states that they undergo
visible changes of form and colour when heated, from which changes
arsenious acid is wholly free ; and it is but reasonable to suppose
that the vapour disengaged from those substances while these
changes are going forward, should itself undergo changes of com-
position affecting the character of the sublimates. This natural ex-
pectation is fully justified by experiences of those alkaloids which,
like strychnine and morphine, yield crystalline sublimates. If we
take strychnine as the type of this class, and conduct the process of
sublimation with care and caution, applying at first a moderate heat,
and increasing it by degrees, we ought to obtain a series of subli-
mates of distinct crystalline formation, both before and after the
melting of the alkaloid ; then a few colourless sublimates without
crystals ; and, last of all, a series of yellow or yellowish-brown sub-
limates, evidently discoloured with empyreuraatic matter, and the
effect of a sort of destructive distillation. If the process be narrowly
watched we shall observe that, so long as the vapour is colourless,
it deposits itself as a mist, in which by degrees snow-white spots,
often circular in shape, and often coalescing into larger spots, de-
velop themselves, which spots are of crystalline formation. But if,
when the mist appears, and before the spots show themselves, we
withdraw the disc of glass, we obtain sublimates of the second order.
Now, if we examine these three orders of sublimates by the micro-
scope, the first is found to have a distinct crystalline texture ; the
second, to consist of circular colourless drops packed close together,
rarely coalescing, and maintaining their separate character for weeks
and months together, or from the first forming a continuous waving
pattern with well-preserved interspaces : the third, also, of drops or
waving patterns, but tinged more or less deeply of the colour with

1 868. J ' Report on Toxicology, Forensic Medicine , ^c. 257

"whicli burning paper stains the fingers. This description is equally
true of morphine, except that the crystalline form rarely shows itself
before the alkaloid melts.

Dr. Guy proposes to call these three varieties of sublimate — the
crystalline, the watery or watered, and the smoked.

Helwig, though he recognises the discoloration of the last-formed
sublimates of strychnine and morphine, does not appear to have
taken any notice of the watery variety. He seems to assume that
the thicker stains of strychnine and morphine, in which, be it recol-
lected, he does not recognise any crystalline formation, are the only
ones worthy of attention ; and to these alone does he apply his
reagents. The watery and the smoked varieties seem to have been
disregarded or rejected. But when we are dealing with substances
which undergo in the heating such changes of form and colour, and
when we call to mind that arsenious acid, which undergoes no such
changes, does not always yield a crystalline sublimate, it is easy to
understand how important it may become to turn to good account
those sublimates of the alkaloids which do not assume a crystalline
texture. And when we further recollect that many of the alkaloids
yield no other sublimates than those which come under the descrip-
tion of watery, watered, or smoTced, we must be still more anxious to
try the effect of reagents upon those varieties, as giving a chance of
discovering some certain means of diagnosis.

To the smoked sublimates the attention of the author was forcibly
drawn very early in this investigation by the extraordinary size and
brilliancy of the crystals instantly formed in a smoked sublimate of
morphine treated with a solution of bichromate of potash — a result due
in part, if not wholly, to the action of the distilled water itself. The
discovery of this very curious and striking reaction with the smoked
sublimate of morphia led him to select that alkaloid as an illustration
of the sort of results which we may expect to obtain with the
alkaloids and analogous active principles. The questions which must
suggest themselves to the practical man equally with the philosophical
inquirer are these : — 1. What proportion of the sublimates of an
alkaloid yielding crystalline forms may be expected to assume this
character? 2. Do the reagents which produce characteristic effects
on the crystalline sublimates affect equally, or similarly, or in any
other characteristic manner, those sublimates, whether watery or
smoked, which are wholly destitute of crystalline forms ? These two
questions are fully answered in an account of a series of experiments
with morphine.

After obtaining eighty characteristic sublimates, the author
arranged them in three classes, according as they contained crystal-
line forms, consisted of watery patterns, or were smoked. He then
selected, for careful experiment and comparison, one specimen from
each group, and applied to them distilled water as a reagent. He
repeated this experiment with distilled water, and then adopted pre-
cisely the same procedure with dilute hydrochloric acid, solution of
carbazotic acid, solution of bichromate of potash, and solution of
nitro-prusside of sodium, successively, his object being to ascertain

81— xii. ' 17

258 Chronicle of Medical Science. ' [Jan.,

whether the reagents wliich produce effects striking and character-
istic with crystalline sublimates affect the two classes of non-crystal-
line sublimates in the same way, or in any other characteristic
manner.

The following reactions supply the answer to this question :

1. Distilled "Watee —

a. Crystalline sublimate. — Immediate solution. The dry spot

shows small crystals and crystalloids.

b. Watery sublimate. — Immediate development of small sparkling

crystals, visible in dry spot.

c. Smoked sublimate. — Immediate development on the smoky

drops, and in the interspaces of large winged crystals and
rosettes ; further development in course of time : crystals
permanent in dry spot.

2. Distilled "Watee, second experiment —

a. Crystalline sublimate. — Immediate formation of crystals

springing from the crystalline pattern at all points.

b. Watery sublimate. — Large rosettes immediately developed.

c. SmoJced sublimate. — Immediate development of large winged

crystals marked with radiating lines, and bearing a curious
resemblance to insects of the order of the dragon-fly.

3. Dilute Htdeochloeic Acid (^\y).

a. Crystalline sublimate. — Immediate solution^of sublimate ; and

on drying bundles of needles and prisms, chiefly at borders
of crust, with numerous cubical crystals scattered over the
centre.

b. Watery sublimate. — Immediate solution ; and, on drying, one

small and one large bundle and numerous cubical crystals,
as above.

c. Smoked sublimate. — No immediate effect ; but, after a time,

separation of layers and detachment of large irregular
fragments. In dry spot no bundles, but numerous cubic
crystals, as above.

4. Caebazotic Acid (-j^^).

a. Crystalline sublimate. — Immediate thickening of liquid as seen

by the naked eye ; colour yellow by reflected, black by
transmitted light. Crystalline spots slowly dissolved. Thick
scum on surface of liquid, with floating bundles of crystals.
Crystals also on glass, like scattered petals of flowers. In
dry spot crystals still visible, and at margin of spot thick
dark masses of coalesced discs.

b. Watery sublimate. — Immediate thickening of liquid with

abundant dark scum, and black granules formed instanta-
neously in the globules. No crystals. In dry spot the
globules retain their shape, but are mottled.

c. Smoked sublimate, with large oily globules. Immediate

thickening of fluid, and development of dark spots, discs.

1868.] Report on Toxicology, Forensic Medicine, ^c. 259

and lines in globules. A few bright crystalline bundles
spring from some of the globules. Here and there bright
stars. In dry spot the globules retain their shape ; but
their tint varies, some having a golden hue, some being
marked with black streaks and ridges. Dark masses at
margin ; but no crystals except those of the precipitant.

6. BiCHEOMATE OF PoTASH (t^tj).

a. Crytalline suhlimate. — The crystalline figure quickly dissolved,

mossy forms float on the surface, and brilliant crystals
(stars, rosettes, and winged crystals, finely veined) spring
Up. Crystals permanent in dry spot.

b. Watery sublimate (watered pattern and drops). — Instanta-

neous development of innumerable brilliant crystals, con-
sisting of rosettes, winged crystals, and patterns of which
the elements are discs and prisms. Some crystals- float on
the surface. Crystals remain in dry spot. ^
ft Smoked sublimate (large coarse specimen). — Instantaneous
solution, and immediate formation of groups of crystals of
immense size and rare beauty, like fine brilliants closely
set, or beautiful feathers springing from a centre, and in
some places, at the end of some member of a group, a fan-
like layer of fine radiating lines covering a considerable
surface, and at the borders of these again fine bold crystals.
Some of the feathery crystals (part of a group) fill the
whole diameter of the field ; also detached solid crystals
of many forms, among which are seen four- and six-sided
prisms. Many of the crystals may be fitly compared to
smoked diamonds. Crystals permanent in dry spot.

6. NiTEO-PEUSSIDE OF SODIUM (^^q).

a. Crystalline sublimate. — Immediate mossy scum, large rosettes

springing from the crystalline patterns and elsewhere.
These patterns gradually dissolved. In dry spot traces of
the sublimate undissolved. Coarse crystals consisting of
ovoid plates, some projecting vertically from the glass.

b. Watery sublimate. — Instantaneous formation of many crystals,

thin and disc-shaped, on radiating lines. Mossy scum. In
dry spot numerous circular spots made up of discs, and the
crystalline form of the nitro-prusside mottled and obscured
by them.

c. Smoked sublimate. — Instantaneous development of innume-

rable brilliant crystals (rosettes, winged crystals, and
scissor-shaped) on the smoked globules. The crystals
everywhere very distinct, with dark defined borders. In
dry spot the smoked globules full of coarse dark crystals,
and innumerable small crystals scattered over the field ;
also some crystalline forms, as in h.

It is thus clear that in the case of morphine, and probably in the

260 Chronicle of Medical Science. [Jan.,

case of other alkaloids which yield crystalline sublimates, very
strongly marked and apparently characteristic reactions are obtained
with both the watery and smoked varieties of sublimate. Hence if,
in any case, we fail of obtaining the crystalline sublimate which we
desire as being most characteristic, we may still interrogate the
watery or smoked deposit with an excellent chance of getting a
marked reaction.

It will, indeed, have been observed that the finest crystalline forms
spring, in four cases out of six, out of the smoked sublimates ; and
though the other two forms yield results remarkable for rapidity and
brilliancy, they are equalled in these qualities, and greatly surpassed
in the element of size, by the smoked variety. Of its reactions it is
no exaggeration to say that, in the size and brilliancy of the crystals
and the rapidity of their formation, they surpass every chemical reac-
tion of which the author has had experience. "Whether these reac-
tions of the several varieties of sublimate of morphine and strychnine
and the other alkaloids will prove as practically useful as they are
strikingly novel and beautiful, is a question which must be reserved
for solution. It will also be necessary to ascertain, by repeated
experiments, whether they are constant, frequent, or exceptional.

One result, bearing directly on the practical application of the
test of sublimation obtained in reference to morphine, is in con-
firmation of a similar result in the case of strychnine. By exposing
first a strong, and then a weaker solution of acetate of morphine to
the vapour of ammonia. Dr. Gruy obtained a score of small crystalline
spots, each of which, without exception, yielded its snow-white crys-
talline sublimate and a carbonaceous residue. The less soluble
acetate of strychnine, treated in the same manner, gave also its crys-
talline spots and its snow-white spotted sublimates, leaving a residue
of crystals, from which, doubtless, other sublimates might have been
procured.

From these experiments with morphine and strychnine, therefore,
we learn what similar experiments with spots of strychnine from
solution in benzole had already taught, that spots deposited from
solutions of these alkaloids yield more certain and satisfactory results
than small fractions of a grain of the commercial alkaloids. The
method of sublimation for simplicity of procedure, delicacy, and
uniformity, will not suffer by comparison with any of our approved
methods of qualitative analysis. — JPharmaceutical Journal for July,
August, and September, 1867.

Microscopic Detection of the Alkaloids. — Dr. Leonard Sedgwick
takes a different view from Dr. Guy of the value of sublimation as a
means of recognition of the alkaloids. He advances the following ob-
jections to the process. The alkaloid may be destroyed ; for all such
bodies — indeed, all organic crystallizable bodies — are decomposable
by heat, and some of the latter at not very high temperatures. The
alkaloid may be lost, for, when reduced to vapour, some escapes
through the chinks and crevices of the apparatus required ; and as
in toxicological researches the quantities are usually small, this loss

1868.] Report on Toxicology, Forensic Medicine, S^c. 261

might be of much importance. Then, although there ia no difficulty
in getting a sublimate of some kind, he contends that the same
alkaloid will sublime in very different forms under slightl}^ dijQferent
conditions, and thus that no reliance can be placed on the shape of the
crystal or deposit as a mode of diagnosis ; and he mentions that he has
in his possession sublimates of very different alkaloids having identi-
cally the same forms. He instances likenesses between strychnine and
santonine, codeine and santonine, and morphine and picrotoxine. The
typical forms of each of these when obtained from the pure alkaloid
and under the same general conditions are distinct and uniform, per-
fectly definite crystals of each alkaloid being obtainable; but the imper-
fect forms, those described by Dr. Gruy, and which would be by far the
commonest productions in toxicological investigations, resemble each
other in a wonderful manner ; and he concludes that the physical
conditions under which the substance is sublimed has as much
influence on the appearance of the sublimate as its chemical consti-
tution. Among the physical conditions which most materially
modify the form and appearance of the sublimate, and which even
determine the occurrence of perfect and distinct crystals on the one
hand, and an amorphous granular mass on the other — with any number
of intervening forms — Sedgwick mentions the longer or shorter period
during which the process is carried on, the comparative purity of
the alkaloid, the nature of the substance with which it may be
mixed, the greater or less amount of heat which is applied, and the
warmth or comparative coolness of the surface on which the subli-
mate is received. These matters are not entirely under control, and
are not to be measured.

If then, as he contends, the form and shape of the sublimate is not
under all circumstances distinctive of the alkaloid from which it is
derived, is there any advantage to be obtained from this process in the
convenience of application of chemical tests, and is there any diagnostic
value in the results ? In answering this question, he remarks that
the manner in which chemical tests act is twofold — by altering or
producing colour, and by throwing down or dissolving a deposit.
Colour tests, he observes, are objectionable for the microscope ; for
just as much as you magnify the object, in so much do you diminish
the intensity of the colour : the processes tend to mutual destruc-
tion. Deposits are of two kinds ; amorphous and crystalline. The
former are clearly not to be relied on ; an amorphous deposit is only
an amorphous deposit, from whatever solution it may be obtained.
We are limited, then, he says, to the production of a crystalline
deposit ; and in order that this may be useful, it must be easily and
always obtained, and imiform in appearance. Crystalline tests do
not develop their distinctive shapes unless both the alkaloid and
the test are in solution.

Why then sublime to redissolve ; why apply heat with some risk
of destruction of the substance experimented on to get a sublimate
dry, which must be dissolved before crystallization can be obtained,
when the same result can be arrived at without any sublimation and
without any heat ? He attaches great diagnostic value to the forma-

262 Chronicle of Medical Science. [Jan.,

tion of crystals under the microscope, and without depreciating
the worth of the carbozotates, the chromates, &c., speaks of the
iodo-sulphates as presenting striking forms, and easy of production.
The remarkable form of iodo-sulphate of quinine and its bearing
under polarized light led him in this direction. Iodo-sulphates of most
of the alkaloids have been formed previously as chemical curiosities,
but he is not aware that advantage has ever been taken of their
peculiarities by the toxicologist for the detection of minute quan-
tities of poisons. One advantage of the iodo-sulphates is that by a
heat much below that which would decompose the organic base, the
iodine may be driven olF, and the suspected substance be left avail-
able for further and different tests. Sedgwick proposes the fol-
lowing as the mode to be followed, pending further experiments.

After reduction to a small compass, the suspected substance is to
be treated with alcohol and dilute sulphuric acid, which will convert
the alkaloid into a sulphate, and will dissolve it, A drop of this
liquid is then to be placed on a microscopic slide, and a minute drop of
alcoholic solution of iodine near it. Tilting the slide, the solutions are
made to run together ; when this is accomplished, which will require
a few seconds, as there is at first mutual repulsion, the combined
liquids are made to run over the slide by alterations of position ;
and whatever will run off is allowed to drop on to another slide,
which is to be treated in the same way ; and, in like manner, a third,
if there be any fluid to run on to it. In a very short time crystals
will form, which may be easily recognised under the microscope by
their shape and also by their colour, which is usually red, or reddish
brown. The polariscope is a great aid in distinguishing them. He says
that it is impossible to give any description in words of the different
crystals, that engravings only can give a correct idea of them ; but
he speaks of the iodo-sulphate of morphia as a reddish-brown
rosette-shaped crystal, the iodo-sulphate of strychnine as a filiform
star, and the iodo-sulphate of atropine as a bright red hexagonal plate,
splitting into perfect triangles. In short, the iodo-sulphates of the
different alkaloids are remarkably distinct in form, and to be recog-
nised with great ease and certainty. — Transactions of the St. Andrew's
Graduates' Association, 1867.

On Poisoning hy Phosphorus. — Dr. J. Pestel reports a case of poi-
soning by phosphorus. A man thirty years of age was brought into
the Hospital of La Chatre on the 10th of December, 1866. The
patient on the 6th of December, about an hour after he had taken
some soup from the hands of his wife, left his home to go to his work.
On his way he was taken ill with sharp pains in his stomach, and
excessive vomiting. Those who saw him at this time affirmed after-
wards that there exhaled from his mouth and from what he vomited
a white thick vapour. "When received, four days later, into the
hospital he was still in the same degree of pain in the epigastrium,
the pain being increased by pressure. The abdomen was retracted,
the sclerotic was yellow, there was a jaundiced condition of the skin,
except in the face, which was congested. The eyes were much

1868,] Report on Toxicology, Forensic Medicine, 6^c. 263

sunken, but the pupils contracted under the influence of light ; the
tongue was large aud moist, the features were contracted, and the
countenance had an air of stupidity. There was free respiration,
the surface of the skin was dry, the heat being moderate ; thirst was
excessive, the pulse was 84 per minute, the intelligence was intact.
He was treated with leeches on the epigastrium, with gum-water,
with calcined magnesia in milk as drinks, and with laxative lave-
ments. On the following day the patient was in intolerable pain,
the body was cold and the limbs were blue (cyanosed). He died
about ten in the morning. The post-mortem was made by Dr.
Pestel in conjunction with Dr. Auroux twenty-four hours after
death. The cadaveric rigidity was marked. The lungs were con-
gested, and there were pleuritic adhesions ; the pericardium con-
tained a teaspoonful of sero-sanguinolent fluid ; the heart was
healthy : the aorta contained venous-coloured blood. The liver was
very remarkable, it was yellow in colour (chamois colour), and mar-
bled : the surface was smooth : the section of the organ was not
granular, but was throughout of uniform yellow tint : in size, con-
sistency, and weight the organ was natural. The spleen, the
pancreas, and the kidneys appeared healthy ; the peritoneum was
also healthy, and free of adhesions. The mucous membrane from
the lips to the stomach was coloured yellow but was intact. The
stomach was ecchymosed, and near the pylorus there was a super-
ficial gangrenous spot. In the small intestine about two meters
and fifty centimetres from the pylorus were two perforations oppo-
site each other, one of these was small, only large enough to admit the
head of a pin, the other was about half a centimetre in diameter. Near
these the mucous membrane was reduced to a pultaceous mass.

The man himself had accused his wife of poisoning him with dog-
bane (colchiq^ue) , but the liver, the digestive tube, and the fluids it
contained having been examined by MM. Tardieu and Eoussin, these
experts came to a different conclusion. They found, besides fatty de-
generation of the liver, a large accumulation in the contents of
the intestines, of ammonio-magnesian phosphate, with small frag-
ments of deposited sulphur, some artificial ultramarine blue, and
a little chip of white wood covered with sulphur ; in a word, all
the chemical constituents of a lucifer match minus the phosphorus.
They were led thus to affirm that the man had died from phosphorus
derived from lucifer matches, an affirmation which the confession of
the wife afterwards verified in a startling manner.

M. Pestel adds to his report a word of caution. He says that if
MM. Tardieu and Roussin did not find phosphorus in the parts
which were submitted to their examination (as appears to have been
the case) the fault rests with himself in that he plunged the struc-
tures destined for analysis into alcohol, not knowing at the time
that the smallest quantity of alcohol would prevent phosphorus from
burning with its characteristic green flame in the apparatus of
Mitscherlich.— i' Union Medicate, August 22nd, 1867.

264 Chronicle of Medical Science. [Jan.,

Calabar Bean as an Antidote to StrycJinia. — Dr. Thomas E. Fraser,
of Edinburgh, has published an admirable essay on the calabar
bean. He first shows that the substance, when injected into the
tissues of a living animal, finds its Avay into the stomach as to an
excretory outlet, in this respect resembling in action antimony and
arsenic, which, administered in whatever way, are eliminated, in part,
through the digestive system. He has investigated the action of the
poison in relation to the functions of various organs, but the part of his
work which is to us of most interest is that in which he dwells on the
bean as an antidote to strychnia. The subject of opposing physiologi-
cal action is, he observes, a favorite one with many writers on poisons,
and " antagonistic eff'ects " have been largely discussed, as might be
expected from their interest and practical applications. Nicotia,
aconitia, and curare, have been proposed as counter-agents to
strychnia, and atropia has been proposed as one to morphia. Calabar
bean has been pointed out by the author and others as an opponent
in action to strychnia ; and, as with curare, its application in the
treatment of tetanus has been recommended. Dr. Eraser believes
that no other drug so directly diminishes reflex action, and is, there-
fore, so likely to be employed with advantage in tetanus, as the
Calabar bean. Curare opposes spasm by paralysing motor nerves,
nicotia by destroying muscular contractility, but Calabar bean
attacks (if we may use the word) the spinal cord, which is
necessarily implicated as the centre of every diastaltic action.
There seems to be no reason why it should not always prove a
certain cure in traumatic tetanus. Its success in strychnia
poisoning will probably depend on the quantity, in relation to the
case, that has been administered, or this poison— strychnia — may be
considered to have two fatal doses ; a smaller, where death is caused
by asphyxia or exhaustion, and a larger, where, even if the
tendency to death by asphyxia or exhaustion be averted, death will
certainly occur by the special action of the poison on the histo-
logical structures which it attacks. Calabar bean may be employed
Tvith advantage. Dr. Fraser thinks, in the case where a small dose
of strychnia has been made to produce its effects. Calabar bean
(or, as it is now more learnedly called, physostigma) has also lately
been proposed as a physiological antidote for atropia poisoning ; and
Kleinwachter has had the courage to employ it for this purpose,
principally on the ground of its " anti-mydriatic " property. Dr.
Fraser proves that the two substances. Calabar bean and atropia,
appear to act in opposite modes on the ganglionic system of blood-
vessels ; but the nature of their eifects on the cerebro-spinal system
is such as to make it irrational to anticipate any success in their
employment as counter-agents. — Transactions of the Boyal Society
of Mdinhurgh, vol.xxiv, 18G7.

Nitrite of Amyl as an Antidote to Strychnia.-r-'We have ourselves
been recently inquiring as to the power of nitrite of amyl as an
antidote to strychnia. Our researches have been confined to frogs.
A frog weighing 590 grains, having been treated with the ^V*h of a

1868.] Report on Toxicology, Forensic Medicine, ^c. 365

grain of stryctnia injected by solution into the dorsal sac, was placed
under a bell-jar having a capacity of 300 cubic inches, at a tempera-
ture of 60° Fahr. In a brief time acute tetanic action was de-
veloped. Then one grain of nitrite of amyl was taken up on a piece
of bibulous paper, and put under the bell-jar with the tetanic
animal. In a few minutes the tetanic action entirely ceased, and
when the animal was touched there was no spasm. An electric
current from a single G-rove cell also failed to excite any action. The
animal, indeed, seemed to be dead. In this state it was left for
several hours under the bell-jar, a little water being poured around it.
Nine hours afterwards, on being touched, it showed once more all the
evidences of life, and the tetanic convulsion was again in full vigour.
The dose of nitrite of amyl was now repeated as before, and with
precisely the same effect. In this manner the action of the strych-
nia was neutralized from time to time for so long a period as five
days ; and indeed, it was not easy to tell the precise time of the
death. The death was clearly caused by the antidote, as it was a
continuance of the cataleptic sleep. The limbs remained flaccid
until the tissues commenced to decompose. In a second e^])eriment,
so soon as the strychnia was injected, the animal, also a frog, was put
into a jar, in which the vapour of nitrite of amyl was diffused in the
proportion of one grain and a half through 300 cubic inches of air.
The action of the nitrite in producing a relaxed condition of the
muscles was such that all the symptoms of strychnia were delayed.
After an hour the frog was taken from the jar, and was exposed to
the air at 60° in a saucer holding a little water. In six hours the
symptoms of strychnine tetanus began to show themselves, and were
soon fully developed. They were quickly subdued by the further
administration of the nitrite, and the nitrite being administered
with more minute care the animal recovered. In a third experiment
the dose of strychnia was increased to the 60th of a grain, and when
the tetanus was quite developed the nitrite was applied m vapour,
as in the first experiment. The results were the same. In two
other experiments the nitrite was injected under the skin, and with
similar results to those which followed inhalation. From all our
experiments we infer that nitrite of amyl is a direct physiological
antagonist to strychnia in frogs, and as it is less permanent in its
action than a solid substance, and as it may be given by inhalation as
well as by injection, it may prove to be an antidote of much value
both in strychnia poisoning, and in tetanus from a wound.

II. Sttmmabt.

On Earth Sewage. By Inspector- General Sare. — Medical Times
and Gazette, Dec. 20th, 1867.

A short paper on Moule's system of earth sewage, and on the prac-
tice of the system in India. The author maintains that the system of
earth closets must in time supersede the water-closet altogether. He

266 Chronicle of Medical Science, [Jan.,

has invented a seat for the closet which allows the solid excreta to be
carried away without mixing with the urine, a separation which is
essential to the proper working of the earth system. This effected,
not more dry earth than tlie weight of the excreted matter itself is
sufficient for the purpose of deodorization, which is, in fact, a process
of drying.

It will be remembered that some years ago Dr. Thudichum per-
sisted on the fact — an original fact, by the way and exclusively his
own — that no system of sewage could be complete, or even reasonable,
that did not commence by a separation of the fluid from the solid
excreta. Dr. Thudichum also invented a plan for carrying out his
suggestion, which is virtually the same as the plan actually carried
out, in India, by Inspector- General Hare.

Gases and Observations relating to Obstetrical PatTiology and In-
fanticide. By John A. Liddell, M.D., of New York. ' Ifew York
Medical Journal,'' July and August, 1867.

Death from Chloroform on its Third Administration. By H. A.
Dubois, M.D., U.S. Army. Ibid.

On Colchicia. By John M. Maisch. ' American Journal of Pharmacy
and Pharmaceutical JournaV for November, 1867.

[A short, useful essay on the nature of colchicia, and the chemical
tests for it. The author looks on colchicia as an alkaloid, the salts
of which are soluble in water, but are decomposed with the forma-
mation of colchiciene, on keeping them in solution as well as on
evaporating them.]

The case of Henry Oabites ; a Medico-Legal Study. By John
Kitching, M.D. ' The Journal of Mental Science,' July, 1867.

[A thougthful review of the career and character of Gabites,
establishing his insanity, in the scientific meaning of the term,
beyond dispute.]

1868.] 267

REPORT ON MIDWIFERY.
By Robert Baenes, M.D., F.R.C.P.,

Obstetric Pliysician to St. Thomas's Hospital ; Examiner in Midwifery to the Royal College of

SuigeoDS.

I. The Non-Peeghstant State.

1. Absence of Vagina ; Voluminous Sivelling formed ly JRetention of

Menstrual Blood; Operation; Death. By Dr. GrOSSELrN".

2. A Case of Ooccyodynia Cured hy Operation. By Dr. George

KiDD.

1. A girl, aged 18, had felt for two years acute pains in the
abdomen, sacrum, and hips, in exacerbations lasting from three to
eight days. No blood ever escaped. A tumour found reaching
above the umbilicus, and filling the iliac fossa. On either side was
a tumour, hard, moveable. These were diagnosed as uterus and
Fallopian tubes distended. No vaginal opening could be discovered.
The catheter in bladder was felt by finger in rectum. Severe colic
pains set in. An artificial vagina was made ; a large quantity of
thick chocolate-fluid was emptied. Later purulent and fetid fluid
issued ; hectic ; and the patient died on the fifth day. The abdo-
minal cavity held a large quantity of chocolate- coloured fluid ; the
omentum was thickened, united by old adhesions to the uterus ;
recent peritonitis. Both tubes and ovaries were adherent ; on both
sides the inner half of the tubes was thickened, the orifice obliterated.
The inner part of the outer half of the tube was thinned, and had on
the right side two, on the right one opening through which the fluid
had escaped into the abdominal cavity. The three openings were
found in spots where old adhesions with the omentum existed, and
the sinking of the emptying uterus probably gave rise to stretching
of the adhesions and rending of the tubes. — Qaz. des Hosp., May,
1867.

2. Dr. Kidd cites the account of the afioction given by Simpson,
Scanzoni, and West. His own case is as follows : He attended a
young lady in her first labour. She had a very long and imyielding
perinseum. When she began to move about she had great pains
in the coccyx ; it was greatest in sitting down and rising up. After
much unavailing treatment, Dr. K. resorted to subcutaneous
incision. He introduced a narrow, long-bladed tenotome at the
point of the coccyx, close to the right side, to above the part found
tender on pressure. He then cut from behind forwards, keeping
close to the bone, dividing all the tissues on that side: he then
carried the knife round the apex, cutting all the fibres attached
there, then passing it up the left side, divided the tissues in the
same way. Only a few drops of blood escaped. The relief gained
was complete. — Dub. Q. Jour, of Med. Sc, Nov., 1867.

268 Chronicle of Medical Science. [Jan.,

II. PEEGNAFCr.

1. On the Structure of the Placenta. By Dr. P. jASSiiirsKT, of
Charkow. (' Virchow's Archiv,' 1867.)

2. Diffuse Myxoma of the Ovum Memlranes. By Dr. Ebeeth.

3. The Treatment of Early Abortion. By Dr. John A. Btene.

4. Case of Early Abortion ; Retention of Placenta ; Phlebitis. By

Dr. G^OGAETT.

5. On Fever Complicated with Pregnancy. By Henet Kennedy, M.B.

6. Two Cases of Abdominal^ Typhus in Advanced Pregnancy. By

Dr. Wallichs.

7. On the Beciprocal Influence\of Pregnancy, Labour, and Childbed

on Malarial Infection. By Dr. Rittee.

8. A Case of Extra-Uterine Pregnancy. By Dr. PiSK. (It termi-
nated fatally ; the dissection is related (' Berliner Klin. "Wochns.,'
April, 1867).

9. Note on Uterine Metrology. Dr. Matthews Duncan. (' Edinh.

Med. Journ.,' Sept., 1867.)

1. The conclusions of Dr. JassinsJcy are — 1, There are thick villi,
which are modifications of the uterine glands.

2. In woman, as in other animals, the chorion- villi grow into the
uterine glands.

3. In the placenta are found immediately after birth two kinds of
villi : {a) free, ordinary chorion-villi, and (b) complex villi, that is,
villi contained in the uterine glands.

4. The free villi consist of a simple layer of ilat epithelium, and of
a simple structureless membrana propria.

5. The complex villi consist of two structureless membranes and
two epithelial layers, of which the outer one consists of cylindrical
epithelium, the inner one of flat epithelium.

6. The number of complex villi is much smaller than that of the
simple.

7. Not all the uterine glands are occupied by chorion villi ; many
of them remain free.

S. In mature placentae, all the glands, the free, as well as those
to which villi have grown, show a marked fatty degeneration.

9. Prom the histological aspect the tissues of the maternal portion
of the placenta belongs to the epithelioid tissues. — Virchow's Archiv,
1867.

2. Dr. EbertWs paper. — The specimen came from a healthy
woman. The membranes were much thickened. On the chorion
were numerous fluctuating flat elevations from the size of a pea to
that of a bean. Presh incisions through membranes showed between
chorion and amnion a gelatinous mass resembling Wharton's fluid.
This gave the reaction of mucin, and traces of albumen. Here
and there ran fine fibrils of connective tissue between the membranes.
The substance also held numerous spindle and star-shaped cells, with
one or multiple nuclei. Amnion and chorion were very tough, the

1868.] Report on Midwifery. 269

intermediate layer had entirely disappeared ; and the myxomatous
growth did not belong to this but to the membranes themselves. —
VircJioivs Archiv, May, 1S67.

Pregnane)/ Complicated loith Sub-acute Peritonitis (Dr. Ringland)
A pluripara had peritonitis begining in the second month of preg-
nancy; the abdomen enlarged enormously. At the end of four
months dyspepsia and cough came on, and the abdominal pain was
more acute. Fluctuation was distinct over the entire abdomen ; the
uterus could not be felt ; urine slightly albuminous ; pulse 120.
Labour set in three weeks before term. Some relief was felt, but
the size of the abdomen was not sensibly lessened. About twenty-
our hours after labour she felt a sudden rushing away of a large
quantity of fluid. It came from the vagina ; the abdominal tumour sub-
sided, and the uterus could be then felt. She recovered. Three weeks
after labour a large quantity of fluid again collected in the abdo-
men and was again discharged by the vagina. This was repeated
four times. It is conjectured that the channel of escape was the
Tallopian tube. — Dubl. Q. Jour, of Med. Sc, August, 1867.

3. Dr. Byrne cites the doctrines of various authors on the questions
of using instruments to remove the remains of the ovum, or the fingers
or plugging. He is in favour of plugging first, then of removing the
placenta by one or two fingers. He thinks the only case warranting
the use of an instrument is that of the ovum lying loose in the
uterus.— ii/t?., Nov., 1867.

4. Dr. Oogarty's Case. — The patient aborted in the third mouth.
The embryo was expelled, but not the secundines. On the fourth
day clotting took place in the veins of the left leg, attended by
sudden fainting. The escape of the placenta was looked for, but
was not detected. Dr. Gf^. advocates the use of Dr. Bond's placental
forceps for removal of retained and adherent debris in abortion. —
Ihid., Nov., 1867.

5. Dr. Henry Kennedy contributes a number of observations in
illustration of this important subject. The form of the fever is not
always clearly indicated. Dr. Kennedy makes the following re-
marks : — The occurrence of fever with pregnancy can scarcely be
looked upon as a very serious aff"ection to the mother. The mor-
tality is very small. He thinks abortion is sometimes critical — the
fever declining with great rapidity. When the child is retained, the
fever runs its usual length. The fever which attacks pregnant women
is rarely typhus, the cases where spots appear beiug exceptional.
"When typhus or typhoid attacks, the case is the more serious. The
treatment should not be modified on account of pregnancy. — Ibid.

6. Dr. "Wallichs, practising in Neumunster, observed an epidemic
of abdominal typhus, during which about 100 persons were aflected;
amongst them two women, in advanced pregnancy, were seized on
successive days. Dr. "W. remarks that observations of this kind
are very rare (and the reporter would add that information as to the
reaction between pregnancy and zymotics is very scanty). His first

270 Chronicle of Medical Science. [Jan.,

case was that of a woman eight months pregnant. Diarrhoea : temp,
in morning 39° C. ; in evening 40° ; pulse 120 ; bronchial-catarrh ;
roseoloid exanthema ; delirium were the symptoms. Acting on the
theory of Eartels and Brand, that the danger in fever depends on
the increase of temperature, and fearing lest the plan adopted to
reduce the temperature by wrapping in wet sheets might excite
uterine contractions, he applied wet cloths to the spine. This
diminished the heat, and was followed by sleep. She did well for
three weeks, when there was a slight relapse. A healthy girl was
born at term ; and puerpery was gone through without accident.
The second, case was that of a woman seized in her seventh month.
The fever was intense. Wet cloths were applied whenever the tem-
perature rose to 40° C. At the end of three weeks the temperature
fell somewhat. Then a strong rigor occurred, and was followed by a
temperature above 40°C. This was repeated in a few hours. These
were the forerunners of labour, which set in and ended in birth of a
living girl. Severe bronchial catarrh and fever delayed recovery,
which, however, was ultimately attained. In an appendix, Dr. W.
cites a memoir by Dr. Kaminsky, who submits that the death of
the foetus in utero is not due to typhus alone, but principally to
the great increase of temperature that attends febrile diseases. He
observed restlessness of the foetus, and increase in the frequency of
its heart-beat whenever the temperature rose above 40°C. — that the
heart-beat ceased at 42° to 43°'5". The children were often expelled
the day after death. K. also observed that metrorrhagia was more
frequent during the first half of gestation, and the mortality much
greater than in the latter half. — Mon.f. Gehurtsk., Oct., 1867.

7. Dr. Ritter concludes that pregnant women enjoy no immunity
from ague. That infection does not dispose to abortion. Large doses of
quinine during pregnancy were not useful. Labour arrests the periodi-
cal attacks, as the author observed four times. He observed fourteen
cases during childbed. In two cases malaria infection occurred
during the first week ; six times during the second ; three times
during the third week. The form of the afiection was always acute.
Childbed seems to be a very powerful influence in causing a relapse
to acute form of very feeble traces of chronic afiection. — VircTioio's
Archiv, 1867.

III. Laboue.

1. Cases Illustrative of the Use of the Forcejys. By Dr. A. B. Steele.

2. Oil Face-Labours. By Dr. Winkel.

3. A Peculiar Method of Extracting the Head in Breech and Foot

Presentations . By Dr. Gosselin.

4. A Peculiar Case in Obstetric Practice. By Dr. "W". Beyce.

5. On Labour in Shoulder Presentation. By Prof. Lazzati.

6. On the Treatment of Prolapsed Funis. By Dr. K. F. I, Bienbaum.

7. Postural Treatment of Prolapsus of the Funis. By J. G. WiisoN,
M.D. (Glasgow Med. Journ., 1867.)

1868.]

Report on Midwifery. 271

8. Cases of Injury to Bones and Joints in Parturition. Dr. Mat-
thews Duncan.

9. Live-horn Twins of apparently Different Stages of Maturity. By
Dr. C. Martin.

10. Observations on Gephalotripsy. By Prof. Chiaea.

1. Dr. Steele's cases illustrate the advantages of timely resort to
the forceps. One case shows that it is not necessary to wait for full
dilatation of the cervix. One illustrates the application to a face
presentation. The head was just^ beginning to engage in the hollow
of the sacrum ; the blades were applied over the sides of the posterior
part of the head ; by a lever action, with scarcely any downward
traction, Mr. Steele caused the occiput to sweep the curve of the
sacrum ; the chin at the same time ascended behind the pubis, and
delivery was soon effected. — Liverpool Med. and Surg. Reports, 1867.

2. Dr. Winkelhas collected a statistical group of 376 cases of face-
labour. He draws the following conclusions as to the causes. Face
presentations rarely happen through one cause alone, but almost
always through the combined action of two or three simultaneously
disposing factors. The most frequent combination is, pelvic narrow-
ing, a large child, scanty liquor amnii ; another is pendulous belly
with pelvic narrowing. — Mon.f. Oehurtsh., July, 1867.

3. This is Dr. Goschler's method. After the shoulders are born
the child's body is laid upon the operator's left fore-arm, and grasped
with the right hand on the neck as high as possible. No more trac-
tions are made than if the forceps were applied. The left hand, with
the child resting upon it, must follow the movements of the right
hand in a straight line, so that during the rotations the spinal column
shall at no point suffer movement, much less bendmg. Through
this plan the author attains the twofold end : — 1. Protection of spine
and medulla from stretching or injury ; 2. To increase considerably
the force of the movement of the head in the pelvic cavity ; since
acting through the length of the lever (the child's body) it is multi-
plied.— Wien Med. Presse, 1867. o>

4. Dr. Bryce's case was one in which a very large renal cyst com-
plicated pregnancy, suggesting, on examination, the complication of
an extra-uterine gestation with uterine gestation. Inflammation
supervened, and death took place shortly after birth of an uterine
foetus. — L^dinh. Med. Journ., Nov., 1867.

5. In an admirable memoir on shoulder-presentation, Lazzati illus-
trates the following propositions : That, wheresoever possible, attempt
should be made to correct this presentation, i. e. to restore the head, as
rendering spontaneous delivery possible. That corrections may be
attempted with prospect of success, either during the end of gestation
or at the beginning of labour, by external compression or manipula-
tions when the head of the foetus is to be brought over the interior
segment of the uterus. That, in labour somewhat advanced, or when
attempt at correction fails, it is better to bring down the nates
practising turning by the feet. That Nature sometimes completes

273 Chronicle of Medical Science. [Jan.,

labour by ilie shoulder by herself, the modes being, (a) spontaneous
cephalic and podalic version ; (b) spontaneous cephalic and podalic
evolution. That spontaneous version by the feet is a true natural
substitution of the pelvic region for that of the shoulder, brought
about whilst the foetus is still entirely in the uterine canty, and
above the brim of the pelvis. That spontaneous evolution is the
true natural labour by the shoulder, which is accomplished, things
being favorable, under the laws and mechanism governing the
passage of all other parts through the pelvic canal. That as to spon-
taneous version we may substitute artificial version by the feet whilst
the foetus is free, so when the shoulder has descended deeply into
the cavity, if spontaneous evolution cannot be effected, labour may
be completed by artificial evolution. That artificial evolution is
always fatal to the child, and somewhat dangerous to the mother. —
Annali TJniversali cU Medicina, Milan, October, 1867.

G. Dr. Birnbaum gives an historical resume oii\iQ plan of replacing
the cord by putting the woman in the knee-elbow position. He
quotes Deventer, 1701 ; John Mowbray, 1724 ; Henry Bracken, 1737,
and others, as having recommended this practice ; and more lately
V. Eitgen (1848). As a pupil of Eitgen's, B. says he has often
practised this method. He says — "When a loop of funis is still high
in the cervical canal, and the cervix scarcely admits the examining
finger, it may be that the knee and elbow-position is useful ; but
Avhen the loop has once passed through the os uteri, whether head,
trunk, or foot present, it will be vain to expect any good from this
position. He remembers no case where manual aid was not also
necessary, in addition to the knee-elbow or side position to replace
the cord, or to extract the child. — Mon.f. Qehurtsk., Oct., 1867.

8. Death from Pulmonary JEmholism. — Case 1. A primipara
had been three days in labour. A large hard head was impacted
in a small pelvis. Large forceps could not deliver. Craniotomy
was resorted to. Two weeks afterwards there were extensive
vaginal sloughs. The patient died on the thirty-seventh after delivery
of pulmonary embolism. She had a fit resembling epilepsy, the
pulse became imperceptible, breathing laboured, face pale; death
very rapid. Both pulmonary arteries contained large decolorised
clots. The right common iliac vein contained a partially decolorised
clot, which extended as far as the vena cava, into which its end pro-
jected. Vesico-vaginal fistula ; sloughy openings between the
bladder and cellular tissues of the pelvis. The promontory of the
sacrum anteriorly denuded to area of a sixpence. At this part a
lamina of the upper articular surface of the first bone of the sacrum
was separated from the rest of the bone, and adherent to the fibro-
cartilage.

2. Abscess of the Si/mphysis. — A secundipara had a difficult labour
terminated by forceps. Urine afterwards passed involuntarily. She
had not been able to use her legs in walking three weeks after labour.
A fissure was found along the top side the whole extent of the
urethra; a probe could be passed three inches behind the symphysis

1868.]

Report on Midwifery. 273

pubis. The symphysis could be felt and heard to move. Three
days later the tiuger could be passed into the pubic joint. Much pus
was discharged. The inter- articular cartilages and some pieces of
bone were subsequently discharged. Three months after delivery
the woman regained her walking powers. Dr. Duncan says the
forceps were unskilfully applied. He has no doubt the injury
was inflicted by the instrument, on the lower border of the sym-
physis pubis.

3. Injury of right frontal (?) hone of child. — A. woman was
delivered of a large child by long forceps. The brim was con-
tracted. On the fourteenth day the child showed a round exca-
vated sore above and in front of the right ear, where the point of
the blade had impinged. A minute sequestrum of bone was dis-
charged.—^c/m. Med. Jour., Oct., 1867.

9. A woman was delivered at about seven months of gestation of
twins. The placentae were united, one common chorion enclosed
the embyos. There was, however, an amniotic septum, giving each its
own sac. One child weighed SM grammes, and measured 17 centi-
metres from breech to skull ; the other weighed 920 grammes, and
measured 23 centimetres. Both looked healthy, and made inspiratory
efforts, but soon died. — Mon.f. GeburtsJc., July, 1867.

10. In a case related, the conjugate diameter was only 54 millim.
(2^-in.). Having baptized the foetus by injection, perforation was
performed by Blot's instrument. Cerebral matter escaped, yet
auscultation revealed cardiac action four hours afterwards, and
fuetal movements were also felt. Depaul's cephalotribe was then ap-
plied. Traction made by instrument ended by slipping off.
Repeated crushings were made, and attempts to turn. These did not
succeed. The professor thinks version should not be attempted when,
the conjugate diameter is below 00 millim. (2^-in.) After attempts at
delivery by the sharp and blunt hooks, another crushing was effected
with the cephalotribe, and the patient was left till the next morning,
about seven hours. By this time uterine action had driven the
broken-up head well into the brim. Another crushing was made,
but the instrument quickly slipped on trying traction. The head
was at last extracted, partly by forceps, partly by hand. The
shoulders resisted the most powerful manual tractions. A strong
cord was then passed round the neck, and attached to Joulin's
appareil a tractions. By this means in a few minutes the body was
delivered. The patient did well. — Pamphlet, Turin, 1867.

The following memoirs were read at the Dublin meeting of the
British Medical Association, and have been since published in the
* British Medical Journal.'

Lectures on Obstetric Operations : the Forceps. By Robert
Baenes, M.D. (Med. Times and Gaz., vol. ii, 1867.)

On the Cephalotribe. By George H. Kidd, M.D., Sir James
Simpson, J. Braxton Hicks, M.D., and John Ringland, M.D.
81— xu. 18

274 Chronicle of Medical Science. [Jan.,

A Clinical Discussion on the Ccesarean Section, and its claims as an
operation of Selection. By Kobeet Gheenhalqh, M.D.

IV. The New-boen iNrANT.

1. A Case of Successful Treatment of Apparent Death of a N^ew-horn

Child hy Transfusion. By Dr. Beneke.

2. On an Apparatus for Catheterization of the Air-passages,
and for Dilatation in New-born Asphyxiated Children. By Dr.

LOWENHABDT.

1. A child delivered by turning, in eighth month, was born
asphyxiated ; its breathing and heart-beat had ceased about fifteen
minutes. Five quarters of an ounce of well- de fibrin ate d and warm
blood was injected by a glass syringe into the vein of the umbilicus.
Breathing and pulsation ensued ; but the ill-developed child died in
nine hours No thrombi were found anywhere. The brain was
ansBmic. — Berlin Klin. Wchns., 1867.)

2. Dr. L. prefaces that a number of examinations of dead children
in whom fruitless attempts at resuscitation had been made, taught
him that what prevented the access of air was the accumulation of
mucus, blood, and other fluids in the larynx and air-tubes, the result
of premature efforts to respire. He further calls attention to a sure
sign of life — it is the existence of pulsation in the foetal part of the
umbilical cord, which may be discovered when every other sign of
life is gone. To feel this pulsation in the umbilical vessels the in-
sertion of the cord must be seized between finger and thumb rather
deeply, and in such a manner that the volar surface of the hand lays
gently on the child's belly over the region of the liver. In no case,
says Lbwenhardt, in which this beat was not felt has the child
recovered. He then describes his apparatus. It consists of a pump
and a fine india-rubber tube ten inches long, with catheter openings
at the end. This tube is inserted by the aid of a fine stilet into the
trachea in the following way: — an assistant with tiiumb and finger
presses the neck above the larynx, closing the oesophagus, whilst the
operator depresses the tongue with his forefinger and slips in the
tube. This tube is then attached to the aspirating pump, which is
used to draw out the obstructing fluids ; then air is gently introduced.
—Mon. f. Qeburtsk., 1867.

1868.] 275

CHRONICLE OP MICROLOGY.
By J. P. Steeatfeild, r.R.C.S.,

Awistant-Surgeon to tlie Royal London Ophthalmic Hospital, and Ophthalmic Surgeon to
University College Hospital, &c.

Past I.— PHTsiOLoaiCAL Micrologt

Coloured Blood- corpuscles of the Vertehrata. — Mr, Grulliver, in
answer to a recent paper of Professor Eolleston's, on the subject of
a nucleated appearance of these corpuscles in the case of the two-
toed sloth, says — " Further observations are required to prove how
far such phenomena may be due either to a solution and displace-
ment of the colouring matter from commencing putrefaction, or to
an irregular refraction of and interference in the tissue by disfigured
and discoloured parts of these decaying corpuscles. As it does not
appear that the so-called nuclei were subjected to chemical examina-
tion, we are left in doubt as to their real character. Coloured cor-
puscles, apparently nucleated, are not uncommon in mammalia, but
never regularly more than one or two of such nucleated corpuscles
to a hundred of the characteristic non-nucleated corpuscles ; and so
scanty are the irregular ones as to render a chemical examination of
them a matter of difl&culty.

" In the coloured corpuscle of most pyrensemata this nucleus is
more or less rounded in form, and an ellipse of variable proportions ;
it is not only insoluble in water and in acetic acid, but is actually
made more distinct under the action of this acid. When a single
or thin layer of these coloured blood-cells is dried on an object-
plate, their nuclei, so far from being rendered invisible by the
moisture of the breath, are more clearly brought into view after we
have breathed upon this stratum of coloured corpuscles ; and so little
are the nuclei prone to putrefaction, that they continue apparent long
after the coloured and pale cells and other forms in the blood hare
been destroyed by this process. The chemical characters of the
nuclei of the blood-discs of pyrensemata and the lymph-globules of
apyrenaemata and birds are identical, excepting some curious minor
points.

" Of oviparous vertebrates, if we look at the fresh-coloured cor-
puscles swimming in the liquor sanguinis on an object-plate, a few
of them may show their nuclei, and more not so. Add some water
to this blood, and the majority of the cells will exhibit their nuclei.
Treat another drop of the same blood with acetic acid, and the mass
of the cells will disclose their nuclei beautifully. Dry a fresh and
very thin layer of the like blood on an object-plate, when some few
nuclei may be visible ; then breathe upon it, and the cells will soon
be seen to be regularly nucleated, and perhaps some of the nuclei
more or less tinged by displaced colouring matter. Finally, set a
separate sample of this blood aside until the form of the cells has
been destroyed by incipient putrefaction, when the nuclei will dis-

276 Chronicle of Medical Science. [Jan.,

tinctly remain the chief morphological objects visible in the field ;
and thus these vertebrates belong to the pyrensemata.

" Next repeat each of these experiments on the coloured corpus-
cles of man and mammalia. The results, as far as regards nucleation,
will be plainly in the negative ; and thus these vertebrates belong to
the apyrensemata.

" It used to be argued, both in Britain and on the Continent, that
the comparative minuteness of the blood-discs of man and mammalia
was the cause that the still smaller nuclei escaped detection. But,
after my discovery of the large size of the coloured corpuscles of the
great ant-eater, two-toed sloth, and capybara, I searched them in
vain for nuclei, when the results proved in this respect as completely
negative as those obtained from other apyrensemata, including
cetacea, marsupialia, and monotremata ; while in certain birds with
the coloured corpuscles, but a shade larger, and some rather smaller,
than many of the coloured corijuscles of the ant-eater, the nuclei
were always very plainly seen ; nor could I ever find that either the
large circular coloured corpuscles of the elephant or the smaller oval
ones of the camels, afford any exception to the non-nucleated charac-
ter of the coloured corpuscles of mammalia.

" In reality, the coloured corpuscle of apyrensemata is quite a
peculiar body, without a known equivalent or houiologue, as a pre-
ponderating organism in the blood, among any of the lower classes
of the vertebrate sub-kingdom." — Journal of Anatomy and Physiology,
Nov., 1867, p. 1.

Peripheral Termination of Motor Nerves. — M. Trinchese, professor
of the Genoa University, has drawn the following conclusions :

" 1. In all the animals in which he has been able to investigate
the subject, a special organ, the motor plate, at the end of the cylinder
axis, has been found.

" 2. The following is the manner in which the nervous element is
united with the muscular fasciculus :

"When the muscular fasciculus is provided with sarcolemma and
the nervous element with a sheath, this blends with the envelope of
the primitive muscular fasciculus at the point at which the nervous
element meets with the muscular fasciculus. At the same point, or
a little before, the medullary substance stops, whilst the cylinder axis
goes on and enters the motor plate.

" 3. The motor plate is placed beneath the sarcolemma. It appears
generally as a cone, of which the summit is directed to the side of
the nerve-tube, whilst the base rests on the primitive muscular
fibres.

" 4. This plate is formed of two superposed and quite distinct layers,
especially in those animals which have large plates — the torpedo, for
instance. The upper layer is of a granular substance; the lower is
perfectly homogeneous, and is probably only an expansion of the
cylinder axis.

" 5. In the substance of the granular layer of the plate is found, in
the torpedo, a system of canals, in which the cylinder axis ramifies

1868.] Chronicle of Micrology. 277

as a large-meshed network. These canals are bounded by a sheath
which forms their walls.

" 6. When the muscular fasciculi have a central canal the granular
substance of the plate is prolonged into the granular substance con-
tained in this canal.

" 7. In animals provided only with smooth muscular fibres the
cylinder axis traverses the granular substance of the plate dividing
into two filaments which have pointed ends at the two extremities
of the contractile element.

" 8. Altogether it appears that each primitive muscular fasciculus
shows one motor plate only. In this one or many nervous elements,
proceeding from the subdivision of the same nervous tube, may
end.

" 9. The diameter of the motor plate increases in proportion with
the size of the primitive muscular fasciculus." — Journal de VAnatomie
et de la Physiologic, Sept. and Oct., 1867, p. 498.

Connective Tissue of the Human Eyelids. — Professor Stieda
remarks, in the first place, that Henle has in the same — that is to
say, in the tarsal conjunctiva — described blind-intcstinal-like glands,
which were unclothed by a regular cylinder epithelium, whilst the
free surface of the conjunctiva has a statified pavement epithelium.
He find^, moreover, also that the different histologists are not quite
of the same opinion concerning the nature of the epithelium of the
connective tissue.

Oil perpendicular section of the properly hardened eyelid the
tarsal conjunctiva forms a strip 0'124— 0-166 mm. broad, which at its
free edge is limited by a tolerably straight-drawn outline, from
which it may be concluded that the mucous coat has here no kind of
irregularity, but is even. In the mucous coat one distinguishes
plainly the connective tissue ground layer and the epithelium. The
connective tissue ground layer has the appearance of a net-likt
connective substance with interspersed lymphoid elements (Henle'g
conglobate gland substance), and is, in the most superficial layer,
changed into a homogeneous elastic membrane, which is limited by
a slightly woolly contour. But the connective tissue ground layer
of the mucous membrane becomes interrupted in sections made per-
pendicularly or obliquely, which extend soon more or less deeply
towards the tarsal tissue. Besides there are found in the tissue
holes or spaces of a roundish shape, or extended lengthways. These
incisions and the spaces are distinguished by their epithelial cover-
ing. Whilst on the free surface three to five layers of cells of
0-007 — 0 011 mm. lie one upon another (the outermost flatter, the un-
dermost rounder), the covering shows, both in the incisions and also
in the spaces, a very regular cylinder epithelium, mostly only a single
layer of distinctly nucleated cells of 002 mm. high and 0 01 mm. broad.
The flat epithelium is seen in the incisions abruptly to change into
the cylinder epithelium; but now, whilst the perpendicular sections
of that incision gives a representation which in cross section a blind
intestinal-like gland calls to mind, Stieda, by horizontal sections of

278 Chronicle of Medical Science. [Jan.,

palpebral conjunctiva, is led to another view ; that is to say, he finds
roundish or irregularly formed masses of the connective tissue
ground-layer of the connective coat edged about with cylinder epi-
thelium, or about it, otherwise to be expressed, he finds the tissue of
the mucous coat traversed by numerous canals anastomosing with each
other, which were covered with cylinder epithelium. The different
appearance of the mucous coat in perpendicular and horizontal
section is explained in that, according to Stieda, only by the accepta-
tion of numerous furrows or incisions traversing the mucous coat in all
direcfions, intersecting abundantly, now deeper, now more superficial,
now directly, now obliquely, penetrating deeply, ending here and there
in blind points, which are everywhere clothed with cylinder epithe-
lium, whilst the epithelium on the free surface consists of roundish
or flat cells. Those parts of the substance of the mucous coat bor-
dered by furrows or incisions one may, perhaps, denote as a papilla,
as is often done.

The difference of authors in regard to the epithelial covering of
the connective coat seems to find a satisfactory conclusion in this,
that in children, in whom the unevenness of the connective coat are
as yet very little marked, such like diff"erences between the epithelium
of the surface and of the deeper parts cannot be recognised ; rather
the whole connective coat of the tarsus is covered with cylinder epi-
thelium. In consequence of the friction which afterwards takes
place the cylinder epithelium on the surface is changed into flat
epithelium, whilst that in the deeper parts can maintain itself
undisturbed. — Schmidt's Jahrbucher, vol. cxxxvi, No. 2, p. 147.

PurTcinjean Fibres of the Heart : of their structure and texture. —
Dr. Obermeier says, in epitome, at the conclusion of a long paper :

1. I have found the Purkinjean fibres in the sheep, ox, pig, horse,
dog, goose and pigeon ; not in the cat, in human beings, in the hare,
in the mouse and frog.

2. The Purkinjean fibres are only found between the endocardium
and the muscular structure, and form altogether a bag-like network
of a form, like the inner surface of the ventricles of the heart.
They are of a moderate (2 to 3 grains) thickness, and varying breadth.
They lie beneath the msin structure and in the elastic fibre layer of
the endocardium, in one, two, three separate layers in succession,
in such a manner that they are always separated from the muscles
by a various scanty connective tissue layer.

3. The Purkinjean fibres partly terminate in the endocardium,
blunt or pointed, or pass deeply into the muscular structure, or so
pass over into the muscular fibres that no definite limit can be made
out between these fibres and the muscular fibres concerned.

4. The polyhedral or cylindrical-shaped divisions formed by the
fibres, the so-called granules, exhibit short cylindrical muscular
bundles, of which the greatest diameter, the axis, lies in the plane
of the endocardium, and follows the direction of the fibres.

5. These short muscular fibres consist of a very hyaline, cross-
streaked muscular substance, and contain numerous hyaline masses,

1868.] Chronicle of Micrology. 279

nucleolar bodies, and granular masses. The latter may only amount
to a minimum, or may be altogether wanting.

6. The Purkinjean fibres lie in a lamellar framework of connective
tissue. These lamellsb have no appearance of any cross streaking.

7. Since the word fibres for these structures is altogether inde-
finite, I venture to propose the expression Purkinjean muscle-chains.
— Archiv fur Anatomie, Physiologic, und JVissenschaftliche Medecin,
1867, Part III, p. 385.

Spermatic Fluid of the Aged. — The investigations of M. Dien, of
the Invalides, gives the results of 105 autopsies of men between the
ages of 64 and 97. There were no spermatozoa in 64 of the 105 ;
that is to say, that in 61 per cent, no spermatozoa were found.
(Other like observations to those of the author would diminish this
per-centage, but they are based on observations in cases of an
average less-advanced age.) Eour of the author's observations were
of nonagenarians ; of these, none had spermatozoa. Of the 64 who
had no spermatozoa, 26 died of old age. The spermatozoa, when
present, are more or less abundant. In 14 cases in which the sper-
matozoa were not abundant, some were perfect in form, but most
of them had truncated tails, whilst others, the last vestige of them,
only showed the heads. If spermatozoa were absent, or almost
wanting, there were other interesting peculiarities in the seminal
fluid — numerous granular cells and great fatty cells, yellow coloured,
like colostrum globules, and strongly refracting light. Ether being
added, they disappeared. Especially when the fluid was of a dark-
brown colour, there were many blood-globules, some normal, and
others undergoing destruction — an evident pathognomonic sign of
little haemorrhagies in the vesiculce seminales. There were also often
rather large masses, more or less yellow, of variable shape, resisting
acetic and sulphuric acids, ether and caustic potash. These were
evidently masses of colouring matter, the result of hasmorrhagies in
the vesiculcB of a more or less recent date. — Journal de Anatomie et
de la Physiologic, Sept. and Oct., 1867, pp. 449, 71.

Miasmata of the Stealthy Human Body. — M. Lemaire's researches
have been made in barracks. The atmospheric watery vapour was
condensed by cold. Microscopically it was found to contain a great
number of little diaphanous bodies, spherical, oval, or cylindrical,
regular or irregular, and of 0*001 — 0002 mm. diameter. In six
hours their number had very much increased. There were also
bacteria and vibriones, and a good many animalculse, considered by the
author to be the monades ovo'ides ichancrees of Ehrenberg. (Is this
monad the cause of typhus ?) In twenty-four hours there appeared
besides the bacteria vibriones and monads, some ovoid spores. The
little diaphanous bodies had very much diminished in number, — as
much as that of the animalculse, — and the spores had increased.
(Are not -these little bodies rudimentary infusoria?) The same
microzoa and microphytes were found again and again in other
similar experiments. The outer air-vapour showed few vibriones

280 Chronicle of Medical Science. [Jan.,

and bacteria, and no ovoid monads ; and, in it, 24 instead of 6 hours
were necessary for the development of the diaphanous bodies, the
animalcules and spores. — ArcJiives GSnirales de MSdecin, Nov.
1867, p. 623.

Paet II. — Pathological Microlo&t.

Aneurisms of the Heart. — In a large work on this subject, Dr. N.
Pelvet, among other forms, considers those of the walls, which are
various, — may be the result of an endomyocarditis,— interstitial or
parenchymatous. That this latter form, as Virchow inconsistently
asserts, is characterized by fatty degeneration of muscular fibre,
the author disputes. He considers, at length, t\Ye fibrous transforma-
tion Qxaenvi^m, — the result of a slowly progressive irritation, charac-
terized by a proliferation of the heart's connective tissue framework,
which extending, developing, suppresses the muscular element and
causes it almost entirely to disappear. Then a fibrous tissue is pro-
duced whose elements (given in an illustration) are composed of very
curious cells. These cellular elements are connective tissue whose
dimensions and form, by compression, have been changed.

As to the fatty defeneration aneurism, as the result of very many
observations, the author admits that it is very often produced by
cpntraction of the coronary arteries, &c. — Archives OSnSrules de
MSdecin, Nov. 1867, p. 639.

Corpora Amylacea in the Lungs. — The only communication
hitherto on this subject has been that of Priedreich. He found them
in five cases, in one of which there was recent pulmonic infiltration,
with brown induration. He explained their origin by capillary
blood effusions in the interlobular connective tissue of the lungs.
By the coagulation of the blood the corpuscles pack themselves into
the form of a little rounded clot, and the fibrinous part of this or
subsequent repeated blood eff'usions are established around the same
in concentric lamella3. Gradually now the colouring matter of the
blood of the central blood-clot dissolves, and colours the fibrinous
enveloping layers, until finally it becomes altogether absorbed, and tlie
discoloured corpuscles, with a granular colourless mass, left behind
in the interior ; or the colouring matter of the blood collects into
crystalline or amorphous bodies, which form the central pigment
nuclei.

By Dr. T. Langhans, the origin of the corpora amylacea is other-
wise explained. He is able to point out the three following forms :

1. Regular concentrical laminated bodies, whose outer contour
runs parallel to the concentric streaks. They consist of an outer,
broader laminated zone, and an inner, non-laminated, briglit, slightly
granular areola. The latter is round, oval, contracted in the middle,
or irregularly indented, bowed, club-like, and so on, much larger
than the surrounding cancroid cells, and frequently includes one or
more variously sharply circumscribed nuclei resembling corpuscles,
which themselves often contain a dark central spot (nucleolus).

1868.]

Chronicle of Micrology. 281

Sometimes more areolae of different sizes are fonnd, and the surround-
ing concentric layers according to this are more or less irregularly
hollowed, but outwards passing always more into the shape of a
sphere. It appears by this an accumulation of smaller to larger
bodies to have taken place, whereby the concentric layers vanish in
the accumulating surfaces, and the areolae unite themselves into
one.

2. Irregular bodies with granular surface, which in profile form
smaller or larger segments of circles. The areola here by the irre-
gular surface becomes not unt'requeutly hidden. In its neighbour-
hood the concentric streaking is most distinctly seen ; towards the
surface the streaks are there certainly also present still, but standing
away at various distances from each other, and formed like the sur-
face itself of the segments of many circles. In the neighbourhood
there were small, bright, sharply-contoured, brilliant spheres like-
wise with concentric streaking, or at least having double contours,
which were in part still isolated, in part already united with the
larger bodies.

3. Just such brilliant, darkly-contoured balls without concentric
streaking of the size of the round cells in the cancroid cones
(0'006 — 0"012 millemetres). These lie singly or compactly grouped,
free in the alveolae, or also in the interior of the cancroid cones. They
often blend one with another to larger bodies with undulating con-
tour, but without concentric division ; sometimes, however, one finds
a double contour or a division begins in the middle. After this the
regular streaked bodies proceed by growing together of these
small balls and the concentric division. There are also numerous
irregular parts of homogeneous, brilliant substance which are like
all the mass of the concentric bodies, and are probably formed by
breaking up of the latter. Near these, by carmine imbibition, very
dark red- coloured bodies, was found a peculiar change of the cylinder
cell cones, into a mass incapable of imbibition, homogeneous, brilliant,
and darkly contoured, which by their form and their evident radiated
streaking in the periphery pointed to their origin, and which like the
other cones enclosed round, isolated, aggregated, or combining cor-
puscles, but without concentric streaking. — Schmidt's Jahrhucher,
1867, Part cxxxv.. No. 3, p. 299.

Crystalline or Amorphous Hematinoptysis. — A thesis, bearing this
title, has been presented by M. Clement. He says, " The name
hematinoptysis has been applied by Lebert to a complication of he-
matic pleurisy, characterized by the presence in the expectoration,
not of globules of blood perfect as in hemoptysis, but of what is called
hematine, in the crystalline state. The author, before studying the
conditions under which this phenomenon is produced, first establishes
the origin of sanguineous exudations of the lungs. They are, he says,
connected with the presence of false meiflbranes on the serous coat,
and caused by the rupture of the vessels, newly formed, which they
contain."

Several cases are then quoted —

" Hematinoptysis," he says, " is a variety of hemoptysis which can

282 Chronicle of Medical Science. [Jan.,

only be produced when the expectorated blood has remained a
long time in a cavity, a condition which is fulfilled in hematic pleurisy
and pulmonary int'arctus. In this last complaint the quantity of
expectorated matter is less ; in the former, when the effusion has
escaped into the bronchi, it may be very considerable."

" The blood in the cavities of the organism show the following
changes : the globulin, the fibrin undergo the fatty degeneration,
the colouring matter is set at liberty, and may be transformed into
crystallizable hematin. When these matters are expelled by the
bronchi, the expectoration has special characteristics, its colour is a
yellowish brown or chocolate ; the colouring matter is contained in
the crystalline state or amorphous. — Gazette Medicale de Lyon, 17th
Nov. 1867, p. 486.

On the Epithelium of the Cornea, and especially in the Multiplica-
tion of its Cells. — Dr. C. Schalygen, after that he had considered the
shape of the epithelial cells of the cornea, as to changes in them by
different reagents, inquired in what way the hyperplasy of these
cells, by irritation of the outer layer of the cornea in living animals
is brought about.

He showed a division of the cells, and certainly in the following
way:

At first the cells only appear somewhat larger, then they seem to
become somewhat more granular, and afterwards the division begins
in the nuclei. These then appear as lines, which one only perceives
at first by the screw of the microscope, which becomes gradually
broader, and at last forms a furrow between two halves of nuclei.
These halves separate from each other, become rounded at their edges,
and show at last two nuclei in each cell. The little streak is gene-
rally rectilineal, sometimes bowed and sometimes undulatory. There-
upon follows the di^'ision of the cell itself, and certainly in the same
way as in the nucleus, either across or obliquely ; seldom vertically.
An actual drawing in, in a biscuit form, of the cell finds no place
there, is also impossible because of their flat polygonal shape. A
cell seldom divides into three, and still seldomer into four parts.

In this it is to be remarked that the vital activity of the cell does
not appear nearly always and much less in all cells in this form, as a
consequence of the irritation. It does not often follow after irrita-
tion has taken place ; but for it there appears only an enlargement
with a more granular and glistening appearance which pointed to
fatty degeneration : commonly, also, division and fatty change are
coincident in certain cells.

The division of the epithelial cells takes place also when the epi-
thelium of the edges of an ulcer from the bottom of the ulcer fills
up by degrees. These new epithelial cells are as transparent as the
normal cells, they only become opaque when they overlie in very
numerous layers confusedly beside the normal coat of the cornea. —
Archivfiir Ophthalmologic, xii, 1, p. 83.

1868.J

Books, 6fC., received for Review.

283

BOOKS. PAMPHLETS, &c., RECEIVED FOR REVIEW.

The Essentials of Bandaging, including
the Management of Fractures and Disloca-
tions, &c. By Berkeley Hill, F.R.C.S.,
University College. London, Walker.
1867. pp. 167.

Softening of the Stomach in Children in
Australia, &c. By C. E. Reeves, M.D.
Melbourne. 1867. Pamphlet.

On Ringworm : An Inquiry into its
Patholog}', Causes, and Treatment. By
"W. J. Smith, M.B. London, Hardwicke.
1867. pp. 75.

Epidemic Meningitis, or Cerebro-spinal
Meningitis. By A. Stille, M.D., Professor
of the Theory and Practice of Medicine,
&c., University of Pennsylvania. Phila-
delphia, Lindsay and Blakiston. 1867.
pp. 178.

Observations and E.xperiments on Liv-
ing Organisms in Heated "Water. By J.
Wyman, M.D. (Reprint from 'American
Journal of Science and Arts,' Sept. 1867.)

On the Physiological Action of the Ca-
labar Bean (Phvsostigma venenosum).
By T. R. Fraser, M.D., Assistant to Pro-
fessor of Materia Medica, University of
Edinburgh. (Reprint from ' Transactions
of Royal Society.') Edinburgh.

Outlines of Physiologv, Human and
Comparative. By John Marshall, F.R.S.,
Professor of Surgery, University College.
In two volumes. Longmans and Co. pp.
607 and 699.

On the Pathology and Treatment of
Albuminuria. By W. H. Dickinson,
M.D., Assistant Physician to St. George's
Hospital, &c. London, Longmans and
Co. 1868. i)p. 26-5.

A Report on Amputations at the Hip-
joint in Military Sursjery. War Depart-
ment, ' Washington Circular,' No. 7.

Transactions of the Pathological Society
of London. Volume XVIII. Ijondon.
1867. pp.317.

The Ph3'siology of Man, &r. By Austin
Flint. Jun., M.D. Applcton and Co.
New York. 1867. pp. 5-56.

On the Distinctive Characters of Exter-
nal Iriflammations, on Inflammatory or
Sympathetic Fever, &c. By J. H. James,
F.R.C.S. London, Churchill and Sons.
1867. pp. 104.

Lectures on the Progress of Anatomy
and Surgery during the Present Century.
By Sir W. Fergusson, Bart., F.R S. Lon-
don, Churchill and Sons. 1867. pp.
302.

Principles of Chemistry, Founded on
Modern Theories. By Mons. A. Naquet.
Translated from the Second Edition bv
W. Cortis, Student, Guy's Hospital.
Revised by T. Stevenson, M.D. Renshaw,
London. 1868. pp. 848.

Handbook of the Sphygmograph ; being
a Guide to its Use in Clinical Research, to
which is adde a Lecture delivered at the
Royal College of Physicians on the Mode
and Duration of the Contraction of the
Heart in Health and Disease. By J.
Buron Sanderson, M.D., F.R.S. London.
Hardwicke. 1867. pp. 83.

Braithwaite's Retrospect of Medicine.
July— Dec, 1867.

The Diagnosis, Patholog}', and Treat-
ment of Diseases of Women, including the
Diagnosis of Pregnancy. By G. Hewitt,
M.D., F.R.C.P., Professor of Midwifery,
&c., University College. Second Edition.
London, Longmans and Co. 1868. pp.
700.

The Bath Waters : their Uses and
Effects in Chronic Diseases. By J. Tun-
stall, M.D. Fourth Edition. London,
Churchill and Sons. 1868. pp. 164.

Remarks on the Climate of Sidmouth.
By J. I. Mackenzie. Pamphlet. Churchill
and Sons.

The Nature and Affinities of Tubercle ;
being the Gulstonian Lectures for the
Year 1867^ By R. Southey, M.D., Assis-
tant Physician to St. Bartholomew's Hos-
pital. London, Longmans and Co. 1867.
pp. 118.

On Chloroform. By C. E:id.l, M.D.
London, Renshaw. 1867. pp. 295.

Germinal Matter and the Contact Theory;
an Essay on the Morbid Poisons, their Na-
ture, Sources, Effncts, Migrations, &c.
By J. Morris, M.D. Second Edition.
London, Churchill and Sous. 1867. pp.
111.

E.Kcision of the Knee-joint : A Descrip-
tion of a New Apparatus for after treat-
ment. By P. H. Watson, M.D. Edin-
burgh, Maclachlan and Stewart. 1867.
pp. 78.

Clinical Illustrations of various forms of
Cancer, and of other Diseases likely to be
Mistaken for Them, with Special Refe-
rence to their Surgical Treatment. By
Oliver Pembert"n, Surgeon to the General
Hospital, Biruiin'rham. London, Long-
mans an] Co. 1867. pp. 120.

Nutrition the Basis of the Treatment of
Disease. The Introductory Address at the
Opening of the Medical Session at Univer-
sity College. London. Oct., 1867. By
G. Hewitt, Esq., M.D., Professor of Mid-
wifery, &c. Longmans and Co.

Egypt and the Nile considered as a Win-
ter Resort for Pulmonary and other Inva-
lids. By J. Patterson, M.D., Egyptian
Medical Service. London, Churchill and
Sons. 1867. pp. 84.

On Hay Asthma and the Affection
termed Hay Fever. By W. Pirrie, M.D.

284

Books, ^c, received for Review. [Jan., 1868.

London, Churchill and Sons. 1868. pp.
95.

On Synthesis as taking Precedence of
Analysis in Education, &c. By H. Mac-
Cormac, M.D. London, Longmans and
Co. Pamphlet.

Researches upon " Spurious Vaccina-
tion," &c., in the Confederate Army dur-
ing the American War, 1861—1865. By
T. Jones, M.D. From the 'Nashville
Journal of Medicine and Surgery.' Uni-
versity Medicine Press, Nashville.

Quinine as a Prophylactic against Ma-
larial Fever. Pamphlet. By the same.

The Morningside Mirror, Vol. xxii.
Oct., 1866— Sept., 1867.

Administration of Chloroform by Deglu-
tition. By G. Cochran, M.D., Mobile,
Alabama. Pamphlet.

Eodent Cancer, with Photographic and
other Illustrations of its Nature and
Treatment. By C. H. Moore, F.R.C.S.,
&c. London, Longmans and Co. 1867.
pp. 128.

Illustrations of Some of the Principal
Diseases of the Eye, with a Brief Account
of their Symptoms, Pathology, and Treat-
ment. By H. Power, F.R.C.S , Surgeon
to the Royal Westminster Ophthalmic
Hospital, &c. London, Churchill and
Sons. 1867. pp. 631.

A Practical Treatise upon Eczema, in-
cluding its Lichenous and Impetiginous
Forms. By Dr. M'Call Anderson, Physi-
cian to Dispensary for Skin Diseases,
Glasgow. Second Edition. London,
Churchill and Sons. pp. 180.

The Cholera ; its Origin, Idiosyncracy,
and Treatment. By F. E. Jencken, M.D.
London, Churchill and Sons. 1867. pp.
82.

The Principle and Practice of Obstetric
Medicine and Surgerj', &c. By F. H.
Ramsbotham, M.D. London, Churchill
and Sons. 1867. pp. 752.

On Diseases of the Ear ; their Nature,
Diagnosis, and Treatment. ByJ.Toyn-
bee, F.R S. With a Supplement by J.
Hinton, Aural Surgeon to Guy's Hospital.
London, Lewis. 1868. pp. 466.

Practical Hints to the Medical Student.
An Introductory Lecture. King's College,
London. Oct. 1, 1867. By W. A. Miller,
M.D., Professor of Chemistry.

0 Pneumogastrico os antimoniaes e a
Pneumonia Memeria, &c. Por Jose T.
de S. Martins. Lisbon. 1867. Typo-
graphia du Academia. pp. 175.

Essais de Physiologie Philosophique.

Par M. J. P. Durand (de Gros). BailliSro.

1866. pp. 594.

Estudo sobre as Hernias Parietaes Da
Bexiga e sobre os calculos vesicaes encar-
cerados. Por J. J. Da Silva Amado.
(Pamphlet.) Lisbon. 1867.

Etudes sur la Tuberculose. Preuves
rationnelles Experimentales de sa Speci-
ficite et de son Inoculabilite. Par J. A.
Villerain. Bailliere, &c. 1868. pp. 640.

Etudes sur les Medications Arsenicale et
Antimoniale et sur les Maladies du Coeur.
Par Dr. L. Papillaud. Bailliere. 1867.
(Pamphlet.)

Etudes sur la Nature de 1' Homme, &c.
Par le Dr. F. Voisin. Bailliere. 1867.
pp. 388.

Sulla Struttura del Tubercoli prodotti
per Inoculazione. Del Dr. G. Bizzozero.
(Pamphlet.)

Sulla Genesi della Fibrina. Ricerche
Sperementali del Prof. P. Mantegazza,
Milano. (Pamphlet.)

Reports, Journals, Reviews, Sec

The Ophthalmic Review. Edited by Z.
Laurence. No. 12. Oct.

The Journal of Anatomy and Pljysio-
logv. Second Series. No. 1. No^'., 1867.

The Liverpool Medical and Surgical
Reports. Vol. I. October, 1867

Edinburgh Medical Journal. Oct.,
Nov., Dec, 1867.

The American Journal of the Medical
Sciences. Oct., 1867.

Pacific Medical and Surgical Journal.
Nov., 1867.

The Journalof Mental Science. Oct., 1867.

Reports on the City of Glasgow Fever
Hospital from May, 1866, to April, 1867.

Journal of Cutaneous Medicine. Vol. I.,
No. 4.

Reports of the Proceedings of the Asso-
ciation of Medical Superintendents of
American Institutions for the Insane.
1867.

Eleventh Annual Report of the Medical
OflBlcer of Health. St. James', Westmin-
ster. June, 1867.

New York Journal of Medicine. Sept.,
Oct., Nov., 1867.

St. George's Hospital Reports. Vol. II.

1867. London, Churchill and Sons. pp.
486.

Army Medical Department. Statistical,
Sanitary and Medical Reports. Vol. VIl.
For year 1865.

The Detroit Review of Medicine and
Pharmacy. Vol. II. No. 10.

THE

BRITISH AND FOREIGN

MEDICO-CHIRURGICAL REVIEW.

APRIL, 1868.

PAET PIEST.
analytical anli (Critical ^thU\o».

Review I.

Fecundity, Fertility, Sterility, and Allied Topics. By J. Mat-
thews Duncan, A.M., M.D., &c., Physician for Diseases of
Women to the Royal Infirmary, &c. &c. Adam and Charles
Black. Edinburgh, 1866. Pp. 378.

The Diagnosis,' Pathology, and Treatment of the Diseases of
Women, including the Diagnosis of Pregnancy. By Graily
Hewitt, M.D. Lond., F.R.C.P., Professor of Midwifery and
Diseases of Women, University College, &c. &c. Second
edition, revised, and enlarged, with numerous illustrations.
Longmans, Green, and Co. London, 1868.

The Practice of Medicine and Surgery applied to the Diseases
and Accidents incident to Women. By Wm. H. Byford,
A.M., M.D., Professor of Obstetrics in the Chicago Medical
College. Second edition, enlarged. Philadelphia. Lindsay
and Blakiston. 1867. Pp. 616.

Uterine Disorders, their Constitutional Influence and Treatment.
By Henry G. Wright, M.D., M.R.C.P., Physician to the
Samaritan Hospital for Diseases of Women. John Churchill
and Sons. London, 1867. Pp. 268.

On the Management of Labour in Contracted Pelvis: An
Inaugural Thesis, for which a First Prize was Awarded by
the Minister of Public Instruction of France. By William
H. Jones, M.D. Paris, M.R.C.S.E. Translated from the
French. Robert Hardwicke. London, 1867. Pp. 59.

On Cephalotripsy. By G. H. Kidd, M.D., F.R.C.S.L, &c.
Assistant-Physician to the Coombe Lying-in Hospital. John
Falconer. Dublin, 1867. Pp. 32.
82— XLi. 19

286 Reviews. [April,

On Ovariotomy (Clinical Surgery, Part vii.j TBy Thomas
Bryant, F.R.C.S,, Assistant- Surgeon to Guy's Hospital.
John Churchill and Sons. London, 1867. Pp. 151.

Contributions to Medicine and Midwifery. By Thomas Edward
Beatty, M.D., T.C.D., President of the King and Queen's
College of Physicians in Ireland, &c. &c. Fannin and Co.
Dublin. Pp. 651.

Obstetrics : the Science and the Art. By Charles D. Meigs,
M.D., late Professor of Midwifery in Jefferson College at
Philadelphia. Fifth edition, revised, with 130 illustrations.
Philadelphia, 1867. [London : Triibner and Co.) Pp. 760.

Obstetric Aphorisms for the Use of Students commencing Mid-
wifery Practice. By J. G. Swayne, M.D., Lecturer on
Obstetric Medicine at the Bristol Medical School. Fourth
edition. John Churchill and Sons. London, 1867. Pp. 139.

The Principles and Practice of Obstetric Medicine and Surgery,
in reference to the Process of Parturition ; with 171 illustra-
tions on steel and wood. By Francis H. Ramsbotham,
M.D., F.R.C.P. Fifth edition, revised. John Churchill and
Sons. London, 1867. Pp. 752.

The books' on our list all refer to subjects connected with the
reproductive organism of woman, and fall into three divisions :
Dr. Duncan's statistical papers ; Dr. Graily Hewitt, Dr. Byford,
Dr. Wright, Mr. Bryant, on diseases of women; Dr. Rams-
botham, Dr. Beatty, Dr. Meigs, Dr. Swayne, Dr. Jones, and
Dr. Kidd, on midwifery and collateral subjects.

The laws affecting the increase and diminution of population
have, until very recently, been studied chiefly in their relation
to the means of subsistence. Statistics, very loosely drawn up,
and figures compiled with the help of the imagination, have
been argued upon dogmatically. At one time Malthus (1791
and 1803) startled the world with the broad assertion that
population increased in geometrical proportion, while their sub-
sistence increased in arithmetical, and therefore it was the duty
of Government to take means to keep down a superal)undant
population. This theory was vehemently denounced and de-
claimed against by Mr. R. T. Sadler, who, in 1830, published
two volumes entitled ' The Law of Population/ which he says
may be thus briefly enumerated : ' The prolificness of human
beings otherwise similarly circumstanced varies inversely as their
numbers." The weakness of the arguments and the absurdities
of Mr. Sadler's style were fully shown up by Macaulay.^

Naturally, one of the chief questions in the consideration of
the growth of populations relates to " generation." Now the
' Edinburgh Bev./ July, 1830, Jan., 1831.

1868.] Recent Works on Obstetrics. 287

laws of the fecundity, fertility, and sterility of women, are up
to the present time undetermined, and this defect arises from
the scanty materials hitherto collected. Dr. Matthews Duncan
has hrought together in the present volume the papers which
he has in the course of some years contributed to the transac-
tions of the Royal Society of Edinburgh and the medical
journals, and which form a valuable contribution towards the
study of this subject. He confines his " basis of operations "
to the returns for Edinburgh and Glasgow in the year 1855,
referring more or less fully to Dr. Collins' report on the women
delivered in the Dublin Lying-in Hospital, the writings of
Nicander (of Sweden), Dr. Stark's and Major Graham's annual
reports for Scotland and England, and the writings of Quetelet,
Braun, Hecker, &c.

Our limits prevent us from undertaking more than a very
brief survey of the opinions put forward, and we must refer our
readers to the volume itself for the tables on which they are based.

Premising that by fertility is meant *' the amount of births "
in contradistinction to fecundity, or the " capability to bear,"
we may pass over the first paper on fertility and fecundity,
merely noting the conclusions drawn by Dr. Duncan : —

" 1. That the actual fertility increases from the commeneeinent
of the child-bearing period of life until the age of thirty is reached,
and then declines.

" 2. That the actual fertility is much greater (about f ) before the
climax is reached than after it is passed."

Dr. Duncan remarks on the sudden decrement that takes
place in the numbers at the ages of twenty-nine and thirty-one
respectively, and thinks it may be explained by the very pro-
bable supposition that the age thirty is given by women as a
round number. We find that a sudden decrement also occurs
at the age of twenty -seven, with a sudden rise at the ages of
twenty-six and twenty-eight in both Dr. Collins' and Dr. Dun-
can's tables.

By comparing the number of children born of women of
difierent ages with the number of women living at the diflferent
ages respectively, the comparative fertility is found, and by
comparing the number of wives with wives' mothers, the com-
parative fecundity. The conclusions drawn are, —

" 1. That comparative fertility increases gradually until the age
of thirty, and then more gradually declines.

" 2. That it is greater in the decade of years following than in
that preceding the climax. Hence it follows that while the mass of
population is recruited from women below thirty, the women from
thirty to forty contribute to the general fertility a larger propor-
tional share than those from twenty to thirty.

288 Reviews. [April,

"3. The fecundity of the mass of wives, not of individuals, is
greatest at the commencement of the child-bearing period of life,
and after that period gradually diminishes.

" 4. This fecundity before thirty is more than twice as great as it
is after that period."

The next point examined is the fecundity of women at different
ages. By an arrangement of tables showing the number of
women who bore children before the end of the first and of the
second years of marriage, Dr. Duncan shows — 1, " that the initial
fecundity of women generally waxes to a climax and then gra-
dually wanes^^ ; 2, " that it is very high from twenty to thirty-
four years of age'^ ; 3, '' that its climax is probably about the
age of twenty-five years;" and by a table exhibiting the number
of wives at various ages compared with the first children born
in the same year, he shows " that nearly all women married
at from twenty to twenty-five years are fecund, and that this
period is the climax of fecundity."

Tables xvi to xxi exhibit the average weights and lengths of
children born at various pregnancies and the ages of the mothers.
The object Dr. Duncan has in view is to disprove Hecker^s pro-
position that primogeniture determines the comparative light-
ness of children and vice versa, and to advance the law that the
determining influence is the age of the mother. The compara-
tive lightness and shortness of firstborn children he concludes
to be due to the fact that the bulk of primiparse are young ; more-
over, the weight and length of these children increase as the
mother gets older, until the period from twenty-five to twenty-
nine is reached, and then gradually diminishes.

The chapters on twins and the laws of their production are
necessarily imperfect from the very scanty materials at Dr.
Duncan's command. By a skilful use of Dr. Collins' and his own
data, he brings forward some presumptive evidence of conclu-
sions which, though not proved, are very interesting. Agreeing
with Dr. Mitchell that twin-bearing is an abnormality, for
woman is uniparous, he argues that twin-bearing is not a good
test of fecundity, and shows from tables that the mean age of
the twin-bearer is older than that of the single bearer corre-
sponding to the commencement of the decline in ordinary fer-
tility ; so that the older a mother is the more likely she is to
have twins, and thus the law is the opposite to that of general
fecundity. Twin -bearing increases in frequency, as the num-
ber of the pregnancy increases, excepting only the first, in
which women are more likely to have twins than in those imme-
diately subsequent. Data are wanting to answer the question
whether twin-bearers have larger families than continuous uni-
par%, but as twin-bearing belongs to the prolific class of women

1868.] Meceni cyorKs on Ubstelrics. 289

it is probable that the families in which twins occur are larger.
• On the question as to the fertility of whole marriages in a
population^ Dr. Duncan contents himself with showing the fal-
lacy in the ordinary mode of computation, viz., the dividing the
births by the marriages, no allowance being made for the wives
who are no longer fecund, and with quoting Major Graham's
report, who assigns the births to the marriages in England in the
years 1862, 1863, and 1864 as 4-255, 4-301, 4-304 respectively.

How many children does a fertile woman produce living in
wedlock from fifteen to forty- five years? The only data Dr.
Duncan offers in answering this question are taken from the
report published by the Statistical Society on the poorer classes
of St. George's in the East, from which it would appear that
the mothers who had been wives thirty- one years had borne on
an average 9-12 children; also making allowance for inexactness
in returns, he concludes that ten is the average fertility, but
that a woman bearing children periodically for thirty years will
have fifteen at least as an average. In chapter x, part iv, the
questions as to the intervals between marriage and the birth of
the first child, and between the subsequent children, is discussed,
and the tables given indicate that in the first case the period is
generally seventeen months, in the second twenty months ; lac-
tation, therefore, has little efiicacy in retarding conception.
After the third or fourth pregnancy the intervals diminish.

It has been maintained that marriages formed late in life are
more prolific than those formed earlier. This does not accord
with the report of the Statistical Society nor with the tables of
Dr. Duncan, from both of which the opposite appears to be the
case, and is doubtless due to the longer continuance of fertility
in the younger. To which is also due the fact that the great
majority of elderly fertile women are mothers of considerable
families.

One main obstacle that meets the statistician at every step is
the enormous difiiculty of getting together and duly estimating
the various disturbing forces, whose value must be calculated
if the result he offers is to be regarded as truthful ; and this is
especially the case in endeavouring to answer the 'question as to
the fertility of marriages at different ages in children that will
survive to adult age. The question is one of wide significance,
inasmuch as it has relation to the longevity of the children,
and for purposes of life assurance, should form an element in
the calculation of the value of lives according to the age of the
parents at their birth. As it has been shown that the fertility
of marriages in the first decade, from fifteen to twenty-five, is
far superior to those subsequent. Dr. Duncan restricts his in-
quiry to this period, and compares the two quinquenniads on the

390 Reviews. [April,

points of 1, fecundity; 2, fertility; S, survival of child-bearing;
4), survival of the offspring ; 5^ healthiness of the offspring.

The third point is discussed more fully in Part VII. On
the whole " the wives of the second quinquenniad may be re-
garded as the most prolific in desirable offspring."

Investigating the sterility of wives. Dr. Duncan finds that
there were in Edinburgh and Glasgow, in 1855, 4373 married
women between the ages of fifteen and forty-four inclusive, and
of these 1 in 6*6 was sterile. Sir James Simpson had the census
taken of two villages, and after correction for age and length
of marriage found that 1 in 10^ was sterile. Taking this
average together with an average drawn from the Peerage. Sir
James makes the total average to be 1 in 8^.

Elaborate tables on the actual and relative sterility of wives
are given, from which it appears, 1, that the question of a
woman's probable sterility is decided in three years of married
life, only seven per cent, bearing children, after this period ; 3,
a wife who, having had children, has ceased for three years to
exhibit fertility, will probably bear no more children ; 3, fertile
wives breed generally every two years. Dr. Duncan especially
calls attention to these deductions as forming a strong argument
against operations proposed to cure sterility. We must, how-
ever, observe that he does not enter at all on the physiologj^ of
the question, nor examine those instances which may be quoted
in opposition. We should be glad if he would draw up tables
showing the relative success or non-success in cases where the
means he condemns have been employed, and distinguishing the
cases where failure followed a perfect operation. In connection
with the same subject statistics of wives who, sterile with the
first husband, become mothers on a second or subsequent mar-
riage, are required.

The next question examined is "the influence the number
of a woman's pregnancy and her age has on childbed mortality.
Taking the tables furnished by Drs. Johnson and Sinclair, Pro-
fessor Hugenburger, Dr. Collins, and the Edinburgh and
Glasgow reports of 1855, Dr. Duncan first compares the rela-
tive mortality from puerperal fever of primiparse and multiparse,
which is about two to one, and then examines the relation of the
number of the labour to puerperal mortality, and finds that as
the number of a woman's labour increases above nine, the risk
of death from all causes increases with the number. " These
statistical facts point," he considers, " to some other pathologi-
cal cause than that expressed by the words accidental, fever,
contagions, epidemic, while the regular increase of mortality
after the ninth labour discountenances the idea that mere dura-
tion of labour, which by some has been cited as the cause of

1868.] Recent Works on Obstetrics. 291

primiparous mortality^ is of itself of any weight/^ but he looks
for it "in the numerous slight complications accompanying
labour, which in the primiparse are chiefly mechanical, in the
elderly multiparae are connected " with the constitution or ute-
rine infirmity."

Dr. Stark considers the great mortality in the first labour
as the principal influence on the whole mortality of married
women before thirty, so that " after the birth of the first child
the female during the rest of the child-bearing life has an equal
chance of life with the unmarried, and a better life after she has
passed her thirtieth year" ; but this opinion must be modified
if we accept Dr. Duncan's statement as to the rapid increase of
mortality in labours subsequent to the ninth.

The relation of age to puerperal mortality is next examined ;
the chief conclusion arrived at is that the age of least mortality
is near twenty-five, and on either side of this age mortality gra-
dually increases with the diminution or increase of age, but
much more considerably with the increase.

The paper on nubility offers some arguments in answer to
the question, — what is physiologically the fit age for female
marriage? Dr. Duncan warns us that menstruation is not to
be assumed as synonymous with nubility ; and allowing it to be
so with puberty, though the exceptions are very numerous, he
quotes M. Joulin, " that nubility is the complement of puberty,
and the one is ordinarily separated from the other by an interval
of several years." The arguments are briefly, —

1. The female pelvis does not acquire the shape best fitted
for the passage of the child until after eighteen, while the bony
structure is not completed until after the twenty-fifth year.

2. The heavy mortality which accompanies first labqurs,
being about double that accompanying all subsequent labours,
is due to the large admixture of premature marriages, while it
has been shown that the age of least mortality of first labours is
between twenty and twenty-five.

3. The avoidance of sterility. For the age of greatest initial fe-
cundity is from twenty to twenty-four, and there is a greater sur-
vival of children born of women aged from twenty to twenty-five.

4. Immature and old mothers are specially liable to bear idiots.
The duration of pregnancy has afforded writers on obstetrics

an occasion for much discussion, and Dr. Duncan, repub-
lishing his paper of 1856, contributes seven chapters. The
point urged by him is, that conception, or the junction of the
sperm with the ovum, may and probably does not take place
till some days after coitus; and that the normal duration of
pregnancy from this time is not more than 275 days. To find,
therefore, the probable day of labour, add to the last day of

292 Reviews. [April,

menstruation nine months + three days; or, if February be
included (excepting in leap year), + five days, making 278
days : " this will give the middle day of the week in which the
labour will probably take place/' Dr. Duncan considers that
protracted gestation is very rare; that in the real cases, the
foetus is always larger than normal, and that most of the
instances alleged may be explained by supposing that the semen
retained its vivifying power some days after it reached the
maternal passages, and that the ovum did not meet with it till at
a distant period from the coitus. He assumes that the ovum is
matured and expelled from the Graaffian vesicle at the menstrual
period ; but Ritchie has shown very good grounds for believing
that the ova are much more frequently shed, and not necessarily
in conjunction with menstruation.

We will now turn to the more strictly medical works on our
list. Dr. Graily Hewitt in this, his second edition, still retains
the plan on which he wrote the first, we cannot think with
advantage to the student, for it necessitates frequent repe-
titions, and the turning over from one part of the book to another
to gain a distinct description of any particular disease. Had the
portion on pathology and treatment preceded that on diagnosis,
which is really the fruit of pathological investigation, we should
have had a more readable and more handy work. At the
same time, we know of no book which gives so thoroughly the
minute points of difference between various diseases which,
simulating in appearance one another, demand acute tact and
varied knowledge to form a true diagnosis. It is especially a
safe and valuable guide to the practitioner who only occasionally
meets with the class of cases treated of, and may be said to
form the complement to West.

Dr. Byford's work is, as he describes it in his preface to
the first edition, a concise yet sufficiently complete practical
and reliable treatise, intended to meet the wants of the student
and junior members of the profession in everyday practice.
In it he has incorporated the views of some of the latest writers
on the various subjects, as Dr. Marion Sims' manner of ope-
rating on the cervix and vagina.

Dr. Wright takes a different stand^point from Drs. Hewitt
and By ford. He deals rather with general features than with
minute observation, and views his subject chiefly in its medical
aspect. The first chapter is a brief sketch of the records of
uterine pathology amongst the ancients, and contains woodcuts
of specula and instruments, some found at Pompeii, and others
described by Scultetus.

He separates his subject-matter into three heads : — Disorders
of Place, of Function, and of Structure.

1868.] Hecent Works on Obstetrics. 298

Under the first head he discusses uterine and ovarian dis-
placements.

The anatomical arrangements for the support of the uterus,
though lengthily, are not very clearly described ; but Dr. Wright
calls attention to the intimate relation existing between the
portal and uterine vascular systems, and urges very properly
the use of cholagogues in diminishing uterine congestion, while
he denounces the ill effects produced by the fashion of sus-
pending the dress from the waist, and girthing the thorax with
stays. We quite agree with him that '' the extent of vulval
protrusion in prolapsus is of less importance than the recognition
of the elements which compose it, and the discrimination of the
manner of its production,^' if we would succeed in remedying,
if not curing the mischief; but we are surprised not to find a
due notice of that very frequent form elaborately described by
Huguier, '' elongation of the cervix,^' nor does he mention the
fact that retroversion of the uterus precedes real"prolapsusuteri."

Dr. G. Hewitt describes and recommends Huguier^s opera-
tion, but advises the use of the ecraseur instead of the knife,
and notices the danger of including the bladder in the loop of
the instrument, or of wounding it when the knife is used.

We wish we could speak with as much confidence as Dr.
Wright of the success of the perineal operation in bad cases of
vaginal prolapse. Unfortunately it does not even generally
afford " a simple and efficient means of permanent cure ;" for
indeed these cases are rarely simple : usually when operative
procedure is indicated, the uterus or the cervix is also prolapsed,
and then simple paring of the perineum is ineffectual, and a
more formidable operation — ablation of as much of the cervix
as can be removed — is also requisite if we want to make a radical
cure, and not be satisfied with a mere temporary expedient,
while the success of this mode is probably due to cicatricial
contraction of all the tissues implicated in the operation rather
than to the actual amount removed.

The consideration of flexions of the uterus gives Dr. Wright
an opportunity of bringing forward his spring intra-uterine stem.
We have used a much simpler and equally efficient instrument,
the invention, we believe, of Dr. Meadows, consisting of a straight
glass or vulcanite rod about two inches in length, seated on a
round flat button of vulcanite half an inch in diameter. The
vagina closing on the button efifectually prevents the extrusion
of the stem, unless such an amount of uterine action is set up
as would counter-indicate its use, while normal mobility is not
interfered with.

Dr. Hewitt gives a modification of this intra-uterine stem, in
which the button is slipped up into the vagina, and readily

294 Reviews. [April,

attached to tte stem after the latter has been passed into the
uterus, a matter of some consequence when the vagina is narrow,
and the walls rigid. He tells us also that he has invented a
modification of Hodge^s Pessary, which he recommends "as
unrivalled in the facility of introduction/' " They are," says he,
" most comfortable and most efficient. This method of support
is much more simple and more certain than instruments having
a stem or perineal bandage."

We wish we could 'share in Dr. Hewitt's opinion of the
immense benefit conferred on womankind by this highly lauded
invention : but we can hardly go so far as he does in the views
he holds as to the great importance of the lesions for the cor-
rection of which these instruments are invented. He declares
that his experience has convinced him that " they play a very
considerable part in the production of the sufferings to which
women are liable, entailing years of discomfort, inability to par-
ticipate in the enjoyments of life being one of the smallest of
the efiects which may be produced." Our own observation
leads us to conclude that the pain and suffering associated with
versions and flexions are due rather to concomitant disease of
the tissues of the organ itself or its appendages. Most fre-
quently a subacute inflammatory action is present, no doubt in
some instances fostered by mal-position, on the subdual of which
by rest and proper local and general treatment the malaise dis-
appears, though the flexion or version remains ; while we often
meet cases where, the flexion being congenital, uterine distress
has only supervened after a morbid condition of the tissues has
been originated by some external cause.

Dr. Wright alludes but scantily to displacement of the ovary,
either as to its cause or importance, though it is a fertile source
of pain in conjugal relations, and Dr. Hewitt contents himself
with a quotation from Dr. Rigby. We doubt much whether
Dr. Wright ever succeeded in returning an ovary displaced into
the recto- vaginal cul-de-sac by an examination, for the finger
per rectum can hardly reach it, and it is felt much more readily
per vaginam. His observations on the ill effects of hard purging
are much to the point.

Dr. Wright classifies disordered menstruation as occurring
under one of three influences — systemic, ovarian, uterine; and
directs his treatment according to the supposed origin. Thus,
in systemic amenorrhoea he gives tonics, mineral acids, and iron ;
and in certain cases, accompanied with a dry, harsh condition of
the skin, he has found great benefit from arsenic. When the
ovaries seem to require stimulation he recommends liniments
to the loins, dry cupping to the breasts, stimulant enemata,
and especially Faradisation ; and when they appear unduly

1868.] Recent Works on Obstetrics. 295

irritable, sedatives, aconite, bromide of potassium, counter-
irritation. Where the uterus seems to be chiefly in fault,
excluding cases of occlusion, he thinks ergot of great service.

Dr. Wright specially calls attention " to the relation between
disordered uterine function and the occurrence of severe joint-
pains," which Dr. Todd called rheumatism, " but which," Dr.
Wright says, " differ from true rheumatism in the absence of
increase of local temperature, and the characteristic general
perspiration of acute rheumatism. Applications to the painful
parts, or treatment directed exclusively for the relief of the
supposed rheumatic seizure, would only exercise a palliative
influence : restoration or establishment of the natural menstrual
relief being the method obviously indicated for insuring per-
manent benefit." But he has previously said, and we agree
with him in this earlier opinion, *' that the menstrual flux merely
represents a provision of supply in excess of demand," and there-
fore we cannot regard it as an excrementitious secretion like
the urine, the non-elimination of which allows the accumulation
of poisonons products in the general circulation.

Menorrhagia, metrorrhagia, and dysmenorrhoea are discussed
in a similar manner as to their origin and treatment. The use of
intra-uterine injections of perchloride of iron when the uterus is
large and spongy, and the metrorrhagia unchecked by ergot and
gallic acid, is recommended, care being taken that the cervical
canal is patulous. Sir J. Simpson and others have recorded
cases of fatal peritonitis following the use of fluid inj,ecta, and
Dr. Hewitt can only quote Routh as to the value of iodine or
other injections, not apparently having made any use of them
himself. We have found that a very safe and effectual applica-
tion is to introduce either the solid or powdered anhydrous
sulphate of zinc or nitrate of silver. Dr. Byford describes an
inexpensive and useful porte caustique for this purpose.

Dysmenorrhoea is considered very fully by Dr. Wright, espe-
cially that form which has been referred to ovarian causes,
which latter he considers under three forms, iieuralgic, cap-
sular, and stromal. Dr. Hewitt, while admitting the influence
of the ovary, evidently leans to the belief that the majority of
cases are due to menstrual retention, and though he does not
think every case can be relieved by division of the cervix, he
is much in favour of opening the cervical canal, either by the
curved scissors, and small knife, which he prefers to the metro-
tome cache, or by tents, but the latter he only recommends when
there is " congenital narrowness of the whole cervical canal,
associated with an infantile uterus, or when simple flexion is
the apparent cause ;" in other cases as " congenital narrowness of
the cervical canal, the uterus being normal as regards size and de-

296 Reviews. [April,

velopment/^ in "cases of inflammatory hypertrophy of the cervix/'
and " where the cervix is elongated, and bending forwards forms
a flexion with the uterus, thus causing stricture," he would
perform incision.

But our limits forbid further examination of these books.
Sufiice it to say, that Dr. Graily Hewitt and Dr. Wright
have written with care and give the honest results of their
experience. The former work is a necessary adjunct to the
library of every medical man. It contains a large store of infor-
mation, and the well arranged index greatly assists the reader
who wishes to make a speedy reference to any particular point.
Dr. Wright's book deserves careful reading; it often is highly
suggestive, and is the work of much thought, and though we may
not always agree with him in his opinions, but think that some
of the theories advanced still require proof, his dispassionate
language and fair dealing with the opinions of others commands
our respect.

Dr. Jones's thesis for the degree of Doctor at Paris is worthy
of more attention than the ordinary run of exercises. Written
in 1864, after three years' study at the " Clinique." he now pre-
sents it to the criticism of his brethren at home. Unfortunately,
in putting it into an English dress, he has not quite laid aside
French idioms. He relates fifty-one cases of dystocia with
contracted pelvis, and discusses fairly and ably the treatment he
thinks should be adopted. Arranged according to Dubois' clas-
sification, in sixteen the pelvis was contracted but measured in
the sacro-pubic diameter three and a half inches (class 1) ; in
fifteen it was between three and a half and three inches (class 2) ;
in eleven it was between three and two and a half inches (class
3) ; and in nine under two and a half (class 4) . Craniotomy
Dr. Jones would avoid whenever possible, and therefore in the
first and second classes he advises an early application of the
long forceps. Should the attempts be fruitless, he would follow
Sir J. Simpson's practice, and perform version, and this, he
thinks, should be attempted even in the third class, though here
most probably embryotomy will be necessary to complete deli-
very. In twenty-four of the cases the cephalotribe was used, and
we are glad of the opportunity of urging the adoption of this in-
strument in English practice. Dr. Kidd has described very fully
the advantages it off^ers to the accoucheur. " Cephalotripsy,"
says he, " may legitimately be tried in all suitable cases in which
the instrument can be passed through the brim of the pelvis."
" It takes the place of the crotchet, hooks and craniotomy
forceps." The base of the skull, the thorax, or pelvis may be
reduced to the smallest possible dimensions without injury to the
mother. Both Dr. Jones and Dr. Kidd speak of M. Pajot's

1868.] Recent Works on Obstetrics. 297

method of " cephalotripsy without tractions/' which Dr. Kidd
thus describes —

" As soon as the os is sufficiently dilated, he perforates ; and
when it is large enough to allow of the introduction of the cephalo-
tribe, he effects the first crushing, taking care to grasp the base of
the skull. Then he slightly rotates the head to the right or left, as
he finds most easy, but does not persist in his efforts to do this if
he finds much difficulty, as the uterus itself will, in a little time, and
often in a very short time, rotate the head so as to bring its dimi-
nished dimensions into the narrow part of the pelvis. After the
first crushing he withdraws the instrument without traction, and
proceeds immediately to make a second, and even third crushing,
and then the patient returns to bed. According to the general and
local state of the patient, and the weakness or energy of the uterine
contractions, he repeats these crushings every second, third, or
fourth hour, making two or three crushings at each sitting ; in some
cases one or two sittings suffice. The head, broken and elongated,
is expelled by the uterine contractions; and if the thorax present
any difficulty it also is crushed once or twice."

Dr. Kidd has figured the instrument, which he thinks nearly
perfect.

" It is straight in the blades, which are long enough to lock
quite clear of the vulva, and the lock is the reverse of the ordinary
mode, being so made that the groove in the upper blade locks for-
wards instead of backwards when the instrument has been intro-
duced, so that the upper blade may be passed first, and then there
will be no difficulty in introducing the second or under-blade."

In Dr. Jones's essay we see the advantages which the Paris
school offers to the student. Acknowledging fully the mortality of
general lying-in hospitals, we would ask why our great. hospitals
might not each reserve a ward of three or four beds for cases of
dystocia, and make arrangements with the parochial medical
officers and the midwives who attend the poor in the neighbour-
ing districts, to send in any case requiring or likely to require
special skill. In this way a great benefit would be conferred on
the mothers while the students would have the opportunity of
learning to recognise abnormal presentations, contractions of
the pelvis, &c., &c., and of seeing the management of necessary
operations. At present, while amputations and special opera-
tions, which are usually, in the case of the poor, performed in
hospital, are seen to satiety, the general student learns
nothing of midwifery difficulties, which he may at any time meet
with in practice, except as it were by accident, or unless he
specially study this branch of medicine.

Mr. Bryant's monograph on ovariotomy comes before us
opportunely. The sensational talk and writing indulged in
about the operation have pretty well subsided, and the subject

298 Reviews. [April,

can now be scientifically and impartially discussed. Those who
will never be called upon to operate will gladly read what can
be advanced as to the justifiability of the operation, its history,
the mode of procedure, the causes of death in ovarian disease,
and the statistics of ovariotomy, treated of in the first four
chapters. These we shall pass over, merely observing, that a
more detailed account than a mere reference would have been
of value as to the mistakes in diagnosis which have been made;
for errors traced out serve as hand-posts for avoidance of
similar disasters. We quite agree with Mr. Bryant,

" That it seems probable most of these errors might have been
avoided had all the means of examination been employed, amongst
which a careful examination of the pelvis is unquestionably to be
named as the most important, by the finger, by the uterine sound,
and by the catheter." " And that when there is doubt as to the nature
of the disease, the operation should be postponed, as in cases of
calculus."

One point also should be specially noted by all who may have
charge of a patient with ovarian disease, that tapping for tem-
porary relief is

"Not unfrequently directly followed by acute peritonitis and
suppuration of the cyst, and that these causes of death are 35*5 per
cent, more frequent when tapping has been employed than when the
disease has been allowed to run its course. While parietal and
omental adhesions " (a chief cause of embarrassment, if not of occa-
sional failure, in the completion of ovariotomy) " are 45 per cent,
more frequent when tapping has been employed."

We will now briefly look at the subject from the operator's
point of view.

The solid benign tumour of the ovary need but seldom be re-
moved. The benign cystic should be removed so soon as the growth
by its size begins to aflfect the general health ; but if the powers
of life have become so enfeebled that there is '' no reasonable
prospect of success," Mr. Bryant would hold his hand. The
cystic tumour may possibly be cancerous, and the diagnosis is
in the early stage often very uncertain. Suspicion of its real
character is raised if both ovaries are involved, if the growth is
very rapid, if the patient's constitution is greatly affected, if
cancer appears in other parts, if the pelvic organs be fixed.

The operationbeing determined upon,no particular preparatory
course need be insisted on, but the general condition should be
raised as much as possible to a healthy standard, and Mr. Bryant
thinks the tinct. ferri perchlor. has a special prophylactic power
against the occurrence of erysipelatous inflammation. He par-
ticularly advises that those engaged in the operation should not
have assisted at a post-mortem, or handled any morbid pre-

1868.] Recent Works on Obstetrics. 299

parations, and would not admit to the operating room a spec-
tator who was engaged at the time with a case of scarlet fever
or other contagious disease. General ansesthesia is far pre-
ferable to local, and he recommends the compound of alcohol,
1 part; chloroform, 2 parts j sether, 3 parts.

The abdominal incision should be made according to the cir-
cumstances of the case; a short one may be sufficient for a
monocystic unadherent tumour, but a long one is required if
there are adhesions, or the tumour is semi- solid.

Having opened the abdominal cavity, any adhesions in front
are to be broken down by the finger ; but Mr. Bryant would not
pass the hand into the abdomen, to see whether the tumour is
free, preferring to divide any lateral and posterior adhesions as
they are dragged forward when the cyst is being emptied.

Almost every operator of note has treated the pedicle in a
different way, either by various modes of fastening the pedicle
outside, or to the walls of the abdomen, by curiously contrived
clamps, hair- lip pins, &c., or by dividing the pedicle with the ecra-
seur and crushing it, or with the actual cautery, and then allow-
ing it to drop into the abdomen, or with the knife and ligature.
Mr. Bryant lays down the right principle, "that the first
object is to prevent haemorrhage, and to employ such means in
doing so as shall be least likely to excite peritonitis,^'' and
approves of dividing the pedicle, passing a whipcord ligature
round it, and then dropping it into the abdomen, as he does
not think the cautery alone can be trusted. He concludes his
little volume with the detailed account of twenty-six cases, and
an analysis, furnished by Dr. J. J. Phillips, of the post-mortems
of ovarian cases made at Guy's during forty years.

Dr. Beatty's position as a scientific practitioner is so well
assured, that the volume bearing his name is certain to be
received with pleasure by all, and with interest by those who are
desirous of tracing the steps by which certain instruments,
modes of treatment, and drugs, which at the time he wrote were
foreign to many of his contemporaries, have become articles of
faith in these later times. To his father. Dr. John Beatty, is
chiefly due the credit of re-introducing in Ireland the use of the
forceps in place of craniotomy, when the latter operation had
become the rule with scarce an exception in the Dublin school.
A letter by " the father'' on premature labour, with death in
utero of the foetus, owing to a syphilitic taint, illustrated by four
cases, in which women, who had previously repeatedly miscar-
ried, bore live children at term, after undergoing a course of
mercury, is well worth perusal at the present time, when
the dispute is still so unsettled as to mercury or no mercury in
syphilitic disease^

300 Reviews. [Aprils

We have also a good example of the course of treatment more
frequently used twenty years ago than now pursued in puer-
peral fever, — the exhibition of large and frequent doses of
calomel and opium, the former in 3-grain doses every two hours.
Dr. Beatty remarks that, in the three cases detailed and ending
fatally, the mouth did not become affected ; but in other cases,
where recovery took place, the mouth was made sore. The
question had not yet been asked, whether the mercurialization
might not be the sign of successful poisoning of the system by
the metal, in addition to the blood-poisoning by the fever,
while the absence of special action of the drug was due either to
the metal remaining unabsorbed in the stomach and intestines,
as has been shown more recently to be often the case in
cholera, or to its passing away in the black stools of half-decom-
posed bile, the result of its destructive power on the blood glo-
bules and otherwise healthy bile. But Dr. Beatty, commenting
in 1866 on what he had written in 1839, marks well the change
of opinion, when he says : " Cases formerly ascribed to .phlebitis
would now be designated as pyaemic, while generous support and
stimulants have taken the place of leeches and mercury, and we
endeavour to uphold the system and enable the patient to live
until the virulence of the poison is subdued."

In chapters v and vi on the use of ergot and chloroform, we
find much well considered advice ; we note especially some
points which are sometimes forgotten in practice, for example,
ergot, unless followed by labour in two hours, is almost certain
to poison the child ;^ when post-partum haemorrhage, or severe
after-pains are dreaded, a dose of ergot given when the head of
the child passes the vulva, frequently averts the threatened
danger and pain ; ergot in small doses is often serviceable in
checking menorrhagia.

Dr. Beatty was one of the first of the Dublin authorities to
follow Sir J. Simpson's practice in exhibiting chloroform ; and to
neglect of his caution as to the necessity of using the anaesthetic
in a pure state may, perhaps, be traced some of the inconve-
niences, and especially the use of large quantities sometimes
complained of. Dr. Gregory's method of testing was to agitate
the suspected chloroform with sulphuric acid, which should be
quite colourless, pure acid, of the full density of 1*840 at least;
the impurity being dependent on volatile oils will be shown by
their charring ; or looking across the test-tube, we shall see the
surface of the acid become concave when the impurities are

^ Some think that this death in utero is due to the tonic contrac-
tion of the uterus impeding the placental circulation, so that the
child dies asphyxiated.

1868.] Recent Works on Obstetrics. 301

destroyed, until then the line of junction between the acid and
the chloroform remains horizontal. Dr. Beatty relates three
cases of death by uraemia consequent on the blocking up of the
ureters by cancerous deposit, which had spread from the uterus,
and a very interesting account of aneurism of the abdominal
aorta. It is true that since this case was first published many
have been added, but the clear and succinct details are well
worthy perusal.

Division of the cervix for dysmenorrhoea is approved of, and
performed by our author, who still prefers the single-bladed
hysterotome to Dr. Greenhalgh's double blade or Marion Sims'
method with the scissors. The remainder of the volume is
occupied by a reprint of certain articles on impotence, rape,
doubtful sex, persons found dead, in the ' Cyclopaedia of Prac-
tical Medicine.'

Professor Meigs, of Philadelphia, has brought out the fifth
edition of his work on obstetrics. Criticism by us of a book well
established in its own country would now be somewhat late, and
we only allude to the work as an acknowledgment of the high
position of its venerable author. Yet we cannot recommend the
volume either to the student or practitioner at home. For the
want of systematic arrangement will confuse the former,
while the latter will object to the diS'use and often un-
scientific style, together with the want of acquaintance shown
as to the late advances made in instruments used in forcible de-
liveries.

We merely give a few instances in justification of these stric-
tures. Thus, while describing the dry pelvis. Dr. Meigs stops
to relate four cases of labour in which the forceps were used
on account of cramp caused by pressure on the sacral nerves by
the head of the child, and gives a long dissertation on the origin
of the name os sacrum, and some pages on the planes which
can be described in the living pelvis.

He also mixes up abnormal with normal conditions, relating
slough with ordinary pregnancy a case of extra-uterine foetation.
In the chapter on forceps he gives a quotation from Tertullian,
while he is wholly silent on the various forceps, cephalotribes,
perforators, &c., of later invention than those of the late Pro-
fessor Davis, and takes great credit for inventing a pair of
pliers for picking away portions of the foetal skull in craniotomy
cases. There is, however, much practical information scattered
in the book, and though we think four pages is rather much
to spend on recommending " with undoubted confidence" a
flannel skull-cap as the treatment for infantile coryza, yet ob-
servations and thoughts will frequently be found to repay the
leisure reading of the obstetrician.

82— XLi. 20

303 Reviews. [April

The fourth edition of Mr. Swayne's obstetric aphorisms will be
as well received as its predecessors. It forms a " handy-book" for
the student, who may use it for testing his knowledge, and as
an index pointing out problems to be studied thoroughly by help
of larger works and practical observation, while the numbered
paragraphs in which the book is arranged serve as texts to be
thought over.

Dr. Ramsbotham's work on midwifery has so long been the
standard book both for student and practitioner, that comment
on the fifth edition now presented is almost superfluous. The
preface tells us that, "the chapter on ansesthetics has been
slightly extended, a chapter on the diagnosis of pregnancy
added, and many emendations and additions made throughout
the body of the work, too inconsiderable, however, to merit a
special enumeration.^'

We cannot help expressing a regret that the chapter on anses-
thetics was not wholly rewritten, for though it may be a grati-
fication to the author to preserve a record of former feelings
on the subject, yet after reading the cogent arguments mus-
tered against the use of chloroform, the student will be surprised
to come upon the recantation of all that he has just carefully
gone through, and read that —

" Since the above was written, eleven years ago, experience has
fortunately proved that the gloomy anticipations which I had formed
respecting the danger universally attending the administration of
ansesthetics have turned out to be in some degree fallacious ; or at
least it is not so great as I feared it would be, for the casualties that
have resulted from their use during that period have been astonish-
ingly few. And I am pleased to have the pleasure of confessing
the value of this drug in those cases where in the body of this work
I have advised its exhibition."

He will also be disappointed in not finding any further argu-
ments for its use, nor directions as to the mode of exhibition,
and will be still more puzzled by the Parthian shot at the
northern school contained in the note where it is suggested
that " the excess of childbed mortality in Scotland over England
may depend on the almost universal employment of chloroform
in labour throughout Scotland which is rarely" (?) " used in
England." We should have been glad also of a new chapter
on craniotomy, and a discussion on the merits of the principal
instruments which of late years have been brought very promi-
nently forward as testified by the exhibition held by the Obste-
tric Society, March, 1866, and in the catalogue since published
by them. Cephalotripsy, of which we have already spoken,
remains still unnoticed in this work, nor is mention made of

1868.] Recent Works on Obstetrics,

other instruments than those represented in the former editions.
The chapter on the diagnosis of pregnancy details concisely the
signs on which an opinion can be formed, none by themselves
being proof positive, except, of course, the fcetal heart, and even
this may be sometimes simulated to an inexperienced ear in the
case of tumours, when the circulation is quickened and the
sounds obscure.

Suppression of the menses, both by Dr. G. Hewitt and Dr.
Ramsbotham, is regarded as a very unreliable sign in the earlier
months; and the former warns us that it may occur two or
three months previous to conception taking place. The pre-
sence of a periodical uterine haemorrhage during the earlier
months of pregnancy is admitted by both; indeed. Dr. G.
Hewitt speaks of one lady within his own knowledge who had a
periodical discharge of blood resembling the catamenia during
the whole of her pregnancy. Dr. Ramsbotham thinks " it quite
within the range of possibility that a female may really men-
struate once or twice after having conceived ; but that, after the
OS uteri is blocked up by its gelatinous plug, the discharge pro-
ceeds from the surcharged vessels in the upper part of the
vagina and cervix,'^ as Whitehead showed by specular observa-
tions. Dr. G. Hewitt adds the caution that the discharge may
be a symptom of extra-uterine foetation. Ballottement, Dr.
Ramsbotham says, he has never had occasion to recur to, and
that "it can only be experienced when the head presents.^'
Dr. G. Hewitt thinks it "one of the most reliable signs of
pregnancy, but then goes on to mention various conditions of
pregnancy in which it may be wanting. The coloration of the
vagina, first brought into notice by Kluge and Jacquemier, con-
sisting of patches of a dusky livid hue. Dr. G. Hewitt considers
as a sure sign of pregnancy, and not simulated by any other
state of the system.

The condition of the mammary areola is by both thought to
be " strikingly distinctive of pregnancy," " when the dark portion
near the edge appears as if it had been partally washed out by
a shower of small drops having fallen on the part" (Mont-
gomery). The other symptoms, such as 'morning sickness*,
' enlargement of the uterus,* on which Dr. G. Hewitt remarks
that during the mid-period of pregnancy the uterus often lies to
the right instead of in the median line, ' the peculiar condition
of the OS and cervix' as pregnancy advances, * the apparent move-
ments of the foetus,* * the presence of kiestein in the urine,' ' the
placental souffle,* are all corroborative, but any one may be either
undiscoverable or be simulated by disease. It is therefore on
the sum total of all the symptoms present that a correct diagnosis
can be founded, and in some cases it is wiser to let time prove.

304 Reviews. [April,

rather than hazard our own or our patient's reputation by a
hasty opinion.

Review II.

Statistical Report of the Health of the Navy for 1863. (By
Order of the House of Commons.) 8vo. Pp. 322. 1866.

Statistical Report of the Health of the Navy for 1864. (By
Order of the House of Commons.) 8vo. Pp.365. 1867.

These health records of the naval service increase in interest
and value from year to year, under the able direction of
Dr. Mackay. Taken in connection with the annual reports of
the army, they form by far the most instructive contributions
to medical geography, as well as to the nosological and hygienic
condition of large bodies of men under diverse and very varying
circumstances, which the profession has hitherto possessed.
No officer in either of the public services should fail in making
himself master of their contents ; they will continually suggest
to him topics of interesting inquiry, as well as of immediate
practical value. It is earnestly to be desired that the medical
department of the navy may ere long be assimilated with that
of the army, and that a school like that at Netley may be
furnished at Haslar, or other suitable place, for special in-
struction in nautical medicine and hygiene. No branch of the
profession has stronger claims for liberal encouragement on the
part of government, and, if duly encouraged, can contribute
more usefully to scientific and technical research. The greatest
praise is due to the present director-general for having origi-
nated, and to Dr. Mackay for so efficiently carrying out, the
publication of these annual reports. We are glad to observe
that the last one, that for 1864, has received considerable
extension, and has thus afforded space for more frequent and
larger extracts from the individual reports of the medical
officers themselves, whenever they are deemed worthy of special
publication. This step will serve to stimulate zeal and generous
ambition among all, and especially among those who have
recently entered the service, and cannot fail to do good in
various ways. We should like to have fuller information from
the large naval hospitals, both at home and abroad ; their expe-
rience might be most valuable, in respect of the health not only
of the nautical, but also of the civil, population around them.
But for this and other additional topics that might be sug-
gested, we must wait till the medical department at Somerset

1868.] Report on the Health of the Navy, 1863-64. 305

House obtains that enlargement which the sister service at
Whitehall has within the last few years received. At present,
the shoulders of one person in the former have to bear the
weight which in the other office is divided among three.

On the important subject of the multiform varieties of fever,
continued and periodic, there are always some interesting
details to be found in the 'Navy Reports.' Most of the cases
of enteric fever in the service — and they occur on every station
— are traceable to direct communication with seaport towns,
which are without exception notoriously unwholesome in those
localities where sailors most do congregate. Portsmouth,
Plymouth, Liverpool, and Leith, were the places where the
home fleet chiefly contracted the disease. In the Mediterranean,
Malta, Gibraltar, Palermo, and Naples, appear to be the most
frequent foci of infection. No spot is worse in this respect
than the dockyard creek in Malta harbour ; it is a constant
seed plot of febrific distemper. In 1862, and again in 1863,
there was a large amount of typhoid fever, due to this source,
among the fleet.

" The emanations," writes the surgeon of the ' Hibernia,' which
suffered severely, " are constant and most offensive ; but though
exposure to them may produce a low condition of health, it is not
until after the early rains, which usually fall about the end of Sep-
tember, or beginning of October, that the state of the creek becomes
absolutely dangerous. During the dry summer an accumulation of
sewage takes places in the sewers, and is swept by the first autumn
rains into Dockyard Creek. There the water is almost always stag-
nant, and the consequence is, that the adjacent atmosphere becomes
contaminated by sewage gases to such an extent as to produce a
more or less poisonous influence on persons exposed to this atmo-
sphere. As a fair proof of this I may state, that more than one-half
of the police force employed in the dockyard and victualling yard
have suffered from the prevalent fever. These men, beyond all other
persons, except those who live in houses very close to the edge of
the creek, are much exposed, both by night and day, to the conta-
minated atmosphere I have described. Moreover, almost without
exception, the residents in the ofiicers' quarters, in the Admiral's
house, and in the victualling-yard houses suffered more or less from
fever during the autumn, and these houses are situated at only a few
yards' distance from the margin of the creek."

Nor were things better in 1864. Dr. Duirs remarks of the
crew of the "Marlborough,'^ that

" One good result of our departure from Malta was, that very few
new cases of fever came on after we left, and there was undoubtedly
a higher standard of health generally in the ships during our absence.

" A few days after our return to Malta, in the end of September,

306 Reviews. [April,

cases of fever began to come in again. They had ceased during our
absence, and now they presented themselves with some grave com-
plications— abdominal tenderness, and diarrhcea, and complete pro-
stration, with deafness, and persistent wakefulness."

Again in 1865, the neighbourhood of the dockyard was one
of the localities where cholera was most prevalent. This dan-
gerous health-condition of the place is obviously a question of
national importance, and loudly calls for prompt and effective
correction.

In the Report for 1864, there is an excellent description of
what is ordinarily called " Malta fever," a species of remittent,
and also of the " dengue" or " break-bone fever," as occurring
in Bermuda.

Respecting yellow fever, and its relations to other forms
of febrile disease, various interesting memoranda will be found
in both reports. In 1863, nine cases appear in the returns
from the West India squadron ; but Dr. Mackay expresses a
doubt as to their nature, and whether they should be regarded
as instances of the true pestilence. Of six cases in the " Barra-
conta," which occurred while the ship was among the Bahamas,
where yellow fever seems to have existed,^ the first had cer-
tainly the characteristic symptoms. After exposure to the
burning rays of the sun at the mast-head, "he was seized with
violent headache, and was in a delirious or unconscious state
during the whole period of the attack. There was yellowness of
the conjunctiva, and, for some hours before death, a black
grumous fluid welled out of the mouth without effort. Imme-
diately after death decomposition set in, the body rapidly
inflated, the skin became black, the extremities mottled, and
the face of a dirty yellow colour." The five other cases, which
occurred about the same time, were mild, and all " recovered
under the influence of quinine."

Again, in the single fatal case in the " Buzzard," while she
was off Vera Cruz, where the fever was reported to be present,
'' the symptoms unquestionably resembled those of specific
yellow fever," although the surgeon of the ship returned the
disease as remittent fever, mainly on the ground, it would seem,
that it did not spread on. board :

" The strange and unaccountable fact is, that although some of
the officers and men were exposed to the same virus, and protected
in the same way by quinine, they were neither infected, nor was the
disease developed on board amongst the ship's company, his being

' " The mortality from cases (of yellow fever) in the district of New Providence
iNassau), amounted to 21, while in 1862 they amounted to 102." — ' Reports of the
British Colonial Possessions for 1863,' p. 14.

1868.] Report on the Health of the Navy, 1863-64. 307

the only case during the ship's detention there, a period of nearly
three months."

But to make the mere absence of contagions properties in
particular instances a diagnostic character of a disease, would
obviously be contrary to experience in respect of yellow fever,
and would sin as much against all sound nosology as Cullen has
unquestionably done when he made contagion an essential attri-
bute of dysentery.

The difficulty, if indeed the possibility, of at times discrimi-
nating bad cases of yellow fever from what is called "malignant,
bilious, remittent,'^ and, on the other hand, mild attacks of the
disease from ordinary remittant, comes forcibly before us in the
present reports.

"To say," observes Dr. Mackay, "that the symptoms of severe
cases (of 'dengue') cannot be distinguished from those of mild
yellow fever, is saying little more than than that they cannot be dis-
tinguished from those of any other fever ; for yellow fever in its
symptoms may be as mild as any ephemeral fever, and yet confer as
perfect an immunity from a second attack as the most virulent
seizure ; just as it does not require small-pox to assume the confluent
form in order to confer upon the affected person exemption from a
repetition of the disease."

And then as to the attacks of more formidable pyrexia, how
are the fatal cases on board the " Handy,^' while at Lagos on
the west coast of Africa, in 1864, to be designated?

" The other fatal case is also stated to have been one of bilious
remittent fever, and was of an extremely urgent character from the
first. Two days after being taken ill vomiting set in, and continued
persistent until his death, which took place on the fourth day of the
disease. The vomited matters in this and the former case were of a
dark or brownish black colour, as frequently occurs in severe cases
of this form of fever, and has so often led to its being confounded
with yellow fever. The surgeon ^ of the * Handy ' says that at the
time the officer died, —

" ' Bilious fever was raging on shore, where out of forty -two
Europeans, twelve died in six weeks. From the accounts given of
yellow fever, I am of opinion that three of the cases on shore were
of that description ; however, as I have never visited the "West India
or other places where this disease makes this appearance, it is pos-
sible I may be mistaken. In all the three cases death took place
within thirty-six hours of the appearance of the disease ; there existed
intense prostration from the commencement, deep yellow skin, and
at last black vomit.' "

It behoves the medical officers of the navy to consider more

' Surgeon Henry Bales.

308 Reviews. [April,

attentively and unbiasedly than they have probably yet done
this difficult question of nosology, as its bearings on practical
hygiene as well as on setiological medicine are of signal impor-
tance. Among other points too of medical inquiry for the inves-
tigation of which their service affords special facilities, may be
mentioned the incubation of malarial and miasmatic poisons.
The following observations deserve notice : —

" Ships employed on river service," remarks the surgeon of the
* Gladiator,' on the "West African station, " for periods of from one
to six weeks, or two months, have remained healthy during the time
they were so employed, but immediately on their return to the open sea,
endemic fever has made its appearance. This is a fact known to all
on the coast, and has happened so often as to preclude the possibility
of its being attributable to mere chance. The first time it was
brought under my own notice was in 1860, when the ' Bloodhound '
ascended the Niger, and remained for sixteen days. During that
time she was in the most unhealthy part of the river (the Delta),
yet there was little or no sickness. A week after her return from
the river, remittent fever appeared, and, with only two exceptions,
went through the whole ship's company. The following year the
'Espoir' was detailed for the same service; she was a much longer
time in the river ; exactly the same thing occurred to an officer and
some men, after she was to all appearances removed from the in-
fluence of malaria. This year the ' Investigator ' has just returned
suffering from a similar epidemic, and upwards of half the comple-
ment, which was lent her from the ' Eattlesnake,' are now on their
way home] in this ship invalided, and I have been told that during
her stay in the river she was particularly healthy, having had only
one or two cases of fever on board."

There is an excellent paper on the fevers and other diseases of
the east coast of Africa by Dr. Pendrith, of the " Rapid," which
will repay attentive perusal. The disastrous epidemic last year
at Mauritius has recently drawn special attention to this region.
We learn from Dr. Pendrith that a fatal fever was prevailing at
Port Louis, in 1864.*

The wide geographical diflPusion of smallpox in 1864 is a fact
of much interest, taken in connection with its more than ordi-
nary prevalence that year in this country. Tn 1863, the number
of cases throughout the navy was 121, while in the following
year it amoimted to 462, or nearly three times as many. No
fewer than 199 cases occurred on the home station, indicating
the prevalence of the disease in our chief seaports. Several cases

1 In 1864 an alteration was made in the limits of the Cape of Good Hope, and
of the East India and China stations. The East Indian division of the latter is
now combined with the Cape of Good Hope into one, while China and Japan form
a distinct station. The useful outline maps affixed to the account of each station
enable the reader to at once perceive their extent and boundaries.

1868.] Report on the Health of the Navy, 1863-64. 309

■were contracted at Malta, at the Piraeus^ and at Smyrna, in all
of which places the disease was prevailing on shore at the time.
Most of the cases in the West India squadron were caught at
Kingston, Jamaica, where the smallpox was unusually severe.
In the case of the adrairal's ship, the " Duncan,^^ there were no
fewer than thirty-five cases during the voyage from Portsmouth,
where the first case occurred shortly before sailing. The history
of this epidemic outbreak is highly interesting ; but our space
prevents the insertion of the details relating to the period of
incubation, &c. On the West African station smallpox was
epidemic at Fernando Po, where two cases were contracted by
the crew of the " Zebra.^^ Again, at Monte Video, two men of
the " Satellite" were infected on shore. In several instances the
disease was caught at Bombay, " where it was very prevalent."
But it was on the China station where our seamen suffered most
from small pox. As many as 150 cases were put on the sick-
list, and, of these, sixteen were fatal. The majority of the attacks
were traceable to Shanghae, and to Yokohama in Japan, in
both of which places it was widely spread. Nearly one half of
all the cases in the squadron occurred in the ^'Euryalus" ; she
lost six of her crew in consequence. The history of the out-
break by her surgeon —

"Is a valuable contribution to the epidemiology of smallpox.
While it by no means unsettles a perfect faith in the protective
influence of vaccination, it suggests the probability of the protec-
tion, in certain cases, being weakened in the course of time, and
consequently the importance of establishing compulsory revaccina-
tion in the public services; it indicates the necessity for a careful
regard to the quality of lymph employed in the operation, and it
opens a question as to the character of the vaccination cicatrix that
may be looked upon as affording the most satisfactory proof of the
operation having been effectively performed. The idea that the co-
existence of the secondary manifestations of syphilis exerts a modi-
fying influence on the variolous poison is interesting, but upon this
point further information is required."

A singular epidemic outbreak of variolous, varioloid, and
varicellar disease occurred on board the " Forte," on the Bra-
zilian station in 1863. A narrative of it, given by her sur-
geon, is exceedingly interesting and instructive, "not only as
showing the great diversity of features which may be presented
by different cases of the same disease during an epidemic, but
as indicating the method of dealing with such an epidemic when
it makes its appearance at sea." We commend its perusal to
all who take interest in the natural history of smallpox and its
modification.

Some interesting memoranda respecting scarlatina and

310 Reviews. [April,

measles, especially the former, are scattered through these
reports. The great majority of cases of scarlatina occurred in
the home and Mediterranean fleets, and chiefly, of course, among
the midshipmen. In 1863 there were no fewer than 159 cases
on the home station, and three of them were fatal. Eighty-six
of the attacks occurred in the training-ship for boys at Ports-
mouth : '' of these forty-two are returned as cases of scarlatina
and forty -four as cases of albuminuria," or scarlatinal nephritis.
An interesting account of an epidemic at Corfu, in the early
part of that year, is given by the surgeon of the " Edgar,^^
among whose crew two cases occurred. The population suflered
severely, as might be expected from the hygienic condition of
the people, and the mode of practice of the native physicians.
Towards the end of the year, the disease appears to have been
prevailing in Malta ; and a good many cases occurred in some
ships of the fleet, both then and in the following year. In
several instances, the simultaneous occurrence of numerous cases
of cynanche, accompanied or followed by albuminuria and
anasarca, on board was very remarkable. Many of the details
are well worth perusal.

" Although only nine persons altogether " (in the ' Meeanee ') re-
marks Dr. 5lackay, " were returned as suffering from this disease, it
appears that throat affections were at the same time very prevalent, and
that in many of these cases as the throat symptoms disappeared, and
even after the patients were discharged to duty, a process of desqua-
mation was observed, from which it may be inferred that the exanthem,
although not so well marked in its symptoms in all cases, had a
much more extensive spread than is assigned to it. As happens, in
fact, in almost all epidemics of this fever, there occurred contem-
poraneously a number of obscure affections, which doubtless were
referable to the action of the scarlatinal poison. One case of this
nature occurred on this occasion, in which the patient, a master's
assistant, was placed on the sick list with the ordinary symptoms of
catarrh. There was cough, with ropy mucous expectoration, general
malaise, debility, and great pallor of countenance. The urine became
albuminous ; serous effusions into the lungs and pericardium, and
various parts of the body took place, and he finally sank exhausted
after a lingering illness."

In the report for 1863 it was stated, on the authority of the
surgeon of the " Rattler,^^ that scarlatina was prevailing at
Nagasaki, in Japan, and that several cases had occurred among
the crew of that ship. The statement would, if correct, have
been of much interest in respect of the geographical distribu-
tion of the disease, which, as far as our present information
goes, is much more limited in extent than that of other exan-
themata ; but, on examination, " the detailed histories of the

1868.] Report on the Health of the Navy, 1863-64. 311

cases in the ' Rattler* lead rather to the conclusion that they
were " examples of irregular action oft he variolous poison/' than
of genuine scarlatina.^ To the medical officers of the navy we
must chiefly look for data on this interesting question ; and it is,
therefore, very necessary that they exercise the utmost accuracy
respecting the diagnosis of cases which occur under their own
notice, as well as the authenticity of statements which may be
made to them of cases on shore.

With respect to measles, it need only be remarked that in
1863, exclusive of the cases, not numerous, on the home station,
a few scattered instances occurred at Malta, and also in one
ship on the Pacific station, where the disease seems to have
been contracted at Valparaiso. In 1864 the irregular form of
measles, to which the term " rubeola notha** has been applied,
was extensively prevalent in Malta and elsewhere ; and a good
many cases of it occurred in the fleet.

" I was at first puzzled," says the surgeon of the 'Eirefly,' "to
name it nosologically, as it had a great deal the appearance of scar-
latina ; the tongue was not characteristic of this latter disease, but
the form of the eruption was not in crescentic patches, as described
in true measles. I believe the case to have been one of Eotheln, a
disease first noticed in G-ermany."

A solitary but well-marked case of measles occurred in the
''Pearl,*' immediately after leaving Hong Kong. There was
also one case in the " Tartar," contracted at Yokohama, where,
the surgeon says, the disease was prevalent on shore. But no
details are given. The history of isolated single cases of any of
the exanthemata should always be reported, after thorough
investigation of all particulars, with precision and fulness.

Diphtheria appears to have been prevalent in some parts of
Australia, as at Sydney and Melbourne, in the latter months of
1864; and a considerable number of cases, one of which was
fatal, seem to have occurred on board the " Cura9oa," while she
was in dock near the former town, chiefly among the boys and
midshipmen.

The following interesting narrative, by Dr. Patrick of the
" Sutlej," bears on the very curious question of the atmospheric
difiiision over wide areas of certain morbific miasmata :

" The ship left Acapulco on the 9th of November, and proceeded
along and parallel to the coast line, at varying distances from the
land, depending on the depth of the bays or projection of the head-

^ "No reference to the existence of that form of fever (scarlatina) amongst
either natives or foreigners in Japan Is made by any officer on the station, while
there were numerous examples of irregularity and diversity in the character of
the eruptions, which were unquestionably occasioned by the variolous poison."
(p. 252.)

312 Reviews. [April,

lands. Througliout this voyage we had usually light and variable
winds ; but on the 14th of November, while crossing the Bay of
Tehuantepec, and about 140 miles off the shore, a strong gale sprung
up off the land, attended by a remarkable phenomenon, and followed
by an outbreak of influenza in so striking a manner,that they could
not fail to be regarded as cause and effect. Though a long distance
from the shore at the onset of the gale, it reached the ship charged
with the perfume of fragrant flowers, such as orange blossom and
jessamine, which scented the atmosphere for a length of time so
agreeably, that all hands lingered on deck to inhale the sweet per-
fume. This phenomenon received no consideration at the time
beyond the pleasant sensation it conveyed, but subsequent circum-
stances invested it with greater importance. Two days after the
gale, on the 16th of November, the ship arrived off San Jose, a
small seaport in the State of Guatemala, and left again in a few
hours, without any one going on shore. On the same day two cases
of influenza occurred ; on the next day, the 17th, four more cases
were added ; and on the 18th five cases. The ship had now reached
La Union, a seaport in the State of San Salvador, and here also
influenza was very prevalent, a large per-centage of the population
being affected by it. It was named by them the ' calentura ' and
not only in this port, but among the population of the whole
country extending to the westward through Gruatemala, the com-
plaint was very severe and prevalent. That some connection existed
between the disease which broke out so mysteriously on board tlie
' Sutlej ' at sea, and the same complaint which we now saw on shore,
could not fail to suggest itself, particularly as it was observed that
the gale which preceded the disease was wafted from off that part
of the land where the complaint at the time w as very active ; and
although we were then some forty or fifty miles from the coast, we
had the strongest evidence, that of our senses, that it carried, even to
that distance, abundant exhalations from the land, in the pleasant
perfumes we inhaled. Is it not certain that the same breeze was
charged with a more subtle and more deleterious agency, imper-
ceptible to the senses, but potent enough to prostrate a large number
of the crew ? I think the conclusion is inevitable. Altogether
fifty-seven cases of influenza were placed on the sick list, but that
did not include nearly all the attacks, for a great number, though
suffering a good deal, were still able to perform their duties."

Next to fevers, alvine flux — including diarrhoea, dysentery,
and cholera — causes the largest amount of sickness, disablement,
and death, in the navy. It is on the China station where these
diseases always inflict the greatest distress and loss. Both
reports contain much valuable information on the subject. In
that for 1863, the evil 66*6018 of impure river water are much
dwelt upon.-

" Of diarrhoea," says the surgeon of the ' Cormorant,' we had a
very large number of cases, the greater portion of which occurred

1868.J Report on the Health of the Navy, 1863-64. 313

at Shanghai and Yokohama, and were, in my opinion, attributable in
a great degree to the use of impure water in both places. The
water supply for the war vessels at Yokohama is taken from a basin
or reservoir standing close to a cliff, the top of which is manured
several times in the year with liquified excrement, and much of this
must necessarily percolate into the water contained in the rude
basin, which is, moreover, studded pretty plentifully with vegetable
matter in every stage, from the embryonic to the last condition of
decomposition."

The medical officers of the fleet are unanimous that the use
of impure water is one, at least, of the elements of mischief
operating on the health of the ships at China and Japan. The
evil effects may to a great extent be remedied by '^ advising and
allowing tea ad libitum for drinking purposes," as the Chinese
do. In the report for 1864, there is an admirable account of
a severe epidemic of dysentery among the Marine battalion in
Japan, between the 7th of June and the 26th of August, by the
surgeon of the battalion. The outbreak occurred soon after
their coming from Hong Kong, where they suffered much from
diarrhoea immediately upon their arrival, after a long voyage
from England. Dysentery is far from being a prevalent or en-
demic disease in Japan, nor did the other European troops or
sailors suffer while the Marines were so severely smitten. Even
the officers of the battalion were but little affected — a fact which
alone suffices to indicate the influence of local and personal
causes in producing and aggravating the sickness.

" On a careful review of the whole circumstances connected with
this disastrous epidemic," observes Dr. Mackay, " it would appear,
that whatever influence may have been exerted by tlie circumstances
under which the men were disembarked, and the soil on which they
were encamped, the disease was unquestionably originally contracted
at Jlong Kong, and that acting with peculiar obstinacy on men
whose vital stamina was reduced by the comparative privations of a
five months' voyage, it was kindled into activity at Yokohama, and
assumed its epidemic character by the unbridled dissipation and
debauchery in which the men indulged, and by the exposure to
which they subjected themselves during a period of unusual climatic
vicissitude. That in some instances infection may have propagated
the disease among the men on shore, as it certainly did among the
crew of the ' Conqueror,' is not improbable, but it would not appear
that its infectious character could have been very great, or could
operate at any great distance, otherwise it must have spread to the
other regiments in the immediate vicinity of the marine camp."

The case is one of great practical value in proving how much
the susceptibility to and the development of dangerous diseases
are influenced by the hygienic condition of persons on their

314 Reviews. [April,

arrival in a foreign station ; andj therefore, how necessary it is
to adopt every possible precaution in respect of troops when
landed in a new climate after a long voyage. With the known
predisposition to alvine disease in the Marines upon their arrival
from Hong Kong, where they suffered considerably from it,
more might surely have been done in the way of precautionary
and preventive discipline, to guard against the evils to which
the men were exposed when they reached Japan.

It was on the East India and China station that all the cases
of cholera occurred, throughout the naval service, in 1863. Of
the fifty cases, twenty-six were fatal. Many of the attacks took
place in Japan, in some parts of which the disease " was pre-
vailing epidemically among the natives.^* Most of^the other
cases were at Shanghai.

Of eighteen cases, of which half were fatal, throughout the
navy in 1864, ten occurred on the China station, in five dif-
ferent ships; so there was evidently no tendency to spread
among their crews. Of the remaining cases two occurred in
the East Indies, two on the West African station, and four on
the home station.

The following judicious remarks by Dr. Mackay, on the pre-
ventive treatment of the disease on board ship, are quite in
accord with medical experience on shore :

" As no amount of eKperience on the part of the men themselves,
and no advice given them appears to be of the least value in inducing
them to present themselves at an earlier period, it will obviously be
the duty of the medical officer, in all localities where cholera is pre-
vailing, to institute such measures as may enable him to obtain a
knowledge of the general state of health of the individual members
of the ship's company. For this purpose a modification of what
is known on shore as house-to-house visitation might readily be
established, a sanitary police, composed of the petty officers of the
different messes, quietly organized, and such instructions given to
those in charge of the head, as would effectually prevent a man
labouring under diarrhoea from making repeated use of it, without
being detected and reported to the medical officer. When cholera
has already established itself on board, too much care cannot be
taken to ensure that the choleraic discharges, whether from the
bowels or stomach, shall be largely mixed with the solution of
the chloride of zinc, or other disinfectants, before they are thrown
away, and that any clothing or bedding contaminated with such dis-
charges should be destroyed ; and it would be desirable to * flush '
the head-' shoots,' and those of the diffferent water-closets in the ship
which are much used, with some disinfectant two or three times
daily. It seems hardly necessary to add, that where there is any
doubt as to the purity of the source from whence the water supply

1868.] Report on the Health of the Navy, 1863-64. 315

to the ship is at such times obtained, all water for culinary or drink-
ing purposes should be obtained by distillation."

An increased amount of berthing space should always, when
possible, be given the men in choleraic seasons and localities.

Among the miscellaneous topics of interest scattered through
the reports, we may notice the following description of leprosy —
a malady which will probably attract more attention now than
it has done for the last century and more, in consequence of
the recent report by the College of Physicians — as it occurs at
Lagos, on the West African coast :

'* Another disease not uncommon here is leprosy, of two varieties.
In one the indurated integument beneath the heel and great toe
becomes thickened and cribriform with an immense number of
minute dry holes. After a time a thin colourless fluid exudes from
these openings, and soon after this a deep ulcer, with elevated edges
and very large granulations, forms. This sore spreads until the
ankle-joint becomes implicated; swelling takes place, with indura-
tions, and small fistulous openings form. The constitution now par-
ticipates ; great emaciation supervenes, with anorexia and sleepless
nights ; very little pain, however, is complained of. The period
at which this disease ends varies considerably, from two to ten years
being about the ranges. Occasionally, but very rarely, nature
eifects a cure, the toes ulcerate off, and the stump heals. As a rule,
however, the disease again breaks out, either in the same or the
other foot."

" In the other form alluded to, the constitutional symptoms are
often the first to appear ; general debility comes on, with anorexia,
and wasting of the body. The inferior extremities then become
numb, the toes become particularly thin, giving them the appearance
of being elongated; then a constriction takes place, exactly as
though a piece of small cord had been tied tightly round the first
phalanx oi one toe ; no ulceration takes place, but the constriction
increases until integument alone is left, and the top of the toe soon
drops off; there is no ulceration and no haemorrhage. As soon as
the distal extremity of each toe is gone, the disease attacks the other
foot, but it is worthy of remark, that it very rarely attacks both
extremities at the same time. While the outward manifestation of
the disease is progressing, the constitution becomes weaker, the
body is reduced almost to a skeleton, very little pain is complained
of, and one day the patient is ' found dead.' "

There is much important information as to the great amount
of syphilitic disease in the navy, and the serious consequences
therefrom, as affecting the efficiency of the service, as well as
respecting the working of the legislative measures which have,
of recent years, been adopted in this country at some of the
principal military and naval stations. No officer seems to have
studied the subject in all its bearings more carefully than Dr.

314 Reviews. [April,

arrival in a foreign station ; and^ therefore, how necessary it is
to adopt every possible precaution in respect of troops when
landed in a new climate after a long voyage. With the known
predisposition to alvine disease in the Marines upon their arrival
from Hong Kong, where they suffered considerably from it,
more might surely have been done in the way of precautionary
and preventive discipline, to guard against the evils to which
the men were exposed when they reached Japan.

It was on the East India and China station that all the cases
of cholera occurred, throughout the naval service, in 1863. Of
the fifty cases, twenty-six were fatal. Many of the attacks took
place in Japan, in some parts of which the disease " was pre-
vailing epidemically among the natives.^' Most of^the other
cases were at Shanghai.

Of eighteen cases, of which half were fatal, throughout the
navy in 1864, ten occurred on the China station, in five dif-
ferent ships; so there was evidently no tendency to spread
among their crews. Of the remaining cases two occurred in
the East Indies, two on the West African station, and four on
the home station.

The following judicious remarks by Dr. Mackay, on the pre-
ventive treatment of the disease on board ship, are quite in
accord with medical experience on shore :

" As no amount of eKperience on the part of the men themselves,
and no advice given them appears to be of the least value in inducing
them to present themselves at an earlier period, it will obviously be
the duty of the medical officer, in all localities where cholera is pre-
vailing, to institute such measures as may enable him to obtain a
knowledge of the general state of health of the individual members
of the ship's company. For this purpose a modification of what
is known on shore as house-to-house visitation might readily be
established, a sanitary poUce, composed of the petty officers of the
difierent messes, quietly organized, and such instructions given to
those in charge of the head, as would effectually prevent a man
labouring under diarrhoea from making repeated use of it, without
being detected and reported to the medical officer. When cholera
has already established itself on board, too much care cannot be
taken to ensure that the choleraic discharges, whether from the
bowels or stomach, shall be largely mixed with the solution of
the chloride of zinc, or other disinfectants, before they are thrown
away, and that any clothing or bedding contaminated with such dis-
charges should be destroyed ; and it would be desirable to ' flush '
the head-* shoots,' and those of the different water-closets in the ship
which are much used, with some disinfectant two or three times
daily. It seems hardly necessary to add, that where there is any
doubt as to the purity of the source from whence the water supply

1868.] Report on the Health of the Navy, 1863-64. 315

to the ship is at such times obtained, all water for culinary or drink-
ing purposes should be obtained by distillation."

An increased amount of berthing space should always, when
possible, be given the men in choleraic seasons and localities.

Among the miscellaneous topics of interest scattered through
the reports, we may notice the following description of leprosy —
a malady which will probably attract more attention now than
it has done for the last century and more, in consequence of
the recent report by the College of Physicians — as it occurs at
Lagos, on the West African coast :

" Another disease not uncommon here is leprosy, of two varieties.
In one the indurated integument beneath the heel and great toe
becomes thickened and cribriform with an immense number of
minute dry holes. After a time a thin colourless fluid exudes from
these openings, and soon after this a deep ulcer, with elevated edges
and very large granulations, forms. This sore spreads until the
ankle-joint becomes implicated; swelling takes place, with indura-
tions, and small fistulous openings form. The constitution now par-
ticipates ; great emaciation supervenes, with anorexia and sleepless
nights ; very little pain, however, is complained of. The period
at which this disease ends varies considerably, from two to ten years
being about the ranges. Occasionally, but very rarely, nature
effects a cure, the toes ulcerate off, and the stump heals. As a rule,
however, the disease again breaks out, either in the same or the
other foot."

" In the other form alluded to, the constitutional symptoms are
often the first to appear ; general debility comes on, with anorexia,
and wasting of the body. The inferior extremities then become
numb, the toes become particularly thin, giving them the appearance
of being elongated; then a constriction takes place, exactly as
though a piece of small cord had been tied tightly round the first
phalanx of one toe ; no ulceration takes place, but the constriction
increases until integument alone is left, and the top of the toe soon
drops off; there is no ulceration and no hsemorrnage. As soon as
the distal extremity of each toe is gone, the disease attacks the other
foot, but it is worthy of remark, that it very rarely attacks both
extremities at the same time. While the outward manifestation of
the disease is progressing, the constitution becomes weaker, the
body is reduced almost to a skeleton, very little pain is complained
of, and one day the patient is ' found dead.' "

There is much important information as to the great amount
of syphilitic disease in the navy, and the serious consequences
therefrom, as affecting the efficiency of the service, as well as
respecting the working of the legislative measures which have,
of recent years, been adopted in this country at some of the
principal military and naval stations. No officer seems to have
studied the subject in all its bearings more carefully than Dr.

316 Reviews. [April,

Sloggett, the medical officer of the " Edgar," the flag-ship of
the Channel fleet. His very valuable report is given in full,
and will well repay attentive perusal. With what difficulties
the question is surrounded, as respects the navy, will be patent
from the following extracts, with which we must close our
notice of these reports :

"The possibility of hygienic measures on board the ship, in
checking the spread of syphilis, is a subject of interesting and serious
inquiry. First, as to men's leave. Commanding officers would
strongly oppose any plan of substituting for the night leave which
is now given whenever it is practicable, day leave at certain fixed
times ; and on those occasions on which I have seen permission
given for the men to go on shore for the afternoon and to return in
the evening, but few have cared to avail themselves of the indul-
gence. The men themselves would be discontented if they were
thus deprived of their usual monthly leave of from twenty-four to
forty-eight hours, and those who are determined to incur the risk
of venereal contagion, would not be deterred even if compelled to
return to the ship at sunset. Secondly, personal cleanliness ; the
means of personal ablution might and ought to be provided in all
ships. In steamships the baths could be heated by steam ; and if
every ship were fitted with a sufficient number, say six, with a con-
stant supply of water, the men would soon learn to look on cleanli-
ness as a duty as well as a pleasure. In the lower deck messes,
where men wash in the large filthy tubs with water filthy with soap,
and the accumulated dirt of their messmates, with no place of
secrecy or retirement, it is not to be wondered at that they rarely
wash their genitals ; and I doubt not, many men have ulcers on the
penis often for days, sometimes perhaps weeks, without being aware
of them. Lastly, weekly inspection of men, though I do not believe
this would have much efi'ect in lessening the number of cases ; it
might be of benefit if properly and efficiently carried out, in pre-
venting men going on shore when diseased, and neglecting to apply
for medical aid until the disease has extended and the patient may
require hospital treatment. 1 have myself on some occasions
inspected the whole ship's company for venereal disease ; but only
when after being a long while in a home port, the ship has proceeded
on foreign service, and the sick-list has been suddenly increased by
the addition of men suffering from venereal disease, who had con-
cealed it so long as they had opportunities of going on shore.
Even in these cases, when most of the older, more respectable, and
more intelligent men have seen the necessity of such general inspec-
tion, it has excited so much discontent as to conviuce me it is a
measure to be carried out rarely, and only on urgent necessity."
-)r -3^ * ^ -x- ^

" Period of Incubation. — The earliest period at which any man has
ever appeared with the characteristic pustule of the early stage of
soft sore has been on the fourth day, but men are so much in the

1868.] WoRMLEY^s Micro -Chemistry of Poisons. 317

habit of concealing their sores either from intention or neglect, that
it is diiBeult to form a correct opinion. Men have often applied
with chancres of both kinds of two months' date, and have de-
clared their ignorance of the existence of these sores until the day of
application."

Review III.

Micro- Chemistry of Poisons, including their Physiological, Pa-
thological, and Legal Relations ; adapted to the Use of
the Medical Jurist, Physician, and General Chemist. By
Theo. G. Wormley, M.D., Professor of Chemistry and
Toxicology in Starling Medical College, and of Natural
Sciences in Capital University, Columbus, Ohio. With 78
illustrations on steel. New York, pp. 702.

It will be seen from the title that in dealing with this work we
have to take into consideration its merits from more than one
point of view. We must as far as possible ascertain the value of
the plates, the accuracy of the processes given, the exactness of
the physiological information conveyed, and the clearness of the
legal definitions laid down. We are of opinion that Dr. Wormley
would have sent out a far more useful work had its scope been
less ambitious, — had he adhered to the chemistry of the poisons
alone, and carefully figured the crystalline forms of the products
obtained by various processes. He has, however, probably with
the idea of rendering it more generally useful, tacked on to it por-
tions relating to the symptoms, post-mortem appearances, &c.,
characteristic of certain poisons. Whilst there is much to admire,
therefore, in this work, there is also much to condemn : for instance,
not only the author, but his reviewer in one of the principal Ameri-
can periodicals, would seem to labour under the impression that
this is the first important contribution to the micro-chemistry
of poisons, thus showing themselves ignorant of the valuable re-
searches of Helwig and Guy. Again, in speaking of the mani-
pulation best adapted for bringing out the crystals characteristic
of each poison, he makes no allusion to the most important of
recent discoveries in this direction, viz. the fact that the alkaloids
(as well as other substances) are capable of being volatilized
and again condensed so as to assume distinct crystalline forms,
not only without any change in their constitution, but also
in quantities incapable of being otherwise collected or esti-
mated. So, also, speaking of the best means of observing the
results obtained by adding chemical reagents to minute quan-
tities of any poison, he very properly recommends low powers as
the best adapted for the purpose ; but he makes no reference

82— XLI. 21

318 Reviews. [April,

whatever to the binocular microscope, which we esteem indis-
pensable to every one following up this line of investigation.

Shortly dismissing this portion of the work, which might, we
think, have been prolonged with advantage, our author proceeds
to discuss the general notions connected with poisons. In doing
so he commits the mistake we have more than once had occasion
to refer to — he attempts a definition of the word poison. Now, a
poison is not an entity — it is a potentiality ; what may occasion
symptoms of poisoning in one man at one time, may at another
and on the same individual have absolutely no effect. True,
there are substances which possess the property of giving rise to
certain bad effects more constantly than others do, but here
again the question of dose steps in, and on investigation it will
be found that there are few even of the most virulent poisons
which when taken in small quantity are incapable of doing good.
For these and many other reasons we hold with Tardieu, that to
give any definition we must fall back on the effects and through
them behold the cause. As to classification, Dr. Wormley adopts
the effete arrangement into irritants, narcotics, and narcotico-irri-
tants. He next speaks of the sources of evidence in poisoning,
which he enumerates as, — 1st, the symptoms; 2nd, the post-
mortem appearances ; and 3rd, chemical analysis : thus omitting
two of the most important, viz., the evidence derivable from
experiments on animals, and that of the moral circumstances of
the case. What would have been the results in the case of De
la Pommerais, had not experiments on animals been accepted
as reliable evidence ? and whence would the proofs as to the
existence of aconite in Mrs. Taylor's (Pritchard^s mother-in-
law) bottle of medicine have come ? It is further impossible
in most instances to come to a correct conclusion as to the na-
ture of a case of poisoning without taking into consideration the
motive or inducement, and although that lies to a certain extent
out of the physician's province, still there are many points
which must be best observed and narrated by the physician or
surgeon in attendance on the poisoned individual. Thus, to take
an illustration, — did not Palmer's conduct with reference to Cook,
and his behaviour with regard to the post-mortem examination
on the remains of that ill-fated gentleman, have a fearfully
prejudicial influence on his case in the eyes of the jury who tried
him ? Did not the motive which De la Pommerais had for sacri-
ficing Madame Paw weigh heavily against him when tried for her
murder ? But what need is there for enforcing a point well known
and recognised by every jurist of eminence. The part that
treats of the evidence derivable from chemistry is good, and
shows that the author is well acquainted with the details of
practical toxicology. One remark he makes is well worth quot-

1868.] WoRMLBY^s Micro-Chemistry of Poisons. 319

ing. He tells us that it is often stated that a reagent will detect
an infinitesimally small quantity of poison, but to know its real
value we must know the state of dilution in which the poison
exists. " The hundreth part of a grain of nicotine in one grain
of water yields with bichloride of platinum a copious and rather
characteristic precipitate, while the same quantity in ten grains
of that liquid yields no precipitate whatever." Tliis concludes
the introductory part of the work.

We now find that the author, for the sake of convenience,
separates all the poisons of which he treats into two groups, the
inorganic and the vegetable, but with the former he includes
of the latter both hydrocyanic and oxalic acids. Nevertheless,
of inorganic poisons treated, the list is a meager one, comprising
only the mineral acids and the alkalies, including ammonia
(oxalic and hydrocyanic acids), phosphorus, antimony, arsenic,
mercury, lead, copper, and zinc. Of vegetable poisons, again,
he only includes nicotine, conine (sic), opium (with meconic
acid, morphine, narcotine, codeine, narceine, opianyl), nux
vomica (with strychnine, and brucine), aconitine, atropine,
daturine, veratrine, and solanine. The work is thus essentially a
fragmentary one ; it aims at completeness, and is incomplete.

Let us, however, examine in detail what is said of each poison,
commencing with the alkalies. Dealing with ammonia Dr.
Wormley fails to distinguish between the effects of this substance
on the glottis and on the stomach when swallowed in bulk ; for
instance, he quotes a case in which the patient died in four
minutes, which could only have occurred through spasm of the
glottis, and immediately after one of poisoning by the same sub-
stance, which proved fatal in three days. He alludes to the
vapour causing death by its irritant effects, but without doubt
spasm of the glottis at times proves fatal when the substance
has been swallowed, as is sometimes the case with sulphuric acid.
If, now, we turn to the portion relating to the chemistry of
the alkalies we find that it is extremely full and elaborate.
With each reagent the reaction of given quantities of the sub-
stance, say from -^ to -nh-o of a grain is given, a fact which
we think adds especial value to the observations. When treat-
ing of sulphuric acid, our author is much more satisfactory than
when speaking of the alkalies. He gives a very fair outline of
its actions, symptoms, and post-mortem appearances, but as be-
fore, the superiority of his chemical over his physiological know-
ledge is very apparent. He tackles the grand difficulty as to
the means of distinguishing sulphuric acid from alkaline sul-
phates. He recommends the precipitation of an acidulated solu-
tion of the suspected substance by chloride of bariam, and then
to compare this precipitate with one obtained by first thoroughly

20 Reviews. [April,

drying the suspected fluid, dissolving by a dilute acid, and then
precipitating by chloride of barium as before.

Every 2"38 parts by weight of the former precipitate
in excess over the latter — correspond to one part of free
monohydrated sulphuric acid. By this plan an approximate
estimate may be formed as to the amount of free acid
contained in the original fluid. Of nitric acid we need say
nothing except that the tests recommended are the copper, the
gold, the sulphate of iron, the indigo, the brucine, and the nar-
cotine tests. But when he speaks of hydrochloric acid or a
chloride as necessary to the decoloration of indigo we conceive
him to be in error, for if free nitric acid be added to a solution
of indigo, it rapidly converts it into isatine, and changes its blue
colour to a yellow one ; not so with litmus, that is only reddened.
The article on hydrochloric acid is short and to the point.

Oxalic acid is what would probably be termed a more deadly
poison than any of which we have yet spoken. The chapter on
its efi'ects is not, however, of much value, but the author gives a
most instructive case occurring in America, in which death did not
occur till the tenth day. An ounce was taken on this occasion,
and water given to facilitate vomiting, a mode of treatment we
are usually taught to avoid. Speaking of hydrocyanic acid, his
remarks on the toxicology of the siibject carry no great weight,
but those referring to its chemistry are of much value ; his
estimates of the relative delicacy of the silver, Prussian blue,
and sulphur tests, are very good, and evidently founded on
careful observations. He places the silver test first in point of
delicacy when dealing with the gaseous acid, the Prussian blue
reaction when in a fluid form, the sulphur test occupying an
intermediate position. Treating of its separation from organic
substances, he makes an important practical distinction, accord-
ing as the acid is given oflF spontaneously by heat alone, or after
the addition of an acid only. This is of importance, as the
ferrocyanide of potassium is, if at all poisonous, but very slightly
so. He also alludes to the important fact, that the acid may
fail to be detected after death by its means, owing to its con-
version into other and allied substances, as, for instance, in
Casper^s case, where it was changed into formic acid.

Phosphorus is treated of in the same chapter as the two last-
mentioned substances, but a full and proper use of the published
materials for a history of this poison does not seem to have
been made. In detailing the symptoms our author does not
allude to the jaundice so often observed in poisoning by phos-
phorus, except in recounting one case ; neither, in speaking of the
post-mortem appearances, does he refer to the fatty degeneration
80 common in all the viscera, but especially in the liver, which

1868.] Worui.'ey's Micro- Chemistry of Poisons. 321

in many cases would seem to have undergone acute atropliy of
its substance. In fact we hold it questionable whether this is
not one of the ordinary methods whereby phosphorus causes
death. For the separation of and detection of phosphorus.
Dr. Wormley refers to the methods of Mitscherlich, Dusart,
and Lipowitz, but does not allude to the very simple one given
by Professor Taylor, viz., the dissolving up of the phosphorus
by means of bisulphide of carbon, the spontaneous evaporation
of the latter, and the estimation of the phosphorus by its con-
version into phosphoric acid.

Antimony, the first of the metallic poisons with which
Dr. Wormley deals, is treated at no very great length. One
very interesting case, where a young man recovered after taking
an ounce of the poison, is probably the most interesting in
the paper. In this instance the skin ultimately became covered
with a true Tartar emetic eruption. Of the tests given he very
correctly lauds that by sulphuretted hydrogen as the simplest
and most accurate : he also gives Reiusch^s test, although he
does not give its inventor's name, and he seems inclined to
rely to a certain extent on the violet colour of the deposit. In
this we think he is wrong ; not only may it be simulated by
arsenic, but one not well acquainted with the process might
take the stain produced on the bright copper by decomposing
organic matter for one produced by antimony. He also
describes Marsh's process, and gives the best plan for making
use of it. He gives two processes for separating antimony from
organic substances, and from the tissues ; the latter of these we
should certainly adopt by way of preference. Its basis is
that of Fresenius and Von Babo, being the destruction of the
organic matters by chlorate of potass and hydrochloric acid.

Arsenic is treated of in the shape of metallic arsenic, arse-
nious acid, and arsenic acid — orpiment, realgar, and arsenuretted
hydrogen, are mentioned, but not otherwise discussed. The
ordinary run of symptoms of poisoning by arsenious acid are
succinctly given; but those of an anomalous nature are not
alluded to sufficiently to enable the student to get a clear idea
of them. Of antidotes Dr. Wormley very strongly recommends
the hydrated sesquioxide of iron, and adduces certain experi-
ments he has made in behalf of his statement. The author's
remarks on the chemistry of arsenious acid are of value, espe-
cially when speaking of its solubility ; he has evidently studied
the matter with great care.

For the removal of mercury from organic substances Dr.
Wormley recommends Reinsch's process. In this, bearing in
mind the many mistakes which have arisen through its use, we do
not agree with him. The other metals demand no special notice.

Turning to the portion which treats of the vegetable poisons,

323 Reviews. [April,

we meet an introduction treating of tlie mode of separating
organic poisons from organic matters. The processes enume-
rated are those of Stas, Rodgers and Girdwood^ Uslar and Erd-
mann, Graham and Hoffmann, and by dialysis. It will thus be
seen that he omits some of the more important ones, as Merck^s
and Sonnenschein's, beside which there are many others.

The first alkaloid noticed is nicotine. As usual the symptom-
atology is extremely imperfect, both as to tobacco and the alkaloid
itself. The author also overlooks some of the published cases
of poisoning by nicotine, as the case narrated by Fonssagrives.
The tests recommended are, bichloride of platinum, corro-
sive sublimate (said to be the best), carbazotic acid, iodine in
iodide of potassium (very delicate), the terchloride of gold,
bromine, and tannic acid. It will thus be seen that he omits
what, when speaking of ammonia, he described as Nessler's
test (by the chlor-iodide of potassium and mercury) one of
considerable value and delicacy. The process recommended for
the separation of nicotine from organic substances is good and
simple, being founded on its ready solubility in chloroform. Very
much the same remarks apply to conia, which he terms conine.

To sum up, we find that all parts of Dr. Wormley's book are
characterised by the same excellencies and the same deficiencies.
Everywhere the chemistry is excellent — the symptomatology
and the pathology poor. The former contains many original
observations, some of them, especially those referring to the solu-
bility of the alkaloids, of great value. The latter appears to be
for the most part mere second-hand material, collected chiefly
from the pages of Taylor and Christison. Occasionally we come
across cases of value or interest, little, if at all, known in this
country ; but this is the exception, not the rule. In fact, we
consider that Dr. Wormley has materially injured his book by
tacking this portion on to its original plan. The work is a
valuable one to the professed chemist or toxicologist, but, compa-
ratively speaking, useless to the general practitioner or lawyer.

Turning to the plates, which are seventy-eight in number, we
are bound to speak of them in terms of the highest praise.
They have been executed on steel by Mrs. Wormley, and are
printed with the greatest possible care. It will be seen that
they enable certain reactions, formerly termed tests, but in
reality nothing of the kind, to be utilized, the deposits formed
constituting an important clue to their nature. We might
have preferred Helwig'splan of photography, even although the
crystalline forms of the reagent are sometimes given as well as
those of the substance tested ; but this portion of the work is
altogether of so great value that we are unwilling to be captious.
When the book reaches a second edition we recommend Dr.
Wormley to stick to chemistry.

1868.] Recent Works on Albuminuria. 323

Review IV.

Jaccoud, Article " Albuminurie." ' Nouveau Dictionnaire de
Medecine et de Chirurgie.' Paris, 1866. P. 517—592.

Jaccoud, Article "Albuminuria." 'New Dictionary of Medicine
and Surgery. Paris, 1866. P. 517— 592.

Pathology and Treatment of Albuminuria. By W. H. Dickin-
son, M.D. London, 1868. Pp. 265.

Albuminuria, with and without Dropsy : its different Forms,
Pathology, and Treatment. By G. Harley, M.D., F.R.S.
London, 1866. Pp. 61.

Since the time that Cotugno, in the year 1770, first detected
albumen in' the urine of dropsical people, that Cruikshank,
Blackall, and Wells divided dropsies generally into those with
and those without albuminuria, and thus helped to pave the way
for Bright's great discovery of the connection between dropsy,
albuminuria, and disease of the kidney, chemistry and microscopy
have, in the hands of many a patient worker, united, the one to
throw fresh light on the nature of albuminuria as a symptom,
and on the concomitant changes in the urine and blood which
make it so formidable a symptom, the other to facilitate the
study of renal lesions attended with albuminuria, and both to
bring the diagnosis of these several lesions to a point of nicety
that is highly creditable to medicine. Nor is it to be wondered
at that this should be the case, if we consider what advantages
a daily examination of so important a secretion as the urine
must ofier for the detection of structural changes in the very
organ by which that secretion is formed, and with what compa-
rative clearness minute alterations can be seen after death in
the kidney, as compared with other internal organs, the spleen,
lungs, etc. Once given the fact that certain changes in the
urine must necessarily follow on certain changes in the kidney,
and there could have been but little doubt that both must ere
long be accurately estimated. Let it not be supposed, however,
that the task is done, that the field is cleared. Opinion is still
divided on more than one point. The remarkable versatility of
albumen, which seems, Proteus-like, to be perpetually changing
its form, and so endeavouring to evade detection, at one time
recognised by its behaviour to certain reagents, at another unin-
fluenced by the self-sarrie reagents, even though still present as
albumen, throws the greatest possible difficulties in the way of
the chemist who wishes to ascertain what are the peculiar changes

324 Reviews. [April,

that take place in the albumen of the blood under the in-
fluence of disease. Much^ too, remains to be settled in connec-
tion with the causes of renal disease ; as to how far alcohol is
really harmful ; why cold and damp act only on certain people
in determining acute Bright^s disease, and then only at certain
times ; what the peculiar condition is that predisposes to such
an attack; whether it be the case or not that renal disease is
more common in certain epidemics of scarlatina than others,
and how far a chill to the surface has any real influence in
determining the attack of scarlatinal nephritis^ a moot point
among pathologists ; what is the proper explanation of the occur-
rence of acute dropsy with acute albuminuria ; all these ques-
tions and many others are yet to be satisfactorily answered.

Before we proceed to consider the difierent forms of renal
disease associated with albuminuria, it will be well to discuss
shortly the question as to how albumen finds its way into the
urine, and what are the causes which operate directly in the
production of this symptom, for it is no more than a symptom.
And first, be it premised, that a modification of albumen is pre-
sent in all healthy urine in the form of a substance not coagula-
ble by heat or nitric acid, but coagulable by chloroform (Gigon)
or, better still, by absolute alcohol (Harley). Here, however,
we are only concerned with albuminuria as a symptom of dis-
ease : nor, in the small space allotted to our subject, would it be
possible to do more than deal shortly with the history of genuine
albuminuria ; so that the so-called false albuminuria of Vogel,
where the albumen is present not as simple albumen, but as a
necessary part of hsematuria, pyouria, or spermaturia, must be
likewise excluded from consideration. First, then, how does
albumen find its way into the urine ? To this it may be an-
swered that it exudes from the blood through the capillaries in
all parts of the kidney, choosing for its passage now one now
another set of capillaries according to circumstances, which will
be afterwards explained. Whether, as some of the German
school pretend, the epithelial cells of the tubules, when irritated
to excessive increase or hyperplasia, take to themselves from the
blood an excess of albuminates, and then again set free albumen
into the tubules, so as to aid in the production of albuminuria,
cannot yet be positively asserted^ but is a reasonable explanation
of certain forms of albuminuria. Secondly, what are the causes
which operate directly in bringing about this transudation of
albumen ? These may conveniently be considered under one or
other of two principal heads. A. Changes in the constitution
of the blood in consequence of which the albumen undergoes
some chemical or physical alteration, and transudes unnaturally
through the capillaries ot the kidney. B. Changes in some part

1868.1 Recent Works on Albuminuria. 325

of the kidney itself, either overdistension of its blood-vessels from
pressure or from nervous influences, or some alteration in the
coats of the blood-vessels which renders them preternaturally
permeable, or hyperplasia of the secreting cells of the tubules.

A. The question how far albuminuria can be present for any
length of time, quite independently of any renal disease, and
simply as a consequence of some fault or change in the con-
stitution of the blood, is one that is for the present difficult to
answer with anything like positive certainty. Even now the
principal authorities are at issue on this point, and each seems
to give his answer according to the special bent of his investiga-
tions. The man who finds a peculiar interest in the chemistry
of the blood, and looks at albuminuria from the chemist^s point
of view, will answer the above question in the affirmative, while
he who has devoted his attention more particularly to the
morbid anatomy of the kidney in albuminuria is of an exactly
opposite opinion, and regards the presence of a persistent albu-
minuria as a sure sign of diseased kidneys. We shall endeavour
to show how far and under what circumstances albuminuria is
known to be present without renal disease. And, first, there
is no doubt that it can be artificially induced by experiment.
Bernard injected albumen in solution into the veins of dogs, and
found albumen in their urine. Subsequently SchifF and Stokvis
showed that this effect does not follow when serum of blood is
thus injected, but only when the white of eggs is employed.
Pavy, wishing to ascertain whether the liver can produce in
albumen the necessary change through which it must pass, and
naturally does pass, in the stomach, before it is fit for absorp-
tion, injected white of egg, milk, and isinglass into the mesen-
teric vein of dogs, and found that albuminuria follows just as
when the above substances are injected into the veins of the ex-
tremities, thus confirming Bernard^s experiments, and at the
same time showing that the liver cannot transform albumen
into albuminose. The experiments of Jaccoud and Stokvis
further prove that if cooked albumen in the solid form be taken,
even in considerable quantity, into the stomach, no albuminuria
appears, but that this symptom regularly ensues if an excess of
albumen in solution be thus taken: from which it follows that
so long as the stomach is capable of acting on albumen, and
converting it into that modification called albuminose or pep-
tone, the natural form in which albumen is absorbed, no albumen
will filter through the blood-vessels of a healthy kidney ; but
that if the stomach, on the one hand, be incapable of fulfilling
its proper functions, or, on the other hand, the stomach being
healthy, more albumen in solution be introduced into the organ
than it can digest, the same thing happens as when white of

326 Reviews. [April,

egg, milk, and isinglass are introduced directly into the blood ;
that is to say, a form of albumen circulates in the blood which
ought not to be there, and which can filter through the blood-
vessels of the healthy kidney so as to be immediately discharged
with the urine. The great importance, then, of this shifting
and changeable nature of albumen — an importance which cannot
be too highly rated — becomes evident. Why it is that when
one form of albumen is present in the blood albuminuria
occurs, and when another form circulates there no albuminuria
takes place, is satisfactorily accounted for by the " great differ-
ence which exists in the diffusibility of different forms of albu-
men,^' as shown by Dr. Pavy^s experiments. It is clear, then,
that albuminuria may occur as a consequence of dyspepsia ; but
with this exception it is, on the whole, doubtful whether it can
in any other single instance be referred positively and directly
to changes in the blood alone. The effect of the inhalation of
poisonous gases — as arseniuretted hydrogen and carbonic acid —
is adduced as an argument in support of the blood theory ; but
although no blood-corpuscles are found to accompany the albumen
in these cases, yet, as Vogel himself asserts, the hsemato-globuline
escapes into the urine, sometimes in enormous quantities, together
with the albumen, and hence these are not cases of genuine
albuminuria, but rather of dissolution of the red corpuscles and
" hsematinuria." Certain injuries of the nervous system, as a
puncture in the floor of the fourth ventricle (Bernard) , division
of the cerebral peduncles, section of the renal nerves, and sec-
tion of the spinal cord in the dorsal region (Harley) will also
give rise to albuminuria; but, as Harley suggests, it is more
probable that the phenomenon is here due to the influence of the
nervous system on the blood-vessels of the kidney, which, be-
coming over-distended through paralysis of their coats, suffer
the albumen to transude, than to any effect produced on the
blood itself by the operation. We confess, then, that we are
inclined to side with the two English authors under review in
their belief that " all cases of permanent albuminuria are, in
the long run, always associated with an organic change of
structure in the tissue of the kidneys." M. Jaccoud is not of
accord in this matter, but believes that there are cases of persist-
ent albuminuria in which the individual is to all appearances in
perfect health, and in which there is no disease of the kidney,
so that the terms " albuminuric persistante^^ and " albuminuric
Brightique" are not synonymous. But Dr. Dickinson shows
how cases of this kind, lasting sometimes from ten to twenty
years, have been found after death to have granular degeneration
of the kidney ; so insidious, chronic, and difiicult of recognition
may this form of disease be.

1868.] Recent Works on Albuminuria. 327

B. Although, as has been stated, the albumen of the blood
in its normal state will not diffuse through the blood-vessels of
the healthy kidney, yet it appears that a comparatively slight
increase in the pressure exercised by the blood on the walls of
the renal capillaries will cause the albumen to filter through
together with the other constituents of the urine. It will be
seen that such an increased intra-vascular pressure is by far the
most important agent in the immediate production of albumi-
nuria. Admirably adapted as are tbe Malpighian tufts to the
important part which they play in the secretion of the urine,
they are at the same time unusually liable to suffer from the
effects of any obstruction to the flow of blood beyond them. It
is easy to see how readily a number of loops coiled thus closely
together, and getting rid of their blood by one efferent vessel
not much wider than each individual loop, must be distended if
there be any unusual pressure on the divisions of their efferent
vessel. Further, if it be remembered how exposed the efferent
vessel is, in its onward distribution among the tubules, to pressure
from any swelling of the tubules or from any increase in the
thickness of the very delicate matrix by which its' branches are
supported, we are furnished with a clue to the explanation of a
very large proportion of all cases of albuminuria. In like man-
ner, if the obstruction be seated still further on in the circula-
tion away from the tufts — either in the renal vein, the vena
cava, or the heart itself — the vasa efferentia as well as the
Malpig];iian tufts will be subjected to intra-vascular pressure
and will bear their share in the production of albuminuria.
Yet another source of albuminuria from pressure is to be
sought, as Virchow thinks, in the arteriolse rectse. These little
arteries spring from the renal artery at the bases of the
pyramids in the form of branches which, after running for a
short space horizontally, turn suddenly downwards at a right,
or even acute, angle, and break up after a short course into
tufts which run down between and encompass the lower bundles
of the tubules. In advanced cases of renal disease, where, from
stasis in the capillaries of the cortex generally, the arterial
blood can scarcely make its way onwards, relief is obtained by
an extraordinary collateral flux into the arteriolae rectse, which,
lying as they do in the pyramids, are comparatively unob-
structed by the disease everywhere pervading the cortex. The
deep red colour so often observed in the pyramids when the
whole cortex is pale and anaemic from disease is pointed to by
Virchow in confirmation of this supposed flux. In this case we
have an active onward pressure at work instead of a passive
backward one, but the effect of both is the same.

It will be well first to consider shortly those less important

328 Reviews. [April,

affections of the kidney which are attended with albuminuria
before entering on the discussion of the severer forms of disease
with their more permanent albuminuria. In the majority of
these slighter affections there is some abnormal condition of the
blood present, some poison at work which irritates the kidneys
in common with many other organs throughout the body. As
a consequence of this irritation the epithelial cells of the tubules
undergo the changes which are comprehended in the term
inflammation : they swell up, become cloudy, and increase in
number so as to fill out the tubules and press on the adjacent
blood-vessels. While there is thus a temporary obstruction
offered to the passage of blood through the Malpighian tufts,
there is at the same time an unusual afflux of blood to the in-
flamed or irritated part, so that the tufts are placed midway be-
tween two evil influences, an active determination of blood to
them from their afferent vessels, and a check to the exit of blood
from them through their efferent vessels. The amount of albu-
minuria will be, therefore, cseteris paribus, in direct proportion
to the amount of irritation present and, consequently, to the
severity of the general affection of the blood.

In the class of cases here alluded to are included all the so-
called zymotic diseases — the eruptive fevers, cholera and
diphtheria, as also puerperal fever, pyaemia, hospital gangrene,
erysipelas. In these cases the kidneys are found after death,
like the liver, the spleen, the lymphatic glands, the follicles of
the intestine and the tonsils, to be the seat of the fthanges
above described — that series of changes to which Virchow has
given the name of " parenchymatous or cloudy swelling.^' It
is important to bear in mind that this is only a mild and
transient form of that which will be presently seen to constitute
one of the most formidable of the diseases of the kidney — the
'' tubal nephritis.^'' M. Jaccoud would make more of the blood-
affection as a direct cause of the albuminuria in this group of
diseases than we are disposed to do. He classifies these cases
under two heads — a. Cases of albuminuria from some abnormal
condition of the blood alone without any affection of the
kidneys ; b. Cases of albuminuria from some abnormal condi-
tion of the blood together with an affection of the kidneys. In
the former of these classes he includes pyaemia and puerperal fever:
in the latter he places the eruptive fevers and hospital gan-
grene. It will be thus seen that he does not deny in toto the
influences of renal disease in the production of albuminuria in
such cases, but he evidently thinks more of the blood-change as
a direct or proximate cause of albuminuria. We are agreed
with him as to the presence of a blood-poison in all these cases,
and as to its indirect or remote influence on the albuminuria. We

1868.] Recent Works on Albuminuria. 329

believe, however, that the albumen passes tlirough the blood-vessels
of the kidneys, not because the constitution of the blood is altered
by the poison circulating in it, but because the circulation in the
kidneys is interfered with by the action of the blood-poison
upon them. At all events, from what we know of the patho-
logy of pysemia, puerperal fever, hospital gangrene and the
eruptive fevers, it would appear more probable that the action
of all in the production of albuminuria is similar, and that they
should all be grouped together, than that they should be disso-
ciated and supposed to act, the two former through the blood alone,
the latter through the blood and the kidneys. Again, the
effect of certain poisons, as lead, phosphorus, cantharides, on
the kidneys has a very important bearing on the question under
discussion. Jaccoud reasonably suggests the advisability of
separating cases of chronic from acute poisoning. In the for-
mer there is no doubt that the kidneys are seriously affected,
and the reason why the albumen transudes is clear. Dr.
Dickinson has especially insisted on this in chronic lead-
poisoning. He says, — " If a man who has a blue line on the
gums have also albuminuria, it is almost certain that he has
also this variety of kidney-disease (granular degeneration or in-
terstitial nephritis) ." And again — " Compared with other
external circumstances, the influence of lead is a more fertile
source of this disease than any other with which we are ac-
quainted.^' But it is the acute cases with which we are here
more particularly concerned : and in them we find renal lesion
just as in the chronic, only bearing evidence of an acuter attack.
Recent investigations into the appearance of the kidneys in
acute poisoning by phosphorus have thrown much light on this
question. A case reported last year by Dr. Habershon, in
which especial pains had been taken to note carefully the
symptoms during life and the post-mortem appearances of the
different organs, bears testimony to the unmistakeable evidence
of positive renal lesion. We are told that, during life, the
urine contained albumen and, under the microscope, a large
quantity of epithelium with casts of tubes and a few blood-cor-
puscles ; and that, after death, the kidneys were light yellow or
pink in colour, the cortex injected, the pyramids deep red, and
the uriniferous tubules loaded with fat. This extreme fatty
degeneration of the epithelium of the tubules seems to have been
the most noticeable feature in the majority of cases recorded.
It remains, therefore, that neither in acute nor chronic poison-
ing have we any evidence of albuminuria save only as a con-
sequence of positive renal lesion, and that albuminuria from
tangible poisons is in all respects identical with that from the
zymotic diseases, where the presence of a poison is suspected

330 Reviews. [April,

but not tangible. Temporary albuminuria is likewise met with
in a variety of cases where its occurrence is more purely mecha-
nical than in the above instances. We allude to those cases in
which temporary pressure on the vena cava causes temporary
congestion of the renal vessels and consequent albuminuria.
Here, as has been already pointed out, both the inter-tubular
capillaries and the Malpighian tufts become the seat of excessive
stasis. A typical instance of the kind is seen in the albuminuria
of pregnancy. The pregnant uterus is found in certain women,
especially primiparse, to cause albuminuria by its pressure on
the vena cava, — a phenomenon usually observed somewhere
between the sixth month and the time of delivery, and ceasing
as soon as labour relieves the kidneys of the obstacle to their free
circulation. At the same time it must be borne in mind that it
is not all cases of albuminous urine in pregnancy which are
thus explained and thus easily removed. Dr. Harley enters at
length into this question and shows how the above albuminuria
of pregnancy must be distinguished from pregnancy with albu-
minuria (i. e. where positive renal disease supervenes during
pregnancy) on the one hand, and, on the other, pregnancy in a
woman already suffering from disease of the kidneys. In
neither of the two latter forms can the albuminuria be called
temporary, for it is not relieved by labour, but persists, being
dependent on some more serious structural affection of the
kidneys, whether induced as a secondary effect of venous en-
gorgement or pre-existing before conception had taken place.^

From these transitory and less important kinds of albuminuria,
we pass on now to the consideration of that which is more per-
sistent in its nature, and is a direct Consequence of some more
marked and more abiding change in one or other of the tissues
of the kidney. Let it not, however, be supposed, that there is
any wide gulf of separation between this and the transient form.
For, first, the same mechanical influences which are at work
in the production of the one, are also mainly concerned in the
causation of the other ; and, secondly, the pathological changes
which have already been shown to be present in the one, are
likewise active in one form at least of the other. Between the
transitory albuminuria of typhus or diphtheria, and the per-
sistent albuminuria of nephritis from cold, there is no difference
of kind, but only of degree. In both alike it is reasonable to
believe that there is some irritating influence at work which acts
on the secreting structure and blood-vessels of the kidney:
but in the one case the irritant is slight, and its effects are

1 For a full account of this subject, see Abeille, ' Traite des Mai. a Ur. Album,
el Sucr.'

1868.]

Recent Works on Albuminuria. 331

transient; in the other the irritant is severe, and its effects
permanent.

The idea of classifying the different varieties of renal disease
attended with albuminuria on an anatomical basis ; the idea,
that is, of taking the several structures of the organ one by one
- — the tubes with their epithelial contents, the interstitial con-
nective tissue, and the blood-vessels — and studying separately
the pathological changes in each, seems to have sprung in the
first instance out of the teaching of the cellular pathology, and
to have emanated from the school of Berlin. Virchow has for
many years past thus unravelled the difficulties of Bright's
disease in his lectures at Berlin; and Rasmussen, in an able
paper on the subject, in the year 1862, divides those diseases of
the kidney which may be grouped under the general deno-
mination of Bright's disease into "parenchymatous nephritis,
interstitial nephritis, and amyloid degeneration," according as
the one or other of the three different constituents of the
kidney is primarily affected. This classification seems now to
be accepted as the best, and has been adopted by Dr. Dickinson.
We cannot, however, agree with certain writers, who propose to
banish the term Bright's disease from our nomenclature; nor
would we, as Dr. Harley advises, reserve it for that one par-
ticular kind of renal disease alone in which the tubules are
inflamed. We had rather, without losing sight of the necessity
for investigating separately, both from a clinical and an ana-
tomical point of view, the three forms of disease above men-
tioned, group them together under the common title of Bright' s
disease, as a generic term for a series of diseases, which, though
clinically distinct, have yet all features in common, and, though
anatomically separate, yet frequently complicate one another.
Dr. Bright^s esteemed name has gone forth into all lands, and is
heard in every hospital at home and abroad, never to be disso-
ciated from the particular forms of disease with which it is so
honorably connected. Thus considered. Dr. Dickinson's book
may be said rather to treat of Bright's disease than of the wider
subject of albuminuria. For a complete exposition of the
pathology and treatment of albuminuria, we would refer our
readers to the French article at the head of our list. For the
most perfect treatise yet written on the anatomy of Bright's
disease, we would recommend them Dr. Dickinson's book. This
author's attention has been mainly directed to the post-mortem
appearances of the kidney in health and disease. By great per-
severance he has succeeded in bringing the microscopic
examination of the organ in question to a degree of perfection
that it had never before reached. He is enabled by his method
of treating the tissues to preserve them all in situ, and thus

333 Reviews. [April,

obtain, by means of large sections, an accurate view of the exact
relation that they bore to each other during life. His extended
observation of healthy specimens has satisfied him that, even in
the healthy kidney, the epithelial cells are sometimes " charged
with oil-globules," and that it is quite the exception to find the
tubes and their epithelium in what is considered to be their
typical state as represented in books on physiology. Under the
influence of post-mortem changes ''the cells rapidly become
granular and crumble up, while they separate from the basement
membrane and fill up the cavity." Hence, although appear-
ances of granular degeneration do often follow on inflammatory
changes, and coexist with renal disease, yet they are not of
themselves necessarily morbid. The real points to be con-
sidered in deciding as to the presence of disease are, whether
there be an increase in the width of the tubes, the presence or
absence of fibrinous casts in them, and whether there be any
great increase or loss of epithelium.

The first of the trio of diseases which constitute Bright's
disease, is seated in the secreting part of the kidney, and is well
named by Dr. Dickinson " tubal nephritis." In this disease we
have but a more extensive, a severer and more damaging form of
what has been already noticed as the parenchymatous swelling
of blood-poisons. The pathology of both is essentially the same.
Some irritant present in the blood — whether from returned
excreta that should have been thrown off in the sweat, or
from scarlatina — falls with especial violence on the epithelial
cells of the kidneys and inflames them, giving rise to the hyper-
plastic increase already described, distending the tubules so that
they press on their surrounding capillaries, causing an active
determination of arterial blood to the inflamed structures, and
hindering the onward flow of this blood out of the Malpighian
tufts by the check offered to the circulation in the compressed
vasa efferentia. Hence arise the well-known large, swollen,
bloody kidneys of acute tubal nephritis — swollen because of the
hyperplasia of epithelium, bloody because of the acute congestion
and stasis in the capillaries. At a still later period the swelling
is found to have still further increased, and the redness of con-
gestion to have proportionately diminished. The blood finds
more and more difficulty in its passage ; the myriads of epithe-
lium cells tend to pass into a state of fatty degeneration, and
there are now found very large, smooth kidneys, with a dull-
white or yellowish cortex, and, not uncommonly, deep red
pyramids, which off'er a remarkable contrast to the cortex. The
blood, checked in its passage through the cortex, is forced in
unnatural quantity through the collateral branches in the
pyramids, unless the disease has been so general as to involve

1868.] Recent Works on Albuminuria. 333

the straight tubes equally with the convoluted^ in which case the
same impediment is met with in the pyramids as in the cortex,
and the whole organ is alike pale. In the majority of cases this
is the final change ; these kidneys '^remain large and smooth to
the last.'^ It is quite settled now that they never degenerate, as
Frerichs supposed, into the small granular kidney. Dickinson
thinks, however, that they may in rare instances have super-
added to them the amyloid degeneration, and in this way
become smaller in size while still retaining their smoothness of
surface. The rule is that they remain large, becoming more and
more fatty the longer life lasts. The tubal nephritis is, com-
paratively speaking, an acute form of Bright's disease; when fatal,
rarely protracted beyond from six to twelve months. It is
especially common in the- first decennium of life (period of scar-
latina), and is unknown in old age. It is as a rule attended
with dropsy, and is more often complicated with inflammatory
afifections of the lungs and peritoneum than of the heart.
Vomiting is commonly present. Convulsions are especially apt
to occur, and generally precede coma when this supervenes. The
urine is generally highly albuminous, scanty, often bloody : its
specific gravity much as in health : it throws down an abundant
deposit of renal epithelium with casts, first of simple transparent
fibrine enclosing epithelium, then granular, and, at the very
last, quite transparent or waxy from the straight tubes. Che-
mically, all its constituents are diminished, especially the water
and urea. The plan of treatment adopted and strongly recom-
mended by Dr. Dickinson in this disease is worthy of mention, as
being a good deal at variance with that so generally in vogue
among us. Purging with jalap, and other active remedies of
the kind are condemned, for the reason that the water of the
blood is thus diverted from the clogged tubules. The real
object in view is to increase as much as in your power lies the
secretion of water at the kidney itself, and thus flush out the
choked-up tubules. On this principle he gives copious draughts
of water to his patients, and repeated doses of digitalis (Infus.
Digit, f. 5j — f- 5iv^ ter in die). ''In the majority of cases thus
treated the urine will increase, the dropsy diminish, and the
patients pass into convalescence without the occurrence of the
various secondary evils which tend to swell the mortality of the
disease .^^ Iron, especially the perchloride, is, of course, highly
spoken of in the after-treatment. When uraemia and head-
symptoms have declared themselves, he seems to place but little
faith in any treatment. " Bloodletting is out of the question.'*
And again,—" The attacks, when of the convulsive character,
frequently pass off of themselves, leaving the patient much as
before." He thinks that chloroform has the power of hold-

82— XLI. 22

334 Reviews. [April,

ing in check the convulsions^ but must be used with great
care.^

We now come to the second of the trio — that in which the very-
delicate interstitial connective tissue of the organ is the seat of irri-
tation, and consequent hyperplasia. Dr. Dickinson employs here
the name of " granular degeneration/' but we prefer Rasmus-
sen's title of '^interstitial nephritis/' and shall adopt it through-
out. The essence of this aflFection consists in a slow irritation
of the connective tissue, especially that which immediately sur-
rounds the Malpighian capsules and blood-vessels, followed by an
increase in quantity of that tissue, so that it gradually usurps
the place of the tubules which it contracts and flattens till they
become mere threads. The earliest appearance of this change
is met with, according to Dr. Dickinson's observation, at the sur-
face, immediately beneath the capsule, whence it extends in-
wards at right angles to the surface, in the form of little " stream-
lets of fibrous tissue." At each point where this takes place,
the surface is slightly drawn or puckered in by the contraction of
the new product, and becomes consequently granular, each little
granule or prominence representing the healthy tissue that
remains uninvolved, and each little pit or depression correspond-
ing to the seat of disease. It will thus be clear that we shall
have an infinite variety in the size of the granulations, according
to the extent of the disease, whether larger or smaller tracts of
the organ are involved. The change is identical with that of
cirrhosis in the liver, and the same contraction and condensa-
tion of tissue occur in the kidney as in the liver. The Malpi-
ghian bodies seem to be the last parts to suficr from the pres-
sure of the surrounding disease, even where all the adjacent
tubules are obliterated ; and, as a consequence, one of the
peculiar microscopic features of this form of kidney, as Dr.
Dickinson's sections show, is the unnatural aggregation of
the Malpighian bodies. Another consequence of the pres-
sure on the tubules is the formation of cysts, which are peculiar
to this form of nephritis, and which arise either by accumula-
tion of fluid in, and distension of, that part of a tubule which

1 In connection with this doubtful treatment of ursemia we are reminded of a
story that we have heard told of one of the first of living physicians, who was
on one occasion summoned to meet a young practitioner in consultation on a case
of the kind. After examining their patient, the two doctors retired into an ad-
joining room, where tlie following dialogue ensued. Young Practitioner. — " Well !
what shall we do ?" Physician. — "Ah ! wliat shall we do ?" Young Practitioner.
— " Suppose we put on a blister." Physician. — " Suppose we do. Where shall
we put it ; on the bed-post ?" It will be remembered that Dr. Richardson, in his
' Asclepiad,' speaks even more strongly in favour of bloodletting than Dr. Dickinson
speaks against it. He quotes some very striking instances where, -as the blood
flowed from the arm, consciousness returned, and where he could hardly doubt
that life was prolonged by the treatment.

1868.] Recent Works on Albuminuria. 335

remains open between two points of obstruction^ or, as Wilks
suggested fifteen years ago (' Guy's Hospital Reports,' 1853), by
dropsical distension of Malpighian capsules whose necks bave been
similarly closed by external pressure. Dr. Dickinson. suspects
that certain specimens of the very large cystic kidney, where
the entire organ is converted into cysts, may be only an exag-
gerated form of that which is usually present in a much milder
degree as a part of the interstitial nephritis. The mechanism of
albuminuria in this nephritis is the same as in the tubal form.
In both, the escape of blood from the Malpighian tufts is checked
by pressure on the intertubular capillaries j but, whereas in the
latter the pressure was seen to be caused by the distended
tubules, it is accounted for in the former by the adventitious
connective tissue. Perhaps, too, as Virchow suggests, a colla-
teral flux to the pyramids will account in part for the pheno-
menon, at least in very advanced stages of the disease. Among
the direct causes which act as special irritants on the connec-
tive tissue, and give rise to the form of disease under considera-
tion, alcohol is usually ranked as the first. Dr. Dickinson has
here struck out of the beaten track, and, in a chapter devoted
to the question, has endeavoured to show that much too promi-
nent a place is given to alcohol as a cause of renal disease. After
a careful examination of the facts which bear on the question,
he comes to the unlooked-for conclusion that though alcoholic
excess causes pre-eminently cirrhosis of the liver, and, as has
been recently shown, of the lungs, yet it rarely injures the
kidney. He is also at variance with other writers in his asser-
tion that when it does act prejudicially it gives rise to the tubal
nephritis with fatty degeneration of the epithelium, rather than
to the interstitial nephritis. The facts adduced in support of
his belief are these. First, after examining a large number of
bodies that had died of delirium tremens, and comparing the
post-mortem appearances with those found in an equal number
of bodies that had died from accident, he discovered that granu-
lar degeneration of the kidneys was even less frequently ob-
served after death from delirium tremens than when death had
resulted from causes quite independent of alcohol. Secondly,
in forty cases of cirrhosed liver, not depending on heart disease,
but associated with spirit- drinking, the kidneys were only found
granular eight times, and then only in an early stage of the
disease. Thirdly, on comparing the proportion of deaths from
alcohol with those from renal disease in different parts of Eng-
land and Scotland, as collected from the reports of the Registrar-
General, he finds that the prevalence of the one bears no rela-
tion to the prevalence of the other, but that the contrary rather
holds good J that, for instance, London, Lancashire, and

336 Revieivs. [April,

Glasgow, in which intemperance stands highest, suffer less from
renal diseases than many of the agricultural districts, in which
the wages of the labourer render any great intemperance
impossible, and where the rate of mortality from alcohol is
lowest. The valuable researches of Dr. Anstie have an impor-
tant bearing on this question, and rather tend to confirm from
another point of view this belief. He shows, with much reason,
that alcohol ceases to exist in the blood as alcohol shortly after
it is absorbed, and that it is not eliminated by the kidneys
unless a considerable excess — so considerable as to produce signs
of narcosis — has been taken. The common belief that alcohol
undergoes no changes in the blood, but is separated as alcohol
by the kidneys, irritating them in its passage just as it irritates
the liver, has received a rude shock from his experiments and
those of Schulinus. It is thus quite intelligible that the liver,
exposed as it is to the direct action of the alcohol, should suffer
much more than the kidneys, yet it still remains a fact that an
excess of alcohol does pass through the kidneys as alcohol ; and
if to this be added the very close resemblance which the morbid
anatomy of cirrhosis bears to that of interstitial nephritis, we
shall find it difficult to dispossess ourselves entirely of our old
and cherished belief that alcohol does play a certain part^ though
a less important one than was supposed, among the causes of
interstitial nephritis. Most unmistakeable in their action are
all those " conditions which produce and maintain venous con-
gestion of the kidney .^^ Such are, pre-eminently, heart disease,
and, more rarely, pregnancy, where the stasis has been unusually
severe and prolonged. The peculiar red appearance and tough
consistence of the kidneys in valvular disease is notorious to all
who are used to post-mortem examinations. The granulations
are, as a rule, smaller than when the disease has occurred from
other causes, and the kidneys themselves are often of the natural
size; but the change is, nevertheless, invariably interstitial.
The poison of gout ranks high in importance as a cause of this
nephritis, and we have already alluded to the influence ascribed
by Dr. Dickinson to chronic poisoning by lead. Lastly, a very
considerable number of cases remain for which none of the
above causes will suffice, but which creep on as it were spon-
taneously, being probably due to the effects of climate, of
which more hereafter. Interstitial nephritis is essentially
chronic in its progress, and insidious in its onset. It " belongs
to middle life and advancing age, and is most common between
fifty and sixty.'' Dropsy, which was the rule in tubal disease,
is long absent in this and sometimes never appears. As com-
plications, inflammatory aff'ections of the heart and its mem-
branes show themselves more often than pulmonary affections.

1868.] Becent Works on Albuminuria. 837

HypertropTiy of the left ventricle is the rule. Another not
infrequent complication is apoplectic extravasation in the brain,
which is well accounted for by the atheromatous degeneration
of arteries so commonly present, and is aggravated by the hyper-
trophy of the heart. Vomiting is even more common in this
than in the tubal disease, and whereas, in the latter, convulsions
are frequent, in the former, coma more often supervenes with-
out any convulsions, the patient gradually sinking into a quiet
stupor. The urine is increased in quantity and passed more
frequently than usual ; is generally bright, clear, and of a low
specific gravity; is at first free from albumen and casts, but
later on contains a few granular casts and a trace of albumen
(though it is no uncommon thing to see a case in which for
days or weeks no albumen can be detected, but then suddenly
shows itself and again for a time disappears ; so that there is
no form of kidney disease in which a daily patient examination
of the urine is so necessary as this). The casts are coarse,
large, granular, opaque, and differ essentially from those of
the tubal nephritis, in that they do not contain epithelium or
pus-cells as a part of their structure. Chemically, there is
this important difference between the urine under consideration
and that in tubal disease, that the water is increased, instead
of being diminished, in quantity : the decrease of the other
constituents being a prominent feature in both forms. Most
important in the treatment is change of climate, a subject
which will be again referred to. If this cannot be obtained,
iron is generally beneficial : the skin must be kept active
by the vapour bath, and warmly clad : the diet must be
light and nutritious, with but a moderate supply of nitro-
genous food, since experiments show that the quantity of
albumen in the urine is increased after the ingestion of highly
nitrogenized foods.

There remains for consideration, thirdly and lastly, the
pathology of the renal blood-vessels. Passing by the sclerosis
and atheroma, which may be met with even in the small
arteries, we come to the special form of disease for some years
past spoken of as amyloid degeneration. This important dis-
covery of Virchow's has lately been the subject of much discus-
sion among pathologists, and its real nature has been interpreted
in a very different light from that in which it was first regarded
by Virchow. The fact remains unchallenged that the blood-
vessels of the kidneys do, under certain circumstances, become
the seat of a strange deposit, which is at once recognised by
the peculiar deep wine-red colour imparted to it by the action
of iodine. Virchow's error really consisted in regarding this
deposit as akin to starch or cellulose, and naming it " amyloid."

338 Revieivs. [April,

Dr. Pavy, in a very interesting paper, in the year 1864, exposed
this error, and showed, from analyses and ohservations by
Schmidt, Freidreich, Kekule, and himself, that the so-called
amyloid substance has no affinities whatever with starch, but is
a " nitrogenized material:^' so that he proposes to discard the term
amyloid from our nomenclature. Dr. Dickinson has carried his
investigations in this direction still farther, and in an elaborate
contribution to the last volume of the ' Med. Chir. Transactions '
has come to some most interesting conclusions, which may be
briefly summed up as follows : — That the amylo'id substance has
no affinities with starch, but is a fibrinous substance, a '' dealka-
lized fibrine.^' This is inferred (a) from its ultimate analysis;
(b) from the fact that a substance identical with it, and giving
the characteristic colour with iodine, can be made artificially
out of fibrine by neutralizing or removing the alkali which the
fibrine naturally contains; [c] that if potash or soda be added
to the amyloid substance (thus artificially making a natural
fibrine of it), it at once ceases to give the red colour with
iodine ; [d] that if a solution of sulphate of indigo be added to
liealthy tissue, the colour of the solution is destroyed by virtue
of the alkali contained in the tissues, but if the same solution
be added to amyloid substance, the colour is vividly retained,
because of the absence of alkali in that substance ; (e) that an
analysis of amyloid liver shows a diminution by one fourth of
alkaline salts. He has, further, insisted on the great frequency
with which amyloid degeneration depends on chronic suppura-
tion that has taken or is taking place in some part of the body,
and hazards the theory that the blood being drained by suppu-
ration of its albumen and alkali, retains an excess of fibrine,
minus potash and soda, which dealkalized fibrine is deposited
in certain organs. He consequently proposes the term " depu-
rative nephritis '' for that form of B right's disease in which the
blood-vessels of the kidney are infiltrated with this deposit.
This is not altogether a satisfactory name, because the very
same form of disease is occasionally met with in cases of old
syphilis, where there has been no suppuration. We have had a
tubal and an interstitial nephritis, why should not this be called
^^ arterial nephritis"? The blood-vessels primarily and chiefly
afiected with the change in question are the Malpighian tufts,
the vasa afferentia, and the arteriolse rectse of the pyramids.
The change consists in thickening of their coats and infiltration
with the peculiar deposit. In advanced stages of the disease
the surrounding interstitial tissue is similarly aff'ected, and
assumes the characteristic appearance of rind of bacon or white
wax. How far the new deposit when once efl'ased among the
tissues can, as Dr. Dickinson supposes, become " converted into

1868. Recent Works on Albuminuria. 339

fibroid tissue" is very doubtful. He shows, it is true, a very
beautiful specimen, in which the microscope reveals the presence
of an abundant finely nucleated connective tissue : but we can-
not help doubting whether this adventitious tissue be not a
consequence of interstitial nephritis superadded to this specific
change, and that we have here an excessive formation of con-
nective tissue infiltrated with the deposit. It is hard to believe
that a '^ dealkalized fibrine " can become organized into fibrous
tissue. Rasmussen maintains that the amyloid degeneration is
in the majority of cases complicated with interstitial nephritis,
and would doubtless explain in this way the above appearances.
The same material which is thus poured out into the interstitial
tissue exudes also into the tubes, where it takes the form of
waxy casts, which occasionally give the red colour with iodine.
Fatty degeneration is frequently associated with this disease.
The occurrence of albuminuria is here explained by an excessive
porosity in the coats of the blood-vessels from the changes they
have undergone. The kidneys are pale, anaemic, and slowly
increase in bulk ; some of the largest kidneys that are ever seen
being of this kind. Their surface is smooth, or faintly granular.
The cortex, at first thicker, denser, and heavier than natural,
becomes later on, as the interstitial change progresses, slightly
puckered and contracted, and its capsule more adherent; while
the deep red of the pyramids often contrasts strangely with the
pale cortex. By far the most frequent cause of the arterial
nephritis is chronic suppuration, not necessarily, but often con-
nected with tubercular and scrofulous disease, especially of bone.
Virchow and others have remarked on its frequent connection
with protracted syphilis, a cause which must be likewise recog-
nised. Like the interstitial, the arterial nephritis is chronic
and insidious in its onset, but variable in the rate of its progress.
It may occur at any period of life, but prevails between twenty
and thirty (the decennium in which phthisis is especially pre-
valent). It is often attended with dropsy, which makes its
appearance but slowly. As complications, pulmonary, especially
pneumonia, are more frequently seen than cardiac ; but most
common and deadly of all is diarrhoea, which is caused by an
extension of the disease to the blood-vessels of the intestine, as
shown by the action of iodine on them. The face has often a
waxy pallor and cachectic aspect. Cerebral symptoms are un-
common. The urine closely resembles that in the interstitial
nephritis ; the chief microscopical difi'erence being the hyaline,
waxy appearance of the casts in the arterial nephritis. The
little that can be done in the way of treatment consists in the
administration of nutritious food, iron, and cod-liver oil. Dickin-
son hints at the importance to the surgeon of the study of this

310 Reviews. [April,

disease, as a warning to him against any operation which is
likely to be attended with protracted suppuration.

Although these three types of disease have been thus sepa-
rately described, it must be remembered that two, or even all
three of them, are sometimes combined in one and the same
kidney. A kidney that is the seat of mixed arterial and inter-
stitial nephritis may, for instance, be suddenly attacked by
tubal nephritis. Nor is this a matter for surprise when we bear
in mind the very intimate way in which the three several struc-
tures are blended together, and interwoven one with the other.
The types, nevertheless, are quite sufficiently marked to warrant
a separate description of each for itself.

A few observations on dropsy, as it occurs in connection with
albuminuria, will not be out of place here. It is too much the
custom in writing on this subject to treat this dropsy as if it
were a consequence in all cases, either directly or indirectly, of
the renal disease. We are told that the blood becomes im-
poverished by the loss of albumen; that its water increases
above measure from a checked urinary secretion; that the
blood-vessels are subjected to an increased pressure, partly by the
superabundance of water in the blood, partly by the impediment
which an impure blood meets with generally in its passage
through the capillaries, partly by the obstruction offered to the
circulation through the kidneys ; and that as a consequence of
one or more of the above causes dropsy ensues. But not one
of these factors will satisfactorily account for that form of dropsy
which is acute and general in its onset, and which sometimes
shows itself actually before the albuminuria betrays the pre-
sence of kidney-disease. We see a person exposed to cold, and
becoming affected in a few hours with general and acute dropsy.
Simultaneously with the dropsy appears the albuminuria; or
either may precede the other ; or — a very strong argument
against the dependence of the dropsy on the albuminuria — either
may be present without the other. Here it is impossible that
the dropsy can be the eflFect of impoverishment of the blood, or
in any way a consequence of albuminuria ; the two are rather
independent, but coexistent phenomena. If it be not then a
sequel of renal disease, how is this dropsy produced? And
here it is better at once to confess our ignorance. No hypo-
thesis that has yet been framed meets all the difficulties that beset
the question, or arrives at a satisfactory conclusion. A reflex
paralysis of the vaso-motor nerves from the effect of cold on the
sensitive cutaneous nerves; an altered condition of the blood
which allows the albumen to filter into the urine, while it causes
the serum to filter into the subcutaneous tissue ; an excess of
water thrown back on the blood by a sudden suppression of the

1868,1 Recent Works on Albuminuria. 34]

sweat — all of tliese hypotheses are insufficient. This is one of
the paths that has not yet been fairly trodden^ and where there
remains much to be explored by future investigators.^ How
Avidely different from this is the oedema which slowly creeps on
in chronic renal disease, and is evidently regulated by the
amount and kind of renal disease present, bearing in its inten-
sity a direct relation to the quantity of albumen in the urine,
and an inverse relation to the amount of water present in that
secretion. Here there can be no doubt that the loss of albumen
and the hydrsemia, both of them effects of the kidney disease,
are the causes of the dropsy. There are, then, two totally dis-
tinct forms of dropsy associated with albuminuria, distinct in
their onset, distinct in their nature, and distinct in their pro-
duction. The one acute, the effect of a cause which is not yet
clearly ascertained, affecting the subcutaneous tissue of the body
generally, and occurring independently of the albuminuria.
The other chronic, slowly extending from below upwards, and a
direct consequence of the impoverished state of blood which
owes its existence to disease of the kidney.

Some instructive views concerning the effects of climate
on renal diseases are contained in the closing chapter of Dr.
Dickinson^s. book. His arguments go to prove that the most
potent of all agents in the production of Bright^s disease, and
more particularly the interstitial nephritis, is climate. He shows,
from a series of carefully-constructed tables, that Bright^s
disease is essentially a disease of temperate climates, scarcely
known either in extreme heat or extreme cold, but prevailing
" chiefly where the mean temperature of the year is not far
removed from 50°." Thus in Melbourne it is almost as destruc-
tive as in Great Britain. In Iceland, on the other hand, it is
very rare; and any one who has read Dr. Chambers's
little work on the climate of Italy must have been struck
with the comparative immunity that Italy is there shown to
enjoy in this respect. Again, great variability of temperature
is equally prejudicial. The eastern counties in this kingdom
are, consequently, found to suffer more than the western, Aber-
deen being of all places that which is most afflicted with renal
disease. If further investigation shall confirm the views here
put forward — and the facts adduced by Chambers and Dickin-
son are hard to dispute — a very great service will have been
rendered to medicine. We shall be able to do that for the in-
tractable diseases whose pathology we have been considering,
which drugs and home treatment have hitherto failed to eftect ;

1 The difficulties that beset this subject have been very clearly set forth by
Dr. Andrew, in his Thesis for the M.D, degree, 1864 ; which we noticed on a
previous occasion.

343 Reviews. [April,

and we sliall recommend at once, as of the most vital import-
ancCj to any case of the kind_, a change to a warmer and more
equable climate. The Mediterranean coast and the Cape seem
to enjoy special advantages.

We cannot conclude wdthout once more mentioning, in terms
of the highest praise, the work of Dr. DicluDson. In demon-
stration of the morbid anatomy of the kidney he is certainly un-
equalled ; and the beautiful illustrations of his preparations, by
Tuffen West, contribute in no small degree to the merits of his
book. Hanhart's chromo-lithographs are likewise admirably
executed, and portray with great faithfulness the naked-eye
appearances in typical examples of the three forms of Bright's
disease.

Review V,

Bidrag til Kundskah om de i Island endemiske Echinokokker.
Af Jon Finsen, Distriktslsege. (Sserskilt Aftryk af
' Ugeskrift for Lteger,' 3die Rsekke, 3die Bind, Nr. 5—8) .
Kjobenhavn. ¥. S. Muhle, 1867.

A Contribution to our Knowledge of the Echinococci Endemic in
Iceland. By John Finsen, District Physician. (Reprint
from the 'Ugeskrift for Lseger/ 3rd Series, vol, 3, Nos.
5_8). Copenhagen, F. S. Muhle, 1867, 8vo, pp. 46.

Although we have in our nineteenth volume (p. 112), in our
thirty-fifth (pp. 139 and 330), and in our thirty-eighth (p. 285),
paid much attention to subjects closely allied to that of the
work now before iis, we think that we may with advantage
devote a few pages to the consideration of Dr. Finsen's book.
The author has, in fact, had special opportunity for collecting
the kind of information to be found in his pamphlet, having
been for ten years the district physician of a part of Iceland
containing 10,144 inhabitants, i. e. one sixth or one seventh of
the whole population of the island. He remarks that while
this disease (which though elsewhere occurring but rarely, con-
stitutes a plague for the inhabitants of Iceland, in many other
respects also unfortunately circumstanced) has been the subject
of important works from Eschricht, Krabbe, Christensen, Ras-
mussen, Storch, Aarestrup, and others, "it will probably have
surprised many that the physicians in Iceland, who beyond all
others must have the opportunity of acquiring rich experience
in this direction, should have remained perfectly passive, and
not have made the least exertion to elucidate a disease almost
peculiar to their country.'' As an excuse for them he refers to

1868.] FiNSEN on Echinococci. 343

tlieir isolated position, the absence of the means of scientific
research, and their extremely laborious and disagreeable, pecu-
liar practice. The present work he oflFers " as an instalment of
the debt which, he fully admits, the Icelandic physicians owe to
medical science respecting echinococci.''

Frequency of the Disease. — Dr. Finsen is of opinion that
the statements made by various writers, that one seventh of the
population suffers from echinococci, or, as has been even said,
that every fifth individual is carried off by the disease, are ex-
aggerated. Of 7539 cases of illness treated by him during nine
years that he kept a journal, 280, or only 1 : 26*9, were cases of
echinococci.

Seat of the Disease. — Of 255 patients 74 were males and 181
females. In these 255 cases the origin of the echinococci was
in 176 or 69*4 per cent, situated in the liver; in 3, or 1'17 per
cent., it was in the kidneys ; in 2, or 0'78 per cent., in the
spleen; in 54, or 21'17 per cent., in the abdominal cavity, the
original seat of the disease having been undetermined ; in 7, or
2'7 per cent., it was in the lungs; in 4, or 1'5 per cent., in the
head ; in 1, or 0*39 per cent., in the nape of the neck ; in 2, or
0"78 per cent., in the supra-spinous region; in 1 in the sub-
clavicular ; in 2 in the axillary ; in 1 in the mamma ; in 1 in the
arm; and in 1 in the thigh. The source of the echinococci has
been found in the abdominal organs in more than 92 per cent.,
and of these in the liver in 69'4 per cent. In the lungs it
occurred in only 2*7 per cent., and in the external tissues of the
body in 5*09. No case was met with in which the osseous
system, the brain, or the eye was the part so implicated*

Symptoms. — Experience seems to show that echinococci may
be present in internal organs, even for several decades, without
producing any symptom whatever indicative of this disease.
The most frequent and earliest symptom is pain often present
long before the tumour becomes perceptible. This pain is
liable to remissions and exacerbations, the latter, which are
sometimes so severe as to affect the general health, being appa-
rently connected with the increase of the tumours, and not with
the occurrence of inflammation. When the echinococci are
situated in the liver the patients generally suffer from pain in
the shoulder and clavicle. Dyspeptic symptoms, especially con-
stipation, but scarcely ever nausea or vomiting, often accompany
hepatic and abdominal echinococci, probably in consequence of
pressure on the stomach and intestine; nutrition, too, may be
more or less impaired. Jaundice is rarely observed as a result
of echinococci in the liver, this symptom having occurred only
seven times among the author's 176 cases. In some instances
the jaundice has been remitting. Ascites and oedema also

344 Revieios. [April,

seldom attend abdominal echinococci. Bright's disease, without
contemporaneous presence of echinococci in the kidneys, was
met with in two cases.

The general health suffers to a greater or less extent ; in some,
however, this is scarcely perceptible, as the patients, notwith-
standing the size to which their tumours frequently attain,
are nearly fully competent to their work, and their condition
does not indicate any delicacy ; but in others the general de-
rangement is considerable ; the patients are no longer able to
discharge their functions, they emaciate, their appearance
becomes pale and unhealthy, and their temper gloomy.

" On examination by the touch, when the cyst is superficial, a
smooth, elastic, most frequently rather resistant, roundish or oval
tumour, more or less fluctuating, is felt. If the cyst be situated
in the right lobe of the liver, the diaphragm is pushed upward,
and the lower part of the thorax is dilated. If the echinococcus
tumour arise from the posterior part of the right lobe of the liver,
it will often be covered by the ribs, while the anterior part of the
same lobe is pushed downward, as the echinococci increase, and
forms a tumour in the right part of the abdomen.

" FrSmissement hydatidique I did not succeed in discovering in
the cases in which I have looked for this sign. Indeed, I have not
in general looked for it, as my diagnosis has usually been clear
and distinct ; but I have looked for it often enough to enable me to
state that it is not a usual symptom."

Pathological Anatomy. — The author's observations on this
head are based upon his experience at the bedside, rather than
at the dissecting table :

" Abdominal Echinococci in Iceland often attain a much more
considerable size than writers state, their size being usually said
to be limited to that of a child's head, or of the hand of an
adult. In Iceland they sometimes grow so large that the abdomen
becomes as much distended as it would be by highly developed
ascites ; I ouce evacuated upwards of eighteen quarts from a
patient. In the cases in which I have opened such enormous cysts,
the latter have always contained daughter-cells. "Writers generally
state that the compound echinococcus is met with in preponder-
ating frequency in man, while the single occurs only exceptionaJl3^
This does not agree with my experience, as in forty-eight patients
operated on, I found daughter-cells only in nine, and in one of these
they were not present directly on the cyst being opened, but ap-
peared first a month subsequently, and therefore after the cyst had
long been the seat of inflammation. In the course of several days a
large quantity of these small daughter-cells were evacuated, all
being at about the same stage of development, viz., of the size of
boiled sago-groats. In one case the daughter-cells were floating

1868.]

FiNSEN on Echinococci. 345

freely in the abdominal cavity without being enclosed in any sac."
—p. 13.

In forty-eight patients operated on the echinococci only
twice contained a partly purulent, in one case a viscid, choco-
late-coloured fluid ; in all the others the contents were clear ;
and in the cases examined by the author exhibited no trace of
albumen when boiled. With the exception of the echinococci
on the hairy part of the head, where they in general occur in
numbers of from five to ten, but almost never singly. Dr. Finsen
was able only in six cases to distinguish more than one echino-
coccus in the same individual. Of 86 hepatic echinococci, 58
proceeded from the right lobe and 28 from the left, a proportion
corresponding to that given by Frerichs and other writers, but
not coinciding with Schleisner's statement, that echinococci
proceed more frequently from the left lobe.

Causes. — Respecting the origin of echinococci from the
Taenia echinococcus of the dog, the author refers to Dr. Krabbe's
treatises on the subject. We also may refer to the articles
already alluded to, to be found in our thirty-fifth and thirty-
eighth volumes. As to sex, males were in the author^s prac-
tice less frequently the subjects of the disease than women, in
the corrected proportion of 1 : 2"37. This preponderance of
females the author attributes to the occupation of women in
cooking, and in washing utensils, rendering them more liable to
swallow the ova of the Tcsnia echinococcus of the dog than men
are, in consequence of dogs often licking the vessels employed
in the kitchen. The age at which most cases occurred was from
ten to thirty, and particularly from twenty to thirty years.
The youngest patient treated by Dr. Finsen was four years old,
but in some of his patients the disease was said to have com-
menced at two years. The author's experience is rather against
the disease being of an hereditary nature. Want of cleanli-
ness is an evident cause of the affection.

As to the duration and. course of the disease, the author
adduces three cases in which it appeared to last eighteen, six-
teen, and fifty-two years respectively. These cases are, however,
not very conclusive, as they are those of persons long absent
from Iceland, in whom it is inferred that they must have brought
the disease thence, an inference based merely on the great
frequency of the disease in that island, and its great rarity in
Denmark.

"When the growth of the echinococcus has advanced so far that
the tumour becomes perceptible to both the patient and the phy-
sician, it usually progresses very slowly, often periodically, the
swelling being in the interval stationary, or even occasionally be*

348 Reviews. [April,

surface, their ordinarily rather oblong form, and by their elasti-
city."—p. 30.

From what has gone before it may easily be inferred that the
author is of opinion that the prognosis in this disease ought to be
more favorable than it is usually considered to be.

In the treatment of abdominal echinococci. Dr. Finsen speaks
highly of Recamier's method, which, as is well known, consists
in cauterising the integuments so as to produce adhesion be-
tween the echinococcus and the abdominal wall, and then opening
the echinococcus. For this purpose he has latterly employed a
" Vienna paste,'' prepared with equal parts of potassa fusa and
magnesia calcinata, which has the advantage over the potassa
cum calce of remaining dry, no matter how long it may be kept,
and which proves constant in its action. We shall give his
mode of proceeding in his own words —

" I apply the Vienna paste on the most fluctuating and most
prominent part of the tumour ; but if the latter be everywhere
fluctuating, I apply the paste as near as possible to the point of
origin of the echinococcus. After the lapse of fifteen minutes I
remove it. Three days after the first cauterisation, I split longi-
tudinally the crust formed by the paste, and again apply the
caustic in the split. Three days later I dissect away the scab
formed in the split, and then continue to cauterise every third
day, until the echinococcus has either opened spontaneously, or has
appeared as a prominent, slightly bluish coloured vesicle in the
bottom of the ulcer, and in such case I open it with the lancet. The
time the cauterisation has taken has varied immensely, viz., from
fourteen days to five or six months, without my being able to
account for this great difference."

Having evacuated the contents of the echinococcus as far
as possible. Dr. Finsen introduces a tent into the cyst, which
tent he subsequently removes daily, to give exit to the fluid
gradually again collected. Usually in about a week after the
echinococcus has been opened, the proper sac begins to come
away in pieces of various sizes, a process which it is generally
necessary to aid with the forceps.

The author first adopted E-ecamier's operation in 1857, since
which he has resorted to it forty-three times in forty patients,
having in one employed it for three abdominal echinococci and
in another for two. Of these forty patients five for various
causes gave up the treatment before the echinococcus was
opened, and the operation was therefore performed in thirty-five
patients, with thirty-eight echinococci. Of these thirty-eight
echinococci, thirty-one were cured ; in two patients, however,
echinococci remained in the abdomen, which were not operated

1868.] Irish Poor Law Report. 349

on, in seven cases death was the result. Of these seven cases.
Dr. Finsen gives detailed reports, in order to show that the
fatal termination was not in all attributable to the operation.
From his remarks it would appear that —

" Of thirty-eight operated on, thirty-one were cured, five or six
proved fatal from causes independent of the operation, and one or
two proved fatal in which it was doubtful whether death was due to
the operation or not."

The author next proceeds to refute some objections which
have been raised against the foregoing operation, and concludes
his very interesting, practical, and clearly- written treatise with
a few remarks upon the treatment of echinococci by puncture,
incision, and electricity, to all of which methods he prefers
Recamier^s operation. The treatment of external echinococci
must, of course, consist only in extirpation, which he has per-
formed seven times, always with success.

Review VI.

Annual Report of the Commissioners for Administering the Laws
for the Relief of the Poor in Ireland ; including the Twentieth
Report under the 10 ^ 11 Vic, c. 90, and the Fifteenth Report
under the 14 ^ 15 Vic, c. 68, with Appendices. Dublin :
printed by A. Thorn, for Her Majesty's Stationery Office^
1867. Pp. 260.

The Report of the Irish Poor Law Commissioners for the
past year (1866) appears at a time, when the condition and
management of our institutions in England have attracted, in
some instances at least, an undesirable species of publicity.
The Report, which we proceed to consider, necessarily briefly,
presents some features of peculiar interest in themselves, for the
year 1866 was remarkable as that in which the last cholera
visitation occurred in Ireland. While we would draw the atten-
tion of the Government to the necessity for the establishment
of a species of coastal as well as foreign supervision, if not of
quarantine, as strongly seen in the mode of approach of the
epidemic cholera to Ireland last year, we would do the whole
machinery of the Irish Poor Law an injustice, if we did not
acknowledge the general eflficiency and promptitude with which
that most formidable disease was met and combated. Indeed
it may be said that "Ireland^s necessities" have been "oppor-
tunities " for England to establish some admirable institutions,

82— ILL 2

850 Reviews. [April,

in which the British Government have been ably seconded by
the national quickness and perception of the Irish themselves.

The systems of poor-law administration and of police thus
present, in Ireland, some features of excellence, and tend
materially to facilitate the conduct of other matters connected
with the government of that country, and the relief of sickness,
not possessed by other countries far more highly favoured in
other respects. And we trust that the efforts of those,
whether of foreign origin or not, who would retard the pro-
gress of Ireland and the enlightenment and development of
her people's better natures and many genial and estimable
qualities, may be defeated. Nor do we despair of the result,
provided that justice be firmly and impartially administered,
and the requisite encouragement and protection afforded by
our Government to the many intelligent, enterprising, and inde-
fatigably industrious classes and individuals, of whom Ireland,
labouring under not a few adverse circumstances, can boast.

The relief afforded to the poor of Ireland by the Poor Law
authorities for each week of the year ending 16th February,
1867, is stated, both to persons in the various workhouses
of Ireland and that given to poor out of the workhouses.
Diagrams and tables are also given, representing the amount of
relief afforded in each of the eight years ending at the date
above named. 1859-60 was the most favorable year which has
occurred since the famine.

The following tables represent in figures the maximum,
minimum, and average daily numbers for the eight years
1859—1867 :

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352 Reviews. [April,

The average daily number of inmates shows a decrease ; and
we had hoped at the date of our last annual report that the
gradual decrease of pauperism in the workhouses since the year
1863 would be continued throughout the succeeding series of
fifty-two weeks for 1866-67. That period^ however, proved to
be one of an eventful character, having been marked in the first
place by a threatened invasion of the cattle plague ; secondly,
by an actual visitation of cholera; and, finally, by the Feniau
movement.

The succeeding winter was also one of extreme severity, and
has been protracted to an unusual date, the whole face of the
country being, at the time of writing this report, covered with ■
snow. A great part also of the period under consideration has
been very rainy and tempestuous, creating, in addition to the
usual amount of febrile complaints, an extraordinary amount of
sickness and mortality by bronchitis and other diseases of the
respiratory organs. Persons acquainted with the interior of
Irish workhouses, and the description of cases admitted there,
will easily understand, that an increased number of admissions
must take place during a season of the character described. It
is perhaps the best proof of the value of the Irish system of
poor-law relief, that the numbers, in the workhouses, fluctuate
from time to time in almost exact acordance with the character
of the seasons.

To the above causes must be added the decrease of employ-
ment and wages, arising from the languid state of trade during
the financial crisis, so far as the same may have affected the
towns and villages of Ireland. On the other hand, agricultural
enterprise was stimulated by the prospect of good prices, and
the result of the harvest was such as to prove remunerative ;
and in no recent year has the payment of rent and taxes by the
tenantry have been made with more promptitude and cheerful-
ness. The increase of pauperism, therefore, under the circum-
stances described, must not be received as any positive indica-
tion of a general decrease of prosperity.

The report goes on to show the marked effect severe weather
exercises upon the demand for workhouse relief, and that fine
weather immediately lessens the number of applicants for the
same.

The amount of outdoor relief given of late years has extended
considerably, as will be seen by reference to the figures given
above.

The average weekly cost of maintenance in the workhouses
in Ireland, exclusive of clothing, rose from 2*. in 1864 (January)

2*. 5^6?. in 1867, having risen continuously in the intervening.

1808.] Irish Poor Law Report. 353

years, owing to the gradual increase in the cost of provisions.
This state of things, and some change in the dietaries, has
occasioned "a material part of the increase of the relief ex-
penditure,^^ which is noticed in another part of the report.

Of the causes of death we must content ourselves with
quoting a few of the more prominent. Thus, in the year ended
on 9th February, 1867, of 12,582 which occurred in workhouses,
2383 were attributed to old age, 851 to atrophy, 298 to brain
disease, 233 to cancer, 13 to childbirth, 249 to cholera, 1081
to consumption, 233 to convulsions, 557 to diarrhoea, 463 to
dropsy, 165 to dysentery, 981 to fever, 394 to heart disease,
2,166 to inflammation or other diseases of the lungs, 442 to
paralysis, 206 to scrofula.

There were less deaths by fever in the last year than in the
preceding by nearly 300; and it was mainly owing to the
very severe weather in the eight weeks ending 9th February,
1867, that the increase in the number of deaths, 960, as con-
trasted with the year ending February, 1866, occurred, no
less than 900 deaths having taken place in the period first
mentioned.

The commissioners, very reasonably, attribute the remarkable
diminution in the number of fatal cases of smallpox, in the work-
houses, to the operation of the Compulsory Vaccination Act of
1863 : the numbers stand thus, in the years 1865-7 respectively,
145-59 and 9. It may, however, appear to many that tlie
epidemic or pandemic tendency has also had something to say
to the result. We say this without at all desiring to undervalue
the importance of compulsory vaccination.

Within the last seventeen years no less a number than 25,174
persons, chiefly women and cliildren, have been assisted to
emigrate from the poor-rates, " usually to join friends alreadv
settled.''

The Poor Law Administration was made the means whereby
.€13,474 was collected by a farthing rate, on the rateable pro-
perty of the unions in Ireland, for the purpose of '' immediately
stamping out the plague," wherever it might first appear, and
for compensating the owners of all cattle slaughtered for that
purpose. It is well known how very satisfactorily this proceed-
ing turned out. We do not certainly advocate the same mode
of treating human beings who import disease into any country,
but we would say that the experience of Ireland with respect to
cholera, to which we have above alluded, shows the necessity for
a system of prevention as regards arrivals from places aff'ected
with contagious diseases. The Sanitary Act of 1866 and all
acts and parts of acts incorporated with it were published by
the Poor Law Commissioners in one volume, and forwarded to

854 Reviews. [April,

the several boards of guardians, &c., for their guidance during
the recent cholera visitation.

The net annual value of property rated for poor relief and
medical charities has risen from £11,175,586 in 1853, to
£12,989,026 in 1866.

The amount of poor-rate collected, which was £1,109,630 in
1852, and had gradually decreased to £509,380 in 1860, has
since risen to £749,757 in 1866, the rate amounting to a
poundage of Is. 2d. last year. The increased rates being due
mainly to the enhanced price of provisions, the commissioners
apprehend a still heavier rate in 1867, as the number of inmates
in workhouses has increased, unless a decline in prices occurs.

We would suggest an inquiry into the causes of the high
prices of provisions in Ireland, being now aware of the immense
gain to the public, which has followed the recent determined
inquiry by the people and press in Great Britain, and knowing
as we do the very large amount of live stock in the United
Kingdom generally. We cannot help thinking that good would
also arise from investigation into the high price of cereals, &c.

The Poor Law Commissioners anticipate much improvement,
especially in remote parts of the western coasts of Ireland, from
the funds now allocated from the Civil Service estimates for
medical charities, whereby they shall be enabled to place the
machinery, so to speak, of the medical relief on a more efficient
footing, without pressing too heavily upon poor and thinly
peopled districts.

A diminution in the number of cases relieved by the dispen-
saries and medical officers of Ireland occurred in the year 1866,
attributable, in the opinion of the commissioners, to the decrease
of the population, and an improvement in the condition of the
health of the poor : judging from what we have learned of
Ireland, we would ascribe some of this reduction to the excite-
ment arising from the doings of the Fenian conspirators.

New appointments of midwives were authorised in the past year
in fourteen dispensary districts. There are now seventy dispensary
districts in which the attendance of skilled midwives is provided in
cases of natural labour, in other cases it is the duty of the mid-
wife to call for the aid of the district medical officer. The great
necessity for constant activity on the part of the several boards
of guardians in enforcing the Compulsory Vaccination Act is
dwelt upon, and the comparative facilities afforded by the fact
that the dispensary medical officers are nearly all registrars of
births, &c., for the carrying out of the provisions of the law,
are mentioned in the report. The number of vaccinations and
of births, however, still show a proportional deficiency of the
former,

1868.] Irish Poor Lata Report. 355

The number of cases of fever and smallpox, in the practice of
the dispensary medical officers, is less than the number recorded
in the preceding year ; that of scarlatina is slightly less than in
1865. The number of smallpox cases in Ireland are, it is
thought, underestimated, owing to the illegal practice of inocu-
lation still existing, with itinerant inoculators, and the conceal-
ment of cases so arising by the peasantry. It is hardly neces-
sary to point out the great evil attendant upon such a state of
things.

The Eeport details the proceedings taken, prior to and, on the
appearance of cholera in Ireland, when the advantage of a
manageable and central authority, for directing the measures to
be adopted by the several Poor Law boards of guardians became
evident.

The spreading of the cholera from individuals recently arrived
from infected localities was seen in a remarkable manner, and
the several stages by which the disorder travelled to the affected
localities in Ireland are clearly traceable, establishing most
palpably the fact of the contagiousness of the disease. It is
satisfactory to be able to say that in nine out of twenty localities
visited by cholera, the disease did not spread beyond the persons
first attacked. There were exceptions, however, to the general
rule of the origin of the disease by transmission from the sick
to the healthy, two of which are given in the report. In these
cases there was not evidence to show how the disease arose.

The commissioners consider the prevention of the spreading
of the disease, in the several workhouses attacked, was owing to
the prompt treatment of all cases of incipient diarrhoea. In
only one workhouse, that of Kilkenny, did any considerable
number (34) of cases occur. Up to the 3rd of January last
17 of these persons had been discharged cured, 10 deaths having
taken place. The mortality from cholera, in l^cases treated by
the medical staff of the Irish Poor Law Department, during the
whole or a portion of the duration of the several cases, in or
out of hospital, was at the rate of 53*6 per cent, of cases in 1867,
against 46*8 in 1854. The total number of dispensary cases
of diarrhoea treated throughout Ireland during the last epidemic
was 25-100, with 340 deaths, against 27,423 cases, with 279
deaths in 1854. Mr. Lambert, the inspector sent from England
to inquire into the operation of the Irish Dispensary system,
with regard to the applicability to the London unions, says :
" It provides an organization always ready and capable of ex-
pansion, if necessary, to meet any outbreak of epidemic disease
with promptness, while at the same time it is calculated to
prevent disease becoming epidemic, and procuring the adoption
of precautionary measures in any locality, which may be threat-

356 Revietvs. [April,

ened. These benefits have recently been largely realised in
Ireland in reference to cholera.'^

In two instances the Poor Law Commissioners had to exercise
" the recently enacted power of enforcing adequate remunera-
tion to the medical officers for extra service under the cholera
order."

The Irish Dispensary system is not without its abuses. The
same authority observes :

"The only blot in the system is attributable to the extreme
facility with which the tickets for medical relief are obtainable from
the members of the dispensary committees. I was assured at one
place that retail tradesmen have been known to sign a book of
tickets, and leave them to be distributed amongst any customers
willing to accept them ; and in another, the medical officer informed
me that a member of the committee had sent one of his children
with a ticket, under a fictitious name, and obtained cod liver oil for
a period of three months. The dispenser at Limerick, who is also
the house-surgeon at the Barrington Hospital, stated that the right
conferred upon so many persons to give medical orders is open to
great abuse, and he thought it should be limited to relieving officers
and c.r qflcio guardians, &c."

' " Another reason for the somewhat lavish administration of out-
door medical relief in Ireland is attributable to the professional
etiquette which prohibits even a surgeon from attending a patient
for a less fee than a guinea ; so that the question upon which the
granting of medical relief is supposed to hinge is, whether or not the
applicant is provided with that sum."

From our knowledge of Ireland we cannot agree to this latter
statement. It is probably true with regard to the leading surgeons,
but almost every one of them can be consulted by poor persons,
if they apply as extra cases at the hospitals, or, in some cases,
at the residence of the surgeon ; and from a somewhat extensive
acquaintance with the practice both in England and Ireland we
believe that the small tradesman and artizan can obtain medical
assistance, on quite as easy terms, in the latter as in the former
country. Indeed the extreme facility of obtaining gratuitous
medical aid in Ireland appears rather to tend to produce im-
providence and intemperance ; and it is well known that in not
a few instances a portion of the weekly earnings go to the
encouragement of persons and societies whom if we termed
them political we would use a very mild term indeed.

" Tihe power given to the committee of cancelling the ticket
after it has been issued and acted upon is found," observes the
inspector quoted above, " to be quite inoperative in practice."
If the medical officer ascertains that the applicant is the owner
of houses, or cattle, or other property, or proprietor of a flou-

3868.] Irish Poor Law Report. 357

rishing busiuess, or in the receipt of large wages, as well as,
probably, a small shop managed by his wife, a week or often a
much longer period must elapse before he can obtain the can-
celling of the ticket, if even then he is successful in so doing ;
and moreover he may almost always reckon upon the hostility,
open or concealed, of the member of the committee who issued
the ticket, and he must continue attendance until the ticket is
cancelled. The granting of orders forme dical attendance, upon
persons able to pay for the same, is the greater hardship upon
the medical officers, inasmuch as their payment for harassing
duties and constant exposure to contagious diseases is very in-
adequate.

Theappendix containsbesides the letter of the English inspector,
from which we have quoted some passages above — details of the
working of the several hospitals, dispensaries, and workhouses,
their expenditure, &c., as well as the correspondence and instruc-
tions of the commissioners, inspectors, and medical officers, and
on the subject of the new Sanitary Act, the cholera, &c., and
presents several features of interest in connection with sick poor
relief and the sanitary condition of Ireland.

Last year (1867) an Act^ was passed increasing the duties,
risks, and responsibilities of the Irish Dispensary Medical Officers,
from whom so much had been previously exacted ; for it has
been enacted that they shall examine any person " discovered
and apprehended under circumstances denoting a derangement
of mind, and a purpose of committing some crime," &c., "with-
out fee or reward." Soon after the notification to the Irish
Dispensary Medical Staff of the above-mentioned Act another
circular was issued publishing extremely satisfactory results of
a recent inquiry into the state of Ireland, as to the existence of
smallpox in that country, which reflects the highest credit upon
the medical staff, and shows that variola has fallen to a total of
but twenty deaths in the year 1867 in the whole island. Surely
such a result deserves another reward besides that of inflicting
additional labour, of a most anxious, dangerous, and responsible
kind, upon men already notoriously over-worked and under-
paid. We trust, however, that our professional brethren in
Ireland will find that their invaluable services to the nation
and to society will not much longer remain so ill-requited.

Our limits do not permit us to notice at present certain matters
to which the Poor Law Commissioners have drawn attention, in
connection with the prevention of smallpox in Ireland.

I Act 30 & 31 Vic, c. 118 (section 10).

358 Reviews. [April,

Review VII;

La Fievre Jaune a la Havane, sa Nature et son Traitement. Par

Charles Belot, Docteur en Medecine de la Faculte de

Paris, &c., &c., Directeur de la Maison de Sante Fondee

par son pere h la Havane. Paris, 1865.

Yelloiv Fever at the Havanna, its Nature and Treatment. By

C. Belot, M.D., &c.
An Essay on Yellow Fever, comprising the History of that Dis-
ease as it appeared in the Island of Antigua in the years
1835, 1839, 1842. With an Appendix, continuing the His-
torj'^ to 1853. By Thomas Nicholson, M.D. London,
1866.
The author of the above French work may be said to inherit
a taste for yellow fever ; his father founded an hospital at
Havanna for its treatment, and the son has worked in it for
twenty years with a genuine enthusiasm, stimulated both by
love for his profession and respect for his father^s memory, so
long connected with this particular disease. After watching
eighteen epidemics, and treating annually about 1000 patients.
Dr. Belot gives his experiences to the "world, and these cannot
fail to be of value. He says that he can reckon his autopsies
by thousands, and that in his anxiety to wrest its secret from
nature, he has operated on subjects when they have barely
ceased to live !

"The Havanna," so unhappily notorious for its mortality
from yellow fever, is the chief port in the island of Cuba, and
has one of the finest harbours in the world, from which fact,
indeed, it derives its name. A long and narrow channel leads
into a land-locked bay some nine miles in circumference, and
well protected by hills from the north winds, but freely open
to the sunny south. The town, which has grown with the in-
creasing commerce, consists of a new and an old port, and seems
disposed in such a way as to contravene every principle of
sanitary science.

The old town has narrow streets, with small and low houses,
and it is here that the ships discharge their cargoes, and that
men congregate in the largest numbers. Just at this spot the
sewers empty themselves, and the only river contributes, with its
own streams, the debris of the public slaughterhouse, and the
rejections of the gas factory. At this " meeting of the waters'"*
is the military hospital, with 1400 beds, where, as is not to be
wondered at, the mortality is very great. Outside the walls
is the new quarter, Begla, where the richer classes live,
where the houses are better built, and the situation is more

1868.] Yellow Fever in the West Indies. 359

healthy, and where, of course, the yellow jack is a less familiar
acquaintance.

The rise and fall of the tide makes a difference of about two
and a half feet in the harbour, though it is hardly perceptible
outside, and at the ebb there is an immense surface covered with
vegetation, and also with far less pleasant objects, such as dead
animals and the refuse of the streets, exposed to the force of
a tropical sun.

The climate of Cuba is for the most part hot, and always
moist. In winter the temperature is as low as 60"8 Fahr.,
and in summer it rises to 100'4, while at the same time
the air is charged with moisture, the daily rains being followed
by a burning sun. In the hot season the variations of tempe-
rature are constant and as follows: At 4 a.m., 83*75° Fahr. j
at 8 p.m., 93-65° ; at 4 p.m., 52-4°; at 8 p.m., 91*4°; and at
midnight, 79'45. After sunset the temperature falls rapidly,
the watery vapour, which rises in such abundance, condenses,
falling in a sort of mist, and this phenomenon is much more
marked under the influence of moonlight, a well-established but
unexplained fact.

In the hot season the wind varies from the north and north-
east to south-west, but from June to September south winds
prevail, and these are the most dangerous, from having traversed
the island and arriving charged with miasma. These atmo-
spheric changes have a considerable influence, as shown by yellow
fever existing on the shore, and not on the hills, and by greater
prevalence among those living in the low damp places. Such
are the dangers which await the visitor to the Havanna, and when
we consider that sailors, at least those engaged in trade, on their
arrival are, as a rule, badly provisioned, have unfiltered water, and
are confined on board ship amidst poisonous exhalations, we
cannot wonder that so many of them fall victims to yellow fever.

The character of the attacks varies. Sometimes they run
their fatal course with great rapidity, and kill in three or four
days, but generally the duration is longer. In the acute and
worst forms the attack is sudden, and commences generally in
the night, with violent rigors, followed by intense headache,
pains in the loins and in the joints, and a nasty taste in the
mouth. If left alone for twenty-four hours the progress of the
disease is rapid, the headache increases, the least pressure over
the stomach gives great pain, and the pulsation of the vessels is
extreme, the gums swell and turn livid, the breath is fetid, and
thirst intense, the conjunctivae turn yellow, the urine contains
albumen, and the febrile symptoms become aggravated. After
another twenty-four to thirty-six hours the skin changes colour
and becomes yellow, the tongue is dry and rough, the pain at

360 Reviews. [April,

tlie epigastrium is very severe, and the patient^s sensations
become more dull from diminished cerebral susceptibility. Then
commence the characteristic vomitings, the matter ejected being
at first clear, then yellowish, grumous and afterwards consisting
of dark blood, the urine contains more albumen, or is sometimes
suppressed, delirivim supervenes, and death closes the scene from
the third to the fifth day.

We may thus trace three distinct stages. The first is cha-
racterised by headache, lumbar pain, stiffness, pain in the joints,
bad taste in the mouth, &c. In the second, the pathognomonic
signs arise, viz., gastric pain, dyspnoea, swelling of the gums,
and albuminous urine. In the third, the symptoms are typhoid,
and are consequent on an altered state of the blood. Cases do
not, however, always follow such a regular course, the early
symptoms often subsiding and giving the appearance of a less
serious attack. It is noticed at the Havanna that if the weather
is dry, the temperature high, and the wind blowing from the
south, cerebral symptoms predominate, while, if the temperature
is lower and the air charged with moisture, lumbar pains cha-
racterise the onset of the attack.

Taking the individual symptoms, we may observe that the
rigors vary a good deal in intensity ; if violent, they only last
about two, and if slight, they may continue twenty-four hours ;
but if they begin during the night, they always have a well-
marked remission — a dangerous truce. When the heat of skin is
followed by perspiration, there is hope, but when the dry heat
continues, it becomes a grave symptom. Headache with great
heat of skin at the commencement is a bad sign, but when it
is accompanied by gastric symptoms and persists after these
have disappeared, the typhoid state soon follows. Delirium and
photophobia often accompany the headache, but their continu-
ance after the first twenty-four hours is unfavorable, t The
odour of the breath is peculiar, being due to alterations of the
state of the mucous membrane of the stomach, and it becomes
oflensive when blood is poured out and undergoing change.
Thirst is sometimes very distressing, and our author " has seen
sailors throw themselves into the sea because refused water to
drink."

Vomiting, beginning early and not persisting, is a favorable
sign, but a bad one if it continue beyond the first twenty-four
hours. Black vomit is of frequent occurrence, the matter being
either liquid blood, effused in the stomach, or sometimes that
which has flowed from the mouth or nose into the stomach
and coagulated there.

Jaundice is not an indispensable symptom, and is rare in the
first stage. If it appear before the third day, it is of fatal sig-

1868.] Yellow Fever in the West Indies, 361

nificance, but after the fifth or sixth day may be regarded as
favorable.

The urine is unchanged in the first stage, but in the second
becomes thick, and charged with bile, and afterwards is found
to contain albumen.

The state of the mind in those attacked has great influence,
some being unable to master their dread of the disease, and
this has been observed chiefly among the natives of the north of
Spain and of the south of France.

The pathology of yellow fever offers nothing constant, except
it be in one singular point, viz., changes affecting the sympa-
thetic. The solar and semi-lunar plexus are found red, and at
some points black, and tear easily. The spleen is almost always
hypertrophied, and filled with blackish fluid blood, and the
blood is found decomposed in the stomach and intestines.

As the early symptoms are such as are common to many
diseases, the diagnosis is not always easy at first, and even the
most characteristic symptom, the black vomiting, has been
noticed in the course of other maladies. Thus, in 1858, during
an epidemic of variola at the Havanna, several cases showed this
symptom. Bilious remittent fever, however, resembles in its
phenomena more nearly yellow fever, but there are several well-
marked points of difference. The former is found in all localities
and seasons, while the latter occurs on the sea-board, in low
marshy lands, and never on the heights, and is met with in the
hot season. The latter attacks strangers, the former those
acclimatized. The symptoms, too, differ, for the blood under-
goes considerable changes in yellow fever, which is not the case
in the bilious remittent ; the urine is albuminous in the one,
and not in the other ; and lastly the sympathetic nerves suffer
in the one, and in the other the liver is the organ most fre-
quently affected. The prognosis must vary with the circum-
stances and condition of the patient, but we have to count on a
mortality of twenty to thirty per cent, as a rule in the second
stage of the disease, and in the third, happy are those who
only lose three fourths of their cases. The negroes escape
from this frightful disease, and, as though the colour of the
skin were a criterion of the liability to attack, the Chinese,
who are a shade less dark, are less subject to it than white
men. Atmospheric conditions have considerable influence,
particularly the electric state, and it is not rare, says Dr. Belot,
" to see a patient, approaching convalescence, die rather sud-
denly after a storm.^'' This is not surprising when we consider
how intense are the disturbances of a tropical storm. " At such
times," he adds, '^ fresh meat decomposes immediately, fish is
quite spoiled a few minutes after being taken out of the water,

863 Reviews. [April,

and milk turns sour with amazing rapidity." As regards the
nature of the disease, Dr. Belot says : — " yellow fever is the
result of a miasmatic poisoning, sui generis, which acts at first
on the great sympathetic and abdominal ganglia ; the organs in
relation with this nervous apparatus are more or less altered
in their functions; the blood itself is modified in its consti-
tution.'" In the first stage, the blood is observed to be red and
coagulates very quickly, the quantity of fibrin and albumen
being much increased. In the same persons twenty-four hours
later, the blood is of a mahogany colour, more liquid, does not
coagulate so easily, the serum is yellowish, and the clot soft.
In the third stage it is very fluid and quite black. In a word,
the formation of fibrin diminishes at the expense of the al-
bumen, and the blood not getting oxygen enough passes from
red to black.

" The organs connected with the solar plexus are those that
sufifer most, and hence we see why the epigastric pain is the
last to disappear. The anastomoses of the solar plexus explain
the violent headache, hiccough, lumbar pains, dyspnoea from
paralysis of the diaphragm, and all the other symptoms ; for there
is not one which cannot be accounted for by the direct relation of
the solar plexus and great sympathetic to the organ affected."

The cause of yellow fever is purely miasmatic and is conveyed
by the air, but the first condition for its development is a high
temperature. It may continue through a winter, but no
epidemic has commenced in the cold weather. Those who
can take proper care of themselves, keep in a pure atmosphere,
and avoid the unhealthy quarters, generally escape infection,
and this fact, one would think, might have read a lesson before
this to the authorities, and compelled the sorely-needed sanitary
reforms.

The period of incubation is generally from eight to twelve
days, and this explains how ships arriving in the course of an
epidemic may leave ^the port, congratulating themselves on
escaping the dreaded enemy, and still find it break out when
they have got to sea again.

The chief points in treatment recommended by Dr. Belot may
be summed up as follows. While he deprecates general blood-
letting he advises local depletion, and thinks cupping preferable
to leeches ; for instance, eight glasses to the nape of the neck,
ten to the loins, and eight on the abdomen. At the same
time he uses strong mustard foot-baths every two hours, and
sinapisms to the calves.

As a " great aid in lessening the plasticity of the blood and
relieving local congestions," he gives the Tinct. Aconite in doses
of six drops every hour> and says, "the pulse drops, and

1868.] Yellow Fever in the West Indies. 363

diminishes in frequency, as do also the heat of skin and
perspiration/'

If the attack begins with vomiting, an emetic of thirty
grains of Ipecac, in four ounces of warm water should be
given, and the nausea should be kept up so as to produce dia-
phoresis, as well as merely to empty the stomach, but if the
tongue be clean and the epigastric pain severe, emetics are bad.
A few hours after the action of the emetic, there is generally
some amelioration, and then is the time to give a purgative
of castor oil or of sulphate of magnesia.

Continuous headache is best treated by flying blisters to
the nape of the neck, and applications of camphorated spirit,
and belladonna to the forehead. For the gastric oppression the
same application is useful combined with a very small dose
of tincture of nux vomica internally, and if nausea comes on,
bicarbonate of soda alternated with the nux vomica is of ser-
vice. In the acute and severe cases any treatment is too often
useless, but in the more ordinary it is better to begin with an
emetic, a gentle purge and diaphoretics, particularly Dover's
powder, and when the remission occurs to give quinine in a
single dose of thirty -six grains in di little strong coffee. When
febrile symptoms prevail and rigors are absent, quinine is not
applicable, and the author gives calomel, in small doses, every
half hour till the usual effects are produced, and this method
is, he says, efficacious. Hiccough is be stopped (?) by pressing
on the phrenic nerve near the hyoi'd bone.

Tannin, or perchloride of iron, is good for the haemorrhages
which often occur either from the mouth, nose, stomach, or
bowels. Inflammation of the parotid gland frequently follows
on these haemorrhages, and is a good sign for recovery.

It remains to mention a method tried at Havanna by some
German adventurer, as a preventive against yellow fever, viz.,
inoculation with the poison of a serpent known as Crotalus
horridus. He observed that the Indian prisoners sent from
Mexico to Vera Cruz when bitten by a viper, showed symptoms
like those of yellow fever, and he thought that inoculation might,
perhaps, on homoeopathic principles be a safeguard against the
genuine disease. He pretended to make the serpent bite the
liver of an animal, kept this till it was putrid, and then inocu-
lated with this substance, giving at the same time by the mouth
a syrup of mikiana guaco, and rhubarb with iodide of potassium,
&c. This man made some experiments at the military hospital,
but the results were very unfavorable to his theory, and he
refused to yield to the wishes of the commission appointed to
report upon the experiments, and try the inoculation and physic
separately. The subject has since dropped out of notice. During

364 Reviews. [April,

the epidemic of 1862, 1107 cases of yellow fever were treated
in the Maison de Sante, between June 1 and October 15, of
which 196 died, i. e., about 17" 7 per cent, the victims being
chiefly English, Germans, Spaniards, and French. The matter
vomited was made the subject of careful examination, and it
was found that, when clear, it was generally acid, and when black
it consisted of bile, with excess of gastric juice and altered
blood, this being the form of vomiting best relieved by calomel.
The liquid of the black vomit was acid, and, treated with Bar-
reswiFs solution, was found to contain glucose. Dr. Belot
speaks in high terms of the efficacy of small doses of arsenious
acid in this form of vomiting.

We have said enough to give an outline of the chief facts
contained in this book, which is of considerable merit, being a
record of carefully observed facts in a wide experience, undis-
torted by theories, and honestly worked at by a well-educated
practitioner. Since we have had a threatening of this disease
in our own country, we may feel a closer interest in acquaint-
ing ourselves with its features, so terrible by reputation.

Dr. Nicholson^s essay treats of the epidemics of yellow fever in
Antigua, in 1835, '39, '42, and '53. He published it first in
1849, and has added an appendix with his more recent expe-
riences. He advocates bleeding generally, and disapproves of
the calomel and quinine treatment in large doses. He says,
" This practice is so contrary to what I consider the rational
treatment of ardent fevers, that I could not in my conscience
adopt it in such cases. I might venture to try it in the congestive
form of the disease ; and that, perhaps, is the type most pre-
valent in the swampy colonies of Guiana." In the epidemic of
1853 he attended fifty-three cases, of which he gives an abstract
(p. 56), showing that forty recovered and thirteen died. Of those
attacked thirty-two were Europeans, of whom twenty-three
recovered. The author says, " in all cases in which, at my first
visit, there were symptoms of cerebral or hepatic congestion, or
when the force of the circulation was so great as to threaten
destruction to the capillary system, I had recourse to blood-
letting," which was, it appears, borne well in every instance.
The author has no faith in " any medicinal astringent " after
hsemorrhages and black vomit, or in anything " but the most
diligent exhibition of diffusible stimulants." This little work
is Avorth consulting as a record of personal experience after many
years' residence in the island of Antigua.

The above comments on yellow fever may be read in con-
nection with an article on the same disease in Bermuda in our
number for July last.

1868.] Guy's Hospital Reports. 365

Review VIII.

Guy's Hospital Reports. Edited by C. Hilton Fagge, M.T).,
and A. E. Durham. Third Series. Vol. XIII. London.
Pp. 538.

The Guy's Hospital Reports by this time begin to assume
the dignity of an honorable old age, but with the dignities
none of the weakness and effeteness ordinarily indicative of
that period of life. Indeed, the present volume gives tokens
of as great intellectual vigour as has ever tended to enhance
the reputation of these well-known and highly-esteemed
volumes.

But to begin cur review of the contents, we find that first of
all Mr. Cock contributes a second case of pharyngotomy. The
patient, a servant in the camp at Aldershott, had been accus-
tomed to wear even during his sleep a tooth-plate, from which
all the teeth had been removed or worn away, and one night
swallowed it. All attempts to remove it having failed, the
patient came from the camp to Guy's Hospital, and was there
opsrated on. The incision into the pharynx was made as far
back as possible, to avoid filaments of the recurrent laryngeal
nerve ; a forceps introduced by the mouth was found to facilitate
this part of the operation. The body was found in the ordinary
situation, opposite the cricoid cartilage, and removed without
difiiculty. After the operation the patient was carefully fed
through a tube and by enemata, and in a short time perfectly
recovered. Mr. Cock lays considerable stress on early opera-
tion, before the patient has been weakened by prolonged absti-
nence and local mischief.

Mr. Hilton next contributes some of his clinical lectures,
arranged for publication by Mr. George Eastes. The first
of these details an interesting case of ruptured kidney, the
injury being occasioned by a railway engine, in which death
did not occur until the twenty-fourth day, although the organ
was broken up into several pieces, and a large collection of
bloody matter was found around the kidneys. In fact, the
patient seemed to do well, although hsemorrhage from the
bladder still continued, until, unfortunately, his food was
changed, and made more nourishing, after which he rapidly
retrograded. In this connection, Mr. Hilton makes some im-
portant remarks on the diagnostic value of clots, whether
82— XLI. 24

366 Reviews. [April,

in the urine or elsewhere, pointing out that they assume the
form of the space into which the blood is eflfused, as in this
instance, the broken pelvis of the kidney ; also that the form
of the blood-clot may be unravelled by agitating it in water.
Still continuing on the same subject, Mr. Hilton in a second
and a portion of a third lecture founded on the same case, at
least inasmuch as it starts the subject of bleeding, continues his
admirable remarks on the diagnostic value of blood-clots, as
discharged from the urethra, the rectum, or the stomach. He
points out the importance of attending to the relation of the
bloody discharge and the urine with regard to priority in ap-
pearance when passed as indicative of the urethral nature of the
haemorrhage. He also shows that bladder clots are flat and
circular, not rounded like those from the urethra. So also
with bloody discharges from the rectum, the nature and colour
of the blood, whether clotted or otherwise, may enable the
surgeon to determine the source of this bleeding, and enable
him to apply the proper remedial measures. He also shows
that a blood-clot may destroy life, as often after cut throat or
tracheotomy, and that by deluding the surgeon as to the con-
dition of his patient may lead him to defer operative procedure
for the arrest of haemorrhage until too late, as after injury to
the head, or the incision of a carbuncle, &c.

The next subject discussed by Mr. Hilton is that of loose car-
tilages in the knee-joint, the case selected for description being
complicated with fracture of the tibia. As to such fractures, he
recommends that they should be put up immediately, or else not
until the swelling has subsided, and advises the suspension of
the limb. Of loose cartilages Mr, Hilton recognises three kinds :
decolorised blood-clots, portions of bone and cartilage broken
ofl^", and pedunculate tumours, whose pedicles have been severed.
The case referred to was characterised by the great size of the
tumour in the knee and the absence of pain on moving the joint.
The remarks as to the mode of cure to be adopted in such cases
are, however, of much importance. He deprecates cutting into
the joint as an extremely dangerous operation, and advises
fixation by means of a backsplint. He further says, that, by the
judicious exercise of pressure, the loose body may be made to ad-
here to the synovial membrane, and ultimately become absorbed —
a practical remark of the greatest importance. An allied subject,
floating bodies in the thecae of tendons, is next discussed, and in
this case also Mr. Hilton is opposed to a cutting operation if it
can by any means be avoided, such being too frequently followed
by suppuration and sloughing of the tendon. He also raises a
warning voice against interfering with certain bursas which
communicate with joints. Remarks are also made on the treat-

1868.] Guy's Hospital Reports. 367

ment of an ulcer remaining after a Chopart's amputation of the
foot, and on the treatment of painful ulcers by cutting the nerve
filaments directed to them; tlie hyperaesthetic parts may be
marked with caustic, and the nerves divided below the surface
of the wound by means of a fine knife. The fifth lecture com-
mences with an account of a case of compound fracture of the
thigh, complicated with tetanus. Although valuable for teaching
purposes, we need not enter into details with regard to it, but
will content ourselves with repeating the doctrine cited by Mr.
Hilton, that if under such circumstances the patient can breathe
and swallow well he will probably recover. The case of a man
who suffered from injury over the knee-joint is also given, it
ended in anchylosis of the joint. We need hardly say that
both student and practitioner will benefit by the perusal of
these lectures.

Mr. J. Salter, well known as one of our most scientific deu*
tists, contributes a paper on ' Affections of the Nervous System
dependent on Diseases of the Permanent Teeth.' Such a paper
was greatly wanted. Cases of this kind are not infrequent, but
they have never been collected into a single article. Mr. Salter
divides such diseases into local and remote, but recognises a sort
of intermediate group, which it is hard to assign to either. The
local affections are readily distinguishable, the remote less so,
the most common being neuralgia of the upper part of the face
or head, and painful affections of the fifth nerve. But besides
pain, irritation arising from diseased teeth may give rise to mus-
cular spasm, muscular paralysis, paralysis of some of the nerves
of special sense, perverted nutrition, &c. The diseases which
may give rise to these abnormal conditions are caries with
or without exposure of the pulp, exostosis, hypertrophy of the
crusta petrosa, nodular developments of dentine in the pulp
cavity, periostitis plastic or suppurative, impaction of the
permanent teeth in the maxillary bones, crowding of the
teeth, &c. We cannot enter into these cases, our space does
not admit of it; but we may say that each is of particular
interest, even more so to the general practitioner than to
the dentist, and shows how carefully we ought to examine the
mouth when any local affection in the neighbourhood of the
jaws occurs.

Mr. Cooper Forster contributes an article on acupressure, on
which we must make some remarks. We think that Mr. Forster
deserves very great credit for the trouble he took to make him-
self master of the most approved methods for thus arresting
haemorrhage, even in taking a long and fatiguing journey to
Aberdeen to see the practice of Drs. Pirrie and Keith. Since
the period of that journey Mr. Forster has been unremitting in

368 Reviews. [April,

his endeavours to work out the problem he has set himself to
solve the value of acupressure as a haemostatic ; in this he has
been materially aided by Mr. Durham. Mr. Forster speaks
highly of acupressure as a means of arresting haemorrhage,
but seems disappointed at not attaining such success as has
been obtained in Aberdeen. For this there are doubtless
several reasons : one being the hardier constitutions of the
more northern people; one Mr. Forster seems to think rests
with the diet ; but certainly in Mr. Durham^s cases there is
something far more significant. Mr. Durham ties in the
needles by ligature silk or by catgut. Now this we would
submit is not acupressure, the great object of which is to avoid
the introduction of any non-metallic body into the wound. And
we think it may be noticed in the records of the thirty-one
cases given, that haemorrhage much more frequently followed
the withdrawal of the needles in this than the ordinary, we
might say proper mode of constricting the vessels by pins or
iron wire. Notwithstanding these things, which we cannot
help looking on as drawbacks, Mr. Forster is greatly enamoured
of acupressure, and considers its introduction as great an
advance as was that of the ligature over the actual cautery.
The reasons he gives for maintaining this view are good, but
too long to be quoted here.

Dr. Braxton Hicks follows with forty-one cases of uterine
polypi removed by his annealed steel wire-rope ecraseur. They
are notable as having been neither followed by death, haemor-
rhage, nor indeed by any troublesome symptom, save in two
cases. This is certainly more than average success. There can
be no doubt but that the immediate removal of polypi is a great
advantage over the old plan of allowing them to come away by
sloughing, thus exposing the body to the results of the absorp-
tion of much putrid matter. On one little point Dr. Hicks
strongly and judiciously insists, viz., the absolute necessity for
keeping the patient quiet for a fortnight or three weeks after
the operation. He also highly recommends the injection of a
quantity of warm water every day to remove any undesirable
substances which may have accumulated near the site of opera-
tion. He divides polypi into those small enough to be included
in the speculum, those which will permit the ecraseur to be
adjusted by the fingers, those which will not allow of the
fingers being passed alongside of them ; and, fourthly and lastly,
the most unmanagable of all, those still within the uterus,
bodies in fact presenting more of the characters of fibrous
tumours than of real polypi. The directions given for the
removal of each variety are very clear and explicit, Dr. Hicks
insisting in an especial manner on the employment of a rope of

1868.] Guys Hospital Reports. 369

sufficient strength. We shall not speak of the pathological
characters of these tumours.

Mr. Hinton writes on nervous deafness, contributing a paper
of great value to aurists and other practitioners. Twenty-three
cases are recorded, each with its appropriate commentary.
The whole subject is one of unusual interest, the facts recorded
are so curious, and in the meantime so inexplicable. The first
case which came under Mr. Hinton^s notice, and which seems
to have struck him greatly, was that of a gentleman who, under
the nervous excitement of a call on the parents of a lady to
whom he wished to be engaged, became totally deaf. The signs
on which Mr. Hinton relies for the diagnosis of this form of
deafness are, 1st, the history ; 2nd, peculiarities of hearing, as
hearing better in a noise, or worse from excitement, depression
or fatigue, a better hearing of some sounds than others, a marked
diminution of the power of hearing on inflating the tympanum,
and so on ; 3rd, the degree of deafness, if it be very excessive,
it cannot depend on deficient or absent conduction; 4th, the
tuning-fork applied to the cranial bones is especially useful ; if it
be not, or only very imperfectly heard, the disease is probably
nervous, especially so if it is best heard, by the better ear, when the
meatus has been closed. Finally, a certain peculiarity of appear-
ance marks persons labouring under nervous deafness, which is of
some value as an aid to its diagnosis. The disease with which
it is most likely to be confounded is anchylosis of the stapes.
When speaking on this subject, Mr. Hinton makes some re-
marks as to the causation of aural diseases which must be con-
sidered of great importance; they are with reference to the
effects of earache in children in the production of future deaf-
ness. Mr. Hinton is strongly inclined to believe that the con-
nection between the two is much more decided than has been
suspected, and that the congestion of ear-ache, if it do not
cause disease of the labyrinth, at least leaves it in a con-
dition to be more readily affected in its nerves at a sub-
sequent period. The question is as yet unsolved, but the idea
is certainly good. So also is that which refers the cases of
nervous deafness, in which the sound of the tuning-fork is
diminished by closing the meatus to increased pressure of fluid
within the labyrinth, in fact to glaucoma of the ear. But the
whole paper is one worthy of the most careful study.

Dr. Owen Rees writes on elephantiasis grsecorum, which he
shows to be quite possible in this climate, even in one who had
never been out of the country. One of his cases indicates that
the tuberculated form may be characterised by quite as much
ansesthesia as that ordinarily termed the anaesthetic variety.
He consequently gives in his adhesion to the terminology re-

370 Reviews. [Aprils

commended by the College of Physicians, viz., the division of
the disease into the tuberculated and the non-tuberculated
varieties. The first case, one of the smooth variety, presents
no unusual features beyond the fact of its having been developed
in one who had never been out of Great Britain, but had been
subjected to a good many privations. The second was one of
the tuberculated form, and occurred in a native of India. It
made the most determined progress under all sorts of remedies ;
its conclusion is not given, the record stopping abruptly. Dr.
Rees holds that this is a blood disease, sometimes hereditary, but
he is inclined to think with Dr. Carter and others that spare
diet or decomposing food, especially the latter, have a powerful
influence in inducing the disease, even where there is no here-
ditary taint. The Somalee tribe in India believe that a milk
and fish diet tend to produce elephantiasis.

The next paper is also on cutaneous affections, and is from
the pen of Dr. Hilton Fagge, who has charge of the skin depart-
ment at Guy's Hospital. He treats of rare cutaneous affections,
the first mentioned being circumscribed gangrene of the skin.
This curious form of disease occurred in a patient who died of
phthisis at Guy's. It has been noticed by Sir B. Brodie, by
Morley Rooke (as erythema gangraenosum), and others. The
sloughs were dry and shining, like those of senile gangrene on
a small scale. The next case mentioned is one of what M'Call
Anderson terms eczema rupioides, a term to which Dr. Fagge
objects as too precise, and giving an erroneous conception of
the nature of the complaint. The scales form in crusts, not
unlike those of rupia, but there is no ulceration beneath. A
case of eczema squamosum universale, apparently identical with
Hebra's pityriasis rubra, follows. Dr. Fagge enters into some
details as to the real nature of the disease, and, as seen at first,
holds it to be a variety of eczema rather than of pityriasis.
The one point of importance to the general practitioner in con-
nection with these cases is their tendency to terminate fatally.
A case of acne following smallpox is next given and followed by
one of acne cornea : the latter is a very uncommon variety of
skin disease ; the sebaceous follicles become filled with a hard-
ened secretion, which causes them to assume a tubercular
aspect, somewhat similar to tubercular syphilide. The last case
given is a doubtful one of acute recurrent eczema ; the vesicles
were very delicate, something like those produced by croton oil.

Mr. Hilton follows with a second contribution on a case of
intestinal obstruction, for which colotomy was performed, and
twice repeated. The case is full of interest, all the more so,
probably, as occurring in the person of a member of our pro-
fession. He had been without any motion of the bowels for a

1868.] Guy's Hospital Reports. 371

month before the operation was performed ; but in a few days
after this he had a motion per anum, which happened regularly
every day, until at last the wound healed. Not long afterwards
the constipation returned as bad as ever, and the wound was re-
opened with a like success; but it was again allowed to close,
and the constipation recurred. This time an abscess formed,
communicating with the gut and with the hip-joint, which it
destroyed. A repetition of the operation along with an opening
of the abscess was attended with no very good result, and the
patient soon sank. It was found that the stricture, which was
simple in its nature, occurred about eight inches from the anus,
and that immediately above it the gut was greatly dilated, and
bent at an abrupt angle downwards into the pelvis, probably
thus causing the mischief being then tightly tied down by adhe-
sions ; the acute angle would only be rendered more acute by
distension, and the passage of faeces would be thus prevented
until tlie distension was relieved by operation.

Dr. Taylor's two contributions to forensic medicine, which in-
variably constitute one of the chief recommendations of the
* Guy's Hospital Reports,' are, the one toxicological, the other
on the detection of blood-stains. In the former of these are
recorded sundry cases of poisoning of greater or less interest.
The first is one of poisoning by carbolic acid, probably the first on
record, although deaths have occurred from substances which
much resemble it, as oil of tar, wood spirit, &c. The individual
poisoned was a child, who swallowed the substance which had been
spread out as a disinfectant. About two teaspoonfuls of the liquid
acid were swallowed, and the child died twelve hours after, death
being caused by a portion of the acid having reached the lungs.
The external parts, as the lips, were coloured brown, as in poison-
ing by corrosive substances; the internal were whitened and
thickened. The walls of the stomach were hardened, but not in-
flamed. The next case, one of poisoning by cyanide of potassium,
occurred in a gentleman who, fortunately for himself, had at hand
a solution of the proto-sulphate of iron, and possessed presence
of mind enough to swallow it, following it up with mustard and
water until he vomited. He recovered perfectly, the most notable
symptom left behind being constriction and tremors in the throat.
The most interesting of the lot, however, is one of poisoning by
phosphorus, of a very obspure character, especially as to its nature,
whether suicidal or homicidal. The substance swallowed was
the ordinary phosphorus paste employed for destroying vermin.
The matters vomited soon after the poison was swallowed are
described as having been smoky and luminous. Unfortunately
the patient was not seen at first by a medical man. She died
on the sixth day. Ecchymoses were observed on the skin of the

372 Reviews. [April,

abdomen and on the diaphragm. The liver, as usual in
such cases, was bright yellow, having undergone complete fatty
metamorphosis ; nothing is said about change in its size. In
examining the viscera. Dr. Taylor employed the process known
as Mitscherlich^s for the detection of phosphorus, but found none.
The process is extremely delicate, and depends on the volatiliza-
tion and subsequent condensation of water along with phos-
phorus, this being accompanied by a flash of light. The other
points in connection with the case are of minor importance.

A second paper, by Dr. Hilton Fagge, follows that of Dr. Taylor,
this communication being on certain obscure skin diseases, as
keloid, scleriasis, and morphoea. This article is even better than
his former one, being, in fact, an exhaustive treatise on the
subjects of which he treats. He first deals with the keloid of
Alibert, and the development of the term. Alibert considered
the affection cancerous, an opinion now abandoned. He also
distinguished another variety, known as false keloid, developed
on scars, being especially common in soldiers who have been
severely flogged. The characters of the keloid of Addison are
well defined, a smooth, flat, ivory-like appearance of the skin,
sending out claw-like processes into the surrounding healthy
parts, thickening, and induration with contraction and slight
anaesthesia of the portions thus affected ; and, it must be ad-
mitted, with a tendency to self-cure — quite a diff'erent affection
from the keloid of Alibert. The derivation of the word, adopted
by Addison {Kr\\iq, a spot), probably accounts for this. The most
interesting of Addison^s cases is that of a patient still alive, who
was visited and examined by Dr. Fagge whilst he was engaged
on the present paper. The upper extremities are frequently
affected ; when so they become bound down and attenuated ;
they were so in the instance referred to. When seen by Dr.
Fagge she had evidently improved to some extent, at least from
what she had been when in Guy's. Besides those cases recorded
at Guy's, others have been described by Dr. Alderson, Mr.
Sedgwick, and others. One, however, given by Professor Long-
more as a true case of keloid, does not present the distinctive
characters of the disease ordinarily known by that name.

Next, as to the relations of keloid to sclerema or scleriasis ;
these are tolerably well marked if we accept the original de-
scriptions of Thirial as correct, but there can be no doubt, as
pointed out by Dr. Fagge, that several of the cases described in
foreign journals under this appellation, are cases of Addison's
keloid. The most marked distinction between scleriasis and
keloid is the acute onset of the former, the induration being
perfected in a few days. It also tends to subside much more
speedily than does the more chronic keloid. A most interesting

1868.] Guy's Hospital Reports. 373

series of cases occupying an intermediate position are given by
Dr. Fagge, but we have not space to discuss them at length.

Only one post-mortem is recorded in a case of Forster^ who
sums up his observations by stating that the sclerema was cha-
racterised by a chronic process of proliferation in the connective
tissue of the corium, and particularly of the subcutaneous cellular
tissue, unattended with fever or local inflammatory symptoms.
The treatment of these affections is most unsatisfactory ; many
remedies have been tried, none seem to have any very decided
eftect. To separate the two distinct affections. Dr. Fagge pro-
poses for Addison's keloid the term leuce.

A word or two on the subject of morphoea, and we must leave
this interesting paper. This would seem to commence as a sort of
bald patch on the top of the head, most frequently just on the left
side of the median line, and extending downwards over the nose.
At first this may be slightly elevated and discoloured, ultimately
it becomes depressed, and of a shining white appearance. It
seems to correspond with the distribution of the first division of
the fifth nerve. Finally, Dr. Fagge discusses the relations of
these affections to leprosy, which are but slight, and unimportant.

Dr. Moxon contributes a paper on the history of visceral
syphilis, both interesting and valuable, and we would recommend
his paper to the consideration of those who still believe with
John Hunter, ^'^^that the brain, heart, stomach, and kidneys, and.
several other viscera, have never been known to be affected by
syphilis.^' Surely the researches of Dittrich, of Wilks, Bristowe,
and others ought now to be recognised ; and we think that the
clear and distinct recitals of Dr. Moxon's cases will do much to
dissipate any lingering shade of doubt in candid minds. Of all
internal organs, the liver is the one most frequently affected by
syphilitic lesions, whether by the sulphur-coloured gummous
formations commonly recognised as diagnostic of visceral syphilis,
or by changes of a less marked character, and more closely allied
to those ind uced by other agencies, as, for instance, fibrous hepatitis.
No doubt this form of disease is exceedingly common, following
other causes than syphilis, notably alcoholism, but Dr. Moxon
points out that in subjects undoubtedly syphilitic there is a variety
of the affection of a more strictly limited character, generally
near the surface, which it is fair to conclude follows on syphilis.
So again. Dr. Moxon believes that a certain form of renal dis-
ease— the lardaceous kidney — is also produced by syphilis,
which must therefore be regarded as one of the causes of
Bright' s disease. The vessels are the portions most and pri-
marily affected by the lardaceous change ; the tubules become
dilated, and their epithelium squamose, the whole organ being
now recognisable as the large white-mottled kidney. Besides this

374 Reviews. [April,

change, the kidneys may become the site of true syphilitic
gummata. It has long been known that the Fallopian tubes of
prostitutes are frequently found closed, accounting for the
infrequency of their impregnation. This fact Dr. Moxon seeks
to couple with a syphilitic history, for in at least four out of the
eleven cases given by Dr. Moxon the Fallopian tubes exhibited
well-marked pathological changes. It would appear that the
lungs may also be affected: thev were so in eleven out of
twenty-seven cases, and the appearances left are tolerably cha-
racteristic, being a circumscribed gangrenous patch, iu the
centre of hard hepatized pulmonary tissue, perforating from
above downwards, whilst no marks of tubercle or scrofula are
detectable. The brain, larynx, and testicle are so often affected
that we need say nothing about the lesions to be specially
sought there, but rather advert to the question as to what
really constitutes a true syphilitic deposit. The microscopic
elements of these tumours are not very well marked, being only
imperfect and perishing corpuscles, but the sulphur yellow
colour and the transitional character are sufiiciently distinctive.
We cannot speak of Dr. Moxon's fragmentary comments
appended to each case, although they are to the point, but
will only delay to give some idea of the frequency with which
different parts of the body are affected. Of the 27 cases, 16
were in males, 11 in females; of the former, the testicles were
affected in 8 distinctly, the Fallopian tubes in the women 4
times, the liver was diseased in 21 instances, the air-passages
in 10, the lung itself in 11, the spleen in 10, and the kidneys
in 12. Dr. Moxon's contribution is illustrated by two very
good plates.

Dr. Stevenson follows with a note as to the colouring matter
in a case of melanuria occurring in one of M. Bryant^s patients,
and en passant notices that all such cases previously reported by
Golding Bird, Hughes, Odling, Fetters, &c., have had this
peculiarity, that carbolic acid, either pure or in combination, has
been exhibited internally or externally in each case. Most
specimens of black urine hitherto examined have contained
indigo, or, probably, we ought rather to say indican, and pecu-
liar colouring matters have been observed repeatedly in cuta-
neous discharges from patients suffering from skin disease.
We have seen such, both pink and blue, from cases of psoriasis
and eczema, but according to Dr. Stevenson's researches the
substance contained in the urine in this case had altogether a
different character. To show that it was not indigo, the urine
was rendered strongly alkaline by caustic potash, grape sugar
was added, and a well-stoppered bottle was filled with the
mixture and set aside for sixteen hours, being well shaken from

1868.]

Guy's Hospital Reports. 876'

time to time. The clear portion was then exposed to the
air, but no indigo was deposited, showing that this substance
was not present in the urine. We cannot enter into par-
ticulars as to the various chemical manipulations to which this
substance, or rather the urine containing it, was subjected ; but
we may state that these led to the belief on the part of Dr.
Stevenson, that the urine contained a glucoside or sugar-pro-
ducing body, and that the pigmentary matter which darkened
it was something hitherto undescribed ; it was neither blood-
colouring matter nor was it indigo, the two substances most
frequently found under such circumstances.

The paper that follows is on the extirpation of the spleen,
ending, as such almost invariably do, in the death of the
patient. It is contributed by Mr. Bryant, well known as
one of the soundest, and yet one of the most enterprising
of our metropolitan surgeons. Cases are not so very rare of
a portion or the whole of the spleen having been excised,
and the patient doing well afterwards; but this for the most
part has occurred where tlie spleen was already extruded
from the cavity of the abdomen, as a consequence of the
rupture of its wall. . Only one completely successful case has
been put on record, and that by M. Peau. Koeberle of
Strasburg has been equally unsuccessful with Mr. Bryant, and
the want of success evidently depended on the same cause in
both instances. It must in the first place be remarked, that the
operation has been performed on purely theoretical grounds.
In leucocythemia the spleen is usually much enlarged, but we
cannot, therefore, conclude that the enlargement of this viscus
is the cause of the disease, or that its removal would be attended
with complete recovery, the affection being really a constitu-
tional one, having no distinct local origin. To this view Mr.
Bryant has now acceded. Again, the leuksemic condition is inva-
riably accompanied by a tendency to haemorrhage, so that an
injury ordinarily of little importance may lead to fatal results
by this means. When the spleen becomes very greatly enlarged,
adhesions between it and other organs or the abdominal walls
are to be expected, and the division of these may give rise to
fatal bleeding. This would seem to be the most common
cause of death, as in Mr. Bryant^s last case and in Kobberle's.
In the instance of which we now speak, there were firm and
close adhesions to the diaphragm, which being separated gave
rise to an infinity of bleedmg points from which the flow of
blood could not be arrested, and which rapidly led to death.
Lymphoid bodies were detected in most of the glandular struc-
tures of the subject.

A short paper on malposition of the testicle and of mal-

376 Reviews. [April,

formation of the male and female genito-urinary organs, also
by Mr. Bryant, follows. Its main interest lies in its adding to
our knowledge a certain number of facts, most of them already
known, but which still require increase in number to enable the
man of science to arrive at safe conclusions as to their cause and
frequency. In one case the testicle was situated in the peri-
naeum; in another (an important practical hint), it became
impacted and inflamed in its going down the inguinal canal, and
was found to be much swollen and very tender. Another
curious case is one of inflamed testicle from inability to gratify
sexual passion. A very practical point brought forward by
Mr. Bryant is the propriety of deferring any operative proce-
dure for the relief of extroversion of the bladder until it can
be seen what nature will do in the way of repair. The last
case narrated is that of a female child possessing the ordinary
characters of a hermaphrodite.

The paper which follows is a second contribution from the
pen of Dr. Taylor, on " the guaiacura process for the detection of
blood- stains.'' British literature is singularly barren on this
subject. Since the time Dr. Taylor contributed one of his best
papers to this periodical, the case of Thomas Drory for the
murder of Jael Denny, little or nothing has been done, for
we hold the introduction of the spectroscope as a thing of but
little value. We are glad that the same pen which yielded
the paper we refer to has again produced this most valuable
contribution to forensic medicine. Dr. Taylor has indeed lifted
the guaiacum process from the doubtful position it has hitherto
occupied, into one of the most scientific of our medico-che-
mical processes. Let us see how. It was proposed some years
ago now by a Dutch chemist Van Deen, to employ a solution of
guaiacum along with some ozonized body as a test for the colour-
ing matter of blood, but little was done in the matter until
Liman took up the process in 1863. His results were cor-
roborated by Casper's authority, and the process came into more
extended notice. Nevertheless, he employed as an ozonized
fluid oil of turpentine, inconvenient and unsatisfactory. Dr.
Day, in Australia, proposed to employ ozonized ether, and in
one case showed the efficiency of this process in a remarkable
manner. This was the first great step in advance, but Dr.
Taylor has made a still greater improvement by the introduc-
tion of peroxide of hydrogen, a substance both more cleanly,
more manageable, and more miscible with water. Further, if
we are to accept Dr. Schonbein's views, the substance which
is thus active is not ozone at all, but rather antozone. Now
most people are aware that many things may produce a blue
colour with guaiacum ; thus a favorite experiment is bringing a

1868.] Guy's Hospital Reports. 377

substance containing guaiacum in contact with the surface of
a freshly-pared potato^ when an intense blue is immediately
struck. This is owing to the presence of gluten. Gum does
the same thing, as does unboiled milk, but the colouring matter
of blood does not until an antozonide be added. These facts
have constituted the great stumbling-block in the way of this
test as performed by Dr. Liman, but Dr. Taylor by an im-
provement in the mode of manipulation has been able to
obviate the difficulty. It is true that many substances give
rise to the bluing of a solution of guaiacum, they do so
without the presence of an antozonide, but blood will not, and
it is by separating the addition of these two that the process has
acquired its greater value. Still, there is a difficulty, for sub-
stances may be present along Avith the colouring matter of
blood which would render guaiacum blue, and might thus, per-
haps, lead to the conclusion that no blood was present when
there might be much.

Dr. Braxton Hicks and Mr. Bankart send a paper containing
an account of the dissection of two acephalous monsters.
This subject is full of interest, as it opens up a very important
point : how does the blood circulate in these beings, seeing that
they have no head, heart, lungs, or liver ? It is suggested that
the blood may be driven through the two bodies, if in twins, by
the action of the heart in one of them, provided their vessels
anastomose in the placenta, but this, of course, remains to be
proved. The distribution of the remains of the vascular
system is curious. In the one the intestine was extremely
imperfect, in the other not so much so. Two others still
remain for dissection, which these gentlemen intend to describe
before giving any conclusions with regard to the interesting
points just mooted.

Mr. Birkett next gives two cases of intestinal obstruction of
a very complicated character ; in the one there was intus-
susception of the transverse colon along with an irreducible
omental hernia in the scrotum. The other was intussusception
of the ileum, the patient being in the house at the time suffer-
ing from a simple surgical complaint. In the former case, the
man had laboured under hernia for a very long time, but when
the worst symptoms of intestinal obstruction appeared, there
was no paiu associated with this protrusion, neither was there
much pain caused by pressing on the abdomen. Still it was
deemed advisable to perform an operation, as a small knuckle
of intestine might be lodged behind the epiplocele. On opening
the sac nothing of the kind was discovered, and nine days after
the patient died with the seat of obstruction undiscovered.
After death, it was found that the transverse colon was invagi-

378 Reviews. [April,

nated into the descending colon, forming a mass about four and
a half inches long. In the second case, there was nothing to
account for the occurrence of intussusception except a saline
aperient taken for slight constipation ; the patient died on the
eleventh day. Her case was peculiar, inasmuch as diarrhoea was
present during the last three or four days of her life. This was
accounted for by the post-mortem examination showing a dis-
tinct line of demarcation between the descending and returning
portion of gut; the division was complete, so that the con-
striction was removed. A small slough in the peritoneum
existed just below this, and a dilated portion of the vitelline
duct which had remained was filled with the intestine. This
had probably been one of the causes of the original mischief.

In a second paper, Mr. Birkett discusses the statistics of the
result of operations for the removal of stone from the bladder,
performed at Guy's Hospital during the last ten years. He
gives, first, the total number of cases in which a surgical opera-
tion was performed; there were in all, males and females, 162.
Next, the results ; and here the question of age is seen to be
of vital importance. Of the 162, 103 were under 15, of whom
4 died; 30 under 50, of whom 7 died; and from 50 up-
wards 29, of whom 14 died. The operation of Aston Key that
is with the straight staff, and long scalpel was ordinarily per-
formed ; sometimes, however, median lithotomy was introduced.
Mr. Birkett remarks that henceforth the statistics of lithotomy
will appear much more unfavorable than in times past, so
many of the most promising cases being now selected for litho-
tomy ; but, on the other hand, no doubt the statistics of opera-
tions for the removal of stone will be improved, as many who,
formerly in dread of a severe and dangerous cutting operation,
put off applying for relief until the time for operation was
almost past, will now be induced to submit to the simpler
procedure at an earlier period. That this operation is not in-
variably favorable at its result, Mr. Birkett's statistics dis-
tinctly show, there being in twenty-five cases of lithotrity as
many as six deaths ; but these were all beyond middle age,
most died from intercurrent disease chiefly of the kidneys.
Twenty-six adults underwent lithotomy, of these fourteen were
cured and twelve died, mostly from disease of the kidneys.
Some of the patients operated on were not adapted for the
operation, which might partially account for the greater mor-
tality.

The only paper Mr. Durham contributes this year is on a
case of true haemorrhagic diathesis. The patient, a boy aged
three years and a half, was admitted labouring under stone in
the bladder, after having suffered from the symptoms four or five

1868.]

Guy's Hospital Reports. 379

months. His complexion was pale and clear, and his mother
stated that three of his brothers had bled to death on very
slight causes. Indeed, there was in her family a history of
this diathesis, but only in the males, not in the females. Not-
withstanding this warning, the symptoms were urgent, and a
painful death for the child was inevitable if no operation was
performed. So Mr. Durham, supported in this by his colleagues,
determined to cut into the bladder. During the operation little
blood was lost, and but slight oozing followed until after five
in the evening, when the child became rapidly blanched and
died by half-past eight, six hours after the operation. He had
earlier in life suffered from profuse bleeding from the gums.
This case is of the ordinary type ; but as Mr. Durham remarks
two distinct classes of cases have been termed those of the
hsemorrhagic diathesis, there are cases in which the patient
tends to sink under slight effusions of blood, the other where
copious haemorrhage has followed slight wounds or injuries.
To the latter the term should be restricted. We think, taking
everything into consideration, that Mr. Durham acted rightly
in operating. Under the circumstances, he had the chance of
permanently and completely relieving the child, and death was
inevitable were it not relieved.

Dr. Pavy writes on gastric erosion, that somewhat unac-
countable self-digestion of the stomach under certain circum-
stances, or, rather, the non-digestion of its walls under ordinary
circumstances. Hunter first drew attention to the phenomenon,
and held it to be a post-mortem change. In France, on the
other hand, Cruveilhier and Louis have set it down as the result
of vital action occurring during life, but were thereby led into
certain almost self-evident absurdities, as an extraordinary rapid
progress or a period of complete latency of all symptoms, as it is
well attested that people have been, indeed generally are, found
with those lesions after death, who up to that time had enjoyed
perfect health. Rokitansky would seem to incline to the same
view as the French observers ; but Carswell has taken the oppo-
site side, and done much to elucidate the nature of the process,
as did Mr. Wilkinson King, who showed that the lower portion
of the oesophagus was frequently implicated along with the
great cul-de-sac of his stomach, owing to a regurgitation of a
portion of the contents of that viscus. There can be no doubt
but that the great inducing agents of this gastric erosion are
something swallowed just before death to cause an unusual flow
of the gastric juice, and the maintenance of a temperature
about that of the living body after death has taken place. Still
gastric erosion may occur without the agency of food. Again,
Mr. Burns points out that the occurrence of such post-mortem

380 Reviews. [April,

appearances even in the intestines are not uncommon in young
children while suckling,, probably on account of the ready produc-
tion of lactic acid in their stomachs at that period. But it is
time we considered the causes whereby this chemical solution of
the stomach is prevented from occurring during life, this being the
most important part of Dr. Pavy's paper. As is well known, Dr.
Pavy strongly advocates the alkalinity of the blood as the great
means nature has provided for opposing the action of gastric
juice, but let us examine some of the other theories brought
forward. Pirst, John Hunter held that it was the " vital prin-
ciple" which prevented the living walls of the stomach from
being acted on by the gastric juice, but this view was readily
set aside by Bernard, who showed that the legs of a living frog
were speedily digested in the stomach of a dog, as did Dr. Pavy
with the tip of a rabbit^s ear. Bernard advanced the hypo-
thesis that perforation was prevented by a continual renewal of
the epithelium, which formed the lining membrane of the sto-
mach ; but to this Dr. Pavy demurred, for he was able to show
that if a piece of the mucous membrane of the stomach were
removed, that the tissues underneath were no more affected than
the parts still covered by epithelium. Again, he objects that
ulceration of the stomach is by no means uncommon, yet he
says we do not find that rapid perforation follows as a matter of
course. From a great number of experiments. Dr. Pavy was
induced to come to the belief mentioned above, viz, that it is
the alkalinity of the blood circulating in the walls of the organ,
which prevents these being acted upon and destroyed by the
acid gastric juice. As is well known, the walls of the stomach
are highly vascular, especially during digestion, when they
become gorged with blood. Then, again, the blood which
passes through the more superficial capillaries has already
passed close to the walls of the peptic follicles, and given
up the materials for the secretion of gastric juice; conse-
quently, says Dr. Pavy, the contents will then be more than
ordinarily alkaline. Further, Dr. Pavy states that the union
of the acid with pepsine is necessary Joy the production of a
prope^rly solvent menstruum, but the supply of the former from
the follicles is more or less intermittent of the latter from the
surfac^ tolerably constant. Hence the secretion from the
follicles is not truly solvent until it reach the surface where it
can be neutralized, and is most abundant just where there is
most alkaline blood to oppose its action. How, then, to account
for the digestion of the frog's limb and rabbit's ear, in both
of which alkaline blood is flowing ; yes, but in a very slow
stream and in comparatively speaking remote capillaries, whence
it is not capable of resisting the solvent action of the gastric

1868.] Guy's Hospital Reports. 381

juice. So also stopping the flow of blood in a dog's stomach,
and the addition of a small quantity of acid causes self-digestion.
We cannot say that we are convinced that Dr. Pavy^s explana-
tion is in all respects satisfactory, but we may safely admit
that it is the best yet advanced.

The last paper is by Mr. Bader, its subject being the human eye
in health and disease, as seen by the ophthalmoscope ; it is illus-
trated by two beautiful chromolithographs. In a former paper,
contributed to the volume of reports published in 1865, Mr.
Bader described the plan for interrogating the structures of
the eye by the direct method of ophthalmoscopy; he now
describes the indirect or ordinary method. We fancy that
both of these are fragments of lectures intended to be accom-
panied by demonstration at each step, which being impossible
in a printed work, somewhat detracts from their value'; still they
are good, and calculated to do good. Day by day the use of the
ophthalmoscope, as an aid to the diagnosis of cerebral and other
diseases, is becoming more manifest ; and consequently it is
becoming more and more imperative for every practitioner to
make himself familiar with the ophthalmoscopic appearances of
the eye in health and disease. Now it is a comparatively easy
thing with irides dilated by atropine, and with the patient's head
firmly fixed and all the other etceteras, to make out the condi-
tion of the optic discs, but it is evident that such arrangements
pretty well preclude the use of the ophthalmoscope in ordinary
practice, so that men should be trained to the use of the two
circular discs composing the portable ophthalmoscope. In pur-
suing this study, Mr. Bader's account of the normal structures
of the eye, their appearance, situation, and interpretation, will be
found of great use. We, however, entered so fully into this
subject in the last number of this Review that we need here say
nothing more with regard to it.

We regret to find no communications from Drs. Wilks, Old-
ham, and Habershon, nor from Mr. Poland.

Thus concludes a volume of the highest practical value, for
practicality is ever the great end held in view by the writers of
these reports. Of no paper can it be said that it is poor or bad.
Many are of a high degree of excellence ; it would be invi-
dious under such circumstances to say which we consider best.
The subjects treated are so diverse, that in forming such a
judgment one is too apt to be led away by one's favorite sub-
ject to the injustice of others. We, therefore, prefer to leave
this task to the reader, having in the preceding pages supplied
them with the means of coming to a tolerably correct conclusion.

82— XLI. 25

383 Reviews. [A.pril,

Review IX.

1. The Waste of Infant Life. By J. Brandon Curgenven,
M.R.C.S., &c. London, 1867. Pp. 16.

3. A Few Thoughts concerning Infanticide. By Mrs. M. A.
Baines. London. Pp. 8.

The importance of the subject, the waste of infant life^ can
hardly be appreciated too highly, whether we view it in relation
to national welfare or the social and moral condition of a
nation. A stationary population either from the births not
exceeding the deaths, or whatever the cause productive of
that result, may well excite alarm, as an indication, if not of
national decline, of national weakness. France, at the present
time, is supposed by many to be an example of the kind ; and
this its presumed condition has recently become the subject of
much discussion and anxious inquiry ; and as one of the strongest
proofs of the manner in which the evil is regarded, it is note-
worthy that the Abbe Hyacinthe not long ago addressed
crowded congregations of women in Notre Dame against the
practices conducive to the evil in question, that, indeed, affect-
ing, as he denounces " la vie nationale."

Mr. Curgenven, in the paper now before us, which was read
at a meeting of the health department of the National Asso-
ciation for the Promotion of Social Science, has given a deplo-
rable account of what he well designates " the waste of infant
life ;" and this, sad to think ! in our own country, with its vast
colonial possessions, and with so large a proportion of the
habitable earth unoccupied and uncultivated.

The statistics which he brings forward are of a very striking
kind, as illustrative of this waste. From the registrar-generaFs
report for 1864, it would appear that of children under five
years of age of the well-to-do class, the deaths are 11 per cent.,
whilst the agricultural standard is 20 per cent. ; of the chil-
dren fed by hand from 50 to 70 per cent. ; and of those under
charge of ignorant and negligent nurses, it is as high as from
60 to 90 ! In Normandy, we learn from a report of Dr.
Dennis-Dumont, of Caen, that whilst the mortality of infants
who have had the breast is 10 per cent., that of those fed by
the hand or bottle has reached 50 per cent. Nor is the evil of
improper alimentation and neglect confined to an excessive pre-
mature mortality ; inasmuch as it is demonstrated to affect and
vitiate the constitution of those whose lives are more or less
protracted. Thus, Dr. Routh found, of 150 children who had

1868.] Loss of Infant Life, 888

breast milk alone, up to the age of nine months, 63*6 per cent,
well developed, 23*3 per cent, developed in a medium degree,
14 per cent, badly developed ; of fifty children brought up by
hand, with no breast milk, 16 per cent, were well developed ;
twenty-six in medium degree, sixty-four badly; and, of 407
who had a small supply of breast milk from birth, with other
food, 26'8 per cent, were well developed, 36*3 in a medium
degree, 45*9 badly.

Of substitutes for the mother^s milk, one has lately been
announced "an artificial milk," prepared according to a for-
mula invented by Baron Liebig, which has raised expectation
very high as to its efficacy. What trial it has had in this
country we know not ; but we are sorry to find that in France
the results of its trial, in four instances, made by M. Depaul,
has been a failure, all four children dying, diarrhoea setting in
the day following the giving of the mixture. M. Guibourt,
Dean of the School of Pharmacy of Paris, denouncing this
artificial compound, in addressing the Academy of Medicine
remarked, after pointing out what he considered its defective
qualities : " Nous avons k notre disposition un produit naturel
qui resemble plus au lait de femme qu^un melange de lait de
vache, d^un restant de farine, d'orge germee, de lactate, de
butyrate, ou de bicarbonate de potasse; ^ c^est le lait de vache
lui-m^me." Adding : " on an average woman's milk contains
a little more water, more sugar, less cream and curd than cow's
milk ; now by skimming cow's milk, adding a little sugar and
a fifth of its weight of water, we obtain, as is well known,
what will replace the mother's milk better, far better, than any
artificial compound."i A proposition this, of the learned and
venerable professor, which has our cordial approval.

As to the causes of the great mortality of infants, they may be
summarised as ignorance, negligence, and vice. Mr. Curgenven
very properly asks, adverting to Government aid in the way of
prevention, " Why should the helpless infant receive less con-
sideration than the lunatic ? Let us hope that the time is not
far distant, when it will be no longer necessary to ask such a
question. That much may be accomplished to save infant life
is certain, and there is ample experience in proof. In France,
a good instance of the kind is afibrded ; whilst, where there is
neglect, the mortality rises, as in this country, to 60 and 80
per cent.; in Lyons, under the medical supervision and the
active labours of the Infant Life Protection Society, it is re-
duced to 20 per cent. The author gives other examples of the
kind, and also suggests certain measures to check the fearful
mortality of young life, all very deserving of attention. We

1 ' Journal de Medecine et de Chirurgie,* &c., Juillet, 1867, p. 293.

384 Reviews. [April,

would particularise them did our limits permit ; but this is
the less necessary, as his paper, no doubt, will be published in
extenso in the Proceedings of the Society before whom it was
read. We shall conclude with his summary, displaying the
mean cause of the great evil under consideration, appending the
recommendations of the Harveian Society for the prevention of
infanticide, which are so deserving of being acted upon, and on
that account of being well known.

" Summary. — In the year 1864, the number of inftints lost through
debility and low developmental power of the parents, especially
the mother, giving rise to still-births, premature births, and im-
perfectly developed infants, amounted to . . . . 32,950
Died of smallpox, under the age of fifteen .... 5,374
Died of dietic diseases and diseases of nutrition, under the age of five . 70,073
Died of acute diseases of the respiratory organs, under the age of five . 37,361
Died of hereditary and induced tubercular diseases, under the age of five 15,563
Died of hereditary syphilis, under the age of five . . . 1,191
Died of murder and manslaughter, under the age of five . . 192

162,794

The recommendations of the Harveian Society are the fol-
lowing :

" 1. That the registration of all births should be compulsory.

" 2. That all still-born children should be registered ; and that the
certificates of still-births should only be received from medical men
and certified midwives — a certified midwife to be a person who has
received instruction and a certificate of competency from a lying-in
hospital, or maternity establishment. That no still-born child should
be buried without a certificate,

" 3. That in cases of still-born children where neither a medical
man nor a certified midwife has been present, the Poor Law medical
officer of the district should make inquiry into the case, and, if he
see fit, acquaint the coroner, who may then hold an inquest as to the
cause of death.

" 4. That the registration of an illegitimate child in any other
name than that of its mother, when known, or the registering of an
illegitimate child as a legitimate one, should be punishable offences.

" 5. That the crime of infanticide should no longer be punishable
by death ; but that the recommendation of the Eoyal Commission
on capital punishments be adopted, and that the offence bo consi-
dered as murder in the second degree.

" 6. That evidence be no longer required of complete separation
from the mother — that is of entire live-birth — for conviction ; but
that it be held sufficient for the medical and other evidence to prove
that the child was alive during birth, and that it died from violence
or neglect.

" 7. That a single woman, certified by a medical man to be pregnant,
should be enabled to make a declaration of the father before a

1868.]

Loss of Infant Life. 385

magistrate, when there is reason to believe that he is likely to
abscond.

" 8. That any pregnant woman being destitute, should be at once
admissible into the workhouse by application, on or about the com-
pletion of the eighth month of pregnancy, on condition that she
should engage to remain in the house for at least four months after
the birth of the child, unless she can show clearly that, on leaving
before the expiration of that time, she has a reasonable prospect of
being able to support herself and child.

" 9. That after the period of four months has elapsed, the mother,
if a single Avoman, should be allowed to leave the infant in the work-
house ; and that the guardians be empowered to recover from the
mother in such cases a portion only of the sum required for the
maintenance of the child.

" 10. That the guardians should have the power to recover from
the father of an illegitimate child a weekly sum towards its mainten-
ance ; and that the legal process of recovery should be assimilated
to that for recovering the cost of maintenance of legitimate children
deserted and left chargeable to the parish. The committee consider
that the maximum sum which may be assessed on the father of an
illegitimate child should be raised from half-a-crown to five shillings
per week.

" 11. That laundries, or some other means of remunerative occu-
pation, be established in workhouses for the self-maintenance of the
mother during her stay therein.

" 12. That a classification of pregnant women and mothers should
be adopted in workhouses, whereby the respectable married and
single women should be separated from the vicious and more depraved
class in the maternity and nursery departments.

" 13. That for the rearing of children left in charge of the
guardians, a colonization system should be adopted similar to that
pursued by the Foundling Hospital, and to that followed under the
old Poor Law system.

" 14. That no person be allowed to take charge of an illegitimate
child to nurse who is not registered as a fit and proper person ; and
that she and the child, or children in her care, should be under super-
vision of the district Poor Law medical officer. Any person acting
as a nurse to an illegitimate child, and not being registered, should
be liable to a penalty, and penalties should be enforced in all cases
for neglect or ill-treatment. That no nurse should be allowed to take
charge of more than two children without the consent of the district
medical officer.

" 15. That no single or married woman should take the situation of
wet nurse whose child is not placed in charge of a person registered
as a dry nurse.

" 16. That a central authority or superintendent should be
appointed by the Poor Law Board to carry out the provisions in
regard to dry nurses, and to receive annual reports from the district
Poor Law medical officers on the state of the illegitimate children,
and of the efficiency of the nurses under their superintendence.

386 Reviews. [April,

" 17. That a register of dry nurses should be kept by the district
Poor Law medical officer ; and that certificates of fitness as regards
herself and her residence, signed by the district medical officer, and
also by the minister of the denomination to which she belongs should
be required of every nurse placed on the register.

" 18. That no infant or very young person be allowed to be
entered as members of burial clubs, or to become the subject of life
assurance.

" 19. That the establishment of Foundling Hospitals for the free
and indiscriminate admission of infants would be attended by bad
results.

" 20. In conclusion, the committee are desirous of expressing the
opinion that the following causes of illegitimacy, and indirectly of
infanticide require the attention of Government: — 1. The over-
crowding of the dwellings of the labouring classes in urban and
rural districts. 2. The custom prevailing in the south and west of
England and Scotland of public hiring of servants. 3. The gang-
system in agriculture. 4. The promiscuous lodging of the sexes
during hop-picking, harvests, cider-making, &c.

The ' Few Thoughts concerning Infanticide/ by Mrs. Baines,
a crime which appears to be increasing, are equally marked by
the good sense and the good feeling of the lady who has con-
tributed them; and we call attention to them the more
earnestly^ viewing tbem as the complement of the foregoing —
'^ the waste of infant life.^^

Limited as the space is to which Mrs. Baines restricts her-
self, the view she takes of this crying evil, one of the greatest
of the present time, is sufficiently comprehensive. She traces
it in part to its causes, and points out suggestively certain
means for its prevention.

One of the causes she considers to be the negligence and in-
diflFerence of the police. " It has been said (she remarks) of
the police with too much truth, that they think no more of
finding the dead body of a child in the streets than of picking
up a dead cat or dog •/' she very justly adding, that " the fre-
quency of the occurrence familiarises the public mind to the
offence instead of rendering it still more revolting.^' Another
cause which she points out is, that, besides the facilities which
exist for concealment, the lightness of the punishment awarded
on its discovery and conviction, should be kept in mind ; very
properly insisting that " the taking away of life, whether of an
infant or an adult, is murder in the sight of God ; and, per-
haps, the more heinous crime of the two is the laying hands
upon a little child, an act all the more cowardly and cruel, on
account of the helpless and inoffensive condition of the victim.^'

Of the suggestions proposed by this lady in the way of pre-

1868.] Loss of Infant Life. 387

vention, one is the offering of a reward for the detection of the
perpetrator in every case where now an open verdict is found of
''Found dead." Another, the selection of men of the medical
profession for the duties of coroner. A third, an increased
sense of responsibility on the part of medical practitioners who
give evidence in cases of child murder, so as not to aid the
escape of the criminal. A fourth, to check the abuse of
"Burial Clubs" by a greater attention to their proceedings;
with the enforcement of the registration of " still births," and
that of medical certificates in all cases of the kind. A fifth,
the licensing of midwives " even at a small fee, in order that
they may be put under authoritative supervision.''' A sixth,
that all persons offering themselves as " wet nurses,^' or '' dry
nurses,^' should be registered, and that nurseries should be
subject to the occasional visits of sanitary inspectors. Ano-
ther, and her last and most important suggestion, one founded
on a very humane consideration for the erring and to be com-
miserated women, the mothers of illegitimate children, is to
establish a ''refuge, lying-in hospital, in which there would be
the best prospect of preserving the life of the infants, and of
checking crime, and of reforming the culprit^' under those
softening influences which the care and nurture of her child
would impart to her, and which might be relied on in the
great majority of cases, as a means of holding her in a virtuous
course of life for the future ; a result which can scarcely be
looked for in those women who by force or choice are relieved
entirely from the duties and responsibilities of their maternity."

Mrs. Baines does not finish without making an appeal to
women in the higher walks of life, and pointing out the duty
incumbent on them to give their attention to the subject, and
especially not to give encouragement to profligacy by showing,
wiien in wards, a preference for " single women'' for the office
of wet nurse.

The importance of the subject, and the interest which we have
no doubt our readers will take in it, and as we would hope their
willingness as far as lies in their power to aid in carrying into
effect the excellent design which Mrs. Baines advocates, have
tempted us to be more minute in our notice of it than so short
a pamphlet would seem to warrant. Let us not forget the
value of the life of the infants as regards the prosperity of the
nation. In France, as already pointed out, we see how great
is the apprehension now entertained of a failing population,
and this mainly from the extraordinary proportion of deaths in
infancy, an excess let it be well kept in mind very much con-
nected with illegitimacy. In Paris, it would appear that one
in ten of the births are illegitimate ; and that of the infants

388

Revietvs.

[April,

put out to nurse in the different provinces, from the age of one
day to one year, the mortality varies from 90*50 per cent, to
58-56: this according to "le bilan mortuaire" for 1860. The
particulars are the following :

Loire Inferieure

. 90-50

Seiue-Inferieure

. 87-36

Eure

. 78-12

Calvados

. 78-09

Aube

. 70-27

Seine-et-Oise

. 69-23

Cote d'Or

. 66-46

Indre et Loire

. 6216

Manche .

■__ -VT-

^_ Xl_ -

. 58-66

It is added, that in Normandy, the proportion is from 73 to
87 per cent, " grace a I'alimentation dite au petit pot absurde
et funeste routine qui fait decroitre d^une facon effrayante la
population rurale de la vieille Normandie." Well may the
editor of the journal from which we make this extract,^
say, "la mortalite des enfans est non seulement aujourd'hui
une question d'humanite, mais encore una veritable question
d'etat."

Review X.

The Physiology and Pathology of the Mind. By Henry
Maudsley, M.D. (Lond.) London. 1867. 8vo. Pp.443.

Mental Pathology and Therapeutics. By W. Griesinger, M.D.
Translated from the German, by C. Lockhart Robertson,
M.D., and James Rutherford, M.D., for the New Syden-
ham Society. London. 1867. Pp. 530.

Compared with France and Germany, England has been far
less fruitful in works on mental disorder; and until the appear-
ance of Bucknill and Tuke's treatise, English psychiatry had no
adequate exponent. The great work of Esquirol constituted
the text-book on mental maladies both on the continent and in
this country ; indeed, it will never lose its value as a grand
repertory of facts and observations conveyed in a lucid and
interesting manner. But the foundations laid by Esquirol and
his distinguished predecessor, Pinel, having been enlarged and
built upon by numerous disciples, ceased to represent the
growing edifice of psychiatry, and it therefore became necessary

^ See • Journal de Medicine et de Chirurgie,' November, 1866, where the subject
is discussed at some length.

1868.] Psychological Medicine. 389

that others shiould attempt its portraiture. This has been done
in the several principal countries of Europe, and with much
success ; for whilst we can point with much satisfaction to the
English treatise above mentioned, our neighbours in France and
Germany can take credit for the works of Morel and Griesinger.
Not, indeed, that the works named are the only successful pro-
ductions, for various others of high merit have appeared from
time to time ; but they are simply cited as the best known text-
books in each country mentioned.

M. Morel has not found an English translator, for the reason,
no doubt, that almost all those who desire to peruse his volume
can do so in the original language, and that publishers have
little inducement to charge themselves with the production of
translations of French works. The selection of Griesinger's
treatise by the Council of the Sydenham Society for translation
into English may be assumed as an indication of the high
estimation in which it is held in Germany. It has further
found a French translator, and the statement put forward in
the preliminary note by the authors of the English version, may
be accepted generally, viz., that "Professor Griesinger is
essentially the representative and the acknowledged leader of
the modern German school of medical psychology."

About the same time as the appearance of Griesinger's book
in an English dress, the original and notable treatise by
Dr. Maudsley was published, which, we apprehend, will claim
for itself as high a consideration as even the well-known
German production, and advance the credit of English psycho-
logical medicine. The two works are indeed constructed on
different models ; that by Griesinger abounds much more in
detail and in practical matter, and is altogether more of a text-
book for the student than the volume by Dr. Maudsley, which
is especially calculated to attract the psychologist by its bold
and original doctrines of mental physiology. Nevertheless
there is a necessary approximation in many matters discussed
which will enable a comparison to be instituted between these
two treatises. Both writers, in the first place, agree in this,
that they belong to the somatist school of psychologists, as
opposed to the spiritualist. As physiologists and pathologists
they profess no knowledge of a spiritual or immaterial essence,
no acquaintance with the laws governing the existence of such
an essence, and consequently cannot recognise mental disorders
as symptoms of a lesion of some sort of entity in common parl-
ance vaguely called ''i\\e. mind."

As apprehended by Dr. Maudsley, the term "mind" is a
general one, " acquired by observation of and abstraction from
the manifold variety of mental phenomena It is a meta-

390 Reviews. [April,

physical abstraction that has been made into a spiritual entity."
(p. 40.) It is of a true subjective character, and when viewed in
its scientific sense like other natural forces, is appreciable only
in the changes of matter which are the conditions of its mani-
festation. In other words, it is no independent source of power
and self-sufficient cause of causes ; and, though the highest
development of force, ministered to by all the lower natural
forces, it is at the same time the most dependent of all of them.
In short, physiologically, mind expresses the marvellous energy
arising from the metamorphosis of nerve matter.

In fact, both Drs.Maudsley and Griesinger admit only a material
cause for insanity, and seek for indications of disturbance in
the normal metamorphosis of cerebral matter to account for the
aberrant mental phenomena. Yet both are driven to the admis-
sion, that physical appearances in the nerve-tissue are fre-
quently absent, or otherwise inappreciable in the bodies of
those dying insane ; and that, even where such appearances are
notable, their connexion with, or their part in producing the
insane state, is not demonstrable. It was this failure to demon-
strate the material cause of mental disorder in the brain-mass
that afforded the members of the spiritualistic school their best
argument. But, as Dr. Maudsley rightly urges, we at present know
nothing of the intimate constitution of nerve element and of the
mode of its functional action. Hence

" "Where the subtlety of nature so far exceeds the subtlety of
human investigation, to conclude from the non-appearance of change
to the non-existence thereof would be just as if the blind man were
to maintain that there were no colours, or the deaf man to assert
that there was no sound. Matter and force are necessary coexistents,
and mutually suppose one another in human thought ; and to speak
of change in one is of necessity to imply change in the other. . . .
And there are numerous facts available to prove that the most
serious modifications in the constitution of nerve element may take
place without any knowledge of them otherwise than by the corre-
lative change of energy." (Pp. 367, 368.)

Similar considerations are adduced by Griesinger and en-
larged upon. But he also asserts generally that the brains of
lunatics are only exceptionally and apparently healthy, although
indeed a knowledge of the intimate connexion between the kind
of alteration met with and the form of psychical disease has not
yet been arrived at (op. cit., p. 410).

In fine, nerve physiology and nerve pathology are in their
infancy, and much advance in them may yet be looked for. Dr.
Maudsley is encouraging in this matter. His chapter on the
pathology of insanity is largely occupied with nervous physiology
for the purpose of showing the progress towards the under-

1868.] Pychological Medicine. 391

standing of nerve-force in sickness and in health, accomplished
recently by the researches of Helmholz, Lister, and others.
The successful microscopic investigations of Mr. Lockhart Clarke
on various nervous maladies, which had hitherto been, in
respect to their pathology, on a par in obscurity with mental
disorders, might also be adduced to encourage inquirers in the
search after the physical causes of mental disturbance.

Further, the two authors follow a similar plan in introducing
a section on mental physiology or psychology. Moreover, in
the case of Griesinger, a chapter of " preliminary anatomical
observations^^ is added. This chapter is, in our opinion, uncalled
for. The student of mental disorder may be presumed, if he
has any right conception of the proper order of his studies, to
come to his work v/ith at least as rude an outline of the anatomy
of the brain as Griesinger undertakes to place before him. But,
apart from its redundant character, this chapter is particularly
obscure in its descriptions, for which we apprehend the trans-
lators must be called to account. Many sentences and para-
graphs are clumsy and ungrammatical, and consequently con-
fusing to the reader ; and in several instances German anatomical
terms are left untranslated — unexpressed by their English
equivalents.

Whilst on this subject of the translation of Griesinger's
volume, and the manner of its execution, we may observe once
for all of the whole performance, that it partakes of the faults
too common in translated works — the idiom of the original
permeates the entire composition, and introduces confusion and
grammatical inaccuracies into it. Moreover, the peculiar use of
the words ^'wilF' and '^shalP^ betrays the nationality of one at
least of the translators to be to the north of the Tweed. It
would seem, indeed, that the translators are not quite* easy in
their minds concerning the manner in which they have per-
formed their task, and particularly in the rendering into English
the more strictly psychological chapters ; for, after observing in
their prefatory note, that they have aimed at a literal trans-
lation, and have in this respect followed the example of
Griesinger's French translator, they tell us that " it was soon
evident that any attempts at a more liberal rendering of these
difficulties would only farther obscure — possibly contravene — the
author's meaning,^' his " medico-metaphysics being not easily
understood even in German.''

To return now to the chapters on mental physiology and
metaphysics in the two volumes before us. In the matter of
these Dr. Maudsley is much more original and important, besides
being vastly more lucid than ^Griesinger ; consequently, our
annotations on mental physiology will be based on the English

592 Reviews. [April,

author. Indeed, we may hazard the opinion, that Griesinger
will not perpetuate in the forthcoming neAV edition of his work,
the long and abstruse metaphysical chapter included in the
volume now before us. For, in an introductory lecture given at
Berlin in 1866, translated and published by Dr. Sibbald, in the
'Journal of Mental Science for January, 1867^ (p. 475), he
referred to psychiatry as no longer to be entered " through the
dark portals of metaphysics,^' and added, that '' in Germany the
time has quite passed away when psychiatry could be developed
from a specially philosophico-psychological point of view,'^ and
that predisposition to insanity is no longer to be conceived of as
psychopathic but as neuropathic.

This being admitted, a valid excuse is afforded us for not wading
through Griesinger's metaphysical dissertation on the mental
processes for the purpose of presenting an analysis of it in these
pages. And we may go further, and recommend the would-be
student of psychiatry to avoid the " dark portals of metaphy-
sics^' therein interposed as likely only to darken knowledge and
confuse the understanding, and to follow Griesinger's advice, to
seek both work and fame in etiology, diagnosis, prognosis, and
therapeutics. (Lecture, op. cit,, p. 476.)

One half of Dr. Maudsley's treatise is occupied with the
physiology of mind ; and it is this portion, we have no
hesitation in saying, that will most arrest attention. The
author's first chapter is, " On the Method of the Study
of Mind." In it he asserts the inadequacy of the in-
terrogation of self-consciousness — the method of investi-
gation commonly pursued, to the construction of a true
mental science or an inductive psychology. He shows that
such interrogation is not only not reliable as to the information
afforded* by it, but also impotent as reaching only to states of
consciousness and not to states of mind (p. 11). For conscious-
ness is not co-extensive with mind; the two terms are not
synonymous, and the existence of mind does not necessarily
involve the activity of mind. At the same time, everything
which has existed with any completeness in consciousness is
preserved as a residuum, which may reappear in consciousness
at some future time. To these residua it is that memory owes
its existence. The association of ideas is, besides, independent
of consciousness, as is likewise the assimilation or blending of
similar ideas, or of the like in different ideas, by which general
ideas are formed. Lastly, the brain responds as an organ of
organic life to the internal stimuli which it receives uncon-
sciously from other organs of the body.

The brain has a life of relation ; a, with external nature
through the senses; and b, with other organs of the body by the

1868.] Psychological Medicine. 39^

medium of the nervous system. It has also a life of nutrition —
an organic life, for its building up and repair, which, as a
process, is unattended with consciousness.

"In this, its true organic life, there is a nutritive assimilation
of suitable material from the blood by the nerve-cell, and a restoration
thereby of the statical equilibrium after each display of energy.
The extent of nutritive repair and the mould which it takes must
plainly be determined by the extent and form of the waste which
has been the condition of the display of function: the material
change or waste in the nervous cell, which the activity of an idea
implies, is replaced from the blood, according to the mould or pattern
of the particular idea; statical idea thus following through the
agency of nutritive attraction upon the waste through functional
repulsion of active idea. . . . The deep basis of all mental action
lies in the organic life of the brain, the characteristic of which in
health is, that it proceeds without consciousness. He whose brain
makes him conscious that he has a brain is not well, but ill ; and
thought that is conscious of itself is not natural and healthy thought.
How little competent, then, is consciousness to supply the facts of
an inductive science of mind!" (Pp. 22, 23.)

To build up this science. Dr. Maudsley adopts the objective
method, and therefore appeals to the study — 1, o^ physiology ; 3,
of the jo/aw of development of mind, as exhibited in the animal, the
barbarian, and the infant; 3, of the degeneration of mind as
seen in idiocy and insanity ; and 4, of the progress or regress
of the human mind as exhibited in history. In employing this
method he would have us divest ourselves of the popular error,
that the function of the mind is that of a passive mirror, simply
to reflect natm'al phenomena, and to remember that every state
of consciousness is a developmental result of the relation between
mind and the impression of the subject or object,

" That the development of mind, both in individuals and through
generations, is a gradual process of organization — a process in which
nature is undergoing her latest and most consummate develop-
ment." (P. 31.)

From the author's point of view it follows, therefore, that
what in a physiological sense is called the* mind, is the mar-
vellous energy, which cannot be grasped and handled, pro-
ceeding from cerebral activity. Cabanis represented mind as
the secretion of the brain, as the bile is that of the liver ; but
Maudsley objects to this analogy as crude and erroneous, since
mind is not the material, tangible product of the brain as the
bile is of the liver; but, as just said, the impalpable organized
result of its activity, its true secretion being the products of
nerve waste.

394 Reviews. [April,

In pursuance of the physiological method of studying mind,
Dr. Maudsley in his second chapter gives a sketch of the pro-
gressive differentiation of the nervous system in the various
tribes of animals, commencing with the lowest, noting at the
same time the advancement in nerve function attending an
increasing complexity. Reaction shown to outward impressions
under the simplest form of reflex action, is the lowest expression
of nervous function. But further on in organization, sensation
and motor reaction to sensation exist, where sensory ganglia
connected with the origin of nerves are discoverable, but as yet
no brain proper. And now for the first time can the reaction
be sensorial. When a true brain appears, it is as supplementary
and secondary in order of development, although primary in
dignity. Its function also is to be concluded secondary in
relation to that which the primary constituents or sensory
ganglia fulfil.

" The impressions received by the sensory centres when they do
not react directly outwards, as they may do where hemispheres
exist, and as they must do where hemispheres do not exist, are in
fact passed onwards in the brain to the cells which are spread over
the hemispheres, and are there further fashioned into what are
called ideas or conceptions. Here then we come to another kind of
sensibility, with its appropriate reaction, to which a special nervous
centre ministers ; and it is known as perception, or, more strictly,
ideational perception. The hemispheres have a special sensibility of
their own to the ideas fashioned in them (but not to pain, as have
the sensorial ganglia) ; and those ideas may have other particular
emotional qualities, as pleasurable or painful." (P. 47.)

Dr. Maudsley recognises in man four nervous centres : —
I, primary or ideational, situate in the convolutions of the
hemispheres; 3, secondary or sensational, in the sensory ganglia
of the brain ; 3, tertiary or reflex, mainly in the grey matter of
the spinal cord ; 4, quaternary or organic, existing in the sym-
pathetic system.

The relations and mutual interdependence of these several
centres are set forth in the following quotation :

" Each distinct centre is subordinated to the centre immediately
above it, but it is at the same time capable of determining and main-
taining certain movements of its own without the intervention of its
supreme centre. The organization is such that a due independent
local action is compatible with the proper control of a superior
central authority. The ganglionic cell of the sympathetic co-
ordinates the energy of the separate elements of the tissue in which
it is placed, and thus represents the simplest form of a principle of
individuation ; through the cells of the spinal centre the functions
of the different organic centres are so co-ordinated as to have their

1868.] Pychological Medicine,

subordinate but essential place in the movements of animal life —
and herein is witnessed a further and higher individuation; the
spinal centres are similarly controlled by the sensory centres, and
the sensory centres in their turn are subordinate to the controlling
action of the cerebral hemispheres, and especially to the action of
the will, which, properly fashioned, represents the highest display of
the principle of individuation. The greater the subordination of
parts in an animal, the higher and the more perfect it is,"

Evidence for the location of different functions in different
nerve- cells^ .in groups of such^ and in larger masses as ganglia^ is
obtainable from anatomy, from experiments upon animals, and
from physiological and pathological researches; and it is only
when this evidence is duly recognised, that the groundwork of
a true conception of the relations of mind and the nervous
system can be attained.

"The characteristic of living matter is the complexity of com-
binations and the variety of elements in so small a compass that we
cannot yet trace them ; and in nervous tissue this complication and
concentration is carried to its highest pitch. Nervous tissue with
its energy is, therefore, dependent for its existence on all the lower
kinds of tissue that have preceded it in the order of development :
all the force of nature could not develope a nerve-cell directly out of
inorganic matter. The highest energy in nature is really the most
dependent ; in the fact that it is so dependent, that it implicitly
contains the essence or abstraction of all the lower kinds of energy,
lies the reason of the powerful influence which it is able to exercise
over all the lower forces that are subservient to its evolution. As
the man of genius implicitly contains humanity, so nervous element
implicitly contains nature." (P. 61.)

In the third chapter the physiology of the spinal cord, as
containing the centres of reflex action, is lucidly and philo-
sophically handled, and upon the right apprehension of the
arguments and illustrations in this portion of the work will
greatly depend the understanding of the contents of the follow-
ing chapters of mental physiology. It is abundantly evident
that the spinal cord is not only a centre of irregular reflex
movements, but also of co-ordinate or so-called designed actions;
and, consequently, the design apparent in an act does not neces-
sarily witness to the co-existence of will, forethought, or con-
sciousness. Moreover, not only is the spinal cord the centre of
co-ordinate action which has been implanted in its original
constitution, but also of similar action, which has been acquired
and matured through individual experience.

" Like the brain, the spinal cord has, so to speak, its memory.
. . . With the display of energy there is a coincident change or

396 Reviews. [Aprils

waste of nervous element ; and although a subsequent regeneration
or restoration of the statical equilibrium by the quiet process of
nutrition takes place, yet the nutritive repair, replacing the loss
which has been made, must plainly take the form or pattern created
by the energy and coincident material change. Thereby the definite
activity is to some extent realised or embodied in the structure of
the spinal cord, existing there for the future as a motor residuum,
or as, so to speak, a. potential or abstract movement ; and accordingly
there is a tendency to the recurrence of the particular activity — a
tendency which becomes stronger with every repetition of it, until it
assumes the character of an acquired faculty in the cord, and
represents the secondary or acquired automatic acts as described by
Hartley." (P. 67.)

The phenomena of such acquired acts serve to exhibit the
true mode of origin^ and the nature of Avhat is called design in
many actions of animals ; and particularly when it is also
remembered, that the acquired faculty of the parent animal is
sometimes distinctly transmitted to the progeny as a heritage,
instinct, or innate endowment.

We shall not follow the author in the analysis given of the
causes which affect the functional activity of the spinal cord,
but proceed to notice the physiological doctrines of the fourth
chapter, on the '' Secondary Nervous Centres or Sensory
Ganglia; Sensorium Commune,^' represented by the optic
thalami, the corpora striata, the corpora quadrigemina, and the
ganglionic nuclei of the nerves of the different senses. These
centres give rise to a class of reflex movements of their own —
sensori-motor, for the most part acquired and perfected by repe-
tition, just as in the case of the cord, by the medium of a power
akin to memory. Of this class are, consensual acts, and most
of the instinctive actions of animals. Sensation is not an
inborn faculty of constant quantity, but, in the case of each
sense, is a gradually organized result matured through expe-
rience. The mind

"Implies a plastic power ministering to a complex process of
organization in which what is suitable to development is assimilated,
what is unsuitable is rejected. By the appropriation of the like,
in impressions made upon the senses we acquire. . . A general
or abstract sensation, which exists latent or potential, as a faculty of
the sensory centres, and on the occasion of the appropriate impres-
sion, renders the sensation clear and definite. . . . Coinci dentally
with the assimilation of the like in impressions, there is necessarily a
rejection of the unlike, which, being then appropriated by other
cells, becomes the foundation, or lays the basis, of the faculty of
another sensation, just as nutrient material which is not taken up
by one kind of tissue element is assimilated by another kind. In
the education of the senses, then, there takes place a differentiation

1868.] ' Psychological Medicine. 397

of cells ; in other words, a discernment as well as an improvement of
the faculty of each kind of sensation by the blending of similar
residua. There is an analysis separating the unlike, a synthesis
binding the like ; and by the two processes of differentiation and
integration are our sensations gradually developed." (Pp. 92, 93.)

Sensori-motor acts may be innate or acquired ; those of the
latter class are in man the most important, and are, or otherwise
are not, accompanied by consciousness. Moreover, the reaction
of the motor ganglia in the sensorium commune, whether de-
signed or undesigned, co-ordinate or irregular, may be excited
not only by impressions conveyed to them (whether from with-
out or from within the body) by diflFerent nerves, and by the
so-called organic stimuli, but also by a stimulus descending
from above (the higher nervous centres), either in the shape of
an idea or of an impulse of the will.

" Thus the will is entirely dependent for its outward realisation
upon that mechanism of automatic action which is gradually organised
in the subordinate centres ; the will cannot at once execute success-
fully a new movement, nor can it execute any movement without a
guiding sensation of some kind : the cultivation of the senses and
the gradually effected special adaptation of their reactions are neces-
sary antecedents, essential pre-requisites, to the due formation and
operation of will." (P. 98.)

After a summary of the causes of disorder of the sensory
ganglia. Dr. Maudsley enters upon the consideration of
the cerebral hemispheres regarded as the ideational nervous
centres ; as centres of independent reaction, wherein ideas may
arise and produce movement, without volition, or actually in
opposition to it, and without consciousness. Although the
author recognises the existence of innate acts in connection
with the spinal cord and with the sensorium commune, he
rejects in toto the notion of innate ideas contemporary -with
birth. The formation of an idea is, he urges, an organic
evolution.

" The cells of the cerebral ganglia, in reality, idealize the sensory
perception ; grasping that which is essential in them, and suppressing
or rejecting the unessential, they mould them by their plastic faculty
into organic unity of an idea, in accordance with fundamental laws.
Every idea is thus an intuition, and implicitly comprises far more
than could be explicitly displayed in it."

It is a mischievous error to treat of an idea as an actual

entity, and to regard it as having a uniform quantitative and

qualitative value ; inasmuch as any given ideas will always have a

different value in persons at different stages of cultivation or

82 — XLi. 26

898 Reviews. [April,

civilisation^ and even in the same individual at diflferent periods
of life and under the influence of culture and experience.

The following account is given of the nature of the so-called
fundamental ideas and universal intuitions :

" Because all men have a common nature, and because the nature
hy which all men are surrounded is the same, there are developed
certain ideas which have a universal application, but they are nowise
independent of experience. . . . But their absolute truth, as
expressions of certain fundamental relations between man and
nature, is only guaranteed by the assumption of an unchanging
persistence of these relations;" a new sense conferred upon him
would entirely change the aspect of things, and render necessary a
new order of fundamental ideas."

But ideas when active display their energy by reflex action
in various directions. Thus, when downwards upon the motor
centres and muscular system, they give rise to ideo-motor
movements, which may take place not only without any inter-
vention of the will, but also without consciousness. Again,
when exerted downwards upon the sensory ganglia their energy
is concerned essentially in the formation of clear conception
and representation, and under certain circumstances may even
give rise to illusions and hallucinations.

" The excitation and cultivation of the sensorial cells are necessary
antecedents in the order of mental development to the activity of
the ideational cell ; and the ideational cell in turn effects its complete
function in the formation of a distinct conception by reacting down-
wards upon the sensory centres."

An idea may also operate upon the functions of nutrition
and secretion ; and, lastly,

" As, in reflex action of the spinal cord, the residual force which was
over and above what passed directly outwards in the reaction tra-
velled upwards to the sensorium commune and excited sensation ;
and as in sensori-motor action the residual force which was over and
above what passed outwards in the reaction travelled up to the
cortical cells, and gave rise to idea ; so, in ideational action, the
force which does not pass, or the residual force which may be over
and above what does pass, immediately outwards in the reaction,
abides in action in the cortical centres, and passes therein from cell to
cell. . . . This communication is what does take place probably,
when one idea calls up another by some association, itself disap-
pearing in the act,"

Further, not only may the force be transferred from cell to
cell, but it may also be transformed, and then the tension of
the particular cell, or the idea for the moment active, is attended
with consciousness.

1868.] Psychological Medicine. 399

" That there may be consciousness of an idea, it is necessary not
only that its excitation reach a certain intensity, but that the whole
force of it do not pass immediately outwards in the reaction."

In harmony with this hypothesis, Dr. Maudsley defines
Reflection

" As, in reality, the reflex action of the cells in their relations in the
cerebral ganglia : it is the reaction of one cell to a stimulus from a
neighbouring cell, and the sequent transference of its energy to
another cell — the reflection of it. Attention is the arrest of the
transformation of energy for a moment — the maintenance of a par-
ticular tension."

The like mechanical and physiological hypotheses are em-
ployed in each of the remaining chapters of this first part of
Dr. Maudsley^s work, devoted to the consideration of the emo-
tions, of volition, of the motor nervous centres — motorium com-
mune, and of memory and imagination. A self-conservative
impulse is " immanent in all living organic elements,^' and an
essential condition of their organic nature.

" Such reaction of organic element is as natural and necessary as
the reaction of any chemical compound, because as much the con-
sequence of the properties of matter thus organically combined. When
the stimulus to a hemispherical nerve-cell is not in suflicient force
to satisfy the demands of the latter, — when, in fact, it is inadequate,
— then there is the manifestation of its affinity or attraction by the
nervous centre, an outward impulse, appetency or striving, which,
again, as it occurs in consciousness, is revealed to us as desire,
craving, or appetite."

But consciousness is only a something superadded —

" The striving after a pleasing impression, or the effort to avoid a
painful one, is at bottom a physical consequence of the nature of the
ganglionic cell in its relation to a certain stimulus ; and the reaction
or desire becomes the motive of a general action on the part of the
individual for the purpose of satisfying a want or of shunning an
evil."

Volition is the subject of the seventh chapter. The
teaching of this chapter is conveyed in a quotation from
the French edition of Spinoza placed at its head, and which
may be termed its text. " It is a delusion," says Spinoza, " on
the part of mankind to fancy themselves free agents. What
grounds are there for such an opinion ? Only that they are
conscious of their actions and ignore the causes which determine
them. The idea that men are in possession of their liberty,
arises therefore from the circumstance that they are ignorant

400 Reviews. [April,

of the cause for their actions, for to say that these are dependent
on their will, is simply to make use of words without meaning.
In fine, all that I can say to those who believe that they can
speak, or maintain silence, in a word, can do what they list by
virtue of an unfettered decision of the mind, is that they are
dreaming with their eyes open."

Dr. Maudsley enlarges upon and illustrates this text. The
will is no concrete reality ; it is nothing but the desire or
aversion (physically an available or liberated force, consequent
on the communication of activity from one cell or group of cells
to others in the hemispheres), sufficiently strong to produce an
action after reflection or deliberation. The many voluntary
actions recognised proceed from dififerent nervous centres, and
the will difi'ers greatly in quantity and quality according to the
extent and character of the association of ideas that paust neces-
sarily precede its evolution.

" If, then," argues Maudsley, " the final reaction after deliberation,
which we call will, is, like other modes of reaction of nerve element
previously described, a resultant of a certain molecular change in a
definitely constituted nervous centre, then all the design exhibited
in any given act of will must, like the design displayed in the function
of the spinal cells, or the cells of the sensory centres, be a physical
result of a particular intimate constitution or organization of nervous
matter. In other words, the act of will, which is the final expression
of a process of reflection, must needs contain a conception of the end
desired — such a conception as has been determined by the nature of
the reflection ; the conception of the result, or the design, in the
act of will constituting, in fact, the essential character of the par-
ticular volition," and being also a physical necessity. (P. 150.)

The particular volition, and whatever it contains, whether of folly
or design, is considered to be a product of the organised residua of
all former like volitions, excited into activity by the appropriate
stimulus. The design manifest in a mental act is not a power
which transcends or anticipates experience, but is actually con-
formed in its genesis to experience. The more cultivated the
mind, and the more varied the experience, the better developed
is the will and the stronger its co-ordinating power over the
thoughts, feelings, and actions. In short, the will is looked
upon as an insensibly organized result of varying value, yet as
being the highest mode of energy of nerve elements, its purpose
is to control the inferior modes of energy by operating down-
wards upon their subordinate centres.

We cannot follow the author in the examination of the power
of the will over the movements of the body, and over mental
operations, and of its relations to the emotions, but must hurry
on to analyse his views respecting the motor nervous centres, as

1868.J Psychological Medicine. 401

set forth in the eighth chapter. Those centres, as the region of
motor residua, he would speak of collectively as the motorium
commune, and generically as the region of actuation, inasmuch
as they contain the powers or faculties 'through which the
activity generated reacts upon the muscular system. In mental
action, in truth, the whole bodily life is comprehended, and
every muscular intuition has its due place and influence in our
mental life ; body and mind being separable by no barrier, and
mind the special occupant of no one part of the body. Between
the stimulus and the ensuing reflex action definite motor
intuitions intervene, either attended by consciousness or not.
Where no consciousness obtains, it is evident that the motor
residua have been definitely and adequately organized in the
proper motor centres, so that far from design implying con
sciousness, this last vanishes when the design is firmly fixed in
the nature of the nervous element.

The concluding chapter of this first section of the volume is
on Memory and Imagination. An extract from Darwin's
' Zoonomia' here forms the text, according to which the ordinary
conception of memory as the transference of images to a reci-
pient medium, as pictures are portrayed on the retina, is both
incorrect and inadequate.

" The organic registration of the results of impressions upon our
nervous centres, by which the mental faculties are built up, and by
which memory is rendered possible, is the fundamental process of
the mental life."

Memory is an organized product, and imagination is due to a
similar organic process to that by which like residua are
blended, and general or abstract ideas formed. There are no
actual existences answering to our most abstract ideas, which
are, therefore, so far new creations of the mind, and, when
rightly formed, are valid and real subjective existences that
express the essential relations of things.

There can be no memory of what we have not had experience
in whole or in part; and imagination, therefore, being dependent
on memory, can be productive only as to form and reproductive
only as to material.

" The productive or creative power of imagination, which seems at
first sight to be irreconcileable with knowledge gained entirely
through experience, is then at bottom another, though the highest,
manifestation of that force which impels organic development
throughout nature ; and the imagination of any one creates truly, or
brings forth abortions and monstrosities, according as tlie mind is
well stored with soimd knowledge, and has true concepts, or as it is
inadequately furnished with knowledge, or is furnished vdth erro-

402 Reviews. [April,

neous concepts — according, in fact, as the individual is or is not in
harmony with nature." (P. 186.)

With this extract we conclude our sketch of the principal
doctrines concerning . mental physiology advanced by Dr.
Maudsley. Those doctrines cannot be examined and be treated
with indifference or contempt by the thoughtful and unpre-
judiced; although we imagine some will sniff in them rank
materialism, and scout them as unworthy of discussion. This
is not the place, nor is it our object in this review to discuss
recondite problems in psychology, or to reconcile the hypotheses
of Maudsley with the commonly accepted metaphysics of the
day, or again to attempt to disprove them. It is enough for
our purpose to give an abstract of his doctrines considered as
physiological deductions.

To summarise the hypotheses advanced : — Everything in
mind, — every mental operation or result, is referred to organi-
zation, and no force other than nervous force is recognised.
Mental phenomena result from the functional activity of nerve-
cells called forth by impressions from without or from within,
and modified and directed by the residua of impressions, con-
cepts and ideas heretofore existent. The like mental action
exists in varying extent in all animals ; it is improveable by
hereditary transmission, and some of it is innate. Mind is no
individual entity, but an organic product of ever variable
quantity and quality, modified by surrounding nature and by
the circumstances of life, and progressively evolved from the
reciprocal action of external objects and events, and of the
activity of nerve matter, in such a way that the building up of
the mind is an act of the entire body, with which indeed mind
is conterminous.

It is indeed difficult to conceive the aerial, imponderable, the
most varying and varied, the most subtle and rapidly formed
and executed, and marvellous phenomena of mind to be the
direct products of organization — of material forces existing in
nerve-cells, themselves dependant, like all other animal tissues,
for their functional activity on the proper nutrition of the body.
It is mystifying to be told that material nerve-cells — morsels of
albumen — remember, discriminate, evolve ideas, and arrive at
logical conclusions ; but the author will say that it is for ob-
jectors to prove that this cannot be, — to indicate the line to be
drawn between the nerve functions of animals in the ascending
scale and man, to show wherein — what for another name may
be called — memory of the spinal cord, as illustrated in acquired
automatic acts, differs from memory, in the usual signification
of the term, exhibited in the cerebral hemispheres ; and, in gene-

1868.] Fsychological Medicine. 403

ral, to discover the missing or the faulty link in that chain of
nervous actions which he supposes that he has, by the recog-
nised teachings of physiology, demonstrated as binding together
in one harmonious whole, the so-called mental and nervous phe-
nomena of all animated beings.

We pass on to review the second section of the work in
question, viz., on the Pathology of the Mind ; and now we may
again take up Griesinger's book on mental diseases, and com-
pare its contents with those of Maudsley's volume. The causes
of insanity are taken into consideration by both authors, at the
outset of their chapters on pathology ; but before starting on
their discussion, Griesinger presents a chapter on the Analogies
and general Diagnosis of Insanity, which merits study, espe-
cially for the directions and suggestions offered for conducting
the examination of a supposed case of insanity. He contends
for a thorough examination of the patient, such as can only
be obtained by prolonged observation over a period of more or
fewer days, and by inquiries among friends, in all cases where
any doubt can obtain respecting the mental state.

A similar minute examination is needed also when the
causation of the insanity is to be investigated. Both authors
concur in the assertion that

" It is not a single specific cause under the influence of which the
disease is finally established, but a complication of several, some-
times numerous, causes both predisposing and exciting. Very often
the germs of the disease are laid in those early periods of life from
which the commencement of the formation of character dates. It
grows by education and external infiuences, or in spite of these."
(Griesinger, p. 130.)

The division of causes adopted by Maudsley is into predis-
posing and proximate, whilst Griesinger treats of predisposing
causes^ general and special, and of immediate causes, which,
with regard to their mode of action, are subdivided into
psychical, mixed and physical causes. The psychical and
mixed causes enumerated agree in the main with those com-
monly called moral causes. But in Maudsley's opinion, the
subdivision into physical and moral causes is a mistake, and he
shows how impossible it is in many instances to refer a case to
the one or the other group.

" The thoughts, feelings, and actions leave behind them certain
residua, which become organized in the nervous centres, and thence-
forth modify the manner of their development, or constitute their
acquired nature ; consequently the moral manifestations throughout
life inevitably determine physical organization ; and a slowly
operating moral cause of insanity is all the while producing physical
changes in the occult recesses of the supreme nervous centres of the

404 Reviews. [April,

mental life. When insanity occurs as the consummate exaggeration
of a particular vice of character, as it sometimes does, the morbid
mental manifestations mark an internal definite morbid action in the
supreme nervous centres, — a gradually eflfected modification of the
mental organization." (1?. 200.)

The predisposing causes recognised by the two writers are,
for the most part, the same. Griesinger quotes largely from
statistics to show the relative prevalence of insanity in the prin-
cipal countries of Europe and of America. Were these statistics
trustworthy, they would indeed demonstrate remarkable varia-
tions in the frequency of the disorder in the different countries
cited, but Griesinger himself evidently holds them in light esteem,
and in our opinion they are well nigh worthless. They may
possibly exhibit with some accuracy the number of lunatics who
have become denizens of asylums and the subjects of public
supervision, but the history of lunacy in every country furnishes
a denial to them as representing the extent of lunacy prevalent.
When, however, in reference to this question, uncivilized or
half-civilized communities are brought into comparison with
nations advanced in civilization, it is generally conceded that
insanity is by far less common among the former. This is, as
might on theoretical grounds be, as Dr. Maudsley observes,
expected : for

" In the complex mental organization, with its manifold, special
and complex relations with the external, which a state of civilization
implies, there is plainly the favorable occasion of many derangements.
The feverish activity of life, the eager interests, the numerous pas-
sions, and the great strain of mental work incident to the multiplied
industries and eager competition of an active civilization, can scarcely
fail, one may suppose, to augment the liability to mental disease."
(P. 201.)

These considerations are moreover borne out by such facts as
are available.

" The sort of insanity most common among savages is imbecility,
or idiocy, for the same reason that idiocy is the most common form
of insanity in children; where the mind is not developed, varied
degeneration of it cannot take place, though it may obviously remain
morbidly arrested."

Both authors agree in the conclusion that, in recent times,
there is a real increase of insanity among the people of civilized
countries. In the case of England and Wales, Dr. Maudsley
computes it to be at the rate of 1000 a year, an increase more
than proportionate to an increasing sane population, and he
advances several important considerations in explanation of this

1868.] Psychological Medicine. 405

unwelcome fact. Among others he refers to the social position
of women, and boldly condemns it in a manner that must be
most gratifying to the champions of the rights of women. Over-
crowding of populations, and the eager pursuit of wealth to
escape the degradation (as most certainly allotted it in the pre-
sent state of society) of poverty, are also vigorously and faith-
fully discussed as predisposing causes of insanity. The remarks
on the aspects of religion in relation to the causation of insanity
are characterised by equal vigour and independence of thought;
and most men who look around them, and honestly reflect on
what they see, will endorse the sarcastic sentence —

" That the practical religion of the day, the real guiding-gospel of
life, is money-getting; the professed religion is Christianity."
(P. 209.)

We cannot here follow the two authors in their observations
upon the other several causes enumerated as predisposing to
mental disorder, such as age, sex, education, seasons of the
year, and hereditary tendency, which are equally well discussed
by both ; but we must call attention to Dr. Maudsley^s chapter
on " the proximate causes of disorder of the ideational centres,"
as particularly deserving perusal. Under that head he includes
original differences in the constitution of the ideational nervous
centres, quantity and quality of the blood, reflex irritation,
excessive functional activity, and injuries and diseases of the
brain. The two first of these groups of causes are more fully
examined than is usual in treatises on insanity, and will be read
with interest and profit. Griesinger has sections also on several of
the same causes referred to by Dr. Maudsley, and is particularly
full in detail respecting the physical causes of insanity, which
are but lightly touched on by the writer last named. We
cannot, however, speak in praise of the German author's
dissertation on psychical causes, and especially of that portion
of it in which the mode of action of such causes is examined.
But he may very justly cast much of the blame for obscurity
upon the translator of this portion ; as, for instance, for the
following paragraphs :

" The emotions, particularly the passed-off psychical phenomena,
are the immediate originators of the mental disease, inasmuch as
they produce a state of intense irritation of the brain, which now (?)
continues." (P. 167.)

And again, —

"A mediator of this description (meaning apparently an inter-
current morbid condition, Rev.) of especial importance and fre-
quency in connection with mental disease is continued sleeplessness,

406 Reviews. [April,

which often accompanies the depressing emotions, which (?) over-
excites the brain and lowers the nutrition." (P. 168.)

In Dr. Maudsley's treatise the chapter on etiology is followed
by one of considerable length, and of great interest and origi-
nality, on the " Insanity of Early Life."" Had space permitted
we could wish to have analysed this essay for the benefit of the
reader. We are, however, compelled to pass on. to notice the
varieties or forms of mental disease enumerated in the two
volumes before us. In Dr. Maudsley's treatise the consideration
of these forms is introduced by a sketch of what he terms
the " insane temperament," as seen among persons who cannot
be called insane, but who are characterised by singularities or
eccentricities of thought, feeling, and action. " This peculiarity
of temperament, which undoubtedly predisposes to insanity, does
nevertheless in some instances border very closely upon genius,"
and Dr. Maudsley proceeds at some length to inquire into " the
relations which a form of talent bears to insanity, in order to
exhibit the position of each in the social organization. In both
cases there may be an uncommon deviation from the usual
course of things ; but in one case there is the full recognition
of the existing organization as the basis of a higher development,
a fusing of the past through a new mould into the future j in
the other, there is a capricious rebellion, as the initiation of a
hopeless discord."

The several varieties of insanity fall under two great divisions
— Affective and Ideational. The former includes two sub-divi-
sions, impulsive and moral insanity ; the latter also is separable
into two forms, partial and general. Dementia and general
paralysis take a position as supplementary forms. Such is
Dr. Maudsley's distribution of mental disorders, which, it will be
seen, differs widely from the classification usually adopted, and
which, in its principal features, is followed by Griesinger.
The last-named writer treats of 1. States of mental depression ;
2. States of mental exaltation ; and 3. States of mental weak-
ness; and, as supplementary, the complications of insanity,
represented by general paralysis and epilepsy. The states of
depression include hypochondriasis and melancholia. Under
the latter term are comprised many insane conditions,
having nothing in common except the presence of more
or less mental depression at some part of their course.
Among such conditions are the forms of disorder which make
up Maudsley^s group of the affective varieties of insanity.

The artificial system of classifying mental maladies framed by
Esquirol, and followed generally by Griesinger, has long been
looked upon as very defective, and full of inconsistencies. M.

1868.] Psychological Medicine. 407

Morel rejected it, and attempted a more natural system, and Dr.
Maudsley, on his part, has advanced very valid arguments against
it and further expressed as his conviction that adherence to it
has fettered observation, and hindered the faithful study of the
natural history of insanity.

" The different forms of affective insanity have not been properly
recognised and exactly studied, because they did not fail under the
time-honoured divisions ; and the real manner of commencement of
intellectual insanity in a disturbance of the affective life has fre-
quently been overlooked."

It is, however, only just to Griesinger to note that he accepts
the artificial system simply from want of a better, and that the
two essential varieties of insanity which he admits, viz., disorder
of the emotions, and disorder of the thought and will, bear a
general resemblance to the two grand divisions accepted by
Maudsley.

The history of the forms and of thecomplications of insanity pre-
sented by Griesinger is much more full in all details respecting
their course and symptoms than that attempted by Dr. Mauds-
ley. The manner also in which the chapter is subdivided into
sections, each one devoted to some variety bearing — whether
deservedly or undeservedly we do not say, a special name, neces-
sary to be known by the student — renders it a more fitting text-
book than the work of the English author. The translators
besides, as practical psychiatrists, have, as might be anticipated,
performed their task in a more creditable manner in this
descriptive portion of the work ; and doubtless they found
Griesinger himself much more in his element, much more lucid
and' readable in describing the characteristic features of insa-
nity, than in the more learned and abstruse disquisitions of the
previous portion of his work. Hypochondriasis and epileptic
insanity, moreover, are separately and sufficiently treated of in
Griesinger^s book whilst, for some reason, they have been
omitted from Dr. Maudsley's treatise.

The remaining chapters in the two works are occupied with
the pathological anatomy, prognosis, and treatment of mental
diseases. In the mode of dealing with the first-named subject,
Griesinger is again distinguished from Dr. Maudsley by careful
detail. After some general remarks on pathological research,
and the results to be looked for from it, he enters on a descrip-
tive account of the alterations met with in cases of insanity, in
the cranium, in its bones, membranes, and in its contents seve-
rally, and afterwards proceeds to note the morbid consequences
of disease in all other organs of the body, with which the insane
state may have been considered complicated. On the contrary
his English fellow-author occupies much of his chapter on

4,08 Reviews. LApril,

pathology with recounting the latest physiological doctrines and
experiments concerning the functions of the nervous system, the
individuality of nerve-element and reflex pathological action ; all
of them subjects of the highest importance, but rightly belong-
in- to another section— quite necessary to the right interpreta-
tion of morbid appearances, but somewhat out of place in the
chapter occupied by them. Nevertheless credit must be given him
for what is recounted of the morbid products and appearances
of the brain and membranes, and particularly for an excellent
summary of the kinds of degeneration met with in the bram
after insanity ; morbid changes distinguished m more recent
times, of great importance pathologically, and likely, when more
fully understood, to throw light upon the material cause ot mental

Passing by the other chapters we will, in conclusion, make a
few remarks on the opinions and statements of the two authors
on treatment. Suppose that we assume the correctness ot Dr
Maudsley's hypothesis, that mind is an organic product, the result
of the reaction of nervous matter in response to external nature,
and to internal nerve-residua, and that at the same time the ma-
terial instrument, the brain, must be nourished and kept m health
in accordance with the same laws as govern any other organ ot
the body,— a two-fold mode of treatment in insanity is indicated;
directed on the one hand, towards the modification of external
influences operating on the mental organisation, and on the
other, towards correcting whatever is irregular m bodily tunc-
tion whether this be in the nervous centres themselves or m
other parts of the body with which the well-being of those
centres is indissolubly bound up as members of the same body.
In short, the treatment need be both moral and medical,— psy-
chical and physical, in the language of Griesinger.

It is clear that medical or medicinal treatment can have no
direct efl'ect upon the disturbed mental processes ; yet, never-
theless, it can exert a tangible eff-ect indirectly. The over-
excited and over-worn brain may be thrown into repose by an
opiate, or calmed by a prolonged or a Turkish bath ; or a course
of chalybeate medicines may restore a healthy state ot the blood
and therewith healthy brain function.

Under all circumstances the treatment must be grounded, as
Dr Maudsley observes, "upon the removal of those bodily
conditions which appear to have acted as causes of the disease,
and to be keeping it up, and upon the general improvement ot

nutrition .'•' , . j- • i 4.„

Griesinger passes under review the various medicinal agents

whicli have been more especially resorted to in treating the

insane, and exhibits a correct appreciation of the value ot tne

1868.] Psychological Medicine. 409

various drugs considered as curative of tlie morbid states in which
they are administered. But both he and Dr. Maudsley insist
upon the necessity of early treatment^ and particularly of the
early withdrawal of the patient from those influences to which
the disease is traceable. An entire change in the surroundings
will sometimes of itself lead to recovery.

Yet under the influence of this demand for removal the mis-
chievous, and too often fatal, error is made of being contented
with the transfer of the patient to an asylum, as though this con-
stituted the whole necessary treatment. Against this indiscrimi-
nate consignment of insane persons to asylums Dr. Maudsley
protests strongly. In recent cases an asylum may be abso-
lutely necessary ; but it should be something more than a place
of seclusion ; medical treatment should form a real feature in it.

" Future progress in the improvement of the treatment of the
insane lies (writes the author just quoted) in the direction of
lessening the sequestration and increasing the liberty of them."
■(P. 430.)

Moreover, if we look to our asylums, more especially to the
county asylums, we find, as a rule, overgrown institutions in
which the medical element is reduced to a minimum, and
medical treatment, except on a wholesale, empirical character,
unattainable. Moral and medical means must be combined in
the treatment of curable or recent cases ; and this cannot be
accomplished by certain set rules or a system of routine, but
by special regard being had to the character and circumstance
of each individual case.

" It is necessary (says Dr. Maudsley) to penetrate the individual
character in order to influence it beneficially by normal means, and
to investigate carefully the concurrence of conditions that have
issued in insanity, in order, so far as possible, to remove them."
(P. 431.)

The remarks of Griesinger on this subject are equally decided,
though, may be, the English is not so clear.

" Nowhere (he says) is the desideratum strictly to keep in view
the individual of greater importance than in the treatment of
insanity ; nowhere is the constant consciousness more necessary
that it is not a disease but an individual patient — that it is not
mania, but an individual who has become maniacal — that is the
object of our treatment. Each individual case should be specially
investigated in all its bearings, which constantly vary, and all the
means of anatomical diagnosis and pathological research ought to
be brought to bear upon its elucidation ; in fact, a penetration into
the psychical individuality of the patient is here demanded, which is

410 Reviews. [April,

scarcely ever necessary in ordinary medical practice." (Op. cit.,
p. 462.)

But how different is the position of a patient on being intro-
duced within one of our large English asylums ? He at once
loses his individuality, and is for the future nothing more than
one of the four or five hundred lunatics who claim the attention
of the duly appointed medical officer, and have an equal share
in (as Griesinger describes it) the mechanical nature of the
superintendence and. treatment in operation. In our present
monstrous asylums, as Dr. Maudsley truly observes, anything like
individual treatment is an entire impossibility. Though the in-
curable majority may not require such individual looking after,
the small curable minority have slight and uncertain chances of
satisfactory treatment.

" To the medical officer (he further goes on to remark) there are
not so many individuals, having particular characters and particular
bodily dispositions, with which he is thoroughly acquainted, but
they are apt to become so many lunatics, whom he has to inspect as
he goes his round of the establishment, as he inspects the baths
and the beds." (P. 431.)

And let it be added, that what makes the position and pros-
pects of curable lunatics in our huge asylums still worse is, that
the medical officers being sufficiently occupied in carrying out
the routine of those establishments, and feeling themselves
overwhelmed by the number of patients consigned to their care,
often yield to the temptation to merge their medical character
and usefulness in the routine of supervision, or, as Dr. Maudsley
expresses the fact, " forgetting their character as physicians, dege-
nerate into mere house-stewards, farmers, or secretaries,'^ p. 431.

We have entered rather largely into this question of asylum
treatment because it has become a problem of the day how to
provide for our lunatics, seeing that the plan of building gigantic
structures has failed to meet the demands for accommodation,
and tended rather to the production and accumulation of chronic
insanity, than to cure the insane and benefit the community.

A few words on the treatment of the insane without mecha-
nical coercion. We are glad to find that Griesinger, unlike
many of his countrymen, does not regard this plan as a decep-
tion and mistake. The question (he writes, p. 492) is now
decided entirely in favour of non-restraint. Up to the time of
the first edition of his work he allowed himself, (he states) to
be influenced by the adverse opinion of his fellow-countrymen
but since then he has seen the new system carried out in several
of the large English institutions, and has been convinced.

1868.] Psychological Medicine. 411

Dr. Maudsley accepts non-restraint as unquestionably the correct
plan of management, but, curiously enough, never mentions the
name of Dr. Conolly, although he introduces that of Pinel.
Griesinger, however, is more just to the memory of our great
English champion of non-restraint, remarking that " the name
of Conolly will always be mentioned with that of Pinel, whose
work he has completed," (op. cit. p. 492).

412 1868.]

PART SECOND.

Art. I. — Lectures on the Progress of Anatomy and Surgery
during the present Century. By Sir "William Fergusson,
Bart., &c. &c. London. 1867. Pp. 302.

This reprint of Sir W. Fergusson's Lectures, delivered at
the College of Surgeons in the years 1864-5, contains nothing
in the least degree new; in fact, we have failed to notice a
single alteration — even verbal — from the text of the Lectures
as they were delivered. But the book is a notable one; and
since the form in which the Lectures were first published
precluded us from then noticing them, we gladly avail ourselves
of the opportunity now afforded to us of doing so, without
violating the etiquette of periodical literature.

As we are admirers of Sir W. Fergusson, we are not afraid
to trust ourselves in some personal remarks on him. He has
always been pre-eminently the chirurgus — a man great in the
operating theatre — and greater still in a far wider sphere, in
devising new operative processes, in extending the applications of
operative surgery, and thus widening constantly the domain
of the great art which he has done so much to enrich and to
adorn. Other men may have shown greater philosophic quali-
ties; many surgeons have exceeded him in literary ability,
none in our time have surpassed him as a practical surgeon.
Hence the subject of the present volume is peculiarly the pro-
perty of its author, since a history of the " progress of surgery^'
consists in no mean degree of improvements which he has intro-
duced. His ability as a writer is not so conspicuous, nor does
this volume show traces of any extensive labour in the study.
In fact, his avocations have probably been too arduous to
permit the leisure which such study requires.

It would be hopeless for us to endeavour in a notice like this
to embrace all the points on which the professor touched in the
twelve lectures before us. Those with which his name has ■
been most prominently associated can alone be mentioned.

1868.] Fergusson on Progress of Anatomy and Surgery, 413

The lecture on 'Conservative Surgery' will well repay
perusal. In it Sir W. Fergusson gives a liberal appreciation to
the labours of his colleagues, such as Brodie, Syme, Jones of
Jersey, and others. Especially important is the doctrine which
is still, we fear, too little accepted, that it is not necessary in
operating for diseased bone to conduct the operation through
healthy soft parts, for that the inflamed and thickened tissues
over a diseased joint will rapidly recover themselves when the
joint has been removed. It has often been our lot to see a
surgeon of the olden school insist upon sacrificing the whole
foot and leg, on account of disease of the tarsus, misled by the
thickening and the riddled condition of the soft parts of the
foot, when excision of the diseased bones, or at most Syme's
amputation, would have proved certainly adequate to the cure
of the disease.

The observations which our author makes on harelip can
hardly be considered worthy of his vast experience, extending to
several hundred cases. None of the modern modifications of the
old operation for harelip seem to have attracted Sir "W.
Fergusson's notice ; at least he does not consider any of them
worth mention, though the illustrations he himself gives show
clearly how ugly a notch that method of operation leaves, and
which it is the object of the modifications in question to obviate.
It is possible that such methods may prove failures. But if Sir
W. Fergusson has given adequate trial to the operations which go
by the names of Malgaigne, Nelaton, Blandin, and Bruns, and
has reason to be dissatisfied with them, it would have been
useful to the reader to have been informed of it. Otherwise
the essay can hardly be said to be up to the information of
the day.

On the subject of fissured palate all that falls from our author
must be most valuable and interesting. The present Lecture is
indeed merely a reproduction of what Sir W. Fergusson has
previously taught ; but it is certainly of importance to hear that
he has found nothing to change either in his doctrine or prac-
tice. Nor indeed does he appear to have followed the practice
of other surgeons with much attention; for he speaks of
Diefilenbach^s method of operating as being the same as Pollock's,
whilst, if we understand their works aright, they are perfectly
different. However, much study of other men's practice need
not be expected from a surgeon whose own is so perfect, that
out of 134 operations 129 have been successful.

One of the most interesting chapters in the book is that on
lithotomy in children, and on lithotrity. It is pointed out, and
with incontestible force, that one of the gravest dangers in
cutting for stone in the young subject, is that of tearing or

82— lu. 27

414 Bibliographical Record. [ApHl,

breaking the urethra into two pieces, and pushing the bladder
before the finger deep into the pelvis. A cavity is thus pro-
duced in front of the bladder, which the operator mistakes for
that viscus — the stone is not reached, and the operation has to
be abandoned. It is in this way that Sir W. Fergusson is
induced to explain the frequent occurrence of cases in which it
has been said that the bladder was opened and no stone found.
But that such is not always the explanation is proved by the
well-known case of Mr. Paget, of Leicester ; and other similar
cases have come under our own knowledge in which the bladder
has been fairly cut into and found empty. Sir W. Fergusson's
extensive experience of lithotomy in childhood has impressed
him with a more serious view of its difficulty than is usually
entertained.

In treating of lithotrity Sir W. Fergusson lays great stress
upon the removal from the bladder of the debris of the stone by
means of a lithotrity-scoop, or even of whole stones when only
of small size, such as those figured on p. 94. For this purpose
he recommends a lithotrite with a very small stem, easily
moveable in the urethra. It would be presumptuous in us to
express an opinion derogatory to a practice which so great a
surgeon says he has followed in 60 operations, and with the best
results. But we think we are entitled to say that the general
judgment of operators is against the promiscuous adoption of
this practice. For a surgeon possessed of the exceptional
delicacy of manipulation which distinguishes our author it may
have its advantages — in ordinary hands it seems likely to lead
to risk of laceration and injury much outweighing any possible
advantage from shortening of the term of treatment.

In a subsequent lecture on lithotomy in the adult Sir W.
Fergusson refers with natural pride to the vast extent of his
experience in cases of stone, embracing 162 cases of lithotomy,
and 109 of lithotrity.

We should like to spend much more time on this volume, but
have only room to refer briefly to the subject so peculiarly
connected with its author — excision of the knee. Passing over
the very interesting historical matter with which the subject is
introduced, we come to Sir W. Fergusson's opinion on the
relative fatality of amputation and excision. On this head,
without adopting the flourishing statements of the heated par-
tisans of this operation, who have gone so far as to represent it
as a proceeding of really trifling danger, Sir W. Fergusson yet
professes his belief that it is not more fatal to life than ampu-
tation would be under similar circumstances. If this conclusion
should bear the test of experience, it would indeed be most
satisfactory. He also throws some doubt on the allegations

1868.] Fergusson on Progress of Anatomy and Surgery. 415

generally made as to the protracted period required for cure
after excision. Totally apart from these questions, however,
there is, as our author shows with great force and truth, the
question of the result obtained by excision. Here three prin-
cipal objections are usually made, and to these Sir W. Fergusson
directs his replies. 1st. That the limb after excision is really
little superior to a stump ; a very absurd assertion, only to be
accounted for by perfect ignorance of the subject, and which is
very summarily and very satisfactorily disposed of. 2nd. That
the limb is liable to be much shortened. This Sir W.
Fergusson appears to admit, but he argues that however
shortened it may, be it is superior to a wooden leg. In illustra-
tion he quotes and figures two instances, which certainly seem
to have little bearing on his argument — one that of Caesar Du-
cornet, a man born without arms, and who made his living by
painting, wielding the brush with his feet. This instance shows
the value of a foot when supported by a healthy limb, but not
that of a foot attached to an ankylosed and shortened leg. The
other instance is that of a man whose limbs were of very unequal
length, and much dwarfed, yet who was a celebrated rider, and
who could walk, run, and leap. This shows that unequal limbs
may be very useful when pliable, but has little bearing on the
utility of stiff limbs. We ourselves, however, incline to agree
in Sir W. Fergusson^s conclusion (at least so far as to admit
that any usual amount of shortening will leave the limb superior
to a wooden one), and only regret the weakness of the analogies
by which he has supported it. It is a little singular that he
has not pointed out that this shortening is often not the fault of
the operation at all, but of the operator, who is more anxious to
make a clean and showy operation than to notice the position of
the epiphysial cartilage, which is really much nearer to the lower
surface of the femur than many surgeons seem to know.
3rd. The last objection which is combated here, and very suc-
cessfully, is the tendency to recurrence of disease, and here
Sir W. Fergusson shows how much may often be done by
renewed resection, of which he gives some very interesting cases.
On the whole this lecture on excision of the knee, by one who
may claim to be its author, or, at least, its introducer into
modern practice, is in every way most valuable and in-
teresting.

We regret that we have not space to follow Sir W. Fergusson
more minutely through this volume, which will always remain
as a splendid monument of a long and successful career, and
one which has left an enduring mark on the surgery, not of this
country only, but of the whole world. Whatever literary defects
a carping criticism may discover in his work, Sir W. Fergusson

416 Bibliographical Record. [April,

may well be proud of the achievements which are so faithfully
recorded in it.

Art. II. — Bidrag til Belysning af Asphyxien og Doden, navnlig
fra et hygieinisk og forensisk Synspunkt. Af P. A. Schlbis-
NER, Dr. med., Stadslsege i Kjcibenhavn. Kjobenhavn, F.
Hegel, 1868. 8vo. Pp. 94.

A Contribution to the Elucidation of Asphyxia and Death,
especially from a hygienic and forensic point of view. By
P. A. ScHLEisNER, M.D., Municipal Physician in Co-
penhagen.

The writers who, according to the author, have treated the
subject of apparent death most scientifically and impartially,
are Louis,^ Sommer,^ Bouchut,^ and van Hasselt.*

The first inquiry to which Dr. Schleisner directs his attention
is, whether the accidental interment of living persons has really
occurred so often as has been stated. He shows that most of
the stories of this kind have, on due investigation, been refuted.
It would appear, in fact, that there is on record in France only
one authentic case of this nature which has been confirmed by
a trustworthy physician, and that this dates back more than
100 years. The author believes that in the present day such
an occurrence could scarcely take place, except in cases of
sudden or violent death, and under unusual circumstances, as in
great fields of battle or during destructive epidemics. But even
under such circumstances the danger of interment during life is,
in our civilised age, exceedingly slight, when so great care is
taken of the wounded in battle, and Avhen epidemics do not
occur with the overwhelming violence and malignancy of former
centuries.

The author considers the very general belief in the frequency
of apparent death to depend on the assumption, more or less
well founded, of the uncertainty of the signs of death ; on the
want of sufficient scientific inspection of the dead ; and lastly,
on the more or less perfect legal regulations prevailing in
difierent countries as to the period of interment.

As to the signs of death the principal are : cessation of the

1 ' Lettres sur la certitude des Signes de la Mort,' Paris, 1752.

* ' Dissertatio de signis, mortem hominis absolutam ante putredlnis accessum
indicantibus.' Partes I, et II, Haunise, 1833.

3 ' Traite des signes de la Mort/ &c. Paris, 1849. Crowned by the Institute
of France.

■♦ ' Die Lehre vom Tode und Scheintode.' Bd. 1, Braunschweig, 1862.

1868. 1 ^CHLmsuER on Asphyxia and Death. 417

hearths action^ cadaveric spots and rigor mortis. These must be
considered as sufficient proof of death ; and Dr. Schleisner does
not hesitate to express his conviction, '^that when all these
signs, or only two of them co-exist, death is certain.^'

" The latter two constitute the transition to the first sign of putre-
faction, which consists in a bluish green discoloration of the skin,
especially in the groins and on the abdomen, a discoloration ascribed
to the effect on the colouring matter of the blood of the sulphuretted
hydrogen developed in the cavity of the abdomen (Kokitansky) or
perhaps of the ammonia." (Pp. 22-23.)

It is evident that death can be positively certified only by a
medical man. Hence all writers who have treated of this
subject agree as to the necessity of the rule, that no one should
be buried without the inspection and certificate of an authorised
physician. In France the organization for the verification of
deaths, which had previously been confined to Paris, was, by a
circular of the 24th December, 1866, extended, with some
modification, to the country districts.

The machinery in the capital is as follows : in each of the
arrondissements of Paris are three or four medical verificateurs
de deces ; in addition there are for the whole city four medical
inspectors, and finally there is a committee of inspection of the
verification of deaths, composed of the Prefect of the Seine as
president, different members of the Municipal Council, two
physicians, one being the Dean of the Faculty, and some other
professional members — in all eleven members. The committee
is to meet at least once a month in the Hotel de Ville, to consult
respecting the reports received from the medical inspectors,
who likewise are members of the committee. The honorarium
of the verificateurs is fixed at two francs for each certificate of
death.

In England the same object is attained partly through the
institution of coroners for sudden and violent deaths, dating
from the time of Edward I, and partly by means of the civil
registration of deaths. England had formerly the honour of
being the only country in Europe which had carried out, so far
as possible, a medico-scientific system of deaths certificates. In
1856 there were in England and Wales in all 324 coroners (of
whom a great part were medical men), the cost of this insti-
tution amounting in that year to £67,000, of which £29,068
went for coroners^ fees. The civil registration was established
for England and Wales by the Act of the 17th August, 1836,
for registering births, deaths, and marriages, which was subse-
quently extended to Scotland and Ireland. Dr. Schleisner
remarks upon the " singularly permissive" nature of English

418 Bibliographical Becord. [April,

legislation, wliicli so often has a " may/' where we should expect
a " shall," and he expresses his surprise that the certificate of
registration is not made the express condition on which inter-
ment should be allowed. Stillborn children are not registered,
&c., but he adds :

" It must, on the other hand, he admitted, that this institution,
under the uncommonly talented guidance of the celebrated statis-
tician. Dr. "W. Earr, who, though not by name, is in reality the chief
of the general registration — has attained to great perfection. This
result is due especially to a judicious use of the 7th and 25th sections
of the Act, but also to the benevolent interest with which all the
medical men of the country, recognising its great importance to the
public health, have afforded their co-operation." (P. 27.)

Dr. Schleisner quotes Dr. Farr's Report, to show that, for
the whole of England and Wales, seventy-nine per cent, of the
deaths are certified by medical men, four per cent, by coroners,
and seventeen per cent, without the intervention of medical men,
while in London the proportion is still more favorable, uinety-
two per cent, of the deaths being registered on medical certifi-
cates, five per cent, by coroners, and only three per cent, with-
out medical certificates, a result which, he adds, no other country
in the world can show, and which is the more surprising, as the
number of those who die yearly in England of want and pri-
vation— a cause of death now quite unknown in Denmark — is not
so very small. Nevertheless, Dr. Farr is anxious to eftect a
special medical registration for the fraction of deaths at present
unattested by medical men, a proposition which will more
than double the cost of the institution, raising it from .€41,350
to £91,350 per annum. This change Dr. Schleisner hopes to
see carried out.

On comparing the French and English systems, the author
gives unqualified preference to the latter. The plan of receiving
certificates from those who have not had the deceased under
treatment during life, he condemns as being calculated to lead to
many errors, while it is extremely galling and inconvenient to
the respective families, is very costly, and implies a mistrust in
the whole medical profession in France, which is almost inex-
plicable. "The English system is much simpler and more
certain with respect to the determination of the causes of death,
and security for the discovery of concealed crimes is obtained
by means of the coroner's inquest."

In Denmark it is only in the market towns that the deaths
are attested by a physician; in the country parts this is done by
the inspector of the dead appointed by the "Amtmand," a
superior revenue officer having jurisdiction in certain cases.

1868.] ScHLEisNER OH Asphywitt awd Death. 419

This is, of course, a state of things which calls for reform. The
arrangements for the investigation of violent and sudden deaths
are also very defective ; and therefore, to illustrate this part of
his subject, the author proceeds to lay before his readers some
statistics bearing upon it, derived from other countries, and
" especially from England."

The facts he brings forward are quoted from the coroner's
returns, as given in the average for the five years 1852-56 in
the Nineteenth Report of the Registrar General. Upon these
facts he remarks, that

" This review gives an insight into the whole social life of the
English people, greater and more complete than that which even a
detailed description of the customs and manners of the people could
supply. We see from it, among other things, that it is with very
great sacrifices that England gains the prize of being, in an industrial
and material point of view, the most advanced people in Europe ; and
it is really the case, as Mr. Earr has somewhere remarked, that this
large number of violent deaths has the same effect for England, as if
she every year carried on the most bloody war. But as statistics
have been able to unveil this side of English life, they have also
placed the Legislature and the Administration in a position to adopt
such regulations as year by year, in part at least, diminish and obviate
these calamities. This is so far the case, that the manifold hygienic
agencies, which in this direction are met with in England, may be
said to be based upon the results deduced from the statistics of
mortality, of which the Registrar- General's various reports bear so
many and such eloquent proofs." (P. 35.)

Dr. Schleisner calls attention to the fact, that of the deaths
by violence in England, so large a yearly number as 401 is due
to the administration of poison. A still more surprising and
indeed appalling circumstance is, that of these 286, or nearly
three fourths, should be the result of accident. The author's
remarks on this point deserve special attention. He shows that
this wholesale accidental poisoning does not proceed from an
excessive use of poisons in trade.

" On the contrary it will be seen," he says, " that laudanum, opium,
and morphia, prussic acid, mercury in combination in different secret
remedies, (as Godfrey's cordial and Morrison's pills), and unsuitable
medicines, and too large doses of medicines have, out of the yearly
average, made up the considerable number of 143. This remarkable
result depends upon circumstances peculiar to England, especially
the want of a protecting anti-quackery law, and the fact that in
England pharmacy is a free trade." (P. 37.)

It is curious that in the criminal use of poison a certain
fashion seems to prevail in different countries. Thus, while in

420 Bibliographical Record. [Aprils

England opium occupies the first rank in the accidental,
suicidal, and partly in the criminal poisonings, arsenic has in
France continued to play the same prominent part in criminal
poisonings, which it has held since the middle ages, when, as is
well known, it constituted the principal ingredient in the
" Cantarella" of the Borgias, and in the later famous or rather
infamous " Aqua Tophana.^'' In France, however, phosphorus
seems now to be replacing arsenic. From a statement of the
Prussian judicial chemist, Dr. Sonnenschein, it would appear
that in his country nine tenths of the poisonings are nowadays
attributed to prussic acid and cyanide of potassium {' Deutsche
Klinik,' No. 13, 1867, p. 119).

" The reason why opium in England so frequently gives rise to fatal
poisonings, must be sought partly in the fact that this potent medi-
cament can there be obtained without a prescription in any chemist's
Bhop, and partly in the bad habit which prevails, especially in the
manufacturing districts, of quieting crying children with opium
drops." (p. 39, note.)

The author next directs attention to a very important class of
poisonings, the most dangerous of all, and which seems to have
been very much overlooked by toxicologists, namely, poisoning
at second hand, by the use of the flesh of animals poisoned by
the administration of strong medicines, or in some other way.
A case, brought forward by Mr. Gam gee, is quoted from the
number of this ' Review for January, 1865,' p. 34, in which
107 persons suffered from partaking of the flesh of an ox to
which two ounces of tartar-emetic had been given. The pig is,
however, the animal which is most frequently exposed to poi-
soning, and the author mentions instances in which large num-
bers of swine have been lost from meeting with poisonous
matters in offal. There are thus three ways in which pork may
become dangerous, by communicating trichinosis, splenitis
(miltbrand) and poison (especially phosphorus, arsenic, and
antimony). Of these Dr. Schleisner considers the uncom-
plicated trichinosis, the mode of death in which is far from
being satisfactorily explained, to be the least dangerous.

As deaths by poison are very frequent in England, the same
is undoubtedly true of modes of violent deaths in general,
which scarcely occur in the same proportion in any other coun-
try, not even in Belgium. An exact international comparison
is, however, extremely difficult, as the official reports are not
drawn up upon the same plan, and it is greatly to be desired
that an uniform system of statistics should be, without delay,
adopted in all countries, especially with regard to those causes
of death which may be considered to be of predominant im-

1868.] Physiological Relation of Colloid Substances. 421

portance in a hygienic, forensic, and economico-social point of
view. These are — 1. Deaths from epidemic diseases. 2. Vio-
lent and sudden deaths; and 3. Deaths from diseases which
may be considered as eminently calculated to deteriorate race —
syphilis, glandular and pulmonary phthisis.

We have dwelt so long upon the first three chapters in
Dr. Schleisner^s important and interesting work that the space
at our disposal will not admit of our doing more than stating
the subjects of the remaining two. In the fourth he treats of
the danger, in a sanitary point of view, of permitting a pro-
longed interval to take place between death and burial, and of
the Danish legal regulations on the subject. In the fifth he
speaks of asphyxia, or apparent death in the stricter limitation
of the term ; of the medical definitions of life, disease, and
death ; of the difierent methods of resuscitation ; and he con-
cludes his valuable brochure with an account of the operations
of associations for the rescue of the drowned and of the ap-
parently dead, and especially of the K-oyal Humane Society
at its principal station under the able, experienced, and zealous
direction of Dr. Christian, of Brompton.

Art III. — On the Physiological Relations of Colloid Substances.
By Arthur Eansome, M.D., M.B. London. 1866.
Pp. 22.

Dr. Ransome, in this paper, a reprint from the 'British
Medical Journal,^ of the 3rd of February, 1866, gives a brief
summary of Dr. Graham's very important observations on colloid
substances which, in their vital relations, open a new and most
interesting field of physiological research.

As compared with crystalline substances, '^ crystalloids," they
appear, to use Dr. Graham's words, "like dififerent worlds of
matter, and give occasion to a corresponding division of chemical
science," the distinction between them being that subsisting
between the material of a mineral, and that of an organized
mass."

From the facts already established, it seems highly probable
that the inquiry carefully conducted may afford explanations of
many vital processes at present but imperfectly understood, —
such as digestion, chylification, secretion, excretion, and may
shed light on some of the obscure problems of pathology as well
as of physiology. Much caution and reserve, however, we need
hardly remark, will be required in reasoning on forces so un-
stable and obscure as those which are concerned in all opera-

422 Bibliographical Record. l^w'^h

tions in whicli colloid substances take an active part. One short
extract from Dr. Graham^s original paper may suffice to warrant
such caution,, at the same time that it shows how far-reaching
and important is the inquiry. Contrasting the crystalline and
the colloidal he remarks :

" The colloidal is in fact, a dynamical state of matter ; the
crystalloidal being the statical condition. The colloid possesses
ENERGiA. It may be looked upon as the primary source of the
force appearing in the phenomena of vitality. To the gradual
manner in which colloidal changes take place (for they always
demand time for an element), may the characteristic protraction
of chemico-organic changes be referred." ^

Art. IV. — On the Special Function of the Sudoriparous and
Lymphatic systems, their vital import and their bearing on
Health and Disease. By Robert Willis, M.D., &c.
London. 1867. Pp. 71.

The title of this little volume may well arrest attention.
The author of it, who is favourably known by his excellent
translation of the works of Harvey, and by his translation with
notes of the 'Elements of Physiology' of Rudolph Wagner,
following the example of the illustrious founder of our modern
physiology, has, in the treatise now before us, by induction from
well-known and well-established facts, arrived at conclusions of
a very interesting and novel kind, which, if confirmed and esta-
blished, can hardly fail to solve certain obscure problems, and
introduce a harmony at present wanting in an interpretation of
the working of the animal economy.

Treating first of the sudoriparous system, after considering the
commonly received opinions respecting its function and passing
in review the data, the principal facts on which they have been
founded, and other facts, three especially : 1st. That the fluid
eliminated by these glands is nearly pure water ; 2nd. That the
arterial blood contains more water than venous blood ; 3rd. That
the suppression of cutaneous perspiration by an impervious
varnish is speedily fatal, holds himself warranted to advance and
maintain the following propositions :

1. " That the office of the sudoriparous system of glands is
to abstract mere water from the peripheral circulation.^'

2. That it is thereby "subservient to securing the conditions
necessary to the return into the venous circulation of the fluids

1 On • Liquid Diffusion applied to Analysis.* By T. Graham, F.E.S., &c.
'Phil. Trans./ 1861, p. 184.

1868.] Willis on the Sudoriparous and Lymphatic Systems. 423

that have been shed from the arteries for the purposes of nutri-
tion and vital endowment."

3. " This is the process^ in fact, which, as carried on between
the arteries and veins of a living creature, constitutes venous
absorption, the conditions necessary to which, viz, the higher
density of the blood in the veins, or returning vessels, than in
the arteries or afferent vessels in all the peripheral parts of the
body being mainly due to the action of the sudoriparous
glands-^^

Owing to this system passing to the lymphatic system of
vessels, he arrives at the conclusions enunciated in the following
propositions :

1. That their "one essential function is the abstraction of a
certain quantity of the watery element of the blood for the
specific end of rendering the returning stream in the deeper
seated parts of the body of greater density than the out-going
stream."

2. That " these vessels may in fact be viewed as the essential
elements of a filiform, and all but universally distributed
gland."

The secreted fluid, the lymph, is a fluid holding only about 3*5
per cent, solid matter, identical with that of the liquor sanguinis,
the remaining 96*5 being water.

Next our author treats of the spleen, considering it " as
an element in the lymphatic system, and having a local function
of the same specific nature as that of the lymphatic system at
large ;" founding this his conclusion on the composition of the
spleen, mainly a vascular organ abounding in lymphatics, and
on the fact of the venous blood coming from it containing less
water than the arterial blood entering it.

These several propositions may give our readers some idea of
Dr. Willis's doctrines, but at the same time, we must confess,
a very imperfect one. To appreciate them fully they require to
be read in extenso, and the perusal will amply repay, as his
argument is so well supported, and the facts brought forward,
apart even from his special views, so important in their phy-
siological bearing, — many of them, though not new, hitherto too
little regarded.

As a corollary, a section is added "On the influences pro-
ductive of intermittent and remittent Fevers, and on the patho-
logy of Scarlatina, in connection with the views embodied in
the preceding essays." This portion, too, we can recommend
to the attention of our readers. To us, however, it seems of
unequal merit. His remarks on scarlatina, its varieties and
treatment, though short, are excellent. Of his speculations
relative to the obscure subject of malaria, we more than hesitate

424 Bibliographical Record. [April,

in expressing approval. He has refuted several fanciful specu-
lations regarding its nature, but he has failed to persuade us
that its origin is simply a chill, insomuch as were it so, no
country should be exempt from ague.

Art V. — Notes on Health in Calcutta, and British Emigrant
Ships, including Ventilation, Diet, and Disease. By W. H.
Pearse, M.D. Edin., Government Emigration Service.
London. 1866. Pp. 160.

The subjects treated of in this volume have received less
attention than their importance deserves. This is not from want of
experience, for what people have had the opportunities possessed
by our countrymen of witnessing the effects of the conveyance
of large bodies of men trans mare under almost every
variety of circumstances : but rather from another want,
that of observers, or at least of men with inquiring minds, com-
petent to observe and willing to give to the public the results
of their observations. With one memorable exception — that
afforded by Captain Cook — we cannot call to mind an instance
of any attempt to elucidate, in a systematic manner, the subject
as a whole.

We began the perusal of the work before us with the expec-
tation that in it we should find another exception ; we have to
confess we have finished it with a feeling of disappointment which
we cannot suppress. So far as simple observation is concerned
we give the author credit for zeal, and we hope we may add
accuracy. What most detracts from its value are the specu-
lations which are so much indulged in, constituting indeed, the
larger portion of the whole. Altogether the publication appears
to us singularly incongruous, and its style, moreover, peculiarly
involved, obscure, and repellant.

Of the nine chapters into which the work is divided, the first,
on ventilation, is the most valuable, and will well repay perusal.
The construction of the vessels in which the author served as
surgeon superintendent in voyages with coolies from Calcutta
to the West Indies, and from England with emigrants to
Australia, is well adapted to render the problem of change of
air, and a sufficiency of it, comparatively easy, especially the
circumstance of the clear space, as it were a great room, ^tweeu
decks. The means employed as described, consisted in three or
four hatchways, with a considerable opening at the after end,
and another in the fore end, and the addition of four tubes
about one foot four inches diameter, placed securely at each

1868.] Pearse's Notes on Health, i^c. 425

entrance corner of tlie 'tween decks^ each rising above the
bulwarks and fitted with moveable cowl-heads. By these
simple meansj we think^ it is clearly shown that wholesome
ventilation can be more efficiently accomplished than by any
expensive apparatus hitherto invented. With much propriety
as a defence from strong currents of air, stress is laid on the
necessity of difiusion by a mat or platform of some kind placed
about eighteen inches below the lower mouth of each tube.
Speaking of the form of the tubes, the author remarks that they
are usually ''made with bell-shaped mouths, as though they
were meant to send cool air below; they nevertheless answer
well, though," he adds, " I think a narrow mouth would make
them more perfect as chimneys." In this opinion we cannot
agree with him, as, according to both theory and practice,
chimneys expanding as they ascend are found to be most effec-
tual in the allowing of the escape of smoke with " the heated
air ;" and it is on the same principle, we need hardly remark,
that foul air in a ship must be got rid of.

The second and third chapters in which the author treats of
the coolies, as to their diathesis, management, and diet, and the
influences and effects of a sea voyage on them, may also repay
perusal. Whilst they contain some good observations, they
strongly display the author's speculative turn of thought, and
his large, transcendental and obscure mode of reasoning and
expression. In stating his surprise at the small amount of food
the Hindu requires to support his working strength, Dr. Pearse
seems to forget that one of the articles of his diet, not to mention
others, is highly nutritive, for instance dhoU or dhal, which the
Hindu values so much, abounding as it does in the nitrogenous
element, and so well-fitted to supply to him the place of flesh-
meat.^ Still, even with due allowance for this ingredient, it
must, we think, be admitted that the quantity of food which
satisfies the coolie is proportionally very small. Dr. Pearse
specifies it as commonly consisting of li lb. of rice or flour,
4 oz. of peas (dhal?) a few vegetables, a little butter, and a few
seeds and condiments per day. He notices how very various
are the condiments, and that each article of diet is used in its
native, entire state ; to both which circumstances he attaches
importance, and perhaps justly. The ingredients of the ordinary
daily curry-stuff" of the coolie are as many as nine, viz., lime-
juice, onions, garlic, mustard-seed, chillies, black pepper,
coriander-seeds, turmeric ghee, all in definite proportions. What
their action may be, whether more than simply stimulating, is
deserving, perhaps, of more minute inquiry than has hitherto
been given to them; and also whether our labouring class
' See the October number of our ' Review,' p. 457.

426 Bihliographicai Record, [April,

might not use the like with advantage, especially those whose
diet is chiefly vegetable. If we recollect rightly, pepper is used
much more largely in Ireland than in England, and Mr.Gladstone,
when Chancellor of the Exchequer, assigned that as a reason for
reducing the duty on the article.

In the other chapters, exclusive of the fourth on water, he
treats principally of the diseases to which coolies and other
emigrants are liable, and which, according to his large and
transcendental views, are all nearly allied, and are no more
than natural developments depending on subjective and objec-
tive impulses to which the human species have been subjected
during an indefinite period of time, becoming manifest in con-
sequence of sudden change of circumstances, such as are expe-
rienced on the beginning of a sea-voyage. He apologises for
the use of the word disease, the habitual use of which indicates,
he thinks, a very little advanced state of intellect ; he enume-
rates dysentery, cholera, and intermittent fever as the allied
diseases to which the Hindu emigrant is chiefly liable : " and
insidious lung changes, bronchitis, fever, sore throat," those to
which the European is most subject. We would remind him
that Europeans in India are in no wise exempt from the former
maladies, and that cholera as an epidemic was little known
there before 1818-19; and that since then it has spared hardly
any portion of the globe.

On the author^s speculative views we do not think it neces-
sary to comment. We could have wished that he had omitted
them, and confined himself to observation and induction from
established facts. We have already adverted to Captain Cook^s
paper, that for which he obtained the gold medal of the Royal
Society, and which is to be found in the ^Transactions ' of the So-
ciety for 1776, giving an account of the method which he followed
for preserving the health of his crew on his voyage round the
world occupying three years and a half, and during which he
lost only one man from disease, and that of a chronic lingering
kind. If Dr. Pearse is not already acquainted with it, we
would recommend him to consult it : it is soon read, it occupies
only two quarto pages ; and it should never be forgotten that the
means employed were so few, so simple, and so easily attainable.
To conclude ; how much it is to be regretted that we have not
more accounts written in the same simple and clear manner.
As already remarked, how ample are the opportunities, for
instance, in the naval, transport, and emigrant service. And
what scope would be aff'orded to the medical officers in charge
to distinguish themselves, were they required by the departments
to which they belong, to make special reports detailing the results
of their experience whilst afloat.

1868.] Maoleod on Acholic Diseases. 427

Art. Y1.— Acholic Diseases; comprising Jaundice, Diarrhoea,
Dysentery, and Cholera. With a Preliminary Dissertation
on Bile, the bilious Function, and the action of Cholagogues.
By Alex. Charles Macleod, L.K.Q..C.P.I., &c., Surgeon-
Major on her Majesty^s Madras Establishment. London.
1866. Pp. 230.

This work, which we have read with much attention, we
cannot say with equal satisfaction, is more characterised by
speculative reasoning creative of doubt, than by the sounder
method of induction from well-established facts, such as is
needed to inspire confidence. Even the title, beginning
"Acholic Diseases,^^ aflFords a precognition of what follows,
especially as applied to jaundice, diarrhoea, dysentery and
cholera.

What surprises us not a little is the boldness with which the
author advances his hypotheses, the reliance he has in his conclu-
sions, and the confidence he seems to feel in opposing established
doctrines, and placing himself in antagonism with some of our
highest authorities.

Such being our general impression of this work we do not
think it necessary to engage in its analysis. One quotation
may, perhaps, suffice, in proof of what we have stated of its
nature. The argument prefixed to the chapter on cholera is
the one we select. It is as follows, all in italics :

" Argument. — Cholera is an imponderable matter, or condition of
matter ; tellurial in its origin ; existent in and with the atmosphere,
hut forming no component part of it, being of it as independent as are
the rays of light ; attracted by some other matter or condition of matter
existent in and peculiar to the human body. Where a great space, as
a continent or arm of the sea intervenes, the earth itself may become
the conducting medium. But all matter, whether animal, or vegetable,
or mineral, serves as a conducting medium.

" When present (that is, in the atmosphere, or supra-telluriaV) it is
attracted, and more or less neutralized, by every, even the healthiest,
human body. In certain states, however, of the body, varying from
health, the force of attraction is stronger, and the process of neutraliza-
tion also more active and conspicuous. So long as the vital powers are
sufficient to Jceep up this process of neutralisation, and so preserve an
equilibrium, the system is not overcome by the disease. But under un-
favourable conditions, the powers of life are not adequate to carry on,
through the lungs, a continuous process of neutralization. The poison
is then, of necessity, conveyed through the lungs into the blood. Being

428 Bibliographical Record. [April,

there, a far more energetic process for its neutralization is required.
A violent convulsion of nature ensues and the symptoms of * Cholera *
are present.^'

To those of our profession who are highly imaginative
this quotation may, perhaps, serve as a recommendation of the
volume. We had marked many passages for remark, but on
reflection, averse from the ungracious office of commenting on
them, we shall notice only a few of those parts in which the
author offers the results of his experience on points of treatment,
for instance, the use of cool spring, not iced, water, ad libitum in
cholera ; the assiduous rubbing of the limbs of those labouring
under the same disease, and the friction of the surface of the
body generally and diligently with cajeput oil. So high is his
opinion of the free use of water in cholera, that he appears
to rely on it more than on any other remedial means. He
states : — " In the course of many years, numberless cases
have come to my knowledge of natives of India, who,
attacked at a distance from medicine and aid, and intent only
on the relief of present suffering, and above all of the intolerable
thirst, have sunk down by the side of lake or river, and found
in their limpid waters, the simplest, perhaps the surest, means
of cure." And his commendation of cajeput oil is almost
equally great. He says nothing is equal to it. ''The very
odour seems to afford the patient satisfaction, and its efficacy
in relieving agonizing cramps is truly astonishing." Advert-
ing to children, he adds : " Its powers are conspicuously
displayed in the young, and I have seen children apparently
moribund rapidly revive under its use. In them the absorbents
seem to act with greater vigour ; and, from the results of past
experience, I should be inclined in future to employ it in the
cases of very young children, at first, as an external application
only, and without the co-operation of any other remedy ; cold
water to drink forming under all circumstances, a part of the
treatment.''^ He gives minute directions for its use. Turpentine,
where cajeput oil is not procurable, he considers, tnough ''im-
measurably inferior," its best substitute. We know that others
have given it a trial in some almost hopeless cases, and apparently
with excellent effect. Of internal medicines in this disease he
trusts most to calomel administered in large doses, with the
special caution not to combine it with opium. Whilst of the
former, we think, he is too unqualified in his general praise,
viewing it as a cholagogue, of the latter his reprobation both in
cholera and dysentery, more especially in the latter, seems to us
in no wise justified by well-established facts, putting aside
hypothesis, respecting its action. Credit is due to him, we

1868.] Morris on Germinal Matter, ^c. 429

willingly add, on the score of humanity in calling attention to
" the unseemly custom of hasty interment/' so generally fol-
lowed in India, giving rise to the painful suspicion, as he ex-
presses, " that it does sometimes occur, not only whilst the
spark of life still lingers, but while there yet remains a chance
of recovery/' He well remarks, " An exaggerated notion, not
certainly on the part of medical officers, but on that of the
authorities, and of the public generally, of the danger to the
living from the results of decomposition, leads to this selfish
and unseemly custom." He very properly adds : " No body
should be allowed to be covered up with a cloth, or placed in a
coffin, or otherwise treated as a corpse, till at least twelve hours
have elapsed from the moment of apparent dissolution/'

We heartily agree too Avith all his remarks on the impro-
priety of not taking superficial as well as cubical measurement
into account, as in the allotment of space in barracks and other
buildings where there is danger of crowding, and cannot but
approve his proposition, as a rule, that " the number of persons
sleeping in any building should be a due proportion to the
number of square feet on the ground floor."

Art. Yll.^Germinal Matter and the Contact Theory. By
James Morris, M.D. Lond. London, 1867. Pp. 23.

As an hypothesis for discussion, we see no great objection to
this which Dr. Morris advances, calling it a theory; which,
according to our ideas, is rather an abuse of terms.

That certain diseases are propagated by contact; that is,
inoculation either natural or artificial, is no new doctrine : it
seems to us a distinction of little importance, whether we call
the active matter a specific matter or a germinal matter.

No subject is more interesting than the origin of diseases,
but surely none requires to be investigated with more caution.
Hypothesis is well when leading to research, but is fatal to
science if accredited as truth. Take the instance of ague : it is
an ingenious idea, supported by some analogies, that it may be
owing to inhaled vegetable matter; but this is no warrant for
taking it for granted and for speaking of malaria after Dr.
Morris's manner : wc quote his words : — ^' It would seem that
the spores as they exist in the most deadly malaria, grow, and
that with great rapidity, on the membrane of the capillaries of
the air-cell, passing from time to time into the blood. This
theory of ague gets rid in great part of a puzzle of antiquity —
82— XLi. 28

480 Bibliographical Record, [April,

the cause of the periodicity of ague, which is brought under the
known laws of the periodicity of vegetable development/' We
would ask, do the ascertained facts justify this statement and
explanation; and we might put the same question to some of
the other statements made by the author : even in the matter
of the " dry east wind" being, as he asserts, the most powerful
vehicle of dust, we have more than our doubts ; according to
experience, it would seem to be the moist wind from the opposite
quarter which is most potent.

Art. VIII. — On the Principles of ^Esthetic Medicine, or the
Natural Use of Sensation and Desire in the Maintenance of
Health and the Treatment of Disease, as demonstrated by
Induction from the Common Facts of Life. By Joseph Peel
Catlow, M.R.C.S. London, 1867. Pp. 325.

We have rarely met with a work having any pretensions to
science abounding more than this in vague and barren gene-
ralities. Its synopsis, the author's own, which is appended,
may give better than brief words of ours an idea of its
nature :

" Synopsis.

"The extensive postulates of the living system, with the
passive and active relations of living beings to each other and to
their common Creator, in all its modes of health and disease,
are naturally indicated by the susceptibility of the external
senses to perceptibly pleasant or organically congenial im-
pressions from their severally appropriate objects, as such
impressions are mutually modified'; and by the appetites or appa-
rent motions that are suggested or excited and modified by their
perception, remembrance, or incidence, independently, socially,
or casually induced."

Art. IX. — Recherches sur les Alterations des Arteres a la
suite de la Ligature. Par Th. Cocteau, Docteur en Medi-
cine, &c. &c. Paris, 1867. Pp. 7Q.

Researches on the Alterations in Arteries after Ligature. By
Dr. Cocteau.

This is a moderately well-executed little treatise by' a junior
practitioner, on a subject which has so often engaged the atten-
tion of great surgeons and profound experimental investigators,

1868.] Watson on Ea^cision of the Knee. 431

that a mere secondhand resume of their labours, such as this
is, cannot have any great value. Dr. Cocteau has not, as far
his treatise shows, any personal experience on the subject,
beyond a few experiments on animals. His literary acquirements
also appear to be confined to the writers in his own language,
and such English or other foreign authors as have been trans-
lated into French ; consequently the production before us can
only be used to show what is known in France at present on the
subject, and for this purpose, as the pamphlet is clearly written
and well arranged, we can recommend it to those of our readers
who are investigating the never-ending topic of the ligature of
arteries.

Art. X. — Ewcision of the Knee-joint ; a Description of a New
Apparatus for the After-Treatment, with Illustrative Cases.
By Patrick Heron Watson, M.D., &c. Edinburgh, 1867.
Pp. 78.

We have read with much pleasure this very interesting
pamphlet, with the object of which every surgeon who has had
experience of the operation must warmly sympathize. This
object is to extend the operation of excision from civil to mili-
tary practice. We need hardly point out how great an advance
this would be in conservative surgery, if only the operation
were not found too fatal. The present reviewer has pointed
outji in opposition to the opinion of Mr. Butcher, Mr. Price
and others, that the operation has been found, as hitherto
practised, more fatal under similar circumstances and in similar
cases, than that of amputation of the thigh ; and that this con-
clusion is a correct one, and is likely to be verified by more
extended experience, everything he has since seen of the opera-
tion, in a pretty extensive trial of it has tended to confirm. It
has appeared strange to him that this opinion should have been
so distorted that he has been represented on that account as an
opponent of excision. The fact seems to be that all excisions
which stand on at all equal grounds of comparison are more
fatal than the corresponding amputations. We must except
those of the shoulder and hip, where the deep position of the
joint, and the enormous wound left by amputation renders that
operation exceptionally fatal. Thus the experience of military
surgeons hitherto in excision of the knee-joint has been most
unfavourable. Even as compared with the sorrowful results of
primary amputation of the thigh, those of primary excision of

1 In our number for July, 1862.

43.2 Bibliographical Record. [April,

the knee have been most disastrous. A table given in the
present work (p. 27), shows only four recoveries out of eighteen
cases of resection for gun-shot injury. In eleven cases which are
reported in the circular (No. 6), recently issued from the
Surgeon-Grenerars office of the United States' Army, only two
are said to have survived, and one of these cases is believed by
the reporter to be unworthy of credit. Still the means for the
treatment of this operation have hitherto been imperfect, and it
is possible, as it is no doubt most desirable, that an improved
after-treatment may enable army surgeons to save limbs
by introducing excision in place of amputation in the less
extensive injuries. Dr. Watson's apparatus is intended to
obviate the necessity of confining the patient to bed continuously
for some weeks after the operation, as must be done in the
ordinary method of practice, a necessity which forms an almost
insuperable obstacle to this operation in most of the situations
of actual warfare. The apparatus consists " essentially of two
parts. 1st. A suspension-rod made of iron, about the size of
No. V, of trade wire guage; 2nd. A modelled Gooch splint,
long enough to extend from the tuberosity of the ischium to
beyond the heel." The rod is laid on the anterior aspect, being
bowed upwards over the wound, so as to avoid it, and bent to
the shape of the limb from the groin to the toes. It is provided
with one or more hooks to swing the leg. The rod being en-
veloped in lint, it and the splint are secured by a plaster-of-
Paris bandage, leaving the wound exposed. The splint is cut
away somewhat at the popliteal space, and has a large notch at
the lower part to receive the heel, and avoid any pressure on it.
The advantages claimed for this apparatus are : — " 1. The com-
parative comfort which the patient experiences, from the ease
with which he can shift his lying posture or assume the sitting
position without disturbing the adjustment ; 2. The facility
with which dressings are applied without detaching or removing
any portion of the apparatus ; 3. The permanence of the appa-
ratus, never requiring, when properly applied in the first instance,
to be renewed during the whole period of after-treatment ; 4.
The ease with which the apparatus can be obtained, its simpli-
city and cheapness,'"' (p. 21). As we have not used this appa-
ratus we cannot affect to give any opinion as to its merits.
Prima facie, it would seem that its advantages in keeping the
bones always in position must be somewhat and perhaps entirely
counterbalanced in civil practice by the impossibility of making
any change in the apparatus without removing the whole of it,
which is rather difficult to do without disturbance of the parts,
nor can we divest ourselves of the idea that if inflammation should
run high, as in the first few days it sometimes does, the unyield-

1868.] Watson on Excision of the Knee^ 4;33

ing case might make deleterious pressure on the tissues around
the wound. We have no doubt, however,, that if the operation
is ever to be introduced into military surgery, some immoveable
apparatus must be employed, and Dr. Watson's appears a very
convenient form. We shall certainly take an opportunity of
testing the proposal fairly in practice, and we would recommend
our surgical readers to do the same.

Appended to Dr. Watson^s pamphlet is a collection of cases,
twelve in number, equally divided between successes and deaths.
Observing this large proportion of deaths, we may venture to
remai'k that it appears to us evident from all we see and hear
of this operation that its mortality would be greatly lessened if
it were more clearly recognised as a truth that it is really a more
dangerous proceeding than amputation, and therefore must be
reserved chiefly for the milder and more chronic cases, and for
young persons. Leaving aside the question of the introduction
into general use of primary excision for accident, as not yet
determined, can we doubt that excision should not be practised
in cases of which the following summary can be given. " In the
first of the fatal cases (case 7), there was haemoptysis and
physical symptoms of phthisis pulmonalis. In case 8, dysen-
teric diarrhoea and pulmonary symptoms with constant dyspepsia
had existed for a long period. In case 9, the lad was tall,
overgrown, and emaciated from the very first. [Case 10 was one
of primary excision in a lunatic, set. 32, who had thrown herself
out of window. Pyaemia supervened.] In cases 11 and 12,
the patients were anaemic, had sufiered previously from, hepatic
afi'ections of warm climates, and from the whole progress of
their cases indicated the existence of some internal mischief.''
(p. 68.) It is quite true thtit Dr. Watson says the patients in
all these cases, except two, selected excision in preference to
amputation ; but, unless the greatly increased risk of excision
had been put to them, we should say they were not in a position
to form an opinion, if, indeed, this is a question which the
patient should ever be allowed to decide.

On a few other and minor points we should be disposed to
diff'er with Dr. Watson, as for instance with respect to the
removal of the patella, for retaining which Dr. Watson gives the
following reasons ; (1) Its removal is unnecessary in most cases ;

(2) Its presence in the flap bears up the soft parts from the
line of incision, and, without preventing consolidation, helps to
keep them away from the cut margin of either osseous surface ;

(3) Its removal occasions more bleeding, and (4) the hollow
left after its removal from the centre of the long flap, leaves a
hollow cavity in which matter bags, and requires a separate
incision to drain it efficiently." (p. 7Q.) We think, on tlie

484 Bibliographical Record. [April,

contrary, that the patella is often a source of subsequent disease
if left, that it is of no use whatever, if ankylosis is sought for,
and that there are no such complications of present bleeding and
future bagging of matter as Dr. Watson believes — at least in a
great number of excisions, in all of which we have removed the
patella, we never experienced them. With respect to ankylosis
we fully agree with Dr. Watson's views, in opposition to the
practice of Langenbeck, who attempts to preserve the mobility
of the limb. In the few cases in which we have found mobility
after excision, we have always seen reason to regret it ; for the
limb does not seem at all more useful, and is in constant danger
of becoming bowed.

On the whole we welcome Dr. Watson's work as a very
valuable contribution both to the literature and to the practice
of this operation. The suggestion which it is its chief aim to
enforce is likely to prove a very useful one, and the moderate
and impartial tone of the book, as well as its full statement of
the whole results of the operator's practice, are models of what
ought to be, but is not, the invariable method in which such
questions are to be discussed.

Art. XI.— 7%e Essentials of Bandaging, including the Manage-
ment of Fractures and Dislocations, with Directions for using
other Surgical Apparatus. Illustrated by 110 engravings
on wood. By Berkeley Hill, M.D. Lond., 1867. Pp.
167.

This is a very useful and practical little work, which we may
fairly recommend, not merely to students, for whom, however,
it is chiefly intended, but also to the more advanced practi-
tioners whose line of practice has not made them familiar with
surgical manipulation. Its directions are clear, easily carried
out, and are explained by a sufficient number of very good
illustrations. We know none of the works of this class which
Are should prefer to Mr. HilFs. A second edition will no doubt
be required, and if so Mr. Hill will have an opportunity of
amending a few errors and omissions which must inevitably be
found in a work of this kind, as well as for withdrawing any
unnecessary insertions. As an instance of the latter, we would
ask, whether it is necessary or desirable to describe the
apparatus for club-foot, which can only be very imperfectly done
in the space at Mr. HilFs disposal, and which no one would
think of ordering from a work of this description. Again, if
the dislocations are to be treated of, we think that thev should

1868.1 On Injuries of the Wrist, ^c, and Ankle-joint. 435

be somewhat more fully and satisfactorily described tban that of
the thumb is, for instance, at page 93. It is surely an unsatis-
factory statement of the case to say, that " with the greatest care
and perseverance it is sometimes impossible to replace the bone
unless the constricting bands be divided with a tenotome."
The direction in which the dislocation takes place, and the
cause of the difficulty of reduction should have been explained,
especially as this could have been done in a very few words.
The work is one which will, we have no doubt, become popular
amongst our students and dressers, particularly now that some
steps have been taken at the College of Surgeons towards prac-
tical examinations in surgery.

Art. XII. — Reports of Hospital Cases; On Injuries of the
Wrist and Ankle-joints. By W. M'Cormac, M.D., &c. &c.
Dublin, 1867. Pp. 24.

This little pamphlet contains the reports of five very interest-
ing cases : the three first of injury to the hand and wrist, in
one of which the whole carpus and the last three fingers, with
the proximal end of the second metacarpal bone, were removed at
the time of the accident, in a child of 10 years ; in the second
a very severe injury to the carpus and metacarpus was treated
by the expectant method with passive motion, in a woman
set. 25 ; in the third a similar method of treatment was pur-
sued in a similar injury to a healthy man set. 27. In all three
cases the hand was very useful. They show how much may
be done in preserving the hand from amputation after injury,
and the first is of especial surgical value, as proving the great
utility even of so small a portion of the hand as the finger and
thumb after the removal of the entire carpus.

The two cases of injury to the ankle are one of compound
dislocation, in which the patient (an intemperate man), set. 39,
would not permit amputation, and died of pysemia; and the
other in a man, set. 46, of compound dislocation of the astragalus,
treated by a resection of that bone, and with success — a very
useful limb being the result.

We can hardly say that any novel principle is illustrated by
this series of cases ; but we think them well worth publishing,
and congratulate Dr. M'Cormac on his success in saving useful
members after such serious injury.

436 Bibliographical Record. [April,

Art. XIII. — A Treatise on the Principles and Practice of Medi-
cine, designed for the Use of Practitioners and Students
of Medicine. By Austin Flint, M.D., &c. &c. Second
Edition, Revised and Enlarged. Philadelphia, 1867.
Pp. 965.

This is the second edition of a work which has obtained a
very rapid sale in the United States. The former issue was
exhausted in four months, a remarkably short time for a large
volume addressed to a limited class of readers, if we compare it
with the ordinary sale of scientific books in the old country. It
seems that a text-book on medicine was much wanted in the
class-rooms of the transatlantic schools and colleges; and there
were few authors, perhaps none in America, better qualified to
produce one than Dr. Flint. Our examination of the book has
given us a very favorable idea of it as a whole ; but, as it would
be impossible in the space available for this notice to give a de-
tailed account of its contents, we prefer calling attention to those
portions of the work which have been added in the second edition,
and to one or two passages contained in it which appear to us
likely to interest English practitioners.

The article on Pyaemia in the present edition has been re-
written, and may be taken as affording a fair specimen of the
character of the information which Dr. Flint's book contains.
It gives the reasons for and against the old hypothesis of the
absolute entrance of pus corpuscles from without, and the
theory of transport of pus, which gave rise to such names as
" purulent deposits" and " metastatic abscesses." Dismissing
these views as no longer tenable, the author gives a very clear
and good resume of the light which Virchow and his school
have thrown upon the hypothetical absorption and transmission,
and on the theory of the so-called suppurative phlebitis as the
cause of pysemia. Dr. Flint especially insists upon the vague-
ness of the information hitherto derived from the microscope in
the study of this disease. The close resemblance if not identity of
the pale blood-corpuscle and the pus-corpuscle might make it at
present impossible to discriminate by the microscope alone
between leucocythsemia and pysemia; and it is doubtless to this
close resemblance of the two kinds of corpuscles that the dis-
crepancies in the views of modern observers are to a considerable
extent due. He concludes

" That a morbid condition of the blood exists, giving rise to the
phenomena which have been considered as belonging to pyaemia is
not to be doubted ; but there is no proof that the presence of pus-

1868.] Flint's Principles and Practice of Medicine. 437

corpuscles lias anything to do with the production of these pheno-
mena. As already stated, experiments on inferior animals show that
the phenomena attributed to purulent infection of the blood may be
produced by injecting pus-serum without the pus-corpuscles."
(P. 91.)

A somewhat brief account of the symptoms of the condition
named pysemia, and of the treatment applicable to it, in which
however the experiments of Prof. Polli with the alkaline sulphites
are given full prominence, concludes the section.

Whooping cough is a disease which, as it is generally treated
of in works on diseases of children, was passed over in the first
edition. In the present one the author has given a succinct
account of its symptoms, pathology, and causation, in which, as
might be expected, we fail to find anything very new. The only
point in his summary of the various plans of treatment pursued
in pertussis which struck us as novel, is a mode of using atropia
in that disease, recommended by Dr. Brown- Sequard. At a
meeting of the American Medical Association in May, 1866,
that physician asserted that whooping cough might be cured in
three days by giving atropia in doses large enough to produce
delirium, and continued so as to keep up that condition for
three days, except at night, when the patient is to be quieted
with morphia or codeia. We do not wonder that Dr. Brown-
Sequard ingenuously added, that he found difficulty in getting
the parents to submit to this mode of treatment by an induced
delirium of three days'* duration. Moreover, he allows that this
plan of treatment will only cure the neuropathic symptoms ;
the bronchitis remains after it is discontinued.

General cerebral paralysis, or the paralysis of the insane has
obtained a notice in this edition which it did not receive in the
former. The author prefers the term general cerebral paralysis
to that of paresis on the ground that the latter " is applied by
writers to paralysis dependant on a functional condition of the
brain or cord, and he believes that the disease in question is
always associated with organic change in the brain.'' He also
objects to the designation " paralysis of the insane " the fact
that cases may present all the features of the paralysis without
mental derangement. Not only this fact, but post mortem
records prove to our minds that whilst a group of cases may be
classed together under the term general cerebral paralysis, it
will, in reality, include not essentially one, but many pathologi-
cal conditions. The author relates that of Austin's twenty-six
cases, in twenty-two the optic thalami were either softened, in-
durated, atrophied, hypersemic, or antemic, whilst the soft com-
missure, fornix, septum lucidum, corpora albicantia, crura

438 Bibliographical Record. [April,

cerebri, and corpora striata, were either usually or frequently
implicated. On the other hand, from the examination of fifteen
cases, and their comparison with fifteen other cases of mental
disease, Sankey was led to conclude that sub-arachnoid effusion
increased vascularity of the pia mater, adhesion of the pia mater
to the cortical substance, open convolutions, injection and
abnormal firmness of white substance, dark colour of grey
matter, and a varicose condition of the cortical substance of the
cerebral hemisphere, were common if not constant conditions in
the general paralysis of the insane. May it not be expected
that when cerebral pathology has advanced as much as renal
and pulmonary, the cases now classed as general cerebral
paralysis will resolve themselves into as distinct pathological
groups as have Bright's disease, and pulmonary phthisis.

A section on Polyuria or Diabetes Insipidus, in which Dr.
Flint has made use of Roberts's valuable analysis of seventy-two
cases, is also new. Dr. Flint describes a case which terminated
fatally at the Bellevue Hospital in which, as in one of the fatal
cases collected by Eoberts, the kidneys presented almost entire
destruction of the secreting substance, and had the appearance
of empty sacs. The ureters were greatly dilated, and the walls
of the bladder hypertrophied. The patient was a man set. forty-
two ; diuresis and excessive thirst had existed for two years.
The sp. gr. of the urine was 1008. It was free from albumen
and sugar. The patient died comatose ; the brain, lungs, and
heart were not diseased.

One interesting passage in the book refers to the alcoholic
treatment of phthisis which, as our readers know, has gained
considerable favour in North America. Dr. Flint gives the par-
ticulars of two cases of arrest, one being that of a man aged 42,
the other that of a young lady. In each a pint of whiskey
was taken daily for a very long period ; in the case of the young
lady for two years. Dr. Flint acknowledges that this treatment
does not answer in many cases, and that it is only upon a fair
trial that the effect of alcohol in any case can be adjudged.
With regard to the signs of usefulness or hurtfulness in any
case the author believes, from his experience, that if the imme-
diate effect of alcoholic stimuli be that of a cordial, if they pro-
duce a sense of comfort, and a greater disposition to exercise,
and if they do not excite unduly the circulation and nervous
system, benefit from their use may be expected. The limitation
as to quantity must be determined by their effects. He has
observed that a remarkable tolerance of alcohol is induced in
certain cases of phthisis.

On meeting with foreign books on medicine the reader turns
with interest to the descriptions of the diseases of the so-called

1868.J Flint's Principles and Practice of Medicine. 439

zymotic class. In the case of Dr. Flint^s book he will not be
disappointed. Under the head of continued fevers two epidemics
of interest are described, one of so-called erysipelatous fever,
which prevailed in New England, the middle Western and
Southern States from 1841 to 1846. In some localities large
numbers were affected, and the mortality was large. The fever
was popularly known as '' the black tongue,^^ and by Dr. H. N.
Bennett, who described it, was believed sometimes to follow the
direction of rivers, small streams, and lakes. Pharyngitis, ton-
sillitis, with occasional sloughing, laryngitis, and in some cases,
oedema glottidis were observed. Erysipelas occurred in about
one-sixth of the cases, and was apt to lead to gangrene and
sloughing. Puerperal peritonitis prevailed uniformly with the
epidemic. The other epidemic fever mentioned by Dr. Flint
was characterised by mild erythematic pharyngitis, and prevailed
in the State of New York in 1857. This affection seems to
have been neither scarlatina nor diphtheria, but bore an analogy
to influenza except that the pharynx was attacked, and not the
schneiderian and bronchial mucous membrane.

It will be remembered that cerebro-spinal meningitis or spotted
fever has, on several occasions, made its appearance in various
parts of the United States. We were, therefore, surprised not to
find the disease treated of, under the head of fevers. Dr. Flint
prefers considering it amongst the diseases of the nervous centres,
and gives as a reason its anatomical characters which separate it
from typhus, and its symptomatic phenomena, which are to a
large extent due to inflammation of the brain and spinal cord.
We must confess we think this an error of arrangement as the
history of the epidemics of the disease, its local prevalence, its
evidently toxical character as shown by the ecchymoses which
have given it one of its popular names, and its rarity as a
sporadic affection seem to affiliate it clearly to the zymotic
class.

In taking leave of Dr. Flint's book we would add that
although it is mainly a compilation, as all works of its kind
must necessarily be, it is a good one. We think it not un-
worthy to take a place in the same category with Watson, Wood,
and Aitken.

440 Bibliographical Record. [April,

Art. XIV. — Synopsis of the Pathological Series of the Oxford
Museum ; provisionally arranged for the Use of Students, after
the plan of the Hunterian Collection, and chiefly under the
Divisions of the Hunterian Catalogue. Oxford : At the Cla-
rendon Press. 1867.

This volume is intended as a guide to the student who is
commencing his pathological studies in the Museum at Oxford,
and we can heartily recommend it as well fitted to accomplish
the purpose for which it has been written. Its descriptions,
which were entrusted, and as it proves wisely, to Dr. Tuckwell,
formerly Radclifi'e Travelling Fellow, are exact and clear, yet
condensed, and the knowledge it imparts is well up to the mark
of the time. Some will think there is a little too much Virchow-
worship, but this may be unavoidable at the present day. The
remarks in the Introduction relative to the topics embraced by
Pathology are very much to the purpose. They recognise fully
that it is much more than pathological anatomy, even of the most
minutely scrutinising kind. It is one thing to note accurately the
distinctive features of a tubercle, a typhoid ulcer, or a fibrous
tumour, as far as our means of investigation permit ; and quite
another to expound how these lesions came to be. The story
of disease, as we would anglicise pathology, comprehends to our
thinking the fullest acquaintance possible with the conditions
which give it birth, with its causes. Herein we are inclined to
think that we of the present day are apt to boast ourselves
rather too much of the advances we have made. Not unfre-
quently, after poring over the dead tissue, and noting the ulti-
mate result of morbid changes which had probably been long
in process, we have painfully felt how little, after all, was gained
by the investigation, how far off we were from having attained
any understanding of the all-important actions by which these
changes were brought about. The study of the motors of
disease is the most pressing need of the present day. How
far pathology will avail as a " basis for the classification of
diseases" seems to us doubtful; there does not appear much
prospect of it at present. All notions of a strictly scientific
arrangement are, we believe, postponed by the soundest
thinkers to considerations of mere convenience. One point we
are glad to see noticed, viz., the variability of disease, the
greater malignity of the same disease, at least of what is so
reckoned, in one time or place than in another. Few more
besetting errors exist for the pathologist than the tendency to
regard all groups of phenomena which have a surface-similarity

1868.] Peet on Principles and Practice of Medicine. 441

as iawardly and truly alike ; e. g., to consider pneumonia,
dysentery, rheumatism, delirium tremens, as always identical
in all circumstances, and not to remember that the quality of
morbid action is liable to very great inconstancy.

We cannot close without expressing a thought which will
find general acceptance. There are workers in abundance, good
workers, clever, honest, able workers, but with very few excep-
tions, indeed, the mainspring of action, and an honorable one
too, is the desire of personal advancement. With Dr. Acland
it has been otherwise. A career more tempting to a man of
ordinary ambition lay open to him, and if he did not pursue
it, we believe it was because the form of duty beckoned him
elsewhere. To develope the energies and to direct the efforts
of a great University in the cultivation of biological study, he
has made the chief aim of his life. The results are now
apparent. Si monumentum quseris circumspice.

Art. XV. — The Principles and Practice of Medicine : designed
chiefly for Students of Indian Medical Colleges. By John
Peet, M.D. London and Bombay, 1864.

The author of this work has had a large field for experience
not only in Indian disease, but amongst Indian students, for he is
Principal and Professor of Medicine in the Grant Medical
College, and Surgeon to the Jamsetjee Jejeebhoy Hospital at
Bombay. In his preface he tells us that it has been his aim to
avoid as much possible controversy and speculation, and to
allot space to special diseases in proportion to their importance
and prevalence in tropical countries. He does not claim to have
issued a complete treatise on practice of medicine which might
rival existing standard works. An admission of this kind goes
far to disarm criticism, and to set the reviewer the more pleasant
task of finding out the excellencies of a work rather than that of
discovering and exposing its defects.

Dr. Pectus book is divided into two parts — the first treating
of general, the second of special pathology. Under the former
head the author considers pathogeny, or the nature and consti-
tution of disease, etiology, hygienics, and therapeutics. The
chapter on special hygiene contains some information on a sub-
ject— that of Indian native dietetics, clothing, and customs in
relation to disease — which we should be glad to see treated at
greater length. With regard to diet, as is well known, con-
siderable difference exists amongst the Hindoo classes. The

442 Bibliographical Record, [April,

Brahmins and Bunueas eat no animal food, and in the case of
other castes, who are omnivores, fish to a great extent takes the
place of meat. But in no case is animal food eaten as principal
part of diet ; it is rather used as a condiment to make other
food more palatable.

The staple food of the higher classes of Hindoos is rice ; of
the lower, grain of various kinds, many of which, however, are
so poor in nutritious qualities as to be insufficient to support
health. Dhall, which contains much nitrogen, is used with
rice. Ghee, vegetables, milk, and occasionally, on festivals,
sweetmeats and fruit, complete the dietary of the " mild Hindoo."
The quantity of solid food consumed daily is from eighteen to
forty ounces. As a rule, alcoholic liquors are not taken to excess,
but the same cannot be said of opium, bhang, and tobacco. Ac-
cording to Dr. Peet, when acute disease attacks the opium debau-
chee, it exhibits the same marked tendency towards fatal termi-
nation as in the drunkard. Asthenia, the consequence of
insufficient nutritious diet, is very prevalent amongst Hindoos.
The Mussulman takes a smaller bulk of food than the Hindoo,
but it is of a better character, more animal food and less rice.
The higher Parsees eat largely of rice, but allow more animal
food than the Hindoos. The lower Parsees, who cannot get
meat, are restricted to an inferior kind of fish. Dr. Peet points
out that the subject of native dietetics in relation to health and
disease has never received the attention it deserves, and that a
really good account of the diet of different castes with the nutri-
tive value of each is a desideratum. Clothing is very much
neglected by the natives of India, and the children amongst the
lower classes are left naked until they are seven or eight years
old. Exercise is discouraged, from religious and other prejudices,
amongst the Hindoos and Mussulmen ; but Dr. Peet states that
the Parsees are beginning to learn English games, and he pro-
phesies that future generations of this euterprising race will
not, as regards physical development,' fall far short of their
European brethren. Despite their frequent ablutions, the Hin-
doos are not a clean race ; their houses and clothes are filthy,
and disease often arises amongst them from dirt. There is a
strong and universal native prejudice against the use of water in
diseases attended with fever.

In the section on etiology, the author points out the influence
of certain native customs in favouring and producing disease.
Recent cholera visitations have made us too familiar with the
act that epidemic disease is spread through the agency of 'pil-
grimages and religious assemblies. Long fasts, early marriages,
the consummation of marriage in tlie female before puberty,
the customs connected with menstruation, when Hindoo women

1868.] Peet on Principles and Practice of Medicine. 443

are often insufficiently clothed and made to lie on the ground,
are amongst the causes enumerated by Dr. Peet as producing
uterine and other diseases — general weakness and premature
old age. Parturient women are shut up in close, dark, badly
ventilated rooms for forty or more days, during which time they
are completely segregated, and are subjected to irrational treat-
ment of various kinds. In fact, the author states that it is almost
impossible to exaggerate the evils resulting from the manage-
ment of the native women in the parturient state.

The second and larger part of the work, which treats of
special pathology, is divided into four sections, the three first of
which are devoted to diseases of the abdomen, chest, and head
and spine ; and the fourth to general diseases — fevers, cholera,
and blood diseases. In the first section, one of the most
valuable chapters is that containing the author's description of
acute hepatitis and abscess of the liver. This disease, so rarely
seen in England, but so common and fatal in India, is by no
means a scourge alone of Europeans who venture under a tropical
sky. Dr. Peet tells us that of ninety deaths from hepatitis
which occurred in the Bombay military and civil hospitals in
1861, rather more than one half were those of natives, and that
during the same period twenty-three native patients died from
the same disease in the Jamsetjee Jejeebhoy Hospital. It is
clear, therefore, that no amount of acclimatisation can prevent
the action of those causes which in India produce inflammation
of the liver.

In cases of hepatic abscess, Dr. Peet acknowledges the possi-
bility that under favorable circumstances the pus may be
absorbed. After unequivocal signs of hepatic abscess, it occa-
sionally happens that a patient may recover his health although
the abscess has never burst. Unfortunately, however, these
are exceptional cases. If the patient escape the dangers of
death from asthenia or peritonitis, the contents of the abscess
will be discharged through the lungs, through the stomach
and intestines, or by an external opening. Of these three
modes of outlet. Dr. Peet regards that by the lungs as most
favorable ; and he agrees with Dr. Morehead that evacuation by
the stomach and intestines is most rare, and least to be desired.

On the question of the relation of hepatic abscess to dysentery.
Dr. Peet is not inclined to accept the doctrine unreservedly
which assigns the former to the latter in the relation of effect
and cause. The theory of the absorption and transport of pus
from the ulcerated intestine he believes is not, in very many
instances supported by clinical observation. " The direct
vascular connection between the intestines and liver, by means
of the portal system of vessels, leaves little doubt that hepatic

444 Bibliographical Record. [April,

abscess may be produced by local pysemia ; but experience in
tropical countries has abundantly shown that this is not the
ordinary, nor indeed the most frequent, mode of its production"
(p. 245) . With regard to the treatment of hepatic abscess, the
author is thoroughly opposed to operative proceeding. On this
point he speaks with the authority derived from experience :
''"Whilst always believing the general adoption (of the practice
of opening the abscess) to be unadvisable, I at one time thought
there were exceptional cases to which it was applicable ; more
extended experience has convinced me that in no case is any
material advantage gained by it. The small abscesses in which
it would do no harm open of themselves ; whilst, in those which
do not reach the surface, an artificial opening increases the
patient's sufferings, and hastens his death.

He adds, in a footnote, " I here speak of abscesses which are
clearly apparent. Of the practice of pushing a long trocar
into the liver in order to search for an abscess, I have no expe-
rience" (p. 251).

On the whole, we can pronounce a favorable opinion of Dr.
Peet's book. If not quite so full and precise on certain subjects,
e. g. physical diagnosis and minute pathology, as our home-made
hand-books, we can give it the praise of being thoroughly prac-
tical in its aim and execution, and clear in its style. We think
it very well adapted for the class of Indian students to whom
it is specially addressed.

1868.] 445

PART THIKD.
©rifiinal (Srommunicationg.

Art. I.

On Strychnia Hypodermically administered in Paralytic Affec-
tions. By Chaeles Hunter, late Surgeon to the Royal Pimlico
Dispensary.

It is proposed in this communication, by the author, to point out
the advantages and disadvantages of administering strychnia by the
cellular tissue ; and to indicate, as far as his practical experience of
the use of that alkaloid has gone, what difference of action may be
expected when it is subcutaneously given, from its usual effects when
given by the mouth.

Pereira tells us that, " of all diseases for which nux vomica has
been employed, in none has it been so successful as in paralysis, and
it is deserving of notice that this is one of the few remedies whose
discovery is not the result of mere chance, since Pouquier was led to
its use by legitimate induction from observations of its physiological
effects.^'i

Valuable as strychnia has proved as a nervine tonic, and more
particularly in paralysis, there are some forms of nervous debility in
which it is not only useless, but even injurious.

Yery often strychnia has been given for a considerable length of
time in chronic paralytic affections with entirely negative results.
The question may be asked why the strychnia has been thus ineffi-
cacious, and whether the inertness has been due to its adminis-
tration by the mouth, or whether the lesion has been of some part
of the cerebro-spinal system over which strychnia has no specific
action ?

Now I think I shall be able to prove that the mode by which
this alkaloid is introduced into the system is one cause of difference
of action. That such is the case with morphia and atropia, when
introduced by different means into the system, I have long main-
tained, and am happy to see my views so thorouglily corroborated

' Pereira, ' Materia Medica,' vol. ii, p. 646.
82— XLi. 29

446 Original Communications. [-A-pril,

with regard to those particular alkaloids by the Hypodermic Com-
mittee of the Medical and Chirurgical Society, who have lately con-
cluded their investigations.^

And if morphine can be proved, when introduced into the cellular
tissue, to have greater rapidity of action, intensity of effect, economy
as to the amount required, certainty of action, and that certain un-
pleasant symptoms can be avoided by giving it by this means rather
than by the mouth, and if the same holds good with respect to some
other alkaloids, as I have shown that it does, it is not unreasonable
to anticipate certain advantages from the administration of strychnia
also by the cellular tissue.

It is somewhat curious but there seems to me to be a great pre-
judice on the part of many medical men against — or fear of, the
employment of strychnia subcutaneously, even with many who are
constantly injecting morphia, a drug which requires quite as much
care in its administration.

Certainly one has to study the dose which the constitution of the
patient requires more carefully with strychnia than some other
alkaloids, and to begin with a minimum rather than a maximum
dose, for the effects from a large dose may be almost too rapidly
generated to be subsequently beneficial. Some patients, moreover,
are far more susceptible of strychnia thus administered than others,
but such is also the case with morphia and opium. In one patient,
a lady who was suffering from injury to the spine and severe nervous
prostration, after a fall more than a year previously, I found the
■gVth of a grain of strychnia as large a dose as she could bear ;
on the other hand most patients bear well the -gig^th of a grain, and
some even the -a^th.

That this mode of administering strychnia is more powerful than
others is shown by the experiments of the Hypodermic Committee
upon rabbits, for they found that the yV^^^ of a grain of strychnine
was the smallest dose that killed by the mouth, the -sTrth of a grain
by the rectum, and the -rro ^h of a grain " by the skin'' as they call
it, but more correctly by the subcutaneous cellular tissue. That
committee give no experiments or observations of the therapeutic
effects in man, but allude to the experience of Dr. Biegel, '' who
found one case yield to this method,'' and to my own observations in
favour of its usefulness in certain cases.

I will now shortly detail a few cases of paralysis in which I have
injected strychnine with benefit ; at the same time I would remark
that one must not look for the astonishing or suddenly beneficial
results which seem to and do at times attend the injection of
anodynes in cases oipain, of delirium, &c.

Strychnine should be employed as a nerve tonic or nerve-excitant

^ We hope shortly to give our readers some accounts of these investiga-
tions.— Ed.

1868.] HuNTEB, on Strychnia Injections. 447

in cases in which active irritation is supposed no longer to be going
on about the clot or presumed cause of the lesion.

What we may fairly hope to expect when we inject strychnine is
to lind a beneficial result produced in~ a shorter time and from much
smaller doses than when it is given by the mouth, and benefit may be
expected evea in cases which have, as in case 1, been frequently treated,
for weeks together, by its stomachic administration without benefit.

Case 1. — Hemiplegia of six years' standing. John C — ,
set. 52 years. Had always enjoyed good health, and followed his
occupation in the brewery until six years ago, when, whilst at work
he was suddenly seized with loss of power on the left side of the
body. He has never since sufficiently recovered to permit of his
returning to his occupation, and the utmost he can do is slowly, by
the aid of two sticks, to walk about dragging after him the para-
lysed limb. In addition to the want of power, he nearly always has
pain, chiefly in the loins after walking a few yards, numbness and
coldness, and a sense of weight in the limb, and fatigue from very
trivial efforts, so that when out he has been accustomed to stand
still frequently to rest, and to walk much bent forwards, chiefly to
avoid pain in the loins.

This man had been a patient of mine at the Eoyal Pimlico Dis-
pensary on and off for several years with these symptoms and loss of
power over the bladder, and generally after a few months of
stomachic administration of strychnia and other tonics, the symptoms
have been moderated for a time. On the 24th of July, 1866, I put
him on the -^Vth of a grain of strychnia — the acetate — with sulphate
of magnesia, and some carminatives. This he continued for five weeks
twice a day without improvement, except as regards the loss of power
over the bladder.

On the 31st of August I began the subcutaneous administration
of the alkaloid, expecting little or no more effect, as so little amelio-
ration had attended the stomachic doses during three or four years.

To sum up briefly, this man, from August 31st to December 1st,
that is during three months, had twenty-two strychnine injections;
seventeen of these were in quantity the ^-^ih. of a grain, the remainder
were as strong as the -^i\\. of a grain. During the five weeks
which preceded the hypodermic treatment, he had taken as much as
three grains of strychnia by the mouth without any apparent or
palpable effects of the drug upon the paralysed limbs ; but direct
strychnine effects manifested themselves with \}cis, first as well as with
every succeeding puncture.

Ten injections were given during the first three weeks. The
results were : — 1. Eapid improvement in walking power, and in-
creased steadiness of gait. 2. The previous sensation of cold was
replaced by a sense of warmth of both legs, chiefly of the paralysed

448 Original Communications, [April,

one. This induced warmth has never quite subsided, and was always
well marked for some hours after the puncture, in fact he almost
complained of the heat the injections produced throughout his
system. 3. The " heavy-weighf sensation in the leg was replaced
by a sense of lightness of the limb. 4. The pain both of the loins
and leg were removed.

These good results have continued, and he can now walk several
miles, more upright, with comparative ease, with little or no pain,
and by the aid, for a time, of only one stick.

The question might be put whether the three grains of strychnia
previously given by the mouth did not materially assist in these
results, seeing that by the cellular tissue he only had altogether about
two thirds of a grain ?

My reply is simply that he had more than once taken strychnia
for two or three months by the mouth without such good results.
2ndly. That the effects from the injection were direct and compara-
tively immediate. 3rdly. They were such as have been described
spontaneously by other patients.

Case 2. — William J — , set. 60, of Belgrave Buildings. A tall,
thin, active, intelligent engine-driver was seized in September, 1863,
with right hemiplegia. He was at engine-work when the fit came
on. He became insensible, and had much fever, he says, for some
days. He gradually improved so as to be able to get about with a
stick, but the leg has very little power, feels heavy, and drags ; he
feels that there is no dependence upon it. The arm is weak, espe-
cially the muscles of the upper arm and shoulder, but he can grasp
with his fingers.

December 9th. — Omitted medicines by the mouth. I injected
the -g^th of a grain of strychnia into the arm.

10th. — He felt momentary pains in the course of the evening about
the muscles of the forearm and heel ; no muscular twitchings, but
less " stretchings'"* of the muscles. Repeated the injection.

11th. — Felt a lightness and freedom in the muscles of the limb.
Repeated injection of ^th of a grain.

12th. — Had a few slight muscular twitches in the lumbo-dorsal
region on both sides of body. Injected the -ro^^ o^ ^ grain.

13th. — The paralysed limbs feel stronger and lighter ; has had a
few twitches in the right side of the face, right arm, and both legs.

21st. — Has had three more punctures from ^V^h to -^V^h of a
grain. He had two or three punctures after this date, and by the
end of the month the power both in the arm and the leg had greatly
increased : he could turn his wife's mangle with the arm without
pain or fatigue ; he could stand steadily and strongly upon the leg,
and stamp the foot on the ground with some vigour. On the other
hand, during the ten weeks from the time of the fit to the time of the

1868.] Hunter on Strychnia Injections.

first puncture, no progress, of any note, had been made ; whereas

each puncture {save two) seemed to add fresh vigour to the muscles.

More jerking of the muscles occurred after the last few than after

the first punctures.

^ -x- * * -x- *

April 24th, 1864. — This man again came under treatment, not
for paralysis, but for cramp of the same leg. !For six weeks he had
hardly passed a night free from four or five attacks of cramp which
came only in the leg that had been paralysed.

I gave him a quarter of a grain of morphine subcutaneously ; no
cramp in the night ; a slight twinge in the morning.

26th. — ^Three attacks of cramp in the night. Repeated morphia
injection.

May 24th. — No cramp since.

October, 1866. — Keeps well; able to turn the mangle, and carry
parcels about, the leg remaining as strong as when the puncture was
omitted.

Case 3. — James N — , a sailor, set. 28. Came under my care
on the 25th of May, 1866.

He had received a bullet fourteen months before in the dorsal
region when at Shanghai. The bullet had entered close to the
posterior border of the right scapula, and is somewhere deeply im-
bedded close to the spinal marrow. Paralysis came on gradually
from that time ; but it became much worse after he had been ship-
wrecked off Hong Kong eight months ago. He was two months in
the hospital at the latter place. Strychnine was there given him by
the mouth for some weeks -, it caused jumping in the leg which is
paralysed, but did not increase the power of the muscles.

He now walks very slowly and carefully with two sticks, and
drags the left leg almost like a log; sensation is much impaired ; leg
still jumps occasionally, and would give way at once if he were to try
his weight on it ; has pain in the back and loins after walking many
minutes.

It was doubtful to what extent power could be restored in this
case if, as seemed probable, the bullet was mechanically interfering
with the transmission of nerve power, the more especially as strych-
nine, as above mentioned, had already been given by the mouth
without effect.

On May 25th, 1866, I injected the V^th of a grain of strychnia
into the cellular tissue of the upper arm, and on the 27th, the same
amount into that of the leg.

28th. — Can put the foot more firmly on the ground. Some jump-
ing of the leg after both punctures ; no jumping of the right leg.

28th and 30th. — Repeated the same dose. Leg decidedly stronger
and feels as if it now belonged to him, no longer like a heavy weight ;

450 Original Communications. [April,

can lift the foot higher, and he can now (after five punctures) just
momentarily bear his weight on the foot without pressing on his sticks.

June 9th. — I diminished the dose to the -jVth of a grain still
injected every second, third, or fourth day.

29th. — Can now walk two hours without feeling fatigue, and
without that pain in the leg and loins which used always to occur
after very small efforts. The leg now feels quite supple and
'' sensible."

July 33rd. — Up to this date this man has had twenty- six injec-
tions from the 25th of May, just over two months, and altogether
has had less than one grain injected during that time. The follow-
ing are the chief results from the last few punctures. The -g'^th of
a grain suits him better than the -^Vth of a grain ; it causes much
less jumping, at the same time it always causes the leg to feel
lighter and looser, and as if life had come into the heavy useless
painful weight it formerly was to him.

October 28th. — He comes up once a week from Barnes to report
progress. He can now easily walk three miles without stopping to
rest, and without pain in the loins, and can walk across the room
without his sticks. These good effects still remained when I saw
him nearly one year after I had ceased to attend him.

Case 4. — Several injections of strychnia were given to a young
woman who for some years had suffered from incessant muscular
jactitations, frequent attacks of sickness, pain, and debility of the
spine. The doses injected were from the 4Vth to the uV^h of a grain.
This patient had received great benefit from the atropia injection,
and was not told that the agent injected was different.

The chief effects observed by her were a sensation of warmth in
the spine, of greater strength and less pain in the muscles of the
neck j the sickness of stomach was also removed by it.

Case 5. — Mr. W — , a publican, came to me on the 23rd of
March, 1866. For the last three weeks he had complained of
numbness of the legs and feet, of the sensation of pins and needles
in the latter, and a fear of walking without holding or looking to see
his feet. Is a sallow, puffy, unhealthy-looking man, temperate, bowels
regular, urine often loaded with lithates, and difficult to pass at times,
no albumen in it. Has the tight pain or band across the stomach.
I put this patient upon alkalies, and the Vrth of a grain of strychnia
twice a day by the mouth. He improved a good deal, sold his
business, and went into the country.

On October the 23rd, he came back to London. Had been going
on pretty well until three weeks ago, when his legs again stumbled
and he could now only walk slowly and with difficulty. Urine again
loaded with lithates, more loss of power over bladder, bowels, &c.
I ordered him alkaline saline by the mouth for the state of the

1868.J Hunter on Strychnia Injections. 451

kidneys, &c., and this time gave him the strychnia subcutaneously,
with the following results : — Decided increase of power of muscles
of the legs and hips ; he could, after five punctures, get up from
sitting on a low chair, without supporting himself as before with his
hands. Usually feels a warmth of both legs, increased diaphoresis,
" live-blood " as it were circulating in his thighs, generally also a
stiffness, but no jerking thirty minutes after each puncture, less fear
of falling when walking, diminution of the numbness and trembHng
of the legs, and increased walking power.

He had ten punctures altogether, some in the arm and some in
the thigh. The doses were from ^th to -g^th of a grain.

Case 6. — John B — , set. 31. Came to me in March, 1866,
with loss of power of the muscles of the left arm and forearm,
consequent upon bruising and dislocation of the shoulder-joint some
weeks before. Most of the bruise had disappeared, but the power
did not return, as indeed it often wiU not for months ; he. could not
grasp anything, nor pick up things. I ordered an iodine and
camphor liniment for some days without benefit resulting, and then
had recourse to the injection of strychnia.

This man had seven punctures; three of which were into the
muscles themselves, and four into the cellular tissue of one arm or
the other. The chief effects observed by this patient were, 1st. He
felt the influence usually in ten to fifteen minutes, viz., tingling in
the fingers of the affected limb, some pains in, and increased tempo-
rary power of the muscles of the arm.

The power returned quicker in the muscles of tl^e arm than did
the activity to the fingers.

He did not notice any difference in the time in which the effect
was produced, whether the injection was made into one arm or the
other; but thought the fingers felt its influence most when the
strychnia was injected into the pronator muscles. The dose in this
case varied from the -^Vth to the -^Vth of a grain.

Case 7. — William B — , left hemiplegia. Came to me
November 30th, 1867. Has had left hemiplegia for two years and
a quarter, since a fit, which came on suddenly after two or three
previous threatenings in August, at Madras ; he was a soldier at the
time. The left leg now drags, and he cannot walk (with his stick)
more than fifteen minutes without the leg becoming stiff and painful ;
constantly has cramp in it at night, usually three or four times.
The arm is very useless, and the mouth is still partially drawn ; he
seems very nervous, and frequently laughs when he should not ; sleeps
well, bowels regular, tongue clean, frequent micturition, urine healthy.

January 30th. — Has had eighteen punctures in two months, with
the following results : — Feels generally stronger, not only in the
limb which is paralysed, but " in himself.''^ Has much more control

452 Original Communications, [April,

over his muscles. He looks less foolish, and hardly laughs now as
before without occasion. Always feels " warmer all over " after
each puncture ; feels more power and warmth for some hours in the
leg after the injections, which were all made into the cellular tissue
of one of the arms.

In this man it is the arm, contrary to my experience in the majo-
rity of cases of hemiplegia, which has received the most benefit;
he can grasp much firmer with it, and hold weights which he could
not when he first came ; he is less nervous, and looks as if he now
had some energy and will of his own ; it is also interesting that the
cramps in his leg which used, for many months, to wake him up at
night, have never returned the last six weeks. This patient is still
under treatment.

Bemarhs. — The effects obtained from the hypodermic use of
strychnia are not so remarkable as are those which are constantly to
be observed from the injection of atropia or of morphia. This is
easy of explanation. Anodynes and narcotics are agents acting
especially on nerves of sensation, and on nerve-centres, and are most
valuable thus employed in acute affections, such as delirium tremens,
acute mania, of intense pain, &c. Strychnia is a nerve-tonic, and
nerve-excitant, and its employment is chiefly valuable in cases of
palsy and nerve atony, after all acute symptoms or causes have sub-
sided. But because the case is one in which time is required to
assist the action of the remedy, there can be no reason against trying
to shorten the period required for the cure, or to limit the amount of
the drug from which we expect benefit to accrue.

The chief advantages to be derived from the hypodermic use of
strychnia are,

1st. As a therapeutic test, for three or four injections will almost
always show if strychnia has any power or not over that particular
palsy. If they have no effect it is almost useless to continue their
employment.

2nd. It is economical, both as regards amount of {a) alkaloid to
he used, and (^) time required for it to affect the system.

{a) There is a great saving of the amount of strychnia required
by this means over the stomachic employment of the same drug.
The saving may be put at five-sixths of the amount which would be
given by the mouth. For, as far as my observation goes, the gVth
of a grain, injected every other day for thirty times, will consume
just one grain of strychnia in sixty days : now if the somewhat ordi-
nary dose of Vo^ti of a grain is given twice a day — and some
physicians order the -^^ and even the -rVth of a grain for a dose —
it is evident that, in the sixty days, as much as six grains of strychnia
are taken into the stomach. But, in cases of paralysis, where its
continuance seems necessary, I do not, as a rule, inject the strychnia

1868.1 Hunter on Strychnia Injections. 453

more often than twice a week, so that the saving is nine rather than
six times less than the amount which experience shows us has to
be given by the mouth for a reasonable amount of benefit to ensue.

Nor need this saving of material be considered remarkable nor the
results singular. The experience of many medical men who have
largely employed quinine injections in ague and fevers in India,
Italy and the West Indies, is quite in accordance with my results
with strychnia. Dr. Moore, of the Bombay Medical Service, thinks
four or five grains of quinine under the skin are equal to five or six
times that amount taken by the mouth ; and this opinion is confirmed
by Drs. Chasseaud and McCraith of Smyrna, by Dr. Desvigne in
France ; and more recently by Dr. Huggins and his colleague at San
Fernando in Trinadad.

{b) In addition to the ultimate tonic effects of the strychnia
being more quickly gained, and from a smaller amount of material,
we have also manifested, by its introduction into the cellular tissue,
certain phenomena indicative of the immediate or direct primary
action of the agent upon the system. These are, Istly, a general
warmth or glow of the cutaneous surface. This warmth is expe-
rienced by nearly every patient, especially those benefited by the
injection.^ It is most felt in the paralysed limbs and down the
spine, and at times making the patient " quite hot all over.^' This
sensation lasts a few hours, according to the strength of the dose.
2ndly, a sensation of lightness and freedom in, and a removal of the-
"heavy-weight" sensation of the paralysed part. The leg often feels
"light as a cork," and, tirdly, increased temporary power which
also generally begins in about twenty minutes, and lasts for perhaps
some hours.

As regards the jerking of the muscles. This symptom of the action
of strychnia appears to me to be of less frequent occurrence than
when strychnia is given with a similar object in view for a lengthened
period by the stomach. It seems practically to be the case, as might
theoretically be conceived, that the primary tonic effects — namely,
greater power and improved nervous sensibility — should follow the
small strychnine injections, sooner and more effectually, than after
the system has, by slow degrees, absorbed enough strychnia which
has been administered stomachically, and the quantity of which so
given has been perhaps three or four times as much as has really
been necessary. When, on the other hand, muscular " twitchings,"
spasms, or cramp, have accompanied the palsy or numbness
previous to the employment of the strychnine injection, those
irregular muscular movements seem very quickly to yield to the

1 Diaphoresis is a more frequent effect from the injected strychnia, especially
of the paralysed side of the body. The warm glow is always observed by patients
to be entirely or chiefly in those parts supplied by the paralysed nerves, even
when the strychnia is injected into remote healthy parts.

454 Original Communications. [April,

tonic influence of the puncture, as in case 1, and in a bricklayer
now under treatment.

Thus far, then, in favour of the hypodermic injection of this
alkaloid. What, on the other hand, are the disadvantages of this
method ?

That great care is necessary lest too large a quantity should be
injected of this agent, I need not point out : far better, therefore,
always is it to inject a minimum than a maximum dose, say from the
-s\i\\ to the -Jo^th rather than from the -TjLth to the Vo-th. As a rule,
however, the -aVth of a grain will suit most cases in which a tonic
effect is desired upon a paralysed muscle or nerve.

I think it as well to mention that in two out of about twenty- five
patients in whom I have injected strychnia a carbuncular state of
the nose, or rather a collection of small boils arose. It is ques-
tionable to what extent, or whether or not, the strychnia injection is
to be blamed. We know that belladonna will, at times, produce a
rose-rash, and this is especially the case with atropia, its alkaloid,
when injected.

Both of the patients who had the boils produced about the nose,
had had a good many injections ; one was the sailor with the gun-
shot wound in the spine whose case is mentioned above ; and the
other was an Indian officer who had for years suffered from neuralgia
and muscular prostration, consequent on — according to Brown-
Sequard — " congestion of the spinal marrow."

I have seen no ill results from the injection of strychnia such as have
been described as following the injection of the acetate or sulphate of
quinine. Those salts seem, in many cases, to have set up severe
irritation, and subsequent sloughing of the cellular tissue, and even
tetanus has been attributed in two cases to the injection of that
alkaloid. Strychnia is, however, innocuous to the cellular tissue,
and scarcely ever causes the least smarting, burning, or other local
sign of irritation, when injected. Nor would quinine, as far as my
experience goes, if some more basic salt than those above alluded to
was used.

Art. II.

Cases of the sudden death of Infants in circumstances suggestive of
their having been "overlaid." By Feancis Ogston, M.D.,
Aberdeen University.

Cases such as those that follow not unfrequently present them-
selves both to the medical jurist, and the private practitioner, and
are sure to awaken, if they do not always justify, suspicion of inten-
tional violence, or inexcusable negligence. The suddenness and

1868,] Ogston on Sudden Death of Infants. 455

unexpected death of the infant previously supposed to be in health
and vigour, is apt to lead to the imputation of blame to the mother
or nurse. In the instances of this sort which have come under our
notice, the illegitimacy of the infants in the mass of our cases, and
the interest of the mothers in the opportune removal of their nurslings
had been sufficient to awaken suspicion and justify the inquiries set
on foot by the law authorities.

With but little alteration of the non-technical phraseology of the
original reports, the subjoined outline of these will be arranged, as
far as practicable, into such groups as they appear naturally to divide
themselves.

Case 1. — Susan G — 's female infant, set. three weeks. Eound
dead in the cradle after a reported sleep of two hours.

Post-mortem. — Lower jaw, knees, and ankle-joints rigid. Lips
and nails blue ; left sides of the head, face, trunk, left thigh, and
right lower extremity livid. Tongue protruded beyond the gums
in front. Great toes flexed; nothing unusual in the head, the
spinal column, the mouth, throat, gullet, or air-passages. Eight
cavities of the heart distended with dark fluid blood ; its left cavities
empty. Lungs expanded; of a deep red colour, moderately con-
gested, and everywhere on pressure yielding a copious flow of thin
colourless fluid (serum) . Milk curd in the stomach ; milky fluid in
the lacteals.

Case 2. — Female infant, set. two months. Found dead in bed.
Lips and dependant parts of the trunk livid. Fingers closely con-
tracted; thumbs drawn in to the palms; joints rigid. Pia mater
injected. From two to three drachms of clear serum at the base of
the brain. Interior of the trachea moderately and uniformly red-
dened. Eight cavities of the heart distended with fluid blood ; its
left cavities half-filled with dark clotted blood. Lungs slightly
congested, and giving out on pressure thin frothy fluid (serum).
Milk curd in the stomach.

Case 3. — Eobert E — , set. five weeks. Found dead in the cradle.
Pupils dilated ; joints of the lower extremities rigid. The dependant
parts of the head, trunk, and limbs, livid. Clear yellow fluid,
(serum), escaping from the right nostril. About two teaspoonfuls
of clear serum at the base of the brain. A yellow fibrinous clot
filling and distending the right cavities of the heart ; left cavities of
the heart almost empty. Dark fluid blood in the lungs, liver, and
kidneys. Clear yellow fluid (serum), in quantity, in the lower lobe of
the left, and the two upper lobes of the right lung. Stomach empty.

Case 4. — Matilda McL — , set. six months. Found lying dead
beside its mother on a roadside, the mother in a state of intoxication.

456 Original Communications. [April,

The dependant parts of the head, neck, and shoulders, shghtly livid,
ringer-nails blue; joints rigid. Tip of the tongue protruded
beyond the jaws. Pia mater injected ; puncta vasculosa pretty nume-
rous in the brain. A little clear serum in its ventricles. Dark
fluid blood on both sides of the heart, but in excess in its right
cavities. Two drachms of serum in the pericardium. Surfaces of the
aorta and pulmonary artery, minutely injected. Frothy mucus in
the trachea. Thin frothy mucus filling the bronchi and their larger
divisions. Lungs expanded, dark hued, firm, congested, and their
air-cells filled with reddish, frothy (mucous) fluid. The liver,
smaller intestines, and kidneys congested. A little curdled milk in
the stomach.

Case 5. — Georgina McK — , set. two months. Pound dead;
mother intoxicated. Lips blue. Livid patches on the right side of
the face, the upper and fore parts of the thighs, the groins, the
sides of the arms, the front of the left leg, and the dependant parts
of the head, trunk, and limbs. Tip of the tongue protruded ; joints
rigid. Thumbs drawn in to the palms, and the fingers firmly closed
on them ; great toes partially bent. Feculent matter at the nates.
Pia mater injected ; moderate congestion of the brain and its sinuses.
About three drachms of serum collected from the ventricles, and the
base of the brain. A moderate quantity of reddish serum issuing
from the upper part of the spinal canal. A thin reddish frothy
(mucous) fluid filling the trachea, bronchi, and air-cells of the
lungs. Lungs expanded. Serum in the pericardium and cavities of
the pleura. Blood, chiefly fluid, in excess in the right cavities of
the heart. Blood, mostly clotted, in sparing quantity in the left
cavities of the heart. The roots of the lungs, the liver and the
kidneys, moderately congested ; about a teaspoonful of milk curd in
the stomach. On laying open the spinal column a firm clot of blood
was detected external to the theca vertebralis, at back part extend-
ing from the atlas to the seventh cervical vertebra, and, thickest in
front of the bodies of the second, third, and fourth of these bones.
Fluid blood also found eff'used within the theca of the cord from the
first to the tenth dorsal vertebrae.

Case 6. — James A — , set. two months. Found dead in bed. Lips
and nails blue ; lividities over the right shoulder, the upper and fore-
part of the chest, the lower half of the belly, the groins and tops of
the thighs, and the dependant parts of the body. Fingers closely
contracted ; thumbs drawn in to the palms ; joints rigid. Pupils
broadly dilated ; a little dried blood at both nostrils ; thick frothy
mucus issuing from the right nostril. Scalp bloody. Sinuses and
veins on the surface of the brain very much loaded with dark fluid
blood. Larynx and upper part of the trachea very much reddened.

1868.] Ogston on Sudden Death of Infants, 457

and containing a quantity of frothy mucus of a bright red colour.
Right heart full of dark fluid blood, left heart empty. Poramen
ovale of full foetal size. Lungs, liver, and kidneys loaded with dark
fluid blood. Curdled milk in the stomach.

Case 7. — Male infant, set. nine days. Pound dead in bed. The
body weighing 4 lbs. 3^ oz., measuring 18 inches, and 10^ inches
from the vertex to the centre of the navel. Fingers and toes closely
bent ; finger-nails of a very deep blue, approaching to black ; lips
blue. Tore part of the chest, and the dependant parts of the trunk
reddish. Face sallow ; belly greenish ; joints rigid ; pupils broadly
dilated. Impressions of the gums on the upper and lower surfaces
of the tongue near its point. Cerebral sinuses and veins loaded
dark fluid blood. A little bloody mucous fluid in the back part of
the mouth, and in some quantity in the trachea. Portions of the
lower lobe of the left, and the margins of the inferior lobe of the
right lung consolidated. Right side of the heart distended with
dark fluid blood. Little blood in the left heart. Stomach and
intestinal tube completely empty. Pcetal vessels closed.

Case 8. — Jane P — , set. ten weeks. Pound dead in bed. Lips
and dependant parts of the head, trunk, and limbs, livid. Fingers
bent, and thumbs closed upon them. Left great toe flexed. Tip of
the tongue projecting beyond the gums; joints rigid; scalp pale
and bloodless. Contents of the cranium normal; muco-purulent
fluid in the lower part of the trachea. Right lung reddened through-
out, non- crepitant and firm to the feel. Left lung partly consolidated,
partly yielding a copious quantity of serous fluid on pressure.
Fluid blood, in about equal quantities, in both sides of the heart.
Foramen ovale open. Intestinal tube pale and bloodless. Milk
curd in the stomach. A small serous cyst in one of the ovaries.

Case 9. — ^Elizabeth O — P — , set. three months. Pound dead in
the cradle. The fingers and dependant parts of the body livid.
The thumbs drawn in to the palms, and the fingers clenched on
them ; the toes flexed. The point of the tongue protruded beyond
the gums. A thin yellowish fluid in the nostrils. Joints stiff.
Frothy muco-purulent fluid filling the trachea and bronchi. Excess
of serum in the pericardium. Left lung consolidated and infiltrated
with pus ; cells of the right lung filled with clear yellowish frothy
fluid (serum). Fluid blood in the heart, in greatest quantity on its
right side. Milk curd in the stomach. Liver loaded with blood.

Case 10. — Male infant, set. eleven days. Pound dead in bed. The
body weighing 5 lbs. 13 oz., measuring in length 19i in., and 10|-[in.
from the crown of the head to the centre of the umbilicus. The

458 Original Communications. [April,

joints rigid. Slight projection of the tongue bejond the jaws, with
impressions of the gums on its upper and lower surfaces. The left
cheek and genitals bright red. Lividities more or less distinct on
the left side of the neck, the front of the chest, the left side of the
belly, the shoulders, the back of the right hand, the groins and
upper parts of the thighs, and the dependant parts of the head,
trunk, and lower extremities. Thin frothy fluid at the nostrils.
Fingers and thumbs closely bent ; finger-nails blue. Scalp bloody.
Sinuses and veins on the surface of the brain, turgid with dark fluid
blood. A little milk curd in the throat and upper part of the
trachea. Dark fluid blood in large quantity in the right, and in
sparing quantity in the left heart. Lungs much congested with
dark fluid blood. Stomach full of curdled milk. Foetal vessels
contracted.

Case 11. — Male infant, set. four days. Found dead at a road-
side beside its mother in a state of intoxication. A general blush
of redness over the surface, deepest on the left side and back.
Front of the neck and the sides of the belly also greenish. Larger
joints flaccid. Fingers and thumbs closely flexed. Great toes
flexed. Scalp, bones of the head, and the contents of the cranium,
all much loaded with dark fluid blood. Dark fluid blood on both
sides of the heart, but chiefly on its right side. Lungs, liver, and
kidneys, considerably congested with dark fluid blood. Milk curd
in the stomach. Ductus arteriosus and umbilical arteries contracted,
but containing a thread of clotted blood.

Case 12. — Male infant, aet. three months. Found dead in bed.
Larger joints flaccid ; flngers and thumbs flexed ; flnger-nails blue.
Dependant parts of the body reddish, the eyelids and forepart of the
trunk greenish. Cornese opaque; anterior fontanelle depressed.
Point of the tongue protruded and marked by the gums. Scalp
bloodless. Veins on the external and figured surfaces of the brain
turgid with blood. Pia mater minutely injected. Interior of the
brain pinkish. 5vj of clear serum at the base of the skull. Eight
cavities of the heart distended with dark fluid blood. Blood of the
same character, but in much less quantity, in the left cavities of the
heart. Lungs, liver, spleen, and kidneys considerably congested.
Whitish farinaceous fluid in the stomach.

Case 13. — Female infant, set. five days. Found dead. Face of
a brownish red. The neck, vulva, and nates, reddish. Lips and
nails livid. The thumbs firmly drawn in to the palms, and the
fingers closed on them. Toes flexed; joints rigid. Tongue pro-
truded beyond the gums, and its tip and the interior of the mouth
livid. A httle frothy mucus at the bottom of the trachea. Thymus

1868.] Ogsio^ on Sudden Death of Infants. 459

gland, pericardium, and the surfaces of the heart, aorta, and pulmo-
nary artery minutely injected. The cavities on both sides of the
heart, the veins on its surface, both vense cavse, the aorta and pul-
monary artery, all distended with dark blood, mostly in a clotted
state. Lungs collapsed, of a bright red colour, crepitant through-
out, and very much loaded with dark fluid blood. Thymus gland
congested. Liver, spleen, pancreas, and kidneys much congested.
Intestines minutely injected. Colourless glairy fluid in the stomach ;
meconium in the rectum, and sigmoid flexure of the colon. Ductus
arteriosus, and ductus venosus contracted and empty, as was the
umbilical vein. Scalp vascular ; veins on the surface of the brain
turgid. The pia mater minutely injected ; the interior of the brain
mottled with red patches.

Case 14. — James Alexander D — , set. ten days (?). Pound dead
in bed. Lividities on the right upper extremity, upper and fore-
part of the chest, the lower part of the belly, the groins, and the
dependant parts of the head, trunk, and lower limbs; lips and
finger-nails blue. Joints stiff; fingers closely contracted, and
thumbs drawn in to the palms of the hands. Pupils dilated. A
little dried blood at both nostrils ; tough, frothy mucus at the right
nostril. Scalp bloody ; veins on the surface of the brain very much
loaded with dark fluid blood. Upper part of the trachea very much
reddened, and filled with a frothy fluid (mucus) of a bright red
colour. Eight cavities of the heart filled with dark fluid blood ; its
left cavities empty. Poramen ovale open. Lungs, liver, and
kidneys, loaded with dark fluid blood. Milk curd in the stomach.

Case 15. — Male infant, set. twelve days (?). Pound dead in bed.
Diffuse redness, more or less deep, of the lips, sides of the trunk,
thighs, legs, and forearms, and on the dependant parts of the head,
loins, and lower extremities. Joints rigid ; thumbs drawn on to the
palms and the fingers clenched on them. Jjeft great toe flexed.
Impressions of the gums on the upper and lower surfaces of the
tongue, near its tip ; anterior fontanelle depressed. Scalp bloodless";
less blood than usual within the head ; mucous fluid in the lower
part of the trachea, containing a very few air-bubbles. Dark fluid
blood on both sides of the heart, but in greater quantity in its right
than in its left cavities. Capillary ecchymoses on the thymus gland,
the inner surface of the pericardium, and the surfaces of the heart and
lungs ; pretty numerous in the lungs. Milky fluid in the stomach.
Intestinal tube throughout ansemious. Liver and kidneys congested.
Ductus arteriosus of nearly its full foetal size ; the other foetal vessels
closed.

Case 16. — Male infant, set. three months. Found dead in bed

460 Original Communications. [April,

beside its mother. Dull diffused redness on the front and inside of
the right thigh and right arm, and inside of the left thigh. Lips
blue ; belly greenish. Tongue protruded beyond the gums. Pupils
dilated. Joints flaccid. Fingers of the left hand contracted. Capil-
lary ecchymoses on the right lung, heart, and thymus gland. Dark
fluid blood, about equally distributed on each side of the heart.
Lungs considerably congested, and rather less crepitant than usual.
Pulpy matter in the stomach. Pia mater on the free and figured
surfaces of the brain much injected. Brain soft. Scalp bloodless.

Case 17. — Charles P — , set. eleven weeks. Pound dead in bed,
mother intoxicated at the time. Joints rigid ; thumbs drawn in to
the palms, and the fingers firmly closed on them. Tip of the tongue
protruded beyond, and impressed by the gums. Livid patches on
the sides of the face, right side of the trunk, front of the left shoulder,
outside of the left thigh, insides of the right thigh and leg, and the
dependant parts of the head and trunk. Body emaciated ; anterior
fontanelle depressed; scalp slightly vascular; pia mater vascular.
Interior of the brain containing rather more blood than usual.
Excess of clear serum at the base of the brain, and upper part of the
spinal canal. Prothy mucus with minute air-bubbles filling the
trachea, bronchi, and air-cells of the lungs. Lungs bulky. Capil-
lary ecchymoses on the surfaces of the lungs. Eight cavities
of the heart distended with dark fluid blood ; its left cavity
almost empty. Gall-bladder distended with bile ; liver and kidneys
congested. Capillary ecchymoses on the lower surface of the liver.
Stomach empty.

Case 18. — Pemale infant, set. five days. Pound dead. Weight
4 lbs. 8 oz. Length \1\ in. : centre of the body two inches below
the navel. Diffuse redness of the skin over the head, face, neck,
shoulders, groins, and dependant parts of the trunk. Nails blue;
pupils dilated ; thumbs drawn in to the palms, and the fingers closed
on them. Joints generally flaccid. Blood (dried) around the lips and
nostrils, and (moist) on the lower surface of the tongue. Cerebral
sinuses and veins moderately congested. Thin frothy fluid in the
trachea, and abundantly in the air-cells of the lungs. The lungs
expanded, weighing 990 grains, covered with minute capillary
ecchymoses, their air-cells over their left lower lobe unusually ex-
panded, with minute depots of effused fluid blood in the substance
of their right lowest lobe. Dark fluid blood in the cavities on both
sides of the heart, but in greater quantity on its right, than on its
left side. Ductus arteriosus partially contracted. Poramen ovale
of full foetal size. Milk curd in the stomach. Osseous points at the
lower part of the femur.

Case 19. — Mary J — , set. seven weeks. Pound dead in the

1868.J Ogston on Sudden Death of Infants. 461

cradle. Pupils dilated. Point of the tongue slightly protruded
beyond the gums. Thumbs drawn in to the palms, and the fingers
firmly closed on them. Toes of the right foot flexed. Joints gene-
rally flaccid. Pinger and toe nails blue. Lividities on the fronts
of the thighs and legs, portions of the fronts of both arms, the right
side of the neck, and on the dependant parts of the head, neck, loins,
and lower extremities. Scalp pale and bloodless. Arachnoid
minutely injected. Cerebral sinuses full of blood. Serum, in some
quantity, at the base of the brain. Thin frothy fluid in the trachea,
bronchi, and copiously in the air-cells of the lungs. Capillary ecchy-
moses on the opposed surfaces of the lungs ; intralobular emphysema
to a small extent at several parts of the free surfaces of both lungs.
Dark fluid blood in the cavities on both sides of the heart, but in
greatest quantity in its right cavities ; kidneys congested. A small
milk curd in the stomach.

Case 20. — Helen D — , set. three months. Pound dead in bed.
Lips and nails blue ; belly greenish. Dependant parts of the head
and trunk reddish. Minute excoriations over the nates. Tip of' the
tongue protruded beyond the gums. Pingers closely contracted, and
thumbs drawn in to the palms. Pupils dilated : joints stiffened,
scalp pale. Sinuses and veins on the exterior of the brain, and on
its figured surfaces considerably congested. Dark fluid blood effused
into the left lateral and third cerebral ventricles. Clear serum, in
excess in the remaining ventricles, at the base of the brain, and in
the spinal canal. Larynx and trachea filled with a thick yellow
pulpy matter. Capillary ecchymoses on the surfaces of the lungs,
heart, and thymus gland. Lungs congested with dark fluid blood ;
dark fluid blood in the cavities on both sides of the heart. Stomach
filled with a pulpy matter identical with that found in the larynx and
trachea, which proved to be half-curdled milk. Air-cells at the free
margins of the lungs over-distended.

Case 21. — Adam P — , set. six weeks. Pound dead in bed beside
its mother. Joints rigid. Thumbs drawn in to the palms, and
fingers rigidly closed on them; toes flexed. A uniform blush of
redness over the face, front of the neck, upper and forepart of the
chest, the insides of the lower limbs, and the dependant parts of the
head, trunk, and lower extremities. Belly greenish ; scalp bloodless.
Pontanelles depressed. A few capillary ecchymoses on the inner
face of the scalp, at its back part. Copious frothy fluid in the
trachea and bronchi. Right cavities of the heart distended with
dark fluid blood ; its left cavities almost empty. Lungs dark hued,
expanded, and much congested. Capillary ecchymoses on the
surfaces of the heart, thymus gland, and pericardium. Milk curd
in the stomach,

82— ILL 30

462 Original Communications. [April,

Case 22. — James R — J — , set. two months. Found dead in
bed beside its nurse. Pupils natural. Thumbs drawn in to the
palms of the hands, and the fingers firmly closed on them. Toes of
one foot flexed. A blush of redness over the insides of the arms, the
left side of the belly, the genitals, the left thigh, and the dependant
parts of the body. Upper part of the belly greenish. Joints rigid ;
scalp bloodless ; interior of the brain rose-hued. A whitish, frothy
fluid (mucus) in the trachea, bronchi, and in the whole of the air-
cells of the lungs. Blood, partly clotted, in quantity, in the right
cavities of the heart; and sparingly and fluid in its left cavities.
Capillary ecchymoses on the thymus gland, the left lung, the inner
surface of the pericardium, and on the root of the aorta. Milk curd
in the stomach.

Case 23. — Helen C — , set. four months. Found dead in bed.
Lower extremities mottled with purplish patches. Dependant parts
of the head and trunk of a dusky red. Thumbs drawn in to the
palms, and the fingers closed on them. Pupils natural; tongue
protruded ; scalp very pale ; brain and its coverings natural.
Interior of the trachea reddened, and filled with frothy (mucous)
fluid. Capillary ecchymoses on the surfaces of the lungs, the
upper lobes of which were emphysematous. Both lungs con-
gested, and their air-cells on pressure giving exit everywhere to
a reddish serum. Cavities on both sides of the heart firmly
contracted and empty of blood. Liver and kidneys loaded with
blood. Milk curd in the stomach.

Case 21. — James W — , set. seven weeks. Found dead in bed
beside its mother. Lower part of the belly, fronts of the thighs,
and the dependant parts of the trunk and lower extremities, red-
dened. Lips bluish ; slight greenish discoloration at the sides of
the belly. Points of the fingers bluish ; point of the tongue slightly
protruded. Thumbs drawn in to the palms, and fingers closed on
them; joints stiffened. Blood in greater quantity than usual in the
sinuses and veins on the surface of the brain. Interior of the brain
of a uniform pinkish hue. Frothy mucus at the bottom of the
trachea. Capillary ecchymoses, in sparing number on the surface
of the lungs, pretty numerous on the surface of the heart, and closely
congregated on the exterior of the thymus gland. Upper lobe of the
right lung reddened, and non-crepitant nearly throughout. The air-
cells of this lung giving exit to abundant thin frothy fluid. Dark
fluid blood in the right cavities of the heart ; its left cavities empty.
Foetal vessels closed. A milky fluid in the stomach.

Case 25. — Agnes R — , set. fifteen months. Found dead in bed
beside her mother, in drink. Five scratches or linear abrasions on

1868.] Ogston on Sudden Death of Infants. 463

the left cheek, about three-eighths of an inch in length parallel to
each other. Lips of a deep blue. Point of the tongue livid and
protruded beyond the front teeth. Lividities of the lower part of
the face, the groins, the lower and foreparts of the thighs, the soles
of the feet, and the dependant parts of the head, trunk and extre-
mities. Pupils pretty widely dilated. Joints rigid ; scalp bloodless.
Cerebral veins and sinuses turgid ; numerous puncta vasculosa in
the interior of the brain. Milk curd, of the consistence of soft pulp
in the pharynx and filling the trachea entirely, the pulp in the trachea
containing numerous minute air-bubbles. Eight cavities of the
heart distended with dark clotted blood ; dark fluid blood in smaller
quantity, in the left cavities of the heart. Lungs fully expanded.
tJpper lobe of the left lung emphysematous. Fluid blood and bloody
frothy fluid in the interior of the lungs, with capillary ecchymoses
on their exterior. The stomach nearly full of a similar pulp to that
found in the pharynx and air-passages. Spleen and kidneys con-
gested.

Case 26. — Female infant, set. two months. Found dead, mother
intemperate. Tip of the tongue protruded beyond the gums.
Fingers closely bent, thumbs drawn in to the palms. Skin of a
bright scarlet hue over the lower half of the belly, the genitals, and
the insides of the thighs. Lips very red ; nails very blue. Livi-
dities on the dependant parts of the trunk, and lower extremities.
Joints rigid. Sinuses and veins on the figured surfaces of the brain
congested. Lungs expanded, congested, and when pressed giving
issue to thin, frothy, whitish, or colourless fluid. Capillary ecchy-
moses on the surfaces of both lungs. Fluid blood in considerable
quantity in the right, and sparingly in the left cavities of the heart.
Liver much congested. Curdled milk in the stomach. Pallor of the
intestinal tube.

Case 27. — David C — , set. five weeks. Found dead in bed in his
mother's arms. Lips, genitals, and dependant parts of the body,
generally and uniformly reddened. Finger-nails and points of the
fingers bluish. Thumbs drawn in to the palms of the hands, and
fingers closed on them. Point of the tongue advanced beyond the
gums. Pupils moderately dilated. The veins at the base of the
brain rather turgid. Lungs expanded, and thickly dotted over with
capillary ecchymoses. Two such ecchymoses on the surface of the
heart. Interiors of both lungs filled with thin clear frothy (serous)
fluid. Dark fluid blood, in excess, in the right cavities of the heart
and sparingly in its left cavities. Foetal vessels closed. Milk in
the stomach.

With no authentic or reliable information procurable as to the
state of the abpve infants during life, the determination of the cause

464 Original Communications. [April,

of the fatal event necessarily rested wholly on the post-mortem
appearances. The difficulties thus placed in the way of any very
decided opinions as to the precise causes of death has, therefore, been
kept in mind in stating the conclusions arrived at on this point.

Cases 1 to 3 inclusive were set down as examples of pulmonary
oedema, a mode of sudden death, in its unmixed form at least, rare
in infants, and still rarer in adults.

Case 4 was evidently one of broncho-pneumonia.

Case 5, in which the appearances pointed to bronchitis, is interest-
ing from the co-existence in this instance of well marked spinal
apoplexy.

Case 6 likewise presented the appearances often encountered in
infants perishing in the early stage of acute bronchitis ; the abundant
secretion in the lungs and air-passages causing death by asphyxia
(suffocation).

Case 7 was clearly a case of double pneumonia.

In Cases 8 and 9, besides the pneumonic condition of the lungs,
there was the co-existence of bronchitis and pulmonary oedema.

In Case 10, the milk curd in the trachea, though not in any great
quantity, in all probability sufficed to have led to fatal asphyxia
(suffocation).

In Cases 11 to 14 inclusive, the amount of cerebral congestion
indicated death by coma as met with in children cut off in con-
vulsions.

The presence of capillary ecchymoses in cases 15 to 27 inclusive
(nearly one half of the whole), evidently bring these under the
category of deaths by smothering. Of this we have probably the
only pure instance in Cases 15, 20, and 25 ; as in Cases 17, 18, 19,
21, 22, and 23, the states of the respiratory organs were indicative
of the previous existence in these of bronchitis ; in Cases 16 and 24
of pneumonia ; and in Cases 26 and 27 of pulmonary oedema.

The part played by the milk curd in the trachea in Case 20 may
be differently regarded ; while the cerebral apoplexy in this instance
may properly be looked upon as an effect of the asphyxia.

The distribution of the blood in the heart's cavities supports the
conclusions stated above as to the asphyxial forms of death in all the
different infants ; and if any value is to be given to the states of the
fingers and toes so generally encountered in these, we have the in-
ference suggested that here, as in most instances of sudden death at
this early "period of life, convulsions had attended the closing stage
of life.

1868.]

Ogle's Cases of Non-fatal Chorea. 465

Art. III.

Miscellaneous Contributions to the Study of Pathology. By John
W. Ogle, M.D., Physician and Lecturer on Pathology, St.
George's Hospital.

CHAPTEE I.

JRemarJcs on Chorea Sancti Fiti, including the History, Course, and
Termination of Sixteen Fatal Cases, and also certain details of
Out-patient and other Cases which were not fatal.

Continued from page 234 of the previous number.

Having concluded the details of the fatal cases of chorea which
I have to record, and offered such observations as were suggested
by them, I will now give some particulars regarding eighty non-
fatal cases, all of which, with two exceptions, occurred in my former
out-patient practice at the hospital.^ To these I shall add the
relation of a few cases illustrating one or two of the more unusual
forms of chorea. The eighty cases I have arranged as follows in
a tabular form, which will enable them to be compared with each
other with some degree of facility.

* For help in accumulating the details of many of these cases I have to thank
many of our hospital students, who so willingly from time to time assisted me in
collecting notes of interesting cases in the out-patient department.

466

Original Communications.

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1868.] Ogle's Cases of Non-fatal Chorea. 487

Eeviewing the contents of the foregoing Tables, I will now pro-
ceed to summarise some of the information which they afford ; and
first of all, with regard to the sex of the patients. In giving the
details of the sixteen fatal cases of chorea, in the January number,
page 223, the preponderance of females over males was, it will
be remembered, very conspicuous, the proportion being fourteen of
the former to two of the latter.^ Out of the eighty non-fatal
cases in the Tables it will be seen that the females are very much
in the majority, there being sixty-one of this sex to nineteen of
males, i.e., rather more than three to one — a proportion which
strongly suggests that there are circumstances in their case which
render them especially prone to the affection.^

As respects age, I find that out of the eighty cases all, except-
ing fourteen, were under the age of sixteen. Eleven is the age in
which the greatest number were afFected,'!viz., thirteen.^ Up to this
age the numbers increase pretty uniformly from the age of eight,
and decrease to the age of fifteen, being at the age of eight and nine,
six in number ; at the age of ten, eight in number ; and again (on
the outer side of eleven), being nine at the age of twelve ; seven at
the age of fourteen ; and six at the age of fifteen. The youngest
was five years of age, and that was the only instance under the age
of six.* The only two cases which were above the age of twenty-
one were twenty-four and forty-three years old respectively.
Thus it is very clear that circumstances of age as well as of sex
have marked influence in connection with the affection.^

* Taking the fatal cases registered as having occurred in England during
several years, I find that the proportions as regards sex were as follows : — In
1848, 24 females to 14 males; in 1849, 24 to 10; in 1850, 39 to 21; in 1851,
67 to 10; in 1852, 54 to 19; in 1854, 28 to 20; in 1855, 47 to 22; showing in
some cases a much higher figure for the females in comparison with the males.

' Dr. Willshire, who has had much experience in the diseases of children, states
(see ' Med. Circ.,' Feb. 15, 1865, p. 101) that chorea is much more difficult of
treatment in boys than in girls. It is curious to observe that Hamilton, whose
great panacea for chorea was purgation, hints that the disease is more difficult of
cure in girls, because the structure of the female pelvis allows of greater oppor-
tunity for the accumulation of feculent matter.

^ The influence of youth in predisposing to chorea is also apparent in the lower
animals. Youatt observes that in dogs it oftenest occurs in young ones, and after
the distemper.

■• The patient in case 17 had had an attack of chorea, when aged three and
a half years.

^ In the ' Register of deaths in England for 1839,' p. 121, a case of chorea,
which proved fatal at the age of seventy -five, is recorded. In the ' Lancet,' for
June 1, 1861, p. 530, Mr. Ellis records a case of chorea in a gentleman, aged
seventy-five (the third attack). The movements came on at irregular intervals.
He had a daughter who was epileptic, and a son who was insane. In the ' Medical
Times,' for July 25, 1863, is reported a case of chorea, under Dr. Brown-Sequard's
care, of the age of sixty-eight, and also one under Dr. Peacock's care, of the age
of fifty-seven, the results of alarm. At the same place a case is given of chorea,
from which the patient, aged twenty, had been suffering nearly all his life. Such
a case, recorded by Rostan, is also alluded to in note at foot of page. In the

488 Or'ig'mal Communications. [April,

As respects the parts affected, it does not appear that one side
was much more decidedly affected than the other. For, excluding
ten cases in which no mention of this matter has been made, I find
that in twenty-four cases it is stated that the right side only was
aifected, whilst the left alone was affected in twenty ; and in twenty-
five cases it is recorded that both sides were affected, although in
some instances one or other side was more involved than the oppo-
site one. In one or two cases the movements appear to have
changed from one side to another, as in case 53. In cases 1, and
tJ, and 35, in which the right side was affected, both sides had been
affected in a previous attack ; in case 5, in which the right side
was affected, it had been the left side in a previous attack. In
case 63, in which both sides were affected, the affection had been
one of heinichorea on the left side in a former attack.^

Respecting more restricted localisation of the choreic move-
ments in certain cases (taking any period of the attack), the follow-
ing were worthy of note. In case 19, the first symptoms were
confined to the mouth and tongue; in case 25, they were
confined to the muscles of the face and eyelids ;^ in case 80, the
hands and face were first affected ; in case 29, the hands

' British Medical Journal,' for May, 1867, a case of choreal movements in a woman,
aged seventy -four, under the care of Mr. Hutchinson and Dr. Hughlings Jackson,
is detailed. Mr. Henkeimer describes in the ' Deutsch. Clinik,' 1859, 52, the case
of a man, aged eighty-four, who had a choreic affection of the arm and leg of one
side, following an attack of numbness in the arm and confusion of the mind, after
drinking. Dr. T. Tliompson quotes cases of chorea at the age of seventy and
eighty, recorded by Dr. Powell and Bouteille ; and Trousseau quotes three or four
cases of chorea at the ages of sixty and seventy, and also one described by Roger,
at the age of eighty-three. On scrutinising the ages of 39 fatal cases, which are
registered as having occurred in England, in 1839, I find that they were as
follows : — Under four years of age, 1 ; under five, 5 ; between five and ten,
12 cases ; between ten and fifteen, 7 ; between fifteen and thirty, 1 ; between
thirty and forty, 1 ; between forty and forty-five, 2 ; between forty-five and
fifty-five, 2 ; between fifty-five and sixty, 2 ; between sixty and sixty-five, 2 ;
between sixty-five and seventy-five, 3 ; between seventy-five and eighty, 1.

1 Romberg, in his work on ' The Nervous System,' vol. ii, p. 56, observes that, in
the majority of cases both sides of the body are affected, and that the statement of
Rufz and others, that the left side is more violently and more frequently affected
than the right has not been confirmed. He quotes from Wicke, who found that
out of fifty-eight cases, the left side was affected in twenty-three, and the right
in twenty-six ; that in one case it passed from the left to the right. Trousseau
observes that most commonly unilateral chorea is on the left side. Bond, in an
interesting article on chorea, in the ' Brit, and For. Med. Chir. Rev.,' July, 1860,
observes that, according to See and GrisoUe and others, including himself, chorea
generally begins in the left arm, and that the hemiplegic form generally occupies
the left side, which, if true. Dr. Bond suggests may be owing to the fact that the
left limbs being, as a rule, subordinate to the right, are of weaker organisation,
and therefore more liable to the infiuence of disturbing agencies.

• I have never seen a case in which the muscles of the eyeballs, so as to produce
squinting, were affected, though of course we often had rolling about and dis-
tortion of the eyes. Youatt (op. cit., p. 121) mentions that in dogs sometimes
the muscles of the eye are affected ; I suppose he means the eyeballs. Trousseau
mentions a case of chorea in which strabismus existed.

1868.]

Ogle's Cases of Non-fatal Chorea. 489

were first affected, and then the legs and the left side of the face,
only three days before attendance, the eyes and the other side of the
face remaining ?^»affected. In case 33, the movements con-
sisted in '^ opening the mouth about every minute." In case 78,
the movements were confined to the head and arms. In case 43,
whilst the whole of one (the right) side was affected, it was only
the muscles of the neck of the left side which were affected. In
case 53, the right side was first alone affected, and afterwards the
left alone. In case 67, both legs, but only the left arm, were
affected. It has been observed by some authors that choreic
movements are more localised in the case of adults. Youatt says
that in the dog they are often confined for long to one limb. The
stringhalt in the horse, a local affection^ has been looked on by some
as analogous to choreic movements.

I now pass on to the apparent causes of the choreic affection,
including in one consideration those causes (determining or ex-
citing) which by friends were assigned or thought probable ; and
also those which may be looked upon as being predisposing or re-
mote. I find that out of the eighty cases, in ten no mention is made
of any causation whatever, and therefore no conjecture can be
formed regarding them. In thirty-five it is recorded that no cause
of any kind was suspected by friends. Frigid or mental emotion
being often thought to act as a determining influence, I find that in
five cases this cause alone was assigned. In another case (No. 78)
it was said to have aggravated the already existing affection. In an
additional case (No. 24), fright and quarrel, following an attack of
rheamatic fever, which had existed three months before, were
assigned causes ; and in six more cases fright and the presence of
the common ascarides, or of lumbrici combined, were thought to
have been influential in producing if..^ As respects the presence of in-
testinal worms, in addition to the cases above alluded to, eight were said
to have worms at the time of commencement of treatment, and three
had formerly had them. I have notes of a case under Dr. Bence
Joneses care, in the hospital, June, 1858, who passed a large lum-
bricus whilst in the hospital, and in whom there was loss of power
in the right arm and leg, thought to be choreic.

As respects rheumatistn or rheumatic fever, or cardiac affection, in
connection with the disease, it appears that in eight cases rheumatic

^ In the Registrar-General's return for the week ending February 1st last is
the record of a fatal case of chorea in a girl, aged twelve, " occasioned by the
fright produced by the explosion," i.e., the Clerkenwell Fenian explosion. In the
same return for the week ending February 22, is the record of the death of a
woman from " paralysis, accelerated by fright from the same explosion." We not
long ago had a girl, aged sixteen, at St. George's Hospital with chorea, which was
brought on by an attempt on the part of a young man to strangle her, by
seizing her at the throat. The man had had a summons directed against him
by the magistrates, on the testimony of neighbours, to the committal of the
assault and of its leading to her illness.

490 Original Communications. [April,

fever had existed. In one of these cases (No. 8) no mention of the
state of the heart's valves has been recorded ; whilst in five cases it is
stated that the cardiac sounds were natural, and in one only (No. 12),
(and in this case it was somewhat doubtful whether the fever spoken
of had been rheumatic), were the cardiac sounds interfered with,
there being slight obscuration of the second cardiac sound.

In cases 50 and 77, it appears that a systolic bruit existed at the
base of the heart ; but in both cases it was affirmed that no rheu-
matic fever had occurred. In case 79, a systolic bruit at the apex of
the heart existed ; but there had been no rheumatic attack. Most
likely in several cases there had been unnoticed temporary cardiac
bruits, arising either from an anaemic state of blood, or from irregular
action of the fleshy columns and tendinous chords of the heart.

In case 18, it appears that the attack was ^ixecQ^e^hy palpitation
of three weeks' standing, but it is stated that there had been no
rheumatic attack. Pains, however, in the limbs and palpitation had
been experienced.

Dr. Chambers found that out of thirty-three cases of chorea in
his books, in six the affection either began during rheumatic fever,
or followed immediately after it, or else rheumatic fever succeeded
to the chorea. He, however, made out no connection between the
chorea and previous valvular or pericardial tension of the heart, only
one of the six above cases having any cardiac aifection. He justly,
however, observes that, '' considering how very common inflamma-
tion of the central organ of circulation is in rheumatic children, and
that it is at this age that chorea usually occurs, on the mere
doctrine of chances they would [i.e., chorea and heart disease) often
coincide." In the statistics of the London Hospital for 1864 (see
' Hospital Reports,' p. 388), it is stated that out of twenty-four
cases of chorea twenty had a systoHc bruit at the apex of the heart,
persistent in all but two; and in the statistics for 1865 ('Reports,'
p. 422), it was said that out of thirty-seven cases, 15 or 40^ per
cent, had valvular disease of the heart.

As regards derangements of the uterine system, I find that in one
case (No. 3) the attack followed a miscarriage, and in five cases it
is stated that the catamenia had been scanty and irregular, or over-
abundant and too persistent.^ Looking to what may be termed

' It will be remembered that, among the fatal cases before recorded, two were
related in connection with pregnancy. Of these, I find that one (No. 1) had
been previously related by Dr. Lee, in his ' Clinical Midwifery,' 1848, p, 112.
Dr. Barnes has recently informed me of a patient who had experienced several
attacks of chorea which came on at various intervals always during pregnancy.
In the early part of last year we had, in St. George's Hospital, under the late Dr.
Page's care, a patient with chorea who was pregnant. In the * London Obstetrical
Society's Transactions,' vol. vii, p. 102, are two cases related by Dr. B. Woodman,
showing the combination of chorea with pregnancy ; one, the case of a young
woman who had constantly had chorea from the age of seven to thirteen, in his

1868,] Ogle's Cases of Non~fatal Chorea. 491

alleged causes of miscellaneous character, in case 40, the affection
was thought possibly to have been connected with sores on the head?
In case 75, a fit had occurred, but a long time (four years) pre-
viously ; in case 23, the patient had fallen down stairs three weeks
before the attack came on ; and in case 66, a fall two months pre-
viously. In both the latter cases the fright of the accident may
have been instrumental in causation. In case 74, so-called low
fever had existed ; and in case 80, the attack followed, at a short
interval, an attack of mumps.

In cases 22 and 74, the mothers of the patients had had chorea ;
and in case 11, it was stated that a sister had had it, possibly from
imitation. Authors quite recognise the hereditary character of
chorea in some, though rare cases. Thus Bright mentions it in
page 469 of his work;^ and See says he has found the disease to

own practice, and one following fright, in Dr. Down's, at the London Hospital.
He expresses his belief that choreic movements are chiefly reflex, and connected
with the sympathetic nervous system, and alludes to a third case of chorea in
a pregnant woman which he had heard of. I have before alluded to Dr. Levick's
paper (in the ' American Journal of Medical Science,' January, 1862), giving the
details of three cases of chorea and pregnancy associated. Of these cases one was
fatal, and in this it is said that " the brain was found very much congested
throughout; the heart small and firm, with a bead-like deposit on the aortic
valves." In these cases the choreic movements, though mitigated, did not cease
during sleep. Dr, Levick quotes five cases of chorea, combined with pregnancy,
from Dr. Ingleby ('Lancet,' 1840, p. 783); also two such cases from Dr. M.
Duncan (Ed. 'Med. and Surg. Journal,' January, 1854); and certain cases of
association of convulsive movements and pregnancy, described by Schenkius, in
1609 (' Observ. Med. Rev.,' De Spasmo, pp. 128-9). I would here allude to a
paper in the ' Archiv. f. Path. Anat.,' Bd. xxiii, 1861, by Dr. Morler, in which he
has collected and analysed twenty-one cases of chorea in pregnant women. They
were chiefly of an age between seventeen and twenty-four. Of these five had
had chorea previously, and fourteen were primi-parae. In eight cases fright, or
other mental emotion was assigned as the cause. The period of pregnancy at
which the chorea commenced varied, but in seven cases it was at the second, and
in eight cases at the third or fourth month. It was seldom that one side only of
the body was affected ; in many cases the chorea was accompanied by epileptiform
convulsions, and in most there had been hysteria previously. In very few was
there any intellectual aberration. Pour aborted and three were confined before
the proper term ; three times the abortion was followed pretty rapidly by cessation
of the choreic movements. In five the chorea remained until the end of pregnancy,
and in nine cases recovery occurred before that time. Treatment was chiefly by iron
and zinc. The reader will also find a paper by Mosler, of Giessen, in ' Virchow's
Archiv ' for 1862 (Hft. 1 and 2, p. 149), " Ueber Chorea Gravidarum," in which
the cause, symptoms, course, and treatment of the affection are considered, and a
table given, showing the histories of twenty cases. These include several of
the cases which I have alluded to, and were recorded by Ungen, Frank, Haud,
.Jeffrey, Bezold, Romberg, Helfft, Aran, Duncan, Ingleby, Lever, Scanzoni. The
whole subject of the connection between menstrual and uterine irregularities,
suppression of the menstrual function, &c., and so termed nervous diseases, even
insanity, is of the highest interest, and both worthy and capable of much greater
development and attention than it has at present received.

^ In the ' Brit. Med. Journal ' for May 17th, 1862, a case of chorea, immediately
following a severe burn, is related as being under Mr. Craven, of Hall; recovery
ensued before the burns healed.

2 Dr. Day, in his ' Clinical Histories,' p. 103, alludes to the more than ordinary

493 Original Communications. [April,

be hereditary in very many cases. They also allow that imitation
may be, in certain instances, instrumental in its propagation. I
find that Bricheteau describes the case of eight patients, within a
space of six days, contracting the disorder after the admission of
a severe case into the ward, requiring instant separation of the
patients -^ and Chambers, in his ' Lectures,' before quoted, records
the interesting case of a boy, aged sixteen, who had been operated
on for stricture, and accidentally placed in a bed opposite to
one occupied by another boy with chorea. He soon began to
imitate the movements which he witnessed, although moved into
another ward, eventually died, abrasions and pericarditis (possibly
due to pysemia) having come on. I may mention here that we lately
had two patients with chorea in the same ward, in St. George's
Hospital (as I am informed by Dr. Archer, who was attending to
the cases in the ward). One was much worse than the other, and
the severer case was at onetime so injuriously acting upon the other,
whose imitative powers appeared considerable, that they had to be
placed in separate wards.

As respects the fact of the patient's having had previous attacks
or otherwise, I find that (excluding thirty-three cases in which no
mention of this has been placed on record, and one case (No. 33) in
which it is doubtful), there are nineteen cases in which it is stated
that no previous choreic attacks had been experienced, against
twenty-five in which previous ones had occurred, and out of these
five (viz., Nos. 9, 10, 56, 63, and 67) had suffered from two pre-
vious attacks. In case No. 17, the patient had had seveual
attacks since the age of three and a half years. Case No. 65 had
had chorea every year for seven years, lasting from September to
Christmas. In order to prevent relapses, Sydenham, who bled
regularly for the disease, enjoined bleeding and purging for a few
days on the year following, at the same time of the attack or

frequency amongst the Jews of chorea as an argument in favour of the existence
of an hereditary tendency to the affection ; and he has obligingly furnished me
with the following circtimstances referring to this supposed prevalence of chorea
among the Jews. He observes —

" 1. In 1834 I heard the late Dr. Addison (Guy's) say, during some some bed-
side clinical remarks, that he had noticed ' chorea ' to be very common in Jewish
families.

" 2. Dr. Stiebel says that chorea is particularly frequent amongst the Jews
(vide ' Wochenschrift fiir die gesammte Heilkunde,' No. 1, 1837) ; also the
' Brit, and For, Med. Chir. Rev.,' October, 1837, p. 504.

" 3. In 1842 I attended a family of Jews consisting of father, mother, and five
children — four girls and one boy ; all the four girls had • chorea,' three of the
number being attacked at one time. The mother had had chorea when a child,
and the father's mother had also suffered from the same affection.

" 4. An intelligent old Jew (gentleman), well up in the history and peculiarities
of his nation, told me some short time before his death, which took place in 1865,
that ' his people were often attacked with St. Vitus's dance, and that, when in
Germany, he had known whole families to be affected with it.' "

J ' Gaz. des Hop.' 1863, No. 46.

1868.] Ogle's Cases of Non-fafal Chorea. 493

earlier. Heberden also alludes to the fact that a " little tendency "
to the recurrence of chorea in some cases has been felt every spring
and autumn for three or four years.

Case No. 73 is a pecuhar one, inasmuch as it was stated that the
patient had " had some severe attacks three years previously, and
never quite recovered from them.-'' In several instances the attacks
had been of long standing. Thus, in case 4, they had gradually
been coming^on for four years; in case 25, the symptoms had existed
oS and on for eighteen years ; and in case 76, for six years. In
none of these long-standing cases have we indications showing that
any cerebral or spinal lesion had existed.

I will now pass on to consider such cases as presented any
PECULIARITY IN THE SYMPTOMS whicli it sccms desirable to take
notice of. In addition to other interests, this inquiry might have
special value with respect to the question as to whether the choreic
symptoms had reference, in any cases, to organic disease of the
central nerve organs.^

Taking into consideration the state of the mind, in only two cases
(Nos. 6 and 34) have we mention of any complication. Even in

* To the subject of choreic movements having their source, in some cases, in
obvious disease of the brain or spinal cord, I alluded at pages 227-8, and said that
I purposed to make an inquiry into such cases as I could find, in which organic
lesion existed. I may here, in passing, allude to an interesting case, described
by Youatt (op. cit., p. 122), of a dog which had chorea complicated with " fits,"
and also had a peculiar tendency to run "round and round." After death,
neither inflammation nor softening of the brain were found, but two spicula of
bone were met with, one sixth of an inch long, projecting from the inner surface
of the parietal bone, near the sagittal suture. The brain was, to all appearance,
natural in substance. In the footnote to page 228 I have alluded to the sup-
position of Skoda's, that an exudation in the nervous structure may be the cause
of chorea. I find that a case of chorea in a man aged 19 is described in the
* Wien. Wochenbl./ xvii, 1861, 35 and 36, by Stofiella, in which, along with
softening of the spinal cord young connective tissue-formation was met with in
the form of fine greyish-coloured opaque stripes, the grey substance of the cord
being very fatty. It seems that Rokitansky found similar areolar-tissue-forma-
tion in the spinal cord in certain cases of tetanus and of hypercesthesia. I have at
hand notes of the following recently recorded cases of fatal chorea in which
lesion of the brain or spinal cord was found after death, or suspected : — Bouchut
(' Gaz. des Hop.,' August, 1863) describes a case of semi-chorea with incomplete
hemiplegia in a child, following a fall upon the head and unconsciousness.
The strabismus, deafness, loss of memory, and pains led to the supposition that
cerebral congestion was the cause of the chorea. The patient recovered. At the
Middlesex Hospital, in 1863, was a fatal case of chorea, under Dr. H. Thompson's
care, the result apparently of fright. After death the substance of the brain
generally was found much softened, especially the anterior pillars of the fornix
and the septum lucidum, and the left side was more softened than the right.
Considerable softening also existed of the spinal cord from the third or fourth
to the sixth and seventh dorsal vertebrae, and the cervical swelling was softer
than natural (see ' Med. Times,' July 25, 1863). The reader of Dr. Copland's
' Dictionary of Medicine ' may remember that, in 1821, he recorded a case of
chorea, complicated or alternating witli rheumatism, and with metastasis to the
heart and spinal membranes, which, after death, were found to be covered with
coagulable lymph, &c.

82— XLi. 32

494 Original Communications. [April,

case 6, complication is not quite clear, and in case 34 it was only
in a former attack that the mind had been affected. In case 63,
mental excitement, '' as if she was going out of her mind,^^ had
existed at one time. This comparative immunity from any affec-
tion of the mind in these choreic cases is perhaps worthy of com-
ment, as some authors have spoken of the not unfrequent alliance
between the two.^ In cases 44 and 80, the patients had been more
or less liable to hysterical attacks ; it may be remembered that in
two of my fatal cases, hysteria had co-existed. Dr. Chambers also
records a case (op. cit., p. 365) of chorea in which hysterical attacks
had occurred.^

Regarding pahalytic symptoms, in eleven cases we have distinct
mention of paralysis of some kind or other (viz., in cases 18, 19,
21, 43, 52, 58, 62, 66, 74, 75, and 79). In this category I have
placed only those cases in which actual want of power in the muscles
of the limbs or face existed, and not those cases in which muscular
weakness resulted as a consequence of want of power of direction of
and of harmonising the muscular action.

In cases 30 and 75, positive anaesthesia existed,^ and in the latter

1 Marce, mentioning their frequent coincidence (see number of this ' Review'
for July, 1859, p. 256), describes the association in a systematic manner as being
of five varieties, as follows : — 1. Troubles of moral sensibility, irritability of temper,
sadness. 2. Troubles of intelligence, loss of memory, mobility of ideas, and inability
to fix attention. 3. Hallucinations, between waking and sleeping, and of the sight
chiefly. 4. Maniacal delirium, which, if recovery occur, may leave the mind affected.
In the * Year Book of the Sydenham Society for 1865,' p. 84, are related two
highly interesting cases, recorded by Thore, and quoted from the * Ann. Med.
Psych.,' 1865- '.:i which insanity followed chronic attacks of chorea ; and allusions
are jiade to the writings of several well-known authors, showing that various
kinds of intellectual and emotional insanity may occur in cases of chorea, though
it appears that Thore considers that these mental affections can hardly depend
upon the choreic state, but are chiefly caused by coincident diseases, such as
typhus, rheumatism, or chlorosis. Dr. Inman, in his ' Foundation for a New
Theory of Medicine,' 1861, p. 153, observes that "in chorea we have at times a
mental prostration, amounting almost to idiocy," Romberg, vol. ii, p. 57, observes
that in chorea, " except in complications, no psychical disturbances are manifested."
Trousseau, on the other hand, observes that in every case of chorea there is, with
few exceptions, more or less marked impairment of the intellectual faculties.

2 I have now a boy in St. George's Hospital with chorea, who has had two
or three attacks of chorea, with long intervals previously, and his mother assures
me that on each occasion he has during the attacks forgotten "all his learning,"
so that he actually had to be taught his alphabet afresh after each attack. He
has never had any fright nor rheumatic attack, but has had ascarides.

3 Trousseau speaks of diminution of sensibility existing in most cases of chorea,
and of anajsthesia, when it exists, being greater on the most convulsed side.
I have lately had related to me by Dr. Ilott, of Bromley, a case of chorea, in
which the movement was confined to the right arm, which " was constantly in
motion, unless strapped down to the body; when relieved, the movement
would instantly begin. It was almost entirely devoid of sensation during the
earlier part of the time. This want of sensation gradually improved, and the
movement became less violent." It seems that "the improvement dated from a
time when the patient had a peculiar thrill down his arm, similar in character to
one he had at the commencement of the attack." From this time the move-

1868.]

Ogle's Cases of Non-fatal Chorea. 495

case there was loss of power in the left arm and left side of the face.
The atrophy of the muscles and of the bones of the shoulder, in

luents were mucli "more under control, and it was only when he became
excited that he had any twitching. He has now quite recovered, and is employed
as a French polisher. The medical treatment consisted chiefly in the use of iron
in various forms." The patient was an orphan boy, aged 13, and of average
ability, as Mr. Cattlin, of Brighton, who knew him, informs me. He has also
told me that the boy had paralysis during his first dentition, and also, he
thought, had been the subject of tapeworm. He had been under Dr. Gull's care,
at Guy's Hospital, and also under Dr. Hare's care. The case reminds one of those
cases described by authors, in which the movements consist of " malleation." The
following case, described in Dr. Charlton's book ' on the Bath Waters,' p. 53, may
form a pendant to that of Dr. Ilott's : — A woman had a fright, which first brought
on convulsions and great pain in the stomach. Afterwards she was the subject of
a peculiar involuntary motion of the right arm. This movement was perpetual,
" like the swing of a pendulum," raising the hand, at every vibration, higher than
the head, and seemed to alternate with convulsive movements. The motion of
the arm always ceased during sleep, but returned immediately on waking, and
continued all day. She got well, as was supposed, under the influence of opium,
given in considerable doses.

Dr. Parkes, in 1861, had a case under his care at University College, in which
the movements were limited to the right arm, and were like those produced by
electrical shocks. Sometimes there was anesthesia of the affected arm, and once
a tendency to twitching of the opposite arm. It was described as being like the
cases recorded by Dr. Pignacca under the name of electrical chorea, given by
Dubini, of Milan, and which are probably epileptic in character (see ' Lancet,'
March 2, 1861, p. 214). Dr. Parke's patient recovered. A case of " chorea elec-
trica traumatica" treated successfully by wet-sheet packing is quoted in 'Schmidt's
Jahrbuch,' 1860, p. 305.

Along with these cases also may be quoted one described by Dr. Aspray, in the
* Lancet,' for July 15, 1865, p. 65, in which the patient, a female, was affected by
violent choreic jactitations, first of the right arm, which was thrown upwards
and downwards, from the face to the knee, occasionally changing to the rotatory
motion, and then of the opposite arm. The patient had no return of the attacks.
She had been suffering from constipation.

In connection with the above cases, mention may also here be well made of the
case described by Dr. Sanders, in the ' Edinburgh Med. Journal,' for May, 1865,
under the name of " pseudo-paralysis agitans," or " spinal chorea" (?) a case
belonging to the class " tremores." " The case bore a general resemblance to those
of chorea," but " really diff'ered entirely from this aff'ection," the movements
being shaking, oscillating to and fro by the alternate action of antagonistic
muscles, repeating themselves rhythmically and usually symmetrical. The pre-
disposing cause of the affection seemed to be an accident some months previously,
and the existing cause, fright, occasioned by a second fall; and Dr. Sanders
thought that the affection depended on a weak and excitable condition of the
motor centres in the spinal cord, due to ansemia of its grey substances. Some-
times no doubt the diagnosis between true chorea and other forms of morbid
muscular movements is difficult. Dr. T. Thompson (op. cit.) quotes a case described
by Dr. Dufour and Rennes, in which the choreic movements were " zigzag," in
character, and were mistaken for those of drunkenness.

It has been remarked by Dr. Elliotson, that when the disorder is confined to
the muscles of one arm or of the hand, and especially in the adult, he had never
known the disease cured.

Although not an instanceof chorea, but rather of hysteria, I may here record the
following interesting case which I witnessed : — The patient, a young lady, had been
watching her dying father, whose respirations were very loud and of rather a pecu-
liar rhythm. After his death, the daughter, stunned as it were by her loss, and
hardly realising it, could not shed tears, but for some time (three or four hours)
continued pacing up and down the room with a peculiar movement of the head,

406 Original Communications. [^pi*i^

case 59^ are worthy of notice; but, dating so far back as they do,
they appear to have had no connection with the choreic state. In
case 79, there was atrophy of the adductor muscles of the thumb
on both sides.^

Looking at the condition of the pupils of the eyes, I found that
in many cases dilatation of both pupils existed, as is commonly
noticed by observers of chorea ; but of this appearance I have not
made special note in my cases. In the following cases, however,
disparity between the two pupils was noted (a much more important
phenomena, I need hardly say, than equal dilatation of both),
viz., incases 2, 20, 61, 71, and 74; and in all of these instances
it is curious to note that it was the right pupil which was dilated
more than the left.^

Respecting pain experienced, I observe that, excluding such pain
in the limbs and joints as may be looked upon as being rheu-
matic, &c., we have notice in the following cases of distinct pain in
the head, viz., in case 10 (in which, apparently, some syncope co-
existed) in cases 16, 17, 19, and 64. In case No. 59 " much
spinal tenderness " was complained of.

Regarding acknowledged affections of vision, such seem to have
existed in No. 17, where "something before the eyes was always
noticed ;" and in case 45, where dimness of sight of the right eye,
along with headache, existed ; and in No. 64, where " black spots "
in the sight were spoken of.

As respects any connection between the affection and sleep, it
will be admitted that in cases 16, 17, and 33, the choreic
movements were wont, more or less, to continue during sleep;
whilst in case 36 the patient was said " to plunge when asle^)
in bed ;" and in case 43 the eyes would " twitch much " during
sleep. In case 24, the patient was said to be "always worse in bed
when first roused up from sleep .^'^

In case 60, "foaming at the mouth" was described as exist-
ing ; and in case 40, a liabihty to choking whilst eating. This,
no doubt, is an exaggeration of the difficulty in swallowing,
which, as well as difficulty of speech, is so common a symptom in

which, as did her footsteps, repeated and kept up the same time as the respiration
of the dying man. At last this state had to be checked and arrested by friends.

1 Rostan (quoted by Aitken, in his ' Science and Practice of Medicine,' voh
ii, p. 340) mentions the case of a woman, aged 50, who had been the subject of
chorea, affecting the entire left side since she was a child, in whom the limbs on
the same side were atrojphied. After death no morbid appearances were met
with in the brain.

2 Youatt records the case of a dog with chorea, in which both pupils were much
contracted.

3 Dr. Fox of Clifton has told me of a case now under his care of an old lady in
whom choreic movements of the right leg, hand, and arm, exist. They are most
intense during sleep, but may be absent for a day together, and can almost always
be controlled by a touch of any one's hand.

1868.] Ogle's Cases of Non-fatal Chorea. 4^7

certain of the severer cases of the disease, or it may have been hys-
terical in its character.

Case 35 was remarkable, as exhibiting a tendency to retention
OF URINE, which sometimes lasted for twenty-four hourfe. Dr.
Chambers, in his ' Lectures,' page 360, mentions the case of a boy,
aged nine, with chorea, who was unable to retain his fseces or urine ;
and Trousseau alludes to cases of relaxation of the sphincters of the
rectum and bladder. To the condition of the sphincters in chorea, 1 have
already alluded in connection with one of the fatal cases described
(see footnote, page 224). Dr. Levick,in his paper above quoted,states
that Dr. Pepper, of the University of Pennsylvania, told him that he
had known incontinence of urine to interchange with chorea of the
external muscles and conversely.

In addition to the above cases of chorea, I have notes of one
or two other remarkable cases, in which the symptoms were ex-
ceptional. . Thus, three or four years ago, we had in our wards for
a length of time a case of a lad aged eighteen, the son of a medical
man, affected with a form of chorea in which, in addition to the more
ordinary involuntary spasmodic movements, the most grotesque and
at the same time alarming actions were exhibited, for he was con-
stantly and violently throwing about and twisting his whole body
and his head to and fro, and his arms in all directions, sometimes
falling down as if dragged down by his own contortions ; constantly
" banging himself" against the bedstead, and making his face
quite turgid, and putting himself out of breath by his exertions and
jactitations, making also a peculiar grunting noise; all this time
being made worse whenever he was noticed or questioned about it.
It was said that he had caused the affection by masturbating
habits, and that he had been treated by caustics applied to the
urethra.

He had been in St. Mary's Hospital, and most accidentally I
found that it was the case described in Dr. Chambers' 'Lectures,'
p. 378, as being under his notice in St. Mary's Hospital in 1860.
The movements are well described as " coming on in paroxysms,
principally affecting the muscles of the neck, and twisting his head
so far round sometimes as to cause him to tumble down, screaming
and barking." Among other remedies, morphia was tried subcuta-
neously injected at St. George's Hospital, and it was also tried, along
with other things, at St. Mary's Hospital, but no good appeared to
follow. He left London in much the same state as when he came,
and eventually he was, as it turned out, placed under the care of my
friend. Dr. Boyd, at the Wells Asylum, where I accidentally saw him
several months afterwards, whilst on a visit at Wells. He was out
in the garden, talking to himself among some bushes, and I was told
that his habit was to be out much alone,, which was permitted. He

498 Original Communications. [April,

recognised and was pleased to see me, and talked about St.
George^s Hospital. He was very much quieter than when I had
seen liim previously, though he still knocked about his head and
body to a great extent. In a letter received from Dr. Boyd in
December last, he says, with reference to him — " The young man
with chorea, now aged twenty-four, is still here. He has not been
under any course of medical treatment lately, but he still uses the
cold douche himself or the shower-bath. He is rational, and in
very good health, but still has spasms affecting the muscles of the
face and neck principally; he stammers, and the spasms increase
when spoken to, especially by strangers. During the summer he
was able to join at cricket, also in the weekly dances, and he assist
the attendants out of doors occasionally. He has always cared
little for cold air, but heat oppressed him. He has a large appetite
for food. He might now engage in some suitable occupation.^'

In the case of a young woman, with deformity of the fingers and
toes, who was in our hospital with an hysterico-choreical attack
about two years ago, and who often visits the wards now, the chief
symptom consisted of spasm of the neck-muscles, a peculiar jerk
of the head, accompanied by a remarkable squeaky noise formed in the
larynx, reminding one of that made by a guinea-pig, as if the breath
were suddenly and involuntarily propelled by some spasm of the
expiratory muscles.^ A similar jerking back of the head from chorea
of the neck -muscles is related by Dr. Barker in the ^Medical
Times and Gazette' for 1863, July 25th. No other muscles of the
body were affected; the patient recovered. On the same page (92),
a case of chorea under Dr. Brown-Sequard is recorded, in which
GREAT HYPERTROPHY of the musclcs of the ucck was caused by their
constant action. The above-mentioned peculiar sound or squeak-
ing noise recalls to mind a remarkable case of chorea related by
Dr. Thompson, of Bideford, in the 'British Medical Journal' for
February 11, 1865, in which, along with a variety of other
odd symptoms, the patient had " a peculiar convulsive voice-sound,
somewhat resembling hiccough, repeated with almost the rapidity
of time-seconds, and accompanied by an agitation of the neck much
resembling paralysis agitans."

In another case, which was under my care as an out-patient at the

1 Romberg, in vol. ii, p. 55 of his work (Sydenham edition), relates the case of
a female, set. 48, with chorea of eight years' standing, in whom " inspiration was
often accelerated, and accompanied by a loud ivMstling sound ;" also that of a child,
set. 8, in whom dyspnoea, ■whistling inspiration, and palpitation existed ; and a
third one, a child, in whom was observed a " rapid and short concussion of the
thorax," " invariably accompanied by a brief snapping noise," the result of an
affection of the inspiratory, specially intercostal muscles, and a spasmodic con-
dition of the glottis. Trousseau speaks of the voice being altered in some cases
c f chorea, and the patients uttering " a kind of a bark," and also of the voice
' coming out in inspiration, instead of expiration."

1868.]

Ogle's Cases of Non-fatal Chorea. 499

hospital, the patient (a woman) was constantly rotating the head as fast
as she possibly could ; the velocity of this movement was excessive, but
it appeared to have no important- effect upon the patient, whereas on
trying myself to execute it with the same rapidity, I became quite giddy
at once, and unable to proceed. The patient had been subject to the
affection for some months, and never appeared at the hospital with-
out this rotation of the head going on.^ After a time I quite lost
sight of this patient. In another case, apparently of chorea combined
with hysteria, related lately to me by a non-medical friend, during the
attacks the patient would rotate round her own axis with great
quickness, somewhat reminding one of those singular and rare
cases of disease and injuries of the different parts of the cerebrum
proper, also of the pons Varolii, medulla oblongata, aad cere-
bellum, or its peduncle,^ in which rotatory movements are at times

^ Flourens, in his • Experiments on the Eespective Independence of the Cerebral
Functions,' related to the French Academy, April 1, 1861, found that section of
the semicircular canals produced brusque motions of the head in various directions,
according to the canal injured.

2 It may be of interest here to refer a little to these rotatory motions. Autho-
rities, chiefly French, as to the cause of such movements are mentioned by various
writers of past years, but the reader will find more recent interesting observations,
by Gratiolet and Leven, related to the French Academy, on rotations on
the axis of the body, produced experimentally, recorded in the 'Archives Gen.
de Med.,' vol. i, 1861, p. 112. They found that vertical section in the centre oi
the lateral lobes caused the animal instantly to rotate, and when the rotatory
movements were arrested for a time the least noise or movement produced their
return. Tlie observers came to the conclusion that in the uninjured animal all
the muscular equilibriums were in accord and harmonious, whilst after lesion of
the cerebellum there was a manifest dissociation of these equilibriums, — this
effect constantly resulting from every lesion of the lateral parts of the organ
where resides the sense of co-ordination of the movements of the body. • In the
' Journal de Physiologic,' 1861, Wagner, in his observations on the functions ot
the brain, details the results especially of experiments on the cerebellum. In
addition to other consequences he found that injuries on one side of the cerebellum
produced movements of rotation sometimes on the side of the injury, at others
on the opposite side ; but these movements after a time disappeared. In the same
journal is a note by Brown-Sequard on rotatory movements apropos of a case of
"mouvement de manege '' in a cat, the result of b ttjmorrhage into the pons
Varolii, in which he suggests that rotatory movenients are the result of con-
vulsions localised in certain groups of muscles, and that some direct or indirect
irritation is the cause of these convulsions. In the ' Comptes rendus,' 1860 and
1861, the results of observations, by Flourens and Czermak, on the peculiar move-
ments of the head, caused by injury of the semicircular canals, will be seen. A highly
interesting case of epilepsy in which unmeaning laughter, tetanoid spasm, and
peculiar rotatory movements, chiefly from right to left, has been described by Dr.
Paget, of Cambridge, in the ' British Medical Journal.' In Dr. Brown-Sequard's
* Lectures on the Phys. and Path, of the Central Nervous System,' 1860, remarks
exist (p. 192) about the production of these rotatory or vertiginous movements,
which vary " according to the place injured and the depth and size of the injury,"
and are the result of spasm of certain muscles, or of ansemia or irritation of
distant nerves, — injuries of the different parts of the optic thalamus, the cms
cerebri, the tubercula quadragemina, processus cerebelli, auditory and facial
nerves, and the neighbourhood of insertion of the cervical roots of the par vagum,
according to the experiments of himself, of Flourens, Schiff, Magendie, Lafargue,
M. Magron, &c., being quoted. The various theories regarding such rotatory

500 Original Communications. [April,

manifested.^ Trousseau, among other varieties of chorea, speaks of
chorea rotatoria and chorea oscillatoria.

Similar cases are mentioned by Dr. T. Thompson, M'ho alludes
(op. cit.) to instances of involuntary movements of the whole or of
parts of the body, and observes that rotation of the head had been
noticed by Drs. Conolly and Crawford, and Mr. Hunter, and others ;
he especially quotes also a case of Dr. Wattes, in which a girl was
wont to spin round on her feet like a spinning-top, or to roll rapidly
in bed from one side to the other sixty times a minute. Dr. Winn,
in the 'Med. Times and Gaz.,' 1855, records the case of a child
who, being nine years old, had had from infancy constant rotatory
movements of the body from left to right. Sometimes these move-
ments are doubtless the results of habit. A child with dropsy and
disease of the kidneys, under my care in the hospital lately, had
clearly the habit (without any disease causing it) of rolling the head
on the pillow constantly from side to side. Another child in the
next bed, under the care of my colleague. Dr. Barclay, had this
movement also, but in her case the patient was subject to remark-
able epileptiform attacks, which could be at any moment excited
by a sudden (unexpected or not) tap on or shake of the head. Dr.
Barclay will publish this interesting case, I believe, but allows me
to mention it.

Among these anomalous cases of chorea or chorea-like affections
few are more singular, perhaps, than those which, consisting of bowing
movements, have been termed " eclampsia nutans,^^ and by the late Sir
C. Clarke " salaam convulsions.''^ Of this affection T have only seen
one instance, and that was in a child whom I attended along with
Dr. Marshall Hall, who has described this form of disease. In this,
the patient, a child, was from time* to time affected by a pecuhar
slow and measured to-and-fro motion of the entire body. Levick
(op. cit.) speaks of this variety, and describes two cases of it which
he had seen, one in a child, and another in an adult. He quotes
several authors who have described or given cases of this singular
affection.^

movements are also considered in connection with experiments upon the tadpole,
by Velpeau, in the ' Gaz. Med. de Paris,' 1862, No. 20. Friedbcrg, of Berlin,
communicated to the Academy of Sciences the case of a patient who was trephined
for fracture of the right parietal bone, and who subsequently became affected
with diabetes, then the rotatory or " manege" movements in the longitudinal
axis of the body, then hemiplegia on the right side, and then paralysis of the
par vagum. He takes occasion to make several propositions regarding the
conditions for the production of this rotatory movement. Mesnet also, apropos
of a curious case, has a paper in the 'Archives Gen. de Med,' for May, 1862,
upon the so-called " circular " or gyratory, and the manege movements, which
he likens to the staggers in sheep, except that they are not the result of the
presence of csenuri.

1 This movement has been noticed in the chorea of dogs.

' "West, Barton, Bird, Newham, Wiltshire, Faber. In the 'American Journal
of Medical Science ' for April, X843, a case of " salaam convulsion " is related by Dr.

1868.] Ogle's Cases of Non-fatal Chorea. 501

The following case of anomalous chorea was under my care some
months ago : —

Emma P — , set. 11, one of seven sisters, of whom all others
were healthy, though the family was phthisical, was admitted into
St. George's Hospital, October 4th, 1864, with chorea. She had
been ill twelve months, and done no work all that time. Her illness
was described as having begun with symptoms of cold and swelling
of the knees, and when admitted there was some enlargement of the
inner condyles of both'tibise, and some oedema of the legs. The
heart's sounds were natural. There was a little cough and pain in
the head. The urine was phosphatic and turbid and contained a
slight amount of albumen. The patient left the hospital on the
24th, in the same condition as when she came in ; and it was said
that she had a brother who died after an eighteen months' illness of
the same disease, but without the St. Vitus's dance.

She was again admitted February 27th, 1867, under my care,
but in a much worse state than when she left the hospital, having
for five months quite lost her speech. The catamenia had never
appeared.

When admitted, it was found that she would lie in bed without
changing her. position, but having almost continual choreic move-
ments over the whole body ; when the movements ceased the limbs
were rigid. She was quite unable to articulate, but understood all
that was said to her. She was apparently suffering pain, and she
was frequently putting her fingers into her mouth. The pupils
were rather dilated, but equal in size, and acted well to light ; no
strabismus existed. There was complete paralysis of the sphincters
of the rectum. The limbs were all, as before said, rigid, and when
moved they would remain in the same position in which they were
placed, and the head was generally drawn over to the left owing to
spasm of the right sterno-cleido-mastoid muscle. The pulse was
160 per minute and the skin very perspiring and 99° P. of tem-
perature. She had an oil and assafoetida enema, and scammony
calomel, at the same time.

In the evening the temperature was 101 P.°, and on the following
morning 99*8°. Large crepitation was found in both lungs, and
two or three days later the left hand was spasmodically contracted,
and she had been very noisy and delirious, requiring the subcutaneous
injection of morphia, which was afterwards from time to time re-
peated. Quinine, and steel, and valerian, and stimulants, were

Bennett. Dr. John Clarke informs me he has seen one case of this affection in a
child with mesenteric disease : the movement of the head was from side to side,
and existed hardly without intermission for three weeks. After death, congestion
of the cerebi;^! membranes and softening of the brain with effusion of serum in
the spinal canal were found.

502 Original Communications. [A-pril,

given. About a week after admission, tlie pupil of the left eye was
found from time to time to be smaller than the other one, but not
always so. The lungs continued loaded, but there was no dyspnoea.

The temperature continued very high, generally about 101"6°.
Continual recumbency on the right hand had produced some soreness
and vesication. It was observed that the extensor muscles of the
right arm seemed partly paralysed, whilst those of the left arm and of
the toes of the right foot were spasmodically contracted. She took
strychnia subsequently, along with steel. She varied much both as
to taking food and sleep, sometimes requiring the morphia injection ;
at times she was also much noisier than at others. The profuse per-
spirations were treated by opium and sulphuric acid, though not with
much success. On the 11th of March, it was noticed that an abscess
had formed at the left temple owing to the head being so much drawn
to that side. At the end of March, it is reported that her appear-
ance was improving, and that she continued to take food well.
Both knees were drawn up to the abdomen constantly as before,
the bed-sores looking better. Moist sounds existed extending in
both lungs. The temperature was then generally 98*6°. The tinc-
ture of Cannabis Indica and shower-baths were prescribed. Through-
out, the pupils were very dilated. About April 5th, she spoke a
few words occasionally. The bed-sores continued to. do well ; the
Cannabis was increased, and subcutaneous injections of morphia
and atropine were given. On the 20th she went out having from
time to time spoken a few words. I have heard nothing of her
since.

The high temperature in the above case is of interest, though
perhaps not so much so as if the case had been less complicated.
No doubt it must be considered as resulting from the quickening of
the heart and circulation, consequent u])on the muscular activity.
In many ordinary cases of chorea I have failed to meet with any posi-
tively increased temperature.^

In connection with this subject, as a result of muscular move-
ments, I may here allude to the high specific gravity/ of the urine,
and the amount of urea in that excretion spoken of by some as
exciting in cases of chorea. The reader will know that I allude to
the observations of Walshe (see Lectures on Clinical Medicine,
^ Lancet,^ 1849, vol. i, p. 85),Bence Jones, Todd, and others. For
myself, in a great many ordinary cases of chorea, I have been unable
to find anything of the kind beyond what would doubtless be pro-
duced by the comparatively high feeding which chorea patients are
subject to. In many cases, even where much food was taken, the

• My friend Dr. Fox tells me that he has found the temperature in chorea to be
"99*3° and 100°, and even rather more at night, and that was so in cases where
there was not much muscular movement." He thinks it probable thaU temperature
in chorea is higher in cases in which rheumatic element exists.

1868.] Ogle's Cases of Non-fatal Chorea. 503

urine did ^not range above 1019 or 30°, but litbates were very
abundant.

No doubt under the light of former physiological knowlege it was
naturally expected that an increased excretion of urea would take place
as an inevitable result of tissue metamorphosis in chorea. Present
teaching, however, shows us that we ought neither to have found nor
sought for such increase of urea in chorea. On this matter see the
'Ed. Med. Journal,' Feb. 1866, wherein Dr. K. Anderson describes
the daily amount of urea in the second week of typhus, as being
" decidedly below the standard of health, notwithstanding that the
patients were in a state of high fever with the temperature and pulse
much above the normal state." See also the experiments of Bischoff,
and Voit, and Tick, and Wislicenus of Zurich, corroborated by Pro-
fessor Erankland, from which it appears that muscular power is
derived from the oxidation of hydro-carbonaceous material mainly,
though not entirely. Prankland thinks the mechanical force of the
muscles is derived from the oxidation of matters contained in the
blood, and not from that of the muscles themselves. Dr. Parkes
(see ' Proc. Royal Soc.,' Jan., 1867), from experiments, came to the
conclusion that unless nitrogen be found to disappear through the
skin, it must be 'supposed that muscular force is derived from the
carbo-hydrates, the amount of nitrogen excreted during active
exercise being lower than that excreted during a period of rest,
though in the period of rest following work, it is slightly increased.
Pettenkofer and Yoit noticed recently that muscular work seems to
have no influence on the amount of urea exci'eted.

I will now add the details of a case which was not under my care,
but of which I have been favoured with the following notice. I
have alluded to it at foot-note to page 232.

It was that of a boy who lived in Derbyshire. He had had
some kind of " fever" and was inefficiently nursed, and, subse-
quently, became severely affected by chorea ; during sleep he was
perfectly quiet, but on waking would at once commence singing
and shouting vociferously, and jumping and " working about" as
friends described it, until he was quite exhausted. He would jump
violently, and scream loudly, and by jerking motions eject the
spittle to an einormous distance. Por some time he was unable to
swallow any substance, and at last became in consequence " so frantic
for food " that he swallowed everything whole directly he put it into
his mouth. In this condition he continued for several weeks, and was
treated by T. Penfcem, Esq., of Eyam, who, in addition to other treat-
ment, applied a blister at the back of the neck. At last, it was deter-
mined to take him to the Sheffield Infirmary. • To the boy's delight
(expecting cure at the Infirmary), a carriage was procured for him,
and he was conveyed thither a distance of several miles. He jumped

504 Original Communications. [-^pril,

about and was unmanageable in the vehicle for some time as usual,
but when they arrived at the Infirmary with him it was ascertained
that he was now all but well.^ They kept him in the Infirmary for
two weeks and treated him with tonics, good food, &c., and he left
it still remaining quite well ; and since then he has married, and
has had no return of the affection. It was the conviction of him-
self and his friends that he was cured by the shaking of the carriage.
This case somewhat reminds one of those cases analogous to chorea
termed " epilepsia saltatoria.^^ ^

' I have previously (specially when referring to this fact as a reason against
the supposition of serious injury to the nervous centres existing in such cases)
alluded to the rapid removal of chorea which sometimes takes place. I may here
quote the case of a girl, A. H — , who was admitted into St. George's Hospital with
chorea, under the late Dr. Page's care, not long ago. She became the subject of
scarlet fever, and the chorea almost entirely departed, apparently in consequence
of this attaclv. I find in the ' British Medical Journal,' August 1st, 1863, p. 121,
a case, quoted from the ' Gaz. des Hop.,' of chorea cured, and permanently so by
an attack of fever caught in the hospital. Dr. Painter, of Beaufort Gardens, has
lately informed me of a case of aggravated hysterical paralysis, which was
singularly cured in his presence by the " fright " produced by the sight of a leech
on the ground. Many readers may remember the case of paralysis cured by Sir
H. Davy, merely by the daily placing the thermometers uudar the tongue.

" The reader will find the details of a fatal case of chorea in a girl, a)t. 13,
related by Dr. Inman, of Liverpool, in his work on ' Neuralgia,' 1860, p. 249.
The patient appears to have died of exhaustion ; the choreic motions ceased some
hours before death. "The post-mortem showed as healthy a body as it was
possible to examine." This case is also related along with another fatal case, in
which the symptoms " resembled those of tetanus and chorea, but were identical
with neither," in his work the ' Foundation of a New Theory,' &c., p. 466. In
Schmidt's ' Jalirbiicher,' 1865, Bd. 137, ser. 2, p. 169, are quoted two cases of so-
called " chorea magna," of which one proved fatal. This case had been under the
care of E. Vecchietti, in the Ospedale Maggiore at Bologna, and was that of a boy,
aged 13, who had had acute rheumatism. The choreic movements commenced in
the right arm, and then extended to the entire body. Among other symptoms
pressure on the vertebral column was painful. The temperature loas increased,
and the skin greatly perspiring. After death, in addition to other appearances,
the veins of the vertebral canal were found distended with blood, the cellular
tissue injected, especially about the first dorsal vertebra j and the veins and
capillary vessels of the cerebral membranes were injected. The spinal cord opposite
the first dorsal vertebra was greatly softened, and of a reddish colour. The other
case of " chorea magna " did not prove fatal, and was communicated by Dr. Frangue
of Munich. The patient was a boy 11 years old, who after a fright from a blow
on the shoulder lost his speech for six weeks. Speech returned afterwards for a
single day, and then disappeared again, choreic movements coming on. Speech
again returned, but the choreic movements became worse, and eventually of a
most violent kind. With intervals of intermission the disease continued above
two years. Much urate of ammonia was passed, and on two examinations
abundance of strGAE was found in the urine. Frangue says that in a female
choreic patient he had found sugar in the urine which was not there before, or in
the intervals, after every attack. Other cases of so-called "magna chorea " are on
record, chiefly in German literature, and it seems to bear the name with some
authors of " Chorea Germanorum." As far as I can learn, Skoda first used the name
chorea magna, which he described (' AUg. Wien. Med. Zeitung,' 1858, 36) as being
distinguished from so-called " chorea minor " only by its paroxysm-like invasion :
the movements may be, however, of a springing, revolving character, and generally
are very violent, but not trembling, as in paralysis agitans. Among such instances
of chorea magna, two cases are particularly interesting, one described by Mossier,

1868.] Ogle's Cases of Non-fatal Chorea. 505

In bringing to a close these observations upon chorea, I will (in
reference to the questions connected with the history of the fatal
cases which I have already given) add the notes of yet other
fatal cases/ two of which have not been yet placed on record.
Of these, that already published by Dr. Day, in his 'Clinical
Histories with Comments' (see p. 101), is so interesting that I
may be pardoned giving a brief abstract of it. The case was
that of a boy, aged nine years, who had had acute rheumatic
fever two years previously (? with any heart mischief), and who
experienced a second attack. Four days after the commencement
of the second attack chorea set in. Pericarditis came on, and he
died eventually completely exhausted, retaining consciousness to
the last. It was remarkable that the choreic spasms were not
arrested (only lessened) during sleep j and also that the acid per-
spirations were confined to different parts of the body at a time, some-
times to one side only, or to a particular limb. After death, in addi-
tion to old-standing valvular roughnesses, the fleshy columns and
tendinous chords of the heart were covered with " Ipnph-like
exudations!' The brain was healthy, but the vessels of the spinal
membranes were very distended with blood, and in some cases
had given way. The spinal nerves over a large extent of the chord,
where emerging from the intervertebral notches, seemed pinched,
their membranous covering being " at least four times as thick as
it normally should be, so that it appeared to form a complete stric-
ture, whilst both before and behind this constriction there was ample
evidence of inflammatory action." Moreover, large discoloured spots
were found under the skin of the body in many parts. Dr. Day alludes
to Dr. Stiebel's opinions (see ' Wochenschrift f. d. Gesamm. Heilk,'
1837,No.l.;also,'Brit.andror.Med.-Chir.Eev.,'Oct.l837,p.504),
that chorea was entirely occasioned by spinal-nerve-irritation, the result
of turgescence of the membranes of the spinal cord or medulla oblon-

of Giessen (' Deutsche Klinik,' 1860, p. 30) in a girl aged 12, apparently connected
with menstrual efforts, and ending in hysterical convulsions; and another,
described by Eoth, of Bamberg (see ' Jahrbiich,' vol. cxix, p. 294), in a child aged
11, who became insane and epileptic.

* Dr. Fox, of Clifton, has quite recently sent me the note of the following case
of complicated chorea. It was " that of a girl who had been epileptic for some
years. In spite of this she went to school, and was much impressed by the sayings
and doings of a curate with Revivalist tendencies. She was brought to tlie
infirmary with violent choreic and jactitations of the sides, and spent several
days and nights in screaming, praying, and swearing. She considered me an
impersonation of Satan, and on one occasion bit me severely. In fact, she resem-
bled some of the worst cases of Revivalist hysterical mania, with the element of
chorea superadded. In a few days she became more calm, and the chorea gradually
left her, but, against my orders, the curate was allowed to see her during her
convalescence, and a recurrence of all her symptoms, choreic and other, was
induced. She recovered entirely after a complete separation from the religious
exciting cause. She died some years afterwards of fever, having been convulsed
almost without interruption for forty-eight hours before death, and no lesion of
the spinal cord or brain was detected."

506 Original Communications. [April,

gata, and that possibly such other causes as " injuries to the spine and
metastasis of rheumatic inflammation" may exist, which causes would
of course produce the above-named spinal-nerve-irritation. He,
however, unlike Dr. Stiebel, denies that all cases of chorea are de-
pendent on one universal and unalterable cause, and suggests " that
in the milder and more yielding forms of the affection, there is mere
functional disturbance,'^ while in the '' graver attacks there is always
going on a local lesion of a severe character." In passing, it may
be recollected that in choreic cases we often have pain produced by
pressure on the vertebrae. Dr. Day observes that in the milder
cases the movements were rather like exaggerated natural motions
with a shade of " controllability," whilst in the severe forms " all
control is evidently gone, and the spasmodic affection seems to par-
take almost of the nature of tetanus.^''

Dr. Day adverts also to the suggestion of Dr. Stiebel, that in the
milder cases of chorea, which generally occur amongst young growing
persons, it is probable that, as the spinal marrow and the origin of its
nerves lie within a bony canal, there maybe during development "some
want of due relation between the bones and the enclosed part of the
nervous system, the cavity not corresponding to the increasing marrow,
and then a constriction or pressure may for a time produce an irritat-
ing effect."" I need hardly say that such an anatomical cause would
hardly be consistent with the changing and transitory character,
and the rapid curabihty or removal of the affection in many cases.
Dr. Stiebel remarks that of the nearly one hundred cases of chorea
which he had seen, in not one was there wanting the evidence of
an irritation of the spinal nerves, few of the patients not having had
pain in some one of the vertebrae during the course of the disease.
I would suggest that such pain need not of necessity indicate any
irritation of spinal nerves ; it might have been rheumatic, and con-
nected with the fibrous structures about the vertebrae. In connection
with this symptom a case related by Dr. Marshall and quoted by Dr.
T. Thompson (op. cit.) is interesting, in which symptoms resembling
chorea were apparently produced by hghtning, and these symptoms
were much aggravated by pressure at certain points of the spine.
Dr. Day, in alluding to the discoloured spots under the skhi in his
fatal case, takes occasion to comment on the connection established
by some authors between " nerve lesions" and certain eruptions and
morbid appearances of the skin. I will here refer to the mention
made by Dr. T. Thompson (loc. cit.) of cutaneous diseases, such as
urticaria and roseola, co-existing along with chorea and probably
resulting from the same state of the nervous system. He quotes
one case of chorea of a remarkable kind, in which diffused patches
of a bright-red eruption came out near the elbows, on the day
the motion ceased, and lasted three days. It came on afterwards
again on the arms, when the eruption recurred. I find that Dr.

1868.] Ogle's Cases of Non-fatal Chorea. 607

Bright noticed the coincidence of roseola with chorea (loc. cit.
p. 489).

Dr. Day has obhgingly lately sent me the notes of the following
case which proved fatal.

" A young woman, in the third month of pregnancy, was admitted
into the (Stafford) infirmary, suffering from occasional attacks of chorea.
The involuntary movement of the voluntary muscles were strange
and grotesque, but at first not violent ; they soon, however, became
so, and so uncontrollable, that she was placed in a ward by herself,
all the furniture being removed and the floor being covered with
bedding to prevent her injuring herself. No treatment seemed to
benefit her, and I was requested to see her a few days before she
died. I suggested that the uterus should be emptied; this was not
assented to. I had ice bags applied to the spine (there was con-
siderable spinal tenderness) but this did not make matters any better.
I then succeeded in bringing her under the influence of chloroform,
and she got some rest and disturbed sleep ; upon waking, the move-
ments commenced as violently as before. She obtained rest and sleep
every now and then from the chloroform, but at last died thoroughly
exhausted, retaining her consciousness to the last. Post-mortem
examination disclosed everything natural except the membranes of
the spinal cord, which showed evidence of intense inflammation.'"

The third and last additional fatal case of which I spoke was as
follows. It quite recently occurred at the Somersetshire Asylum,
and for its particulars I have to thank my friend Dr. Boyd.

C. C — , set. 23, married, was six months pregnant with her second
child. She was the subject of most severe spasmodic action of the
limbs and neck ; the cheeks were reddened from friction caused by
jerking of the face against the bedding. She was able to answer
questions but with great efforts. The tongue was moist and white.
The pulse could not properly be counted owing to the jerking of
her arms. Bowels confined ; the swallowing of food was difiicult.
She was labouring also under severe bronchitis and her breathing
was difficult. The oedema had existed three weeks when premature
labour occurred, the foetus having apparently been dead two or three
days ; on the following morning she died. She had sleep from an
opiate the night before her death, but for several nights previously
had had no sleep.

After death the brain, which weighed forty-four ounces, was found
congested but natural in structure. The spinal cord was soft and
pulpy throughout its entire length. It was examined for me by Mr.
Lockhart Clarke, who has sent me the following notes of the speci-
men : " The spinal cord was slit through longitudinally ; only the
lower part of the lumbar enlargement remained entire, and this was

508 Original Communications. [April,

not sufficiently hardened to admit of making thin sections. The
lower portion of the dorsal region which had been slit through was
evidently softened; small fragments examined under the microscope
exhibited, however, chiefly an admixture of granules, with some
compound granular corpuscles, without any remarkable alteration in
the condition of the nerve -fibres. This condition resulted no doubt
from an early stage of softening in which a granular fluid exudation
was poured out. Just below the middle of the lumbar enlargement
the tissue was perfectly pulpy — of the consistence of cream ; and a
small portion of this picked out and placed on a slide with as little
disturbance as possible, showed under the microscope scarcely any-
thing but broken nerve-fibres mixed with granules and some com-
pound granular corpuscles. Almost every fibre had assumed the
form of the well-known globular or oval masses of myalin or white
substance, of different sizes ; so that under a low power the arrange-
ment resembled the cellular structure in a section of wood or stem
of plant. In the lower part of the lumbar enlargement that had
not been slit the grey substance was evidently in a state of disinte-
gration/' The lining membrane of the bronchial tubes was red and
coated with reddish mucus. The abdominal organs -were healthy.

Thinking it might be interesting to search out what might have
been the number of deaths from chorea returned and registered, as
having occurred in England and Wales during a series of years, I
found that from the year 1839, the first year of our present national
plan of registration, they were as follows :

Deaths from

Deaths from

Dciths from

Chorea.

Cliorea.

Chorea.

1839 .

. 54

1851 .

. 77

1859 .

. 55

1840 .

. 25

1852 .

. 73

1860 .

. 66 -

1841 .

. 28

1853 .

. 67

1861 .

. 71

1842 .

. 19

1854 .

. 48

1862 .

. 52

1847 .

. 39

1855 .

. 69

1863 .

. 63

1848 .

. 38

1856 .

. 59

1864 .

. 73

1849 .

. 34

1857 .

. 44

1865 .

. 88

1850 .

. 60

1858 .

. 53

The number of deaths in the various years is very unequal ; it
would be interesting to try and find out if this difference could
fairly be attributable to any peculiar atmospheric or climatic cause.
Many authors (this is mentioned by Bond) have found chorea to
prevail much more in cold weather and winter than in summer, and
certain observers practising in tropical climates have never met with
it. Others again, as quoted by Dr. T. Thompson (op. cit.), consider
it to be more common in summer.

Corrigenda. — At page 229, in the third line from the bottom, in the place of
" the exit of," read " altering "; and in the line below, read " are," in place of
" being." Also, at page 233, in the second line from the top, in place of " and
universally interrupted/' read " and almost universally uninterrupted."

508*

The accompanying woodcut illustrates the fissured condition of tlie lips
desciibed in the history of the 14th fatal case {seepage 220), for the use of which
I have to thank the Council of the Pathological Society.

1868.] 509

PART FOURTH.

(ftf^xonicU of JEetiical Science.

(chiefly foreign and contempoeary.)

REPORT ON SURGERY.
By John Chatto, M.R.C.S.E.

On the Earliest Treatment of Syphilis. — Professor Sigmund, of
Vienna, draws attention here to the importance of attacking,
by local treatment, the very earliest signs of syphilis, which are
usually overlooked or neglected. To wait until the sore or chancre
is formed is to wait until the disease has got possession of the
absorbents, and is then rarely to be arrested by such measures.
Long before this there are changes to be discovered consisting in
mere excoriations, fissures, vesicles, pustules, circumscribed redness
and puffiness, or increased secretion. Slight as these may sometimes
be, they are the precursors of the more tangible symptoms which
are developed after intervals that are sometimes considerable, all
these early signs having perhaps first disappeared. The important
point is that if these latter be promptly treated by caustics, the
disease now being really local, its further manifestation will in a
great number of cases be prevented. Professor Sigmund founds this
statement upon two series of observations he has conducted. The first
of these has been made on persons who have become accidentally the
subjects of syphilis in the pursuit of their avocations, as physicians,
accoucheurs, nurses, &c., and whose cases admitted of the most
exact observation with regard to the period of infection, &c. Of
110 cases of this kind which came under his notice, he has been able
to utilise only 57, the others coming too late under observation ; and,
of these 57, 35 were cauterised between the 1st and the 10th days
after exposure to infection, and 22 left to themselves. Among the
former 22 per cent., and among the latter 50 per cent, became the
subjects of syphilis. But of 24 of the 35 who were cauterised
between the 1st and 3rd day, only 12 per cent, had syphilis, while
of the 11 who were cauterised between the 5th and 10th days, 63
per cent, contracted it, showing that to prove its real utility the
cauterisation should be practised within three or four days after
infection.

The second series of observations is derived from Dr. Sigmund's
clinical observations. He has practised cauterisation in 743 cases,

82— XII. 33

510 Chronicle of Medical Science. [April,

in whicli the contamination was due to connection with syphilitic
women ; and in 340 cases this cauterisation has been followed by
syphilis. But he found that in 312 cases in which it was practised
between the 1st and 3rd days only 86 patients, or about 27 per cent,
became syphilitic, while when it was delayed to between the 4th and
14th days, in 431 patients it failed in 254, or about 59 per cent. As
cauterising agents the author employs the Vienna paste, or a
saturated alcoholic solution of corrosive sublimate, for the more
superficial appearances, and the sulphate of copper when ulceration
is present — taking care that the action of the caustic shall extend
beyond the circumference. When the eschars are detached, the
parts should be washed with strong solutions of chloride of lime.

Local applications of this kind, employed when chancre or indu-
ration have become established, Dr. Sigmund regards as useless,
and as exerting no mitigating influence on the future progress
of the disease. All they can do is to prevent the multiplication
of infection by auto-inoculation or communication to others, and
to favour the healing of the primary sores. In conclusion, he
observes that this question of the prophylaxis of syphilis cannot
be too much and too variously discussed, and endeavours should be
made to correct the erroneous ideas which most patients and many
practitioners entertain respecting it. Patients should be strongly
impressed with the fact that the most insignificant appearance after
a suspected connection is of importance, and practitioners must not
rest contented without careful examination. If the appHcation of
caustic as a prophylactic is not always followed by the desired result,
yet in a great many cases the progress of the disease will have been
prevented. The public will gradually learn to make careful examina-
tion for slight appearances after suspicious intercourse, and to resort
promptly to surgical assistance, and it will no longer be then
believed that the primary form of syphilis once developed can ever
be prevented pursuing its further development by mere local appli-
cations.— Wiener Med. Wochenschrift, 1867, Nos. 43, 44, 46, 53.

Dislocation of Tendons. — M. Jarjavay observes that, while it is
obvious that in severe injuries of joints the displacement of tendons
forms but one of the details of the general lesion, the ques-
tion of whether these admit of displacement without coexisting
fracture of the bones or dislocation of the joints is not so easily
determined ; most authors, however, answering it in the negative.
A portion of the subject he has had opportunities of studying, and
BOW presents the results.

1. Displacement of the Long Tendon of the Biceps. — After a critical
examination of the supposed examples of this occurrence which have
been published, and relating five analogous cases which have come
under his own notice, he arrives at the following conclusions : —

(1) The simple dislocation of the long tendon of the biceps has no
existence, or at all events this has never been demonstrated.

(2) That the lesion which has been mistaken for it is situated in the
Bub-acromial serous bursa. (3) This lesion consists in inflammatory
swelling, caused by the contusion or rupture of the bursa ; or, as a

1868.J Report on Surgery. 511

consequence of the inflammation, in hypertrophy with induration of
its parietes, and a fibrous transformation of the cellular lamellse
which traverse it. (4) The following are the symptoms observed :
A sensation of displacement at the time of the accident ; tumefaction
of the point of the shoulder ; pain which prevents the movements of
the arm, especially abduction ; flexure of the forearm on the arm,
with consequent rigidity of the biceps, and a sense of fatigue at the
bend of the elbow ; increase of pain, and a noise beneath the
acromion when the limb is raised in a state of abduction — that is
when the tuberosity of the humerus is caused to sHde beneath this
apophysis (this noise, a kind of cracking, gives the idea of the
reduction of something displaced, and is reproduced every time the
bone is rotated while held in a horizontal position) ; a disappearance
of the pain, and return of the movements of the part after rest,
placing the forearm in a sling, and the application of resolvent
lotions to the shoulder, the noise persisting even after the pain has
disappeared and the movements of the part have again returned.
(5) The application of electricity to the attachments of the deltoid
and supra-spinatus muscles is an excellent means of immobilising
the scapula, while the arm is at the same time exercised.

2. Dislocation of the Tendons of the Peronei Muscles. — Of the
reality of this lesion M. Jarjavy has no doubt, not only on account
of cases which have been recorded by others, but also because of
two well marked examples he has met with* himself, the particulars
of which he gives. Still it is a very rare accident, for he cannot
agree with M. Demarquay that so obvious a lesion could have been
often overlooked by competent surgeons. In two of the recorded
cases the tendons of both the peronei were displaced, but in the
others only that of one, which M. Jarjavy believes must have always
been that of the longus. In almost all the cases the weight of the
body in falling has borne upon one foot, the extremity of this being
turned inwards. In such a case a fracture of the malleolus or a
bad sprain from distension or rupture of the. ligaments often results ;
but in other cases, when the groove of the malleolus is not very
deep, a rupture of the sheath occurs and the tendons are luxated.
Of eighty persons examined by M. Jarjavy, he found that in four
the posterior edge of the malleolus only incompletely contained the
tendon of the peroneus longus when he induced forcible contraction
of the muscle. This would then act as a predisposing cause, the
efficient one consisting in the energetic contraction of the muscles
when, on a fall upon the anterior extremity of the foot turned in-
wards, an effort is made to replace it. The symptoms much re-
semble those of a severe sprain, the patients often being able to
walk somewhat after the accident. There is swelling with or with-
out ecchymosis, and in the midst of the infiltrated tissue the tendon
is felt rolling under the finger. It is easily replaced by pushing
it from before backwards, the displacement being reproduced at will
by causing the peronei to contract, while the anterior extremity of
the foot is fixed and directed inwards. In some cases it is displaced
spontaneously with the greatest ease. With an appropriate starch

513 Chronicle of Medical Science. [April,

bandage applied, after the swelling has subsided, the cure is gene-
rally completed by about the 30th day. — Gazette Hehdomadaire,
1867, Nos. 21, 23, 25.

On tJie Healing of Penetrating Gunshot Wounds hy the first inten-
tion.— Professor Simon of Rostock remarks that this is very seldom
remarked, and its possibility denied by most surgeons. But this
does not so much arise from the rarity of its occurrence, as from
the fact that, during the first few days after a battle, the whole
attention of the surgeons is taken up by the more complicated
injuries. Simple gunshot wounds, if they have a healthy appear-
ance, are scarcely noticed, or left to the nurses. The circumstances
are quite exceptional for the number of surgeons to be sufficiently
large to leave them leisure to examine the progress of the more simple
cases. And yet several military surgeons of eminence have from
time to time recorded the occurrence of this rapid healing. The
author was placed during the late German war in favorable circum-
stances for examining at his leisure the condition of such wounds
having had charge of one of the military hospitals at Berlin to
which the wounded were transferred seventeen days after the battle
of Koniggratz. The good appearance of the wounds surprised all
the surgical staif which was numerous enough to be able to pay minute
attention to them. Most of the muscular wounds were completely
cicatrized or completely closed in their entire course up to the orifice
of the wound. Even when foreign bodies were present, as balls,
splinters, portions of clothing, the wounds were often closed up, and
only re-opened at a later period for the elimination of these. The
cicatrices looked as if they had been long formed, not having the
red appearance of recent scars, but differing in colour little from the
surrounding skin. Numbers who saw these patients all agreed that
these cicatrices must have resulted from healing by first intention.
The patients declared themselves that their wounds had healed in a
few days, the orifices of entrance only secreting a little pus. There
is much more loss of substance at the orifice of entrance than of
that of exit, where, as well as in the course of the wound, the
parts become closely approximated enough to unite by adhesion,
while at the entrance granulation is usually the process observed.
Several surgeons who were on duty near the battle-fields, and saw the
wounded soon after the engagements, informed Professor Simon that
they had observed cases of undoubted healing by the first intention. —
Deutsche Rlinik, 1867, No. 28.

Sympathetic Ophthalmia. — Dr. E. Meyer observes that on survey-
ing the numerous instances of this affection that have been published
it is found that more than one half of them have been observed in
cases in which the injured eye contained a foreign body. Of the
other half two thirds are cases of penetrating wounds, and one third
simple contusions. Generally the lesion involves the iris and ciliary
region, inducing prolonged inflammation of the injured organ. It is
comparatively rare to find this sympathetic affection succeeding an

1868 .J Report on Surpery. 513

operation. It is seldom met with in children, and its subjects are
usually persons of a feeble, anaemic, or nervous constitution.

Of the two hypotheses which have been advanced to explain the
pathogenic action excited by the injured eye upon the sound one,
M. Meyer believes that while the optic nerve and its decussation
may, in some instances, be the channel of transmission, this is, in a
far greater number, to be sought for in the ciliary nerves. Tbe
affection by no means presents the same serious symptoms, and the
same pathological changes in all cases, and may especially exhibit
itself in three forms. 1. The most dangerous of these is that known
as malignant iritis or irido-cyclitis, which, coming on days, weeks, or
even months after the injury, leads to the deposition and organisa-
tion of false membranes behind the iris, uniting it in a very solid
manner to the capsule, and producing complete immobility of the
pupil. There is excessive sensibility in the region of the ciliary
body, and eventually the globe softens, complete blindness ensuing.
Treatment can here do little. Enucleation of the injured eye after
the irido-cyclitis is developed is of no avail, and its only chance of
success is its employment before any sign of inflammation is present.
Iridectomy is of difficult execution and doubtful benefit.

2. Ordinary serous iritis is the second form observed, the pupil
continuing to dilate, though peiJiaps somewhat irregular from slight
adhesions. The aqueous humour is turbid, and the globe is rather
tense. Although this form is very obstinate it does not lead to
irido-cyclitis. The vitreous humour generally remains intact ; and
in these cases enucleation, being attended with complete success,
should never be neglected.

3. The slightest form of the affection may be appropriately
termed a sympathetic neurosis. It is characterised by considerable
photophobia with consecutive spasm of the orbicularis, slight injec-
tion around the cornea, weeping, a want of energy in vision, and
defective power of accommodation. Enucleation would here be also
a remedy ; but the author, acting on the suggestion of Yon Graefe,
has, in three instances which have come under his notice, resorted
with complete success to the section of the ciliary nerves ; and he
recommends that this operation should be performed when, from
the sensibility of the ciHary region to the touch, sympathetic
ophthalmia is to be apprehended ; practising it indeed before any
symptom of the sympathetic affection has appeared. — Annates d^ Ocu-
listique, Septembre.

Arterial Cirsoid Tumours. — Under this name M. Gosselin indi-
cates an arterial lesion which occupies a place between the erectile
tumours described by Dupuytien, and the cirsoid aneurysm of
Breschet ; for while the first of these concerned the capillaries, and
the second the large arterial branches, the lesion %. question is an
abnormal dilatation of the arteries near their termination, the
arterioli or ramusculi of anatomical language. This dilatation pro-
duces circumscribed tumours, sometimes co-existing with the tvt^o
lesions mentioned, which may give rise to very serious symptoms
calling for surgical intervention. It is not meant to be asserted that

514 Chronicle of Medical Science. [April,

this dilatation of the subcutaneous ramusculi has not been noted
by various authors ; but it has not been sufficiently distinguished
by them from venous tumours and arterial varices.

These tumours are almost exclusively found occupying some
portion of the head, the pulsating vessels constituting them being
in the subcutaneous cellular tissue, differing in that from nsevus
■which is a dilatation of the vessels of the skin. The ramusculi
undergo a remarkable development, some becoming as large as
quills and others the size of earthworms, the flexures being also very
numerous. The agglomeration of these dilated vessels into masses
or packets iinder the skin give the tumour its peculiar cha-
racter. Not very voluminous, it presents a rounded relief, without
being very exactly circumscribed. As it increases in size it
acquires adhesions with the skin, which after a while ulcerates,
giving rise to dangerous haemorrhage. Although the aff'ection may
sometimes be traced to a traumatic origin, it is in general developed
spontaneously, depending upon some special but inexplicable apti-
tude. It usually coincides with a dilatation of neighbouring arterial
branches, or varices properly so called, but the course of the two
affections remains independent, the diminution or disappearance of
the varices not influencing the condition of this tumour.

The tumours are only met with in- subjects from eighteen to forty
years of age ; and if, as is certainly the case, they exist at a much
earlier period of life, they are not sufficiently developed to give rise
to deformity and haemorrhage. The frequency and danger of such
haemorrhage calls for surgical interference, and, rejecting the various
operative procedures that have been proposed, M. Gosselin recom-
mends as an effectual mode of treatment the injection of the per-
chloride of iron into the tissue of the tumour. Wherever the per-
chloride penetrates, induration and cessation of pulsation ensue, and
the injections have to be repeated at the intervals of ten or fifteen
days, as many as six or eight being sometimes required. In two of
M. Gosselin's three cases ulceration took place at the points of
puncture, giving issue to small black and hard coagula. Small ulcers
with sprouting granulations succeeded, and were very tedious in
healing, notwithstanding the use of caustics. Their presence did
not, however, interfere with the curative process. In another case
' suppurative inflammation followed the last injections, considerable
haemorrhage resulting. The tumour was laid open and the actual
cautery applied. The details of the three cases are given. — Archives
Ginerales, December, and Comptes Rendus, October 7.

On Union hy the First Intention after Lithotomy. — Professor
Bouisson maintains that this, although an exceptional occurrence,
may be effected much oftener than might be supposed ; and he relates
four cases in which it took place from among those he has met with
at the St. Eloie Hospital, Montpellier. Two of these were observed in
adolescents, one in a boy six years of age, and the fourth in a man
sixty-four years old — this last being of course an example of a very
rare occurrence. In all of them complete cicatrization was accom-
plished within a week. Toung and healthy subjects are those most

1868.1 Report on Surgery. 515

suited for a trial of the plan, but no particular mode of dressing the
parts is resorted to, although some aid may be derived from observing
a suitable position. The median operation is that most likely to be
followed by this result, and it should be performed with as little
contusion and laceration of the parts as possible. To this end,
when he has to do with too voluminous a stone to admit of extrac-
tion through an incision of small dimensions, M. Bouisson, in place
of using too great traction, prefers completing the operation by
means of lithotrity. Another precaution taken is the prevention
of the flow of urine through the wound by keeping a catheter of
moderate size only in the urethra. In some cases this is not neces-
sary, as the urine at once spontaneously passes by the natural
channel or escapes through the wound in such small quantities as
not to retard its healing. — Gazette Medicale, 1867, Nos. 46-52.

The Statistics of Amputation. — Professor J. F. Hey felder furnishes
a contribution to this subject derived from twenty-two years' (1841-63)
hospital practice in three different places, viz., Erlangen, Helsingfors,
and St. Petersburg.

1. In the surgical clinic of Erlangen, during the years 1841-54
there were performed 127 amputations, with 101 recoveries, and 26
deaths. Of these, 55, with 35 recoveries and 20 deaths, were
amputations in continuity ; and 72, with 66 recoveries and 6 deaths,
were amputations in contiguity or disarticulations. Of the 55 am-
putations, 10 related to the arm, with 4 deaths, and 25 to the leg,
with 8 deaths, 4 to the forearm, with no deaths, 16 to the thigh with

8 deaths. Of the disarticulations, the shoulder supplied 4 cases with
two deaths, and the hip 8 cases with 4 deaths. The remainder were
operations on the foot and hand, all terminating successfully.

2. In the Military Hospital at Helsingfors, the reporter performed
during 1855-56, 39 amputations in continuity, with 14 recoveries
and 25 deaths, viz., 4 of the arm with one death, 4 of the forearm
with no death, 18 of the thigh with 15 deaths, and 13 of the leg with

9 deaths. There were also 24 disarticulations with 12 deaths, 15 of
these being amputations at the' shoulder-joints with 4 deaths, and 2
amputations at the hip-joint, both fatal.

3. In the First Military, Workmen's, and Children's Hospitals of
St. Petersburg, there were performed during 1856-63, 61 amputa-
tions in continuity with 26 deaths, viz., 5 of the arm, with 2 deaths,
9 of the forearm, with no deaths, 14 of the thigh, with 10 deaths,
and 23 of the leg, with 14 deaths. The disarticulations amounted to
43, with 18 deaths, among these there being 5 operations on the
shoulder, with 2 deaths, 3 on the hip, and 6 on the knee, all fatal.

Viewed together, it results from these figures that (1) the issue
of amputation of the forearm was highly favorable, since the whole
17 cases recovered. (2) Next comes that of the arm, 12 recovering
and 7 dying of 19 cases ; the mortality being 40 per cent, at Erlan-
gen, and St. Petersburg, and 25 per cent, at Helsingfors. (3) Am-
putations of the leg were 61 in number, with 30 recoveries and 31
deaths ; the mortality being 32 per cent, at Erlangen, 69 at Hel-
singfors, and 64 at St. Petersburg. (4) Amputations of the thigh

516 Chronicle of Medical Science. [April,

amounted to 48, with 15 recoveries and 33 deaths, viz., a mortality
of 50 per cent, at Erlangen, 83 at Helsingfors, and 71 at St. Peters-
burg. (5) With respect to sex, of the 155 amputations 136 were
performed on males, and 19 only on females ; and the comparative
mortality was at Erlangen 75 per cent, for the males, and 25 per cent,
for the females. At Helsingfors they were all males, and the two
females at St. Petersburgh both recovered. (6) The amputations
were performed at Erlangen for traumatic causes in 14 cases, and
for chronic organic disease in 41. The former ended fatally in 6 cases,
or 42 per cent., and the latter in 14 cases, or 34 per cent. At the
Helsingfors Military Hospital, 30 of the 39 amputations were per-
formed for injuries, with a mortality of 25, or 64 per cent. At St.
Petersburg, 30 of the 61 amputations were for injuries, with 26
deaths, or 86 per cent. The 25 amputations for disease all terminated
well. (7) The ages of the patients are not specified, the reporter
only mentioning that the young under 15 generally recover, while it
is quite exceptional for a patient above 70 to do so. (8) The dis-
articulation of the shoulder-joint proved fatal at Erlangen in 50 per
cent., at Helsingfors in 80 per cent., and at St. Petersburg in 40
per cent. That of the hip-joint did so in 4 out of the 8 cases at
Erlangen, and in the 5 cases at the other hospitals, one of these,
however, perishing from the cholera. The 7 cases of disarticulation
of the knee all proved fatal. Of the 9 operations on the joints of
the hand only 1 proved fatal ; and of 20 tibio-tarsal operations all
but 2 did well. Operations on the fingers and toes were nearly all
successful.

To this statement Dr. Heyfelder adds another statistical abstract,
derived, from cases observed (in private practice, we presume)
in Finland and at St. Petersburg during the years 1855-62.
Erom this it appears that 234 amputations furnished 151 reco-
veries, and 83 deaths, the mortality prevailing in the following
proportions: — amputation of the arm, 33*3 per cent. ; forearm, nil;
thigh, 77-3 ; leg, 53-2 ; shoulder-joint, 66-5 ; hip and knee, 100 ; the
hand, 9"1 ; and tibio-tarsal, 251. — Berliner Klinische Wochenschrift,
September 23.

Summary.

Actipressure. — Billroth. On Acupressure. (Wien. Med. Woch.,
1868, Nos. 1, 2, 3. Holds a very high opinion of the procedure.)

Amputation. — Heine. On Supra and Transcondylar Amputation
of the Thigh. (Deutsche Klinik., Nos. 41, 42, 43. A new modifi-
cation of the amputation, illustrated by a case.)

Aneurysm. — ^Vanzetti. Three Cases of Aneurysm treated by
Digital Compression. (Oaz. des Hop., No. 127.) — Porter.
Aneurysm of the Eight Subclavian, treated by Acupressure of the
Axillary and Direct Pressure of the Innominata. (Dublin Journal,
November.) — Cheevers. Case of Popliteal Aneurysm, treated by
Acupressure. (Boston Med. Journal, October l7.)~Sarazin. New

1868.]

Report on Surgery. 517

Apparatus for making Alternate and Elastic Compression. (Gaz.
Heb., 1868, No. 6.)

Antrum. — Fano. Treatment of Dropsy of the Antrum. (Union
Med. No. 115. After discharging the fluid by perforating the
alveolus a silver tube was left in the aperture.)

Bone. — Healey. Operation with a New Instrument for removing
the debris of a Sequestrum through a small opening in the in vol u-
crum. (New York Med. Jouru., October.) — Volkmann. On Caries
Sicca of the Shoulder-joint. (Berlin. Klin. Woch., No. 43. "Wood-
cuts.)

Bronchocele. — Hamburger. Operative Treatment of Cystic Bron-
chocele. (Wochenblatt d. "Wiener Aerzte, Nos. 29 and 33. From
extensive experience in Bohemia he finds the seton the most safe
and efficacious means.) — Patruban. Treatment of Cystic Broncho-
cele. (AUg. "Wien. Zeit., Nos. 51-53. Believes Hamburger's
treatment highly dangerous, and recommends incising and emptying
the sac and connecting by sutures with the integuments.) — Worms.
Account of an Epidemic of Goitre. (Kecueil de Med. Mil., Oct. and
Nov. Occurred in an infantry regiment stationed at Annecy, in
Tipper Savoy).

Chloroform. — Discussion on the Accidents from Chloroform in the
Paris Surgical Society. (Bulletin, tome vii, pp. 244, 251, 273,
303, 314.)

Dislocations. — "V^igenaud. Case of Intra-coraco'id Dislocation of
the Humerus. (Rec. de Med. Mil., August. Reduced thirty days
after by a modification of Jarvis's Apparatus. Woodcuts of this,
and of the bandage subsequently applied.) — Dauve. Complete Dis-
location of the Clavicle, Outwards and Forwards. (Ibid. Two
cases at the camp at Chalons, one remaining irreducible). — Verneuil.
Etiology of Congenital Dislocation of the Hip. (Bulletin de la Soc.
Chirurgie, t. vii, pp. 252, 318, 329, with a discussion.) — Fanning.
Dislocation of the Femur in a child thirty months old. (New York
Med. Journ., Sept. Eeduced on the tenth day.) — Boisnot. Simul-
taneous Dislocation of both Hip-joints. (American J. of Med. Sci.,
Oct. Reduced by manipulation.) — Sedillot. On the Removal of
the Fractured Malleoli in Compound Dislocation of the Foot.
Comptes Rendus, Oct. 14.)

Ear. — Gruber. Anatomy of the Temporal Bone in relation to
Diseases of the Ear. (Wien. Med. Woch., No. 73. Anatomical
conditions of the Mastoid Process. Illustrated by Woodcuts.) —
Ladreit. Instrument for Removal of Polypi from the Meatus.
(Gaz. des Hop. 139.) — Politzer. On Obturation of the Meatus
Externus in Treatment of Catarrh of the Tympanum. (Wien. Med.
Woch., Nos. 78 and 84.)

Ecraseur. — Nielson. On an Improved Ecraseur (Glasgow Jour.,
Nov.)

518 Chronicle of Medical Science. [April,

ElepJiantiasis. — Yanzetti. Treatment of Elephantiasis of the Leg
by Digital Compression. (G-az. des Hop., No. IM.)

Excisions. — Gritti. Intrabuccal and Subperiosteal Excision of the
Lower Jaw by a New Procedure. (G-az. Med. di Lombardia, No.
38.)— Volkmann. Case of Excision of the Knee consequent on a
Burn. (Deutsche Kliuik., No. 43.)— Thomas. Three Cases of
Excision of the Shoulder-joint. (Australian Med. Journ., July.) —
Cheevers. Two Cases of Successful Excision of the Femur in Hip-
joint Disease. (Boston Med. Journal, Nov. 7.) — Oilier. Sub-
periosteal Excision of the Elbow. (Gaz. Med. de Lyon, Dee. 15
and 22.) — Vanzetti. Two Cases of Successful Excision of the Knee.
(G-az. des Hop., 1868, No. 8.) — Stokes. Cases of Excision of the
Ankle and Knee and Sub-periosteal Excision of the Elbow. (Dublin
Journ., Feb.)-T— Phillippeaux. On Excision in Grave Cases of
Coxalgia. (Giz. Med. de Lyon, 1868, Nos. 5 and 6.)

Eye. — G-alezowski. Changes in the Eetina in the Tubercular Dia-
thesis. (Archives Generales, Sep. With Ophthalmoscopic Designs.)
— Wilson. On Morbid Changes in the Optic Nerve. (Dublin
Journ., Nov.) — Castorani. Treatment of Opacities of the Cornea.
(Gaz. Medicale, Nos. 40, 41, 43. Gaz. des Hop. 143. A saturated
solution of iodide of potassium is the chief agent.) — Treatment of
Purulent Ophthalmia. (Discussion at Paris Surgical Society. Bul-
letin, tome vii, p. 57 et seq.) — Bowen. Ophthalmia at the Indus-
trial Schools. (Australian Med. Journ., Sept.) — Stellwag v. Carion.
Treatment of Convergent Strabismus. (Wien. Med. Woch., Nos.
82, 84.) — Meyer. On a New Operation for Conical Cornea. (Gaz.
Hebd., 1868, No. 9.)— Taylor. On a New Method of Extraction in
Cataract. (Edin. Med. Journ., Eeb.) — Martialis. On Hemeralopia.
(Annales de Med. Navale, Jan.. With Ophthalmoscopic designs.)

Foreign Bodies. — Adelmann. On Foreign Bodies in the Pharynx
and (Esophagus. (Prag. Viertel., 1867, B. 4. An elaborate statistical
compilation. )

Fractures. — Berenger-Feraud. Suture of Bones. (Gaz. Hebdo-
madaire, Nos. 39-41. Summary of 66 cases of this applied to un-
united fractures, most of which have been already published.) —
Packard. Some points relating to Fracture of the Neck of the
Femur. (American Journ. Med. Sc, Oct. Especially relating to
the anatomical relations, and to the union of intra-capsular fracture.
Woodcuts.) — Levi. Case of Fracture of the Eight Clavicle. (Rec.
de Med. Militaire, August. Occurred while raising a burden to his
head.) — Pacquet. Apparatus in Fracture of the Clavicle. (Bull,
de Therap., Nov. 30. Constructed of gutta-percha, into which
peroxide of iron has been incorporated. Woodcuts.) — Lotzbeck.
Fracture of the Neck of the Scapula. (Deutsche Klinik, Nos. 45-
47.) — Tait. Treatment of Fracture of the Thigh. (Dublin Journal,
Feb. Eleven cases treated by Buck's method.)

Hip-joint Disease. Beauclair. On the Utility of Sudden Adjust-
ment in Acute Coxitis of Children, (Gaz. des Hop., No. 112. Three

1868.] Report on Surgery. 519

eases given confirmatory of the value of the practice introduced by
Bonnet, of Lyons.)

Jaw. — Borelli. On Fungous Alveolar Gingival Tumours. (G-az.
Med. di Torino, Nos. 45 and 46.)

Laryngoscopy. — Tobold. Discision of Colloid Cysts of the Vocal
Cords. (Berlin. Klin. "Woch., No. 46. Three cases, and woodcut
of the lancet-knife employed.) — Eossler. Instrument for passing a
thread through, and Fixing the Larynx. (Wien. Med. Woch., No.
80. Woodcuts.)

Lingual Artery. — Demarquay. On Ligature of the Lingual
Artery. (Archives Gen. Fev. Relates four cases in which, in
imitation of Moore, he tied this for palliation of cancer of the
tongue.)

Mouth. — Hart. Case of Excessive Contraction of the Mouth.
(New Tork Med. Journ., Sept. Kelieved by an operation providing
also a new lower lip.)

Ovariotomy. — Giraldes. Fatal Case. (Gaz. Med., No. 38. The
tumour weighed 3950 grammes, and was an example of foetal inclu-
sion.)— Margueritte. Fatal Case at Havre. (G-az. Hebdom., No.
41. General adhesions, the patient dying exhausted during their
separation.) — Koeberle. Several Cases. (Gaz. des Hop., Nos. 110,
114, 117, 142, and 1868, Nos. 7 and 12.)— Dumenil. Suc-
cessful case at Rouen. (Union Med., No. 149.) — Balassa. Success-
ful Case at Pesth. (Wien. Med. Woch., Nos. 85 and 86.)—
Dumreicher. Two Successful Cases at Vienna. (Allg. Wien. Med.
Zeit., No. 42. After several failures at Vienna, six successful cases
have now been recorded.) — Schroeder. Three Cases at the Bonn
Clinic. (Berlin. Klin. Woch., Nos. 40 and 41. Two proved fatal
and one recovered.) — Thulesius. Fatal Case. (Deutsche Klin. No.
44. Pyaemia appeared on the tenth day.) — Spiegelberg and Waldeyer.
An Experimental Contribution to Ovariotomy. (Centralbiatt, No.
39. An attempt to illustrate the behaviour of the pedicle after
ovariotomy by removal of portions of the uterus in bitches !) —
Davies. Successful Case. (Austi-alian Med. Journ., August. Per-
formed in 1852, consequently the first case at the Antipodes.) —
Keith. Fourteen Cases. (Ed. Med. Journ., Nov. and Dec.) —
Krassovysky. Ovariotomy in Russia. (Ibid., Dec.) — Vanzetti.
Three Unsuccessful cases. (Gaz. des Hop., 1868, No. 5.) — Boinet.
Successful case. (Gaz. Hebd., 1868, No. 9.) — Bockenheimer. Two
cases at Frankfort. (Deutsche, Kliu., No. 49. One recovery.)
— Storer. Pocketing the Pedicle. A New and Successful mode of
treating the Ovarian Stump. (American Journ. Med. Science, Jan.)
— Bulloch. Case in which the Wire tying the Pedicle was left to
become Sacculated. (Ibid.) — Lucke. Two fatal cases. Virchow's
Archiv., Band xli, Heft 1. Very careful autopsies by Klebs.)
— Spiegelberg. Four cases, f Monats. fiir. Geb., Dec. Three fatal.)

Polypus. — Houel. Case of Naso-Pharyngeal Polypus. (Gaz.

520 Chronicle of Medical Science. [April,

des Hop., No. 119. Maxillary bone removed. Woodcuts of appa-
ratus afterwards applied.) — Borelli. On Naso-pharyngeal Polypi.
(Gaz. Med. di Torino, Nos. 43 and 44. Based on twenty-nine cases,
ten in females, and nineteen in males.) — Verneuil. Treatment of
Naso- Pharyngeal Polypi. (Bulletin de la Soc. de Chir., tome vii,
pp. 18 and 34. With a discussion.) — Gouley. Case of Polypus of
the Larynx. (New York Med. Journ., Sept. Operation of laryngo-
tracheotomy performed twice.) — Desgrauges. On the mode of ope-
rating for Naso-Pharyngeal Polypi. (Bull, de Therap., Feb. 15.
Woodcuts.)

Spleen. — Koeberle. Case of Extirpation of the Spleen. (Gaz.
Hebd., No. 43. Patient died of haemorrhage.) — Pean. Case of
Successful Extirpation of the Spleen. (Union Med., Nos. 41 and
44.)

Syphilis. — Fournier. Clinical Investigation of Primary Syphilitic
Induration. (Archives Generales, Nov.) — Boulongue. Treatment
of Hypertrophied Inguinal Glands by Enucleation. (Eecueil de
Med. Militaire, Oct.) — Fournier. On Gummy Syphilide of the
Velum Palati. (Gaz. des Hop., No. 144.) — Liicke. On Syphilitic
Dactylitis. (Berlin Klin. Woch. Nos. 50 and 51.

Testis. — Sistach. On a new variety of Parenchymatous Fungus
of the Testis. (Gaz. Med., Nos. 42 and 45.)— Lefort. On Cystic
Tumours of the Testis. (Bulletin de la Soc. Chir., tome vii, pp.
343 and 371. With discussion.)

Tetanus. — Busch. Observations on Tetanus. (Berlin. Klin.
Woch., Nos. 42 and 43. Cases occurring in the late war in
Bohemia.)

Urinary Organs. — Grynfeltt. On Professor Alquie's Procedure
in Lithotomy. (Rev. Med., Aug. 15. States that the late M.
Alquie was in the habit of performing the same operation as that
described by Mr. H. Lee ; but that he died before his work on the
subject was completed.) — Hirschberg. Case of combined Litho-
tomy and Lithotrity. (Deutsche Klinik., No. 32. Occurred in
Prof. Simon's [of Rostock] practice, two very large stones having
been removed by an operation that lasted two hours and a half.) —
(Lee.) Pathology and Treatment of Urethral Calculi. (New York
Journ., Nov.) — Dittel. On Hypertrophy of the Prostate. (Med.
Jahr. d. Wien. Ges., Heft. 6. With Lithographs.) — Squire. Im-
provements in the Treatment of Stricture. (Boston Journal, Dec.
19. Woodcuts.) — Garden. Abstracts of 891 Cases of Calculi
treated during 18 years. (Indian Annals, Jan.)

Wryneck. — Eulenberg. On an Apparatus for Wryneck. (Berlin.
Klin. Woch., No. 34-. Woodcuts.

1868.] Report on Materia Medica and Therapeutics. 521

EEPOET ON MATERIA MEDICA AND THEEAPEFTICS.
By EoBEKT Hunter Semplb, M.D.

Member of the Royal College of Physicians, Physician to the Eastern Dispensary, London.

I. On the Treatment of Lead Colic hy the internal use of Sulphur.
By Dr. Margueritte, of Havre. The employment of sulphur in lead
colic has been recommended by M. Lutz, and Dr. Margueritte has
been induced to follow the example, both because this substance
seems preferable, for internal administration, to the drastic medicines
generally used, and because chemical analogy leads to the belief that
it is an antidote to lead. Sulphur also is quite harmless as a medi-
cine, and it may be administered in large doses. An epidemic of
lead-colic in Havre, from the use of adulterated cider, offered Dr.
Margueritte the opportunity of collecting some details of cases in
which the symptoms were relieved by means of flowers of sulphur
mixed in equal parts with honey. Nearly thirty cases of lead-colic
were thus treated, and in order to avoid all sources of fallacy, the
remedy was employed only in those instances where the bluish
border of the gums proved, beyond all doubt, the presence of lead in
the system. Nine of these cases are related at length by Dr. Mar-
gueritte, but the actual number of them which fell under his obser-
vation was thirty-four, including relapses. In almost all, sulphur
was the principal if not the only remedy employed to restore the
patients to health. The results appear to justify Dr. Margueritte
in drawing very favourable conclusions in respect to the remedial
powers of sulphur in lead-colic, and he lays down the following
deductions from his observations : — 1. Sulphur may of itself dissi-
pate the symptoms of lead-colic, but it must be given in rather large
doses, those hitherto employed being insufficient. It is necessary
to give at once fifty or sixty grammes of sulphur, which may
be done without any danger. 2. The dose of sulphur should
always be large on the very first day. Dr. Margueritte sometimes
found that when he gave only a moderate dose on the first day the
disease rather increased than diminished, and he was able to regain
lost time only by making the patient take on the next day a much
larger dose of the sulphur. 3. When the remedy is administered
in a suitable manner and under the most favorable circumstances,
the first evacuation ensued in general only on the evening of the
second day, or about thirty-six hours after the first spoonful of
the sulphur mixture had been swallowed by the patient. The first
stools were scanty and difficult, but became more abundant and easy
on the third day, and as soon as the stools began to appear there
was a notable diminution of pain and vomiting. 4. Although the
sulphur when employed alone would ensure these results, yet certain
adjuvants may be employed at the same time, such as inunctions of oil
of henbane on the abdomen, poultices, and injections. The mixture

522 Chronicle of Medical Science. [April,

of honey and sulphur generally recommended is taken with diiSculty
by the patients, and therefore Dr. Margueritte combines it with tea
and milk. By this plan the sulphur is taken more easily, and its
laxative power is increised by the addition of the milk and -tea. In
the case of a person attacked with lead-colic. Dr. Margueritte re-
commends the following plan of carrying out the sulphur treatment.
The sulphur mixture (sulphur and honey) to be taken in table-spoon-
fuls every hour diluted with milk and tea ; in the evening an enema
with bran and honey ; inunction of the abdomen with oil of henbane
and then linseed-meal poultices ; and lastly broth and bitter infusion.
This plan is to be repeated the next day, and the day after, and
perhaps also the fourth day, after which the dose may be gradually
diminished, though the sulphur may require to be administered
perhaps for a fortnight or three weeks. — Bulletin General de Thha-
peutique, Oct. 30, 1867.

II. On EpispasHcs as Exciting and Depressing Agents, and their
Influence on the Pulse and Animal Heat. By Dr. O. Naumann, of
Leipsic. — In former investigations Dr. Naumann had arrived at the
conclusions, 1. That the therapeutical action of cutaneous irritants
is brought about only in a reflex manner ; 2. That a proportionately
powerful irritation of the skin diminishes the power of the heart and
arteries, and acts hyposthenically ; 3. That a proportionately feeble
irritation of the skin increases the power of the heart and arteries,
and acts hypersthenically ; 4. That the place where the irritant is
applied is, for the most part, a matter of indifference in regard to the
result required ; and 5. That in general an amount of irritation
corresponding to the circumstances alone regulates the therapeutical
effects. In the present communication Dr. Naumann relates the
results he has obtained by the aid of the hsemodynamometer prepared
by himself. He finds that an intense irritation of the skin very
rapidly produces a diminution of the frequency and especially of the
strength of the pulse. This diminution of the pulse is usually pre-
ceded by a stage of excitement, which, however, is soon passed. The
diminution of the pulse in several cases attains its maximum, during
the irritation, but often only after it has ended, but it continues a
long time after the irritation has ceased. The frequency of the
pulse is, for the most part, somewhat increased at the commencement
of a powerful irritation of the skin, but during the irritation and
sometimes after it, it is retarded, and this retardation often continues
for a long time after the irritation has ceased ; but this occurs much
less frequently than a diminution in the strength of the pulse. In
reference to the changes of temperature, it was observed as a constant
result that a powerful irritation of the skin produced a remarkable
diminution of the animal heat. But generally this cooling is pre-
ceded by a greater or less elevation of the temperature, the duration
of which seems to depend on individual peculiarities, and may be
extended beyond the time of the irritation before cooling begins.
The above-mentioned changes produced by cutaneous irritation take
place in the normal conditions of the body, but still greater altera-
tions are to be expected in cases of disease. In the so-called syno-

1868.] Report on Materia Medica and Therapeutics. 523

chal diseases, the irritability of the body, and the reaction from
irritants is usually increased, and is exhibited, for instance, on the
application of a mustard-poultice, in a well-marked cutaneous inflam-
mation visible to the eye. The reverse is the case in the so-called
asthenic conditions, in which the operation of epispastics is much
weaker, or is not exhibited at all, and thus it may be explained how
the same cutaneous irritant may act in very different ways, and may
operate as a depressing agent in so-called synochal diseases, and as
a stimulating one in asthenic cases, as in threatening collapse.
The results of the present investigations made by Dr. Naumann are
summed up by him in the following manner ; — 1. The changes pro-
duced by an irritation of the skin continued for a long time, last also
for a long time after its discontinuance, and in general the length
of the time corresponds to the long continuance of the irritation, and
in healthy persons the changes may be observed half to three-quarters
of an hour after the irritation. 2. The weakening of the pulse
caused by a powerful cutaneous irritation often attains its maximum
during the irritation, but often only at the end of it. 3. The excit-
ing action of the proportionately feeble cutaneous irritants also
continues for a long time after their discontinuance, but is at last
equally followed by weakness which, however, appears much later,
and in a much less degree than after the application of a strong irri-
tant. 4. After powerful irritation of the skin, there constantly
arises, for the most part after a longer or shorter interval of heating,
a diminution of the animal temperature, which has often not reached
its termination half an hour after the discontinuance of the irritation.
5. The interval of heating differs very much in its duration, and the
cooling often occurs during the irritation, and often immediately
after its cessation. — Schmidfs JahrhucJier der Gesammten Medicin,
March, 1867.

III. On the Pharmacology of the Cinchona Alkaliods. By Pro-
fessor Wenzel, Bernatzik.

1. On a strongly saturated Solution of Quinia for Subcutaneous
Injections. — The difficult solubility of the preparations of quinia, and
even of the acid sulphate, in water, does not allow much more than
a grain at a time to be introduced beneath the skin by the usual
mode of injection. The addition of acid does not remove the incon-
venience, and it causes severe pain to the patient. It is, therefore,
recommended, in those cases where an energetic action of quinia is
desirable, to employ ether as a solvent instead of water. Ether is far
less irritating than diluted acids, alcohol or chloroform, and its dif-
fusive power is checked by its intimate combination with the resin
of the quinia.

2. On the Medicinal Value of Quinidine, and the Preparations most
suitable for its Therapeutical Application. — Quinidine obtained as an
amorphous dark brown precipitate in the preparation of sulphate of
quinia from the mother-liquor, after carbonate of potash and has been
added to the latter, possesses the basic properties of quinia, and has
the same composition, but is not crystallizable, and is therefore called
amorphous quinia. It is the product of the action of heat and light

224 Chronicle of Medical Science. [April,

on the cinchona alkaloids, and is contained in the bark, especially
when it has been much exposed to the sun, and it is also formed in the
preparation of quinia, if heat and light are not withdrawn as far as
possible. Since quinidine is chemically identical with quinia, it may
be considered to be of equal therapeutical value, and the reason why
it is proportionally less employed is attributable only to the circum-
stance that the commercial quinidine is seldom pure, because, instead
of being precipitated, the evaporated mother-liquor is sold as quini-
dine. According to some late researches of De Vry, quinidine may
be obtained pure without much trouble or expense by boiling com.
mercial quinidine in an iron vessel with neutral oxalate of ammonia
until no more ammonia is liberated, and after dilution, filtration,
and cooling, excess of caustic soda is added, and the precipitate is
washed with distilled water and dried. Tried by this process the
common quinidine was found to be very impure, and diiferent
specimens contained very various and sometimes very small propor-
tions of real quinidine. As quinidine is of a dark colour the good-
ness of the commercial article may, in some measure, be estimated
by the presence of that character. The salts of quinidine are also
amorphous, of a brown colour very hygroscopic and very bitter.
From their solubility they are especially well adapted for subcuta-
neous injections. Their internal use is also sometimes more suitable
than that of the strong alcoholic tincture of quinidine. The use of
the pure quinidine in powder is likewise recommended, since by its
less solubility it causes only a slightly bitter taste.

3. Carholate of Quinia. — Carbolic acid, which in solution acts as a
poison upon the lower animal organisms, is borne in proportionate,
though large doses, by the higher animals and man, when introduced
into the body in a diluted state. It was administered to some
animals with advantage in their food in England at the time of the
rinderpest. With bases, even weak ones such as quinia, carbolic
acid loses in a great degree its irritating properties at the point
where it is applied ; when combined in the proportion of two equi-
valents of the acid to one of quinia, the compound is characterised
by a slight sharpness, and a decidedly bitter taste. Professor Ber-
natzik proposes a preparation composed in this manner, and he hopes
that it will prove an energetic disinfectant for internal use. Gl-. Braun
has given it with benefit in puerperal diseases, and Duchekin several
typhous cases, and in one of pyaemia. Pills containing 1 grain of
quinia with '6 of a grain of carbolic acid were given repeatedly
without causing the slightest inconvenience, and according to these
statements 3 to 6 grains of carbolic acid were given daily without
injury. The compound was prepared by dissolving 60 parts of car-
bolic acid with 100 of quinia, in 300 of highly rectified spirit, filtering
the solution, distilling and evaporating to the consistence of turpen-
tine, and then mixing some extract of acorus and powdered cassia.
— Jahrbilcher der Qesammten Medicin, Aug. 28, 1867.

lY. On the Treatment of Porrigo Favosa-ly Carbolic Acid. By
Dr. Prior, of Bedford.— Porrigo Pavosa is a rare disease in this
country, and Dr. Prior has seldom met with it, but it is distinguished

1868.] Beport on Materia Medica and Therapeutics. 52S

from other scalp diseases by the shape and the colour of the eruption
and by the microscopical appearances of the parasitic fungus which
forms its essential character. The case related was that of a young
woman, belonging to the lowest class, a patient in the Bedford
workhouse, and the disease covered nearly three-fourths of the scalp.
The carbolic acid was used as a lotion, in the proportion of one part
to six of water, applied by means of a little mop daily to the fungoid
eruption. The effect was remarkable, and in less than a week the
crust began to come off in large flakes. "Within a fortnight nine-
tenths of the disease were obliterated, and in four months the
patient left the house with only a few suspicious-looking patches.
But, being purposely left without treatment, the disease returned,
occupying about one-half the extent which it did when first treated.
The use of the carbolic acid was now resumed with the same success
as before, the disease being reduced to one-tenth of its extent, but it
does not appear that it was entirely cured, and Dr. Prior thinks that
the treatment can be carried out with complete success only in a
public institution, under immediate medical supervision. He recom-
mends epilation in addition to the use of the carbolic acid, and he
believes that without any poultice, or any other remedy, the disease
may be thoroughly cured in two months. A shorter period is in-
sufficient because the mycelium penetrates the surrounding tissues,
and one neglected spot may rapidly extend the disease again over
the entire scalp. Carbolic acid appears to Dr. Prior the safest and
surest parasiticide for Achorion Schonleinii, and since reporting the
above case, he has met with three other cases which have been simi-
larly treated, and which, at the date of the report, all apparently
promised well. — British Medical Journal, Oct. 26, 1867.

V. On the Therapeutical Employment of Alcohol in Children. By
Dr. P. Gingeot, of Paris. — In the first part of his paper Dr. Gringeot
passes in review the different opinions and modes of practice, in
reference to the use of alcohol in the treatment of disease, of the
modern English and Prench school of medical practitioners ; and he
decidedly inclines to the belief that the doctrines of Dr. Todd, with
certain modifications, are founded upon truth and justified by expe-
rience. He admits that the alcoholic treatment has been frequently
pushed too far, but still he thinks that the results obtained in
England deserve the most serious consideration. In France this
mode of treatment has been lately adopted with success in the
diseases of children, especially by MM. Barthez and Eilliet, who
employ it in acute suffocative bronchitis; by MM. Trastour and
Gatterre, who give alcohol in large quantities even to infants ;
by M. Cazin, who orders hot wine in certain adynamic forms of
smallpox ; and by M. Bricheteau, who employs alcoholic drinks to a
great extent in infectious diphtheria. But until very lately, says
Dr. Gringiot, no one in France has employed the alcoholic treatment
in children in the manner indicated by Dr. Todd, and therefore he
conceives that his own results will be received with interest. In
prescribing alcohol to several patients. Dr. Gingeot has not confined
his treatment specially to cases of a manifestly adynamic character,

82— XII. 84

526 Chronicle of Medical Science. [April,

but has administered brandy in well-marked sthenic cases, as well
as in those where depression was a prominent feature. The mode of
administration was in gum-julep or in sugared water. The cases so
treated were eight of pneumonia, of which seven were cured, and one
died ; one of typhoid fever, ending in recovery ; one of capillary
bronchitis, following whooping cough, and ending in death ; two of
pulmonary tuberculosis, following whooping cough, and ending in
death ; two of measles in a severe form, one being followed by a cure,
the other by death. In reference to the general effects of this
treatment. Dr. Gingeot finds that the alcohol has never caused any
serious disturbance of the digestive system, and that in many cases
the appetite has been increased, and the tongue and the mouth have
been cleaned and rendered moist. In certain cases there was
diarrhoea or constipation, but these symptoms could not be referred
to the treatment, inasmuch as they ceased upon the daily dose being
increased. As to the circulatory apparatus, one of the most frequent
effects of the alcoholic treatment was to lower the pulse, and a
record of cases is given to show the precise effect of the use of alcohol
in this respect ; and the temperature in several instances was
lowered in a sensible manner, although the lowering of the pulse did
not always coincide with the diminution of heat. The nervous
symptoms, such as cephalalgia, heaviness of the head, restlessness,
sleeplessness, and delirium, were very considerably relieved by the
use of brandy, and in no case did brandy produce them. Stupor and
singing in the ears yielded in the same manner, as well as subsultus
tendinum, and never did the least symptom betray itself of any
intoxication or subsequent depression. There was no dif&culty in
ascertaining the beneficial influence of the treatment on the
restoration of the strength and the rapidity of the convalescence, for
as soon as the patients were able to get up, the greatest part of them
were firm on their legs. Of all the peculiarities evinced by Dr.
Gingeot's patients, the most worthy of attention was perhaps
the morbid tolerance of the alcohol ; and he remarks upon the
extraordinary facts, that a girl of fourteen should drink 250 grammes
of brandy, and children of two years, or two years and a half old,
should take 60 or 80 grammes without showing any sign of in-
toxication, or betraying the smell of alcohol in the breath. As to
the modus operandi of alcohol, employed therapeutically. Dr.
Gringeot thinks that it can be explained upon the theory that it
prevents the waste of the tissues. The most general indication in
therapeutics is to maintain the strength of the patient until the
disease has accomplished its spontaneous evolution, and this indi-
cation is often fulfilled by alcohol ; but whether it acts as a direct or
indirect food, or whether it repairs specially the nervous substance,
the deterioration of which is the cause of the nervous prostration,
are matters of which we are still in ignorance. As to the efficacy of
alcohol in fever, Dr. Gingeot believes that it diminishes the fever
by exciting the medulla oblongata, and he adduces some theoretical
considerations in support of this view. Other substances, such as
tartar emetic and veratria, also reduce fever, but their mode of

1868.] Report on Materia Medica and Therapeutics. ^27

action is very different from that of alcoholic fluids, for, far from
exciting any part of the cerebro-spinal system, they depress the
whole of it, thus allowing free liberty to the vaso-motor nerves
to contract the small vessels, to increase vascular tension, and
to lower the pulse. This property, according to Dr. Gingeot, renders
these drugs serviceable in pulmonary inflammations,but it tends also
to produce nervous depression from anaemia and the development
of suppuration. — Bulletin G6n6ral de Therapeutigue, Aug. 15 and
30, 1867.

VI. On the supposed existence of Iodine in the Air and in different
articles of Food. By G-. Nadler.— Iodine is found in sea- water, but
in larger quantities in plants and animals living in the sea, and
scarcely at all as a saline combination, but as a constituent of the
organic substance, for Sommer was able to extract only one part of
iodine from sea-sponges by means of water, while another part was
recognised after the decomposition of the sponge. Hopfer de I'Orme
and Hausmann found iodine in fish-oil, L. Gmelin found none in
seal's blubber, but some in pure oil from the liver ; but, according to
De Jongh, iodine forms an elementary constituent of the fat in pure
liver-oil, for it may be detected when the soap prepared from the fat
has been decomposed by heat. In a large quantity of salt herrings
Jonas found very small traces of iodine. The air was first tested for
iodine by Chatin, and he states that he found in 4000 litres about
0*002 milligrammes of iodine. Pourcault also has found iodine in
the air. Marchand and Niepce confirmed the statement of Chatin,
and the latter extended it still further in carrying out his theory of
scrofula. On the other hand Lohmeyer, Macadam, Martin, Lucca,
Kletziusky, and Cloez, do not confirm the statements made as to the
existence of iodine in the air, although they examined thousands of
litres, and only Van Ankum arrives at any positive result. Chatin
states that he has found iodine also in milk, eggs, and wine, but
Lohmeyer and Macadam have been unable to confirm the statement.
The methods of investigation employed by Chatin are described, but
they failed to exhibit evidence of iodine in the air, or in spring- water
from the mountain of Zurich, or in the lake of Zurich. Some water-
plants also from the lake of Zurich contained no iodine, and none
was found in bread made from the flour of the Triticufn Spelta, or
in cows' and goats'-milk. In fifty and twenty eggs no trace of
iodine could be detected, but, on the other hand, in an experiment
made with the albumen of eighteen eggs, very small, but distinct
traces were present. Three kinds of liver-oil were also examined.
250 grammes were saponified, the acids were removed by hydro-
chloric acid and washed, and the alkaline solution, as well as the
fatty acids, were separately examined. Only the alkaline solution of
the third kind contained iodine, but the acids of all contained it.
In reference to the presence of iodine in animal fluids, after the
administration of that element, Liebig found iodine in the whey of
the milk of a cow which bad drunk the Wildbad waters, but he
failed to find it in the whey of a cow and of a nurse to whom a
drachm to half an ounce of iodide of potassium had been admi-

528 Chronicle of Medical Science. [April,

nistered ; and hence lie inferred that the iodide of potassium only-
passes into the animal fluids when it is introduced in a state of great
dilution. Nadler gave to a goat half a gramme (about seven and a
half grains), of iodide of potassium ; the first milk drawn after
twenty-four hours contained a considerable quantity of iodine in the
whey, but there was less in the whey of the milk drawn after twenty*
four hours, and less still in the milk drawn after thirty six hours ;
that drawn after forty-eight hours contained very slight traces, and
that drawn after sixty hours contained none at all. Iodide of potas-
sium was given to three others ; one had one-fifth of gramme, the
two others had half (about seven and a half grains). The first hen
laid an egg after twenty-four hours, and the solution pressed out from
the coagulated albumen contained a large quantity of iodine, but the
albumen itself contained only slight traces, and the yolk none at all ;
the second egg (in sixty-four hours), contained in the solution
pressed out from the albumen only some traces of iodine ; and the
yolk none. The two other hens laid an egg each after twelve and
thirty-six hours ; in the solution pressed from the albumen in the
first eggs, there was a considerable quantity of iodine, but none in
the yolk ; the second eggs contained only traces of iodine. — Schmidt'' s
Jalirbucher der Oesammten Medicin, January, 18C8.

VII. On the Therapeutical Applications of Peroxide of Sydrogen.
By Dr. Stohr, of Wurzburg. — Thenard, who, in 1818, discovered
peroxide of hydrogen, found that it was decomposed by the fibrine
of blood into water and oxygen. A. Schmidt observed that coloured
proteinaceous matters act in the most energetic manner as catalytic
agents on the peroxide, but albumen, globulin, and fibrin, much less so,
and moreover he found that it is of great importance to the catalytic
operation of these substances, whether their solutions have a neutral,
acid, or alkaline reaction. Dr. Stohr describes his experiments made
by the external use of peroxide of hydrogen, which was obtained by
the decomposition of peroxide of barium, by means of hydrochloric
acid.

1. Action of the Peroxide of Hydrogen on the Living Organism in
General.— The strongest solutions apj^lied to the back of the hand
or the tip of the tongue caused no great sensation of pain, but only
a slight tingling. Apj^lied to the conjunctiva of a rabbit, they
caused irritation and inflammation. When freshly drawn venous
blood was brought in contact with the peroxide, there was violent
efifervescence, and the solution became suddenly yellowish-red, then
pale yellow, and lastly, after five or six minutes, colourless and
opalescent. The blood corpuscles are changed in various ways
according to the concentration of the solutions. In a weak solution
they shrivel, become jagged and otherwise irregular, and no longer
arrange themselves in rouleaux. When the peroxide is poured on
pus, a considerable quantity of gas is developed, but not so much as
in the case of blood. When sprinkled on the epidermis, there is a
burning sensation of pain, and a small vesicle is formed, which soon
disappears. When applied to bleeding surfaces, a yellowish red
scum is formed, and with weaker solutions an unpleasant itching,

1868.] Report on Materia Medica and Therapeutics. 529

but with stronger ones a short burning pain. Similar phenomena
are observed in the case of blistered surfaces and humid eczema.

2. Experiments with the Peroxide of Hydrogen in the Healing of
TJlcers. — In these experiments the poison of chancre was employed.
Seven male patients with soft multiple sores on the genitals were
inoculated on both thighs from their own sores, and these places
exhibited in three days the characteristic appearances of inoculated
chancre. Half of these sores were now touched three times a day
with a strong solution of peroxide of hydrogen, and also bound up
with charpie moistened with a dilute solution. At first only a slight
itching was complained of, and after four or five hours each sore was
covered with a thin whitish film which coloured the surrounding
epidermis in a similar manner. The development of gas ceased after
repeated moistening of the inoculated chancre with the peroxide, but
began again after the whitish film covering the sore had been
mechanically removed. On the third day of this treatment the sores
appeared almost larger than those which were bound up dry, but
they healed rapidly, and on the eleventh day they exhibited only
excoriations. The sores which were bound up dry exhibited the
usual appearances of such inoculated spots, two became phagedenic,
and were cauterised, and the rest were bound up with solution of
acetate of copper. The healing of the sores treated with peroxide of
hydrogen was accomplished on the average within twelve days, but
the others only within twenty-three days. Other cases are recorded
in which the results were equally favorable, and the conclusions
drawn on the whole subject by Dr. Stohr are the following : — The
peroxide of hydrogen decidedly accelerates the healing process in
virulent ulcers, especially in the soft multiple chancre. It changes
the secretion in such a manner that the inoculability is lost, and it
takes from the sore its specific character. A considerable amount of
the peroxide is necessary for the destruction of the inoculability.
The remedial operation of the peroxide is most remarkable in
diphtheritic sores. The peroxide is not a corrosive agent in the
ordinary sense, since it does not destroy the tissues, and probably
only influences the fluids, such as pus, &c. But the secretion of
sores, and the exudations of croup and diphtheria are directly and
remarkably altered by the peroxide in their morphological as well as
in their chemical constitution. — Schmidt's Jahrhilcher der Qesavimten
Medicin, January, 1868.

yill. On the Employment of Injections, especially tliose of Iodine,
in the Treatment of Ascites. By Dr. Ernest Besnier, of Paris. — Most
of the authors who have treated of the use of iodine injections in
ascites have discussed at length the mechanism of the cure, some
arguing that the development of an adhesive peritonitis is the
condition of the definitively favorable termination of the case, while
others speak of a physical or functional modification of the serous
membrane without any inflammatory affection ; and others again
suppose that the combination of iodine with the elements of the
ascitic serosity modifies its molecular composition in such a manner
as to facilitate at once the absorption of the effusion and its elimi-

530 Chronicle of Medical Science. [April,

nation out of the sygtem. But it is admitted that in a certain
number of cases the injection of iodine causes purulent peritonitis,
acute in its course and rapidly fatal ; and even in less unfavorable
cases, the post-mortem examinations have shown that inflammation
has been the cause of more or less extensive and solid adhesions.
There is, however, another category of cases in which the cure is
obtained without the appearance of any really inflammatory action ;
and if this claas of cases could be extended, the utility of iodine
injections would be universally admitted. Dr. Besnier thinks that
the reason why injections of iodine are harmless in certain cases is
because they are attenuated by their mixture and combination with
the fluid left in the peritoneum after the operation of tapping.
Then the question arises, whether the injections preserve their
remedial action when they have been so neutralised and decomposed
as to render them harmless ? The reply appears to be in the
affirmative, according to the observations of Teissier, of Lyons, whose
method consists in leaving in the peritoneal cavity a part of the
serosity, in examining the nature of the liquid removed by tapping,
and in causing the injection to be more or less charged with medicinal
principles, according as the fluid is found neutral or alkaline, as it
contains more or less of albumen, as it is clear or thick, or as it
contains blood or pus : the injection ought to be made slowly and
gently, so as not to be thrown upon the visceral peritoneum. Dr.
Teissier objects therefore to iodine injections made according to a
fixed formula, and he gives the following rules for the composition
and the measurement of the injections : — When the liquid is clear,
yellowish, slightly alkaline, and slightly albuminous, he injects into
the peritoneum 20, 25, or 30 grammes of tincture of iodine, and
2 grammes (a gramme is 15 grains) of iodide of potassium. "When
the serosity is decidedly albuminous, gangrenous, or purulent, or
very alkaline, then he injects 40 to 50 grammes of the tincture, and
4 grammes of iodine. Lastly, when the eff'usion is very glutinous
(which, however, is very rare), when it contains a considerable quan-
tity of albumen or of muco-extractive matter, he injects a watery-
solution made with 100 grammes of water and 6 or 8 grammes of
iodine, or a strong solution of iodide of potassium (20 grammes to
100 of water). The success which has attended the use of iodine
injections in the manner recommended by Teissier, seems to indicate
that this method of treatment may be considerably extended in the
cure of ascites. Although these injections are almost entirely
contra-indicated in all cases of chronic ascites connected with in-
curable organic lesions, it is evident that they may be employed
more extensively and at an earlier period in cases where ordinary
treatment has been unsuccessful, but where the nature of the patho-
genic condition remains doubtful and its curability uncertain.
Nevertheless, says Dr. Besnier, the importance of this mode of treat-
ment must not be exaggerated, and it must not be forgotten that,
even according to the admission of its most ardent advocates, the
treatment can only be advised in idiopathic cases, or at least in those
which are unaccompanied by any actually serious lesion. — Bulletin
OSneral de Therapeutique, July, 1867.

1868.] Report on Materia Medica and Therapeutics. 531

IX. On the Influence of the Alpine Climates on Pulmonary
Consumption. By Dr. Hermann Weber. — It is well known that
consumption is rare in some elevated regions, and that consumptive
persons are sometimes improved by removal from low to high locali-
ties. Bat the degree of elevation necessary for producing immunity
from tubercular phthisis seems to vary in different latitudes, and
appears to be lower in the temperate than in the tropical regions.
In the latter, phthisis may be regarded as becoming rare above
7000 feet, but in Switzerland the frequency of the disease diminishes
above 3000 feet, and in the mountains of central Grermany above
1400 feet. But elevation alone does not appear to cause the
exemption, for many other circumstances assist or counteract its
influence, as the geological structure of the soil, the exposure to
wind, the hygrometric condition of the atmosphere, the degree of
sunshine which the locality enjoys, and many other conditions of a
like nature. Dr. "Weber thinks that the treatment of consumption
by removal to Alpine regions has been unduly disregarded by the
medical men of Europe, and he discusses the principal objections
which may be offered to such a plan. The chief of these are , the
coldness and roughness of the Alpine climates, the great rarefaction
of the air at elevated regions, and the difficulty of finding a proper
mountain residence for the invalid. The first objection is refuted
by the facts, that cold countries are not those in which phthisis is
most prevalent, and that cold in temperate countries is only inju-
rious so far as it compels ill-fed, ill-clothed, and delicate persons to
remain in-doors, often in ill-ventilated and otherwise insalubrious
rooms. To the second objection it is replied, that the tendency to
haemoptysis said to be caused by mountain air has been either very
much exaggerated, or is unfounded in fact ; for although, under
special and peculiar circumstances, hsemoptysis may have occurred,
yet such bleeding is almost or altogether unknown to the Alpine
guides who accompany travellers in their mountain ascents, and at
all events it is unlikely to happen, as the result of the climate, to
quiet invalids living in elevated valleys. The third objection has
some foundation, and in the mountains of Great Britain there are
no houses where invalids can obtain the necessary comforts, with
society, occupation, and amusements, although such localities may be
found in the mountain ranges of the British colonies, as in the
Himalaya range. In Europe itself there were until lately no
arrangements for the wintering of delicate persons in elevated situ-
ations, but at present there are in some of the valleys of the Grisons-
not only villages and inns to live in, but trustworthy medical men to
superintend the cases. One of these valleys is that of the upper
Engadin, and another is the Davos, at an elevation varying from
4500 to 5000 feet. It appears that in the village of Davos am Platz
there are two medical men who devote themselves particularly to
pulmonary affections, and keep accurate notes of the progress of the
cases under their charge. According to Dr. Sprengler, one of the
medical men alluded to, there is no endemic disease in the valley of
the Davos, and scrofulous diseases introduced from abroad are

633 Chronicle of Medical Science. [April,

favorably influenced by a prolonged residence in the mountains.
There is an entire absence of tubercular diseases of the lungs among
the natives who have never left the valley ; and cases of consumption
have been mentioned as having occurred abroad, which have been
cured on a timely return. Dr. Weber relates several cases, from his
own practice, showing that persons from mountainous regions, who
had become consumptive in England, were either cured or very much
benefited by a return to their native |homes, and in two of his cases
the disease recurred, and was fatal by an injudicious return to
England. Dr. Unger, the other medical practitioner of Davos am
Platz, was himself consumptive, but derived great benefit from a
residence in that place. Dr. Weber thinks that the evidence in
favour of the beneficial influence of mountain regions in the treat-
ment of consumption is too strong to be further resisted, and he
adduces some theoretical considerations to show that the rarefaction
of the air, by increasing the expansive power of the lungs, must act
in a salutary manner in the treatment of tubercular phthisis. —
British Medical Journal, July 20 and 27, and Aug. 24, 1867.

X. On the Treatment of Dysentery and Dysenteric Paralysis hy
Nux Vomica. By Dr. de Savigny. — Dysentery, according to Dr. de
Savigny, is in great measure due to intestinal paralysis ; and in a
treatise he has published on the former disease, he has shown that
its proximate cause depends upon a lesion of the spinal cord, which
paralyses the excito-motor nerves of the muscular layer of the large
intestine, as well as the vaso-motor nerves of the capillaries spread
over the mucous membrane. According to this method of viewing
the nature of dysentery, its principal phenomena, and the modi-
fications they undergo by favorable treatment, are explained much
better than by any other theory. Dr. de Savigny finds that the
powder of nux vomica is the best preparation, if it is desirable to act
specially upon the intestine, to restore its contractility, and to dimi-
nish the number and to change the morbid nature of the evacuations.
He gives it in the dose of from 20 to 60 and 75 centigrammes in a
day, but he advises that the quantity given daily should not exceed
a gramme (15 grains), and he mixes it with powdered canella. He
has employed this treatment especially in cases of the most severe
kind, namely, those brought from hot countries, and it has therefore
sometimes failed; but he has been struck with certain efifects
produced by the remedy which confirm his views as to the nature of
dysentery, namely, the return of tonicity and intestinal contractility,
very distinctly perceived by some intelligent patients, and demon-
strated moreover by the disappearance of the involuntary eva-
cuations, or by the power of resisting a little better the manifestation
of the imperious necessity of evacuation. At the same time he
found that the muscular depression of the limbs diminished and the
digestion improved, and the nutrition was more complete, so that
the natural alvine evacuations were restored. — Bulletin General de
Th6rapeutique, Sept. 15, 1867.

1868.]

Report on Pathology and Medicine. 533

EEPOET ON PATHOLOaT AND PEINCIPLES AND
PEACTICE OF MEDICINE.

By Eeancis C. Webb, M.D., E.L.S.,

Member of the Koyal College of Physicians, Physician to the Great Northern Hospital.

On the Ophthalmoscope in the Diagnosis of Meningitis. — M. Bouchut
has published a large series of cases illustrative of the value of ophthal-
moscopic observation in the diagnosis of tubercular meningitis. The
following is a condensed account of a case in which the diagnosis in a
great measure depended on the facts revealed by that instrument.

V. M— , set. 7, brought to L'Hopital des Enfants, July 24, 1866.
The only history that can be obtained is that the child has vomited
for four days. But for twenty-four hours the vomiting has ceased, and
she has not been purged. She complains of frontal headache ; does
not scream ; is not drowsy ; the abdomen is a little retracted ; pulse,
unequal, irregular, intermittent, 72. Examination by the ophthal-
moscope. In the fundus of the left eye are observed some discolouration
of the choroid, or choroidal atrophy ; dilatation of some of the veins of
the retina ; some atrophy of the papilla, and in the inferior part two
white elongated granulations which seem beneath the retina, for the
vessels are seen anteriorly to them. A third granulation is noticed
externally, and there is a mass of smaller granulations in the fundus of
the retina. In the right eye there is papillary hypersemia with some
serous infiltration externally. The child continued much in the same
state for several days ; at one time there was divergent strabismus, but
no general convulsions, or paralysis. Before death the pulse ceased to
be irregular or intermittent, and became excessively rapid. She died
on August 6th. Autopsy twenty-four houi's after death. Brain seems
tumefied and compressed in the dura mater ; the layers of the arachnoid
are extremely dry, and glued the one to the other. Pia mater red and
injected, especially on the outer side of the hemispheres ; meningeal
veins numerous and distended with blood. Sinuses filled with liquid
blood. Convolutions flattened, adherent to pia mater, and slightly
softened on the surface. There is capillary hyperaemia of the grey
matter, and considerable injection of the white, but no appreciable
softening of the latter. Lateral ventricles not distended. In the
fissure of Sylvius on both sides, and at the base of the brain, in the
cerebral hexagon, and on the upper part of the cerebellum the pia
mater is infiltrated with greenish-yellow pus ; it contains here and
there grey semi-transparent granulations, which are also numerous in
the choroid plexuses, and there are some scattered on the external
surface of the brain in the neighbourhood of the middle lobe. A
microscopical examination of the eyes was made by M. Ordonez. The
left eye presented a well-marked choroidal atrophy ; the internal layer
no longer existed, but was represented by a few cells almost entirely
depigmented. The external layer existed throughout, but was paler
than natural. In the retina there were three small yellowish masses

534 Chronicle of Medical Science, [April,

around the papilla, visible to the naked eye. They were found to be
composed of fatty granules and globules. The different layers of the
retina present nothing remarkable, unless it be the layer of "myelocites"
in the middle of which some of the elementary bodies are three times
the normal size, almost transparent and perfectly spherical. In the
right eye the veins are gorged with blood, and the circulation inter-
rupted in places. M. Bouchut, after noticing the value of the ophthal-
moscope in this case, where it enabled him to decide on the existence
of tubercular meningitis, remarks that the microscopic examination of
the eye showed for the first time the structure of the white patches on
the retina — that they are composed of fatty granulations due to the
repression of the normal elements. — M. Bouchut, Gazette Medicals de
Paris, Fev. 22, 1868.

On Pseudo-hypertropMc Muscular Paralysis or Paralysie Myo-
Sclerosique. — Dr. Duchenne, of Boulogne, in a very elaborate memoir
on this disease, states that the principal morbid phenomena which he
has observed in its course in children and young persons may be
arranged in the following order. 1. In the commencement feebleness
of the lower extremities. 2. Separation of the limbs, and lateral
balancing of the trunk in walking. 3. Lumbo-sacral curvature {ensel-
lure) in standing or walking, preceded in the early stage by a slight
inclination of the trunk backwards, but becoming more and more
pronounced, until it produces a kind of ensellure or lumbar lordosis.
4. Equinism — bilateral club-foot is one of the constant symptoms of
pseudo-hypertrophic paralysis. 5. Visible muscular hypertrophy ;
augmentation of the volume of the muscles producing the enfeebled
movements, accompanied, in the cases M. Duchenne has observed, by a
diminution in the development of other muscles. All the paralysed
muscles, however, are not always visibly hypertrophied, and the degree
of paralysis is not in proportion to the hypertrophy. 6. A stationary
state lasting some years. 7. Generalisation and aggravation of the
paralysis. With regard to the pathological anatomy of this disease in
a case published by Eulemburg and Cohnheim no alteration could be
detected by the microscope in the nervous centres. The condition of
the hypertrophied muscles has been examined by excising (by
harpoon) small portions in the living, by Griesinger and Bilroth,
Wernich and Heller. These observers failed to discover any change in
the muscular structure. The author's observations, however, led him
to a different conclusion. He has observed that the muscular fibres
are less numerous, and mixed with a large quantity of interstitial tissue.
Some of the muscular fibres were thinned, and in some the transversa
striation had disappeared, and in others longitudinal striation was
visible. — Arch. G6n. de Med., Fev. 1868.

Paralysis Glosso-pharyngo-lahialis. — Dr. Huber reports as a con-
tribution to the clinical history of the malady, a case of Duchennes
disease which was apparently complicated with progressive muscular
atrophy, but, unfortunately, the post-mortem examination was veiy
imperfectly made.

A labouring man's wife was, in the autumn of 1864, affected with
weakness of the right arm, without other symptoms. Six months

1868.]

Report on Pathology and Medicine. 535

later there was disorder of articulation, and next disturbance of deglu-
tition. A year after the commencement of her illness her condition
was as follows : The muscles of the face, and the senses, were in a
normal state, only as regards the parts supplied by the| facial nerve
the muscles round the mouth and nose were enfeebled ; the naso-labial
furrows were strongly expressed, but she could neither blow, whistle,
nor spit ; morsels of food collected between the cheeks and the teeth,
the soft palate was imperfectly raised, and the uvula turned somewhat
to the right ; the vertical movements of the lower jaw were normal.
Faradisation excited moderately strong contraction in the muscles of
the face. The tongue lay motionless on the floor of the mouth
(? atrophied), and fibrillary movements were noticed in it. Speech
was almost unintelligible ; of the vowels only a could be distinctly, and
of the consonants, g, k, d, t, m, 1, and r, could not be at all, pro-
nounced.

The urine was normal, and the sphincters acted naturally. The
right arm was entirely paralysed, not atrophied ; there were frequent
fibrillary quiverings in it, especially in the biceps ; sensibility was mate-
rially diminshed, and electrical contractility almost abolished. In the
left arm there was paresis, sluggishness of circulation, and great dimi-
nution, almost abolition, of electrical contractility There was entire
absence of brain-symptoms.

In the course of the next six months the paralysis extended to all
the extremities, and was absolute, sensibility also being lost ; only the
muscles of the trunk were moderately useful, the head sank forwards,
the arms became cedematous ; fibrillary movements were observable
over the extremities and the trunk ; the sphincters retained their power,
and the intellect its clearness to the very end ; difficulty of respiration
came on a year and a half after the commencement of the malady.

Post-mortem examination. — The brain, the pons Varolii, and the
diamond-shaped space, the medulla oblongata, at a section made below
the olivary bodies, and these bodies themselves, were all normal, and
the nerve trunks at the base all clear white. The microscopical ex-
amination, which unhappily left much to be desired, extended only to
these last ; in the hypoglossal nerves were numerous degenerated
granular fibres, besides most of the fibres having cloudy and granular
contents |(scholligem und kriimligen Inhalte) ; the [facial nerve pre-
sented similar appearances in contrast to the normal state of the
trigeminal nerve ; in the vagus nerve, which seemed somewhat attenu-
ated, were a few healthy fibres, but mostly broad streaked bundles.

The spinal cord and its nerves, and the muscles, were not examined ;
the arteries of the base were healthy. — Dr. Huber, Memmingen
C Deutsch. Arch. f. Khn. Med.,' II, 4 and 5, p. 520, 1860) ' Schmidt's
Jahrb.,' Band 133, p. 163, 1867.

Injurious Influence of Nitrate of Silver in Tales Dorsalis. —
Dr. Hitzig had under observation a case of tabes with strongly
marked anaesthesia of the feet, very considerable disturbance of the
co-ordination power in the legs, some diminution of muscular power,
and partial amaurosis, but without any pain. It seemed to have
originated in prolonged residence in cold and damp places.

536 Chronicle of Medical Science. [April,

The patient took daily one grain of nitrate of silver. After a short
use of this, symptoms of irritation of the digestive and the genital
organs came on, and necessitated a suspension of the exhibition of the
medicine. Later it was given again, but in smaller doses. Still the
same symptoms returned, though more slowly ; perfect paraplegia of
the legs, and almost absolute palsy of the muscles of the spine came
on. At the same time, the anaesthesia spread upwards almost to the
armpits, and constipation and fever were present. The use of the
nitrate of silver was then abandoned, and in its place iron was given,
and galvanism employed twice a day (it is not mentioned in what
form). Under this treatment the patient in three months recovered
so far as to be ahle to walk short distances with the help of a stick.
He always felt better after the galvanization.

Dr. Hitzig declares that among numerous cases of disease of the
spinal cord, he has only twice, in cases of slow and typical course,
noticed any improvement under the nitrate of silver treatment, and
that he has observed affections of the bladder, but otherwise either
no effect or deterioration, especially disorder of the digestive organs.

In order to avoid evil consequences he advises that the nitrate be
given only when the patient can be closely watched, and that at first
only small doses, such as the twelfth of a grain, should he exhibited. — By
Dr. Ed. Hitzig, ' Berl. Klin. Wchnsch.,' iv, 31, 1867. 'Schmidt's
Jahrb.,' Band 136, p. 22, 1867.

Tlie Symptomatic Value of Herpes Zoster. — Dr. W. Moore relates
two cases of herpetic eruption which occurred in patients labouring
under thoracic aneurism. He accepts the theory of Von Barensprung
that herpetic inflammation depends upon abnormal irritation of the
nerves, and he finds in the pressure produced on the nerves by intra-
thoracic tumours a probable cause of herpes, the occurrence of which
he believes may assist us in the diagnosis of such tumours. — Dr. W.
Moore, Dublin Quarterly Journal Med. Science, Feb, 1868.

Fyopneumothorax without Perforation. — M. E. Boisseau, in an elabo-
rate memoir, endeavours to establish the occasional occurrence of pneu-
mothorax without perforation, complicating purulent pleuritic effusions.
He has collected a number of cases from different authors in proof of
his position, and relates an instance, of which the following is an
abridged account : — X — , £Bt. 38. Admitted at Val-de-G-race, January
12th, 1867. His state was too grave to admit of much examination,
but it was found that he had been suffering for several months from
oppressed breathing, which had become rapidly worse in the pre-
ceding night. There was extreme dyspnoea, with a cyanosed condition
of the face and lips. The left side was manifestly dilated ; at the
level of the nipple it measured three centimetres more than the right,
On the left side there, behind, was absolute dulness to about an inch
below the spine of the scapula. In front, under the clavicle, there was
exaggerated resonance. Behind, there was large tubular breathing,
but no amphoric breathing, and no rales. In front respiration was
very feeble. On the right side there was puerile respiration; the
heart deviated to the right. As the oppression was extreme, tho-

1868.] Report on Pathology and Medicine. 537

racentesis was determined on. On placing the patient on his right
side, and percussing, to assure himself of the dulness at the point at
which he wished to puncture, M. Boisseau was astonished to find at
the level of the fifth rib, at the posterior part of the base of the
axillary space, a sound elicited of metallic " timbre," in fact, a true
" bruit hydro aerique." On listening, a sound was heard resembling
metallic tinkling. A diagnosis of tuberculous perforation was made,
and the operation was rehnquished. The man died on the morning of
the ISth.

Autopsy. By puncturing the fourth intercostal space, and intro-
ducing a trocar, a large quantity of very fetid gas, producing a
well marked sijfflement, was evacuated. The left pleural cavity
contained a large quantity of purulent matter (more than two
litres) ; the left lung was free from all adhesion to the parietal
pleura. The visceral pleura was covered with false membranes, very
soft, thickish, and easily detached. The surface of the pleura itself
was perfectly smooth, and presented neither tearing nor ulceration.
The lung was condensed and flattened. Nothing particular was noted
on the right side of the chest. InsuflQation was practised with great
care and perseverance before the removal of the thoracic organs, and
afterwards under water. The left lung was distensible, but not the
smallest perforation could be found. On cutting it there was no
tubercular granulation, or pneumonic spot, or any other lesion which
could be supposed to give rise to perforation. The following are M.
Boisseau's conclusions: — 1. That pneumothorax without perforation
may complicate purulent pleural effusions is incontestible, although it
is a rare occurrence. 2. The gas produced is the result of fermenta-
tion of the effused fliuids in the pleura. 3. It is possible to distinguish
this pneumothorax from that which accompanies broncho-pleural
fistula (by the history of the case, e. g., one of tubercular phthisis,
and by the exceedingly sudden dyspnoea and pain produced by per-
foration ; also by the respiratory bruits, which are more clear and
accented, the respiratory being replaced by an amphoric bruit, and by
the ease with which metallic tinkling is produced by breathing and
voice as well as by cough, in the case of perforation). 4. The opera-
tion of thoracentesis is always indicated when we are certain that no
communication exists between the pleura and the air in its cavity. —
Prof. M. E. Boisseau, Archives Generales de Me'decine, Juillet et Aout,
1867.

On Dilatation of the Bronchi or Bronchiectasis. By Dr. T.
Grainger Stewart. — True bronchiectasis must be distinguished from
the following lesions, which may be confounded with it, viz. — 1. A
general dilatation of the bronchi from hooping-cough or from capil-
lary bronchitis. 2. Dilatation from stricture of bronchi, taking
place on one or both sides of the stricture, and manifestly connected
Avith it. 3. Slight, local dilatations from long-standing indurations
of lung-substance, tubercular or inflammatory. 4. Spurious bron-
chiectasis, the remains of chronic tubercular cavities or abscesses in
the lung-tissue. Of true bronchiectasis there are two forms — The
general or uniform, and the saccular or ampullary. These, however,

6S8 Chronicle of Medical Science. [April,

constantly co-exist in the same lung, and even in tlie same tube —
the whole course being dilated, but special sacules projecting from
the side here and there. "When dilatations exist in neighbouring
bronchi, it frequently happens that communications become esta-
blished between them, and thus several bronchial tubes may at last
open into one common cavity.

In some dilatations the mucous membrane is natural ; in others
the membrane is thickened and opaque, the epithelial elements,
though still distinct and characteristic, are granular and swollen,
and the vessels are congested. In yet others the membrane pre-
sents a velvety appearance, numerous villous processes projecting
from the surface. In this condition the epithelium is more altered,
though still distinctly characteristic. In others ulcerative or
necrotic destruction of the membrane is seen ; superficial or deep,
limited or extensive abrasions existing. These conditions are met
with in successive stages of the affection, and the author refers the
changes in the mucous membrane, not to a morbid action originating
in itself, but to the effect of changes in the contents of the tubes,
especially to the decomposition of retained mucus. " In the earlier
stages the membrane is unaltered, but as the secretion accumulates
it becomes granular and opaque ; further accumulation and decora-
position of the retained material produces, of course, greater irrita-
tion, the villous condition, and ulceration." There is distinct wasting
of the muscular and elastic coats of the bronchi. With high powers
the tissues appear granular and indistinct, so that the individual
elements of the muscular and elastic fibres can scarcely be recog-
nised. "The atrophy sometimes advances in a very remarkable
manner, particular portions of the wall wasting, and others retaining
their natural volume ; the latter parts form bands or ridges, elevated
above the surrounding mucous membrane. As the atrophy of the
neighbouring parts advances, these become more and more pro-
minent, drawing gradually closer till they resemble a mesentery
connecting the unatrophied band with the bronchial wall. At
length, apparently, by gradual absorption, the mesentery-like mem-
brane disappears, and the band is left as a bridge stretching across
the lumen of the dilated tube." The author believes that com-
munications between neighbouring bronchiectases are formed by a
process identical with the above, neighbouring dilatations expanding
until two of them come into contact. Through their walls an open-
ing forms, which gradually enlarges without any truly ulcerative
process. The mucus contained in the dilated tubes is found in dif-
ferent cases in different conditions : —a. There may be copious yellow
mucus, free from fetor, not differing from the natural secretion
microscopically, h. An inspissated mucus of a grey-yellow and
rather opaque colour, usually free from disagreeable odour, contain-
ing some altered cells, but mostly composed of granular and fatty
matter, c. Casts of tubes opaque and greyish in colour, and, as
pointed out by A. Q-amgee, assuming a purplish hue on the applica-
tion of iodine. These casts are usually accompanied by fetor, and
under the microscope show innumerable fine crystals of margarin.

1868.] Report on Pathology and Medicine. 539

d. Fragments of pulmonary tissue are sometimes mingled with the
foregoing, such as are commonly seen in the contents of tubercular
vomicae, e. The content!} sometimes become inspissated and calca-
reous. These varieties, excepting the fourth, may be produced by
changes in the natural bronchial secretion. The chemical nature of
the fetid sputa in bronchiectasis is not yet satisfactorily determined.
The lung-tissue surrounding the dilatations may be unaltered, or it
may be collapsed or atrophied ; it is not spongy and does not
crepitate, but it is not indurated and no excess of the fibrous
element can be detected in it. In other cases the tissue is con-
solidated; the lung-substance is in a state of cirrhosis or fibroid
degeneration. In others the surrounding tissue forms an abscess,
in the centre of which the thin walls of the dilated bronchus may be
seen. In others the walls of the bronchi and the surrounding lung-
tissue are destroyed by gangrenous inflammation. All these con-
ditions of the lung-tissue are referable to changes within the bronchi.
The author draws the following conclusions from his own observa-
tions : — " 1. That the essential element of bronchiectasis is atrophy
of the bronchial wall ; that the cause of such atrophy is not yet
ascertained, but may, perhaps, be connected with constitutional
peculiarities. 2. That the walls, being so thinned and weakened,
readily yield to the pressure of air, it may be in deep and sudden
inspirations or during violent muscular exertions, certainly in the
sudden expiratory effort made while the glottis is closed in the act
of coughing. 3. The enfeebled and dilated condition of the bronchi
favours the accumulation of the mucus secreted by the bronchial
membrane. 4. That the mucus, accumulating and undergoing
decomposition in the dilatations, irritates the mucous membrane, leads
to inflammation, and the formation of villous processes from it, to
the formation of increased connective tissue in the walls, to irrita-
tion of the cartilages, and frequently to consolidation of the sur-
rounding lung-tissue and pleuritic adhesions, sometimes also to
abscess or to limited gangrene." In many cases this affection of
the bronchi 'comes on insidiously, and in the majority of cases the
disease tends to a fatal result. The author appends to his paper
eight illustrative cases. — Edinburgh Medical Journal, July, 1867.

Chorea, Rheumatism, and Diseases of the Seart in Children. —
According to M. Henri Roger, rheumatism is entirely exceptional
before the ages of three and five years ; in the second period of child-
hood it is almost as frequent as in adults ; but at this age neither
the acuteness of the disease, nor its extension to a number of articu-
lations, are in the same degree as in the adult. Altogether cardiac
complications at this age are sufficiently frequent to warrant us in
saying that, as a rule, the coincidence of rheumatism and cardiac
affections is fatal. Often to the cardiac complication is added a left
pleurisy, and often a double pleurisy. Cerebral rheumatism is less
frequent and less grave in children than in adults. The intimate con-
nections which unite rheumatism and chorea are proved — 1. By the
occurrence of rheumatism with chorea ; the one appearing during con-
valescence, or a little after the cure of the other. 2. By rheumatism

540 Chronicle of Medical Science, [April,

being complicated by chorea during its commencement or progress.
3. By cases of the coincidence and alternation of rheumatism and of
chorea. It is, however, slight rheumatism which is complicated with
chorea. There is a kind of antagonism in severity of phenomena
between the one disease and the other. Acute polyarticular rheuma-
tism is complicated, at its commencement, or iu its course, by cardiac
inflammations, and not by chorea ; and the latter, when it occurs, is
partial, shght, or not of long duration. Inversely, slight rheumatism
is complicated by more severe and longer attacks of chorea. —
M. Henri Roger, Archives Qenerales de Medecine, and Gaz. Med. de
Paris, Mars 7, 1868.

On a Case of Acute Yellow Atrophy of the Liver. — Dr. A. Christy
Wilson records a case of acute yellow atrophy of the liver, in which
the temperature was very high, until shortly before the patient's
death. According to Frerich's, the temperature is only raised during
the premonitory febrile stage, or when delirium and convulsions are
excessive. The patient was admitted into the Edinburgh Royal
Infirmary on December 6th. For several months previously she had
suffered from occasional vomiting ; but her appetite continued good
until three weeks before her admission, when she noticed symptoms of
jaundice. "When admitted she answered incohei'ently ; she was drowsy;
her skin and conjunctiva) were of a bright yellow ; hepatic dulness ;
measured little more than one inch vertically in the mammary line ; the
left lobe of the liver could not be discovered on percussion. She died
on December 10th, having previously had hsemorrhage from the bowels
and vagina ; muscular rigidity and slight opisthotonos. Temperature
on December 9th and 10th was 104° — 105°. Urine contained balls
of leucine, acicular crystals of tyrosine, fusiform crystals of creatinine
and numerous fatty casts.

Autopsy. — Liver weighed less than two pounds; much of its substance
was of a bright ochre yellow colour ; many of the hepatic cells were in
a state of fatty degeneration, and many were completely broken up.
Some were swollen and opaque. The destruction was mbst advanced
at the periphery of the lobules. The kidneys were also diseased. The
cortical substance was dense and opaque, and the tubules were full
of dense opaque matter — cells swollen and opaque, or fatty, or com-
pletely broken down. — Dr. K.G. Wilson, Edinh. Med. Jbwm.,Feb.,1868.

Case of Gastritis Fhlegmonosa. — Dr. T. Grainger Stewart gives a
case of this rare disease, in which it was accompanied by inflammation
and gangrene of the bladder. E. W — , a)t. 28 ; in general healthy, but
had twice suffered from gall stones. After an insufficient diet, she went
to live in a family where she was plentifully supplied. She then began
to complain of pain in her left side, and had constant craving for food,
especially butcher's meat. She was first seen on Monday, October 14th.
Her symptoms were, vomiting of green and yellow bile, flatulent dis-
tension, and pain in the upper part of the abdomen, neither acute nor
aggravated on pressure. These symptoms were at first relieved by
treatment, but on the 19th October she had a relapse. She was taken
to the Infirmary on the 25th, where she was under the care of
Dr. Balfour, and died on the 29th. Her symptoms were flatulent

1868.]

Report on Pathology and Medicine. 541

distension ; vomiting ; pain, not increased on pressure, which extended
into the throat, and in the latter part of the case the symptoms of
exhaustion.

Autopsy.' — Body well nourished ; no icterus, nor oedema ; lungs
congested and slightly oedematous ; peritoneal cavity contained
serum and pus ; coils of intestines were connected together by recent
lymph, and there were recent adhesions between the liver, diaphragm,
and stomach. Gall bladder was thickened and indurated, with a gan-
grenous opening in its anterior wall, which communicated with the
peritoneal cavity ; it was filled with biliary calculi, and a few similar
concretions were found in the ramifications of the hepatic duct.
Stomach of its natural size, distended with air ; contained a small
quantity of fluid. Its walls were throughout greatly thickened — the
thickening tolerably uniform. On section, pus escaped from the cut
surface, mostly from the sub-mucous cellular tissue. The mucous
membrane was thickened, dense, and almost coriaceous, of a reddish-
grey colour. Its tubules and stroma contained pigment, but did not
appear otherwise altered. The muscular coat was in some parts firm
and continuous, in others partially disorganised. The peritoneal coat
was inflamed and thickened. There was no pus in the sub-peritoneal
cellular tissue; in the submucous it was in parts infiltrated, in
parts collected in little sacs of various sizes. Intestines natural, except
the peritoneal surface. Kidneys natural. — Dr.Grrainger Stewart, Edinb.
Med. Journ., Feb., 1868.

The Histological Development of Epithelial Tumours {Cancroid). —
Drs. Ranvier and Cornil state that they have carefully observed the
manner in which cutaneous cancroid is developed at the expense of the
sudoriparous glands. They found in the lower layers of the healthy
epidermis, either occupying the place of the glomeruli of the glands,
or around tubes which were in a normal state, an anastomotic network
of epithelial cylinders, the diameter of which varied from 0"05 to O'l
millemeters. These cylinders presented pavement cells much larger
than the nuclei and small cells of the normal glands, which filled the
lumen of the tube from which the hyaline membrane had disappeared.
There was an abundant multiplication of the elements of connective
tissue around the epithelial masses. The authors are disposed to think
that a disposition of the epithelium in anastomosing cylinders in
tumours of the skin always originates in the sudoriparous glands.
Passing to^ the study of the development of cutaneous cancroid at the
expense of sebaceous glands, MM. Eanvier and Cornil show that the
first modification which occurs in these glands, in the neighbourhood of
cancroid, consists in an increase of the number of the layers of the
small pavemental cells of the periphery of the cul-de-sac. In propor-
tion as these multiply they push towards the centre of the cul-de-sac,
the sebaceous cells, which at last disappear. The pavemental epithelium
thus accumulating in the centre, takes on the globular form. But at
this period the sebaceous glands have lost their proper wall, but retain
their dimensions, and have only become more globular. On a fine
section we find these masses occupying the situation of the sebaceous
glands around the sheath of the hair. The neighbouring dermis is

82— XLi. 35

543 Chronicle of Medical Science, [April,

normal. Later they extend considerably, at the same time that the
papillae elongate, and the Malpighian network penetrates between them.
Lastly the authors have studied cancroid developed at the expense of
the Malpighian network, by enlargement of the interpapillary spaces,
and the advancement of the cells of the mucous layer between the
papillae. — Drs. L. Ranvier and V. Cornil, Journal de V Anatomie et de
la Physiologie Normales et Pathologiques and Gazette MH. de Paris,
Fevrier 8, 1868.

Cryptogamic Origin of Syphilitic Diseases. — Dr. J. H. Salisbury
believes that he has discovered the specific cause of syphilis and gonor-
rhoea, in two new algoid vegetations. His microscopic studies connected
with syphilis were commenced in 1849, but it was not until 1860 that
he made any progress " for plants of this character had been but little
studied on account of their habitat, their resemblance to connective
tissue filaments, and their extreme minuteness." The plant which
he believes is the cause of syphilis he terms Crypta Syphilitica. No
substantial progress was made by the examination of pus from primary
sores alone, although it was observed that the pus contained small
highly refractive spheroid bodies, which were afterwards found to be
the spores of the Crypta Syphilitica. By dissecting the beds of
chancre, and subjecting the tissue to careful microscopic examination,
a peculiar filament was discovered running in all directions, singly and
in bundles, through and among the diseased connective tissue elements.
This organism was found to be algoid ; it was found in multitudes, and
in all stages of development, from the spore to the mature filament.
The author states that he has found it in one hundred cases. When
the disease has become constitutional it is found in the blood, and he
believes its presence or absence in the blooa is a sure guide for con-
tinuing or discontinuing treatment. The following is the author's
description of this minute organism: — Genus, Crypta (Salisbury). —
Minute, transparent, highly refractive algoid filaments, which develop
in living organic matter from spores. Species, C. Syphilitica, (Salis-
bury).— A homogeneous filament, with extremities obtusely rounded
The filaments are of such uniform structure throughout that no trace
of transverse markings are visible save iu their early stage of develop-
ment ; neither can the contents be distinguished from the outside wall
of the filament. The filaments are either straight, coiled, or arranged
in curves. They develop from spores, which may be active or inactive
in the connective tissue, and may be transplanted from one individual
to another by inoculation, or by contact with mucous membtanes. The
connective tissues, cartilage and bone, furnish a fertile soil for the
development and propagation of this plant. When the spores are
planted on a mucous surface, they vegetate, the filaments making their
way through the basement membrane, instead of extending laterally in
the epithelial tissue. The epithelial tissue, in the primary disease, is
only destroyed immediately over wh«re the plants first penetrate the
glue tissue beneath." A somewhat similar cryptogam the author
believes to be the specific cause of gonorrhoea. It occurs as spores in
the pus, and among and in the epithelial cells, and as filaments, single
and in knots, in all stages of development. In the embryonic filaments

1868.] Report on Pathology and Medicine. 54d

a moniliform structure could be observed, exhibiting the outlines of the
individual spores, while the more advanced and mature filaments were
usually homogeneous throughout their entire length. To this plant
the author gives the name Crypta Gonorrhoea. It limits its invasion
to the epithelial tissue, whilst the Cypta SyphiUtica confines itself
mainly to the connective, cartilaginous and osseous tissue. — J. H. Salis-
bury, M.D., American Journal of Med. Sciences, Jan. 1868.

On the Diffusion of Trichina spiralis. By Dr. T. S. Cobbold. —
The author performed numerous experiments by feeding various
animals with trichinous flesh. His results correspond very closely
with those obtained by investigators on the Continent. Thus, H. A.
Pagenstecher and C. J. Fuchs found that ingested muscle trichinae
acquired sexual maturity within the intestinal canal of birds ; but they
never found young trichinse in the muscles of birds, nor did they per-
ceive any evidences of an attempt on the part of the escaped embryos
to efiect a wandering or active migration on their own account. So
seven experiments performed by the author on birds gave negative
results. No trichinae were found either in the muscles or in the
intestinal canal. Not a few persons entertain the notion that trichinse
are liable to infest all kinds of warm-blooded and even also many kinds
of cold-blooded animals, such as reptiles and fishes. Certain nema-
todes found in earthworms have been described as trichinse, and,
consequently, pigs and hedgehogs were said to become trichinous
through eating the annelids. The minute flesh- worms (described by
Bowman) from the muscle of the eel are not true trichinse, any more
than the somewhat similar parasites {Myoryhtes Weismanni) which
Eberth found to infest the muscles of the frog. The negative results
obtained may therefore fairly be taken as positive, in one sense, inas-
much as they help, with the aid of other experiences, to define the
area of distribution legitimately assignable to Trichina spiralis. The
author obtained positive results in dogs, cats, pig, guinea-pig, and
hedgehog. '* Carnivorous mammals, and especially those which sub-
sist on a mixed diet, appear to be most liable to entertain trichinse ;
nevertheless it is quite possible to rear flesh-worms in herbivora.
Pagenstecher and l^uchs succeeded in rearing muscle trichinse in a
calf, and they found three female intestinal trichinse in a goat, but
apparently no muscle flesh- worms, although twenty-seven days had
elapsed since the first feeding with trichinized rabbit's flesh. In
three sheep experimented on by the author no trace of trichinae
could be found. In their natural state it is clear that herbivorous
mammals can seldom have an opportunity of infesting themselves,
whilst the reverse is the case with swine, carnivorous mammals, and
man. Other parasites, the common fluke, for instance, are limited
to a larger or smaller number of hosts ; whilst, on the other hand,
in not a few cases, the territory occupied is that of the body of a
single species. The two most common cestodes liable to infest man
have a very limited distribution ; and the same is true of nematodes,
Oxyuris vermicularis being confined, as far as is known, to man. The
author adds that in England ordinary precautions will sufiice to
prevent the introduction of trichiuiasis. English swine are almost

544 Chronicle of Medical Science. [April,

entirely, if not absolutely, free from this disease, and not a single
case of trichiniasis in the living human subject has been diagnosed
in the United Kingdom. Some twenty or thirty cases have been
discovered post mortem ; but it is most probable that all these indi-
viduals had contracted the disease by eating G-erman sausage or
other preparation of foreign meat. — From the Proceedings of the
Linnean Society, vol. ix, No. 36, Sept. 14, 1867.

The following papers and memoirs are cited by title only, as want of
space prevents a more extended notice of them.

Case of JEmpyema with Inequality of the Hadial Pulses, and Para-
lysis of the Diaphragm. By James Cuming, M. A., M.D., &c. Dul.
Quart. Journ., Feb. 1, 1868.

Two Gases of Epilepsy. By Gr. W. Balfour, M.D. Edin. Med.
Journ., March 1868.

Functional Hemiplegia. By J. H. Kidder, M.D., &c. American
Journal of Med. Sciences, Jan. 1868.

Cases of Inflammation occurring under Peculiar Conditions, ivith
some Thoughts and Reflections on the Nature, Constitution, and Pur'
poses of this Organic Process in the Animal Organism. By Samuel
Jackson, M.D. American Journal of tlie Medical Sciences, Jan. 1868.

On Double Facial Paralysis. By Dr. Pierreson. Arch, de Mede-
cine, Aug. 1867,

Remarks on the Etiological Analogies of Pulmonary Tubercular
Phthisis. By Dr. Jules Arnould. Gaz. M6dicale de Paris, Mars 7, 1868.

On Two Cases of Sub-meningeal Ucemorrhage. By R. Lepine.
Gaz. MSd. de Paris, Nov. and Dec, 1867.

On the Treatment of Group by Humid Vapour of the Sulphide of
Mercury. Gaz. Med. de Paris, Sept. 1868.

On cholera. By Dr. Nicaise. Gaz. Med. de Paris, Fev. 1868.

On Abdominal Tumours. By Dr. J. Guipon. Gaz. Med. de Paris,
Janvier, 1868.

Rupture of an Aneurism of the Ascending Aorta into the Pericar-
dial Cavity, By Dr. E. R. Hun. JVew York Med. Journ., Jan. 1868.

On Tuberculous Disease in North- West em Texas. By Dr. E. M.
Morse. Ibid.

Niemeyer's Views on Tubercle, a rhume of. By Dr. "W. T. Lusk.
Ibid., Dec, 1867.

On Tuberculosis of the Lungs : a revieio of the more important
German, French, English, and American contributions to the Pathology
and Therapeutics of this affection; from the year 1855 to 1863. By
Drs. P. Kersten, and Ed. Friedrich, of Dresden. Schmidt's Jahrb.,
Bd. 133. 1867.

On Poisoning by Phosphorus : a notice of recent communications
on acute Phosphor-poisoning. By Dr. Otto Schraube, Querfurt. Ibid.,
Bd. 136. 1867.

A Rhume of Knowledge and Opinions about Gonorrheal Rheuma-
tism. By Dr. Edm. GiiAtz. Ibid., Bd. 136. 1867.

Report on Epidemic Cerebro-Spinal Meningitis, gathered from the
latest observations and investigations. By Dr. H. Meissner, of
Leipzig. Ibid., Bd. 129 ; and Bd. 136. 1867.

1868.]

Repoj't on Midivifery. 545

REPORT ON MIDWIFERY

By EoBEET Baenes, M.D., P.R.C.P.,

Obstetric Physician to St. Thomas's Hospital ; Examiner in Midwifery to the Royal College of

Surgeons.

I. The NoN-PsEaNANT State.

1. On Polypus Uteri. ByDr. Dtce.

2. The Nerves of the Uterus and~ their Termination in the Smooth
Muscular Fibres. By Dr. F. Fkankenhatjsee.

1. Dr. Dyce records the result of forty cases of polypus uteri
treated by bim. Several cases of special interest are described. One
point be insists upon is tbe importance of always plugging after
removal of a polypus by excision. In one case a patient nearly died
from bsemorrbage. — Fd. Med. Journ., Dec, 1867.

2. Dr. Frankenbaiiser, in an elaborate memoir, not only traces the
nerves in their course into the uterus, but discovers their termina-
tions in the nuclei of the muscular fibres. He also gives a careful
historical review of the subject. He says tbe best and truest
account is that in Walter's tables, Berlin, 1783. He extols Hunter's
description of the uterine sympathetic nerves, and also Tiedemann's.
The results of Robert Lee's researches are contradicted by Snow
Beck ; but Snow Beck is incomplete and erroneous in his descrip-
tion. The histological investigation of the genital nerves has made
little progress since Franz Kilian's time ; but ganglia have been dis-
covered in the substance of the uterus by Frankenbaiiser, Kohrer
and Korner. Jena, 1867.

II. Peegnanct.

1. The Decidua Menstrualis. By Dr. Hausmaists'.

2. A Case of Jaundice fatal in the Seventh Month of Pregnancy. By

Dr. Paul Datidson.

Dr. Hausmann gives an historical review of the researches hitherto
made on this subject. He then explains the conclusions he has
arrived at after examination of many specimens and histories, for
which he is indebted to Professors Martin and Virchow. He says
he has never observed an entire cast of the uterine cavity, the mem-
branes having always been expelled in three or more pieces. The
membranes were from one to four centimetres long, of variable width,
and usually thinner at the margin of transition from the anterior to
the posterior wall of the cavity, at times only hanging together by
a few shreds. The inner wall showed a smooth surface, and upon
more minute examination several crossing forks, already described
by Follin, enclosing, when recent, in their midst, deeply red areas.
These last, as well as partially translucent spots, depend upon an
unequal thickness of the detached mucous membrane, as may be
easily seen by sections made through these spots. Within these
larger crossings the inner surface shows a number of punctate, small

546 Chronicle of Medical Science. [April,

openings, which are the expanded mouths of the uterine glands, an
appearance which made Hunter call the membrane the membrana
crihrosa. The outer surface was rough from hanging shreds. The
microscope made manifest the uterine glands, accompanied by capil-
lary network ; broad, rounded cells, mostly having a large nucleus
and nucleolus, which sometimes was elongated and pointed at one
or both ends, giving a spindle shape. With these cells were a few
free nuclei; and near the outer surface was an abundant, loose,
fibrous connective tissue.

As to the origin of this casting of the uterine mucous membrane,
Dr. Hausmann contends that it is the result of impregnation.
He disputes the statement that the membrane is shed every four
weeks. He says it commonly occurs after intervals longer than
ordinary ; that it occurs only in married women, or in women
exposed to sexual intercourse. He calls attention to the fact that
women who before marriage never had anything of the kind
begin to expel these membranes afterwards, and cites a case from
Tyler Smith of a patient who, whilst single, had been healthy, who
from the date of her marriage to the death of her first husband had
observed membranes of this nature at irregular intervals, who again
became free whilst a widow, and again dishacrged these membranes six
months after a second marriage. Hence he concludes that these
membranes are abortions of some days or weeks, the mucous mem-
brane of the uterus converted into decidua being expelled, after the
perishing or escape of the ovum. This occurs preferably at a men-
strual epoch, and thus may favour the idea that it is a simple
menstrual decidua; but often the interval is longer than four weeks.
The membrane is expelled commonly within six to twenty-four hours
after the beginning of the haemorrhage, sometimes later, and generally
after pains. There are probably various causes of the abortion, but
probably the premature destruction of the embryo precedes it. The
frequent catarrh of the uterine mucous membrane and chronic
metritis associated with this condition are generally the consequence
of it. The treatment is divided into that which is indicated for the
abortion and into that proper for the disease. The most essential
rule is abstinence from sexual relations for several months. —
Monatsschr.f. Gehurtsk, Jan., 1868.

2. Dr. Paul Davidson adds a case to those illustrating the interest-
ing subject of jaundice in pregnancy. A single woman, set. 26, was
brought into the Breslau Clinique in labour. She was a large,
robust primipara. She had recovered fiom an attack of cholera
Avhen three months pregnant. For the last five or six days she felt
depressed and weak, headache, loss of appetite, constipation, but
went about her work. Three days ago a yellow tinge efface appeared,
and at the same time the urine became like brown beer. The day
before admission she had vomiting, and labour-pains set in. Some
blood was discharged from the vagina during the night. The water
broke, and a child was quickly expelled. The placenta soon followed.
There was little blood. The uterus contracted. The child, which
had died in utero, was about twenty-five weeks old. It was deeply

1868.] Report on Midwifery. 547

stained yellow, without sign of decomposition. The woman was
now intensely icteric ; pulse 78, respiration 18, temperature 36'5 C. ;
pupils natural ; answers correctly. Percussion in region of the liver
was not painful- The dulness began in the fifth intercostal space,
and ended with the edge of the ribs. A profuse atonic metrorrhagia
set in an hour after labour. It was arrested by cold injections.
The uterus continually showed a disposition to relax. Soon vomit-
ing set in ; at first of watery clear fluid, with excitation, thirst ; then
of black, coffee-like fluid. Blood appeared in the vomited matter.
Six ounces of urine, drawn by catheter, was turbid, dark brown, with
yellow foam, copious sediment of uric acid salts ; a marked biliary
motion ; no albumen, no cylinders. Vomiting continued ; blood
always in the ejecta. Pulse remained at about 70. Percussion
showed a marked diminution in size of the liver. The urine was
almost suppressed. Death ensued after increasing collapse and
coma, within twenty-four hours after delivery.

The urine, carefully examined, showed abundance of biliary salts
and leucin-globules.

Autopsy. — The pericardium contained a considerable quantity of
jaundice-coloured serum ; some small punctated ecchymoses in the
muscular substance of the heart near its base ; the papillary muscles
showed similar ecchymosis, and the muscular fibres were in a state of
fatty degeneration. The contracted liver had shrunk quite an inch
above the rib cartilages ; the cells were in advanced degeneration ;
the ductus choledochus was plugged with mucus ; both kidneys were
swollen ; the parenchyma soft, stained yellow, and in a state of fatty
degeneration ; spleen enlarged. The uterus reached above the sym-
physis. In the broad ligaments were some extravasations of blood.
Blood was found in the intestines. — Ibid., 1867.-

III. Labour.

1. On Obstetrical and Gyncecological Measterements and Weights. By
Dr. Cabl Maetin.

2. A Case of Carcinomatous Sarcoma of both Ovaries ; Premature

Twin Labour. By Otto Spiegelbeeg.

3. On Jht/rning in Narrow Pelvis. By Prof. E. Maetin.

Dr. Carl Martin contributes an elaborate memoir on obstetric and
gynaecological weights and measurements. In 1700 measurements
he found the distance between the anterior superior spinous pro-
cesses of the ilia to give a minimum of 18*9 centimeters, a maximum
of 31"5, and a mean of 254. Out of 1500 measurements this
diameter in 451 cases was above 24 and below 25 ; in 757 it was
over 25. He concludes that the proper diameter is 25 centimeters
= Q\ inches.

The distance between the crests of the ilia gave a minimum of 24,
a maximum of 33"8, and a mean of 28'5. The standard distance
he concludes to be 28 centimeters = 10^ inches.

The distance between the trochanters justified a standard of 31
centimeters or 11^ inches, closely agreeing with the measurements
of Michaelis and H. F. Naegele.

548 Chronicle of Medical Science. [April,

The external conjugate showed in 1700 measurements a minimum
of 16'4, a maximum of 25, and a mean of 20 centimeters = 7' 5".
This he takes as the standard.

The right external oblique diameter gave in 1500 cases a minimum
of 19, a maximum of 27, and a mean of 22'6. The left external
oblique diameter gave somewhat smaller measurements ; the maxi-
mum was only 26'5, the mean only 22 "5. The mean of the two
oblique diameters must be taken at 22"5 centimeters.

The eonjugata vera he has determined on 16 dead subjects. He
took 4 inches as the standard. The transverse diameter of the
brim he found in 25 dissections of narrow pelvis to be 13"2, in 34
middling and large pelvis to be 13'8, in the whole 54 to be 1358. He
adopts 13'5 centimeters, = 5 inches, as the standard. The oblique
diameter he obtains is 12'5 centimeters = 4f inches. The sacro-
cotyloid diameters measure 9 centimeters = 3^ inches.

In 560 mature boys he found a mean weight of 3330 grammes
= 6f pounds : and in 500 mature girls a mean of 3220 grammes
= 6| pounds.

He found a mean length in both sexes, from head to breech, of
35 centimeters ; from head to heels of 50 centimeters.

The following are the head measurements : — 1st. The anterior
transverse diameter, i. e. at the lower ends of the coronal suture
= 8 centimeters = 3 inches. 2nd. The posterior transverse diame-
ter, i.e. between the tubera parietalia = 9 centimeters = Z-^ inches.
3rd. The straight diameter from the glabella to the hindermost point
of the occiput = 11*5 centimeters :=: 4i inches. 4th. The long
oblique diameter from chin to the furthest point of the occiput
= 13'5 = 5 inches. 5th. The short oblique diameter from the
foremost point of the neck to the furthest point of the forehead
= 9'5 centimeters = 3| inches.

In 200 cases of mature birth he weighed the afterbirths; he
obtained for the whole afterbirth a minimum of 350, a maximum of
870, and a mean of 585 grammes; for the length of the cord a
minimum of 35, a maximum of 102, and a mean of 56 centimeters. —
Ibid., Dec, 1867.

2. Dr. Spiegelberg relates an interesting case of ovarian tumour
complicating pregnancy. A woman, a)t. 36, primipara, was delivered
prematurely of twins. Soon after almost sudden stupor and delirium
set in. Albumen was found in the urine. Diarrhoja followed. A
tumour, the size of the fist, was felt in the right side. The abdo-
men became painful and meteoric. Rigor appeared. The pulse and
temperature rose. Exhaustion and death on the third day. A large
quantity of green, turbid, bad-smelling fluid, mixed with yellow exuda-
tive fluid, was found in the abdominal cavity. A tumour covered
with blood and layers of fibrine lay in the iliac fossa ; it was con-
nected with the broad ligament by a pedicle. No trace of a normal
ovary was found. Di\ Spiegelberg is of opinion that the stimulus to
growth of the ovarian tumour caused by pregnancy caused throm-
bosis in its structure, with apoplectic and necrobiotic foci, the
rupture of which occasioned the fatal peritonitis.

1868.]

Report on Midwifery. 549

3. Professor E. Martin discusses the use of turning in contracted
pelvis. He denies the proposition that the head enters the brim
with more facility base first, if the child is living. He insists that
when the vault presents moulding may go on gradually and safely
for hours ; whereas if the base come first, the moulding must be
effected by force, and within five minutes, in order to save the child.
He points to the importance of getting the smaller or bi-temporal
diameter of the head into the contracted conjugate diameter, and the
occiput with the greater or bi-parietal diameter into the larger side
of the pelvis. This may be efiected in three ways : — 1st. By a fitting
position of the woman. Let her lay on that side towards which the
forehead is directed ; the fundus of the uterus will gradually sink
with the pelvic end of the child to this side ; the spine draws down
the occiput to the opposite side of the pelvis, and the forehead goes
more deeply towards the middle of the brim. Martin refers to a
case in which he successfully executed this, the pelvis measuring
only three inches. 2nd. The forceps is a means of releasing the
engaged posterior or larger transverse diameter from being locked
in the conjugate. This explains the frequent easy extraction when
a little traction is made. This method is indicated when signs of
exhaustion or of need for delivery exist ; but it must not be trusted
to overmuch. We must be prepared to perforate. 3rd. Turning
by the feet. When this has been done, Martin has always found the
depression caused by the promontory to be on the temporal bone.
In many of these cases he found, after some hours, signs of blood-
effusion in the cranium, ex. gr. convulsions in the face. He thinks
turning is advisable only when the transverse diameter of the pelvis
is great enough to allow the occiput to pass by the side of the
promontory.

In the case of one-sided distortion of the pelvis, turning is hardly
admissible. Martin refers to cases in which the occiput descending
in the narrow half of the pelvis, delivery had to be accomplished by
perforation ; whereas, when the occiput was turned to the normal side
of the pelvis, the forceps delivered easily. This occurred in the same
patient. He also gives cases in which the occiput, being unfavorably
situated, a face-presentation was developed. This happened twice
in the same woman, under his own observation.

The indication for turning in narrow pelvis occurs when it is
possible to bring the smaller anterior diameter of the head into rela-
tion with the narrowed conjugata, and the occiput into the larger half
of the pelvis ; and when this more favorable position of the head
conies to be effected by placing the woman in a fitting position.
He then asks. Can the head be so placed by turning ? In conse-
quence of the known law, that in incomplete foot-presentation the
foot that is drawn down always comes under the pubic arch, if the
foetus is not abnormally small or the pelvis too large, in drawing
down the right foot the child's back and also its occiput will come
into the right half of the uterus, and vice versa. — Ibid.

550 Chronicle of Medical Science. [April,

IV. The Pueepeeal State.

1. The Intra- Uterine 'Pessary as a Scemostatic in the Puerperal
State. By Dr. Heetz.

2. A Case of Inversion of the Uterus. By Dr. Sohnoee.

3. On the Production of Inverted Uterus. By Dr. Matthews

DUNCAK.

4. Observations on the Contagion of Puerperal Fever carried by a
Midwife. By Dr. Kaueeman.

5. Case of Suppression of Urine fatal on the thirteenth day. By
Dr. John Millee.

1. Dr. Hertz having to treat a case of repeated and profuse
secondary haemorrhage after labour, finding there was ante-version
and flexion of the uterus, introduced an iodia-rubber intra-uterine
pessary in the sixth week. The haemorrhage ceased. The patient
wore the instrument for ten days without inconvenience, and without
return of bleeding. Professor E. Martin, commenting upon the case,
cautions against the use of the sound to correct flexions of the uterus
in women so early as six weeks from labour. — Monats. f. Oeb.,
Aug., 1867.

2. A primipara was delivered by forceps of a child presenting in
first position. After pressing upon the fundus uteri to drive down
the placenta, and drawing upon the cord, the placenta came down
attached to the inverted uterus. Dr. Schnorr separated the placenta,
and immediately reduced the uterus. The uterus then contracted.
The patient had slight peritonitis, from which she recovered, to die
later of phthisis. — Ibid., July, 1867.

3. The reference made in a former report to Dr. Duncan's views
on inversion of the uterus was so imperfect as to occasion misinter-
pretation. As these views are important they are now cited more
fully. Four kinds of inversion occur after delivery : — 1. Sponta-
neous passive uterine inversion. 2. Artificial passive. 3. Sponta-
neous active. 4. Artificial active inversion. The only uterine con-
dition essential to the production of all these kinds is paralysis or
inertia, or complete inaction. Tbis is the condition of the whole
organ at the time of the production of the two first kinds. In the
two last kinds it is accompanied by uterine activity, i. e. there is
partial activity, partial inertia. Activity of the whole of the uterus
makes inversion impossible. Activity of a part of the uterus renders
introcession of that part impossible. There must, therefore, be para-
lysis of the whole or a part before inversion can be begun. The para-
lysed part that falls in is generally the placental seat. Action takes
place below this in the form of an hour-glass contraction. Hour-glass
contraction cannot exist unless the parts above the contraction are
in a state of inertia, for were the higher parts of the uterus in even
moderate action the hour-glass contraction would soon be overcome.
Dr. D.'s account of the passive forms of inversion does not differ
materially from those generally known. Spontaneous active inversion
occurs in the following way : — Bearing down presses the paralysed
portion of the uterus into the cavity ; this is seized by the adjacent

1868.]

Report on Midwifery. 551

contracting segments of the uterus, is pushed down, and expelled
through the uterus. — JEdinb. Med. Journ., May, 1867.

4. Observations on the Contagion of Puerperal Fever through a
Midwife. By Dr. Katjfmann. — Dr. Kaufmann relates the follow-
ing history : In Durkheim, at a time when there was no other
epidemic present, a man had diphtheritis, and was convalescent,
when at the end of April a young primipara was delivered in his
house. Two days afterwards she sickened with puerperal fever.
She was attended by a midwife, M — . She died. Exsudation in the
abdomen, and diphtheritic endometritis found. Within the last
fortnight four other women were attacked, all of whom had been
attended by the same midwife. During the month of May M —
attended six women, five took the fever, and four died. During the
same time two other midwives attended twenty-one cases, all with^
out accident. — Monatssch.f. Gehurtsk., April, 1867.

5. Case of Suppression of Urine, fatal on the thirteenth day. Dr.
Jko. Millee. — A pluripara had mammary abscess. At the end of a
fortnight from labour there was suppression of urine. Towards the
end there was intense pain in the region of the kidneys. Intel-
ligence unafii"ected. Little or no oedema. No convulsion. Serum
drawn from a blister gave urea. Kidney exhibited numerous oil-
globules. A thin section presented the appearance of stearosis,
intermingled with that of inflammatory epithelial degeneration of
the tubules. (The case appears to be analogous to acute atrophy
of the liver. E. B.) — Edin. Med. Journ., June, 1867.

The following are referred to by title only for want of space :

A Case of Abdominal Gestation ; spontaneous Perforation of tha
Abdominal Wall ; gradual Expulsion and Extraction of the Foetus ;
Pecovery. By Dr. Jactjbowitz. — Wien. Med. Presse, 1867.

Experiences of Eclampsia during the Reproductive Period of Women.
By Dr. Webeb. — Ibid.

Absence of Uterus. — Rtsch. — Berlin Klin. Wbchsohr., 1866.

An Ovariotomy in 1701. E. Koeberle. — Gaz. Hebdomad., 1866.

Two Successful Ovariotomies performed in the separate Wards of the
Poyal Lying-in Institution of Berlin. E. Mabtin. — Berl. Klin.
Wochensch., 1866.

One-sided Hcematometra with a Double Genital Canal. Schroteb.
—Ibid.

The Significance of the Levator Ani Muscle in the use of Pessaries.
Dr. HiLDEBRANDT. — MoYi. f. GcburtsTc., April, 1867.

Cases Illustrative of the Insanity of Pregnancy. Dr. John B.
TuKE. — Edin. Med. Journ., June, 1867.

Two Cases of Fatal Haemorrhage from the Gums after Scarification.
James Toting, M.D. — Ibid.

Case of Congenital Fistula in the JSfeck. By Dr. KooH. — Mon. f.
Geb., 1867.

Description of Double-monsters. Dr. Donitz. — Archivf. Anatom.,
1866.

Seven Cases of Ovariotomy. By Dr. Kbassowbki. — Peter sb. Med.
Zeitsch., 1866.

553 Chronicle of Medical Science. [April,

On Cases of Vagina Duplex of Uterus Simplex, and of Saccated
Uterus. J. Matthews Duncan. — Journal of Anat. andFhys., vol. i,
1867.

Observations on Thrombosis and Embolism. Dr. Playfaie. — Lancet,
1867.

Lectures on Obstetric Operations : Turning. Dr. Baenes. — Medi-
cal Times and Gazette, Oct., Nov., Dec, 1867.

Two Cases of Cephalotripsy. By Dr. Angus Macdonald and
Dr. A. Inglis. (Edinb. Med. Journ., Feb., 18G8.)

Further Cases of Ovariotomy. By TnoMAS Keith. Some cases
are related in detail. The general result of sixty-two operations is
forty-nine recoveries and thirteen deaths. (Ibid., Dec, 1867.)

On the Use of Pressure and Vis a Tergo in Operative Midwifery.
(Ploss'sche Ztschzt. fur Medicin, &c., 1867.)

EEPORT ON TOXICOLOGY, TORENSIC MEDICINE,

AND HYGIENE.

Bt Benjamin W. Richaedson, M.D., E.R.S.

I. Toxicology.

Micro-Sublimation. — "We have twice before reported on micro-subli-
mation, and have again to direct attention to the same subject. Mr.
"Waddington, following in the steps of Helwig, Guy, and Sedgwick,
records : —

The results obtained by the method that he has adopted are so at
variance with much that has been described in various chemical works
that they must, if substantiated, tend in some degree to modify
existing ideas on this subject.

The statement so commonly met with in the descriptions of the
behaviour of alkaloids when submitted to heat, that they partly sub-
lime and partly decompose, is decidedly open to objection. It cannot
mean that the sublimation of a part is dependent upon the decom-
position of a part, and yet it is difficult to put any other construction
upon it. He supposes it must be admitted, almost as an axiomatic
principle, that what is true of a part is true of the whole, or, more
correctly, the properties possessed by a part must also be possessed by
the whole ; and therefore if a part is capable of sublimation the whole
is so too.

No substance can sublime and decompose at the same temperature :
partial sublimation and partial decomposition must be owing to the
mechanical defect of the substance being unequally heated. That the
subliming and decomposing points of many substances approximate
very closely is most probable, as, when the heat has been most care-
fully applied, a sublimate has been contaminated with coloured matter,
which could only have arisen from decomposition. And in many
instances the range of temperature at which a substance sublimes is
very limited ; the addition of one or two degrees of heat being quite

1868.] "Report on Toxicology, Forensic Medicine, ^c, 553

sufficient to decompose it, while the deficiency of one or two degrees
prevents any sublimation taking place. Thus in subliming from pa-
pavarine, he was unsuccessful for eight or ten hours, owing to the tem-
perature being defective or excessive, but at another time he obtained
a sublimate in as many minutes.

The statement that a substance sublimes without decomposition is,
he thinks, equally objectionable ; it is somewhat equivalent to saying
that a substance remains stable without alteration. It may be, and no
doubt is expressive, but it is hardly correct. Sublimation indicates
stability, not decomposition, and, as he before remarked, a substance
could not undergo both at the same temperature. It may be urged
against this that some substances decompose when heated into other
definite compounds, as tannin into metagallie and pyrogallic acids,
but it "would be as correct to say that tannin sublimed with decom-
position as to say of any other substance that it sublimed without
decomposition.

All sublimates from bodies unchanged by heat should possess the
crystalline form of the original substance, and in every case he has not
considered a sublimate satisfactory unless this result has ensued.
Certain conditions are no doubt necessary to produce a sublimate in
typical crystals, but the statement that many alkaloids sublimed in
round granules is hardly correct. A sublimate, consisting of round
granules, was more or less common to all organic sablimates. It was a
modification which he believed admitted of explanation, but at present
he had been unable to investigate it. If the process is cautiously
continued, the sound granules generally disappear. Crystalline sub-
limates, more or less defined and typical, taking their place. This
would be observed in many slides where the process has been stopped
before the whole of the granules have disappeared. He was convinced
that their production depends in some measure upon the heat of the
receiving glass ; the most perfect crystals are obtained when no
granules appear, but if the glass became too hot these crystals melt
and the granules again form.

Much doubt has existed as to whether the sublimates were identical
in composition with the original substance. The sublimate of strych-
nine was identical with that substance itself, both as to its crystalline
form, and also to its behaviour with various chemical tests ; and
although the fact of one or two alkaloids subliming unchanged cannot
be taken as a proof that others will do the same, yet when coupled with
the knowledge that perfect sublimates were obtained from nearly every
alkaloid operated on, it affords strong grounds for supposing that they
do. The fact that one or two alkaloids yielded no definite sublimate
can hardly militate against this, as he has every reason to think that
these may be sublimed when the heat is more effectively applied.

He thinks that by the method he describes, it is probable, nay
more, almost certain, that during some of the process perfectly typical
crystals of the substance operated on may be obtained, and that from
quantities not exceeding the -jjjth of a grain ; for, as a rule, the smaller
the quantity the better the result. Thus in submitting the -j^th of a
grain of any sublimable substance to heat, the first sublimate will per-

654 Chronicle of Medical Science, [April,

haps possess little distinctive feature, the second will be better, and so
on until the substance is nearly dissipated, when the crystals will gene-
rally be most perfect. Notwithstanding this, he must acknowledge
that the variety of form occasionally produced on the sublimates, pre-
cludes at once any certain definition of their nature from the crystalline
appearance. It may suffice to mention that he has obtained sublimates
of codeine, strychnine, and santonin, so identical in form, that had they
not have been labelled, it would have been impossible to separate the
one from the other. The apparatus he has used consists of a spirit-
lamp, a piece of thin iron plate, and a few glass rings. Three straight
lines should be marked on the plate, one across the centre, the others
an inch and a half on either side of it. This will be found of great use,
as the centre of a slide is at once shown. There should be the merest
possible curve in the centre of the iron plate, so that when a glass slip,
3 inches long, is laid upon it, the centre does not touch by the |^ or -^
of an inch. This has the decided advantage of never allowing the
glass holding the substance to come into actual contact with the iron
plate, thus modifying the heat considerably. He has entirely discarded
the use of thin glass for receiving the sublimate, for two or three
reasons. As a rule, much better sublimates are obtained upon hot
than upon cold glass, and on account of the small bulk of the circles of
thin glass they cool too rapidly. They are inconvenient to use, as they
cannot be manipulated by the fingers alone ; and when the sublimate
is upon a elide, it is much more convenient for examination, and, if
necessary, for applying liquid tests. In subliming arsenious acid, for
instance, he could never obtain such good sublimate upon the thin glass
as upon the slide itself. Very long directions have been given for
obtaining sublimates of arsenic, but, with two pieces of glass and
a glass ring, sublimates of arsenic may be obtained which cannot be
surpassed.

A ring is placed on a glass slip, a minute quantity of arsenic put into
the centre of it, and the slip placed on the iron plate before mentioned,
and heat applied. When the arsenic begins to sublime, another piece
of glass, which has been laid on the iron plate or allowed to become
warm by any other means, is placed over it to receive the sublimate,
the glass ring being its only support. If the glass slip be hot enough,
the arsenic will sublime in regular octahedral crystals, not at all crusted,
but leaving a good margin between each crystal. If the result of the
sublimation, owing to the glass being insufficiently heated, is crusted,
it should be rapidly wiped off and returned to its place, and this pro-
cess mav be repeated until a satisfactory result is obtained. The glass,
by this means, continually increases in heat, each successive sublimate
being an improvement on its predecessor. It may be thought some-
what unnecessary to give such a detailed account of the sublimation of
arsenic, a subject by this time nearly exhausted, but he has done so
because it may be taken as the type of all other sublimates. The only
modification of it consists, in some substances having been mixed with
powdered glass and then sublimed. Powdered glass possesses some
advantages over sand, which was recommended in the case of theine
by Dr. Stenhouse ; it is more easily cleaned, it can be obtained in a

1868.] Report on Toxicology, Forensic Medicine, ^c. 555

finer state of division, and on account of its perfect whiteness the least
change of colour may be well observed. Its use is a great advantage
in many, but not in all cases.

The heat requires very carefully regulating, but as the iron plate is
of some little size, different degrees of heat may be obtained by moving
the slides to the right or left. The flame of the spirit lamp should not
be immediately under the substance subliming, but a little on one side
of it. He has tried the method of keeping the receiving-glass cool,
by means of blotting-paper constantly wetted, but he could not speak
favorably of it. The great point seemed to him to get the receiving-glass
only a few degrees lower in temperature than the glass from which the
substance is sublimed.

A cold slide should never be placed to receive the sublimate after heat
has been applied. It may be so before, but not after, and for this reason,
that when a cold slide is approached to the subliming substance a por-
tion of it is often attracted by it, possibly by the two glasses being in a
different electrical condition.

A somewhat curious feature is often observed in sublimation by this
process, that many substances in subliming are deposited on the glass
in curved lines, which at first present no crystalline appearance. As
the sublimation proceeds, crystals form at all points of these lines.
Morphia seems to have a tendency to sublime in this way ; he has
obtained sublimates of this alkaloid consisting of nothing but curved
lines, commencing at the segment of a circle, and progressing through
subsequent stages, until a perfect figure 8 is obtained. For some
time he could not but imagine that this was owing to the glass
being imperfectly cleaned, and he accounted for the circular shape
by supposing that the cloth used had become soiled, and that in
the act of wiping circles had been described on the glass. This does
not hold good for two reasons ; first, the circular figures are so small
as to preclude all possibility of their being hand-made ; secondly, that
upon one occasion, when endeavouring specially to guard against this
phenomenon, he took care to wipe the glass from end to end, precisely
the same result ensued.

Many substances yield two sublimates differing, he believes, only in
form and not in composition. The second sublimate will be found as
very thin platy crystals, perfect in shape, with the peculiar feature,
that, instead of being attached to the slide superficially, they are
pendent by a single angle. Owing to their extreme tenuity and their
angular position, they decompose light considerably ; so much so, that
the field of the microscope is often entirely obscured. They may be
removed with facility, by allowing another glass slide to touch them ;
even if this rests upon them, they suffer little damage.

For obtaining larger quantities of sublimates I find that the best
method is to mix with powdered glass, and to sublime from a flat
surface on to a shallow watch-glass. This answers much better
than double watch-glasses; but the process is very precarious and
tedious, and the sublimate is generally contaminated with coloured
matter.

To obtain a sublimate from strychnine a quarter of a grain was

556 Chronicle of Medical Science. \k^r\\,

mixed with five or six times its bulk of powdered glass, and a small
portion of this mixture submitted to heat in the manner described for
arsenious acid. A slide made warm was placed over it, and the whole
left until the sublimed crystals appeared of sufficient size. If the
crystals were small, the slide was returned to its place ; but if they
were crusted or otherwise unsatisfactory, a fresh slide (of course made
warm) was commenced. By this means very perfect and typical crystals
were obtained. Strychnine appears to sublime within a few degrees of
the heat at which it commences to change colour and decompose, as
with very careful treatment the mixture of glass and strychnine turns
brown and the sublimate sometimes appears slightly coloured. When
heated to decomposition, strychnine emits a most suffocating odour,
resembling the smell of asphalte. By operating upon larger quantities
of strychnine, half a grain of sublimate was obtained, and upon sub-
mitting this to the usual tests, the characteristic reactions of strychnine
resulted.

Salicin sublimes with comparative ease in needles, small plates,
and other forms. If the process is continued for an hour and a half or
two hours (being carefully watched that the receiving glass does not
become hot enough to fuse the sublimate), there will be found the
secondary sublimate in thin plates before mentioned.

All the cinchona alkaloids yield sublimates which possess little, if any,
similarity.

Quinine. — By careful manipulation, quinine yields a crystalline subli-
mate. About the tenth of a grain of quinine was mixed with four or
five times its bulk of powdered glass, and heated in the usual way.
The first sublimate was obtained at too great a heat, and when removed
from the fire appeared as a drop of fluid, as it cooled it solidified, and
when examined under the microscope it was distinctly crystalHne. By
more carefully regulating the heat a sublimate in very small granules
was obtained, this was kept in its place for some time, and it gradually
gave way to a crj'^stalline sublimate, which slowly spread over the whole
surface in flowery patterns. Upon leaving it still longer the quinine
began to sublimate in long filaments (I can hardly call them needles),
and wherever a piece of dust formed a nucleus, the sublimate crystal-
lizing round it assumed a more definite shape. When the slide was
removed the sublimed quinine had completely filled the glass ring, and
could be lifted off in a single flake.

Ginchonine may be sublimed very easily and without the least change
of colour. It bears a considerable amount of heat, and sublimes in very
perfect crystals.

JPicrotoxin. — Some difficulty is experienced in obtaining a sublimate
from this substance. It bears a considerable amount of heat, and may
be sublimed without powdered glass. The round granules are first
produced, it being requisite to continue the heat five or six hours before
a crystalline sublimate entirely takes their place.

The alakloids of opium yield crystalline sublimates which bear little
resemblance to one another.

Morphine sublimates readily either with or without powdered glass,
but a slight elevation of temperature causes it to change colour. Mor-

1868.]

Medical Intelligence. 557

phine seems to possess in a great degree the peculiarity of subliming in
curved lines, it being almost impossible to obtain a sublimate which is
wholly free from it. The sublimate crystallizes at all points of these
curved lines, the predominating form being thin plates which polarize
light.

Narcotine sublimes with some little difficulty in regular crystals. He
has exposed narcotine to a heat sufficient to sublime it for three hours
without observing the least trace of decomposition.

Narceine yields a crystalline sublimate with difficulty, the round
granules are first produced ; with very careful manipulation these give
place to needly crystals similar to those deposited from solution.

Codeine may be easily sublimed in regular crystals.

Papaverine sublimes when cautiously heated. He has exposed it to
a heat sufficient to sublime it for nine hours, and the last sublimate
has been as uncoloured as the first. The sublimate consists of perfect
crystals, or when more rapidly sublimed of fan-shaped groups.

Meconin. — A sublimate is obtained with comparative ease, and with-
out the least change of colour. It consists of perfect crystals, and if
too great heat has been used, of round granules, which, on cooling, crys-
tallize in tufts.

Thebavne yields a sublimate with as much ease as morphine or strych-
nine. When heated after melting it increases in colour ; kept in this
condition it sublimes readily.

Piperin, when heated, melts at a comparatively low temperature,
crystallizing again on cooling. It sublimes under favorable circum-
stances in perfect crystals.

Uholesterin. — "When heated, it melts and sublimes in crystals pre-
cisely similar to those deposited from solution ; a few perfect crystals
are obtained, but the general sublimate is in large tabular pieces.

Atropine and Dattirine. — On account of the great similarity between
these two substances, it will be as well to speak of them together.
Atropine is described by Gmeliu as partly volatilizing. Pereira says
that daturine and atropine both melt at 190° F. without losing weight
or undergoing decomposition ; at a higher temperature both are de-
composed. Atropine and daturine present, when submitted to heat,
precisely similar features ; they melt and remain perfectly colourless, and
sublime in perfect crystals ; the two sublimates closely resembling each
other. — Pharmaceutical Journal and TransactionSf'M.SkYch, 1868, p. 409.

MEDICAL INTELLIGENCE.

The subjoined Memorial shows in the clearest manner how strongly the pro-
fession recognise the necessity there is for a thorough and comprehensive exami-
nation, by a competent tribunal, of the vexed subject of quarantine. When we
see the Presidents of the Colleges of Physicians and of Surgeons, the President
of the Medical Council, the medical chiefs of the Army and Navy, and the medical
officer of the Board of Customs, together with such men as Sir James Clark, Sir
Thomas Watson, Sir Ranald Martin, and others of the highest note and experience,
associated with several influential members of the Legislature (including the
Members for Liverpool, Southampton, and Sunderland), urging such an inquiry,
there can be but one opinion as to its desirableness and importance.

82— XLi. 36

558 Chronicle of Medical Science. [April,

From the publication of the great Report of the French Academy of Medicine,
' Sur la Peste et les Quarantaines/ in 1845, which first dissipated most of the old
errors and prejudices respecting the Plague, and pointed out the need of reform
in the modes of ^quarantine then existing, there has been no little discrepancy of
opinion in the profession as to the wisdom or suitableness of the whole system as
it has generally been enforced. The repeated visitations of other forms of pesti-
lence since that date have served to afford abundant opportunities of observing
the effects of its operation in different countries, and of the results which have
been obtained therefrom, both at home and abroad. But, as yet, no endeavour has
been made on the part of any Government to collate and compare this large and
accumulating mass of available evidence for the purpose of determining to what
practical conclusions it should lead in respect of a question which is confessedly
not only of high scientific interest, but also of very great national importance.
The attempt which has been twice made, of recent years, to solve the problem
by means of a costly international conference having not succeeded, it may
reasonably be presumed that the Government of this country, which is unques-
tionably far more concerned in the matter than any other,- will, upon such a
representation as the Memorial sets forth, not hesitate to accede to the petition
that a Royal Commission should be forthwith appointed for the investigation of
this important subject in all its bearings, affecting, as these do, the public health,
commercial and social intercourse, and the interests of our army and navy.

MEMORIAL ON QUARANTINE.

Addressed to the Lord President of the Privy Council.

1. During the last twenty years the subject of quarantine has, on several
occasions, engaged the attention of Government and of the public in this country
and on the Continent.

2. In 1848, on the approach from the East of the second visitation of epidemic
cholera, several of the European governments, as well as our own, refused to
re-adopt the rigorous restrictions which had been imposed on freedom of inter-
course in the first visitation of the pestilence in 1831-2. These had signally
failed as a means of defence, and they had, moreover, inflicted serious inconvenience
and distress, especially upon the poor and working class of the communities.

3. The General Board of Health in this country presented to Parliament in that
year a report recommending the substitution of sanitary precautions in respect of
merchant shipping and of maritime ports, for the ordinary quarantine detention
of infected or suspected arrivals.

4. As much difference of opinion continued to prevail throughout Europe
respecting the necessity for quarantine, as hitherto carried into effect in regard
not only to cholera, but also to yellow fever and the plague, — the three diseases
against which it is specially directed — the French Government, in 1850, proposed
that an international conference should be held for the examination of the subject
by delegates, medical and consular, from all the leading countries of Europe.

5. The conference, which consisted of twenty-four members from twelve of the
chief states of Europe, was held in Paris in 1851, and continued its sittings for
eight months. From the discordance of opinion among the members on various
topics which were discussed, the Conference separated without having arrived at
unanimous conclusions on several very important points, and the British Govern-
ment declined to accede to the report agreed upon by the majority of the
delegates.

6. At the end of 1852, when yellow fever was prevailing in the West Indies,
several of the royal mail steamers suffered from attacks of the disease on the
voyage from St. Thomas to Southampton, and, in some instances, had cases on
board at the time of their arrival. None of the infected vessels were sent to the
" Mother Bank" or were detained in quarantine at Southampton for more than
two or three days. The healthy passengers and crew were permitted to land, and
the sick and convalescent were removed to suitable accommodation on shore. No
detriment to the public health appears to have followed, either in Southampton or
elsewhere.

7. On the occasion of the third European epidemic of cholera in 1854-55,

1868.] Medical Intelligence. 559

quarantine restrictions were almost everywhere suspended in consequence of the
war in Turkey and the Crimea. It remains, therefore, to be ascertained whether
this suspension led to a wider dissemination of the disease, and to a greater
mortality from it in Continental countries.

8. In 1857, in consequence of the outbreak of a malignant fever (which had
existed for many weeks before it was officially declared to be the plague), at
Benghazi, on the north coast of Africa, between Alexandria and Txmis, freedom
of intercommunication throughout the whole of the Mediterranean and the ad-
joining maritime countries was, for more than two months, interrupted by the
quarantine that was generally established. The disease never extended beyond
the Arab district, where it broke out, and it speedily ceased upon the adoption of
simple hygienic measures among the wretched starving population who were
affected.

9. The outbreak of Cholera at Mecca and other places in Arabia in the early
summer of 18t)5, and the subsequent extension of the pestilence, as the season
advanced, to Egypt and thence to Exrope, so strongly impressed the public mind
in many Continental countries that the Emperor of the French deemed it neces-
sary to propose that an international conference should be assembled, with the
special view of determining what measures ought to be adopted to prevent, if
possible, the recurrence of a like calamity. The conference — which consisted of
twenty-four delegates, medical and diplomatic, representing the chief European
states — was held at Constantinople at the beginning of 1866, and continued its
sittings throughout that year.

10. The results of the labours of the conference are embodied in a voluminous
report which has recently been made public. A rigorous and lengthened quaran-
tine is strongly insisted upon as an indispensable measure for the exclusion of the
disease in future ; and, for this purpose, it is recommended that a comprehensive
scheme of lazarets and of health-police be instituted at every large commercial
port in all the maritime countries throughout Europe.

It is manifestly of national importance that the soundness, or otherwise, of these
doctrines be duly investigated, as professional opinion both in this country and
abroad is known to be far from unanimous on the subject.

11. At no former time have quarantine restrictions against epidemic cholera
been carried into effect, in the south of Europe, with such extreme rigour or to
so great an extent, as during the last two years and a half, and there appears to
be at the present time a marked disposition generally to the re-institution of
more stringent external precautions than have, for many years past, been deemed
necessary for the protection of public health.

12. In the course of the winter of 1866-67, and again during the last few
months, restrictive measures have been ordered by the Government in respect of
several of the royal mail steamers, arriving at Southampton from the West Indies,
so much more rigorous than were adopted, under apparently similar circumstances,
in 1852-53, that it is most desirable that the public should be made acquainted
with the nature of the proceedings which are in future to be taken, and with the
reasons for their adoption.

13. During last session of Parliament, it was officially declared in the
House of Commons that quarantine in this country was resorted to not on medical
or public health grounds, but solely on commercial grounds, and to meet the
requirements of foreign Governments ; by

Lord Robert Montague, April 4, 1867.

May 3, „
Mr. Cave May 21, „

14. Much of the uncertainty and obscurity which have always surrounded, and
which still surround, the quarantine question is owing to the want of authentic
evidence as to the working and the results of the system in those places where it
has been most rigorously carried into effect.

15. No committee of either house of the legislature has examined the subject since
1824 ; and there has been no publication of official correspondence relating to it
since 1843-46, with the exception of a short document in 1860 having reference
to the practice of quarantine in Turkey.

560 Chronicle of Medical Science. [April,

16. The detailed evidence respecting the practice of quarantine in Malta and
Gibraltar during 1865 and 1866, contained in the recently-published reports from
the War Office on the visitation of cholera in these colonies, aflbrds a strong
argument as to the necessity for a comprehensive investigation of the whole
subject.

17. No country is so deeply concerned in the right solution of this difficult
question of state medicine as Great Britain with her colonies. Besides the mag-
nitude of her commercial relations with every part of the world, the interests of her
army and navy, scattered as these are over the face of the globe, and liable to be
subjected, by tlie operation of quai'antine regulations, to serious inconveniences in
moving from one place or station to another, demand such an inquiry at the
present time.

18. It is, moreover, confidently believed that the well-considered expression of
opinion by this country, after a searching investigation, could not fail to have
great influence with most Continental States, as well as with all our colonies, and
would eventually lead to the adoption of a more judicious system of defence
against the introduction of foreign disease thau is at present generally relied
upon.

19. In view of the above considerations, it is submitted that it is extremely
desirable, in the interests of the national welfare that a thorough examination of
the subject of quarantine — -in its bearings on public health, commerce, and the
military and naval services — should be made by a Royal Commission, which could
call for and collect evidence from all suitable sources, and after mature delibera-
tion, might thus be enabled to adopt such practical conclusions as would serve for
safe guidance in futui'e.

S. R. Gbaves, M.P.
Thomas Bazley, M.P.

D. McLaren, M.P.
Russell Gubney, M.P.
Thomas Chambers, M.P.
John Candlish, M.P.

H. W. AOLAND, M.D., F.R.S., Regius Prof, of Med., Oxford.

James Aldeeson, M.D., F.R.S., President of R. Coll. Physicians.

A. Bryson, M.D., C.B., F.R.S., Director-Gen. Navy Med. Department.

G. Burrows, M.D., F.R.S., Presidens of the Medical Council.

James Clark, Bart., M.D., F.R.S., Physician in Ordin. to the Queen.

Walter Dickson, M.D., R.N., Med. Inspector to Board of Customs.

William Farr, M.D., D.C.L., F.R.S., General Register Department.

Douglas Galton, Capt., F.R.S., Ass. Under Sec. of State, War Dept.

John Hilton, F.R.S., President R. Coll. Surgeons.

William Jenneb, Bart., M.D., F.R.S., Physician to the Queen; Pres.

Epidem. Soc.
T. G. Logan, M.D., C.B., Director-Gen. Army Med. Department.
J. R. Martin, C.B., F.R.S., Phys. to Secretary of State for India.
Gavin Milhoy, M.D., Med. Commiss. in Jamaica, 1851, and in Crimea, 1855-6.

E. A. Parkes, M.D., F.R.S., Prof, of Hygiene, R. Victoria Hospital.
R. Partridge, P.R.S., Ex-President R. Coll. Surgeons.

J. Sutherland, M.D., War Office, Mem. of Internat. Conf. on Quar., 1851.

A. Tweedie, M.D., F.R.S., Consult. Phys. Fever Hospital.

T. Watson, Bart., M.D., D.C.L., F.R.S., Ex. President R. Coll. Physicians.

A deputation, consisting of the President of the Collegeof Physicians, theDirector-
General of the Medical Department of the Navy, Sir William Jenner, Drs. Tweedie,
Dickenson, and Milroy. had an interview, on the 17th inst. (March), with the Duke
of Marlborough at the Privy Council Office. Lord Robert Montague was also pre-
sent. After listening attentively to the reasons [set forth in the Memorial] alleged by
the members of the deputation, viz., the great discrepancy of opinion and practice
on the subject in this country and abroad, the unsatisfactory issue of the two inter-
national conferences held at Paris in 1851, and at Constantinople in 1866, and the
magnitude of the public interests which now suffer from the unsettled state of
things — his Grace stated that the question of quarantine in reference to the

1868.]

Books f S^c.y received for Review.

561

Royal Mail steamers which suffer from yellow fever on the voyage from the West
Indies has recently been under the consideration of the Privy Council, and that
steps were at the present time being taken to obtain evidence which might guide
the Government in respect of the measures to be hereafter adopted. If such
evidence should not be found sufficient, then he was very much of the opinion of
the deputation, that the whole subject should be examined into by a Royal Com-
mission. The duke also alluded to the extreme difficulty of arriving at any general
agreement among the different European governments as to the nature and extent
of the quarantines to be imposed, and mentioned Spain in particular as a country
which stood much in the way of any relaxation being effected. The deputation
informed him that it was for this very reason that they sought to make the pro-
posed inquiry rather a national than an international one, and that paragraph 18
of the Memorial had been framed with this object, the nonsuccess of the two
Conferences at Paris and Constantinople having shown that it is in vain at present
to look for concordance of sentiment on many points of practice among some of
the nations of Europe.

ROOKS, PAMPHLETS, &c., RECEIVED FOR REVIEW.

Plastics : a New Classification and a
Brief Exposition of Plastic Surgery. By
D. Prince, M.D. Philadelphia, Lindsay
and Blakiston, 1868. pp. 93.

On Spinal AVeakness and Spinal Curva-
tures ; their Early Recognition and Treat-
ment. By W. J. Little, M.D., Late
Senior Phj'sician and Lecturer at the
London Hospital. London, Longmans.
1868. pp. 121.

Catalogue of the Surgical Section of the
United States Army Medical Museum.
Prepared under the Direction of the
Surgeon-General, U.S. Army. By A. A.
Woodhull, Assistant- Surgeon, &c. 1866.

Neligan's Medicines; their Uses and
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Royal College of Surgeons, Ireland.
Seventh Edition. 1867. Dublin, Edin-
burgh, and London, pp. 934.

First Step in Chemistry. A New Me-
thod of Teaching the Elements of the
Science. By E. Galloway, F.C.S. Fourth
Edition. London, Churchill and Sons.
1868. pp. 477.

■The Co-existence of Two Species of
Inflammation, with Special Reference to
the Forms of Pneumonia. By W. Addison,
M.D., F.R.S. London, Churchill and
Sons. Pamphlet.

On Ovarian Dropsy ; its Nature, Dia-
gnosis, and Treatment. By I. Baker
Brown, F.R.C.S. Second Edition. London,
Hardwicke. 1868. pp. 280.

On certain Moral Aspects of Money-
Getting. Bv W. T. Gairdner, M.D.
Glasgow. 1868. Pamphlet.

Synopsis of the Pathological Series in
the Oxford Museum, provisionally ar-
ranged for the Use of Students, after the
Plan of the Hunterian Museum, &c.
Oxford, Clarendon Press. 1867. pp.
61.

Observations on the Nature and Treat-
ment of Polypus of the Ear. By E. H.

Clarke, M.D. Boston, Ticknor and Fields,
1868. pp. 71.

An Epitome of the Venereal Diseases,
&c. By A. Bruce, F.E.C.S., &c. London,
Lewis. Pamphlet.

Stone in the Bladder, with Special Re-
ference to its Prevention, Early Symp-
toms, and Treatment by Lithotrity. By
W. J. Coulson, F.R.C.S., Surgeon to the
Lock Hospital, &c. London, Churchill and
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Guinea "Worm, or Dracunoulus; its
Symptoms and Progress, &c. By J. A. B.
Horton, M.D., &c. London, Churchill
and Sons. 1868. Pamphlet.

Transactions of the Ethnological Socusty
of London. Vol. VI. New Series. 1868.
pp. 364.

Mechanical Therapeutics, a. Practical
Treatise on Surgical Apparatus, Appliances,
and Elementarv Operations, &c. By
P. S. Wales, Sl.D., and Surgeon U.S.
Navy. Philadelphia, Lea. 1867. pp.
685.

Pennsylvania Hospital Reports. Vol. I,
1868. Philadelphia, Lindsay and Blakis-
ton. pp. 420.

A System of Medicine. Edited by J. R.
Reynolds, M.D. Vol. II, containing Local
Diseases. London, Macmillan and Co.
1868. pp- 990.

The Diseases of the Prostate ; their
Pathology and Treatment, &c. By Sir
H. Thompson, F.R.C.S. Third Edition.
London, Churchill and Sons. pp. 364.

Researches in Obstetrics. By J. M.
Duncan, M.D., &c. Edinburgh, Black,
1868. pp. 467.

Statistical Abstract of the Health of the
Navy for the Year 1866-67.

Proposal to Stamp out Smallpox atjd
other Contagious Diseases. By Sir J. T.
Simpson, Bart., M.D., &c. Edinburgh.
Pamphlet.

The Natural and Morbid Changes of the
Human Eye, and their Treatment. By

563

Books, 8^c., received for Review. [April, 1868.

C. Bader, Ophthalmic Assistant-Surgeon
to Guy's Hospital. London. Triibner.
1868. pp. 505.

Plates Illustrating the Natural and
Morbid Changes of the Human Eye. By
the same.

Pathological Anatomy of the Female
Sexual Organs. By B. J. Klob, M.D.,
Professor at the University of Vienna.
Translated by J. Kammerezt, M.D., and

B. F. Dawson, M.D. New York. 1868.
pp. 299.

Obstetric Clinic : a Practical Contri-
bution to the Study of Obstetrics and the
Diseases of Women and Children. By
G. T. Elliot, jun., M.D., New York.
Appleton and Company. 1868. pp. 458.

Reports of Hospital Cases : on a Case of
Injury to the Spine in the Cervical Region.
By W. Macnamara, M.D. Pamphlet.
Reprint from ' Dublin Quarterly Journal,'
November, 1867.

The Climate of Worthing, &c. By
W. G. Barker, M.B. Second Edition,
Churchill and Sons. 1867. pp. 95.

Corporal Punishment in the Public
Schools. Pamphlet. ByM. Wyman, M.D.
Cambridge, U.S. America.

Review of the History of Medicine. By
T. A. Wise, M.D., &c. Vols. I and II,
London, Edinburgh, and Calcutta, pp.
397.

The First Principles of Modern Che-
mistry. By U. J. Kay-Shuttleworth.
London, Churchill and Sons. 1868. pp.
214.

The Surgery of the Rectum ; being the
Lettsomian Lectures on Surgery before the
Medical Society of London, 18'65. By H.
Smith, F.R.C.S. Second Edition. London,
Churchill and Sons, 1868. pp.152.

The Half Yearly Abstract of the Medical
Sciences. July to December, 1867.

On the Diagnosis and Treatment of the
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lation to the Pathological Origin of the
different Forms of Indigestion. By
Wilson Fox, F.R.C.P. Second Edition.
London, Macmillan and Co. 1867. pp.
247.

A Practical Treatise on the Diseases of
Children. By D. F. Condie, M.D. Sixth
Edition. Philadelphia, Lea. 1868, pp.
783.

Report of Cases of Insanity Treated at
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M.D. No. 6. Pamphlet.

Chemical Notes for the Lecture Room
on Heat, Laws of Chemical Combination,
&c. By T. Wood, Ph. D., F.C.S., Chemi-
cal Lecturer at the Brighton College.
Second Edition. London, Longmans,
Green, and Co. 1868. pp. 116.

Vaccination ; its Tested Effects on
Health, Mortalitv, and Population. By

C. T. Pearce, M.D. Bailliere, 1868. pp.
120.

Vaccination Impartially Reviewed. By

F. E. Jencken, M.D. London, Churchill
and Sons. Pamphlet.

Lectures on the Theory and Practice of
the Ophthalmoscope. By H. Wilson,
F.R.C.S., Assistant-Surgeon to St. Mark's
Ophthalmic Hospital, Dublin. Dublin
and London. 1868. pp. 148.

Care and Treatment of the Insane Poor,
with Special Reference to the Insane in
Private Dwellings. By A. Mitchell, M.D.,
&c., Deputy Commissioner in Lunacy for
Scotland. Edinburgh, Oliver and Boyd.
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Southam on the Spontaneous Fracture
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let.

Annual Abstract of Therapeutics, Ma-
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for 1867. By A. Bouchardat. Translated
by M. J. De Rocet, M.D. Philadelphia,
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Dell 'Azione del Dolore sulla Respira-
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Traite des Maladies Infectieuses. Par
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Archives de Physiologie Normale et
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Die Optischen Fehlen d. Auges mitihren
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Sulla Diffusione d. Tisichezza Polrao-
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1867. pp. 150.

Reports, Journals, Reviews, Sec.

American Journal of the Medical
Sciences. January, 1868.

Dublin Quarterly Journal of Medical
Science. February, 1868.

Edinburgh Medical Journal, 1868. Jan-
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New York Medical Journal. Nos. 33,
34, 35.

Annual Report of the Surgeon-General,
United States Army. 1867. Pamphlet.

Third Annual Report of the Glamorgan
Lunatic Asylum, Bridgend, for 1867.

The Indian Annals of Medical Science,
January, 1868, No. 23. London and Cal-
cutta.

Report of the Liinehouse District Medical
Officer of Health, for the year ending Lady-
day, 1867.

INDEX TO VOL. XLI.

O THE

BRITISH AND FOREIGN MEDIC 0-CHIRURGICAL REVIEW.

Acholic diseases, on . . . 427
Adams on ligature for aneurysm . 118
-(Esthetic medicine, on . . . 430
Albuminuria, works on . . . 323
Alcohol in children's diseases . 525
Alkaloids, Guy on . . . 256

Sedgwick on . . 260

AUbutt and Teale on ophthalmo-
scope 126

Alpine climate, on . . . 531
Amaurosis, on ... . 126
American war, medical history of

the 153

Amyloid degeneration, on . . 120
Aneurysm, Adams, J., on . . 118

abdominal . . . 121

Aneurysms of heart, on . . 280

treatment of . . 116

Asphyxia, Schleisner on . . 416
Axillary artery, rupture of . . 110

Baines, Mrs., on infanticide . . 382
Baker on cancer inheritance . 113

Balkowki on spinal cord . . 243
Barnes' obstetric chronicle . 267, 545

obstetrical operations . 270

Beale, Lionel on sarcolemma . 91

Beatty on midwifery, &c. . . 285
Beaufort on bromide of potassium 252
Begbie, J., on bromide of potassium 249
Belladonna poisoning . . . 120
Belot on yellow fever . . . 358
Beneke on the new-born infant . 274
Bernutz and Goupil on diseases of

women . . . . .49
Besmer on iodine injections . . 529
Birnbaum on labour . . . 270
Bischoff on nerves . . . 253
Blood-globule measurement . . 235
Blood-corpuscles, Gulliver on . 275
Blood-movement on . . . 235
Blood in muscular work, on . . 161
Boisseau ou pyopneumothorax . 536
Bouchut on ophthalmoscope 126, 533
Boiiisson on lithotomy . . . 514

PAGE
Bonnefon on bromide and iodide

of potassium .... 248
Bromide and iodide of potassium,

on 248, 249

Bronchiectasis, G. Stewart on . 537
Brown, G., on belladonna poisoning 120
Brown on bromide of potassium . 251
Bryant on ovariotomy , . . 285
Bursse, enlarged, on , . . 110
Bryce on labour .... 270
Byford on women's diseases . . 285
Byrne on abortion . . . 268

Caesarian section, Greenhalgh on . 274
Callender on stricture of urethra . 117

on rupture of the axillary

artery ..... Ill
Carbuncle, treatment of , . 250
Carcinoma, symmetrical, on . . 124
Cancer inheritance, on . .113

Carbolic acid in porrigo favosa . 524
Carter on knee-joint suppuration . 121
Catlow on aesthetic medicine . 430
Cells of small intestine, on . . 237
Cephalotribe, Chiara on . . 271
Cephalotripsy, Kidd (G. H.), on . 285
Cerebral haemorrhage, on . . 122
Chatto's surgical report . . 507
Chiara on cephalotrispy . . 270
Chloroform, death from . . 266

Cholera, Milroy on . . . 167

venous injections in . . 120

Chorea, Ogle on . , . 208, 465

and rheumatism, Roger on 539

Christy on acute atrophy of liver , 546
Ciliary movement on , . . 243
Cinchona alkaloids, on . . . 523
Cancroid tumours, on . . . 541
Clement on hoematinoptysis . . 281
Cobbold on trichina spiralis . . 543
Coccodynia, operation for . . 267
Colchicia, Maisch on . . . 266
Contractile tissues, works on . 91
Colloid substances, Eansome on . 421
Consanguinity, marriages of . 122

564

INDEX TO VOL. XLI.

PAGE

Coote on joint disease . . . 113

H., on talipes equinus . 112

Cornea, epithelium of the . . 282
Corpora amylacea of lungs . . 280
Curgenven on infant life . . 382
Curling on gastrotomy . . . 121
Cutaneous diseases, on . . . 163
Cystic tumours, Smith, T., on . 108
Cysts, intra-cranial, containing
hair 109

Daly on abdominal aneurysm . 121
Davidsonon jaundice in pregnancy 545
Deglutition, Moura on
Delagarde's surgical cases .
Delirium tremens, on .
Demarquay on use of iodoform
Diabetes, Fraser, on
Dickinson on albuminuria .
Dien on spermatic fluid
Diphtheria, on . . .
Donders' ophthalmic reports

on psychical processes

on food •

Down on idiots . . . .
on marriages of consan-
guinity . . . _ . .
Dubois on chloroform poisoning .
Duchenne on paralysie myosclero-

245
115
123
247
119
223
279
108
1
155
159
123

122
266

sique ....
Duckworth on oxaluria
Duncan, M., on labour .

on inverted uterus

. on uterine metrology 268

. — on fecundity, &c .285

534
114
270
550

Ear, haemorrhage from
Earth sewage. Hare on
Eberth on muscular tissue
on myxoma

115
265

91
268
342
116

91
117

Echinococci, Finsen on
Eck on treatment of aneurysm
Eckhard on muscular tissue .
Edwards on palpation

on mercuric methide

poisoning ....

Engelken on the spinal cord
Epispastics, on .
Epithelial tumours, on .
Epithelium, Schalygen on .
Eucalyptus globulus as a febrifuge 250
Extra-uterine foetation,operation in 124

116
243
522

541

282

Farm physiology . . . 161

Farre on pericarditis . . . 114
Fayrer on clinical surgery . . 64
Fecundity, Duncan on . . 285

Fergusson on anatomy and surgery 412
Finsen on echinococci . . . 342

PAGE

Flint on principles of medicine . 436
Food absorption, on . , . 237

■ Donders, on . . . 159

Forensic medicine, chronicle of . 552
Fox, W., on muscular tissue . 91
C. M.. on climate of Scar-
borough ..... 164
France, climatology of . . .34
Frankenhauser on uterine nerves . 545
Fraser,Dr., on belladonna poisoning 120

on carcinoma . . . 124

on diabetes . • .119

on delirium tremens . . 123

Friedreich on corpora amylacea .' 280

Galezowski on the ophthalmoscope 126

Gastritis phlegmonosa, on
Gastrotomy, Curling on
Geissler on injuries of eye
Germinal matter, on
Gingeot on alcohol treatment

on labour

on vagina absence

Gouty phlebitis, on
Guanara, Mantegazza on
Gulliver on blood-corpuscles
Gunshot wounds, on
Guy on alkaloids
Guy's Hospital Reports

540
121
1
429
525
270
267
110
154
275
509
256
865

Hsematinoptysis, on . . . 281
Hsematoidin, Holm on . . 235

Hsemorrhagic diathesis, case of . 247
Hare on earth sewage . . . 265
Harley (G.) on albuminuria, &c. . 323
Hausmann on decidua menstrualis 545
Heart, Obermeier on . . . 278
Heaton on muscular work . .161
Hernia, Langton on . . .112
Herpes, Hutchinson on . . 119

Herpes zoster, Moore W. on, . . 536
Hewitt (G.) on diseases of women 285
Hitzig, on tabes dorsalis . . 535
Holden on hemorrhage from ear . 115

on medical and surgical

landmarks .... 116

Holm on Hsematoidin . . . 235
Hospital Reports — St. Bartholo-
mew's and London Hospitals . 107
Huber on paralysis . . . 534
Hunter on strychnia injections . 445
Hutchinson on nerve-section . 124

on spine injuries and

diseases ..... 124

on herpes . . . 119

Hydi'ochlorate of ammonia, on . 252

Idiots, classification of
Indian clinical surgery

123
46

INDEX TO VOL. XLI.

565

PAOE
Infanticide, Baines (Mrs.) on . 382

Liddell on . . 266

Infant life, Curgenven on . . 382
Iodoform, a case of . . . 247
Iodine in air and food . . . 527
Iodine injections, on . . . 529
Irish Poor Law Report . . 349
Jaccoud on albuminuria . . 323
Jackson (H.) on ophthalmoscope . 126
on cerebral haemor-
rhage ..... 122

on optic thalamus . 124

Jacobson on blood-movements . 235
Jarjavey on dislocated tendons . 508
Jassinsky on placenta . . . 258
Joint disease, on ... 113

Jones (W, H.) on labour . . 285
Junor on tetanus .... 251
Kauifmaun on puerperal fever . 550
Keaton on muscular work . . 161
Kennedy on pregnancy . . 268

Kidd (G. H.) on cephalotripsy . 285

on coccodynia . . . 267

Kidney, Southey on . . . 107
Knee-joint, on excision of . . 515

suppuration of, on . 121

Labour works, on . . 270, 547

Lancereaux on amauroses . . 126
Langton on hernia . . . 112
Lawson on injuries of eye, &c. . 1
Lazzati on labour . . . 270

Lead colic, Margueritte on . . 521
Leavitt on carbuncle . . . 250
Lemaire on miasmata . . . 279
Letheby on spectrum analysis . 118
Letzerich on food absorption . 237

Liddell on infanticide . . . 266
Lithotomy, on ... . 514
Lithotrity syringe, on a . . 121
Little on venous injections in cholera 120
Liver, acute atrophy of . . 540
Lowenhardt on asphyxia . . 274
McCarthy on extra-uterine fcetation 124
Macleod, on acholic diseases , . 427
Macnamara on eye diseases . . 2
Maisch on colchicia . . . 266
Mantegazza on guanara . . 154

surement ....

. 235

Marme on thallium

. 254

Marrotte on hydrochlorate

of

ammonia ....

. 252

Marsh on joint diseases

. 113

Martin on labour

. 270

(C.) on obstetrics

. 547

Materia- medica, report on .

. 247

Maudsley on the mind

. 388

Maunder*8 clinical lectures .

. 119

lithotrity syringe .

. 121

PAGE

Meigs on obstetrics . . . 285

Mercuric methide, poisoning by .116

Meteorology, works on . . . 1 64

Meyer on ophthalmia . . . 512

Miasmata, Lemaire on . . . 279

Micrology, chronicle of. . . 275
Microscopic detection of alkaloids 260

Micro-sublimates, on . . . 552

Midwifery, report on . . . 545

Miller on suppression of urine . 550

Milroy on cholera . . . 167

Mind, Maudsley on . . . 388

Moore on herpes zoster . . 536
Mooren's ophthalmic observations 1

Morris on germinal matter . . 429

Motor nerves, Trinchese on . . 276

Moura on deglutition . . . 245

Myopia, congenital, on . . . Ill

Nadler on iodine .... 627

Naumann on epispastics . . 522

Navy, health of . . . . 304
Nerves of uterus .... 545

— — ■ — ■ section of, on . . .124

Newman on diphtheria _ . . 108

Nicholson (T.) on yellow fever . 358

Nux vomica in dysentery . . 532

Obermeier on fibres of heart . 278

Obstetrics, works on . . . 285

Obstetric chronicle, Barnes' . . 267
Ogle's cases of chorea . . 208, 465

on the ophthalmoscope . . 126

Ogston on sudden death . . 454

Ophthalmia, Meyer on . . 512

Ophthalmic Hospital reports . 1

surgery, works on . 1

Ophthalmology, medical, on . • . 126

works on . . 127

Ophthalmoscope in meningitis . 533

Ovariotomy, Bryant on . , 255

Ovaries, carcinoma of . . . 547

Oxaluria, Duckworth on . .114

Oxford Pathological Museum . 440

Palpation in lung disease . .117

Paralysie myosclerosique . . 534

Pearse's notes on health . . 424

Pellagra, Typaldos on . . .30

Pelvet on cardiac aneurysm . . 280

Pericarditis, on opium in . . 114

Peroxide of hydiogen, on . . 528

Pestel on phosphorous poisoning , 262
Pharmacopoeia, companion to the . 166

Phlebitis, Paget on . . .110

Phosphorus-poisoning . . . 262

Phthisis, vapour bath in . . 253

Physiology, Powers' chronicle of . 235

Poisons, micro-chemistry of . . 317

Porrigo favosa, Prior on . . 524

Power's Physiological Chronicle . 235

566

INDEX TO VOL. XLI.

PAGE

Power on diseases of tlie eye . 1

Pregnancy, works on . . . 168

Psychical processes. Bonders on .155

Psychological medicine, on . . 388

Puerperal state, works on . . 550

fever, contagion of .550

Pyaemia, Savory on . . .109

Pyopneumothorax, on . . . 536

Quarantine, memorial to Privy
Council on ... • 557

Ramsbotham on obstetrics . . 285
Ransome on Colloid substances . 421
Ranvier and Cornil on cancroid 541
Richardson's chronicle of forensic
medicine .... 254, 552

Ritter on pregnancy .
Rodolfi on gunshot wounds
Roger on chorea
Rouget on contractile tissues
Rumsey on state medicine
Russell on hemiplegia .

268
502
539
91
162
127

Sachs on intestinal cells . . 237
Salisbury on syphilitic disease . 542
Salter and Stephens on live stock 161
Savigny on dysentery . . . 532
Savory on phlebitis, &c. . . 109

on enlarged bursse . . 110

Scharley on rickets . . .557
Schiff on vomiting . . . 237
Schleisner on asphyxia, &c. . . 416
Schnorr on inverted uterus . . 550
Sedgwick on alkaloids . . . 260
Semple's chronicles of materia

medica, &c. . • • 247, 521
Sigmund on syphilis . ... 507
Simon on gunshot wounds . . 589
Smith (T.) on cystic tumour . 108

Solomon (V.) on glaucoma, &c. . 1

strabismus . . 1

Southey on pathology of kidney . 107
Spectrum analysis, on . . . 118
Spence on strychnia . . . 159

Spermatic fluid of aged, on . . 279
Spinal cord, on sensibility of . 243

Spine, on injuries of . . . 124
Squire's ' Companion to the Phar-

macopceia' .... 166
State medicine, Rumsey on . . 162
Statistics of St. Bartholomew's

Hospital . . . .117
Steele on forceps in labour . . 270
Stewart (G.) on amyloid degene-
ration ..... 201

on bronchiectasis . 537

gastritis phlegmonosa 540

Stieda on the eyelids . . . 277

PAGE

Stohr on peroxides of hydrogen . 528
Streatfeild's chronicle of micrology 275

Strychnia injections, on . . 445

Spence on . . . 159

Stuart on ciliary movement . . 243

Sudden death of infants, on . 454
Sudoriparous and lympathic 521

systems, on ... . 422
Sulphur in lead colic .

Surgery, report on . . . 507

Surgical cases, Delagarde's . . 115

Swayne's obstetric aphorisms . 285

Syphilis, origin of . . . 542

Hutchinson on . . 125

Sigmund on . . . 507

Tabes dorsalis, on
Talipes equinus, on
Tendons, on dislocation of .
Tetanus, tobacco in
Thallium, Marme on
Thermometer in disease
Trichina spiralis, on
Trinchese on motor nerves .
Trousseau's clinical lectures .
Trousseau on the vapour bath

phthisis ....
Tumours, Virchow on .
Turner on hair-containing cysts
Turning, Merton on
Typaldos on pellagra

. 535
. 112
. 508
. 251
. 254
. 109
. 543
. 276
. 151
n

. 253
. 70
. 109
. 547
. 30

. 116

. 285

. 267
. 34
. Ill
. 70
. 237

Waddington on micro-sublimation 552
Wallichs on pregnancy . . 268

Warter on tliermometer in disease 109
Watson on excision of the knee-joint 515
Weber, H., on Alpine climate . 531
Wenzel on cinchona . . . 523
Willis, R., on sudoriparous system,

&c. ..... 422

Williams on ophthalmic science . 1
Wilson, J. G., on labour . . 270
Winkel on labour . . • 270

Women's diseases, Bernutz and

Goupil, on .... 49

Wormley's micro-chemistry of

poisons . . • • . oi-t
Wright, H. G., on uterine disorders 285

Yellow fever, on . . • • 358

Urethra, stricture of, on
Uterine disorders, Wright on

Vagina, absence of
Valcourt on Climatology
Vernon on myopia
Virchow on Tumours .
Vomiting, Schiff on

END OF VOL. XLI.