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3  THE 

BRITISH  AND  FOREIGN 

"I 

MEDICO-CHIEUEGICAL 
REVIEW 

OE 

QUARTERLY    JOURNAL 

OP 

PRACTICAL  MEDICINE  AND  SURGERY. 


/ 


VOL.  XLIX. 

JANrAET— APEIL,    1872. 

l1^ 


LONDON: 

J.   &   A.   CHIJECHILL,  ]SEW   BUELINGTON  STEEET. 

MDCCCLXXII. 


h 


PlUiXTED  BY 
J.    E.    ADLARD,    BARTHOLOMEW    CLOSE,    E.C. 


^r^' 

^  ^ 


CONTENTS  OF  No.  XCTII 

OF  THB 

BRITISH  AND  FOREIGN 
MEDICO-CHIRURGICAL    REVIEW, 

JANUAET,  1872. 


analytical  ants  (Erittcal  l^ebietos. 

PAGE 
Rev.    . — 1.  The  Local  Governmeut  Board  Act,  1871   .  .  .  .1 

2.  A  Bill  to  consolidate  and  amend  the  Law  relating  to  Public  Health 
and  Local  Government  in  England  and  Wales,  except  the  Metropolis. 
Ordered  by  the  House  of  Commons  to  be  printed,  25th  July,  1871        .     ib. 

3.  Report  of  the  Joint  Committee  on  State  Medicine  of  the  British 
Medical  and  Social  Science  Associations  on  the  Report  of  the  Royal 
Sanitary  Commission.     London,  1871  .  .  .  .     ib. 

4.  The  Recommendations  of  the  Royal  Sanitary  Commission.  Extract 
from  an  Address  at  the  Social  Science  Congress  in  Leeds.  By  G.  W. 
Hastings,  LL.D,,  President  of  the  Council.     1871      .  .  .     ib. 

5.  An  Address  on  Public  Health  and  its  modern  requirements.  By  G. 
Godwin,  F.R.S.,  President  of  the  Health  Department  of  the  Social 
Science  Association.     1871         .  .  .  .  .  .     ib. 

6.  An  Address  by  A.  P.  Stewaet,  M.D.,  F.R.C.P.,  President  of  the 
Section  of  Public  Medicine  at  the  British  Medical  Congress  in  Ply- 
mouth.    1871    .  .  .  .  .  .  .  .     ib. 

7.  Report  of  the  Association  of  Certifying  Medical  Officers  of  Great  Bri- 
tain and  Ireland.   Newcastle-under-Lyrae,  1870  .         .         .         .     ib. 

Ret.  II. — Lectures  on  Surgery.  By  James  Spence,  F.R.S.E.,  Surgeon  to 
the  Queen  in  Scotland,  Professor  of  Surgerv  in  the  University  of  Edin- 
burgh, &c.,  &c.     Parts  III  and  IV.     Edinburgh,  1871         ...     IS 

Rev.  III. — The  West  Riding  Lunatic  Asylum  Medical  Reports.     Edited  by  J. 

Crichton  Browne,  M.D.,  F.R.S.E.     Vol.  i,  1871       .  .  .25 

Rev.  IV. — A  Manual  of  Medical  Jurisprudence  for  India,  including  an 
Outline  of  a  History  of  Crime  against  the  Person  in  India.  By 
Norman  Chevers,  M.D.,  Surgeon- Major  H.M.  Bengal  Army, 
Principal  of  the  Calcutta  Medical  College,  &c.  Calcutta,  1870.  Pp. 
xix  and  861        .  .  .  .  .  .  .  .46 

Rev.  V. — 1.  Physical  Degeneracy.     By  Nathan  Allen,  M.D.     New  York, 

1870 62 

2.  The  Intermarriage  of  Relations.  By  Nathan  Allen,  M.D.  New 
York,  1869 ib. 

3.  Population ;  its  Law  of  Increase.  By  Nathan  Allen,  M.D.  Lowell, 
Mass.,  1870        .  .  .  .  .  .  .  .     ib. 

4.  The  Physiological  Laws  of  Human  Increase.  By  Nathan  Allen,  M.D. 
Philadelphia,  1870  .  .  .  .  .  .  .     ib. 

5.  On  Genealogy  in  Connection  with  Anthropology.  By  G.  M.  Maeshall, 
L.L.M.     London,  1865  .  .  .  .  .  ,     ib. 

6.  Blood-Relationship  in  Marriage  considered  in  its  influence  upon  the 
Offspring.     By  Arthtje  Mitchell,  M.A.,  M.D.     London,  1866  .     ib. 

§ 


ii  CONTENTS   OF   NO.   XCVII. 

PAGE 

7.  Inquiry  into  Consanguineous  Marriages  and  Pure  Races.  By  Dr.  E. 
Dally.  Paris,  18G3.  Translated  by  H.  J.  C.  Beavan,  F.R.G.S.  'An- 
thropological Review,'  May,  18G4  .  .  •  •  .02 

8.  Sur  les  Dangers  des  Unions  Consangmnes.  Par  Dr.  Boudin. 
Paris,  18G3         ........     ib. 

9.  Un  Mot  sur  les  Mariages  Consanguins.  Par  Dr.  E.  Dally. 
Paris,  1863 •  •  •     'b. 

10.  On  the  Stature  and  Bulk  of  Man  in  the  British  Isles.  By  John  Beddoe, 
M.D.     London,  1870     .  .  .  .  .  •  •     ib. 

11.  Influence  of  the  Climate  of  North  America  on  the  Physical  and  Psy- 
chical Constitution.  By  E.  Desoe.  '  Centralblatt  fiir  Naturgeschichte 
und  Anthropologic,'  1803  .  .  .  .  .  .     ib. 

12.  Hybridity  in  the  Genus  Homo.     By  Dr.  Paul  Beoca.     Translated  by 

C.  Caetee  Blake,  Doct.  Sci.     London,  1804    .  .  .  .     ib. 

Rev.  VI. — Selected  Obstetrical  and  Gynaecological  Works  of  Sir  James 
Y.  Simpson,  Bart.,  M.D.,  D.C.L.,  late  Professor  of  Midwifery  in  the 
University  of  Edinburgh.  Edited  by  J.  Watt  Black,  M.A.,  M.D. 
Edinburgh,  1871 73 

Ret.  VII. — The  Deformities  of  the  Human  Body :  a  System  of  Ortho- 
pa3dic  Surgery.  Being  a  Course  of  Lectures  delivered  at  St.  George's 
Hospital.  By  Beenaed  E.  Beodhtjest,  F.R.C.S.  London.  Large 
8vo.    Pp.259 87 

Rev.  VIII. — Die   Blutkrystalle.   Untersuchungen.     Von  W.  Peeyee.     Mit 

drei  farbigen  Tafeln.     Jena,  1871.     8vo.     Pp.  203      .  .  .90 

Rev.  IX. — Practical  Lithotomy  and  Litbotrity ;  or,  an  Inquiry  into  the  best 
modes  of  Removing  Stone  from  the  Bladder.  By  Sir  Heney  Thompson, 
Surgeon-Extraordinary  to  H.M.  the  King  of  the  Belgians  ;  Professor 
of  Clinical  Surgery  and  Surgeon  to  University  College  Hospital. 
Second  edition  .......  100 

Rev.  X. — Studi  Clinici  ed  Esperimentali  sulla  Pellagra.  Del  Dott.  Cesaeb 
LoMBEOSO.  Memoria  Premiata  dal  R.  Instituto  Lombardo.  Bo- 
logna, 1871 113 

Clinical  and  Experimental  Observations  on  the  Pellagra.  By  Dr. 
Cesaee  Lombeoso.  a  Prize  Essay  of  the  Royal  Institution  of  Lom- 
bardy.     1871      .  .  .  .  .  .  .  .     ib. 

Rev.  XI. — 1.  Neuralgia,  and  the  Diseases  that  resemble  it.     By  F.  E.  Anstie, 

M.D.,  &c.     London  and  New  York         .  .  .  .  .117 

2.  Lehrbuch  d.  functionellen  Nervenkrankheiten.  Von  Dr.  Albeet 
EuLENBTJEa.     Berlin    .  .  .  .  .  .  .     ib. 


Aet.  I. — Notes  on  Comparative  Anatomy  :  a  Syllabus  of  a  Course  of  Lectures 
delivered  at  St.  Thomas's  Hospital.  By  William  Millee  Oed,  M.B,, 
M.R.C.P.     London,  1871  .  .  .  .  .  .133 

Aet.  II. — 1.  General  Outline  of  the  Organisation  of  the  Animal  Kingdom, 
and  Manual  of  Comparative  Anatomy.  By  Thomas  Rymee  Jones, 
F.R.S,,  &c.     Fourth  edition,  illustrated  by  571  engravings.     London, 

1871.     Pp.88e '.  .135 

2.  Advanced  Text-book  of  Zoology  for  the  Use  of  Schools.  By  H, 
Alleyne  Nicholson,  M.D.,  &c.  Edinburgh  and  London,  1870. 
Pp.  340  ........     ib. 

Aet.  III. — Animal  Plagues;  their  History,  Nature,  and  Prevention.  By 
Geoege  Fleming,  F.R.G.S.,  &c..  President  of  the  Central  Veterinary 
Medical  Society.     London,  1870  .....  136 


CONTENTS    OF   NO.  XCVII.  •    111 

PAGE 

Aet.  IV. — Introdnctory  Text-book  of  Meteorology.  By  Alexander  Bitchan, 
M.A.,  F.R.S.E.,  Secretary  of  the  Scottish  Meteorological  Society;  Pre- 
sident of  the  Botanical  Society  of  Edinburgh ;  and  Honorary  Member 
of  the  Austrian  Meteorological  Society.  Edinburgh  and  London,  1871. 
Octavo,  pp.  218.     With  illustrations  and  tinted  plates  .  .  139 

_j^jjx.  V. — llesources  of  the  Southern  Fields  and  Forests,  Medical,  Econo- 
mical, and  Agricultural;  being  also  a  Medical  Botany  of  the  Southern 
States,  with  practical  information  on  the  useful  properties  of 
tile  Trees,  Plants,  and  Shrubs.  By  Feancis  Peyee  Poechee,  M.D., 
&c.     New  edition.    Revised  and  largely  augmented.    Charleston,  1869. 

Pp.  733 141 

Aet.  VI. — The  Discovery  of  the  Nature  of  the  Spleen.     By  Henet  Silves- 

tee,  B.A„  M.D.     Lond.  .  .  .  .  .  .143 

Aet.  VII. — Year-book  of  Pharmacv.     Issued  by  the  British  Pharmaceutical 

Conference.     Pp.  596.     London,  1870  .  .  .  .146 

Aet.  VIII. — The  Life  of  JohuHeyshain,  M.D.,and  his  Correspondence  with  Mr. 
Joshua  Milne  relative  to  the  Carlisle  Bills  of  Mortality.     Edited  by 
Heney  Lonsdale,  M.D.     London,  1870.     Pp.  173       .  .  .  147 

Aet.  IX. — 1.  Fracastor,  La  Syphilis,  a.d,  1530.     Le  Mai  Fran^ais,   extrait 
du  livre  '  De  Contagionibus,'  a.d.  1546.     Traduction  et  Commentaires. 
Par    Dr.  Alfeed   Foueniee,    Medecin    des    Hopitaux,  &c.      Paris, 
1870  .  .  .  ...  .  .149 

2.  Jacques  de  Bethencouet.    Nouveau  Careme  de  Penitence  et  Pnrga- 
toire  d'Expiation,  a  I'usage  des  maladcs  affectes  du  Mai  Fran<jais  ou 
Mai  Venerien.     Ouvrage  suivi  d'un  dialogue  oii  le  mercure  et  le  gaiac 
exposent  leurs  vertus  et   leurs  pretensions  rivales  h  la  guerison  de  la 
dite  maladie,  A.D.  1527.     Idem,  idem  .  .  .  .     ib. 

Aet.  X. — La  calentura  roja  observada  en  sus  apariciones  epidemicas 
de  los    anos    1865  y  1867.      Por    D.  Ramon  Hernandez  Poggio. 

Madrid,  1871  151 

The    Red  Fever  as    observed  in  the  Epidemics  1865  and  1867.      By 
Don   Ramon    Heenandez    Poggio.      Madrid,    1871.     Large  8vo, 
pp.  74     .  .  .  .  .  .  .  .  .     ib. 

Aet.  XL — On  the  Treatment  of  Hyperpyrexia,  as  illustrated  in  Acute  Arti- 
cular Rheumatism,  by  means  of  the  external  application  of  cold.     By 
Wilson  Fox,  M.D.,  &c.     London,  1871.     Pp.  78         .  .  .  153 

Aet.  XII. — Lectures  on  Clinical  Medicine.     By  A.  TEOUSSEAr,  M.D.,  &c, 
Translated  from  the  edition  of  1868  by  John  Rose  Coemack,  M.D., 
&c.     New  Sydenham  Society,  1871.     Pp.  470  .  .  .  154 

Aet.  XIII. — Du  Traitment  des  Coliques  Hepatiques.     Par  le   Dr.  H.  Senac, 

Medecin  h  Vichy,  1870  .  .  .  .  .  .     ib. 

Aet.  XIV. — The  Liverpool  Medical  and  Surgical  Reports.     Edited  by  P.M. 

Beaidwood,  M.D.,  and  Reginald  Haeeison,  F.R.C.S.  .  .  156 

Aet.  XV. — The  Physiological  Anatomy  and  Physiology  of  Man.     By  R.  B. 
Todd,  W.  Bowman,  and  Lionel  S.  Beale.     A  new  edition  by  the  last- 
named  author.     Part  II  of  vol.  i.     London,  1871.     Pp.152      .  .     ib. 
Aet.  XVI. — O  Correio  Medico  de  Lisboa.       Publica9ao    quinzenal.     1   de 

Julhi,  1871 157 

The  Medical  Courier  of  Lisbon.     Fortnightly  medical  review,  from  1st 
July,  1871  .  .  .  .  .  .  .  .     ib. 

Aet.  XVII. — Transactions  of  the  Clinical  Society  of  London.  Vol.  iv.  London, 

1871.     Pp.200  .  .  .  .  .  .  .158 

Aet.  XVIII. — Restorative  Medicine  :  an  Harveian  Annual  Oration.  ByTno- 
MAS  King  Chambees,  M.D.     With  two  Sequels.    Philadelphia,  1871. 

Pp.  85 .  .  .  159 

Aet.  XIX . — A  Practical  Treatise  on  Fractures  and  Dislocations.  By  Feancis 
Hastings  Hamilton,  A.M.,  M.D,,  LL.D.,  Professor  of  the  Practice 
of  Surgery  with  Operations  in  Bellevue  Hospital  Medical  College ; 
Surgeon  to  Bellevue  Hospital,  New  York,  &c.  Fourth  edition,  revised 
and  improved.     Illustrated  with  322  woodcuts  .  .  .  160 


iv  CONTENTS   OF   NO.  XCVII. 

PAGE 

Art.  XX.— The  Geogmpliical  Distribution  of  Heart  Disease  and  Dropsy  in 
England  and  Wales.  Illustrated  by  a  large  Coloured  Map.  By 
Alfbed  Haviland,  M.R.C.S.,  &c.  &c.     Pp.  61  .  .  .  162 

Aet.  XXI.— Notes  on  the  Treatment  of  Skin  Diseases.     By  Robebt  Liteing, 

M.D.,  &c.     Second  Edition,  with  Additions.     London,  1871.     Pp.  104  164 

Aet.  XXII.— Nouveau  Dictionnaire  de  Medeeine  et  de  Chirurgie  pratiques, 
illustre  de  figures  intercalees  dans  le  texte.  Tome  xiii.  Em— Erg. 
Paris,  1870 ib- 

Aet.  XXIII.— Handy- Book  of  the  Treatment  of  Women's  and  Children's 
Diseases,  according  to  the  Vienna  Medical  School.  With  Prescrip- 
tions. By  Dr.  Emil  Dillinbebgee.  Translated  by  Pateick  Nicol, 
M.D.     London,  1871.     Pp.  208  .  .  .  .  .  165 

Aet.  XXIV. — A  Manual  of  Practical  Therapeutics,  considered  chiefly  with 
reference  to  Articles  of  the  Materia  Medica.  By  Edwaed  John 
Waking,  M.D.,  &c.     Third  Edition.     London,  1871.     Pp.  875  .  166 

Aet.  XXV.— a  Handbook  of  Therapeutics.      By   Sydney   Ringee,   M.D. 

Second  Edition.     London,  1871.     Pp.  483        .  .  .  .     ib. 

Aet.  XXVI. — Transactions  of  the  Pathological  Society  of  London,  com- 
prising  the  Report  of  the  Proceedings  for  the  Sessions  1869-70  and 
1870-71.     Forming  vols,  xxi  and  xxii    .....   167 

Aet.  XXVII. — Essentials  of  the  Principles  and  Practice  of  Medicine.  A 
Handbook  of  for  Students  and  Practitioners.  By  Heney  Haets- 
HOENE,  M.D.,  &c.     Philadelphia,  1871.     Pp.  487         .  •  •  168 

Aet.  XXVIII. — The  Journal  of  Anatomy  and   Physiology.     Conducted  by 

Professors  Humphey  and  Turnee.     November,  1871  .  .  168 

(Original  <!!£immuutcations. 

Aet.  I. — On  the  Proper  Management  of  Tedious  Labours.  By  Dr.  G.  Hamil- 
ton, Falkirk  .  .  .  .  .  .  .  171 

Aet.  II. — On  the  Recent  Progress  of  Uroscopy.     By  Dr.  Kael  Beethold 

Hoemann,  Lecturer  in  the  University  of  Vienna  .  .  .  193 

Aet.  III. — The  Administration  of  Medicines  in  comparatively  small  and  fre- 
quent doses.  By  John  Kent  Spendee,  M.D.  Lond.,  Surgeon  to  the 
Mineral- Water  Hospital,  Bath  .  .  .  .  .209 


(Kfironicle  of  if^etJical  ^tknn. 

(chiefly    eoeeign    and    contempoeaey.) 

Report    on    Obstetrics    and    Gynaecology.      By    W.    S.    Playpaie,    M.D., 

F.R.C.P.  .  .  .  .  .  .  .  .237 

Report  on  Physiological  and  Pathological  Chemistry.     By  Prof.    Chuech, 

M.A.      .  .  .  .  .  .  .  .  .249 

Report  on  Toxicology,  Forensic  Medicine,  and  Hygiene.     By  Benjamin  W. 

RiCHAEDSON,  M.D.,  F.R.S.        ......  258 

Report  on  Surgery.     By  Aleeed  Poland,  F.R.C.S.    ....  274 

Rooks  Received  foe  Review  ......  281 


4. 


CONTENTS  OF  No.  XOVIII 

OF  THE 

BRITISH  AND  FOREIGN 
MEDICO-CHIRURGICAL    REVIEW. 

APEIL,  1872. 


^nalgfical  antr  (Critical  itebietois. 

PAGE 

Ret.  I. — A  System  of  Medicine.    Edited  by  J.  Rtjssell  Reynolds,  M.D., 

F.R.S.     Vol.  iii,  containing  Local  Diseases  {continued).     1871  .  285 

Rev.  II.— The  Dynamics  of  Nerve  and  Muscle.     By  Dr.  C.  B.  Radcliffe    .  308 

Rev.  III. — Contributions  towards  the  Materia  Medica  and  Natural  History 
of  China.  For  the  Use  of  Medical  Missionaries  and  Native  Medical 
Students.  By  Feedeeice  Poetee  Smith,  M.B.  Lond.,  Medical 
Missionary  in  Central  China.     1871,  pp.  237.     Shanghai  and  London.  322 

Rev.  IV. — The  Medical  Jurisprudence  of  Insanity.  By  J.  H.  Balfoue 
Beowne,  Esq.,  of  the  Middle  Temple,  Barrister-at-law.  London, 
1871 331 

Rev.  v.— 1.  The    Fortnightly  Review    (February    1st,    1869).      "  On  the 

Physical  Basis  of  Life."    By  Professor  Huxley.     London      .  .  338 

2.  Protoplasm  of  Life,  Force  and  Matter.  By  Lionel  S.  Beale,  M.B., 
F.R.S.,  Fellow  of  the  Royal  CoUege  of  Physicians,  Physician  to  King's 
College  Hospital.     Second  edition.     London     .  .  .  .  ib. 

3.  As  regards  Protoplasm  in  relation  to  Professor  Huxley's  Essay  on  the 
Physical  Basis  of  Life.  By  James  Hutchison  Stieling,  F.R.C.S., 
LL.D.  Edin.     Edinburgh  .  .  .  .  .  .  ib. 

4.  Essays  on  Physiological  Subjects.  By  Gilbeet  W.  Child,  M.A., 
F.L.S.,  &c.,  Lecturer  on  Botany  at  St,  George's  Hospital.     London     .  ib. 

5.  The  CeU  Doctrine,  its  History  and  Present  State,  for  the  Use  of 
Students  in  Medicine  and  Dentistry.  By  James  Tyson,  M.D., 
Lecturer  on  Microscopy  in  the  University  of  Pennsylvania,  &c. 
Philadelphia       .  .  .  •  •  .  .  .  ib. 

Rev.  VI.— a  System  of  Surgery,  Theoretical  and  Practical,  in  Treatises  by 
various  authors.  Edited  by  T.  Holmes,  M.A.  Cantab,,  Surgeon  and 
Lecturer  on  Turgery  at  St.  George's  Hospital.  Second  edition,  in  five 
volumes,  with  illustrations.    London,  1869,  1870,  and  1871     .  .  346 

Rev.  VII. — 1.  Some  Propo^-itions  on  Hospitalism.     By  the  late  Sir  J.  Y. 

Simpson,  Bart.    '  Lanc< ' '  1870  .....  359 

2.  A  System  of  Surgery,  Theoi^tical  and  Practical,  in  Treatises  by  various 
authors.    Edited  by  T.  HoLM/S,  M.A.  Cantab.,  Surgeon  and  Lecturer 


il  CONTENTS  OP  NO.  XCVIII. 

PAGE 

at  St.  George's  Hospital.    Second  edition,  in  five  volumes.    London, 

1870-71 359 

8.  St.  George's  Hospital  Reports.    Vol.  v  .  .  .  .  ib. 

4.  Mortality  of  Childbed  and  Maternity  Hospitals.  By  J.  M.  Duncan, 
A.M.,  M.D.,  &c.     Edinburgh,  1870 ib. 

5.  Introductory  Notes  on  Lying-in  Institutions,  &c.  By  Floeence 
Nightingale.     London,  1871     .        .  •  •  •  •  ib. 

6.  The  Medical  Times  and  Gazette,  1871,  pp.  787,  and  The  British 
Medical  Journal,  1871,  pp.  736,  containing  a  notice  of  the  37th  Annual 
Report  of  the  Glasgow  Maternity  Hospital        ,  .  .  .  ib. 

7.  Report  of  the  Rotunda  Lying-in  Hospital.  Read  before  the  Obstetrical 
Society  of  Ireland,  January,  1872  .  .  .  .  .  ib. 

Rev.  VIII. — Lectures  on  the  Principles  and   Practice  of  Physic.     By  Sir 

Thomas  Watson,  Bart.,  M.D.,  F.R.S.    Fifth  edition.     London,  1871  369 

Rev.  IX. — Report  of  the  Royal  Commission  upon  the  Administration  and 
Operation  of  the  Contagious  Diseases  Acts.  Vol.  ii,  Minutes  of 
Evidence,  &c.    London,  1871.    Folio,  pp.  846  .  .  .  .  388 

Rev.  X.— Practical  Lithotomy  and  Lithotrity.  By  Sir  H.  Thompson,  Sur- 
geon Extraordinary  to  H.M.  the  King  of  the  Belgians ;  Professor  of 
Clinical  Surgery  and  Surgeon  to  University  College  Hospital.  {Con- 
tinued from  our  last  Number)     ......  395 

Rev.  XL — 1.  On  the  Origin  of  Diabetes,  with  some  new  Experiments  regard- 
ing the  Glycogenic  Function  of  the  Liver.  By  W.  T.  LuSK,  M.D., 
Professor  of  Physiology,  L.  I.  Medical  College.    New  York,  1870        .  418 

2.  Sugar  Formation  in  the  Liver.  By  J.  C.  Dalton,  M.D.,  Professor  of 
Physiology  in  the  College  of  Physicians  and  Surgeons,  New  York. 
Reprinted  from  the  'Transactions  of  the  New  York  Academy  of 
Medicine,'  June,  1871    .  .  .  .  .  .  .  ib. 

3.  Sulla  Poliuria  e  il  Diabete,  Studi  e  Considerazioni.  Del  Prof.  Pieteo 
BuEEESi.  Estratte  dal  volume  secondo,  f  ascicolo  primo,  della  *  Revista 
Sclentlfica  de  Fisiocritici  de  Siena.'     1870        .  .  .  .  ib. 

4.  Diabete  Sucre.     Jaccoud.     'Nouveau  Dictionnairc  de  Medecine  ct 

de  Chirurgie  Pratiques,'  tome  onzieme.     Paris,  1869    .  .  .  ib. 

5.  Remarks  on  Diabetes,  especially  with  reference  to  Treatment.  By 
William  Richaedson,  M.A.,  M.D,,  &c.     London,  1871  .  .  ib. 

6.  The  Skim  Milk  Treatment  of  Diabetes  and  Bright's  Disease,  with 
Clinical  Observations  on  the  Symptoms  and  Pathology  of  these 
Affections.    By  Aethue  Scott  Donkin,  M.D.,  &c.  &c.    London,  1871  ib. 

Rev.  XII. — On  the  Use  of  the  Ophthalmoscope  in  Diseases  of  the  Nervous 

System  and  of  the  Kidneys.    By  T.  Clifford  Allbutt,  M.D.  .  429 


i^ttliosrapfiical  i^ecpv'e. 


Aet.  I. — The  Modes  of  Origin  of  Lowest  OrgPUisms,  including  a  Discussion 
of  the  Experiments  of  M.  Pasteur,  f  ad  a  Reply  to  some  Statements 


CONTENTS  OP  NO.  XCVIII. 

PAGE 

by  Professors  Huxley  and  Tyndall.    By  H.  Charlton  Bastian,  M.A., 
M.D.,  F.R.S.     London  and  New  York.     1871  .  .  .  .448 

Aet.  II.— Zanzibar ;  its  City,  Island,  and  Coast.     By  Captain  E.  F.  Bfeton. 

8vo.     London.     1872     .  .  .  .  .  .  .451 

Aet.  III. — St.  Andrew's  Medical  Graduates'  Association  Transactions,  1869. 
Edited  by  Leonaed  W.  Sedgwice:,  M.D.  London,  vols,  iii  and  iv. 
1870  and  1871 454 

Aet.  IV. — Digitalis ;  its  Mode  of  Action  and  its  Use.  An  Inquiry  illustrating 
the  Effect  of  Remedial  Agents  over  Diseased  Conditions  of  the  Heart. 
The  Hastings  Prize  Essay  of  the  British  Medical  Association  for  1870. 
By  J.  MiLNEE  FoTHEEGiLL,  M.D.     London.    1871     .  .  .  457 

Aet.  V. — Sketch  of  the  Present  State  of  our  Knowledge  respecting  the 
Action  of  Mercury  on  the  Liver.  By  Thomas  R.  Feasee,  M.D., 
F.R.S.E.,  F.R.C.P.E.,  Lecturer  on  Materia  Medica,  Therapeutics,  &c. 
Edinburgh,  1871 458 

Aet.  VI. — Clinical  Lectures  on  Diseases  peculiar  to  Women.     By  Lombe 

Atthill,  M.D.  Univ.  Dub.     Pp.  208.     Dublin,  1871   .  .  .459 

Aet.  VII. — The  Rapid  Cure  of  Aneurism  by  Pressure ;  illustrated  by  the 
Case  of  Mark  Wilson,  who  was  Cured  of  Aneurism  of  the  Abdominal 
Aorta  in  the  year  1864.  By  William  Mueeat,  M.D.,  &c.,  Lecturer 
on  Physiology  in  the  University  of  Durham,  &c.  London,  1871.  Pp. 
43 464 

Aet.  VIII. — A  New  Operation  for  Bony  Anchylosis  of  the  Hip-joint ;  with 
Malposition  of  the  Limb  by  Subcutaneous  Division  of  the  Neck  of  the 
Thigh-bone.  By  William  Adams,  F.R.C.S.,  Surgeon  to  the  Royal 
Orthopsedic  and  Great  Northern  Hospitals,  &c.  London,  1871.  Pp. 
68 465 

Aet.  IX. — Text-book  of  Skin  Diseases.  By  Dr.  Isidoe  Neumann.  Translated 
from  the  second  German  edition  by  special  permission  of  the  author 
by  Aleeed  Pullae,  M.D.     1871.     Pp.  327     .  .  .  .  ib. 

Aet.  X. — The  Science  and  Practice  of  Surgery.  Illustrated  by  470  wood 
engravings.  By  Feedeeick  James  Gant,  F.R.C.S.,  Surgeon  to  the 
Royal  Free  Hospital;  formerly  Surgeon  to  Her  Majesty's  Military 
Hospitals,  Crimea  and  Scutari.     London,  1871.     Pp.  1265       .  .  467 

Aet.  XI. — Notizie  Cliniche  sulla  Difteria.    Per  Gavino  Gulia         .  .  468 

Aet.  XII. — Camp  Life  as  seen  by  a  Civilian ;  a  Personal  Narrative.     By 

Geoegb  Buchanan,  A.M.,  M.D.    Glasgow,  1871.    Pp.  298   .  .  469 


> 


(©riflinal  (^Communications. 

Aet.  I. — Observations  on  the  Use  of  Mercury  in  general,  and  in  certain 

diseases  of  the  Brain  in  particular.    By  E.  Copeman,  M.D.,  F.R.C.P.  471 
Aet.  II. — On  Cancer  of  the  Tonsil  Glands.    By  Aleeed  Poland      .  .  477 

Aet.  III. — On  Hereditary  Transmission  of  Structural  Peculiarities.  By  John 
A.  Ogle,  M.D.,  F.R.C.P.,  Physician  to  and  Lecturer  at  St.  George's 
Hospital  .  .  .  .  .  .  .  .500 


^ 


CONTENTS  OIT  NO.  XCYIII. 


(Ettotticle  of  ^elJical  Science. 

(chiefly    foeeign    and    contempoeaey.) 

PAGE 

Report  on  Physiology.  By  Heney  Powee,  F.R.C.S.,  M.B.  Lond.,  Senior 
Ophthalmic  Surgeon  to,  and  Lecturer  on  Ophthalmic  Diseases  at,  St. 
Bartholomew's  Hospital  ......  622 

Report  on  Materia  Medica  and  Therapeutics.  By  Robeet  Huntee  Semple, 
M.D.,  Meraher  of  the  Royal  College  of  Physicians,  Physician  to  the 
Bloomsbury  Dispensary,  London  .....  534 

Report  on  Pathology  and  Principles  and  Practice  of  Medicine.  By  Feancis 
C.  Webb,  M.D.,  P.L.S.,  Member  of  the  Royal  College  of  Physicians, 
Physician  to  the  Great  Northern  Hospital         ....  546 

Books  eeceived  foe  Review         .  .  .  .  .  .558 

Title,  Contents,  Index. 


THE 

BRITISH    AND    FOREIGN 

MEDICO-CHIRURGICAL  REVIEW. 

JANUAEY,    1872. 


I.— Sanitary  Legislation. 

That  session  of  Parliament  cannot  be  called  sterile  wliich 
has  produced  the  Act  for  constituting  a  Local  Government 
Board,  an  Act  resembling  some  other  important  and  sweeping 
measures  in  its  brevity.^ 

It  may  be  as  well  to  remind  our  readers  that,  for  some  time 
past,  tlio  central  functions  of  Government,  relating  to  public 
health,  local  governm.ents,  drainage,  etc.,  prevention  of  disease, 
and  mexlical  poor  relief,  have  been  distributed  among  several 
departments  of  the  State,  only  three  of  which  are  included  in 
the  new  Act. 

Briefly,  then,  to  show  what  the  Act  covers  and  what  it  omits. 
(1)  The  Privy  Council  was  previously  empowered  to  direct 
scientific  researches,  to  inquire  into  the  causes  and  circumstances 
of  any  excessive  local  mortality,  and  to  issue  orders  and  regu- 
lations, at  will,  in  times  of  pestilence  ;  its  action  being  directed 
by  the  distinguished  medical  officer  who  now  advises  the  new 
central  authority.  (2)  The  supervision  of  medical  poor  relief  was 
long  ago  committed  to  the  chief  destitution  authority  of  the 
country,  now  transformed  into  the  Local  Government  Board, 
which  is  also  empowered  to  control  local  arrangements  for 
public  vaccination,  previously  administered  under  the  direction 
of  the  Privy  CounciL  (3)  The  Home  Secretary  was  made  the 
controlling  authority  in  proceedings  under  the  Public  Health 
and  Local  Government  Acts ;  the  inspectors  appointed  under 
the  latter  reporting  to  him,  and  the  definition  of  areas  of  local 
government,  and  the  formation  of  localboard  districts  and  certain 
special  drainage  districts,  being  also  submitted  for  his  approval 
or  correction.  (4)  The  department  which  collects  and  compiles 
our  national  statistics  of  population,  mortality  and  reproduction 

1  '  The  Local  Government  Board  Act,  1871." 
97— XLix.  1 


^  ttevietos.  [Jan., 

was  a  mere  clepeiulency  of  the  Home  Office,  as  it  is  now  of  the 
Local  Government  Board.  (5)  Enactments  relating  to  public 
baths  and  washliouses ;  (C)  to  public  improvements  ',  and  (V)  to 
artizans'  and  labourers'  dwellings ;  each  previously  referred  cer- 
tain matters  to  the  decision  of  the  Home  Office.  All  these  sub- 
jects are  now  combined  under  the  new  Board.  0^)  Those  large 
areas  of  local  management  formed  under  Land  Drainage  Acts, 
so  important  to  the  public  health,  are  determined  by  the 
Inclosure  Commissioners,  who  are  practically  independent  of 
the  Secretary  of  State,  and  report  direct  to  Parliament.  More- 
over, by  a  provision  in  the  Sewage  Utilization  Act  of  1865, 
(transferred  from  that  into  Sir  C.  Adderley's  Bill,  clause  165) 
these  Commissioners  are  empowered  to  control  works  for  the 
distribution  of  town  sewage;  and  they  are  also  the  central 
authority  under  a  so-called  "private"  Act  of  1867,  for  the 
same  purpose.  Yet  this  commission  remains  untouched  by  the 
Local  Government  Board,  (9)  Again,  the  Board  of  Trade, 
originally  an  offshoot  of  the  Privy  Council,  has  been  authorized 
to  control  Gas  and  Water  Companies,  to  issue  provisional  orders, 
and  to  direct  the  inspection  of  Alkali  Works ;  neither  does  this 
central  authority  appear  to  be  superseded  by  the  Local  Govern- 
ment Board. 

Then,  with  regard  to  subordinate  departments.  (10)  The 
working  of  the  Burial  Acts  and  the  inspection  of  burial  grounds, 
now  under  the  Home  Office,  ought,  according  to  the  Royal 
Sanitary  Commission,  to  pass  to  the  new  central  authority ; 
but  of  such  change  we  see  no  notice  in  the  new  Act.  (H)  The 
same  overburdened  department  still  superintends  the  adminis- 
tration of  sanitary  enactments  relating  to  labour;  the  inspectors 
of  factories  and  mines  reporting  to  the  Secretary  of  State. 
It  is  to  be  observed  that  the  Factory  Acts  Extension,  and 
the  Workshops'  Regulation  Acts  of  1867,  with  subsequent 
measures  in  the  same  direction,  have  brought  under  inspection 
almost  every  description  of  collective  industry.  These  measures, 
protecting  the  health  and  safety  of  millions  employed  in  manu- 
facture, "  form,"  as  the  Royal  Commissioners  justly  remark, 
"  one  of  the  most  important  parts  of  sanitary  legislation," 
although  they  embrace  educational  and  other  requirements 
which,  the  Commissioners  think,  should  constitute  them  "  a 
distinct  part  "  of  such  legislation. 

(12)  In  the  Memorandum  prepared  by  some  members  of  the 
Commission,  the  Lunacy  Commissioners  are  specified  as  one  of 
the  departments  *^  who  in  fact  now  act  as  Health  Inspectors." 

(13)  There  are  also  the  heads  of  the  Army  and  Navy  Medical 
Departments,  deeply  concerned  with   sanitary  measures.     And 

(14)  the  General  Medical  Council,  under  the   Privy  Council, 


1872.] 


Sanitary  Legislation.  3 


is  authorized  to  determine  the  qualifications  of  those  medical 
men  who  are  to  be  employed  in  sanitary  administration.  The 
Privy  Council  has  also  powers  under  (l^)  the  Pharmacy  Acts, 
and  is  (16)  the  chief  authority  in  Cattle  Disease  prevention. 

Here,  then,  we  have  noticed  some  nine  or  ten  departments  and 
sub-departments  of  the  State  which  superintend  a  host  of 
measures  intimately  affecting  the  public  health.  All  these,  we 
hoped,  would,  as  far  as  that  object  is  concerned,  have  been  co- 
ordinated more  or  less  closely  in  the  great  work  now  before  the 
nation. 

But  that  curious  incompleteness,  that  strange  inconsistency, 
which  so  often  characterize  British  legislation,  have  again 
prevailed,  not  only  to  cause  the  omission  of  all  notice  of  the 
majority  of  these  departments,  but  also  to  exempt  several  items 
of  sanitary  administration  (dependencies  of  the  Ilome  Office  and 
Privy  Council)  from  the  action  of  the  new  central  Board.  For, 
as  we  have  stated,  there  is  no  intimation  that  the  important 
powers  which  the  Board  of  Trade  either  exercises  singly,  or 
shares  with  the  Home  Office,  will  be  transferred  to  the  Local 
Government  Board  ;  and  the  Inclosure  Commissioners  who  have 
been  proposed  as  the  proper  central  authority  for  River  Con- 
servancy, may  still  go  on  forming  areas  of  drainage,  independent 
of  and  sometimes  conflicting  with  town  jurisdictions.  The 
inspection  of  hospitals  for  different  purposes  of  public  medicine, 
may  still  remain  unconsolidated ;  and  the  qualifications  of 
medical  and  sanitary  officers  may  still  be  left  to  departments 
unrecognized  by  the  new  Act. 

This  defect  in  principle  is  evidently  due  to  the  fact  that  no 
Council  of  Health  is  provided  to  advise  and  aid  the  Local 
Government  Board  in  the  extensive  work  before  it, — a  council 
which  might  include  representatives  from  many  of  the  ignored 
departments  and  institutions,  and  confer  a  scientific  authority 
on  the  Central  Board,  to  which  at  present  it  can  lay  no  claim 
beyond  the  possession  of  a  single  medical  officer,  Mr.  Simon. 
For  the  composition  of  the  ncAv  Board  is  precisely  the  same  as 
that  of  the  late  Poor-law  Board,  except  that  all  Her  Majesty's 
Secretaries  of  State  are  now  members.  And  without  ques- 
tioning the  administrative  fitness  and  sanitary  knowledge  of 
the  Secretary  at  War,  the  Secretaries  for  India  and  the  Colonies, 
the  Foreign  Secretary,  and  the  Lord  Privy  Seal,  we  may  be 
allowed  respectfully  to  doubt  whether  they  are  competent  to 
afford  anything  like  as  efficient  assistance  to  Mr.  Stansfeld,  as 
half  a  dozen  gentlemen  whom  we  could  select,  with  general 
approbation,  from  the  bodies  and  functionaries  who  have  been 
passed  over.  It  is  of  the  utmost  importance  that  the  central 
sanitary    authorities   should  command    the   confidence  of  the 


4  keviews.  [Jan., 

(n)untiy.  On  this  point  wc  would  refer  to  some  observations 
in  a  former  number  (xciii,  p.  58). 

Sir  Charles  Adderley's  Bill/  which  stands  over  for  considera- 
tion in  the  next  Session,  is  in  reality  a  collection  of  several 
measures  which  a  Select  Committee  of  the  House  of  Commons 
might  well  separate  and  deal  with  singly  as  distinct  enactments 
of  one  sanitary  code.  Several  clauses  of  that  enormous  Bill 
have  already  been,  in  fact,  so  dealt  with,  and  the  Local  Govern- 
ment Board  Act  is  the  result. 

Another  complete  measure  might  be  formed  of  those  clauses 
which  relate  to  local  authorities  and  officers  and  areas  of  ad- 
ministration, beginning  with  Counties.  The  Rating  Clauses 
and  those  which  confer  borrowing  powers,  those  also  which  direct 
the  course  of  legal  procedure  and  which  regulate  appeals  and 
other  like  matters,  might  form  a  third  Bill.  Those  numerous 
clauses — more  than  200 — which  treat  of  the  powers  of  local 
authorities,  under  the  various  heads  of  sanitary  administration, 
might  well  form  so  many  separate  measures.  For  example : 
one  might  relate  to  dioellings  and  dwelling  places — under  the 
following  subdivisions  ;  house,  street,  and  building  regulations, 
lodging-houses,  closets,  sewage,  nuisances,  and  toater  supply. 
The  pollution  of  water  would  probably  belong  to  a  distinct 
measure  for  rive}'  conservancy  and  land  drainage,  not  dealt  with 
in  the  new  Bill.  Another  measure  might  relate  to  occupations, 
under  the  heads  of  offensive  trades,  noxious  vapours,  gas  works 
and  chemical  processes,  slaughter-houses,  markets,  sale  of  dis- 
eased and  bad  food.  Probably,  legislation  against  the  adultera- 
tion of  food,  drinks  and  medicines  might  be  distinct,  as 
would  also  be  the  sanitary  regulation  of  mines,  factories  and 
icorksliops.  Another  enactment  would  apply  to  means  of  loco- 
motion, as  far  as  the  health  of  the  public  and  safety  of  travellers 
are  concerned — under  the  heads  of  roads  and  highways,  ships, 
harbours,  river  and  canal  navigation,  and  railways.  Lastly,  a 
more  distinctly  medical  enactment  might  include  regulations 
respecting  the  registration  of  births,  deaths,  causes  of  death, 
and  sickness  ;  the  supervision  of  hospitals,  dispensaries,  medical 
poor  relief  and  vaccination;  directions  for  disinfection,  mortu- 
aries, burial  grounds  and  burials. 

At  all  events,  if  the  gigantic  project  of  legislation,  which  the 
Chairman  of  the  Royal -Commission  has  with  much  skill  and 
wonderful  industry  prepared  for  Parliamentary  mangling,  were 
separated  into  at  least  half  a  dozen  consistent  bills,  covering  the 
whole  area  of  public-health  legislation,  we  venture  to  say  that  a 

^^  A  Bill  to  consolidate  and  amend  the  Law  relating  to  Public  Health  and  Local 
Government  in  England  and  Wales,  except  the  Metropolis. 


I 


1872.] 


Sanitary  Lefjislation. 


more  thorough  and  satisfactory  consideration  and  settlement 
of  each  branch  of  the  great  subject  would  be  secured. 

To  discuss  at  all  fairly  the  numerous  details  of  Sir  Charles 
Adderley's  Bill  would  be  impossible  within  the  limits  of  a  review, 
and  we  think  that  the  main  object  of  this  article  will  be  better 
fulfilled  by  confining  the  following  remarks  to  those  proposals 
Avhich  concern  the  definition  of  areas  of  administration,  the 
constitution  of  local  authorities,  and  the  appointment  of  officers. 

But  before  supporting  Mr.  Hastings,  and  the  Joint  Committee 
so  far  as  they  agree  with  him,  in  advocating  the  extension  of 
the  sphere  of  sanitary  administration  to  counties,  we  propose 
to  call  attention  to  the  paramount  importance  of  a  general 
revision  of  the  areas  of  local  management.  The  error  of  defi- 
nition, the  want  of  coincidence,  the  conflict  of  boundary,  which 
characterize  the  many  systems  of  territorial  division  for  sundry 
purposes  of  local  administration  in  the  provinces,  have  long  been 
the  butt  of  social  and  sanitary  critics.  The  Report  of  the 
Commission  itself  shows  very  plainly  the  inconvenience  and 
anomalies  of  the  present  system,  in  the  following  paragraphs  : 

"  Unions,  and  sometimes  even  parishes,  overlapping  county  boun- 
daries ;  registration  districts  making  incomplete  correspondence  with 
them  in  statistics  of  births  and  deaths ;  highway  districts  made 
optionally,  and  irrespectively  of  all  other  areas,  or  coinciding  some- 
times with  one,  sometimes  with  another;  petty  sessiooal  divisions  gene- 
rally difiering  from  all ;  cause  altogether  to  a  country  whose  life  is  self- 
administration,  probably  the  maximum  of  embarrassment  and  waste  of 
local  government  and  the  utmost  loss  of  means  and  effectiveness. 

"  The  same  boundaries  should  as  far  as  possible  define  the  areas  of 
all  these  kinds  of  provincial"  executive,  and  their  officers  should  be, 
as  far  as  possible,  the  same  for  all  those  purposes." — (p.  53.) 

Yet  with  unaccountable  inconsistency,  neither  among  the 
final  resolutions  of  that  Report,  nor  in  Sir  C.  Adderley's  Bill, 
is  there  any  provision  for  ensuring  coincidence  of  area  for  these 
several  objects  in  the  same  locality.  Powers  to  combine,  divide, 
dissolve,  and  incorporate  districts  are  indeed  to  be  granted  to 
the  proposed  central  and  local  authorities  ;  but  the  exercise  of 
these  powers  is  to  be  optional ;  and  the  necessity  for  a  general 
revision,  so  as  to  insure  that  coincidence  of  area  and  consolida- 
tion of  functions  which  the  commissioners  recommend,  is  no- 
where expressed.  On  the  other  hand,  their  almost  fanatical 
cultus  of  a  once  popular  idol  has  led  them  not  only  to  oppose 
all  interference  with  the  small  local-board  districts  which  dis- 
figure and  perplex  the  country,  as  shown  in  the  evidence, — and 
to  leave  them  under  separate  authorities,  called  ''  urban"  by 
courtesy, — but  also  even  to  propose  their  unlimited  multiplica- 
tion ;  and  this,  in  opposition  to  the  recommendation  of  the  prin- 


6  Reviews.  [Jan., 

cipal  witnesses.  The  new  Bill  goes  further  in  this  direction 
than  the  Report,  actually  making  it  compulsory  (Clause  S2)  on 
the  central  authority  to  form  more  and  more  of  these  insulcB  of 
local  government,  without  combining  the  various  functions  that 
are  to  be  performed  in  each. 

We  have  more  to  say  about  the  project  of  districts  and  autho- 
rities put  forth  by  the  Commissioners,  but  must  first  explain 
the  three  different  principles  on  which  the  areas  of  sanitary 
administration  are  or  might  be  defined. 

1.  There  is  the  principle  sanctioned  by  the  Commissioners, 
of  maintaining  and  multiplying  the  small  areas  of  management, 
formed,  chiefly  since  1858,  under  the  Local  Government  and 
Sanitary  Acts,  each  district  being  governed  by  a  separate 
elective  Board. 

^.  There  is  what  may  be  called  the  scientific  principle,  recom- 
mended principally  by  those  who  regard  town-drainage,  sewage 
utilization,  and  river-conservancy  as  the  paramount  objects  of 
sanitary  legislation,  and  who  would  take  elevations  and  depres- 
sions of  land  surface,  with  water  courses,  as  physical  indications 
for  determining  the  extent  and  boundaries  of  administrative 
areas.  The  advocates  of  this  method  generally  accept  local- 
board  and  special-drainage  districts  as  inevitable  units  of  their 
plan,  and  would  proceed  without  much  regard  to  older  divisions 
of  the  country,  to  group  such  units  of  drainage  into  sub-conser- 
vancy districts  for  the  smaller  or  tributary  streams,  and  these 
again  into  whole  river-basins,  under  "  intermediate  authorities." 
The  River  Pollution  Commission  and  many  of  our  eminent 
engineers  support  some  such  method  of  district  definition.  It  is 
an  intelligible  and  defensible  principle,  and  might  be  well 
applied  to  a  newly-settled  country ;  but  it  is  clearly  subversive 
of  all  the  established  traditions  and  divisions  of  an  ancient 
kingdom,  and,  to  carry  it  out  with  logical  severity  in  England, 
some  of  our  large  municipal  areas  might  have  to  be  split  up  into 
"  Special  Drainage  Districts,"  each  with  its  separate  unit  of 
authority,  while  our  old  county  governments  would  be  over- 
ridden by  independent  River  Boards. 

3.  There  is  the  historical  or  statistical  principle — that  is,  to 
take  the  counties,  the  boroughs,  the  parishes  and  townships  of 
the  kingdom,  as  they  are — reconciling  their  old  conflicts  of 
boundary,  and  combining  the  parochial  units  into  districts,  or 
rather  accepting,  subject  to  revision,  the  present  unions,  the 
large  boroughs  and  cities,  as  well-known  combinations  of  those 
units,  for  local  administration. 

After  carefully  weighing  the  arguments  for  the  adoption  of 
each  of  these  opposed  principles,  we  decidedly  support  the  third. 

Many  of  the  commoner  objects  of  health   must,  pace  Mr. 


1872.] 


Sanitary  Legislation. 


Hastings,  be  effected  in  smaller  areas  than  those  of  counties. 
We  venture  to  think  that  this  able  social  reformer  has  some- 
what missed  the  meaning  of  the  term — unit;  for  by  this  we 
understand  the  smallest  area  or  district  in  which  a  community- 
may  be  empowered  to  act  for  itself  in  any  matter  of  local 
administration.  Now,  for  ordinary  puposes,  as  scavenging, 
nuisance-removal,  medical  relief,  &c.,  it  will  be,  as  it  has  been, 
found  desirable  to  combine  the  parochial  units  into  unions  or 
borough-districts  ;  although,  for  the  higher  purposes  of  sanitary 
inspection — so.  well  described  by  Mr.  Hastings  and  the  Joint 
Committee — if  not  for  the  constitution  of  an  intermediate 
authority,  it  is  most  important  to  establish  a  Board  or  Court 
for  an  entire  county. 

If  it  be  said  that  the  full  recognition  of  time-honoured  boun- 
daries, in  the  definition  of  areas,  does  not  pay  sufficient  regard 
to  physical  topography,  we  reply  that  it  is  easy  for  either  a 
borough  council  or  a  county  court  to  divide  its  territory  with 
some  regard  to  the  natural  features  of  the  locality,  and  to  appoint 
a  committee  of  its  body  in  every  such  division  for  those  purposes 
which  can  be  best  effected  within  smaller  limits.  This  is  no 
new  or  untried  principle  of  action.  There  is  nothing  Utopian  in 
it,  which  is  more  than  can  be  said  for  the  scientific  principle. 
There  is  no  empirical  pretence  of  infinitesimal  self-government  in 
it,  which  is  more  than  can  be  said  of  the  principle  advocated  by 
the  Royal  Commission. 

Now  to  comment  briefly  on  the  districts  and  authorities  pro- 
posed by  the  Commission,  and  defined  by  Sir  C.  Adderley  in  his 
Bill.  The  list  of '^  urban  "  authorities  looks  exceedingly  like  some 
of  the  schedules  or  introductory  clauses  of  existing  sanitary  enact- 
ments. For  we  see,  first  the  town  council,  or  the  commissioners 
in  boroughs  under  Local  Acts ;  then  the  town  council  in  all 
other  boroughs ;  then  the  local  board  in  all  places  or  districts 
under  the  Public  Health  and  Local  Government  Acts ;  while  in 
all  other  places  having  known  boundaries,  as  well  as  in  all 
areas  to  which  defined  boundaries  shall  be  assigned  by  the 
central  authority,  the  minimum  of  population  for  local  government 
must  be  oOOO ;  and  the  formation  of  a  district  in  these  places  is 
made  compulsory  (Clause  3,^).  An  aggregation  of  only  3000 
persons  is  thus  held  to  be  a  criterion  of  competency  for  inde- 
pendent sanitary  administration.  What  magic  there  is  in  that 
number  to  secure  intelligence  and  public  spirit  enough  to  meet 
the  emergencies  of  public  health,  we  know  not.  But  the  new 
Local  Government  Board  is  not  to  be  thu&  strictly  limited  in 
the  manufacture  of  ^'  urban  "  authorities  ;  for,  according  to  the 
Bill  of  the  Commissioners,  it  may  constitute  a  local  board  in  any 
place  not  coming  under  any  of  the  above  descriptions.     The 


8  Reviews,  [Jan., 

Central  Board  would  tlius  have  absolute  discretionary  power  to 
form  small  areas  of  administration  all  over  the  country.  This 
is  apparently  the  design  of  the  framcrs  of  the  measure ;  for  it  is 
proposed  to  add  to  the  above  category  all  Special  Drainage 
districts,  constituting  them  Local  Board  districts.  The  country 
is  therefore  to  be  dealt  with  on  a  totally  different  principle  from 
the  great  towns,  in  each  of  which  the  several  wards  or  sub- 
districts,  although  rated  separately  and  sometimes  for  different 
objects,  are  under  a  single  board  of  management  for  the  whole 
area.  If  the  principle  adopted  by  the  Commission  be  sanctioned 
by  Parliament,  we  may  soon  see,  as  the  Joint  Committee^  pre- 
dicts, the  surface  of  the  country  honeycombed  by  more  than  a 
thousand  limited  and  isolated  areas  under  so-called  "  urban  " 
authorities.  We  heartily  join  in  the  earnest  protest  of  that 
Committee  against  such  a  project  of  local  government. 

These  elective  districts,  be  it  observed,  have  no  relation  to 
parishes  or  other  long-settled  divisions  of  the  country ;  and  as 
they  often  consist  of  parts  of  one,  two,  or  more  parishes,  they 
serve  mainly  to  increase  the  complexity  of  local  administration. 
All  the  residue,  all  places,  parishes,  and  parts  of  parishes  in 
each  Union,  not  thus  picked  out,  seem  to  be  treated  as  a  corjms 
vile  for  experiment  under  the  Board  of  Guardians  as  "  rural  " 
authority.  But  these  country  parishes  may  be  quite  as  well 
administered  as  the  spots  favoured  by  "  urban  "  attentions,  for 
no  one  now  doubts  what  is  asserted  by  the  Joint  Committee, 

"  that  petty  elective  authorities  in  small  separate  districts  are  apt 
to  obstruct  rather  than  forward  sanitary  improvement,  and  that  for 
the  most  part  they  render  any  uniform  and  efficient  system  of  ad- 
ministration almost  impossible"  (p.  5). 

The  theory  of  the  Royal  Commissioners  is  that  there  shall  be 
in  every  place  one  authority,  and  o?ie  only,  for  all  public  health 
purposes.  This  has  been  paraded  in  almost  every  channel  of 
publication.  And  they  have  obtained  immense  credit  for  what 
does  not  prove  to  be  the  fact ;  for  practically  they  sanction,  if 
they  do  not  propose,  two  authorities  in  each  place. 

Thus,  we  do  not  find  that,  in  ^'  urban  "  districts,  the  Local 
Board  is  to  supersede  the  Board  of  Guardians  in  the  relief  of 
destitution.  Medical  relief  and  all  cognate  functions  would 
therefore  still  be  administered  under  the  Board  of  Guardians, 
while  the  managements  of  roads,  the  removal  of  nuisances,  and 
the  prevention  of  disease  would  be  under  the  direction  of  the 
Local  Board  or  Town  Council.  And  how,  then,  about  vacci- 
nation ?  which  of  the  rival  local  authorities  is  to  act  ?     Unless 

^  '  Report  of  the  Joint  Committee  on  State  Medicine  of  tlie  British  Medical  and 
Social  Science  Associations  on  the  Report  of  the  Royal  Sanitary  Commission.* 
London :  Richards,  Great  Queen  Street,  1871. 


I 


1872.]  Sanitary  Legislation.  9 

more  complete  measures  are  proposed,  two  bodies,  concerned 
with  the  public  health,  would  still  exist  in  the  same  town  ; 
the  one  containing,  the  other  excluding,  the  magistracy ;  the 
one  having  a  complete  medical  staff,  the  other  being  com- 
pelled to  appoint  its  own  medico-sanitary  officers.  So  also  in 
rural  districts,  according  to  our  interpretation  of  the  new  Bill, 
the  management  of  the  roads,  including  the  appointment  of  a 
scientific  surveyor,  so  necessary  in  sanitary  management,  may 
continue  under  a  different  authority,  namely,  a  Highway  Board, 
from  that  which  is  to  administer  relief,  medical  or  other,  and 
to  execute  preventive  measures.  Here  again  there  would  be 
a  duplication  of  authority  in  the  same  districts. 

Certain  clauses  (169,  170,  171,  172,  and  196)  of  the  new 
Bill  foreshadow  the  difficulties  and  embarassments  which  will 
attend,  as  past  experience  has  shown,  the  intrusion  of  small 
nrban  districts  upon  highway  districts,  to  the  disturbance  of  any 
effective  system  of  road  management  in  large  areas,  thus  repro- 
ducing the  very  abuse  which  Sir  George  Grey  exposed  in 
1863,  and  which  led  to  the  legislative  disallowance  of  local- 
board  districts  with  a  population  of  less  tban  3000 — even 
smaller  places  having  then  actually  taken  advantage  of  the 
Local  Government  Act  to  procure  exemption  from  the  operation 
of  the  Highway  Act. 

The  oddity  of  the  whole  scheme  is  that  the  two  authorities 
which  are  to  coexist  in  urban  districts,  would  exercise  different 
groups  of  functions  from  those  committed  to  the  two  authorities 
in  rural  districts. 

"It  cannot  be  doubted,"  adds  the  Committee,  "that  this  compli- 
cation of  authority  and  duty  would  lead  to  much  administrative 
confusion,  and  hinder,  as  it  has  already  hindered,  the  progress  of  im- 
provement in  local  government." 

On  the  other  hand,  should  the  almost  unanimous  suggestion 
of  the  principal  examinees,  referred  to  in  Resolution  12  of  the 
Report  of  the  Commission,  be  adopted,  and  should  the  Highway 
Boards  and  sanitary  authorities  in  rural  districts  be  consoli- 
dated by  Parliament,  which  is  not  proposed  in  the  Bill,  an 
unanswerable  reason  would  be  supplied  for  a  similar  consoli- 
dation in  urban  districts.  Again  to  quote  the  Joint  Com- 
mittee : — 

"The  great  majority  of  town  districts  in  England  are  included  in 
registration  districts  of  a  somewhat  larger  area.  It  is  extremely  im- 
portant that  the  two  or  more  governing  bodies  within  that  larger  area 
should  be  united,  at  the  very  least  intermediately,  by  representation, 
for  the  purposes  of  the  proposed  Act." 

Should  the  principle  of  an  extension  of  area  be  admitted,  we 
do  not  see  it  expedient,  if  it  were  possible,  to  stop  short  of  our 


10  Reviews,  [Jan., 

largest  known  sphere  of  local  administration,  i.e.  the  County. 
We  say,  unhesitatingly,  that  our  county  management,  by  the 
Great  IFnpaid,  is  distinguished  by  its  disinterestedness,  efficiency, 
ability,  and  freedom  from  party  spirit ;  and  we  should  be  quite 
willing  to  leave  the  execution  of  certain  sanitary  measures 
in  the  hand  of  the  Justices,  who  are  real  representatives  of 
the  country ;  but  no  one  who  has  watched  the  progress  of  this 
question  in  Parliament  doubts  that  ere  long  county  authorities, 
of  a  more  popular  constitution  than  the  present,  may  be  es- 
tablished ;  and  yet  that  they  should  not  be  entrusted  with  any 
functions  relating  to  the  Public  Health,  would  indeed  be  a 
solecism  in  legislation,  of  which  Parliament  would  hardly  be 
guilty.  The  evidence  taken  by  the  Royal  Commission,  although 
not  unanimously  in  favour  of  county  sanitary  administration, 
contains  many  important  facts  and  opinions  in  support  of  the 
proposal  to  make  use  of  any  authorities  which  may  be  consti- 
tuted over  extensive  areas,  and  which  would  consist  of  members 
unlikely  to  be  swayed  by  petty  interests  and  sordid  views,  for 
some  higher  and  wider  purposes,  and  as  courts  of  appeal, 
to  consider  and  report  on  applications  from  localities  and  if 
necessary  to  execute  works. 

We  are  reminded  that  the  magistrates,  in  Quarter  Sessions, 
have  already  to  administer  and  enforce  the  law,  to  control 
institutions  (as  hospitals  for  the  [insane,  reformatories,  and 
prisons)  and  appoint  their  officers,  also  to  perform  certain  duties 
connected  with  the  health  and  safety  of  the  people,  as  the 
control  of  coroners'  inquests,  the  appointment  of  analysts, 
surveyors,  &c.  It  seems,  therefore,  not  only  reasonable  but 
practicable,  either  that  the  powers  of  the  magistracy  should  be 
extended  so  as  to  comprehend  the  care  of  the  pul3lic  health, 
or  that  boards  containing  the  magistrates  and  ratepayers  in 
due  proportion  should  be  forthwith  constituted  for  the  direction 
and  control  of  sanitary  administration. 

Mr.  Goschen's  dropped  Bill  was,  in  some  respects,  an  im- 
provement upon  the  Report  of  the  Royal  Commission,  for  it 
contained  provisions  for  the  establishment  of  County  Boards, 
to  which  it  is  clear  many  such  duties  as  we  suggest  might  be 
committed.  By  the  26th  clause  of  that  Bill,  the  Local  Go- 
vernment Board  might  delegate  to  the  County  Board  the 
powers  of  the  smaller  local  authorities,  when  these  fail  in  their 
duties,  until  the  default  is  remedied.  It  is  unfortunate  for  this 
question  that  Mr.  Goschen  did  not  remain  at  the  head  of  the 
Poor  Law  Board.  We  trust  that  the  precedent  which  he  es- 
tablished may  be  followed  by  his  able  successor,  and  that 
Parliament  will  pass  no  general  sanitary  enactment  which  does 
not  contain  a  provision  of  this  kind. 


1872.] 


Sanitary  Legislation.  11 


We  have  before  noticed  (No.  xcii,  pp.  299,  300)  several  im- 
portant sanitary  reforms  which  require  a  wider  sphere  of  admi- 
nistration than  that  of  an  urban  or  union  district,  such  as  the 
provision  of  sites  for  hibourers'  dwellings,  to  be  erected  under  a 
revised  code  of  building  regulations,  and  the  water-supply  of 
towns  and  villages,  when  it  has  to  be  procured  from  distant 
sources.  On  the  latter  point  w^e  observe  that  Lord  Robert 
Montagu,  in  a  separate  report,  adduces  forcible  reasons  for  the 
establishment  of  Boards  in  what  he  calls  "  watershed  areas," 
meaning  river  basins ;  and  these  boards  he  would  make  inter- 
mediate authorities  between  the  strictly  local  bodies  and  the 
central  department.  Agreeing  with  his  Lordship  as  to  the 
necessity  for  some  such  authorities,  we  believe  that  the  first 
and  safest  step  towards  the  formation  of  river-basin  boards 
would  be  the  constitution  of  county  authorities,  by  means  of 
which  (singly  or  in  combination,  according  to  the  extent  of  area 
within  the  watershed  line)  the  river  boards  might  be  most  judi- 
ciously appointed. 

There  are  other  purposes  for  which  county  authorities  would, 
generally,  be  far  more  suitable  than  local  boards ;  for  instance, 
the  control  of  the  smoke  and  noxious  vapour  nuisances  of 
mining  and  manufacturing  districts ;  the  allotment  of  sites  for 
animal-refuse  depots  and  public  abattoirs, in  connection  with  mea- 
sures against  cattle  diseases ;  the  provision  of  recreation  grounds, 
so  necessary  for  the  health  and  Avelfare  of  crowded  populations; 
the  appropriation  of  land  for  sewage  utilization,  where  local 
bodies  cannot  procure  it ;  the  allocation  of  sites  for  hospitals  to 
receive  fever  and  other  contagious  diseases,  always  most  safely 
treated  in  sparsely  populated  districts ;  and  in  some  localities, 
'^provision  for  the  burial  of  the  dead  withoutinjury  to  the  living." 

This  last  object  is  rightly  specified  by  the  Royal  Commission 
as  one  of  the  requisites  for  civilized  society ;  but  local  boards 
are  not  always  able  to  make  the  provision  on  practicable  terms ; 
and  neither  the  Burial  Acts  nor  Sir  C.  Adderley's  bill  give 
compulsory  powers  of  land-purchase  for  this  object.  A  county 
authority  for  all  such  purposes  is  far  preferable  to  a  central 
department,  as  being  more  cognizant  of  the  wants  and  circum- 
stances of  districts  within  the  county,  and  more  interested  in 
the  speedy  and  safe  settlement  of  territorial  questions.  On  the 
other  hand,  it  ^^  would  not  be  subject  to  the  self-interestedness 
and  isolation  of  mere  town  legislation."  ^ 

But  there  is  no  plea  for  wide  administrative  areas  more  for- 
cible than  the  last  which  we  shall  offer,  viz.,  that  they  would 
provide  greater  opportunities  and  a  superior  machinery  for  the 
selection  of  scientific  officers,  whether  medical  or  engineering, 
^  See  Lord  Robert  Montagu's  paper  on  *  Conservancy  Boards.'     p.  347. 


12  Reviews.  [Jan.j 

of  high  and  special  qualifications,  tlian  would  be  at  the  command 
of  any  local-board  district  or  union. 

On  the  important  question  of  the  appointment  of  the  higher 
sanitary  officers,  we  would  advise  our  readers  to  compare  the 
report  and  memorandum  of  the  Royal  Commission  with  the 
report  of  the  Joint  Committee  and  the  addresses  of  Mr.  Hastings 
and  Mr.  Godwin  at  Leeds.^ 

Doubtless,  the  former  ''  express  very  ably  the  principal  needs 
and  resources  of  existing  local  government  in  this  respect ;"  but 
the  latter  state  as  forcibly  their  objections  to  a  scheme  which,  if 
adopted,  "  would  soon  show,"  in  the  words  of  a  leading  journal, 
'^  that  efficiency  had  been  sacrificed  to  a  spurious  economy."^ 

The  report  of  the  Joint  Committee,  well  supported  as  it  has 
been  by  Mr.  Hastings  and  Mr.  Godwin,  will  amply  repay  a 
thoughtful  perusal,  though  it  may  be  too  independent  in  its 
tone  to  obtain  the  support  of  a  partisan  press.  It  is  well  that 
the  opinions  of  two  eminent  provincial  physicians,  and  of  one 
still  more  distinguished  who  has  been  taken  from  us,  are  given 
in  their  own  words  in  the  appendix  to  that  report.  When  Dr. 
Strange,  the  earliest  of  living  English  writers  on  State  Medi- 
cine ;  Dr.  William  Budd,  the  keenest  of  medical  logicians  in 
the  contagion  controversy ;  and  the  late  lamented  Dr.  Symonds, 
than  whom  no  higher  authority  could  be  quoted  as  to  the  ethical 
and  official  relations  of  the  medical  profession  to  the  public, 
concur  in  taking  the  same  view  of  the  position,  duties,  and 
qualifications  of  the  health  officer,  and  when  the  Joint  Commit- 
tee itself — no  mean  embodiment  of  sanitary  science  and  expe- 
rience— endorses  these  opinions,  and  shows  at  length  how  they 
may  be  practically  applied  to  existing  circumstances,  we  feel  on 
solid  ground  in  supporting  them  in  opposition  to  the  Royal 
Commission. 

Considering  that  on  the  Commission  there  were  five  gentle- 
men of  the  highest  mark  in  our  profession,  it  is  a  matter  of  equal 
astonishment  and  regret  to  find  that  their  ideal  of  a  country 
officer  of  health  reaches  no  higher  than  the  ordinary  district 
medical  officer  of  a  Poor  Law  Union.  It  seems  as  if  all 
that  had  been  done  and  said  by  the  leaders  of  this  movement, 
among  whom  we  may  name  Robert  Baker,  Edwin  Chadwdck, 

1  '  The  Recommendations  of  tihe  Royal  Sanitary  Commission.'  Extract  from 
an  address  at  the  Social  Science  Congress  in  Leeds,  by  G.  W.  Hastings,  LL.D., 
President  of  the  Council.     1871. 

'An  Address  on  Public  Health  and  its  Modern  Requirements/  by  G. 
Godwin,  Esq.,  F.R.S,,  President  of  the  Health  Department  of  the  Social  Science 
Congress  in  Leeds.     1871. 

~  'Pall  Mall  Gazette,'  June,  1871.  This  clever  though  short  notice  shows  a 
thorough  Ivuowlcdge  of  the  question,  and  deserves  to  be  read  by  all  who  are 
interested  in  it, 


1872.] 


Sanitary  Legislation.  13 


Farr,  Laiikester,  Liddle,  Ranald  Martin,  Michael,  Riimsey, 
Simon,  Stewart,  and  Alfred  Taylor,  liad  been  said  and  done  in 
vain  ;  as  if  all  the  costly  Avork  of  the  State  Medicine  Committee 
of  the  General  Medical  Council  were  to  be  fruitless  ;  if,  after 
all,  a  corps  of  health  officers  is  to  be  formed  on  a  principle 
which  ignores  the  conditions  long  ago  laid  down  for  securing 
special  and  complete  acquirements,  thorough  training,  efficiency 
of  action,  independence  of  opinion,  and  devotion  to  public  duty. 
If  the  Commission  had  referred  to  the  Minute  of  the  last  General 
Board  of  Health,  and  had  weighed  as  it  deserved  that  category 
of  the  duties,  qualifications,  and  conditions  of  the  office  advised 
by  Mr.  Simon  sixteen  years  ago,  and  quoted  with  great  effect 
by  Mr.  Hastings  at  Leeds,  they  could  hardly  have  put  forth  so 
imperfect  and  fallacious  a  scheme. 

Dr.  Stewart,  in  his  admirable  address  at  Plymouth,^  said  in 
criticism  of  that  scheme  : 

"  We  feel  also  that  we  have  a  right  to — and  we  do — complain  that, 
while  they  were  not  only  empowered  by  the  terms  of  their  appoint- 
ment, but  expected  to  investigate  with  special  care,  and  to  report 
upon,  the  number  of  officers  and  the  local  expenditure  required 
under  the  present  disjointed,  chaotic,  and  fragmentary  plan  of  opera- 
tions, as  compared  with  the  coherent,  orderly,  and  comprehensive 
system,  suggested  in  our  Memorial  to  the  Grovernment,  the  Com- 
missioners have  adopted  the  existing  chaos  as  the  summum  honum, 
have  quietly  ignored  the  existence  of  any  other  plan,  and  have  fur- 
nished us  with  no  data  for  determining  the  cost,  either  absolute  or 
comparative,  of  that  propounded  by  themselves." 

Except  on  grounds  of  a  fictitious  economy,  indeed,  we  know 
not  why  the  commission  has  pronounced  so  decidedly  against 
the  compulsory  separation  of  private  practice  from  public  em- 
ployment in  the  higher  sanitary  offices.  The  weight  of  evidence, 
whether  from  places  in  England  where  health-officers  have  been 
appointed,  or  from  Germany,  where  the  poorly  remunerated 
Kreis  Physicus  has  for  many  years  been  a  state  institution, 
proves  that  the  union  of  the  two  occupations  and  the  necessity 
of  making  an  income  out  of  curative  practice  to  supply  the  fiscal 
deficiency  left  by  a  wholly  inadequate  salary  for  preventive 
duties,  have  failed  to  confer  that  influence  upon  the  officer  and 
to  secure  those  qualifications  for  it  which  are  necessary  to  its 
full  efficiency. 

An  unfair  attempt  has  been  made  to  show  that  the  Joint 
Committee  and  its  supporters  have  underrated  the  qualifications 
of  the  Union  medical  officers,  and  treated  them  as  unfit  to  be 
entrusted  with  any  sanitary  duties.     This  is  simply  a  misrepre- 

1  An  Address  by  A.  P.  Stewart,  M.D.,  F.R.C.P.,  President  of  the  Section  of 
Public  Medicine  at  the  British  Medical  Congress  iu  Plymouth,  August,  1871, 


14  Revieivs,  [J 


an, 


sentation.  The  fact  is  that  hoth  parties  in  this  controversy 
propose  to  commit  the  same  sanitary  duties  to  the  poor-law 
medical  staff,  and  for  the  same  reason,  namely,  the  obvious 
advantage  of  employing  those  engaged  in  medical  attendance  on 
the  poor  to  report  on  the  causes  of  their  sickness  and  on  their 
domestic  conditions  of  health.  None  have  expressed  more 
clearly  than  the  Joint  Committee  the  ability  of  the  poor-law 
staff  to  render  this  public  service,  and  the  great  importance  of 
securing  their  co-operation  on  equitable  terms.  If  that  com- 
mittee has  judiciously  avoided  the  gross  and  transparent  flattery 
which  the  authors  of  the  '  Memorandum'  have  heaped  on  the 
medical  officers  of  unions  (Report,  vol.  ii,  pp.  352,  358),  they 
cannot  be  truly  described  as  *'  attacking"  those  officers.  Yet 
Mr.  Hastings  has  been  accused  of  this  by  a  recent  writer  in 
the  '  Times,'  who  signs  himself  "  A  Member  of  the  Royal  Sani- 
tary Commission,"  although  the  former  had  by  anticipation 
refuted  so  unjust  an  accusation,  when  he  said  at  Leeds : 

"  No  one  had  a  higher  sense  (than  myself)  of  the  services  and 
merits  of  a  body  of  men  signally  underpaid  for  their  work,  denied  the 
social  recognition  of  enrolling  in  the  civil  service  of  the  Crown,  and 
struggling  manfully,  in  the  great  majority  of  cases,  though  beset 
with  difficulties,  to  do  their  duty  to  the  poor.  But  I  cannot  believe 
that  these  meritorious  officials  possess  the  qualification  so  necessary 
for  (the  higher)  sanitary  work;"  adding,  after  a  reference  to  Dr. 
Symonds  and  to  the  Minute  of  the  General  Board  of  Health  in 
1855,  '"'  But  I  would  not  be  supposed  to  argue  that  they  may  not  be 
usefully  employed  in  our  sanitary  organization.  I  believe,  on  the 
contrary,  that  they  could  render  valuable  aid  as  subordinates,  with 
some  increase  to  their  present  meagre  salaries,  under  a  highly  trained 
superior,  such  as  a  county  administration  could  supply." 

In  the  sonorous  platitudes  which  that  Royal  Commissioner 
employs  when  praising  the  recent  statutory  union  of  the  ^^  medi- 
cal department  of  the  Privy  Council,  the  Home  Office,  and  the 
Poor-law  Board,  with  all  their  staff,  central  and  local,  inspectors, 
lawyers,  engineers,  and  medical  men,"  in  one  body,  for  the 
purpose  of  health  legislation,  he  by  no  means  succeeds  in  justi- 
fying the  proposed  use  of  an  inadequate  local  machinery.  If 
this  be  statesmanship,  save  us  from  such  statesmen. 

The  choice,  as  regards  sanitary  inspection  and  reports,  does 
not  lie  between  poor-law  medical  officers  and  thoroughly  trained 
experts  acting  in  extensive  districts ;  for  those  who  object  to  the 
scheme  of  the  Commission  would  employ  both  classes  in  sanitary 
work.  The  real  question  is,  whether  a  superior  class  of  health 
officers  might  not  supersede  the  necessity  for  a  vast  increase  in 
the  staff  of  inspectors  attached  to  the  central  office — a  prospect 
which  is  carefully  veiled  by  the  Commission. 


1872.]  Sanitary  Legislation.  15 

No  one  who  is  practically  acquainted  with  the  working  of 
present  arrangements  would  venture  to  assert  that  the  generality 
of  poor-law  medical  officers,  compelled,  as  most  of  them  are,  to 
enter  into  practice  with  a  mere  legal  qualification  at  twenty-one 
years  of  age,  and  ahsorbed  in  the  struggle  of  life,  could  possibly 
discharge  the  arduous  functions  and  responsibilites  described  in 
a  former  article  of  this  '  Review'  (No.  xciii,  pp.  66 — 69),  or  that 
any  sanitary  reform  would  be  real,  complete,  and  effective  which 
left  those  functions  and  responsibilities  undischarged.  To  men- 
tion merely  two  kinds  of  duty  which  ought  to  be  performed  by 
superior  health  officers ;  (1)  the  compilation  and  abstract  of  the 
vital  and  sanitary  statistics  of  an  extensive  area  from  the  returns 
made  by  medical  charities,  district  officers,  and  registrars,  and 
their  local  utilization;^  (2)  the  superintendence  of  large  preven- 
tive measures,  especially  during  epidemics,  and  the  visitation  of 
asylums  and  sanative  institutions  of  various  kinds. 

The  alternative,  therefore,  w^ould  be  to  commit  these  and 
other  duties  of  local  supervision  to  a  vast  organization  of  in- 
spectors at  the  beck  of  the  central  office.  Let  our  readers  un- 
derstand the  real  issue  Of  this  controversy,  well  weighing  the 
remarks  made  by  Mr.  Hastings  at  Leeds,  and  by  the  Joint 
Committee  (Report,  §  41)  on  the  hypercentralization  of  the 
Commissioners'  project,  and  we  have  little  doubt  about  their 
decision. 

Another  side  blow  has  been  aimed  at  a  normal  organization 
of  Health  Officers  by  a  London  journalist,  who  reproduces  an 
old  and  exploded  fallacy  in  order  to  evade  the  crushing  objec- 
tions to  a  combination  of  public  employment  with  private  prac- 
tice for  the  chief  sanitary  officer.  This  writer  proposes  to 
convert  that  officer  into  a  poor-law  medical  officer,  w^hich  could 
only  be  done  by  enlarging  the  district  for  medical  relief,  so  that, 
with  his  sanitary  functions,  it  might  occupy  the  whole  time  of 
the  compound  officer  and  entitle  him  to  a  salary  that  would 
justify  the  prohibition  of  professional  attendance  on  paying 
patients. 

Had  that  proposal  not  been  sufficiently  demolished  by  a  reply 
published  in  a  contemporary  journal,^  we  might  have  felt  it 
necessary  to  do  more  than  merely  refer  to  it.  As  it  is,  we  need 
only  remark  that  an  abrupt  separation  of  curative  duties  among 
the  destitute  and  dependent  classes  from  that  among  the  middle 
and  upper  classes  would  be  a  serious  disadvantage  to  the  sick 
in  all  ranks  of  society  and  disastrous  to  medical  science.  The 
evils  would,  perhaps,  be  less  apparent  in  London,  and  in  a  few 

1  See  an  article  on  the  "  National  Registration  of  Sickness "  in  tliis  Review, 
No.  xciv  (April,  1871). 

2  '  British  Medical  Journal,'  Nov.  11,  1871. 


16  Rei)iews.  [Jan., 

of  our  lai-o'CvSt  cities  ;  hut  only  a  metropolitan  writer,  ill-informed 
about  medical  practice  in  the  provinces,  would  have  proposed 
such  a  measure  for  the  whole  country.  Moreover,  the  project 
would  he  enormously  more  expensive  than  either  that  pro])osed 
by  the  Royal  Commission  or  that  advocated  by  the  Joint  Com- 
mittee. 

Thoroughly  sympathising  with  the  efforts  of  the  Association 
of  Poor  Law  Medical  Officers,  we  hail  the  prospect  of  an  amended 
system  of  medical  relief,  and  the  proposed  introduction  of  Dis- 
pensaries on  the  Irish  model,  with  a  fair  augmentation  of  tlie 
salaries  of  the  surgeons, — provided  that  this  great  reform  be 
founded  on  an  improved  county  machinery  for  poor-law  and 
sanitary  administration,  and  be  accompanied  by  such  improve- 
ments in  the  qualification  of  the  officers  as  we  urged  in  the 
article  before  referred  to  (No.  xciii).  The  measure  which  Mr. 
Corrance  is  to  bring  forward  may  possibly  complicate  the  dis- 
trict question,  unless  the  Local  Government  Board  should 
determine  on  a  general  revision  of  districts,  so  as  to  insure 
coincidence  of  area  for  all  purposes  of  local  administration.  It 
is  highly  satisfactory  to  be  assured  that  the  whole  subject  is 
under  the  consideration  of  Mr.  Stansfeld,  who  is  uncommitted 
to  any  project,  and  who  ought  to  be  heartily  encouraged  and 
aided  by  the  whole  sanitary  party.  If  a  better  measure  than 
that  of  the  Royal  Commission  should  be  tlie  result,  no  little 
honour  will  redound  to  the  Joint  Committee. 

The  first  safe  step,  we  repeat,  is  to  constitute  County  Autho- 
rities, and  to  empow^er  them  and  their  officers  to  inquire  into 
the  extent  and  boundaries  of  districts  in  each  county,  prepara- 
tory to  their  readjustment.  This  could  only  be  done  satis- 
factorily by  persons  of  special  qualification  and  thoroughly 
acquainted  with  the  localities ;  and  these  proceedings  would, 
of  course,  be  subject  to  general  instructions  from  the  Local 
Government  Board,  so  as  to  insure  uniformity  of  principle. 
It  is  obvious  that  the  districts  for  dispensaries,  medical  relief, 
and  sanitary  visitation  should  correspond,  singly  or  collectively, 
with  the  Registration  sub-districts.  The  number  of  medical 
relief  districts  in  the  provinces  (that  is,  exclusive  of  the  metro- 
polis) is  said  to  be  not  less  than  3100, — whilst  there  are  2062 
Registration  sub-districts  therein.  As  the  number  of  district 
medical  officers  may  require  to  be  increased  rather  than  dimi- 
nished, and  as  there  seems  to  be  no  necessity  for  a  multiplication 
of  the  Registration  sub-districts,  it  follows  that  a  large  propor- 
tion of  the  latter  would  embrace  two  medical  relief  districts, 
or  at  least  be  attended  by  two  medical  officers  attached  to  one 
dispensary. 

We  cannot  conclude  without  noticing  a  very  important  body 


1872.J 


Scmiiary  Leyislation.  17 


of  medical  officers,  engaged  in  tlie  industrial  department  of 
preventive  medicine,  who  have  been  unaccountably  passed  over 
not  only  by  the  Royal  Commission  but  also  by  others  who  have 
taken  part  in  this  movement. 

The  certifying  Surgeons  of  Factories  are  performing  duties 
most  essential  to  the  safety  and  physical  well-being  of  children 
employed  in  manufacture.  They  should,  therefore,  form  a  part 
of  any  system  of  sanitary  organization ;  for  preventive  and  ex- 
amining duties  in  factories  and  workshops  are  distinct  in  their 
nature  from  the  ordinary  duties  of  a  health  officer.  No  one 
who  has  read  the  annual  publications  of  the  Association  of 
Certifying  Surgeons  can  doubt  that  some  of  the  gravest  sanitary 
difficulties  come  under  their  observation,  and  that  so  far  from 
its  being  advisable  to  limit  or  curtail  their  functions,  it  is  im- 
portant to  develop  and  extend  them. 

We  would  direct  special  attention  to  their  last  Report,^  and 
to  the  remarks  of  Mr.  Inspector  Baker  on  this  subject.  He 
shows  clearly  that  these  surgeons  might  constitute,  under 
amended  regulations,  a  yet  more  effective  machinery  for  im- 
proving the  health  of  the  operatives  and  the  sanitary  condition 
of  w^orkplaces. 

The  President  of  the  Association,  Dr.  Arlidge,  concluded  his 
interesting  address  with  the  following  weighty  observations  on 
the  then  probable  establishment  *^  of  a  central  Health  Board, 
and  the  consolidation  of  the  numerous  sanitary  acts  in  existence, 
among  which  the  Factory  Acts  hold  a  place." 

"  This  being  so,  the  existing  stall'  of  certifying  surgeons  may  find 
themselves  either  disestablished  and  disendowed,  or  otherwise  trans- 
formed into  District  Sanitary  Officers,  with  a  multitude  of  duties 
over  and  above  those  they  have  now  to  perform  ;  and  I  feel  pretty 
confident  that  instead  of  the  Factory  Department  being  developed 
according  to  Mr.  Redgrave's  ideas,  so  as  to  ingulf  sanitary  legislation 
in  general,  it  will  have  itself  to  be  merged  in  a  large  scheme  of  sani- 
tary organization." 

Our  view  of  the  proper  status  of  Factory  Surgeons  in  such  a 
scheme  is,  that  they  should  become,  like  the  poor-law  medical 
officers  and  the  sanitary  officers  of  small  towns.  Deputy  Officers 
of  Health.  As  the  district  and  town  officers  would  have  to  do 
with  dtvelling  places,  so  would  the  latter  with  work  places. 
The  visitation  of  the  one  would  be  domiciliary,  of  the  other 
industrial.  Aided  and  strengthened  by  a  superior  officer 
(appointed  by  the  authorities  of  a  county  or  first-class  borough 
and  made  independent  of  private  practice),  both  classes  of 
deputy  officers  would  become  of  far  greater  utility  and  efficiency 

1  "  Report  of  the  Association  of  Certifying  Medical  Officers  of  Great  Britain  and 
Ireland."     Newcastle-nnder-Iiyinc  :  Hickson,  1870. 

97— XLix.  2 


18  Revieivs,  [Jan., 

than  is  possible  in  their  present  unprotected  and  disjointed 
state  of  organization. 

Finally,  no  great  measure  of  legislation  on  any  matter  affecting 
the  higher  interests  of  the  people  can  be  expected  to  become  law, 
or,  if  enacted,  to  be  carried  into  operation  in  this  country,  with- 
out a  vast  amount  of  discussion, — rarely  without  sharp,  if  not 
acrimonious,  controversy.  Questions  of  Public  Health  form  no 
exception  to  the  rule.  Our  national  discordance  of  opinion  on 
this  subject  may  be  due  to  the  facts  that  it  has  never  until  lately 
been  thought  worth  the  undivided  attention  of  a  distinct  depart- 
ment of  the  State,  that  the  elements  of  physiology  have  formed 
no  part  of  a  liberal  education,  and  that  money-getting,  protec- 
tion of  property,  party  politics  and  polemics,  have  absorbed  the 
thoughts  and  energies  of  the  people,  so  that  when  called  upon 
to  enact  and  administer  good  health  laws,  they  and  the  govern- 
ments whom  they  support  are  ^^  at  sea."  False  maxims,  private 
interests  and  established  wrongs  combine  to  obstruct  and  pervert 
sound  principle  and  true  progress. 

Moreover,  not  only  has  the  care  of  the  national  health,  in  its 
several  sections,  been  unadvisedly  distributed  among  various 
departments,  but  even  in  the  present  advance  towards  unity  there 
is  no  little  danger  in  its  combination  with  Local  Government  and 
Poor-Law  Administration.  Still  we  may  accept  that  combination 
in  hope  and  trust,  demanding  only  that  the  physical  condition  of 
the  people  and  the  improvement  of  the  race  shall  be  the  primary 
object  of  the  newly  constituted  authorities,  central  and  local ; 
and  that  however  slow  and  cautious  may  be  the  steps  taken  to 
secure  that  object,  each  shall  be  consistent  with  the  other,  so 
that  in  the  end  we  may  witness  the  completion  of  a  system  of 
Sanitary  Administration  worthy  of  so  great  a  nation. 


II.— Spenee's  Lectures  on  Surgery.^ 

These  two  parts  complete  Mr.  Spenee's  work  upon  Surgery. 
The  general  principles  of  surgery,  and  the  diseases  and  injuries 
of  special  structures,  were  fully  considered  in  the  earlier  portions 
of  the  work,  which  received  notice  in  this  review  shortly  after 
publication. 

The  portions  now  placed  before  the  profession  form  not  only 
the  largest,  but  also  the  most  important  and  the  most  interesting 
section  of  the  work,  inasmuch  as  they  deal  with  that  branch  of 

^  Lectures  on  Surgery  by  James  Spekce,  P.R.S.E.,  Surgeon  to  the  Quecu  in 
Scotland,  Professor  of  Surgery  in  the  University  of  Edinburgh,  &c.,  &c.,  Parts  III 
and  IV.     Edinburgh,  lS7l. 


1872.]  Spencers  Lectures  on  Surgery.  19 

surgery  which  will  always  have  a  special  attraction  to  surgeons, 
namely,  the  practical  relief  which  can  be  given  to  patients  by 
operative  means.  This  relief  is  in  many  cases  so  complete 
and  immediate  that  it  both  gratifies  our  sense  of  humanity, 
and  makes  us  feel  proud  of  the  scientific  position  which  the 
healing  art  has  attained.  These  considerations  will  induce  us  to 
presently  lay  before  our  readers,  a  few  short  extracts  to  enable  them 
to  judge  of  the  ability  of  Mr.  Spence,  as  a  trustworthy  and  most 
experienced  guide  through  the  difficult  and  intricate  paths  of 
modern  surgery.  We  will,  however,  for  a  moment  direct 
attention  to  the  general  scope  of  the  great  work  now  completed. 

If  we  peruse  the  preface  (which  is  to  be  found  at  the  end  of 
the  4th  part),  we  observe  with  pleasure  that  our  author  justifies 
the  omission  of  ophthalmic  surgery  altogether,  a  proceeding  in 
which  we  entirely  concur.  The  surgery  of  the  eye  cannot  be 
embraced  within  the  limits  of  a  chapter ;  it  demands  a  separate 
treatise.  It  has  made  such  enormous  progress  since  the  inven- 
tion of  the  ophthalmoscope,  that  it  is  hardly  possible  to  do  justice 
to  it  in  a  work  on  general  surgery.  This  we  may  see  by  looking 
at  any  of  the  modern  treatises  which  profess  to  include  it ;  for 
example,  the  new  edition  of  Sir  William  Fergusson's  ^  System 
of  Practical  Surgery^  would  have  been  better  if  the  chapter  on 
the  eye  had  been  altogether  omitted.  And  this  leads  us  to 
speak  of  another  point  upon  which  Mr.  Spence  has,  as  it  appears 
to  us,  exercised  a  wise  discretion.  He  tells  us  that,  while  he 
has  omitted  no  subject  which  ought  properly  to  find  a  place 
in  a  course  of  lectures  upon  systematic  surgery,  he  has  dwelt 
at  greatest  length  upon  certain  subjects  for  the  study  of  which 
he  has  had  unusual  advantages.  At  the  present  day  so  ex- 
tended is  the  field  of  surgery,  and  so  diligently  have  its  difierent 
parts  been  cultivated,  that  it  is  impossible  for  any  one  man  to 
be  equally  conversant  with  all  its  departments.  It  is  wise, 
therefore,  that  each  should  claim  to  speak  with  authority  only 
on  those  points  with  which  he  is  fully  acquainted ;  and  it  is 
on  this  principle  that  Mr.  Spence  has  spoken  in  most  detail 
upon  such  subjects  as  the  excision  of  joints,  amputations, 
injuries  of  the  air  passages,  hernia,  and  the  diseases  of  the 
urinary  organs. 

We  will  now  lay  before  our  readers  two  or  three  extracts 
relative  to  these  subjects  upon  which  Mr.  Spence  can  speak 
with  the  greatest  authority,  and  in  the  first  place  we  will  quote 
his  opinions  as  to  excisions  of  joints,  a  class  of  operations  whose 
history  is  specially  connected  with  the  Edinburgh  school  of 
surgery.  On  the  subject  of  excision  of  the  knee-joint  and  its 
advantages  as  compared  with  amputation,  Mr.  Spence  says  :— 

*'  Excision  of  the  kuee-joinfc,  so  far  as  the  operation  has  yet  been 


fj()  Reviews.  [Jan., 

tested,  can  scarcely  contrast  favorably  with  ampntation  at  the  lower 
part  of  the  thigh  for  disease  of  the  knee-joint.  I  am  aware  that 
favorable  comparisons  have  been  made  by  contrasting  cases  of  ex- 
cision of  the  knee-joint  with  amputations  of  the  thigh  generally;  but 
the  comparison,  to  be  a  fair  one,  must  be  between  cases  of  amputa- 
tion performed  for  diseased  conditions  similar  to  those  for  which  the 
excision  is  had  recourse  to.  My  experience  of  amputation  has 
shown  me  that  not  only  the  extent  of  the  limb  removed,  but  also 
the  nature  of  the  disease  for  which  it  is  removed,  make  a  great  dif- 
ference as  to  the  success  or  fatality  of  the  operation,  and  that 
amputation  in  cases  of  simple  strumous  disease  of  the  knee-joint 
affords  the  greatest  amount  of  success  ;  and  this  is  the  class  of  cases 
for  which  we  perform  excisions.  "With  all  my  feeling  in  favour  of 
excision  ofthe  knee-joint  as  a  substitute  for  amputation  of  the  thigh, 
I  cannot  help  believing  that  in  certain  conditions  it  is  more  dan- 
gerous than  amputation,  and  that  the  character  of  the  operation  is 
likely  to  be  perilled  by  its  being  indiscriminately  resorted  to.  In 
reference  to  an  absolute  advantage  of  excision  of  the  knee  over 
amputation  as  regards  the  results  in  successful  cases,  no  one  can 
doubt  that,  and  I  think  the  question  now  to  be  considered  in  regard 
to  the  comparative  mortality  of  these  operations  is  to  endeavour  to 
discriminate  between  the  cases  in  which  the  one  or  the  other  of 
these  operations  presents  the  least  risk  of  life.  Here,  as  in  ampu- 
tations, it  is  difficult  or  impossible  to  gain  much  from  mere  general 
statistics.  What  we  want  to  know  in  considering  such  a  point  is, 
all  the  circumstances  of  the  cases  operated  on,  which  may  have 
influenced  the  result,  and  hence  the  surgeon  will  learn  more  from, 
and  naturally  be  more  impressed  with,  the  result  of  his  own  cases, 
or  of  cases  which  he  has  opportunities  of  closely  observing.  My 
own  experience  of  excision  of  the  knee-joint  is  comparatively 
limited,  and  therefore  in  stating  to  you  the  results,  any  deductions 
I  may  draw  from  my  cases  are  to  be  regarded  as  merely  suggestive, 
not  positive." — p.  710. 

In  continuation  of  his  observations,  Mr.  Spence  goes  into  a 
lengthy  and  careful  analysis  of  eighteen  cases  in  which  he  has 
performed  excisison  ofthe  knee-joint — the  sort  of  analysis  which 
is  urgently  needed  if  we  are  to  be  able,  in  any  given  case,  to 
strike  a  nice  balance  between  the  pros  and  cons  of  excision  and 
amputation.  Indeed,  one  of  the  most  valuable  features  about 
the  present  work  is  the  elaborate  analysis  that  he  gives  of  his 
own  cases.  This  is  still  more  apparent  when  he  comes  to  speak 
of  amputations.  As  a  civil  surgeon  he  has  performed  an 
unusually  large  number  of  such  operations  : — 403  in  all 

This  number  is  sufficient  to  form  a  fair  basis  for  drawing 
eonclusions;  and  our  author  analyses  them  carefully,  giving 
the  exact  nature  ofthe  disease  or  injury  in  each  case,  and  the 
precise  result,  whether  favorable  or  unfavorable.  It  is  obvious 
that  statistics  so  prepared  are  of  very  great  value ;  indeed,  they  are 


1872.]  Spence's  Lectures  on  Surgery.  21 

the  only  statistics  that  will  in  any  degree  satisfy  the  demand  that 
there  is  at  the  present  day  for  accurate  and  discriminating  in- 
formation. 

Among  other  subjects  which  Mr.  Spencc  has  had  singular 
advantages  for  studying  are  croupous  and  diphtheritic  affections 
of  the  throat.  These  are  always  a  difficult  class  of  cases,  for  the 
practitioner  is  usually  called  to  them  suddenly;  he  finds  his 
patient  in  urgent  distress,  something  must  be  done,  and  whether 
that  something  ought  to  take  the  form  of  an  operation  is  often 
a  very  perplexing  question. 

The  opinion,  therefore,  of  the  Edinburgh  Professor  upon  that 
questio  vexata,  the  value  of  tracheotomy  in  croup,  will  be 
perused  by  our  readers  with  special  interest.    He  thus  writes  : — 

"The  presence  of  any  extensive  exudation  of  false  membrane 
must  always  be  a  formidable  objection  to  tracheotomy.  If  partially 
loose  it  may  be  so  placed  as  to  act  as  a  valvular  obstruction  at  the 
lower  aperture  of  the  tracheotomy  tube ;  and  if  the  membrane  exist 
in  the  complete  tubular  form,  as  in  that  state  it  is  often  but  loosely 
attached,  it  may  collapse,  on  the  trachea  being  opened,  and  cause 
immediate  suffocation.  If  I  am  correct  in  holding  the  opinion  that 
bronchitis  or  croupous  exudation,  when  present  to  any  extent,  form 
objections  to  tracheotomy,  it  must  be  evident  that  very  few  of  the 
cases  which  we  see  in  young  children  admit  of  its  performance  with 
reasonable  chance  of  success,  except  at  a  much  earlier  period  of  the 
disease  than  is  generally  thought  proper  to  consider  of  its  propriety 
in  this  country.  In  estimating  the  success  of  the  operation  for 
croup  in  France  bj  M.  Trousseau  and  otlier  surgeons,  we  must 
keep  in  mind,  not  merely  the  comparatively  great  success  of  what 
has  proved  by  no  means  so  successful  an  operation  in  this  country  ; 
but,  taking  into  account  the  early  stage  in  which  it  has  been  per- 
formed there,  we  must  ask  ourselves  whether  many  of  the  cases 
might  not  have  recovered  under  active  treatment  without  such  a 
hazardous  operation.  In  very  young  children,  under  three  years  of 
age,  besides  other  dangers  incident  to  the  operation  at  that  period, 
the  bronchitis  which  follows  the  operation  must  render  the  chance 
of  success  very  small  indeed,  and  the  unfortunate  results  of  such 
cases  often  prevent  the  surgeon  being  permitted  to  perform  tracheo- 
tomy in  cases  proper  for  it." — p.  1097. 

Again,  in  speaking  ofstrangulated  hernia,  Mr.  Spence  pursues 
the  same  course  as  he  has  followed  with  regard  to  other  subjects, 
such  as  excision  and  amputation,  and  presents  an  analysis  of  his 
own  operation  cases. 

"  Several  years  since  (he  writes)  I  looked  over  the  results  of  127 
cases  of  hernia  in  which  I  had  operated,  and  in  these  there  were 
twenty-six  deaths  :  in  seventeen  out  of  the  fatal  cases  the  gut 
was  distinctly  gangrenous,  and  therefore,  though  the  operation  was 
the  only  chance  of  saving  the  patient's  life,  the  state  of  the  intes- 


23  Reviews.  [Jan., 

tino  was  sucli  that  a  favorable  result  could  hardly  be  expected. 
In  seven  cases  peritonitis  had  commenced  before  the  operation ;  and 
of  these  four  were  cases  of  congenital  hernia,  where  peritonitis 
occurs  rapidly.  In  one  case  pyaemia  proved  fatal  on  the  eighth  day, 
but  this  case  was  a  very  complicated  one.  In  one  recent  case  a  fatal 
result  occurred :  here  the  operation  was  extra-peritoneal,  and  the 
hernia  was  very  large  and  bulky,  and  had  come  down  rather  rapidly 
while  the  patient  was  at  work.  The  man  made  violent  efforts  at 
the  time  to  reduce  the  hernia,  while  afterwards  attempts  were  also 
made,  but  without  success.  In  this  case  the  hernia  had  only  been 
down  for  twelve  hours.  When  I  operated  I  divided  the  integument 
and  the  fascia  down  to  the  deep  ring,  and  then,  by  dividing  the  tex- 
tures external  to  the  neck  of  the  sac,  I  was  able  to  reduce  the  hernia 
with  ease.  After  a  time  the  patient  began  to  pass  bloody  stools, 
showing  that  hsemorrhage  from  the  interior  of  the  gut  had  taken 
place,  evidently  in  consequence  of  the  efforts  the  man  had  made  to 
reduce  the  hernia  at  first.  I  believe  that  if  cold  had  been  applied 
to  the  tumour,  and  the  taxis  properly  employed  at  first,  the  hernia 
might  have  been  reduced  without  any  operation.  The  real  cause  of 
the  fatal  result  was  evidently  the  mischief  produced  by  the  violent 
and  ill-directed  efforts  made  by  the  patient  to  reduce  the  hernia 
when  it  came  down." — p.  1162. 

In  speaking  of  the  important  subject  of  urethral  stricture  we 
are  gl[id  to  see  that  Mr.  Spence  dismisses  the  "  spasmodic 
stricture  "  from  the  list  of  strictures  proper.  He  says  that  the 
spasmodic  or  engorged  constriction  ought  scarcely  to  be  called 
a  stricture.  In  this  we  quite  agree  with  him.  If  the  urethra  is 
merely  congested,  as  it  frequently  is  when  acute  gonorrhoea  is 
present,  the  condition  ought  not  to  be  termed  "  stricture ;" 
while  if  there  is  a  real  spasm  of  the  muscular  fibres  surrounding 
the  canal,  we  believe  it  filways  points  to  a  pre-existent  organic 
stricture ;  and  in  such  a  case  the  organic  stricture  and  not  the 
spasm  is  the  matter  to  which  the  surgeon  ought  to  address  himself. 

While  we  are  on  the  subject  of  stricture  it  will  be  interesting 
if  we  lay  before  our  readers  the  author's  estimate  of  "Holt's 
operation."  A  few  years  ago  the  method  which  Mr.  Holt 
introduced,  or  revived,  was  in  the  ascendant.  Now,  however, 
there  seems  a  tendency  to  decry  it.  The  opinion  of  Mr.  Spence 
will,  moreover,  be  read  with  more  interest,  inasmuch  as  he 
tells  us  that  he  was  at  first  strongly  opposed  to  the  operation, 
and,  when  he  gave  it  a  trial,  he  did  so  under  some  amount  of 
prejudice. 

"  I  was  at  first  prejudiced  against  this  plan,  owing  to  what  I  had 
seen  of  the  efiects  produced  by  the  forcible  dilatation  with  the 
conical  sound.  In  cases  where  that  instrument  had  been  used  I 
had  noticed  that  an  irritable  and  resilient  state  of  the  contraction  was 
the  almost  invariable  result,     From  some  opportunities  I  had   ot 


1872.]  SrENCE^s  Lectvres  on  Surgery,  23 

examining  strictures  dilated  by  this  method  on  the  dead  body,  I 
found  the  mucous  membrane  at  and  on  either  side  of  the  stricture 
fissured,  and  I  considered  this  condition  so  similar  to  that  of  fissure 
of  the  rectum,  that  the  intense  irritability  seemed  to  me  referable  to 
this  fissured  condition  of  the  mucous  membrane.  Hence  the  imme- 
diate dilatation,  by  Mr.  Holt's  method,  seemed  to  me  as  likely  to 
lead  to  the  same  disagreeable  results ;  but,  after  trying  it  in  some 
cases,  and  having  had  an  opportunity  of  examining  a  stricture  which 
had  been  treated  by  his  method,  I  found  there  was  a  difference 
between  its  action  and  that  of  the  conical  bougie.  I  saw  that  by 
his  plan  the  stricture  was  fairly  ruptured,  not  only  through  the 
mucous  membrane,  but  through  the  condensed  submucous  tissue 
forming  the  contraction.  Now  we  know  all  that  is  required  to  cure 
the  excessive  irritability  of  fissure  of  the  anus  is  division  of  the  fissure 
fairly  through  its  hard  base  ;  and  whilst  we  usually  eftect  that  with 
the  knife,  still  it  can  be  effected  by  the  coarser  method  of  rupture 
with  the  fingers ;  so  that  Holt's  method,  by  fairly  rupturing  the 
hardened  basement  texture  of  the  contraction,  prevents,  or  even 
cures,  the  irritable  condition  of  the  stricture,  and  thus  acts  very  dif- 
ferently from  the  partial  fissuring  of  the  mucous  membrane  caused 
by  the  conical  bougie.  Forthe  last  nine  or  ten  years  I  have  practised 
Holt's  method,  and  with  great  success,  so  that  I  feel  no  hesitation 
in  recommending  it  as  at  once  efficacious  and  safe — that  is,  as  free 
from  danger  as  any  operation  on  diseased  urinary  organs  can  be." 
—p.  1319. 

It  is  curious  and  instructive  to  study  the  general  remarks 
which  Mr.  Spence  makes  with  regard  to  the  arrest  of  haemor- 
rhage  in  amputations  and  the  mode  of  dressing  stumps,  remarks 
which  we  presume  may  be  taken  as  applicable  to  a  much  wider 
series  of  cases  than  those  with  regard  to  which  they  are  made. 
The  haemorrhage,  he  tells  us,  from  large  arteries  is  to  be  arrested 
by  the  ligature  or  hy  acupressure.  Scotland  is  still  loyal  to  the 
suggestion  of  Sir  James  Simpson,  and  carries  out  his  method. 
But  on  this  side  of  the  Tweed  it  is  almost,  if  not  quite 
abandoned.  We  believe  we  are  right  in  saying  that  no  metro- 
politan surgeon  uses  acupressure  except  in  certain  rare  cases, 
and  in  certain  situations  to  which  it  is  specially  applicable.  It 
has  yielded  the  palm  to  torsion.  But  this  latter  method  is 
scarcely  alluded  to  by  our  author,  indeed  it  finds  no  place  at 
all  in  his  practical  instructions.  There  is  a  strong  feeling 
among  English  practitioners  that  acupressure  cannot  be  relied 
on — that  the  way  in  which  it  occludes  the  vessel  is  not  trust- 
worthy— and  that  there  is  more  danger  of  secondary  haemorrhage 
after  its  employment  than  when  we  use  either  the  ligature  or 
torsion. 

Again,  it  is  curious  to  observe  that  in  his  directions  for  dress- 
ing stumps  and  tying  large  arteries  in  their  continuity,  nothing 


21  Reviews.  [Jan., 

is  said  about  the  antiseptic  treatment  of  wounds  or  the  carbolised 
ligatures  of  animal  membrane,  about  which  we  hear  so  much 
from  another  distinguished  Edinburgh  professor.  This  silence 
is  ominous.  Indeed,  Mr.  Spence's  method  of  dressing  stumps 
consists  in  laying  them  on  a  pillow  and  leaving  them  entirely 
alone,  a  method  which  is  the  very  reverse  of  Mr.  Lister's  ;  so 
that  the  students  of  the  Edinburgh  University  have  the  advan- 
tage of  seeing  two  very  different  methods  of  dressing  carried  out 
in  the  wards  of  the  infirmary. 

Throughout  Mr.  Spence's  work  are  scattered  clinical  cases, 
the  details  of  which  are  given  in  extenso.  At  the  end  of  each 
chapter  a  few  such  are  to  be  found.  They  are  for  the  most  part  very 
illustrative  cases,  and,  at  the  same  time,  very  curious  instances 
of  surgical  disease.  Indeed,  such  could  hardly  fail  to  be  the 
case,  for  they  are  selected  from  a  hospital  practice  of  thirty-five 
years'  duration.  We  would  gladly  lay  one  or  two  before  our 
readers,  but  they  are  reported  at  such  length  that  we  must 
forbear,  and  content  ourselves  with  the  few  extracts  which  we 
have  given  as  illustrative  of  his  teaching. 

We  cannot  congratulate  Mr.  Spence  upon  the  form  in  which 
he  has  brought  out  his  Lectures.  A  w^ork  v>'hich  comes  out  in 
parts,  and  which  reserves  the  title-page,  preface,  and  table  of 
contents  to  the  end  of  the  last  instalment  is  unsatisfactory  to 
the  reader,  and  is  apt  to  place  the  author  at  a  disadvantage. 
It  is  putting  the  cart  before  the  horse,  and  that  does  not  give 
fair  play  to  either.  It  would  have  been  better  if  Mr.  Spence 
had  waited  till  his  whole  series  of  Lectures  was  complete,  and 
then  have  brought  them  out  at  one  time.  However,  the  mode 
of  publication  is  a  thing  which  may  fairly  be  left  to  the  author's 
convenience.  If  he  brings  out  his  work  in  a  way  that  does  not 
commend  itself  to  the  public,  he  will  probably  be  reminded  of 
the  fact  by  a  slow  and  tardy  sale.  But  there  is  another  point 
which  is  a  fair  subject  for  criticism,  and  that  is  the  character  of 
the  illustrations  which  are  scattered  through  the  book.  On  this 
point  we  have  before  expressed  an  opinion  in  noticing  the  two 
previous  volumes,  and  what  we  there  said  we  can  only  reiterate 
now,  and,  if  possible,  with  greater  force  and  emphasis.  Mr. 
Spence  is  undoubtedly  a  very  able  and  experienced  surgeon,  but 
he  is  evidently  not  an  artist.  He  has  not  the  gifts  which  Sir 
Charles  Bell  possessed,  and  which  enabled  that  great  surgeon  to 
use  the  pencil  with  fully  as  much  skill  as  the  scalpel.  But  Mr. 
Spence  has  not  even  an  artistic  eye ;  he  does  not  seem  to  know 
good  illustrations  from  bad  ones.  It  is  evident  that  he  has 
gone  to  great  expense  in  getting  up  the  chromo-lithographs, 
engravings  and  woodcuts  with  which  his  pages  abound,  but  his 
outlay  has  been  productive  of  a  very  poor  return.    The  chromo- 


1872.]      JVest  Riding  Lunatic  Asylum  Medical  Reports.        25 

lithographs  in  these  present  voUimes  are  as  coarse  and  bad  as  those 
which  preceded  them,  and  coarse  chromo-lithographs  are  very 
had  indeed ;  while  of  the  woodcuts  we  may  safely  say  that  not 
a  few  convey  no  clear  idea  of  what  they  are  intended  to  repre- 
sent. The  illustrations  in  works  of  this  kind  should  speak  for 
themselves.  They  should  be  so  sharp  and  clear,  and  the  point 
of  the  drawing  ought  to  be  brought  into  such  prominence,  that  a 
mere  tyro  can  tell  what  they  are  intended  to  show.  But  if  Mr. 
Spence's  illustrations  are  tried  by  this  rule,  a  great  many  will 
be  found  to  fall  grievously  short.  When  his  Lectures  reach  a 
second  edition,  there  is  nothing  in  which  he  could  so  much 
improve  the  work  as  by  expunging  many  of  the  present  illustra- 
tions and  introducing  new  ones.  And  we  sincerely  hope  that 
it  will  not  be  long  before  he  has  an  opportunity  of  carrying  out 
this  suggestion.  His  work  is  quite  worthy  to  stand  on  our 
shelves  in  company  with  '^  Syme,"  and  "  Miller,^^  and  "  Pirrie," 
and  other  modern  ornaments  of  Scottish  surgery ;  it  is  quite  en- 
titled to  hold  a  place  with  the  "  Systems,"  which  have  lately 
issued  from  the  hands  of  English  surgeons,  and  we  hope  that 
that  large  number  of  students  and  practitioners  who  look  to 
Edinburgh  as  their  Alma  Mater,  will  not  be  slow  to  show 
their  appreciation  of  it. 


III.— Medical  Reports  of  the  West  Riding  Asylum. i 

We  believe  the  volume  of  Asylum  Reports  under  review  to 
be  the  first  of  its  kind.  It  inaugurates  a  new  era  in  ])sycho- 
logical  literature,  and  the  originators  may  be  congratulated  on 
their  enterprise. 

Several  attacks  have  recently  been  made  upon  the  medical  staff 
of  the  public  lunatic  asylums  of  this  kingdom.  Superinten- 
dents have  been  charged  with  not  contributing  their  clue  share 
to  medical  knowledge  ;  with  failure  to  advance  materially  the 
British  school  of  pathology ;  and  with  so  devoting  their  best 
powers  to  executive  and  organisation,  as  largely  to  sink  the 
physician  in  the  manager.  Some  of  these  attacks  were  in  part 
levelled  against  the  assistant  physicians.  We  believe  that 
a  correct  appreciation  of  the  position  and  responsibilities  of 
asylum  officers  will  show  that  these  charges  are  in  the  main 
unfounded;  that,  though  true  with  regard  to  a  few,  they  are  not 
applicable  to  the  majority.  Much  has  been  accomplished  by 
our    asylum   medical   officers.       They   have   issued    works    on 

^  The  West  Riding  Lunatic  Asylum  Medical  Reports.  Edited  by  J.'  CmcHTON 
Beowne,  M.D.,  F.R.S.E.     Vol.  i,  1871. 


20  Reviews.  [Jan., 

psychiatry;  tlieir  contributions  to  the  medical  serials,  including 
their  own  'Journal  of  Mental  Science,' are  numerous;  their 
association  meetings  educe  much  scientific  labour  ;  their  experi- 
mental investigations  into  new  views,  and  trials  of  new  remedies, 
are  often  elaborate ;  while  thoy  have  enriched  the  therapeutic 
art,  and  widened  the  application  of  its  resources. 

That  greater  results  have  not  been  achieved  by  them  may  be 
partly  from  remissness,  but  is  largely  to  be  accounted  for  by 
urgent  reasons.  To  effect  the  curative  and  mitigatory  objects 
of  an  asylum,  its  whole  arrangements  must  be  under  medical 
supervision,  and  form  part  of  a  comprehensive  treatment.  With- 
out a  general  directing  control,  the  best  efforts  of  the  asylum 
physician  may  be  frustrated.  The  moral  element  in  the  treat- 
ment, and  especially  the  importance  of  personal  influence  on 
the  insane,  must  be  kept  in  mind.  Now  the  general  scheme  of 
treatment,  the  regulating  moral  influence  and  tact  required, 
make  large  demands  on  the  powers  of  the  ''  silent  worker  "  for 
unobtrusive  ministry  of  love,  and  philanthropic  but  exhausting 
labours.  The  average  lunatic  asylum  contains  several  hundred 
patients,  whose  treatment  must  be  undertaken  by  the  superin- 
tendent and  assistant  medical  officer.  Many  of  these  patients 
live  on  year  after  year,  incurable,  changing  but  slightly,  affording 
no  basis  for  special  continued  medical  observation ;  yet  often 
perhaps  troublesome  or  turbulent,  and  then  necessarily  absorb- 
ing much  attention.  If  the  first  thoughts  of  the  medical 
oflicers  are  for  the  recovery  and  comfort  of  their  charges,  the 
time  left  available  for  original  and  minute  investigations  must 
be  limited. 

A  systematic  enunciation  of  the  experience  of  asylum  physi- 
cians is  not  stimulated  by  conjunction  of  the  lunatic  hospital 
with  medical  schools,  or  by  its  wards  becoming  the  theatre  of 
flourishing  classes.  No  "  registrars  "  or  "  hospital  dressers  " 
exist  here  to  record  minute  observations,  and  furnish  the  crude 
material  for  lectures  and  publications  of  "  the  staff.'^  For  the 
above  reasons  it  would  be  unjust  to  compare  the  contributions 
to  medical  science  which  issue  from  asylums  with  those  which 
issue  from  general  hospitals ;  especially  from  the  Metropolitan 
hospitals,  with  their  large  staffs,  their  attached  medical  schools, 
their  rich  resources  and  variety  of  cases. 

But  there  are  further  considerations.  From  a  purely  medical 
point  of  view,  the  difficulties  which  the  physician  to  a  lunatic 
hospital  has  to  encounter  are  of  no  common  order.  They  may 
be  exemplified  in  the  obstacles  to  diagnosis  and  treatment  of 
the  bodily  and  mental  disorders  of  the  insane  ; — obstacles  which 
are  at  oiice  appreciated  by  those  who  pass  from  private  to  asylum 
practice.     The  diagnosis  of  the  ordinary  (bodily)  diseases  of  the 


1872.1      JVest  Riding  Lunatic  Asylum  Medical  Reports.        27 

insane  is  often  beset  ^vitli  peculiar  difficulties.  Mental  impair- 
ment may  lessen  sensibility  to  patliological  processes^  and  the 
lethargy  of  the  excito-motor  powers  may  curtail  the  usual 
perturbation  of  disease,  and  obscure  its  phenomena.  Unwilling- 
ness to  be  examined,  anomalous  complaints,  maniacal  incoherence, 
or  fatuous  utterance,  too  often  are  sad  substitutes  for  the  desirable 
correct  communication  of  subjective  feelings.  It  is  only  neces- 
sary to  recall  how  frequently  disease  in  the  insane  is  latent ; 
how  phthisis  may  make  ruin  of  the  lungs,  while  slight  emacia- 
tion, slight  failure  in  strength,  and  listlessness,  are  the  only 
perceptible  symptoms ;  how  pneumonia  may  advance  far,  uncom- 
plained  of,  and  presenting  nothing  beyond  the  physical  signs, 
save  slight  dyspnoea,  anorexia,  and  frequent  pulse.  Or  suppose 
a  rib  to  be  broken  ;  the  diagnosis  will  not  be  facile  in  a  storming 
raving  maniac.  Nor  are  th3  difficulties  in  the  treatment  of  the 
bodily  diseases  of  the  insane  of  inferior  gravity  to  those  of 
diagnosis.  These  unfortunates  already  labour  under  disease  of 
an  organ  of  exquisite  structure  and  primary  importance,  whose 
marvellous  sympathies  are  coextensive  with  the  whole  organism, 
and  whose  disorders,  as  a  rale,  bear  adversely  on  every  part  and 
function.  Constitutional  degeneration  is  too  often  concomitant, 
and  any  special  disease  occurring  tends  to  partake  of  the 
asthenic  character,  and  its  products  incline  towards  devitalisa- 
tion.  Insane  refusal  of  food  and  medicine,  and  dietetic  anomalies 
may  neutralise  the  best  directed  effi)rts.  The  management  of 
fractures  may  be  grievously  complicated  by  manaical  furor, 
melancholic  delusion,  or  demented  intolerance  on  the  part  of 
patients,  leading  to  ceaseless  effi)rts  to  cast  off  all  surgical  appli- 
ances. Such  illustrations  might  be  vastly  multiplied.  The 
asylum  physician  finds  these  conditions  hostile  to  his  efforts; 
his  results  will  not  be  so  quickly  attained,  nor  average  so  satis- 
factorily, as  they  would  if  he  was  physician  to  an  ordinary 
hospital. 

But  lunatic  asylums  are  especially  expected  to  elucidate 
psychical  disorders.  In  this  connection  we  need  only  mention 
the  impossibility  of  an  anatomical  diagnosis  in  most  cases  of 
mental  disease,  and  the  difficulty  of  gaining  a  clue  to  the  maze 
of  words  or  pantomime  of  action  ;  while,  with  regard  to  the 
treatment  of  insanity,  we  must  bear  in  mind  the  frequency  of 
incurable  organic  lesions  therein,  and  the  subtle  fallacies  that 
attend  any  conclusion  drawn  from  its  treatment  by  drugs. 

We  believe,  therefore,  that  too  much  has  been  expected  from 
public  lunacy  experience.  But  a  mass  of  pathological  record 
must  exist,  locked  up  in  the  case-books  of  our  asylums,  and 
while  the  medical  officers  to  these  have,  as  a  rule,  done  much  in 
search  and  observation,  it  may  be  that  they  have  not  made  com^ 


28  Beviews,  [Jan., 

mciisurate  efforts  in  exposition.  There  is  special  interest,  there- 
fore, in  the  vohinie  under  notice,  the  first  of  an  annual  series  of 
medical  reports.  It  will  to  some  extent  answer  the  strictures 
made  on  asylum  medical  officers  of  all  grades ;  for  eleven  of  the 
thirteen  contributions  are  from  the  pens  of  gentlemen  who  are 
or  have  been  clinical  assistants  or  junior  medical  officers  at 
Wakefield,  while  the  two  other  articles  are  written  by  the  medi- 
cal chiefs  there. 

Most  of  the  papers  testify  to  the  scientific  character  of  the 
work  done  at  the  West  Riding  Asylum,  to  minute  accuracy  of 
observation,  to  patient  multiplication  of  experiments,  and  to  the 
rich  resources  of  the  records. 

We  will  say  a  few  words  about  each  of  the  articles  included 
in  the  volume,  in  the  order  in  which  they  occur. 

I.  Cranial  Injuries  and  Mental  Diseases.  By  J.  Crichton 
Browne,  M.D. — This  article  awaits  completion  in  the  next 
volume.  In  the  present  portion  the  importance  of  cranial  inju- 
ries as  causes  of  mental  disease  is  insisted  on,  and  the  sugges- 
tion is  made  that  such  injuries  infl.icted  on  the  child  during 
parturition  are  a  prolific  source  of  mental  defects  and  derange- 
ments; while  attention  is  drawn  to  certain  rarer  causes  of  cranial 
injury  during  childhood.  This  prominence,  claimed  for  cranial 
lesions  in  the  etiology  of  mental  derangement,  is  apparently 
negatived  by  the  custom  of  many  American  tribes.  From  long 
antiquity  they  have  taken  precautions  to  deform  the  skulls  of 
their  infants.  The  tribes  which  follow  this  ancestral  custom  are 
not  known  to  generate  mental  defect  or  disorder  thereby,  but 
share,  with  other  similar  tribes,  that  singular  immunity  from 
psychical  diseases  which  is  enjoyed  by  races  of  inferior  civilisa- 
tion. But  this  non-effect  of  the  artificial  cranial  deformity  on  the 
mental  integrity  of  those  subjected  to  it,  will  not  contravene  the 
position  that  cranial  lesions  do  really  play  an  important  part  in 
the  causation  of  mental  disease  ;  for,  as  Dr.  Browne  points  out, 
the  procedure  obtains  survival  of  the  fittest  infants,  by  extin- 
guishing the  more  weakly  beings ;  it  causes  displacement  of  the 
brain,  but  neither  arrest  of  its  development,  nor  diminution  of 
cranial  capacity;  it  exaggerates  the  conformation  of  the  skull 
natural  to  the  race ;  it  leaves  the  brain  free  to  exert  a  growing 
pressure  from  within,  and  to  resume  more  or  less  its  pristine 
site ;  it  inflicts  more  osseous,  than  nervous,  damage  on  these  un- 
cultured tribes,  whose  skulls  are  thicker,  and  whose  nervous 
systems  are  much  less  susceptible  than  those  of  long  civilised 
nations.  European  crania  would  not  undergo,  with  safety  to 
their  more  exquisitely  delicate  contents,  the  distortions  common 
to  the  head  forms  of  the  dwellers  on  the  mighty  pampas,  or 


1872.1      JVest  Hiding  Lunatic  Asylum  Medical  Reports.        29 

within  the  shadows  of  the  Andes.  Nor  could  the  European 
hrain  sustain  with  impunity  the  shocks  to  which  that  of  the 
African  is  often  subjected.  The  negroes  of  the  American  states, 
in  their  quarrels,  make  fierce  onsets,  charging  with  lowered 
heads,  so  that  the  vertices  of  the  opponents  often  come  into  vio- 
lent collision,  rarely,  however,  causing  any  injury  to  their 
cerebral  functions. 

Dr.  Browne  points  out  that,  with  the  advance  from  barbarism 
to  civilisation,  we  also  find  advancing  in  a  parallel  manner  an 
increasing  insanity,  an  increasing  average  size  of  head,  and  an 
increasing  difficulty  of  childbirth.  These  three  coincident 
facts  possibly  bear  a  more  intimate  relation  than  is  usually  sup- 
posed;— a  relation  which  would  seem  to  be  supported  by  the  more 
frequent  dystocia  and  cranial  lesion  in  male  births,  dependent 
on  the  larger  average  cranial  measurement  in  these.  It  would 
seem  probable,  therefore,  that  cranial  injuries  received  during 
birth,  and  resulting  from  disproportion  between  the  foetal  head 
and  the  maternal  passages,  form  one  of  the  factors  of  the  modern 
increase  of  insanity.  Idiocy,  insanity,  or  a  proclivity  to  exag- 
gerated predominance  of  the  nervous  symptoms  in  any  acute 
disease,  seem  sometimes  to  be  the  effects  of  cranial  lesions  from 
the  application  of  the  forceps  at  birth. 

M.  K — ,  though  feeble  in  mental  powers  and  ineducable,  pos- 
sessed certain  musical  and  other  aptitudes,  and  is  cited  by  our 
author  as  "  typical  of  that  kind  of  idiocy  which  generally  results 
from  tedious  and  abnormal  but  non-instrumental  labours."  The 
case  coincides  with  a  form   of  hereditary  idiocy,  and  cannot  be 
laid  down  as  at  all  a  type  of  what  maybe  the  outcome  of  abnor- 
mal pressure  inflicted  on  the  foetal  head  in  certain  forms   of 
dystocia.     The    injury    caused    to    the    foetus   by    unsuccessful 
attempts  to  procure  abortion,  was  found  by  Dr.  Howe  to  be  the 
cause  of  idiocy  in  several  cases.     Encephalitic  changes,  gene- 
rated by  the  accidents  of  birth,  may  lay   the  foundation  for 
"future  insanity.     But  in  many  cases,  thought  to  exemplify  this 
statement,  it  is  difficult  to  assign  its  proper  value  to  this  possible 
factor.    For  diathesis  and  the  degeneration  of  form  accompanying 
the  insane  in  certain  families,  would  lead  to  more  frequent  dys- 
tocia, to  more  frequent  cranial  injury  of  the  offspring,  while  at 
the  same   time  there  would  be  a  perplexing  concomitance  of 
greater  hereditariness  of  mental  instability.     Cranial  injury  is 
probably  but  a  small  factor  of  the  increase  of  insanity  amongst 
the  civilised.     Fortunately,  in  children,  depression  of  bone  from 
an  accident,  and  consequent  compression  of  brain,  is  often  only 
temporary;  the  natural  resiliency  of  the  bone,  at  that  age,  with 
the  pulsatory  movements  of  the  brain,  lead  to  restoration  of  the 
osseous  outline, — a  result  which  may  often  be  aided  by  the  trac- 


30  Reviews,  [Jan., 

tion  of  an  exhausted,  and  properly  adjusted,  cupping-glass.  In 
such  cases,  the  concussion  effects  alone  remain  to  implicate  the 
integrity  of  the  nervous  centres — a  class  of  effects  less  prejudicial 
to  that  integrity  in  childhood  than  the  effects  of  coarser  physical 
lesions  of  the  brain  are.  But  in  adults  concussion  is  more  im- 
minently dangerous  as  a  pathway  to  mental  disorder.  The  well- 
known  statistics  of  Schlager  show  a  disastrous  supervention  of 
such  diseases,  frequently  at  a  period  long  subsequent  to  con- 
cussion and  cranial  injury.  But  if  the  hereditary  tendency  to 
mental  disorder  is  strong,  a  slight  injury  will  often  bring  about 
a  rapid  catastrophe,  as  is  well  illustrated  by  Dr.  Browne  in  the 
case  of  J.  W.  M— .  He  cites,  also,  two  cases  in  support  of  the 
frequent  observation  that  idiocy  or  insanity  often  afford  an 
apparent  immunity  from  the  ordinary  ill  effects  of  blows  on  the 
head.  In  several  cases  where  patients  have  the  extraordinary 
habit  of  beating  their  own  heads  on  the  tables  or  forms,  we  have 
thought  that  their  mental  powers  suffered  some  slight  obscura- 
tion as  a  direct  consequence,  but  this  is  difficult  to  decide. 

IT.  Observations  on  the  Physiological  Actmi  of  Nitrous 
Oxide.  By  Samuel  Mitchell,  M.D. — Sir  II.  Davy  compared 
the  action  of  nitrous  oxide  to  that  of  the  diffusible  stimuli,  but 
operating  violently,  so  as  to  cause  death.  It  produced  certain 
changes  in  the  blood  and  organs  of  animals  breathing  it,  at 
*^  first  connected  with  increased  living  action,  but  terminating 
in  death."  This,  he  thought,  was  the  result  of  its  excessive 
stimulating  property,  aud  he  retained  the  view  that  it  increased 
vital  action,  in  spite  of  the  facts  that  its  inhalation  does  not 
obviate  the  debilitating  effects  of  hydrogen,  and  that  animals 
which  have  breathed  it  drown  more  quickly  than  others  which 
have  not. 

Ziegler  concluded  that  nitrous  oxide  is  "  a  powerful  arterial, 
nervous,  and  cerebral  stimulant."  Draper  attributed  its  intoxi- 
cating effects  to  "  the  oxidizing  action  which  it  establishes." 
Mr.  Holmes  and  Dr.  Mitchell  summarise  Hermann's  observa- 
tions thus  : — "  Nitrous  oxide  neither  enters  into  combination 
with,  nor  suffers  changes  from,  nor  produces  changes  in,  the 
blood,  though  easily  soluble  in  it.  Blood  saturated  with  it 
shows  no  sign  of  change,  the  spectrum  change  being  the 
same." 

In  disproof  of  Sir  H.  Davy's  conclusion,  that  nitrous  oxide  kills 
by  its  property  of  excessive  stimulation  of  the  animal  tissues.  Dr. 
Mitchell  adduces  several  elaborate  experiments,  to  show  that 
the  death  of  animals  placed  in  jars  of  the  gas  is  asphyxial,  and 
that  they  die  somewhat  as  they  do  by  submersion  in  water.  Yet 
Ziegler   attributed   to   the  gas    in    solution   direct  revivifying 


1873.]      West  Riding  Lunatic  Asylum  Medical  Reports.        31 

powers,  antidotal  to  asphyxiating  agents  used  experimentally 
on  animals.  In  fact,  here,  as  elsewhere,  the  practical  possi- 
bilities of  the  agent  must  not  be  obscured  by  the  effect  of 
lethal  dosage.  Without  entering  into  the  possible  chemical 
history  of  the  gas  after  its  absorption  into  the  blood-current, 
or  further  discussing  its  effects  on  animals,  we  will  briefly 
notice  its  effects  when  inhaled  in  mixture  with  common  air, 
firstly,  on  man  in  health  and  sanity;  and,  secondly,  on  the 
insane. 

1.  The  effect  of  the  dilute  gas  on  the  sane.  Dr.  Mitchell 
lays  stress  on  a  peculiarity  of  the  delirium  caused  by  inhalation 
of  the  dilute  gas  : 

"  The  ideas  seem,  as  it  were,  to  expand  beyond  the  recognition  of 
the  mind,  which  at  this  point  in  its  disordered  activity  also  seems  to 
vault  over  that  interval  which  in  its  normal  condition  it  recognises 
to  exist  between  the  wish  and  its  realisation.  Automatic  acts 
succeed  each  other,  or  are  repeated  with  great  rapidity,  and  are 
performed  in  an  exaggerated  manner,  the  subject  of  the  experiment 
shouting  and  gesticulating  with  the  greatest  vehemence  should  he 
wish  to  communicate  any,  even  the  most  trivial  thing,  and  often 
repeating  the  last  word  of  a  sentence  many  times,  and  each  time 

in  a  louder  key On  one  occasion on  emerging  from 

the  state  of  delirium I  fancied  that  I  either  had  shouted 

or  Vv^as  on  the  point  of  doing  so,  in  a  triumphant  voice,  '  I  have  filled 

it  again' I  found  that  I  really  had  turned  the  key  to  admit 

more  of  the  gas  into  the  bag.  Had  I  not  come  to  myself  at  that 
moment  I  have  no  doubt  that  in  the  next  this  trivial  occurrence 
would  have  been  magnified  beyond  recognition,  and  have  left  the 
feeling  that  I  had  discovered  the  secret  of  the  universe." 

At  a  certain  stage  of  the  action  of  the  gas  it  was  found  that 
artificial  contortion  of  the  muscles  of  expression  in  imitation  of 
laughing  or  crying,  acted  with  peculiar  potency  in  causing  a 
.paroxysm  of  either  corresponding  emotional  display.  We  cannot 
coincide  with  Dr.  Mitchell's  suggestion,  that  the  general  pro- 
pensity to  laughter  may  be  partly  explained  by  the  convulsive 
contractions  of  the  diaphragm  imitating  an  important  movement 
in  the  automatic  series  accompanying  laughter.  This  contrac- 
tion would  eq[ually  tend  to  produce  crying,  and  "  the  actions  of 
laughter  and  crying  seem  never  to  originate  in  the  respiratory 
system"  (Carpenter). 

But  to  what  is  the  exhilarant  effect  of  nitrous  oxide  due? 
Assuming  "  that  in  nitrous  oxide  we  have  a  chemical  compound 
which,  like  chloroform,  sether,  and  alcohol,  possesses  both  stimu- 
lating and  anaesthetic  properties,  our  author  discards  ''  the 
doctrine  that  stimulants  and  anaesthetics  owe  their  influence  to 


32  Reviews.  [Jan., 

the  elective  affinity  possessed  for  them  by  the  nervous  substance," 
ill  favour  of  the  one  "  that  choloroform,  ether,  and  similar  sub- 
stances, Avhen  present  in  certain  quantities  in  the  blood,  have 
the  effect  of  limiting  those  combinations  between  the  oxygen  of 
the  arterial  blood  and  tissues  of  the  body  which  are  essential  to 
sensation,  volition,  and,  in  short,  all  the  animal  functions."  He 
questions  whether  the  primary  exhilaration  produced  by  these 
substances  is  not  the  first  sign  of  the  progressive  loss  of  the 
power  of  the  mind  rightly  to  appreciate  surrounding  condi- 
tions,  which  culminates  in  complete  paralysis  of  the  cerebral 
functions." 

2.  The  use  of  dilute  nitrous  oxide  in  insanity.  Used  in 
melancholia  it  often  caused  transitory  feelings  of  happiness, 
perfect  rest,  or  self  confidence.  Profuse  flow  of  tears,  and  much 
miserable  moaning,  or  even  screaming,  characterised  one  stage 
of  the  action  in  some,  even  in  some  of  those  whose  black 
cloud  of  melancholia  seemed  lifted  by  the  passing  perturbation 
of  the  agent  \  and  several  afterwards  denied  having  experienced 
any  repressive  emotion.  Both  melancholies  and  dements,  under 
its  influence,  occasionally  exhibited  an  unaccustomed  power  of 
remembrance,  and  more  coherent  speech  in  reference  to  long- 
buried  memories.  Dr.  Mitchell  compares  this  temporary  return 
of  partial  lucidity  to  that  sometimes  seen  in  lunatics  before 
death,  and  suggests  whether  both  instances  are  not  *Mue  to 
the  inability  of  the  vital  powers  any  longer  to  supply  sufficient 
nutriment  to  the  whole  nervous  mass,  the  functional  activity 
of  that  portion  of  the  cerebral  substance  built  up  under  the 
most  favorable  conditions  of  life  alone  surviving."  Now  the  rare 
ante-mortem  lucidity  of  lunatics  seems  to  occur  especially  in 
reflex  insanity;  or  if  observed  in  insanity  with  marked  structural 
brain  lesion,  it  seems  to  depend  rather  on  the  equilibration  of 
lessened  powers  than  on  any  restoration  of  vigorous  action. 
The  beneficial  influence  of  nitrous  oxide  on  melancholia,  de- 
mentia, and  mania,  when  it  occurs,  is  unfortunately,  like  that 
of  ether  and  chloroform,  transitory  and  fleeting.  The  mind 
soon  reverts  to  its  usual  state,  the  rifted  cloud  recloses,  the 
spectral  semblance  of  coherence  is  lost  amidst  the  more  steadfast 
ruins  of  mental  processes.  We  would  suggest  its  employment 
in  puerperal  insanity,  where  the  exigencies  of  the  special  case 
may  imperiously  demand  a  short  calm.  The  greater  safety  of 
the  nitrous  oxide,  as  compared  with  ether  and  chloroform, 
would  seem  to  warrant  its  substitution  for  the  latter  agents, 
whose  use  in  such  cases  has  found  many  advocates.  We  join 
in  the  hope  that,  by  a  wider  application  of  the  uses  of  nitrous 
oxide,  it  may  prove  useful  in  insanity. 


1872. J      West  Riding  Lunatic  Asylum  Medical  Reports.        33 

III.  The  Sphygmograph  in  Lunatic  Asylum  Practice.  By 
George  Thompson,  L.K.C.P.  Lend. — This  is  really  a  paper 
on  the  sphygmographic  tracings  in  general  paralysis  of  the 
insane,  with  an  hypothesis  as  to  the  state  of  the  arterioles  in 
that  affection.  Mr.  Thompson  finds  the  sphygmographic  tracing 
in  various  stages  of  general  paralysis  to  be  of  one  general 
character,  and  similar  to  that  found  in  "  chill."  In  both,  he 
supposes  the  arteries  and  capillaries  to  be  in  a  state  of  spasmodic 
contraction.  Ergot,  atropine,  and  bromide  of  potassium,  can 
also  produce  contraction  of  the  smaller  vessels,  and  a  parallel  is 
drawn  between  the  symptoms  of  "  ergotism "  and  those  of 
general  paralysis.  We  may  add  that  Heusinger's  report  of  the 
Hessian  epidemic  of  poisoning  by  ergot,  confirms  the  superficial 
resemblance  of  ergotism  to  general  paralysis.  Calabar  bean  and 
inflammatory  fever,  which  are  presumed  to  paralyse  (more  or 
less)  the  vaso-motor  nerves,  and  consequently  relax  the  spasm 
of  the  capillaries  and  arterioles  in  general  paralysis,  restore  a 
more  healthy  pulse-form  in  that  affection ;  while  Calabar  bean 
consentaneously  mitigates  the  general  symptoms.  Mr.  Thompson 
therefore,  sums  up  his  views  as  follows  : — 

"  General  paralysis  of  the  insane  is  a  disease  which  may  be  pre- 
sumed to  be  owing  to  a  considerable  extent  to  persistent  spasm  of 
the  vessels  which  leads  to  change  in  their  component  elements,  but 
more  especially  in  the  muscular  substance.  This  persistent  spasm, 
by  reducing  the  amount  of  blood  which  can  pass  through  the  vessels 
to  the  parts  to  be  nourished,  prevents  renewal  of  these  parts,  and 
consequently  wasting.  The  most  rational  treatment  indicated  is  to 
relieve  this  spasm.  Further,  the  sphygmograph,  by  indicating  the 
true  nature  of  the  disease  at  a  period  when  it  could  barely  be  sus- 
pected by  other  symptoms,  affords  an  opportunity  of  applying 
remedies  when  mere  function  is  disturbed,  before  actual  change  has 
begun,  and  when  the  remedial  means  can  be  of  the  most  avail." 

But  these  conclusions  are  much  too  large  for  the  basis  on 
which  they  rest.  Granting  that  the  changes  in  the  cerebral 
vessels  indicate  a  similar  change  in  the  vessels  of  the  entire 
body,  and  granting  that  Calabar  bean  produces  its  good  effects 
in  the  occasional  attacks  of  excitement  in  general  paralysis,  by 
relaxing  the  assumed  spasm  of  the  smaller  vessels,  how  is  it  that 
bromide  of  potassium,  having  an  antagonistic  effect  on  the 
same  vessels,  is  so  useful  in  the  same  paroxysm?  Again, 
Mr.  Thompson  finds  the  tracings,  indicative  to  him  of  persistent 
arterial  spasm,  not  only  in  the  very  early,  but  also  in  the  late 
stages  of  general  paralysis.  Now,  though  the  complete  patho- 
logical anatomy  is  by  no  means  settled,  enough  is  known  to 
show  that  the  small  vessels  of  the  brain  undergo  various  and 
widely  different  changes  in  this  affection.     Meschede  describes 

97— xLix.  3 


34  tleviews.  [Jan., 

the  highly  developed  capillary  network  crammed  with  hlood- 
corpuscles,  as  often  dilated,  atheromatous,  or  ftitty.  Rokitansky 
speaks  of  the  capillaries  as  enlarged,  twisted,  doubled,  or  pre- 
senting aneurismal  bulgings,  and  the  increased  growth  of 
connective  tissue  as  beginning,  partly  at  least,  on  their  walls. 

Sankey  states  that,  *^  there  appears  to  be  some  amount  of 
tortuosity  in  the  capillaries  in  every  case  of  general  paresis," 
and  he  further  speaks  of  the  tortuosity  as  amounting  to  a  sharp 
curve,  or  a  kinking  of  the  vessel,  or  to  such  a  complex  twisting 
as  to  form  "  little  knots  of  varicose  vessels." 

Wedl  notes  a  variety  of  changes  (not  confined  to  general 
paralysis)  ;  transverse  markings,  thickening  from  hyaline  em- 
bryonic connective  tissue,  nucleated  granular  cells  in  the  areolar 
coat  of  the  dilated  vessels,  leading  to  contraction,  calcareous 
deposition,  &c. 

Wilks  describes  calcification  of  the  minute  vessels ;  and 
Tigges  declares  the  contractility  of  the  coats  of  the  arterioles  to 
be  destroyed  by  amyloid  degeneration. 

Thus  we  see  how  the  calibres  of  the  small  vessels,  their  elas- 
ticity, and  their  relation  to  the  blood  current,  may  be  so  mor- 
bidly changed  as  to  seriously  involve  the  nutrition  of  the  parts 
supplied,  and  finally  lead  to  atrophy  and  dementia,  without  a 
condition  of  persistent  spasm  of  the  small  cerebral  vessels,  or 
those  throughout  the  body,  being  postulated.  Such  a  state  of 
spasm  of  the  small  vessels  frequently  occurs  in  Bright's  disease, 
but  usually  leads  to  hypertrophy  of  these  vessels  and  of  the  left 
ventricle  of  the  heart  (comparatively  rare  in  general  paralysis), 
and  to  a  '^  square-headed"  sphygmographic  tracing.  Again, 
Sankey 's  researches  shoAv  that  hypertrophic  arterial  change  is 
more  frequent  in  other  forms  of  insanity  than  in  general  para- 
lysis ;  in  fact,  the  frequent  varicosity  of  the  capillaries  in  the 
latter,  led  him  to  a  conclusion  directly  opposed  to  that  of  Mr. 
Thompson,  viz. :  "  If  the  function  of  the  muscular  coat  of  the 
small  arteries  is  rightly  attributed  to  be  that  of  checking  or 
regulating  the  amount  of  the  blood  supply,  the  condition  would 
indicate  that  this  interposing  function  w^as  at  fault;  that  no 
alarm,  as  it  were,  was  felt  by  those  vessels ;  that  this  action, 
in  fact,  was  involved  in  the  general  paralysis."  Of  course  it 
remains  to  be  seen  whether  changes  noted  by  Wedl  and  Sankey, 
may  not  really  be  due  to  the  normally  existing  perivascular 
lymph  sheaths  and  spaces  of  Robin  and  His. 

Instead  of  changes  following  persistent  spasm  of  the  vessels, 
the  earlier  pathological  changes  would  rather  appear  to  be 
degenerative  processes  in  and  around  the  vascular  walls, 
checking  circulation,  impeding  nutrition,  and  associated  with 
overgrowth  of  connective  tissue  in  the  cortical  substance.  While 


1872.1      West  Ridrng  Lunatic  Asylum  Medical  Reports.       35 

we  dissent  from  tlie  theory  of  vascular  spasm,  we  may  accept 
the  diagnostic  value  of  the  pulse-form  in  early  general  para- 
lysis. 

IV.  The  Ophtliahnoscope  in  Mental  and  Cerebral  Diseases. 
By  Charles  Aldridge,  L.K.C.P.  Lend. — This  is  the  longest 
article  in  the  volume.  It  embodies  the  results  of  numerous  and 
careful  observations.  Mr.  Aldridge  finds  the  ophthalmoscopic 
appearances  after  death  from  failure  of  the  moving  powers  of 
the  circulation  (syncope)  to  be  : — 

Optic  disc ;  of  a  papery  whiteness,  or  faint  pink  tinge. 

Veins ;  often  small  or  medium  in  size,  sometimes  not  seen  on 
the  disc,  or  beaded  in  form. 

Arteries ;  thin,  attenuated,  often  not  seen  over  the  disc,  but 
appearing  to  spring  from  its  edge. 

The  same  appearances  were  noted  before  death,  but  in  a 
lesser  degree.  In  one  case  of  death  by  apnoea  (phthisis),  the 
appearances,  four  hours  before  death^were:  optic  disc  congested; 
veins  dilated  and  tortuous,  containing  dark  blo(3d ;  arteries  of 
good  size;  but  no  examination  w^as  made  after  death.  Now,  if 
in  such  a  case  the  ante-mortem  and  post-mortem  retinal  appear- 
ances resemble  each  other,  and  if  it  was  clearly  established  that 
such  universal  and  marked  differences  existed  in  the  post-mor- 
tem retinal  condition,  according  as  death  was  by  syncope  or 
apnoea,  an  important  medico-legal  test  would  be  obtained,  Avhich, 
in  a  given  case,  might  found  a  presumption  that  death  had  been 
due  to  asthenia  on  the  one  hand,  or  to  suffocation  on  the  other, 
according  as  the  retina  was  anaemic  or  congested.  This  is 
broached  at  page  80. 

Observations  on  the  eyes  of  epileptics, — (1.)  During  the  pa- 
roxysm. One  case  only,  chanced  to  be  examined  during  the 
stage  of  clonic  convulsion.  "  The  disc  became  very  pink,  .  .  . 
the  arteries  were  very  small,  but  there  was  no  alteration  in  the 
size  of  the  veins."  This  does  not  seem  to  bear  out  the  author's 
remarks  on  the  case  that,  "  during  the  convulsive  stage  in  the 
case  of  A.  S — ,  No.  1,  the  optic  disc  was  seen  to  be  greatly 
injected,  and  the  arteries  larger  than  usual."  Several  epileptics 
were  examined  just  after  the  clonic  convulsions,  and  when 
wholly  or  partially  unconscious,  with  spluttering  respiration. 
The  usual  appearances  were,  paleness  of  the  optic  disc,  and 
smallness  and  attenuation  of  the  retinal  arteries,  while  the  veins 
were  mostly  unchanged.  Afterwards,  as  consciousness  became 
fully  established,  the  capillary  tint  of  the  disc  deepened,  the 
arteries  increased  in  size,  and  the  usual  retinal  state  succeeded 
to  the  anaemia  of  the  state  of  stupor.  But  if  maniacal  excite- 
ment followed  the  fits,  active  hypersemia  also  ensued,  with  the 


36  Reviews.  [j; 


111. 


disc  deep-red  in  hue,  and  the  arteries  and  veins  engorged  with 
blood. 

(2.)  Observations  on  the  eyes  of  epileptics  during  the  inter- 
paroxysmal  period. — Mr.  Thompson  records  102  cases  fully. 
Passive  hyperemia  of  the  retina  and  optic  disc  was  found  the 
most  frequent  condition  present.  The  veins  were  often  large, 
tortuous,  numerous,  much  branched ;  the  optic  disc  in  such 
cases  of  a  deep-red  tint ;  the  arteries  usually  not  much  changed. 
Taking  Schroeder  van  der  Kolk's  evidence  as  to  the  dilatation 
of  the  capillaries  of  the  brain  and  medulla  oblongata  of  epilep- 
tics, he  assumes  "  the  ophthalmoscopic  appearance  of  the  retinal 
circulation  as  an  index  and  guide  to  the  condition  of  the  cere- 
bral." On  this  basis  he  investigates  the  influence  of  various 
drugs  on  the  intra-cranial  circulation.  Finding,  that  the  degree 
of  passive  retinal  hypersemia  present  is  often  in  direct  ratio  to 
the  number  and  severity  of  the  epileptic  fits  ;  that  a  diminution 
of  the  number  of  fits  by  bromide  of  potassium  lessens  the  hyper- 
semia ;  that  when  the  fits  recur  with  their  former  frequency  the 
hyperaemia  recurs  also,  our  author  concludes  that  *^  the  reduc- 
tion in  the  amount  of  passive  hypersemia  does  not  take  place 
immediately  as  a  direct  effect  of  the  action  of  the  bromide  upon 
the  blood-vessels,  but  is  rather  due  to  the  reduction  of  the 
number  of  fits  which  cause  the  constant  congestion."  Now  it 
may  be  that  the  less  amount  of  hyperaemia  found  in  the  cases 
benefited  by  the  bromide  only  means  this, — that  the  bromide 
does  not  so  often  control  the  morbid  tendency  after  the  constant 
vascular  disturbance  of  the  fits  has  led  to  marked  passive 
hypersemia,  but  frequently  controls  it  when  the  changes  are  not 
so  far  advanced.  Among  the  102  cases  we  find  many  have 
been  treated  by  bromide  of  potassium.  On  analysing  a  number 
of  the  cases  where  no  benefit  resulted,  we  find  the  optic  disc 
was  in  order  of  numerical  frequency,  (4)  deep  red,  (3)  pink  j 
the  veins,  (7)  tortuous,  (6)  large,  (4)  medium  in  size.  Where 
benefit  resulted  the  order  was :  optic  disc,  (7)  transparent  pale 
pink,  (6)  medium  pink;  the  veins,  (12)  medium  in  size,  (6) 
large  ;  thus  showing  much  more  passive  hypersBmia  existing  on 
the  average  in  the  cases  not  benefited  by  the  drug. 

Ergot, — The  effect  produced  on  the  retinal  circulation  by 
ergot  is  considered.  An  epileptic  woman,  aged  40,  who  had 
never  been  treated,  and  whose  eyes  showed  marked  hypersemia 
of  the  retina  and  optic  disc,  took  ^ij  of  the  liquid  extract  of 
ergot  without  appreciable  ophthalmoscopic  change  two  hours 
afterwards.  "  She  was  ordered  to  take  the  same  dose  of  the 
drug  three  times  a  day,  and  fourteen  days  afterwards  she  was 
again  examined  with  the  ophthalmoscope.  The  fits  had  in  the 
mean  time  become  less  frequent,  as  formerly  she  had  had  a  fit 


1872.]      I'Vest  Riding  Lunatic  Asylum  Medical  Reports.        37 

every  day,  but  during  the  last  week  slie  had  only  had  three  fits 
in  all.  The  changes  in  the  retinal  circulation  were  now  found 
to  consist  in  contraction  of  the  arteries,  lowering  of  the  capillary 
tint  of  the  disc,  and  a  decided  reduction  in  the  calibre  of  the 
veins."  Mr.  Aldridge  adds  :  "  This  case,  with  the  two  recorded 
at  page  93,  will,  I  think,  be  sufficient  to  establish  the  fact  that 
ergot  produces  contraction  of  the  minute  arteries  of  the  retina ; 
and  also  that  such  effect  is  not  produced  instantaneously,  but 
that  some  time  is  required  before  any  evident  change  can  be 
seen."  The  case  just  given  above  seems  strong  evidence  in  his 
favour,  but  not  so  the  two  cases  cited  by  him  to  support  his 
conclusion.  Both  were  cases  in  which  epileptic  fits  were  fol- 
lowed by  maniacal  excitement  with  marked  active  hyperaemia 
of  the  retinae,  and  both  had  ergot  in  large  doses,  one  returning 
to  her  usual  quietude  in  a  fortnight,  and  the  other  in  four  days ; 
when,  and  not  until  when,  the  active  engorgement  was  replaced 
by  the  usual  vascular  state.  And  this  was  to  be  expected  as 
soon  as  the  excitement  passed  off,  and  therefore  we  cannot  see 
that  these  two  cases  prove  the  power  of  ergot  to  contract  the 
minute  retinal  arteries.  Our  objection  does  not  apply  to  the 
case  first  quoted. 

Nitrite  of  A?nyl. — A  number  of  interesting  cases  are  given 
where  ophthalmoscopic  examination  was  made  of  those  inhaling 
the  nitrite  of  amyl,  and  where,  coincidently  with  the  bright 
flush  about  the  face  and  neck,  the  fuller  and  more  frequent 
pulse,  and  the  confusion  passing  into  hilarity  ;  the  retinal  circu- 
lation was  also  excited,  the  arteries  increased  in  size,  and  the 
capillary  tint  deepened.  Similar  results  were  obtained  by  oph- 
thalmoscopic examination  of  those  inhaling  nitrous  oxide.  The 
observations  made  on  those  who  had  taken  chloral  hydrate  are 
too  few  to  bear  the  weight  of  any  conclusion  resting  on  them. 

This  whole  contribution  is  evidence  of  great  industry  and 
ability. 

V.  A  Co7itrihutio7i  to  the  Statistics  of  General  Paralysis. 
By  J.  WiLKiE  BuRMAN,  M.B. — This  is  a  careful  statistical 
study  of  341  cases  of  general  paralysis  which  were  admitted 
into  the  Devon  County  Asylum  from  its  opening  in  1845  to  the 
end  of  18T0.  Numerous  interesting  tables  are  given,  for  which 
we  must  refer  the  reader  to  that  paper  itself.  Causes  are 
assigned  for  less  than  one  third  of  the  cases.  The  "  moral " 
and  "  physical  "  causes  are  in  nearly  equal  proportion ;  mental 
anxiety,  pecuniary  distress,  and  domestic  affliction,  taking  the 
numerical  lead  in  the  former  class;  drink,  injury  to  the  head, 
and  sun-stroke,  in  the  latter.  These  figures  bear  out  to  a 
certain  extent  the  view  that  strong  or  imperfectly  controlled 


38  Reviews.  [Jan., 

emotion,  intellectual  exertion  carried  on  under  mental  distress, 
or  adverse  strokes  of  fortune,  often  cause  a  naturally  impression- 
able hyperecsthetic  brain,  to  break  down  in  general  paralysis. 
Sexual  and  alcoholic  excesses,  seem  to  have  played  too  prominent 
a  part  in  the  assigned  etiology  of  this  disease,  and  must  be 
looked  on  as  a  part  only  of  that  "sensuality  "  and  "  fast- 
ness '^  to  which  again  only  one  class  of  the  cases  can  be 
referred. 

Salomon  wrote  in  1863, "  The  diffuse  periencephalitis  (general 
paresis)  presents  incontestably  a  striking  analogy  to  diffuse 
nephritis  (=  morbus  Brightii).  The  former  is  anatomically 
characterised  by  a  degeneration  in  the  tissue  of  the  cortical 
substance  of  the  brain,  destroying  the  nerve-tubes  and  nerve- 
cells.  Clinically,  it  is  characterised  by  a  profound  alteration  in 
the  function  of  the  cortical  substance  of  the  brain.  The  latter 
is  anatomically  characterised  by  a  degeneration  of  the  tissue  of 
the  kidney,  and  by  alteration  in  the  urinary  canals  and  mal- 
pighian  bodies.  Clinically,  it  is  characterised  by  a  profound 
change  in  the  functions  of  the  kidneys.  In  both  diseases  we 
observe  stages  of  hypersemia,  increase  of  volume,  degeneration 
(softening)  and  atrophy."  Mr.  Burman  mentions  the  same 
homology  between  the  brain  disease  in  many  cases  of  general 
paralysis,  and  that  presented  by  contracted  granular  kidney  and 
cirrhotic  liver,  and  adds,  ^^  Why  should  not  such  morbid  changes 
occur  from  toxic  causes  in  the  brain  as  well  as  in  the  ^  gouty ' 
kidney  or  the  '  gin- drinker's  '  liver  ?  and  is  there  not  reason  to 
believe  that  alcohol  is  an  important  agent  in  producing  the 
disease  of  the  nervous  system  in  many  cases  of  general  paralysis? 
The  frequent  occurrence  of  the  disease  amongst  drunkards,  and 
the  fact  that  the  morbid  changes  are  in  the  first  instance 
vascular,  and  occur  in  those  parts  of  the  brain  where  vessels 
most  abound,  tend  to  make  us  believe  that  the  disease  is  often 
of  toxic  origin.  These  remarks  only  apply,  of  course,  to  one  (yet 
a  large)  class  of  cases  of  general  paralysis."  This  is  not  a  new 
suggestion.  Far  from  it.  It  was  made  by  Dr.  Hitchman 
(amongst  others)  twenty  years  ago  (*  Journ.  Psych.  Med.,'  vol.  iii, 
p.  244). — "  The  blood  may  be  so  contaminated  as  to  give  rise  to 
a  temporary  general  paralysis  ;  and  if  to  a  temporary  disease, 
then  to  a  permanent  one ;  for  it  is  obvious  that  the  general 
paralysis  would  last  precisely  as  long  as  the  alcohol  in  definite 
quantities  should  remain  in  the  blood  unremoved  by  the  excror 
tory  vessels  of  the  system.  Now,  if  it  can  be  produced  by  one 
extraneous  element  in  the  blood,  it  may  be  by  others ;  and 
hence  the  importance  which  a  diseased  heart,  especially  endo- 
carditis, or  an  affected  kidney,  may  have  in  inducing  this 
malady,  in  such  very  rare  and  isolated  cases  as  those  detailed 


1872.]       West  Riding  Lunatic  Asylum  Medical  Reports,       39 

by  Lelut,  where  no  appreciable  lesion  could  be  detected  in  the 
brain  or  its  membranes." 

Marked  changes  Avere  found  in  the  brains  and  cerebral  mem- 
branes of  drunkards,  by  Dr.  F.  Ogston,  in  his  numerous  autop- 
sies. Wedl  describes  calcareous  deposits  in  the  small  cerebral 
vessels  of  some  drunkards.  Dr.  G.  Johnson  has  shown  that 
morbidly  altered  blood  may  cause  contraction  of,  and  subsequent 
changes  in,  the  minute  arteries  of  various  parts,  including  the 
brain.  Prominent  amongst  the  pathological  changes  in  general 
paralysis,  are  the  changes  in  the  arterioles  of  the  pia  mater  and 
brain;  and  it  is  interesting,  in  this  relation,  that  chronic 
alcoholismus  often  much  resembles  the  paresifying  mental 
disease.  In  short,  it  seems  not  unlikely  that  certain  cases  of 
general  paralysis  may  be  "  toxic  "  in  origin. 

VI.  On  the  Treatment  of  Insanity  hy  the  Hijpodermic  Injec- 
tion of  Morphia.  By  J.  Bywater  Ward,  B.A.,  M.B. — In 
many  cases  of  insanity  where  the  patient  refuses  and  struggles 
against  medicine  administered  by  the  mouth,  or  where  gastric 
disorder  might  interfere  with  the  passage  of  the  drug  into  the 
circulation,  the  hypodermic  use  of  certain  remedies  is  valuable. 
Too  much  was  claimed  at  first  for  this  special  method  of 
exhibiting  morphia.  With  all  the  advantages  of  a  ready  and 
certain  access  to  the  circulation,  we  -have  found  the  hypodermic 
use  of  morphia  in  insanity,  subject  to  certain  drawbacks  to 
which  all  forms  of  opiate  influence  are  liable.  Nausea,  vomit- 
ing, or  headache,  have  not  infrequently  followed.  Dr.  Ward's 
evidence  is  confirmatory  of  this.  In  one  of  his  cases  of  melan- 
cholia, vomiting  occurred  after  the  nightly  injection  of  one  third 
of  a  grain  of  morphia,  while  three  grains  were  taken  daily  by 
the  mouth  without  that  unpleasant  result.  In  such  cases  of 
vomiting,  &c.,  after  the  morphia  injection,  Reissner  recommends 
the  substitution  of  narceia ;  and  we  have  lately  found  the  un- 
pleasant effects  of  morphia  much  obviated  by  half-drachm  doses 
of  potassium  bromide,  given  three  or  four  hours  beforehand,  as 
recommended  by  Da  Costa. 

In  one  of  Dr.  Ward's  cases  of  mania,  the  patient,  aged 
seventy-four,  had  not  been  relieved  by  chloral  and  hyoscyamus, 
and  the  injection  of  a  sixth  of  a  grain  of  morphia  failed  to  pro- 
cure rest,  but  next  morning  "  the  countenance  was  extremely 
pallid,  the  pulse  very  feeble,  and  the  surface  of  the  body  cold." 
He  rallied  under  stimulants.  Dr.  Mcintosh  published  a  number 
of  cases  of  insanity  treated  by  this  method,  ten  years  ago.  In 
one  of  his  cases  (a  woman,  aged  thirty-four),  the  injection  of 
one  grain  of  morphia  was  followed  by  alarming  symptoms. 

Dr.   Ward's   cases   are  not  numerous,  nor  are   the  results 


40  Reviews.  [Jan., 

decisive.  Some  are  scarcely  illustrations  of  the  morphia  treat- 
ment. The  exacerbations  of  excitement  in  chronic  mania 
afforded  the  most  satisfactory  instances  of  relief.  In  two  out  of 
four  cases  these  attacks  were  much  shortened,  in  the  third  the 
injection  soon  lost  its  good  effect,  and  in  the  fourth  it  caused 
obstinate  vomiting.  The  treatment  was  not  as  successful  as 
might  have  been  anticipated  in  melancholia.  In  one  case,  the 
injection  of  one  third  or  one  half  of  a  grain,  every  night  failed 
to  improve  the  mental  state,  though  continued  for  several 
months.  A  peculiar  deferred  action  of  the  drug  was  noted  in 
one  case  of  puerperal  mania.  It  usually  caused  sound  sleep, 
but  not  until  eight  to  twelve  hours  after  the  hypodermic  injec- 
tion of  a  third  of  a  grain. 

VII.  On  Mollities  Ossiuma7id  Allied  Diseases.  By  George 
Henry  Pedler,  L.R.C.P.  Lond. — Eight  cases  illustrate  this 
paper,  and  in  several  of  them  post-mortem  examination  showed 
the  bone-changes  and  the  deformities  characteristic  of  the 
affection.  One  or  two  of  the  cases  appear  to  be  examples  of 
allied  fragilitas  ossium.  The  general  literature  on  the  subject 
is  much  absorbed  by  the  obstetric  relation  of  these  deforming 
affections,  which  are  really  worthy  of  study  as  bearing  on  the 
"  rib  breaking"  cases  in  asylums.  The  cases  met  with  in  asylums, 
as  a  rule,  have  supervened  during  asylum  residence,  and,  there- 
fore, have  not  been  complicated  by  the  aggravating  influence 
of  gestations  under  miserable  and  insanitary  surroundings. 
Several  of  the  cases  mentioned  by  Mr.  Pedler  had  been  under 
asylum  care  for  years  before  the  advent  of  bone-softening, 
and  we  have  met  with  one  case  in  which  the  mollities  came  on 
when  the  patient  had  been  an  asylum  inmate  for  nineteen  years. 
It  may  be  useful  to  remember  these  cases  when  the  nature  of 
the  disease  is  under  discussion.  The  nature  of  the  affection 
has  been  the  subject  of  a  variety  of  opinions.  Leaving  out  of 
view  several  theories  which  have  obtained  less  hold  on  the  pro- 
fession, the  two  which  appear  most  prominently  in  the  literature 
of  the  subject  are ;  first,  that  mollities  ossium  is  of  an  inflam- 
matory nature,  that  it  is  a  sort  of  slow  ostitis  ;  second,  that  it 
is  due  to  arrested  or  impaired  bone-nutrition,  from  loss  of  nerve 
power  and  failure  of  its  normal  influence  on  that  nutrition. 
This  was  more  or  less  set  forth  by  Mr.  Durham,  and  by  Dr. 
Jones  of  Georgia.  Mr.  Pedler  gives  his  adhesion  to  the  latter 
theory,  and  argues  that  the  dilated  vessels  and  increased  vascu- 
larity of  the  grumous  and  fatty  bone,  is  due  rather  to  paralytic 
vascular  dilatation  than  to  inflammation.  He  also  coincides 
with  the  view  that  the  diminution  of  lime-salts  in  the  bones  is 
due  to  failure  of  their  natural  deposition,  as  part  of  the  failure 


1872. J      West  Riding  Lunatic  Asylum  Medical  Reports.        41 

of  osseous  nutrition,  rather  than  to  their  increased  atrophic 
absorption.  MoUities  ossium  usually  arises  under  exhausting, 
depressing  circumstances  of  life.  These  circumstances  are 
sadly  too  frequent.  It  remains  to  be  shown  whether  mala- 
costeon,  in  these  cases,  is  brought  about  by  the  failure  of  the 
part  played  by  nerve-agency  in  the  nutritious  processes.  Minute 
examination  of  the  nerves  of  the  parts  is  required.  Mr.  Pedler's 
article  indicates  the  point  from  which  this  work  might  be 
begun. 

VIII.  On  Locomotor  Ataxy  and  some  other  forms  of  Locomotor 
Deficiency  as  found  in  the  Insane.  By  Patrick  Nicol,  M.A., 
M.B. — Some  years  ago,  Westphal  drew  attention  to  the  mental 
disease  following  after  long  existing  grey  degeneration  of  the 
posterior  columns  of  the  spinal  cord,  as  presenting  a  marked 
similarity  to  general  paralysis  of  the  insane.  Common  to  both 
are  the  grandiose  delirium,  giddiness,  loss  of  consciousness,  and 
convulsive  seizures.  But  the  former  differs  strikingly  from  ordi- 
nary general  paralysis,  in  the  symptom  that  staggering  and 
falling  occur  when  the  eyes  are  closed.  Some  of  Dr.  Nicol's 
cases  resemble  forms  of  general  paralysis  most  strongly,  if  we 
accept  some  later  observations  by  Westphal.  The  latter  finds 
in  the  disordered  gait  of  general  paralysis  two  great  clinical 
groups;  the  tahic  ^\\i\. paralytic.  General  paralytics  with  the 
tabic  form,  lift  their  legs  high,  throw  them  out  with  force, 
advance  in  a  staggering  manner,  and  on  closing  the  eyes  when 
standing,  they  stagger  or  fall.  Those  with  the  paralytic  and 
usual  form  raise  the  feet  but  slightly,  advance  slowly  and  in- 
securely, and  do  not  stagger  or  fall  when  the  eyes  are  closed. 
Moreover,  the  '^  tabic"  form  of  gait  may  be  traced  to  grey  de- 
generation of  the  posterior  columns  of  the  cord,  while  the 
'^  paralytic"  form  has  relation  to  the  chronic  myelitis  found  when 
the  lateral,  or  the  posterior  and  lateral,  columns  are  the  site  of 
spinal  disintegration.  In  a  fully  recognised  set  of  cases  of 
general  paralysis,  spinal  disease  precedes  psychical  disturbance, 
and  this  set  includes  those  of  early  tabic  gait,  and  (probably)  some 
of  Dr.  Nicol's  cases  which  appear  to  fall  under  this  class.  It 
remains  to  be  proved,  then,  how  far  such  "  manie  des  grandeurs" 
or  buoyancy,  as  frequently  occurs  in  the  ataxic  insane,  has 
special  connection  with  Duchenne's  disease. 

The  ataxia  has  been  accounted  for  in  a  variety  of  w^ays  by 
authors,  and  Dr.  Nicol,  accepting  Trousseau's  conclusion  that 
"  spasm"  is  an  essential  element  in  the  locomotor  disorder,  pro- 
pounds the  view  that  ataxia  is  a  disease  of  escaping  force  ;  that 
lesion  of  the  incito-motor  nerves  of  locomotion  disturbs  the 
efficiency  of  the  corresponding  motor  centres  of  the  spinal  cord, 


4.2  Reviews.  [J 


an. 


subordinate  to  the  brain  ;  that  increased  volitional  effort  results, 
with  copious  irregular  spasmodic  supply  of  nerve  force  to  the 
limbs,  causing  ataxic  movements.  Space  will  only  allow  us  to 
add,  in  his  own  words.  Dr.  Nicol's  views  of  "  the  connection  of 
this  disease  of  unstable  power  with  insanity."     He  writes — 

"  Our  active  states  are  in  part  connected  with  a  feeling  pleasur- 
able in  quality,  called  the  feeling  of  power.  When,  therefore,  a 
dribbling  or  gushing  away  of  power,  shown  as  muscular  activity,  is 
connected  with  a  disease  of  the  cerebral  hemispheres,  and  presum- 
ably arouses  in  its  course  the  mysterious  phase  of  life  we  call  mindy 
what  ought  we  to  expect  but  that  the  pecuHar  emotion  of  activity — 
the  pleasure  of  power — should  come  abundantly  forth,  like  corus- 
cations of  electric  light,  distinctive  of  what  medium  a  current  is 
passing  through  ? 

"  Grranted  that  locomotor  ataxy  is  a  disease  in  which  running  away 
of  power  is  an  essential  element,  and  granted  that  there  is  that  open- 
ness for  transmission  of  organic  impressions  towards  the  mental 
centres  which  is  so  often  marked  in  the  insane  diathesis ;  or,  on  the 
other  hand,  that  the  necessity  for  decay  which  lay  upon  the  afferent 
fibres  of  locomotion,  and  produced  (as  we  say)  the  lesion  there,  may 
extend  by  anatomical  analogy  to  other  fibres  which  subserve  the 
comparisons  between  objective  circumstances  constantly  going  on  in 
our  minds  subordinately  to  our  volitional  life  ;  fibres,  namely,  which, 
with  help,  collect  all  the  impressions  for  us,  carry  them  towards  the 
brain,  and  often  are  privileged  to  draw  power  for  an  '  ideo-motor' 
action  of  their  own ;  granted  that  these  too  are  involved  in  the 
ruin,  and  that  the  stored-up  power  they  formerly  set  in  motion  is 
left  to  rush  off  wildly  with  each  mad  attempt  to  volitionize  apart 
from  a  true  sense  of  externals,  and  it  will  no  longer  remain  a  matter 
of  surprise  that  exaltation  is  the  phase  of  emotional  life  which 
locomotor  ataxy  determines  in  the  brain." 

The  article  closes  with  some  loosely  connected  cases  and 
remarks  (on  other  forms  of  locomotor  deficiency),  the  omission 
of  which  would  have  been  an  improvement. 

IX.  Oil  the  Artificial  Feeding  of  the  Insane.  By  William 
Lawrence,  M.B. — Several  w^ays  of  feeding  those  insane  per- 
sons who  are  bent  on  refusing  food  are  here  described,  especially 
the  method  in  use  at  the  West  Riding  Asylum.  We  believe 
that  for  the  majority  of  such  patients.  Dr.  Moxey's  plan,  as 
detailed  by  him  in  the  '  Lancet'  of  March  20th  and  27th,  1869, 
will  be  found  superior  to  any  described  in  this  paper. 

X.  Arachnoid  Cysts.  By  Henry  Sutherland,  M.A.,  M.B. — 
Leaving  out  of  view  the  possible  formation  of  cysts  in  me- 
ningeal haemorrhage,  by  splitting  up  the  layers  of  the  dura 
mater,  as  described  by  Abercrombie ;  or  by  the  peeling  off  of  the 
parietal  arachnoid  from  the  dura  mater  by  the  blood-clot ;  there 


1872.]      West  Riding  Lunatic  Asylum  Medical  Reports,        43 

are  two  leading  views  relating  to  the  production  of  cysts  in  the 
membranes  of  the  brain.  The  one  most  in  favour  attributes  them 
to  an  effusion  of  blood  into  the  arachnoid  cavity ;  the  peripheral 
layer  of  which  blood  soon  encloses  the  effusion  as  a  membrani- 
form  layer,  or  such  membrane,  at  least,  is  formed  around  the  clot 
without  inflammation.  These  walls  become  stronger,  organised, 
and  form  cysts  ;  while  various  changes  take  place  in  the  in- 
cluded blood.  The  second  view,  that  the  heemorrhage  is  from 
the  newly  formed  vessels  of  the  organised  layers  and  meshes  of 
former  inflammatory  products,  and  becomes  encysted  in  these, 
has  not  found  much  favour  with  English  pathologists,  but  is 
probably  the  true  explanation  of  some  cysts  found  in  the  aged. 
Dr.  Sutherland  adheres  to  the  former  view,  and  gives  ten  cases 
in  which  arachnoid  cysts  were  found  after  death  ;  five  in  *  or- 
ganic' dementia,  three  in  general  paralysis,  and  one  each,  in 
idiocy,  and  imbecility.  In  five  of  these  cases  the  cysts  were 
over  both  hemispheres,  and  it  has  been  noticed  by  Dr.  Ramskill 
that  they  are  not  always  confined  to  one  side.  It  is  not  a  little 
interesting  that  ''  in  cases  where  one  cyst  only  exists,  the  entire 
brain  seems  to  be  pushed  across  towards  the  other  side  of  the 
skull,  which  is  found  to  be  unsymmetrical,"  bulging  in  that 
direction  under  the  pressure  of  the  brain.  The  history  of  an 
injury  to  the  skull  existed  in  four  of  the  cases,  and  in  the  others 
atheroma  of  the  vessels  of  the  base  of  the  brain,  or  of  the  aorta, 
was  found ;  and  further,  from  the  analysis  of  his  cases,  Dr. 
Sutherland  concludes  that  some  impoverished  condition  of  the 
blood  predisposed  to  cyst-formation. 

"  In  one  case  repeated  crops  of  boils  harassed  the  patient ;  in 
another  amenorrhoea  with  anaemia- chlorosis  was  present;  in  two 
cases,  erysipelas ;  in  three,  purpura ;  in  four,  oedema  of  the  legs, 
from  some  cause  or  other ;  and  in  no  less  than  six  cases  tubercular 
deposits  were  found  in  the  lungs." 

In  one  case  only,  did  hemiplegia  exist,  and  was  probably  due 
to  destruction  of  the  opposite  corpus  striatum  by  an  old  apoplectic 
clot.  In  Dr.  Ogle's  case  (^  Journal  Ment.  Sci,.'  vol.  x,  p.  525) 
the  hemiplegia  existed  on  the  same  side  as  the  arachnoid  cyst, 
and  probably  was  not  due  to  the  latter,  as  changes  existed  in 
the  pons  varolii,  and  the  corpus  striatum  and  optic  thalamus 
opposite  to  the  side  paralysed,  were  slightly  softened.  In  fact, 
intra-arachnoid  haemorrhage  with  subsequent  cyst  formation, 
seems  to  be  rarely  associated  with  motor  paralysis,  but  often 
with  mental  impairment  tending  to  fatuity. 

XI.  Phthisis  and  Insanity ^  by  Patrick  Nicol,  M.A.,  M.B., 
and  W.  Watson  Dove,  L.R.C.P.,  M.R.C.S.  This  is  mainly 
controversial.     Dr.  Clouston  gives  precedence  to  tuberculosis  in 


44  Reviews.  [j 


an. 


llie  relation  between  it  and  insanity.  Our  authors  would  ratlier 
reverse  the  order,  but  as  the  gist  of  their  pa])er  is  negative, 
"  suggesting  doubts  and  queries,"  we  prefer  a  brief  statement  of 
their  case  to  special  criticism.  Tubercle  (say  they)  is  a  disease 
of  the  vegetative  life,  and  such  diseases  rarely  invade  the  terri- 
tory of  the  animal  functions,  while  diseases  of  the  latter  (mental 
diseases)  often  seriously  modify  bodily  disorders.  It  is,  therefore, 
a  priori  improbable  that  tubercle  will  markedly  affect  the 
functions  of  animal  life  (cause  mental  disease). 

Against  Clouston's  conclusion  that  phthisis  is  a  more  frequent 
assigned  cause  of  death  in  the  insane  than  in  the  sane  population 
(29:21),  they  bring  the  West  Riding  Asylum  statistics  to  prove 
that  the  percentage  is  really  lower  among  the  insane.  The 
bases  of  both  the  opposing  conclusions  are  narrow  and  fallacious. 
Clouston  found  the  age  at  death  of  the  tubercular  insane,  below 
that  of  the  insane  generally.  Messrs.  Nicol  and  Dove  point 
out  that  many  of  the  insane  are  young,  and  youth  is  the  special 
age  for  tubercle,  so  that  "  it  is  not  a  matter  of  surprise  that  it  is 
in  the  young  insane  ^'  that  tubercle  is  most  fatal.  When  they 
are  found  together  which  preceded  ?  Phthisis  or  insanity  ? 
Phthisis  (as  a  rule),  according  to  Clouston.  From  his  cases  he 
thought  the  phthisis  could  not  often  have  been  engendered  after 
the  insanity  had  set  in.  Our  authors  bringthe  West  Riding  Asylum 
statistics  to  show  that  the  greatest  proportional  number  of  those 
dying  in  the  first  stage  of  phthisis,  when  the  tubercle,  therefore, 
was  not  the  sole  cause  of  death,  died  within  three  years  of 
admission ;  showing  that  the  tubercular  involvement  was  often 
probably  during  the  course  of  insanity.  But  suppose  phthisis 
and  insanity  contemporaneous  in  their  onset.  As  both  are 
largely  hereditary,  and  the  hereditary  predisposition  to  insanity 
more  frequent  among  the  tubercular  insane  than  the  insane 
generally,  "  a  strong  tendency  to  tubercle  may  have  been  present, 
when  the  sudden  exacerbation  of  self-neglect  and  exposure  to 
sources  of  disease,  that  always  mark  the  beginning  of  insanity, 
came  on.'  Thus  the  cotemporaneous  arrival  of  the  insanity 
and  the  phthisical  symptoms  is  accounted  for  in  anotlier  way 
than  by  supposing  the  tubercle  to  cause  the  insanity." 

Next,  as  to  the  *^  phthisical  insanity  "  of  Clouston,  our  authors 
urge  that,  granting  the  fact  of  the  connection  between  one  form 
of  insanity  and  tuberculosis,  "it  proves  nothing  in  itself  as 
regards  the  causal  arrangement  of  the  association.  It  may  be, 
indeed,  that  phthisis  tends  more  to  produce  that  form,  but  it  may 
be  that  that  form  tends  most  to  produce  phthisis,"  and  they 
press  into  view  the  habits  of  melancholies,  and  of  suspicious 
monomaniacs,  with  the  oft  ill-regulated  previous  lives  of  the 
latter,  as  tending  to  phthisis,     Moreover,  phthisis  is  not  always 


1872.]      West  Riding  Lunatic  Asytam  Medical  Reports.        45 

the  same  lesion  ;  hence,  if  it  occurs  with  a  certain  form  of 
insanity,  we  should  rather  consider  "  the  insanity  as  affecting 
the  lung  than  the  decay  of  the  lung  as  causing  the  insanity, 
unless  it  could  be  shown  that  the  phthisis  was  in  all  the  cases 
at  bottom  one  and  the  same  lesion." 

The  effect  of  Insanity  on  Phthisis  is  the  second  great  division 
of  the  subject  under  discussion  ;  and  here  Messrs.  Nicol  and 
Dove  enunciate  the  sources  of  vital  depression  springing  from 
insanity,  and  so  tending  to  tubercle.  Their  argument  is  in 
direct  opposition  to  the  statistics  of  Clouston,  which  seem  to 
show  that  the  tendency  to  tuberculosis  decreases  in  proportion 
to  the  length  of  insanity.     The  latter  writes  : 

"The  fact  that  phthisis  is  not  common  in  the  last  and  deepest 
stages  of  dementia,  when  the  nerve  functions  are  carried  on  with 
minimum  activity,  is  not  favorable  to  the  idea  that  the  ordinary 
forms  of  insanity  predispose  to  tuberculosis.  The  tendency  to 
tuberculosis  which  we  have  seen  diminishes  rapidly  in  proportion  to 
the  length  of  the  insanity,  although  partly  explained  by  the  rarer 
occurrence  of  phthisis  as  age  advances,  yet  is  pretty  clear  proof  that 
on  the  whole  insanity  does  not  tend  to  the  development  of  phthisis." 

Cases  of  mania,  or  rather  of  the  delirium  of  advanced  phthisis, 
such  as  conclude  thepaper,  are  mentioned  (the  authors  say  not)  by 
Dr.  Clouston,  who  calls  them  *^  the  connecting  links  between 
phthisical  irritability  and  phthisical  mania."  The  authors  desire 
to  show  that  Dr.  Clouston's  facts  do  not  prove  the  insanity  to 
depend  (as  a  rule)  on  the  tuberculosis,  when  these  coexist. 
There  is  much  to  recommend  their  negative  conclusion,  that  "  this 
is  a  matter  in  which  nothing  is  easier  than  to  see  that  there  is 
some  causal  connection,  and  nothing  perhaps  more  difficult  than 
to  see  what  precisely  is  the  order  of  the  connection." 

XII.  Acute  Delirious  Melancholia.  By  Charles  He:niiy 
Mayhew,  L.R.C.P.  Lond.,  M.R.C.S.  —  This  contribution 
attempts  to  erect  into  a  separate  variety  of  disease  one,  of  the 
forms  of  "  acute  delirious  mania"  (acute  maniacal  delirium, 
acute  delirium,  delire  aigue),  the  writer's  knowledge  of  which 
appears  to  spring  from  Dr.  Blandford's  recent  work,  though  it 
has  been  described  by  English  and  Continental  authorities. 
Mr.  Mayhew  would  give  the  name  acute  delirious  melancholia 
to  those  cases  of  the  affection  in  which  anguished  emotion  pre- 
dominates, and  offers  two  graphic  examples  in  illustration. 
Such  occasional  excess  of  anxious  fear,  «&c.,  has  been  recognised 
in  former  descriptions  of  the  disease,  and  we  fail  to  see  the 
benefit  of  the  divorce  suggested. 

XIII.  Ergot  of  Rye  in  the  Treatment  of  Mental  Diseases. 
By  E.  Churchill  Fox,  M.B.,  CM. — The  use  of  this  drug  in 


46  Reviews.  [J 


an. 


insanity  has  been  treated  of  by  Dr.  C.  Browne  in  a  late  number 
of  the  *  Practitioner,'  and  the  cases  cited  by  Mr,  Fox  may  be 
taken  as  illustrations  of  the  views  enunciated  there.  Epileptic 
mania,  recurrent  mania,  and  the  paroxysms  in  the  course  of 
chronic  mania,  are  represented.  The  very  irregular  course 
of  such  attacks,  the  manner  in  which  they  often  suddenly  sub- 
side without  treatment,  call  for  circumspection  in  conceding 
the  power  of  arrest  to  any  drug  exhibited.  The  second  and 
third  cases  related  demand  such  circumspection,  while  the 
fourth  is  strong  testimony  to  the  value  of  the  ergot  (epileptic 
mania).     We  need  only  add  the  closing  remarks  : 

"  It  has  sometimes  occurred  to  me  that  bromide  of  potassium,  the 
value  of  which  I  would  be  far  from  depreciating,  has  a  tendency,  in 
some  cases,  to  aggravate  the  attacks  of  epileptic  mania.  It  seems 
to  relieve  the  muscular  at  the  expense  of  the  mental  element  in  the 
epileptic  condition.  The  fits  are  reduced  in  number  and  severity, 
but  the  paroxysms  of  mental  disturbance  are  intensified  and  pro- 
longed. Under  such  circumstances,  ergot  becomes  of  the  highest 
service ;  its  use,  alternated  with  that  of  the  bromide  of  potassium, 
places  the  two  phases  of  the  malady  under  equal  and  powerful 
control." 


IV. — A  Manual  of  Medical  Jurisprudence  for  India.  ^ 

(second  notice.) 

We  now  proceed,  in  accordance  with  the  intention  which  we 
expressed  in  our  first  notice  of  this  valuable  work  (October, 
1871),  to  give  a  sketch  of  the  vast  mass  of  information  which 
Dr.  C hovers  has  collected  upon  the  poisons  employed  in  India, 
and  especially  in  Bengal. 

Secret  poisoning  seems  to  have  been  a  common  crime  in  India 
from  the  earliest  tim.es.  Few  of  our  readers  are  probably  aware 
that  the  Suttee,  which  we  have  taken  such  trouble  to  suppress, 
was  originally  introduced  (certainly  before  the  time  of  Strabo, 
who  lived  at  the  commencement  of  our  era)  as  a  check  upon  the 
practice  common  amongst  Indian  women  of  poisoning  their 
husbands.  Passing  over  seventeen  centuries  Ave  have  the 
evidence  of  Captain  Hamilton,  who  traded  in  India  between 
1688  and  1723  (quoted  by  Dr.  Chevers)  that  the  same  sy-stem 
was  then  in  existence : 

"  In  Canara  (he  observes)  there  are  several  customs  peculiar  to 
itself,  and  many  of  them  are  spread  abroad  to  remote  countries. 

1  A  Manual  of  Medical  Jurisprudence  for  India,  including  an  Outline  of  a 
History  of  Crime  against  the  Person  in  India.  By  Noeman  Chevees,  M.D., 
Surgeon- Major  H.M.  Bengal  Army,  Principal  of  the  Calcutta  Medical  College,  &c. 
Calcutta,  1870.     Pp.  xix  and  861. 


1872.]       A  Manual  of  Medical  Jurisprudence  for  India,        4^7 

Here  it  was  that  tlie  custom  of  wives  burning  on  tlie  same  pile  with 
their  deceased  husbands  had  its  beginning.  It  is  reported  that, 
before  the  Brahmins  invented  this  law,  poison  was  so  well  known 
and  practised  that  the  least  quarrel  that  happened  between  a  mar- 
ried couple  cost  the  husband  his  life,  and  this  law  put  a  great  stop 
to  it ;  and  now  custom  so  far  prevails  that,  if  any  faint-hearted  lady 
has  not  courage  enough  to  accompany  her  spouse  to  the  other 
world,  she  is  forthwith  shaved  and  disregarded,  and  obliged  to  serve 
all  her  husband's  family  in  all  kinds  of  drudgery." 

Purchas  quotes  two  authorities,  Plericus  and  W.  Methold, 
who  similarly  explain  "the  cause  of  burning  the  wives." 

The  custom  (prevalent  apparently  in  India  as  formerly  it  was 
in  Greece  and  Rome)  of  administering  philtres  or  love-charms,  in 
which  the  ingredients  are  stupefying  and  often  dangerous,  and 
a  very  frequent  cause  of  poisoning.  A  ^vriter  in  ^  The  Jubbulpore 
Miscellany,'  a  periodical  which  we  have  never  had  the  privilege 
of  seeing,  but  which  is  quoted  by  Dr.  Chevers,  states  that  this 
system  is  mostly  practised  "by  jealous  women,  or  desperate  lovers 
of  either  sex,  for  the  purpose  of  captivating  affection,  of  infatu- 
ating and  enthralling  the  object  of  desire.  But  it  is  also  resorted 
to  for  baneful  purposes,  to  cause  disease,  death,  or  some  strange 
aberration ;  and  whether  employed  in  love  or  in  hate,  it  has 
certainly  been  always  intimately  connected  with  some  real 
knowledge  of  medicine,  and  has  veiled  a  great  deal  of  down- 
right poisoning.  The  ingredients  of  which  the  philtres  are 
ordinarily  compounded  are,  to  this  day,  not  a  whit  less  disgust- 
ing than  the  contents  of  the  witches'  cauldron  in  '  Macbeth,' 
and  perhaps  Shakespeare  got  from  the  East  the  idea  of  adding 
a  tiger's  entrails  and  a  baboon's  blood." 

Owls'  flesh  seems  to  have  a  peculiar  reputation  in  the  East. 
Dr.  Chevers  was  asked  by  a  judicial  officer  whether  a  person 
could  be  rendered  impotent  by  eating  it ;  and  a  w^ork  of  some 
celebrity,  the  ^  Taleef  Shareef,'  contains  the  statement  that 
"the  women  of  India  give,  it  to  their  husbands,  that  by  the 
mental  weakness  it  produces  they  may  obtain  more  liberty  of 
conduct  than  might  otherwise  be  agreeable." 

Attempts  have  been  made  by  the  Government  to  obtain  from 
the  civil  surgeons  on  the  different  stations  a  complete  and 
accurate  list  of  all  the  poisons  obtainable  in  Indian  bazaars ; 
and,  from  the  lists  thus  sent  in,  Dr.  Chevers  has  compiled  the 
table  given  in  the  following  paragraph : 

"  Great  (he  observes)  as  is  the  obscurity  which  envelopes  the  his- 
tory of  many  of  the  poisonous  substances  used  in  India,  the  present 
inquiry  leads  me  to  feel  convinced  that  the  number  of  poisons  which 
are  used  freely  by  the  natives  of  the  three  Presidencies  is  very 
limited  indeed.  The  chief  of  these  are  comprised  in  the  following 
table : — 


48  ReDieios.  [Jan. 


For  assassination  and  suicide. 


"  I.  The  prepnrations  of  Arsenic  . 
Aconite  .... 

Nux  vomica  .... 

Opium 

Lall  chitra | 

Oleander J 

"]   With  a  view  to  producing  intoxication, 
,,    y^  ,         ,  insensibility     or    fatuity,    but     not 

G     -^h^ I        P^^^^^PS  w^^^i  ^"*ent  to  kill,  although 

"^•^^  I         death  frequently  results  from  their 

J         use. 

III.  Lall  chitra For  abortion. 

IV.  Sulphate  of  copper         .         .         .  "1 

Arsenic .         •  1  in  the  BlsJi  Baree^  I  ^^^^'^  ^^  medicines  in  poisonous  doses. 
Snake  poison .  J  J 

"  Doubtless,  farther  experience  may  call  for  additions  to  tins  list, 
and  especially  to  the  third  and  fourth  classes  ;  but  it  must  be  repeated 
that  the  number  of  poisons  commonly  employed  with  criminal 
intent  in  India,  probably  does  not  much  exceed  that  given  in  the 
first  and  second  classes  of  the  above  list." — p.  108. 

Arsenical  poisoning  is  first  considered ;  and  as  the  arsenic 
trade,  which  exceeds  2000  hundredweights  in  Calcutta  alone, 
is  unrestricted,  and  is  almost  entirely  in  the  hands  of  natives, 
it  may  be  easily  supposed  that  the  preparations  of  this  article 
are  often  used  for  improper  purposes.  Arsenic  is  legitimately 
employed  in  India  for  numerous  objects,  as  to  poison  rats  ;  to 
protect  timber,  and  other  substances  against  the  ravages  of  insects ; 
to  destroy  animal  life  in  the  holds  of  vessels  ;  to  prepare  certain 
kinds  of  thick  leather,  &c. ;  but  besides  these  purposes  it  is  fre- 
quently employed  by  native  doctors  to  a  very  considerable  extent 
for  not  only  intermittent  and  remittent  fevers,  but  for  every  form 
of  fever,  including  typhus;  also  as  an  aphrodisiac  in  cases  of 
recent  as  well  as  of  long  standing  impotence;  as  an  alterative  in 
rheumatism,  gout,  and  secondary  syphilis ;  as  a  substitute  for 
opium  in  the  case  of  opium-eaters  wishing  to  reform;  and, 
lastly,  as  a  useful  external  remedy,  and,  mixed  with  milk,  used 
as  a  wash  in  various  skin  diseases,  especially  the  scaly  varieties. 
It  seems  also  to  be  employed  both  externally  and  internally  as 
a  remedy  for  scabies. 

With  the  best  intentions  on  the  part  of  native  doctors,  this 
form  of  practice  must  inevitably  often  lead  to  fatal  mistakes ; 
but  independently  of  accidental  poisoning.  Dr.  Chevers  finds  that 
in  the  fifteen  years  preceding  March,  1870,  no  less  than  two 
hundred  and  eleven  cases  in  which  white  arsenic  was  used  as 
a  poison,  were  brought  before  the  Calcutta  chemical  examiner. 

The  diabolical  crime  of  poisoning  well  or  tank  water  is  not 
unknown  in  India.     In  the  winter  of  1815  the  army  in  Guzerat, 

^  The  Bish  Baree  or  Bish  Boree  is  a  popular  preparation  amongst  the  Bengalee 
praf'titioners. 


l87^.]     A  Manual  of  Medical  Jurisprudence  for  India.  4i) 

on  reaching  their  camping-ground,  were  told  that  the  enemy's 
cavaky  had  poisoned  the  wells  with  arsenic,  and  although 
orders  were  given  that  water  should  not  he  drawn  from  them, 
several  of  the  followers  suiFered  severely.  Dr.  Chevers  gives  us 
a  later  case  of  well-poisoning  that  occurred  in  1868.  The 
water  from  a  well,  in  the  station  of  Kyouk  Phyor,  when  used, 
produced  vomiting,  giddiness,  and  irritation  over  the  surface  of 
the  hody,  and  on  examination  was  found  to  contain  arsenic  in 
considerahle  quantity. 

We  are  not  aware  that  any  such  cases  of  arsenical  poisoning 
as  the  following  have  ever  previously  been  put  on  record. 

"  The  late  Mr.  Henry  Piddington,  coroner  of  Calcutta,  sent  me 
two  cases,  in  which  unmistakable  and  very  violent  symptoms  of 
irritant  poisoning  distinctly  arose  from  eating  the  salted  ox 
tongues  commonly  sold  in  the  bazaars  of  Calcutta.  It  is 
certainly  also  remarkable  that  I  was,  two  years  ago,  consulted 
in  the  fatal  case  of  a  European  lady  in  this  city,  who  was 
attacked  with  cholera  shortly  after  having  eaten  some  cold 
slices  of  such  a  tongue  at  breakfast.  I  should  have  considered 
that  the  poison  here  was  an  animal  one,  except  that  Mr. 
Piddington  notes — "  I  have  heard  from  several  persons  that,  in 
hot  weather,  arsenic  is  used  to  make  the  meat  take  the  salt,  a 
portion  being  mixed  with  the  salt."  Thus  used  it  would, 
doubtless,  also  assist  to  prevent  the  meat  from  becoming  tainted. 
It  is  remarkable  that,  in  one  of  Mr.  Piddington's  cases,  where 
several  of  a  fimiily  were  poisoned,  a  dog,  which  it  was  believed 
had  eaten  of  the  tongue,  was  also  sick"  (p.  120.) 

Dr.  Chevers  throws  more  light  than  any  other  author  whom 
we  can  call  to  mind  on  a  peculiar  form  of  post-mortem  appear- 
ance that  seems  always,  at  least  in  India,  to  be  connected  with 
arsenical  poisoning,  namely,  the  presence  of  ecchymosis,  in 
patches  or  diffused,  in  the  endocardium.  The  following,  in  an 
abbreviated  form,  are  his  remarks  on  the  subject. 

In  1866  Dr.  Bonavia,  of  Lucknow,  stated  that,  in  several 
cases  of  arsenical  poisoning,  he  had  invariably  found  livid 
patches  in  the  inner  lining  of  the  heart,  more  especially  that  of 
the  left  ventricle,  about  the  columnce  carnece,  so  much  so  that,  in 
cases  of  suspected  poisoning,  he  always  examines  the  heart  first ; 
if  he  discovers  these  patches,  he  invariably  finds  arsenic  in  the 
stomach.  The  greater  or  less  size  and  depth  of  colour  of  the 
patches  appear  to  bear  some  proportion  to  the  more  or  less 
extent  and  intensity  of  redness  in  the  mucous  membrane  of  the 
stomach. 

He  refers  to  an  observation  by  Andral,  that  arsenic  is  one  ot 
the  causes  of  endocarditis  ;  he,  however,  notices  that  Dr.  Taylor, 
in  his  Avork  on  Poisons,  rejects  the  idea  that  tliere  are  any  heart 
97— xLix.  4 


50  Reviews.  [Jaii.j 

changes  which  indicate  arsenical  poisoning.  Dr.  Bonavia 
remarks  that  "  when  the  natives  use  arsenic  for  poisoning  they 
do  it  thoroughly,"  and  suggests  that,  where  death  is  caused  hy 
comparatively  small  doses,  this  cardiac  lesion  may  not  be  pro- 
duced. Dr.  Bonavia's  observation  has  since  been  confirmed  by 
several  Indian  authorities. 

Dr.  Kenneth  McLeod,  then  of  Jessore,  gives  the  case  of  a 
young  man  who,  not  being  able  to  bear  the  disgrace  of  having 
contracted  syphilis,  killed  himself  by  swallowing  half  a  tolah 
(90  grains )  of  arsenious  acid. 

On  post-mortem  examination,  four  hours  after  death,  the  left  ven- 
tricle of  the  heart  was  found  empty,  with  the  Iming  membrane  of  a 
dark  livid  colour.  This  tint  was  deeper  on  the  columnm  earned^ 
than  between  them,  and  was  well  marked  over  the  whole  surface 
of  the  cavity.  The  deep  colour  extended  about  an  eighth  of  an 
inch  into  the  substance  of  the  heart,  and  seemed  to  be  owing  to 
a  layer  of  blood  extravasated  beneath  the  lining  membrane^ 
which  was  quite  smooth;  otherwise  the  heart  was  not  in  any 
way  affected  by  the  poison. 

Mr.  McReddie  found,  in  a  Mussulman  of  Hurdui,  "  patches 
which  might  be  termed  sub- endocardial  ecchymosis  in  the  left 
ventricle,  about  the  carnece  columnce,  not  in  them.  These  patches 
extended  about  a  line  in  depth ;  they  were  not  numerous, but  were 
well  marked."  The  chemical  examiner  for  Oudh  found  "  un- 
equivocal proofs  of  arsenic  in  the  stomach." 

Dr.  Harris's  remarks  on  those  appearances,  in  the  case  of  a 
young  Mussulman  who  committed  suicide  by  swallowing  white 
arsenic  are  very  suggestive : 

"  It  has  been  said  that  the  size  of  the  patches  in  the  heart  appears 
to  bear  some  relation  to  the  extent  of  those  met  with  in  the  stomach. 
I  think,  however,  it  should  rather  be  said  that  they  both  are  related 
to  the  greater  or  less  amount  of  the  poison  taken.  As  some  small 
doses  of  arsenic  cause  congestion  of  all  the  internal  organs,  it  does 
not  require  a  great  stretch  of  the  imagination  to  conceive  that  a 
larger  dose  may  produce  a  stage  of  disease  in  advance  of  this,  in  the 
form  of  effusion  from  the  already  congested  vessels  of  these  organs, 
constituting  in  the  brain  serous  or  sanguineous  eifusion  into  the 
meshes  of  the  arachnoid,  and  in  the  heart  sanguineous  effusion  into 
the  endocardium  ;  the  last,  perhaps,  immediately  due  to  the  bruising 
of  the  congested  capillaries  of  the  endocardium  by  the  powerful  mus- 
cular action  of  the  left  side  of  the  heart.  It  will  be  very  interesting 
in  future  to  observe  the  stethoscopic  sounds  in  these  cases  during 
life"  (p.  122). 

The  preceding  observations  apply  specially  to  white  arsenic  or 
arsenious  acid  (Sumool-hhar')  ;  the  yellow  sulphide  {Hartal),  and 
the  red  sulphide  (3Iansil)j  are  also   occasionally  employed  as 


1872.]      A  Manual  of  Medical  Jurisprudence  for  India.         51 

poisons.  Two  cases  of  chronic  poisoning,  caused  by  sleeping  in 
rooms  papered  with  arsenical  green,  have  been  recorded  in 
India,  one  by  Dr.  Shortt,  and  the  other  by  Dr.  Horace  Day. 
The  case  reported  by  Dr.  Day  is  singular  for  its  complications. 
The  Patient  had  symptoms  resembling  dysentery,  which  was  so 
rare  a  disease  in  the  locality  that  another  cause  for  the 
symptoms  was  sought  for  and  found  in  the  bedroom  paper : 

"  But,  besides  the  symptoms  of  poisoning  by  arsenic,  a  periodic 
headache,  lasting  about  six  hours,  came  on  every  day.  It  appeared 
that  he  had  formerly  suffered  from  Guzerat  fever.  Here,  then,  was 
a  cause  for  the  headache,  which  lasted  after  the  other  symptoms 
had  abated ;  removal  from  the  bedroom  having  removed  those, 
quinine  soon  cured  the  headache.  Atteution  is  drawn  to  the  fact 
that  the  arsenic  and  the  fever-poison  were  simultaneously  at  work. 
Dr.  Day  suggests  that,  but  for  the  arsenic,  tertian  fever  might  have 
occurred  instead  of  mere  headache." 

Dr.  Chevers  has  only  one  slight  note  of  a  case  of  paralysis  from 
arsenical  poisoning,  viz.  that  of  an  officer,  who  came  before  the 
Medical  Board  at  Calcutta  in  a  state  of  considerable  emaciation 
and  cachexia,  and  Avith  paralysis  of  the  forearms,  almost  as 
complete  as  ever  occurs  in  painters.  He  quotes,  however,  a 
case  of  this  affection,  wiiich  gives  us,  in  so  far  as  treatment  is 
concerned,  a  curious  glimpse  of  native  therapeutics  : 

"  Mr.  Jayaker  admitted  one  Foola  Mona  to  hospital  at  Ahmedabad 
(Bombay  Presidency)  with  Carter's  disease  of  the  foot  in  an  advanced 
stage.  The  leg  was  amputated,  and,  except  that  there  was  an 
attack  of  secondary  haemorrhage,  the  stump  did  well ;  but  amesthesia 
of  both  hands,  which  had  been  complained  of  on  admission,  continued 
to  increase.  The  hands  were  partially  paralysed,  and  the  flexors  of 
the  fingers  were  strongly  contracted.  It  was  discovered  that,  two 
months  before  his  admission,  he  had  a  poultice  applied  for  about  a 
■week  by  a  hakeem,  which  contained  nearly  three  ounces  of  arsenic, 
and  an  incredible  quantity  of  cayenne  pepper  (seven  pounds).  This 
having  given  rise  to  constant  vomiting  and  purging,  the  arsenic  was 
omitted  after  the  second  (?)  application.  It  was  followed  by  a  burn- 
ing sensation  throughout  the  body,  which,  after  the  operation, 
continued  to  be  present  in  the  extremities,  the  stump  not  excepted. 
The  symptoms  in  the  hands  made  their  first  appearance  a  fortnight 
after  the  last  application.  He  gradually  improved  under  peroxide 
{sic)  of  potassium  and  tincture  of  belladonna,  until  he  was  discharged 
cured  in  about  nine  weeks"  (p.  127). 

The  antidotes  used  by  the  native  doctors  are  almost  as 
bad  as  the  poison  itself.  In  Madras  a  lump  of  sulphate  of 
copper,  of  unknown  weight,  is  rubbed  on  a  cut  lime,  whicli  is 
then  squeezed  into  the  patient^s  mouth.  The  froth  of  the  soap- 
nut  is  also  used  as  an  emetic  in  these  cases,  but  it  is  very  irri- 
tant and  uncertain  in  its  action.     The  natives  of  Bengal  use 


rvo. 


Revieios.  [Jr 


111. 


the  washings  of  stmking  fish  and  human  ordure  as  emetics  in 
cases  of  poisoning;  and  in  a  case  of  arsenical  poisoning  that 
occurred  hitely  at  Tepherat  Dr.  Cli overs  was  informed  that 
*'  the  symptoms  were  not  relieved  till  the  man  had  swallowed 
some  human  faeces." 

In  a  section  on  *''  Cattle  Poisoning  "  we  have  a  mass  of  very 
curious  facts.  After  pointing  put,  on  the  authority  of  Mr.  Borrow 
('The  Zincali,'  4th  ed.,  p.  12),  that  gypsies  to  the  present  day 
occasionally  poison  cattle,  horses  and  swine,  for  the  sake  of  obtain- 
ing the  carcass  of  the  animal,  Dr.  Chevers  gives  a  case  in 
which  the  horses  of  our  artillery  were  poisoned  in  considerable 
numbers  for  their  skins.  Elephants  are  sometimes  poisoned, 
hut  cattle  afford  by  far  the  greatest  number  of  victims.  They 
are  poisoned  in  various  ways,  of  which  the  following  is,  perhaps, 
the  most  ingenious : 

"  In  August,  1852,  the  first  magistrate  of  Pubna  was  informed 
that  the  Chumars  of  a  certain  village  bad  been  for  some  months  in 
the  habit  of  killing  cattle  in  the  neighbourhood  for  the  sake  of  their 
skins,  by  thrusting  into  the  rectum  certain  poisonous  balls.  Some 
of  the  poisoners  confessed  and  produced  several  balls,  two  of  which 
were  sent  to  the  chemical  examiner.  They  also  produced  a  pointed 
stick  at  which  the  end  of  the  ball,  it  was  understood,  was  fixed  and 
thrust  into  the  body.  When  the  stick  was  withdrawn  the  ball  re- 
mained ;  the  consequences  were  that  the  body  swelled,  and  in  some 
cases  a  small  quantity  of  blood  was  passed,  and  the  animal  died  in 
about  twelve  hours  in  great  pain.  The  balls  were  found  to  be  per- 
forated with  an  aperture  for  the  pointed  stick,  and  contained  a  resin- 
ous matter,  kept  in  ibrm  by  being  mixed  with  a  large  quantity  of 
hair  rolled  up  somewhat  like  a  silk-worm's  cocoon  with  one  end  oft'. 
The  nature  of  the  resinous  matter  could  not  be  decided  by  analysis" 
(p.  130.) 

In  1854  Mr.  George  Campbell,  then  magistrate  at  Azinghur, 
discovered  that  a  surprisingly  extensive  system  of  cattle-poison- 
ing  was  carried  on  by  a  leather  dealer,  who  employed  certain 
agents  to  administer  arsenic  in  balls  of  flour  to  cattle  in  their 
hay,  &c.  We  fully  agree  with  Dr.  Chevers  that  it  is  fully  time 
that  *'  the  importation,  or  at  all  events  the  sale,  of  arsenic  in  India 
should  be  regulated  by  a  stringent  legislative  enactment." 

From  the  consideration  of  arsenic  the  author  passes  to  Aco?iite, 
to  which  about  a  dozen  pages  are  devoted.  The  following  are 
some  of  the  uses  to  which  it  is  applied  by  the  natives. 

"  The  preparation  of  the  root  of  the  Aconitiim  ferox,  or  JBish.  is 
much  used  in  all  the  hill  districts  of  India  to  poison  arrows  for  the 
destruction  of  wild  beasts. 

*'  In  a  tank  of  water  destined  for  part  of  the  British  army  on  a 
halt  in  pursuit  of  the  retreating  Burmese,  the  water  hnd  been  pois- 


1872.]      A  Manual  of  Medical  Jurisprudence  for  India.        53 

oned  by  the  Aconitv.m  ferox,  bruised  and  thrown  in  by  the  enemy 
before  they  evacuated  the  pkice  ;  undoubtedly  fatal  consequences 
would  have  ensued,  had  not  Dr.  Wallich  discovered  it.  Dr.  Wallich 
says  of  the  Vishavish  or  Bish,  that  the  Gorkhalese  pretend  that  it  is  one 
of  their  principal  securities  against  invasion  from  the  low  countries. 
*'  In  medicine  the  Bish  is  chiefly  employed  by  the  natives  in  the 
treatment  of  leprosy,  fever,  cholera,  and  rheumatism.  A  Lepeha 
described  the  root  to  Captain  "Walter  Sherwill  as  being  '  useful  to 
sportsmen  for  destroying  elephants  and  tigers,  useful  to  the  rich  for 
putting  troublesome  relations  out  of  the  way,  and  useful  to  jealous 
husbands  for  the  purpose  of  destroying  faithless  wives'  "   (p.  13G). 

The  active  principle  of  the  Assam  poison,  known  as  Mismee 
Bish,  is  undoubtedly  the  juice  of  the  root  of  this  plant,  although 
the  composition  of  it  is  kept  a  profound  secret.  Considering 
that  even  a  scratch  from  an  arrow  so  poisoned  is  followed  by 
almost  instant  death,  we  can  fully  recognise  the  noble  self- 
devotion  of  Dr.  White,  now  of  Debroghur,  who,  when  his  men 
were  wounded  by  the  Abors  (an  Assam  tribe)  with  these  arrows, 
*^  sucked  the  wounds,  and  suflTered  to  a  marked  degree  from  that 
numbness  of  the  lips  and  tongue  which  characterises  aconite 
poisoning.'^ 

The  case  of  a  boatman  aged  35,  who  had  taken  a  small  por- 
tion of  aconite  root  by  mistake,  and  was  successfully  treated 
in  the  Hospital  by  Baboo  Tarprosunno,  a  late  native  assistant 
of  Dr.  Che  vers,  illustrates  very  clearly  the  ordinary  symptoms  of 
aconite  poisoning,  of  which  no  less  than  thirty-six  instances  came 
under  the  notice  of  the  Calcutta  chemical  examiner  in  the  ten 
years  from  1860  to  1869  inclusive. 

"  The  peculiar  action  of  the  poison  was  fully  exhibited  ;  the  acridity 
was  manifested  by  the  obstinate  retching  and  vomiting,  constant 
spitting  of  saliva,  and  burning  sensation  in  the  pit  of  the  stomach. 
The  depressing  influence  of  the  poison  rendered  the  pulse  small,  slow, 
weak,  and  intermittent,  and  gave  rise  to  the  hurried  laborious  breath- 
ing and  the  sense  of  void  within  the  cardiac  region.  Its  narcotic 
action  was  illustrated  by  the  immediate  impairment  of  sensibility, 
characterised  by  the  tingling  and  numbness  of  the  lips  and  tongue, 
almost  coincident  with  the  chewing  of  the  root.  At  first  the  action 
was  exerted  locally  upon  the  peripheral  distribution  of  the  nerves, 
but  it  subsequently  aftected  the  central  ganglia,  as  proved  by  the 
tingling  and  numbness  becoming  universal,  and  the  inability  of  the 
patient  to  stand  on  his  legs  owing  to  the  paralysis.  He  could  move 
his  arms  about  without  any  difficulty,  and  could  steady  them  in  any 
position  at  will.  The  disordered  sensibility  continued  more  or  less 
till  the  other  symptoms  of  poisoning  had  subsided.  The  great  peculia- 
rity of  the  poison  was  that  it  left  the  mental  faculties  perfectly  clear, 
even  during  the  height  of  the  symptoms.  The  pupils  became  dilated  up 
to  a  certain  degree,  but  never  reached  that  extreme  dilatation  which  is 


54  Reviews.  [Jan., 

characteristic  of  the  solanaceous  plants.  They  were  totally  paralysed, 
without  affording  any  sign  of  that  irritability  of  the  nerves  of  the 
iris  indicated  by  alternate  dilatation  and  contraction"  (pp.  145-6). 

There  is  a  prevalent  belief  that  an  antidote  for  aconite,  pre- 
pared from  the  roots  and  barks  of  trees,  is  known  to  the  hill- 
men  ;  but  no  trustworthy  facts  on  the  subject  have  been  adduced. 

TJmggee  hy  poison  is  the  subject  of  a  very  interesting  chapter. 
Dr.  Chevers  tells  us  that  there  is  scarcely  a  village  in  which  a 
hag  of  low  caste  is  not  to  be  found  "  suspected  as  a  witch,  pro- 
fessedly a  midwife,  equally  ready  at  all  times  to  practise  as  a 
doctress,  a  sorceress,  or  a  bawd,  and  carrying  on  a  systematic 
trade  in  the  procuration  of  abortion  by  the  use  of  the  most 
deadly  poisons ;  and  that  it  is  the  belief  of  persons  well 
acquainted  Avith  the  habits  of  the  natives  that  these  women  are 
professional  poisoners."  Besides  these  there  is  a  class  of 
thieves  who  eke  out  their  other  atrocities  by  occasional  recourse 
to  drugging  or  poisoning.  There  does  not  appear,  however,  to 
be  any  organized  system  of  road  poisoners  in  Bengal,  although 
two  or  three  may  sometimes  act  in  concert.  In  the  north-west 
provinces  there  appears  to  be  a  class  of  miscreants  who  drug 
their  victims  by  employing  children  as  cats'* paws,  and  several 
illustrative  cases  are  given  by  our  author ;  while  there  is  ano- 
ther class  whose  occupation  lies  in  administering  drugs  to 
women  of  the  town,  and  then  robbing  them  of  their  ornaments, 
in  which  these  women  generally  invest  their  gains.  After  some 
acquaintance  a  drinking  bout  is  proposed,  to  which  no  objection 
is  ever  made,  and  as  the  victim  becomes  intoxicated,  the  drug 
(generally  dhatoora)  is  mixed  with  the  liquor,  and  whilst  she  is 
insensible  her  property  is  carried  off.  In  one  of  the  cases 
quoted  the  woman  became  insensible  in  the  evening,  and  was 
unconscious  till  3  p.m.  next  day;  in  another  she  was  insensible 
for  two  days. 

In  Scind  poisoning  seems  to  have  been  a  regular  profession 
not  many  years  ago.  In  1856  *  The  Scindian'  reports  that  in 
Upper  Scind  "  a  gang  of  notorious  characters  have  just  been 
unkennelled,  who  have  been  in  the  habit  of  disguising  them- 
selves as  fakeers  and  administering  poison  to  people  possessed 
of  wealth,  which  they  appropriated  to  themselves  after  they  had 
succeeded  in  putting  them  to  death.  Some  time  back  Govern- 
ment offered  a  reward  of  one  thousand  rupees  for  the  discovery 
of  the  guilty  party,  and  this  seems  to  have  had  the  wished-for 
result,  as  the  whole  gang  have  been  apprehended." 

Dr.  Chevers  has,  in  the  present  edition,  collected  a  large 
mass  of  facts  on  this  form  of  thuggee  since  1856.  Dhatoora  is, 
he  believes,  the  poison  usually  employed.     It  is  given  in  various 


1872.]      A  Manual  of  Medical  Jurisprudence  for  India.         55 

ways,  one  of  the  inost  common  being  to  mix  it  in  flour,  or  to 
give  it  with  bread  itself,  and  great  ingenuity  is  often  shown  in 
the  manner  in  which  the  poisoner  manages  this. 

"  Dr.  Irving  speaks  of  many  ways  of  giving  the  seeds,  as  mixed 
whole,  with  hrinjal  {Solanum  melongena^,  between  the  seeds 
of  which  and  those  of  the  drug  the  victim  does  not  observe  any 
difference,  and  pounded  in  flour,  goor,  dhall,  rice,  milk,  infused 
in  spirits  and  in  tea,  and  made  up  in  sweetmeats.  The  leaves 
are  also  given  as  sag  (spinach).  These  miscreants  also  use 
arsenic,  opium,  hemp  (bhang),  aconite,  and  oleander  (kunere). 

^•'  In  1868,  the  '  Police  Gazette,  N.  W.  P.,'  published  the  con- 
fession of  one  Pamadheen,  not  quite  twenty- one  years  of  age. 
who,  for  the  previous  twenty  months,  has  followed  the  calling 
of  poisoner.  A  local  writer  says,  '  There  is  no  nonsense  about 
Ramadheen ;  he  does  not  pretend  to  scruples  or  remorse  of  any 
kind.  He  calls  his  victims  "  shikar"  (game),  and  alleges  no 
other  excuse  for  his  practices  than  that  it  was  very  dull  at 
home  in  his  village.  So  far  as  we  can  enumerate  the  persons 
he  poisoned  in  the  year  and  a  half,  they  are  about  twenty- 
seven  ;  but  he  is  very  cavalier  and  careless  in  figures,  and  talks 
of  a  family  whom  he  may  murder  with  a  lordly  negligence  as  to 
the  number  of  its  members.  Ramadheen  is  not  in  the  least 
superstitious.  Most  of  his  victims  were  either  brahmins  or 
fakeers,  and  his  favourite  hunting  grounds  were  what  he  calls 
"holy  places" — Bindachull,  near  Mirzapore,  and  the  Megh  Mela 
here' "  (p.  175). 

Many  curious  details  of  "poisoning  for  plunder"  have  been 
collected  from  reports,  relating  not  only  to  the  north-western 
provinces,  where  Dr.  Irving  has  specially  considered  the  sub- 
ject, but  to  Bombay,  Madras,  and  the  lower  provinces. 

There  seems  reason  to  believe  that  since  the  more  murderous 
form  of  thuggee  by  strangulation  has  been  suppressed,  cases  of 
drugging  for  the  purpose  of  robbery  have  increased. 

A  judicial  officer,  up-country,  obtained  about  four  years  ago 
a  box  containing  "  samples  of  diflerent  preparations  of  datura 
employed  by  the  professional  poisoners  of  Upper  India  for  the 
purpose  of  robbery,"  and  it  contained  the  six  following  articles  : — 
(1)  datura  seeds;  (2) powdered  prepared  datura  seeds,  parched, 
but  not  cleaned  or  fit  to  mix  with  food  to  drug  a  victim ;  (3) 
ditto,  fit  to  mix  with  food — dose,  half  a  tolah;  (4)  distilled 
essence  of  datura,  used  with  tobacco,  sugar,  attah,  &c. — dose,  ten 
drops  to  a  chillum,  or  a  quarter  teaspoonful  in  a  meal  of  attah  ; 
(5)  attah  drugged  with  datura  flour ;  and  (6)  suttoo  similarly 
drugged. 

The  chapter  on  "  Thuggee  by  Poison  "  is  followed  by  one  on 
Datura  generally,  in  which  the  author,  after  quoting  the  early 


56  Beviews.  [Jan., 

historical  references  to  poisoning  by  this  drug,  and  describing  the 
three  species  which  are  used,  \iz:  D.fastuosa  or  purple  flowered, 
Z).  alba  or  white  flowered,  and  D.  fer ox,  discusses  the  botanical 
characters  of  the  seeds,  their  physiological  action,  the  means 
of  testing  chemically  for  them,  poisoning  by  datura  leaves, 
drugging  or  slow  poisoning  by  datura,  datura  a  cause  of  insanity, 
symptoms  of  datura  poisoning,  the  physiological  differences  in 
the  signs  of  poisoning  by  datura  and  aconite,  &c.  There  are 
many  of  these  topics  to  which  we  should  gladly  refer  if  space 
permitted,  but  we  must  confine  our  remarks  to  a  few  of  the 
most  important. 

The  following  is  a  good,  although  very  brief,  resume  of  the 
symptoms  consequent  on  eating  the  cakes  known  as  chupatties, 
when  the  flour  had  been  mixed  with  coarsely  grown  brownish- 
yellow  particles  of  the  datura  seeds : 

"  On  the  24tb  January,  1866,  two  patients  were  brought  to  the 
Chupra  Dispensary  suffering  from  the  following  symptoms  : — Chatter- 
ing delirium,  with  a  tendency  to  perform  strange  antics ;  they  were 
stupid  and  unintelligible;  their  pupils  were  widely  dilated;  the 
skin  natural,  pulse  quick  and  small,  tongue  white  and  moist.  They 
both  recovered  under  appropriate  treatment.  On  subsequent  in- 
quiry it  was  found  that  these  curious  symptoms  supervened  rapidly 
after  eating  chupatties  made  of  flour,  some  of  which  remained." 

This  flour,  on  microscopical  examination,  showed  distinctly 
the  presence  of  a  peculiar  structure  characteristic  of  the  exo- 
sperm  of  the  seed  coverings,  which  is  fully  described  in  p.  18T  of 
this  work. 

When  the  seeds  have  been  so  well  ground  that  the  microscopic 
test  fails,  we  must  extract  from  the  vomited  matters,  or  the 
mass  found  in  the  stomach  if  death  ensues,  the  alkaloid,  and 
apply  the  physiological  test.  The  essence  containing  the 
alkaloid  must  be  dissolved  in  a  little  water,  and  injected  into 
the  stomach  of  a  puppy  or  kitten,  if  the  animal  will  not  take  it 
mixed  with  the  food.  In  September,  1866,  one  half  of  the 
extract  of  the  contents  of  the  stomach  of  a  woman  who  destroyed 
herself  by  this  poison  was  given  to  a  kitten  at  noon,  and  occa- 
sioned the  following  symptoms : 

"  The  little  cat  soon  began  to  breathe  with  difficulty  and  froth  at 
the  mouth ;  in  ten  minutes  her  pupils  were  dilated,  and  they  continued 
to  remain  so,  only  to  a  still  greater  extent,  the  rest  of  the  day,  never 
for  a  moment  being  contracted  or  even  less  dilated  when  exposed 
to  a  strong  sunlight.  After  twenty  minutes  she  was  placed  in  the 
middle  of  the  room  and  encouraged  to  walk,  but  she  staggered  and 
fell  on  attempting  to  do  so.  In  half  an  hour  from  the  time  of 
administration  she  was  quite  unconscious;  up  to  this  period  she 
had  felt  pain  when  pinched  with  a  forceps,  but  now  a  severe  pinch 


1872.]      A  Manual  of  Medical  Jurisprudence  for  India.         57 

only  caused  a  slight  movement  of  ^e  limb  without  any  expression 
of  pain.  The  respiration  was  still  laboured,  she  continued  to  froth 
at  the  mouth,  and  the  pupils  remained  very  widely  dilated.  Con- 
sciousness began  to  return  at  two  o'clock ;  she  then  got  up,  sat 
staring  widely,  and  commenced  to  perform  a  series  of  grotesque 
actions,  uttering  a  low  moan  from  time  to  time.  When  pinched, 
she  felt  pain,  but  not  very  acutely.  She  appeared  very  irritable, 
almost  wild,  but  was  neither  vicious  nor  bad  tempered.  At  3  p.m. 
the  pupils  were  dilated  extremely,  the  iris  being  a  mere  thread.  By 
4  p.m.  she  had  recovered  so  far  as  to  be  able  to  come  when  called, 
and  to  feel  acute  pain  when  pinched,  the  pupils  continuing  as  large 
as  ever. 

"  A  small  portion  of  the  same  extract  or  essence  was  applied  to 
the  eye  of  another  kitten  ;  it  caused  the  pupil  to  dilate  in  half  an 
hour.  Another  portion  of  the  same  was  applied  to  the  experi- 
menter's lips  without  producing  any  numbness  "  (p.  190). 

Dr.  Chevers  tells  us  that  when  he  first  published  his  manual 
"  there  existed  among  the  missionaries  in  this  country  a  very 
strong  conviction  that  datura  was  frequently  administered  by 
their  relatives  to  natives  who  evinced  an  inclination  to  embrace 
Christianity.  In  1856  I  was  authorised  to  quote  the  following 
passage  from  a  note  lately  written  by  an  eminent  and  experi- 
enced missionary,  then  residing  in  Calcutta,  but  now  deceased, 
in  reply  to  queries  on  this  subject : 

'I  always  understood  that  the  drug  administered  in  the  cases 
referred  to  was  the  dhatoora  in  small  dose.  The  symptoms  have 
been  heavy  dull  eyes,  with  a  prostration  of  mind,  rendering  the 
victim  an  idiot,  and  looMng  very  much  like  one,  with  a  listless  heavy 
countenance,  indicating  that  the  brain  has  somehow  or  other  been 
affected.  I  believe  the  victim  can  be  for  months  in  that  listless, 
heavy,  dreamy  state ;  but  gradually  under  a  proper  treatment  and 
a  change  of  scenery  I  always  heard  recovery  was  possible.  There  is 
no  mistaking  the  symptoms  of  the  poison,  as  it  transforms  the  victim 
in  a  short  time  into  a  totally  different  heing  from  what  he  was  in  his 
normal  state'  "  (p.  204). 

Dr.  David  B.  Smith  gives  notes  (quoted  by  our  author)  of  the 
case  of  Mr. ,  set.  42,  a  European  of  very  regular  and  tem- 
perate habits,  residing  at  Mussoorie,  the  subject  of  "  irritative  ^' 
or  *'phosphatic  dyspepsia,"  but  not  otherwise  diseased,  who 
was  nearly  drugged  to   death  by  datura.     On  the  morniiig  of 

the  Snd  November  Mr. was  ill  and  in  a  confused  state.    On 

the  5th  the  following  facts  were  elicited  : — "  Went  to  bed  on 
evening  of  1st  November  perfectly  well.  Got  up  at  usual  hour 
in  morning  with  a  sensation  of  extraordinary  giddiness  and  of 
rolling  motion.  In  getting  up  to  bathe  found  himself  swaying 
from  side  to  side.  All  the  limbs  felt  perfectly  powerless,  and 
also  the  tongue.     Could  not  speak  properly.     No  pain  in  heacl 


58  Reviews.  [J: 


in. 


or  spine ;  no  sickness  of  stomach.  Could  not  sec  at  all  to  read 
or  write.  Could  see  large  objects,  but  not  small  ones,  such  as 
letters.  Any  one  approaching  him  seemed  to  have  a  white 
muslin  net  over  him.  Face  was  puffy  under  the  eyelids.  Tongue 
moist-looking,  but  he  complained  of  dryness  of  mouth  and 
throat/'    On  the  evening  of  the  6th  word  was  sent  to  Dr.  Smith 

that  Mr. was  delirious.    On  visiting  him,  however,  he  was 

asleep.  On  being  roused  his  pulse  was  steady,  and  he  answered 
some  questions.  His  pupils  were  broadly  dilated,  and  he  was 
evidently  drowsy.  "  Still,^''  says  Dr.  Smith,  "  I  had  no  suspicion 
of  his  having  been  unfairly  dealt   with."     On   the  morning  of 

the  7th  Dr.  Smith  received  a  note  from  Mr. .     It  appears 

that  the  beginning  of  it  was  steady,  legible,  and  sensible,  whilst 
the  conclusion  of  it  was  rambling,  confused,  and  almost  illegible. 
Dr.  Smith  found  him  in  a  very  peculiar  state.  Face  somewhat 
purplish,  eyes  bright,  the  pupils  greatly  dilated  and  insensible 
to  light.  Pulse  tolerably  natural.  He  wandered  about  in  a 
confused  state,  arching  hi^  eyebrows,  rubbing  his  hands,  and 
complaining  of  cold  and  numbness  down  the  right  side  of  his 
body.  He  went  from  room  to  room,  and  showed  an  inclination 
to  wander  outside.  His  daughter  led  him  about,  and  prevented 
him  from  going  out  of  doors. 

He  spoke  incoherent  nonsense.  Looking  out  he  suddenly 
exclaimed,  with  a  placid  but  startled  expression,  "  See,  doctor, 
there  is  snow  on  the  ground."  On  being  told  "  It  is  sunlight 
you  see,"  he  replied,  with  an  air  of  confusion  and  disappoint- 
ment, ^'  Oh !  sunlight  is  it  ?  I  thought  it  was  snow ; "  and 
immediately  he  rambled  incoherently  about  other  matters.  He 
then  wandered  into  a  room  where  Dr.  Smith  was  writing  a 
prescription  ;  came  up  to  the  waiting-table  and  began  touching 
various  things  without  any  definite  object.  He  looked  towards  the 
pigeon-holes,  where  he  had  private  papers,  and  stumbled  in  their 
direction,  but  took  nothing  out.  His  gait  was  peculiar,  and  he 
walked  in  a  sort  of  stealthy  manner,  mumbliiig  to  himself. 
He  appeared  in  a  feeble  and  pitiable  state.  He  was  not  the 
least  violent. 

Dr.  Smith  perceived  that  this  condition  was  very  peculiar. 
He  apprehended  a  paralytic  attack,  but  he  did  not  yet  suspect 
foul  play. 

On  this  day  (7th)  Dr.   Smith  heard  that  one  of  Mr. 's 

servants  had  expressed  a  suspicion  that  his  master  had  been 
poisoned  ;  Dr.  Smith  replied  that,  if  so,  the  poison  was  probably 
dhatoora.  On  the  8th  he  was  found  lying  perfectly  sensible, 
but  weak,  and  still  somehat  confused  and  unlike  himself.  On 
the  10th  he  wrote,  still  complaining  of  "  dryness  of  the  mouth 
and  throat."     On  the  13th  he  went  to  Dr.  Smith's  house,  and 


1872.]     A  Manual  of  Medical  Jurisprudence  for  India.         59 

talked  the  whole  matter  over.  He  then,  for  the  first  time,  said 
that  he  felt  convinced  that  he  had  been  poisoned.  He  believed 
there  were  four  occasions  on  which  he  had  reason  to  suspect 
that  poison  had  been  administered  to  him.  He  could  not  recall 
dates,  but  came  to  the  final  conclusion  that  the  first  occasion 
was  on  the  evening  of  the  1st,  the  second  on  the  evening  of  the 
6th,  the  third  on  the  morning  of  the  7th,  and  regarding  the 
fourth  he  was  uncertain.  Shortly  after  the  meals  on  the  6th 
and  7th  he  lost  all  recollection  of  what  happened  round  him. 
Meanwhile,  however,  he  experienced  a  feeling  of  intoxication 
and  giddiness,  difficulty  in  swallowing,  confusion  of  ideas, 
a  coldness  and  numbness  of  the  surface,  a  pricking  sensation  in 
the  nose,  and  an  irresistible  inclination  to  rub  it  violently  v 
He  had  also  convulsive  twitchings  of  the  legs  after  dinner  on 
the  6th.  He  had  no  fever  and  no  vomiting,  but  considerable 
drowsiness.  In  addition  to  the  symptoms  noticed  above,  there 
were  frequent  coughing  ;  attempts  to  hawk  and  spit ;  haziness 
and  confuson  of  objects,  as  if  everything  were  badly  focussed ; 
a  sensation  as  if  smoke  or  fog  were  rising  around  him.  The 
moment  he  touched  any  object  he  went  off  in  a  purposeless 
manner  to  some  other  object  at  a  distance.  As  he  did  this, 
he  was  led  and  supported  by  his  daughter,  and  looked  the 
picture  of  feeble  nervous  agitation.  After  recovering  to  a  certain 
degree,  he  still  evinced  a  partially  incoherent  mental  state ; 
his  vision  continued  indistinct,  the  eyes  were  bright  and  glistening, 
and  the  pupils  continued  to  be  widely  dilated.  He  also  ex- 
perienced a  sense  of  very  considerable  exhaustion,  walked  about 
feebly,  and  was  altogether  sadly  unlike  himself. 

Hence  Dr.  Smith  concludes,  that  he  was  powerfully  under 
the  influence  of  dhatoora.  Mr. appears  to  have  had  con- 
siderable causes  of  mental  distress.  Dr.  Smith  adds  that, 
taking  it  for  granted  that  an  excessive  quantity  of  dhatoora  was 
administered  in  this  case,  it  is  not  easy  to  determine  with  what 
specific  object  it  was  given,  whether  to  kill  at  once,  or  to  effect  the 
same  end  by  slow  poisining,  or  whether  it  was  intended,  by 
degrees,  to  stupefy  and  w^eaken  the  intellect.  It  is  to  be 
observed  that  the  natives  fully  believe  in  the  possibility  of 
rendering  a  person  fatuous  by  such  means. 

Reporting  the  case  a  year  subsequently.  Dr.  Smith  adds  that 
his  patient  was  then  "  perfectly  well  and  happy." 

This  case,  which  from  its  peculiarity  we  have  described  at  con- 
siderable length,  seems  to  have  occurred  in  1867,  and,  especially 
if  taken  in  association  with  another  also  given  by  Dr.  Chevers,  that 
occurred  in  1865,  to  which  a  European  railway  inspector  at  Jub- 
bulpore  was  the  victim,  tends  to  show  that  a  condition  resembling 
dementia  may  be  induced  and  kept  up  for  a  considerable  time. 


60  Reviews.  [Jan., 

This  gentleman  saw  his  servant  squeezing  the  juice  of  a  pounded 
dhatoora  fruit  into  a  stew  that  was  being  prepared  for  his  supper. 
Stating  that  he  was  not  hungry,  he  tokl  his  kitmutgar  to  put  it 
by  for  breakfast,  and  intended  taking  it  the  next  morning  to  the 
doctor.  In  the  morning,  however,  his  breakfast  was  obviously 
poisoned  by  the  same  drug,  for  on  his  ride  to  the  doctor's  he  was 
obliged  in  consequence  of  giddiness  to  stop  at  the  house  of  a 
friend,  who  could  not  make  out  what  was  the  matter,  as  he  was 
talking  incoherently,  going  reeling  about  the  room,  and  every 
now  and  then  squeezing  and  twisting  bis  coat  tails,  and  looking 
about  the  room  as  if  to  illustrate  his  meaning.  Having  taken 
only  a  single  dose,  he  recovered  on  the  following  day. 

The  next  poison  described  by  Dr.  Chevers  is  Cannabis  sativa, 
known  also  as  Indian  hemp,  bhang,  ganjar,  &c.  AVe  learn  for 
the  first  time  that  this  drug  may  cause  aphasia. 

In  1860  Dr.  James  Wise,  the  present  civil  surgeon  of  Dacca, 
wrote  to  the  author  from  Muttra,  that  he  had  lately  met  with 
several  cases  in  which  complete  loss  of  speech,  not  of  voice, 
followed  intoxication  from  hemp,  in  confirmed  smokers  of  that 
drug.  One  of  these  occurred  in  a  kidmutgar,  who  had  been 
addicted  to  this  vice  for  years.  Having  been  deprived  of  it 
for  some  time  while  out  in  the  district,  he  recommenced  smoking 
it  on  his  return  to  the  station.  One  morning  he  was  found 
lying  insensible,  with  a  cold,  clammy  skin,  breathing  slowly. 
He  recovered  from  this  after  emetics  and  purgatives  had  been 
given,  but  his  speech  was  lost.  He  understood  what  was  said, 
and  made  vain  attempts  to  speak.  He  continued  so,  at  least 
up  to  the  time  at  which  Dr.  Wise  wrote  to  Dr.  Chevers,  five 
weeks  subsequently,  well  in  physical  health,  but  dumb.  Another 
case  was  that  of  a  syce.  He  went  to  the  maidan  one  morning; 
while  returning  he  fell  down.  When  picked  up  he  was  dumb, 
and  could  not  walk.  He  had  a  vacant  stare ;  had  no  signs  of 
paralysis,  and  was  otherwise  in  good  health.  After  strong  pur- 
gatives and  blisters  to  the  nape  of  the  neck  he  recovered  his 
speech  and  was  discharged  to  duty. 

Dr.  Chevers  remarks  that  "several  narcotic  poisons,  and  especially 
datura,  interfere  greatly  with  articulation,  even  to  the  production  of 
complete  aphonia  ;  but  considering  the  lamentable  frequency  of  the 
vice  of  ganjar-smoking,  it  is  remarkable  that,  in  my  own  practice,  I 
have  only  met  with  one  case  similar  to  those  described  by  Dr.  Wise. 
Possibly  hemp  only  produces  this  effect  in  persons  whose  brains 
are  prone  to  those  neurolytic  conditions  which  lead  to  aphasia." 

"  Dr.  E.  C.  Bensley  has  noticed  that  very  moderate  doses  of 
tincture  of  cannabis  are  liable  to  cause  rather  serious  symptoms  in 
delicate  women  in  India — fainting  followed  by  torpor  and  collapse, 
pallor,  coldness  of  the  surface,  exceedingly  weak  pulse,  and  dilatation 
of  the  pupils"  (p.  224), 


1872.]      A  Manual  of  Medical  Jurisprudence  for  India,         Gl 

In  the  chapter  on  Opium  there  is  less  original  matter  than  in 
those  on  arsenic,  aconite,  and  datura.  This  drug  is  largely  used 
to  destroy  the  female  children  of  the  East,  the  mother  either 
giving  the  infant  a  small  pill  or  rubbing  her  own  nipples  with 
opium  before  putting  it  to  the  breast.  European  children  are 
not  unfrequently  drugged  with  opium  by  their  nurses.  A 
physician,  whose  name  is  given,  when  at  Dum-Dum  found 
a  piece  of  opium  as  big  as  the  end  of  the  little  finger  in  his 
infant's  mouth. 

Under  the  title  of  Poisonous  Fungi  we  have  a  remarkable  case 
recorded  by  Dr.  C.  Palmer,  of  Calcutta,  which  occurred  in  1853, 
and,  as  far  as  we  know,  is  unique.  The  action  of  these  unknown 
mushrooms  resembles  that  of  the  well-known  Amanita  muscaria. 
Mr.  C.  S — ,  an  accomplished  civilian  of  very  temperate  habits,  was 
ordered  out  of  the  Collector's  Court  at  11  a.m.,  in  consequence 
of  being  apparently  drunk.  On  the  following  morning  he  was 
seen  by  Dr.  Palmer,  who  reports  as  follows : 

"  I  found  him  in  a  state  of  great  depression  and  distress,  from  the 
recollection  of  the  occurrences  of  the  preceding  day.  He  informed 
me  he  had  had  his  breakfast  as  usual,  had  a  small  bottle  of  claret 
which  he  always  took,  and  was  not  aware  of  having  partaken  of  any- 
thing unusual,  and  certainly  not  to  excess.  That  he  went  to 
Cutcherry  at  the  usual  hour,  and  felt  unable  to  control  his  actions  ; 
felt  drunk;  everything  and  person  appeared  ludicrous;  he  laughed 
immoderately  in  open  court,  joked  with  the  Omlahs,  and  ridiculed 
in  an  absurd  way  his  superior  officer,  the  collector,  by  whom  he  was 
taken  to  his  house.  After  some  hours  he  recovered,  considerably 
depressed  from  the  effects  of  the  stimulant,  and  from  the  feeling  of 
shame  at  having  made  such  a  ridiculous  spectacle  of  himself  before 
his  court,  but  more  so,  as  he  assured  me,  that  this  was  the  third 
time  a  similar  attack  had  seized  him,  and  he  feared  he  would  go 
mad,  for  he  could  not  with  the  utmost  effort  control  his  actions, 
and  had  been  seized  in  precisely  the  same  manner  at  the  same  time 
of  the  year  three  years  in  succession  "  (p.  281). 

Dr.  Palmer,  to  console  him,  promised  to  return  to  tiffen,  at  which, 
amongst  other  dishes,  w^ere  stew^ed  mushrooms.  Before  the  meal 
w^as  finished  he  became  very  excited,  and,  as  he  had  taken  very  little 
beer  and  no  other  stimulating  drink,  it  suddenly  flashed  across  his 
mind  that  the  mushrooms  were  the  cause  both  of  his  own  and 
of   his    friend's    intoxication.     His    symptoms    were    identical  to 

those   described   by    Mr.   S ,   and    were   very    similar   to    the 

exhilaratory  effects  of  alcohol;  every  person  appeared  ridiculous, 
the  most  ordinary  remark  was  full  of  fun  and  wit,  and  his  immoderate 
laughter  provoked  equal  merriment  in  others.  "  I  took  (be  writes) 
a  drive  in  the  evening,  and  I  never  before  or  since  have  seen  the 
lights  and  shades  cast  by  the  setting  sun  so  brilliant,  and  every 
object  looking  so  perfectly  beautiful.  These  exaggerated  sensations 
continued  for  some  hours  ;  until,  at  the  request  of  my  friends,  I  put 
an  end  to  them  by  taking  a  full  dose  of  ipecacuanha,  and  thus  got 


6^  Reviews.  [Jan., 

rid  of  a  considerable  quantity  of  the  fungi  still  undigested.  I  ex- 
perienced no  after  ill  eii'ects  whatever." 

Amongst  poisons  acting  mechanically,  Dr.  Chevers  notices 
powdered  glass,  diamond  dust,  and  finely  chopped  human  hair 
which,  when  administered  in  curry  or  other  soft  food,  is  a 
recognised  mode  of  slow  poisoning  in  Singapore,  especially  by 
women  intent  upon  destroying  their  husbands. 

A  remarkable,  and  we  believe  unique,  case  of  poisoning 
by  chloride  of  cadmium,  that  occurred  in  the  Calcutta  Native 
Hospital,  is  given  at  p.  297.  From  experiments  made  in 
relation  to  this  case,  it  appeared  that  fifteen  grains  would  kill 
a  cat  in  less  than  five  minutes. 

The  toxicological  part  of  this  valuable  work,  for  which  we 
offer  our  hearty  thanks  to  Dr.  Chevers,  concludes  with  a  chapter 
on  the  poisonous  grains  and  legumes  occurring  in  India,  some 
of  which  give  rise  to  very  singular  forms  of  disease. 


V. — Physical  Degeneracy  in  the  United  States.^ 

The  question  of  physical  degeneracy  has  for  the  last  ten  years 
occupied  so  much  of  the  attention  of  physiologists,  of  statists, 
and  even  of  politicians,  that  we  make  no  excuse  for  bringing  a 
subject  which  has  so  many  social  bearings  before  the  notice  of 
our  readers.  As  Dr.  Arthur  Mitchell,  the  accomplished  Deputy 
Commissioner  for  Lunacy  in  Scotland,  has  observed — 

"If  we  carefully  study  the  literature  of  the  subject,  we  find  that 
it  abounds  ia  unsupported  assertions,  and  that  important  conclusions 

^  1.  Physical  Degeneracy.     By  Nathan  Allen,  Esq.,  M.D.     New  York,  1870. 

2.  The  Intermarriage  of  Relations.  By  Nathan  Allen,  Esq.,  M.D.  New 
York,  1869. 

3.  Population ;  its  Law  of  Increase.  By  Nathan  Allen,  Esq.,  M.D.  Lowell, 
Mass.,  1870. 

4.  The  Physiological  Laws  of  Human  Increase.  By  Nathan  Allen,  Esq.,  M.D. 
Philadelphia,  1870. 

5.  On  Genealogy  in  Connexion  loith  Anthropology.  By  G.  M.  Marshall,  L.L.M. 
London,  1865. 

6.  PloocU Relationship  in  Marriage  considered  in  its  injluence  upon  the  Offspring. 
By  Arthur  Mitchell,  M.A.,  M.D.     London,  1866. 

7.  Inqidry  into  Consanguineous  Marriages  and  Pure  Maces.  By  Dr.  E.  Dally, 
Paris,  1863.  Translated  by  H.  J.  C.  Beatan,  F.R.G.S.,  '  Anthropological  Review,' 
May,  1864. 

8.  Sur  les  Dangers  des  Unions  Consanguines.     Par  Dr.  BoFDiN.     Paris,  1863. 

9.  Un  Mot  sur  les  Mariages  Consanguins.     Par  Dr.  E.  Dally.     Paris,  1863. 

10.  On  the  8tature  and  BulJc  of  Man  in  the  British  Isles.  By  John  Beddoe, 
M.D.     London,  1870. 

11.  Influence  of  the  Climate  of  North  America  on  the  Physical  and  Psychical 
Consliiuiion.  By  E.  Desor.  '  Ccutralblatt  fiir  Naturgeschichte  und  Anthro- 
pologic,' 1863. 

12.  Sylridity  in  the  Genus  Homo.  By  Dr.  Paul  Broca.  Translated  by  C. 
Carter  Blake,  Doct.  Sci.     Loudon,  1864. 


1872. J        Phijsical  Degeneracy  in  the  United  States.  63 

are  very  often  made  to  rest  on  a  basis  which  is  undefended  and 
clearly  too  narrow." 

The  powerful  advocacy  of  Dr.  Dally  in  favour,  and  of  the 
late  Dr.  Boudin  against,  the  prevailing  doctrine  that  consan- 
guineous marriages  are  productive  of  physical  degeneracy,  has 
had,  across  the  Atlantic,  fresh  attention  called  to  it  by  Dr. 
Nathan  Allen.  It  will  be  our  duty  to  consider  carefully  some 
of  the  conclusions  to  which  this  author  has  been  led,  in  order 
that  they  may  be  compared  with  those  of  investigations  in  the 
Old  World.  The  author  confines  his  investigators  chiefly  to 
persons  having  their  origin  and  nativity  in  New  England,  and 
among  whom  certain  physical  changes  have  been  observed. 

It  is  first  necessary  to  eliminate  all  changes  which  are  pre- 
sumed to  have  taken  place  from  what  M.  de  Quatrefages  terms 
the  influence  du  milieu. 

"Among  these  external  agents  may  be  mentioned  the  effect  of 
changes  in  private  and  public  institutions,  in  the  style  of  dress  and 
state  of  society,  in  the  kinds  and  modes  of  doing  business,  in  the 
changes  of  soil,  of  vegetation,  of  air,  of  dwellings,  in  methods  of 
education,  habits  of  domestic  life,  &c.,  &c. ;  but  then  many  of  these 
external  agencies  cannot  be  considered  separately  from  the  internal, 
which  may  be  summed  up  under  three  general  heads,  viz.  exercise  in 
all  its  diversified  forms  ;  food,  including  drinks,  medicine,  and  what- 
ever enters  into  the  system  ;  and  the  last,  though  by  no  means  the 
least,  the  ejQfects  growing  out  of  the  laws  of  hereditary  descent." 

Such  changes  are  effected  either  by  natural  laws  of  growth, 
by  the  violation  of  natural  laws,  by  disease,  or  by  the  operation 
of  the  inexorable  rules  of  hereditary  descent.  Dr.  Nathan 
Allen  assumes  that  man  in  the  beginning  was  created  perfect, 
i.e.  free  from  disease  ;  and  we  think  that  both  the  perfectionists 
and  derivationists  will  grant  him  this  premiss.  For  on  the 
hypothesis  of  the  separate  creation  of  man  it  is  difficult  to  con- 
ceive an  individual  in  whom  the  tissues  were  imperfect;  and 
on  the  theory  of  his  origin  from  an  inferior  form,  the  high  degree 
of  athletism  which  it  is  necessary  to  presuppose  that  the  first 
simioid  possessed  would  have  been  obviously  incompatible  with 
the  view  of  physical  weakness  or  disease.  It  is  therefore  con- 
venient to  assume  this  proposition. 

Dr.  Nathan  Allen  quotes  at  great  length  the  investigations  of 
Dr.  B.  A.  Gould,  under  the  direction  of  the  Sanitary  Commis- 
sion, into  the  physical  characters  of  over  a  million  of  soldiers.  In 
the  old  world,  Quetelet  and  many  authorities  have  satisfactorily 
proved  that  the  maximum  stature  of  man  is  reached  at  the  age 
of  twenty-five.  It  Avas  shown  by  Dr.  Gould,  on  the  other  hand, 
that  it  was  not  till  thirty  years  of  age  that  the  typical  American 
reached  his  maximum  height.  The  backwoodsmen  of  Tennessee 
and  Kentucky  were,  as  might  be  expected,  the  tallest  in  stature, 


Gi  keviews.  fjj 


111. 


far  exceeding  those  from  the  manufacturing  states.  Dr.  Allen 
considers  that  this  excess  is  due  to  the  exercise  of  certain 
muscles  and  hones,  Avhile  in  a  state  of  grovvtli  and  under 
favorahle  circumstances.  Whilst  the  American  soldiers  ex- 
ceeded in  stature  those  of  other  nations  measured,  they  were 
far  inferior  to  the  Irish  and^Germans  in  weight,  strength,  girth, 
and  certain  other  properties,  and,  in  fact,  may  be  said  to  have 
"  run  to  stalk." 

The  results  of  the  measurements  have  only  confirmed  the  in- 
duction which  has  been  already  thoroughly  established,  that 
pure  races  are  always  superior  to  mixed  races  in  their  physical 
stamina.  In  all  these  investigations  the  volunteers  were  care- 
fully omitted ;  for  in  America,  as  well  as  elsewhere,  they  are 
composed,  on  the  average,  of  more  healthy  and  better-fed  men 
than  the  members  of  the  regular  army.  Dr.  Allen  believes  that 
among  the  American  race  at  the  present  time  a  gradual  loss  of 
muscle  and  a  rapid  increase  of  the  nervous  temperament  are 
observable.  This  is  not  advanced  as  a  mere  whim,  like  the 
fancy  sketch  in  the  amusing  work  *  The  Coming  Race,'  but 
appears  to  be  borne  out  by  the  most  careful  research.  The  in- 
creasing migration  of  the  American  people  from  the  country  to 
the  city  is  decidedly  unfavorable  to  the  physical  well-being  of 
the  population ;  and  the  statistics  collected  by  Dr.  Beddoe, 
respecting  the  enormous  differences  which  prevail  between  the 
urban  and  country  populations,  are  amply  corroborated  by  Dr. 
Allen.  He  furthermore  proves  that  the  invention  of  machines, 
whereby  physical  labour  is  replaced,  has  tended  enormously  to 
depreciate  the  strength  of  the  population.  Fifty  or  a  hundred 
years  ago,  the  exigencies  of  the  settlers  required  an  enormous 
amount  of  hand-work  to  be  done  in  clearing  the  forests,  in 
tilling  the  ground,  and  in  the  erection  of  dwellings,  but  this 
work  once  accomplished,  within  the  area,  relieves  the  following 
generations  from  the  like  necessity  for  labour,  and  the  result  is 
a  visible  deterioration  of  the  physique.  Desor  has  well  shown 
this  in  an  argument  of  which  we  extract  the  most  striking  points  : 

"  When  a  Grerman  or  Swiss  emigrant  arrives  in  New  York,  the 
climate  appears  to  him  much  the  same  as  that  of  his  native  country. 
But  if  he  takes  up  bis  residence  in  that  country,  he  soon  finds  it 
necessary  to  change  Iris  mode  of  life  and  habits. 

"  It  is  about  two  hundred  and  thirty  years  since  the  first  colonists 
arrived  in  JSTew  England.  They  were  all  true  Englishmen,  endowed 
with  all  the  characters  of  the  Anglo-Saxon  race. 

"  Another  chief  characteristic  of  the  American  is  the  length  of  the 
neck ;  not  that  it  is  absolutely  longer  than  amongst  us,  but  appears 
longer  on  account  of  leanness.  The  Americans,  again,  soon  recog- 
nise the  European  by  the  opposite  characters.  '  He  is  a  stranger ; 
look  at  his  neck,  an  American  has  no  such  neck.'  " 


1872.]        Physical  Degeneracy  in  the  United  States.  65 

The  physical  difference  between  the  American  and  European 
is  not  only  manifest  in  the  muscuhir,  but  also  in  the  glandular 
system  ;  a  matter  that  especially  deserves  the  attention  of  the 
physiologist,  as  it  concerns  the  future  of  the  American  race. 
The  most  intelligent  Americans  perceive  that  the  increasing 
delicacy  of  form  (especially  in  the  women)  ought,  if  possible,  to 
be  arrested.  Despite  of  their  instinctive  aversion  to  the  Irish 
(forming  the  largest  contingent  of  immigrants),  they  are  aware 
that  the  development  of  the  glandular  system  of  that  race  is 
well  calculated  to  neutralise  the  influences  of  the  climate  for  a 
considerable  time.  It  has  been  observed  that  the  finest  women 
are  descended  from  European  parents. 

There  are  few  Europeans  who  get  fat  in  the  United  States ; 
the  Americans,  on  the  contrary,  who  reside  for  a  considerable 
time  in  Europe,  become  more  healthy  and  portly.  This  occurs, 
also,  to  the  European  when,  after  a  lengthened  stay  in  America, 
he  returns  to  Europe.  The  author  (Desor)  quotes  himself  as  an 
example  of  the  kind.  We  look  in  vain  among  American  chil- 
dren, despite  of  all  the  care  taken  by  their  mothers,  for  curly- 
headed  children,  so  frequently  seen  in  England.  The  hair  of 
the  European  becomes,  in  America,  drier,  and  requires  pomatum, 
&c.,  to  keep  it  glossy  and  soft.  The  want  of  depth  in  the  voice 
of  Americans  is  also  ascribed  to  the  influence  of  climate.  Every 
European  who  arrives  at  New  York,  Boston,  or  Baltimore,  will 
be  struck  with  that  feverish  activity  the  American  displays. 
Every  one  is  in  a  hurry ;  the  people  do  not  walk — they  run. 
Something  like  it  is,  no  doubt,  seen  in  the  large  commercial 
towns  of  England  ;  but  the  activity  of  the  Englishman  seems 
more  under  the  control  of  reason  ;  that  of  the  Yankee  is  instinc- 
tive, or  at  any  rate  the  result  of  habit  or  of  an  innate  restlessness. 
They  even  exhibit  this  accelerated  activity  during  their  meals, 
which,  even  if  they  have  nothing  important  to  do,  are  despatched 
in  equally  short  time. 

Dr.  Allen  is  also  of  opinion  that  the  use  of  spirituous  liquors 
is  more  destructive  in  America  than  in  our  climate,  and  in  evi- 
dence quotes  the  fact  that  Europeans  who  are  accustomed  to 
strong  drinks  in  their  own  country  have  either  to  renounce 
their  use  or  to  limit  the  quantity  in  America,  to  avoid  their  ill 
consequences. 

At  this  time  the  characteristics  of  pure  English  breed  are  no 
longer  seen  among  the  inhabitants  of  the  United  States,  but 
have  been  replaced  by  a  new  type.  This  type  is  not  the  product 
of  intermixture,  since  it  is  seen  in  the  most  marked  form  in  the 
eastern  states,  where  the  race  is  less  mixed ;  but  it  must  be 
attributed  to  external  influences.  One  of  the  first  physiological 
characters  of  this  American   type  is  an  absence  of  corpulence. 

97— xLix.  5 


66  Reviews.  [Jan., 

On  perambulating  the  streets  of  New  York,  Boston,  Philadel- 
phia, and  other  towns,  scarcely  one  portly  individual  will  be  en- 
countered among  a  hundred  persons,  and  the  one  met  with  will 
frequently  turn  out  to  be  a  foreigner. 

In  the  time  of  the  pilgrim  fathers  of  New  England  there  was 
relatively  much  more  acute  disease,  far  greater  violence  in  its 
attacks,  and  a  decidedly  higher  grade  of  inflammation,  than  exist 
at  the  present  day.  Venesection  and  cathartics  were,  according 
to  Dr.  Allen,  not  only  administered  but  required.  Since  that 
time  scrofula,  general  debility,  dyspepsia,  anaemia,  and  neuralgia, 
which  formerly  used  to  be  extremely  rare,  are  now  very 
common. 

An  analysis  of  the  death-rate  of  Chicago  from  1852  to  1868, 
during  which  time  the  population  had  increased  from  50,000  to 
^50,000,  led  Dr.  S.  W.  Mitchell  to  conclude  that  the  diseases 
classed  as  strictly  nervous  had  increased  threefold.  In  Massa- 
chusetts, likewise,  there  has  been  a  great  increase  of  diseases  of 
the  brain  and  nervous  system  ;  and,  generally  speaking,  cases 
of  inflammation  and  congestion  of  the  brain,  of  apoplexy,  of 
paralysis,  epilepsy,  and  convulsions,  are  far  more  common  now 
than  formerly ;  and  the  two  former,  instead  of  being  confined 
to  the  aged,  from  sixty  to  eighty,  frequently  occur  among  those 
from  forty  to  sixty  years  old. 

The  loss  of  muscle  and  increased  nervous  excitability,  and  the 
change  in  the  type  and  character  of  diseases,  are  conditions 
much  more  pronounced  among  women  than  men.  Dr.  Allen 
considers  that,  in  the  case  of  females,  the  time  bestowed  upon 
what  passes  in  America  for  school  education  would  be  better 
spent  in  housework.  This  appreciation  of  the  value  of  female 
education  in  America  may  well  be  disputed,  and  we  believe  that 
Dr.  Allen  must  seek  for  some  deeper  cause  to  account  for  results 
he  deplores  among  American  women. 

The  same  writer  considers  that  the  increased  use  of  tonics,  espe- 
cially the  preparations  of  iron,  in  the  case  of  females  particularly, 
is  evidence  also  of  physical  debility  ;  but  he  would  have  estab- 
lished his  case  better  had  he  given  precise  statistics  to  show  the 
augmentation  of  diseases,  instead  of  quoting  the  increase  in  the 
quantity  of  certain  remedies  employed. 

The  amount  of  uterine  diseases,  due  in  great  part  to  customs 
nearly  peculiar  to  the  United  States,  are  mentioned  by  Dr. 
Allen  as  further  strong  evidence  of  decline  in  the  physical 
status  of  the  American  people.  The  deficiency  in  quantity,  and 
still  more  the  poor  quality,  of  the  mammary  secretion  is  assigned 
as  a  cause  of  the  small  number  of  the  American  children  reared 
and  healthily  developed. 

Dr.  Allen,  who  adopts  an  obsolete  classification  of  tempera- 


1872.]  Physical  Degeneracy  in  the  United  States.  67 

ments,  considers  that  the  lymphatic  and  sanguine  temperaments 
are  not  properly  developed  in  the  American  race.  There  is  a 
marked  deficiency  in  the  organs  of  nutrition  and  secretion,  and, 
in  connection  with  these  facts,  it  is  to  be  borne  in  mind  that  all 
imperfect  developments,  morbid  weaknesses,  or  strong  pre- 
dispositions, are  transmitted  in  an  intensified  form  to  suc- 
cessive generations,  unless  other  opposing  favorable  conditions 
intervene. 

The  question  of  longevity  in  the  American  population  also 
affords  elements  of  criticism.  In  the  history  of  nearly  all  nations 
there  will  be  found  a  slight  excess  of  births  of  males  over  females, 
to  provide  for  the  greater  exposure  and  liability  to  sudden  death 
in  the  former.  Professor  Loomis,  after  a  comparison  of  New 
York  and  the  New  England  states,  proves  that  in  the  census  ot 
1860  there  were  in  these  seven  states  850,000  boys  and  830,000 
girls  under  ten  years  of  age.  At  the  age  of  twenty  there  were 
15,000  females  in  excess  of  the  males,  and  at  the  age  of  thirty 
there  were  75,000  more  females  than  males.  Now,  making 
proper  allowance  for  emigration,  these  figures  follow  very  closely 
the  law  of  life,  as  seen  in  the  following  six  states — England, 
Scotland,  Ireland,  Belgium,  Norway,  and  Sweden ;  but  at  the 
age  of  forty,  instead  of  this  excess  of  the  number  of  females 
continuing  in  America  as  it  does  in  those  six  European  nations, 
we  find  that  these  75,000  females  have  all  disappeared,  with 
2000  more,  and,  at  the  age  of  fifty,  20,000  in  addition  have  fol- 
lowed them.  Thus,  97,000  females  have  passed  away,  as  they 
would  not  have  done  had  they  lived  in  those  other  countries 
named.  The  census  fails  to  give  statistics  of  the  health  of  a 
community,  but  it  is  well  known  that  when  vitality  is  so 
depressed  as  to  cause  such  a  fearful  increase  of  deaths,  results 
are  more  perceptibly  seen  among  the  living. 

The  descriptions  and  portraits  of  the  Puritan  women  of  past 
times  represent  them  for  successive  generations  as  possessing 
well-developed  bodies^  in  many  instances  of  large  size.  Even 
the  last  generation  of  New  Englanders  are  larger  and  stronger 
than  the  present  race. 

With  regard  to  other  unfavorable  conditions  of  life  enume- 
rated by  Dr.  Allen,  these  may  chiefly  be  summed  up : — 
in  undue  hurry  and  excitement  in  all  the  affairs  of 
life,  intemperance  in  eating,  drinking,  and  smoking,  and  in 
general  disregard  of  the  true  laws  of  health.  To  these  may- 
be added  the  enormous  consumption  of  patent  medicines,  the 
hasty  manner  of  eating,  the  practice  of  eating  an  excess  of 
fine-flour  bread,  the  abuse  of  tea  and  coflee,  the  increased  use  of 
a  rich,  highly-seasoned,  and  stimulating  diet,  and  the  constant 
employment  of  iced  water.      The  dental  records  of  America 


68  Reviews.  [Jan., 

show  that  to  tlie  hist  cause  especially  may  be  attributed  the 
excessive  prevalence  of  diseases  of  the  teeth ;  at  the  same  time 
no  inconsiderable  influence  must  likewise  follow  from  the  fre- 
quency of  the  scrofulous  diathesis. 

On  the  subject  of  alcoholic  drinks,  tobacco,  and  opiates,  Dr. 
Allen  repeats  the  same  arguments,  if  they  can  be  so  called, 
which  have  been  urged,  usque  ad  nauseam,  by  numerous  writers 
in  the  old  world.  That  excessive  drinking  and  smoking  are 
injurious  is  a  truism;  but  that,  on  the  whole,  Americans  drink 
or  smoke  more,  or  that  there  is  a  greater  relative  amount  of 
narcotics  consumed  in  America  than  in  Europe,  are  assumptions 
which  up  to  the  present  time  do  not  rest  upon  well- ascertained 
and  recorded  facts,  and  in  dealing  with  so  important  a  question 
something  more  might  justly  have  been  required  of  Dr.  Allen 
than  mere  unsupported  assertions.  Such  might  have  been 
obtained  from  the  statistics  of  liquors,  tobacco,  and  opiates,  used 
for  home  consumption,  or  from  criminal  statistics.  That  a  large 
consumption  of  corn  spirit  takes  place  in  America  there  can- 
not be  the  slightest  doubt,  but  before  we  bring  the  charge  of 
drunkenness  against  the  inhabitants  we  must  not  forget  that 
the  amount  of  beer  and  wine  consumed  by  them  is  compara- 
tively small. 

The  most  serious  matter,  however,  which  Dr.  Allen  adduces 
in  proof  of  degenerescence  among  his  countrymen  is  based 
upon  more  tangible  ground,  resting  on  the  undoubted  fact 
that  the  birth-rate  is  continually  diminishing.  The  regis- 
tration returns  of  births,  deaths,  and  marriages  have  now  been 
made  in  Massachusetts  for  over  twenty-five  years ;  and  no  fact 
from  these  returns,  as  well  as  from  other  sources,  is  more  appa- 
rent than  that  the  birth-rate  of  the  American  people  has  been 
constantly  diminishing.  From  1850  to  1860  the  average  birth- 
rate, by  these  returns,  was  1  to  33,  omitting  the  fraction ;  but 
during  the  five  years  of  war  the  average  was  1  to  39,  and  since 
the  war  the  average  has  been  1  to  o^.  In  1850  the  census 
returns  the  population  of  Massachusetts  994,514 ;  American, 
830,066,  and  foreign  164,448;  the  registration  reports  make 
the  whole  births  27,664;  American,  16,189,  foreign,  8197, 
with  3278  mixed,  most  of  which  are  of  foreign  descent.  The 
last  census,  1865,  returns  the  whole  population  in  the  same 
state,  1,267,003 ;  American,  1,002,545,  and  foreigners,  265,486. 
The  registration  report  makes,  for  the  same  year,  the  whole 
number  of  births  30,249:  American,  13,276;  foreign,  14,130; 
and  mixed,  2406. 

In  the  census  column  headed  '^  American,"  a  large  number 
of  persons  are  included  simply  because  born  there,  whose  paren- 
tage is  strictly  foreign  ;  and  so  in  the  registration  reports,  under 


1872.]  Physical  Degeneracy  in  the  United  States.  69 

the  column  "  Births,  American/'  there  are  enrolled  some  of 
foreign  descent.  Hence  it  is  very  difficult  to  obtain  separately 
the  exact  birth-rate  of  the  two  classes. 

After  making  the  best  attempts  we  can  to  analyse  these 
returns,  and  to  compare  the  births  of  the  two  classes  since  the 
war,  we  find  the  birth-rate  of  the  foreign  (that  of  the  whole 
averaging  1  to  36  for  several  years)  below  1  to  30 ;  whilst  that 
of  the  American  ranges  considerably  above  1  in  40,  and,  perhaps, 
extends  nearly  to  1  in  50. 

In  the  history  of  European  nations  it  has  been  found  that,  in 
order  for  any  nation  to  increase  much  in  population,  the  birth- 
rate must  reach  about  1  in  30.  The  last  United  States'  census 
report  gives  the  birth-rate  of  the  following  nations  thus,  omit- 
ting fractions  :— Saxony,  25  ;  Prussia,  26  ;  Austria,  26 ;  Sardinia, 
27;  Bavaria,  29;  Netherlands,  30;  England,  30;  Norway,  31; 
Denmark,  32;  Sweden,  32;  Hanover,  32;  Belgium,  34; 
France,  37. 

The  foregoing  are  the  principal  facts  which  appear  to  show 
beyond  a  doubt  that  the  American  race  is  suffering  from  a 
process  of  physical  degeneration.  Whether  the  causes  which 
Dr.  Allen  has  assigned  may  not  fairly  be  pronounced  inadequate 
for  the  most  part,  we  will  not  discuss.  Many  of  them  contain 
their  own  answer  so  entirely,  are  so  inconsistent  and  so  little 
supported  by  statistics,  that  they  are  unworthy  of  serious  criti- 
cism. The  late  Dr.  Knox  remarked,  "  Already  the  United  States 
man  differs  in  appearance  from  the  American;  and  America 
will  still  require  English  blood  to  keep  up  its  people,  and  then 
be  a.  kind  of  European  settlement," 

The  mixture,  for  example,  of  the  Chinese,  Irish,  Negro, 
Mohawk,  Dutch,  German,  Spanish,  French,  and  English  races 
in  the  synthesis  which  is  called  the  American  population  con- 
tains too  many  heterogeneous  elements  to  possess  perfect  vita- 
lity. Dr.  Paul  Broca,  in  his  researches  on  hybridity,  has  very 
well  pointed  out  the  limits  within  which  it  may  be  said  that 
**  mixed  breeds  die  out;"  and  whether  we  consider  the  compli- 
cated metis  which  exist  between  the  various  members  of  the 
human  family,  especially  in  the  Southern  States  and  in  Central 
America,  the  rule  becomes  perfectly  prominent,  that  in  the 
same  ratio  as  the  breed  is  complex,  or  as  it  is  derived  from 
ancestors  far  or  nearly  related,  so  the  infertility  can  be  pre- 
dicted. 

The  consideration  of  this  loss  of  human  hybridity  appears  to 
be  at  the  foundation  of  the  whole  question.  Hybrid  races  have 
been  divided  by  Paul  Broca  into  Agenesic,  Dysgenesic,  Para- 
genesic  and  Eugenesic.  In  the  first  case,  mongrels  of  the  first 
generation  are  entirely  infertile,  either  between  each  other  or 


70  Reviews.  [Jan._, 

with  tlie  two  parent  species,  and  are,  consequently,  unable  to 
produce  either  direct  descendants  or  mongrels  of  the  second 
generation.  The  dog  and  cat,  and  most  allied  genera  of  animals, 
may  be  cited  as  examples.  In  the  second  or  dysgenetic  class, 
the  mongrels  of  the  first  generation  are  nearly  altogether  sterile, 
as  in  the  mule  between  the  horse  and  ass.  The  third  or  para- 
genetic  class  are  mongrels  of  the  first  generation,  which  have 
a  partial  fecundity.  Tbey  are  sometimes  scarcely  fertile  or  in- 
fertile i?ite7'  se,  and  when  they  produce  direct  descendants  these 
have  merely  a  decreasing  fertility  tending,  to  necessary  extinc- 
tion at  the  end  of  some  generations.  Sometimes,  however; 
they  breed  easily  with  one  at  least  of  the  two  parent  species. 
The  mongrels  of  the  second  generation  issued  from  this  second 
breeding  are  themselves  and  their  descendants  fertile  inter  se 
and  with  the  mongrels  of  the  first  generation,  with  the  nearest 
allied  pure  species,  and  with  the  intermediate  mongrels  arising 
from  these  various  crossings.  The  various  human  mixed  breeds 
of  Central  America  may  be  taken  as  examples.  In  the  fourth 
or  eugenesic  division  mongrels  of  the  first  generation  are  en- 
tirely fertile.  They  are  fertile  inter  se,  and  their  descendants 
are  equally  so.  They  breed  easily  and  indiscriminately  with  the 
two  parent  species ;  the  mongrels  of  the  second  generation  in 
their  turn  are  themselves  and  their  descendants  indefinitely 
fertile,  both  i7iter  se  or  with  the  mongrels  of  all  kinds  which 
result  from  the  mixture  of  the  two  parent  species. 

Such  being  the  laws,  it  is  easy  to  see  that  the  mixed  character 
of  the  races  which  inhabit  the  United  States  has  induced  an 
amount  of  cross-breeding  which  naturally  tends  to  terminate  in 
the  extinction  of  the  mixed  progeny.  The  researches  of  Count 
Oscar  Reichenbach  have  shown  that  the  coloured  race  in  the 
United  States,  leaving  the  pure  blacks  out  of  consideration,  are 
rapidly  becoming  extinct.  Emancipation  has  caused  a  decrease 
of  coloured  population  in  the  Northern  States,  for  there  is  no 
natural  increase  of  the  coloured  population  in  those  states,  and 
there  are  no  emigrants,  manumitted  and  fugitive,  augmenting 
them.  On  the  contrary,  some  have  migrated  to  the  South, 
where  climate,  economical  conditions  and  society,  are  somewhat 
more  congenial.  In  fifty  years  hardly  any  mulattos  or  quad- 
rovers  will  be  found  in  the  present  Northern  States,  and  over 
the  whole  extent  of  the  country  their  numbers  would  probably 
not  amount  to  more  than  9,000,000,  a  number  more  likely  to 
decrease  than  increase  from  that  time  forward,  from  causes  still 
more  powerful  than  those  which  operate  on  the  transmutation 
of  people  in  Ireland.  These  facts  are  of  the  very  highest  im- 
portance to  those  who  take  an  interest  in  the  future  of  the 
negro  race  in  America.     One  of  the  evils  which  has  been  fre- 


1872.]  Physical  Degeneracij  in  the  United  States.  71 

quently  pointed  out  as  incidental  to  the  coloured  population  is 
the  great  mortality  amongst  the  chiklren  of  the  African  race  as 
seen  in  Virginia.  It  has  been  attempted  to  show  that  this  was 
peculiar  to  the  negroes  in  the  Slave  States  ;  but  it  is  now  clearly 
demonstrated  that  the  mortality  was  far  greatei  in  the  Northern 
States,  where  there  is  absolutely  no  increase  at  all,  while  in  the 
former  Slave  States  the  negroes  increased  twenty  per  cent.  The 
real  cause  of  this  mortality  will  not  be  found  in  the  political 
institutions  of  slavery  or  freedom,  nor  in  the  social  incidents  of 
work  or  starvation,  but  in  climate.  And  the  great  mortality 
observable  in  negroes,  and  to  a  still  greater  extent  in  the  mixed 
breeds  of  the  Northern  States,  appears  due  to  pulmonary  diseases 
alone,  the  result  of  those  abnormal  climates  to  which  they  are 
exposed.  In  Maine  the  decrease  between  1850  and  1860  was 
^'14  per  cent.,  in  Vermont  1*25  per  cent.,  in  New  Hampshire 
5  per  cent.,  and  in  New  York  0*13  per  cent;  whilst,  on  the 
other  hand,  in  South  Carolina  the  increase  was  1063,  in 
Missouri  36'44,  and  in  Alabama  19.  The  fortieth  degree 
of  north  latitude  is,  perhaps,  higher  than  any  negro  can  exist 
in  in  a  normal  condition.  It  was  absurd  to  talk  of  Virginia 
as  a  "  breeding  state,"  for  that  state  was  never  so  well  suited 
to  the  negro  constitution  as  the  states  further  south.  Nature 
has  thus  gradually  done  the  work  for  which  the  advocates  of 
emancipation  fought  so  long.  Where  the  white  man  can  labour 
there  is  no  chance  for  the  negro  and  still  less  for  the  coloured 
population.  It  is  a  sufficient  fact  that  the  inexorable  and  change- 
less fiat  of  the  natural  law  of  hybridity  has  done  more  to  ex- 
tirpate the  mulatto,  races  than  all  the  blood  and  treasure  which 
was  wasted  in  the  American  war.  AVhilst  armies  were  fighting 
and  countries  were  being  devastated,  the  teterrima  causa  belli 
has  nearly  become  extinct,  and  a  very  few  more  years  must 
mark  the  termination  of  the  unfortunate  race. 

The  fact  that  no  distinct  hybrid  race  of  men  can  be  found  to 
exist  anywhere  in  the  old  or  new  world  (the  Griquas  of  the 
Cape  of  Good  Hope  having  been  long  since  dismissed  to  what 
Professor  Owen  calls  ^*  the  limbo  of  all  hasty  blunders"),  must 
impress  students  of  physical  degeneracy  wdth  the  real  laws 
which  influence  the  apparent  diminution  of  the  vitality  in  the 
American  races.  When  we  turn  to  the  old  world,  we  see  with 
what  strength,  vigour,  and  vitality,  the  pure  races  are  endowed, 
who  through  centuries  have  kept  apart  from  the  surrounding 
population.  The  very  existence  of  such  a  race  e.  g.  as  the 
Basques  in  North  Eastern  Spain  and  South  Western  France,  is 
a  stumbling-block  to  the  student  who  imagine  that  races  have 
their  cycles  of  greatness  or  decay.  The  purest  races  in  the  old 
world,  unmixed  with  any  other  blood,  appear,  so  far  as  our  time 


71 


Reviews.  [Jan., 


or  our  history  can  estimate,  to  be  eternal  and  unvariable.  As 
the  Late  Robert  Knox  said — 

"  The  sterility  of  hybrids  is  the  check  which  nature  employs  fop 
the  preservation  of  her  primitive  forms  of  life.  There  is  a  consan- 
guinity, no  doubt,  in  all  that  lives  ;  for  life,  being  a  property  inherent 
in  matter,  must  at  its  origin  have  been  one,  but  this  consanguinity 
does  not  extend  to,  or  include,  specialities.  It  goes  no  further 
than  genera,  and  most  commonly  not  so  far." 

In  1846,  when  Knox  applied  these  biological  doctrines  to 
political  events,  much  contempt  was  poured  upon  him,  yet 
events  in  Italy,  Austria,  and  America,  have  shown  the  supre- 
macy of  simple  physiological  facts  connected  with  the  viability 
of  the  species  over  political  theories.  In  1872  we  are  able  to 
estimate  the  value  to  be  placed  upon  generalizations  like  those 
of  Knox,  Nott,  Gladdon,  Broca,  Pouchet,  or  Quatrefages. 
When  considering  the  diminution  of  births  amongst  the  coloured 
populations  of  America — when  watching  the  peculiar  features 
which  mark  the  mixed  population  of  Central  America,^  features 
which  appear  in  strong  contrast  to  our  own  ideas  of  the  pro- 
portions of  the  sexes — we  are  compelled  to  admit  that  we  must 
seek  for  an  explanation  of  the  laws  which  regulate  the  extinc- 
tion of  great  masses  of  human  beings  somewhere  else  than  in 
the  mere  speculations  of  the  politician.  It  remains  to  be  seen 
whether  the  mixed  progeny  of  Celt,  Teuton,  Scandinavian,  and 
Romano-Latin  origin  found  in  America  is  destined  to  live  many 
generations  longer  than  the  mulatto  or  the  quadroon.  It  is 
true  that  the  ancestors  of  the  present  white  races  were  not  so 
far  removed  from  each  other  as  the  negro  and  the  white  man ; 
yet  even  this  is  a  mere  question  of  degree,  and  it  remains  to  be 
seen  whether  or  not  many  more  hundred  years  they  will  last 
than  the  mulatto  or  the  quadroon. 

It  is  attempted  by  Dr.  Nathan  Allen  and  others  to  show  in 
some  degree  that  the  degeneracy  of  wdiich  we  have  spoken  at 
such  length  is  due  to  the  intermarriage  of  relations.  We  con- 
sider that  in  this  respect  the  supporters  of  M.  Daily's  theory 
have  entirely  failed  to  make  out  their  case.  That  consanguineous 
-^^marriages  under  certain  conditions  might  produce  a  feebly  viable 
population  is  beyond  doubt,  but  whether  such  a  fact  obtains 
universally,  or  whether  consanguinity  in  all  cases  is  the  pre- 
cursor of  scanty  and    unhealthy  progeny,  we    think  that  Dr. 

'  In  February,  1868,  the  births  in  a  mestizo  population  of  the  hill  districts  of 
Nicaragua  were  4 ;  the  number  of  deaths  from  natural  causes  188.  There  was  no 
epidemic.  It  was  impossible  to  estimate  precisely  the  population,  which  amounted 
to  about  2000.  The  women  in  the  district  were  under  fifty  in  number.  Of 
course  this  is  given  as  an  extreme  case.  Such  a  race  cannot  be  expected  to 
increase.  In  other  parts  of  Central  America  Mr.  Crowe  (not  a  very  trustworthy 
authority)  says  that  the  proportion  of  females  to  males  is  "four  or  five  to  one," 


1872.]     Simpson's  Obstetrical  and  Gyruecological  Works.       73 

Allen  has  not  clearly  proved.  He  appears  to  have  written  in 
perfect  ignorance  of  Dr.  Arthur  Mitchell's  large  memoir  on  the 
suhject,  as  well  as  of  the  voluminous  controversies  which  took 
place  before  the  Societe  d^ Anthropologic  de  Paris.  Dr.  Mitchell's 
paper  in  the  ^  Edinburgh  Medical  Journal'  for  1812  is,  of  course, 
referred  to.     Dr.  Mitchell  arrived  at  the  following  results  : 

"1.  It  is  no  law  of  nature  that  the  offspring  is  injured  by  con- 
sanguinity in  the  parentage.  2.  That  this  injury  assumes  various 
forms.  3.  That  in  all  classes  and  conditions  of  society  its  manifes- 
tations are  not  alike.  4.  That  the  evil  appears  in  some  measure 
under  control.  5.  That  isolated  cases  or  groups  of  cases  may  pre- 
sent themselves  where,  in  addition  to  consanguinity,  all  the  other 
circumstances  are  so  unfavorable  that  a  confident  prediction  of  much 
evil  would  be  expected,  but  where  no  such  evil  appears.  6.  That 
where  the  children  seem  to  escape,  the  injury  may  show  itself  in  the 
grandchildren,  so  that  the  defect  may  be  potential  where  it  is  not 
actual.  7.  That  as  regards  mental  disease,  unions  between  blood  re- 
lations induce  idiocy  and  imbecihty  more  than  they  do  other  forms 
of  insanity ;  that  with  reference  to  Scotland  it  may  be  estimated 
with  safety  that  about  nine  or  ten  per  cent,  of  existing  idiocy  is  re- 
ferable directly  to  consanguineous  marriages.  In  forming  this  esti- 
mate, the  proper  deductions  were  liberally  made,  so  as  to  avoid  an 
over-estimate." 

But  the  literature  of  the  whole  subject  is  so  vast  that  it  will 
be  years  before  any  one  can  venture  upon  general  conclusions. 
As  the  research  and  knowledge  of  nearly  every  writer  on  the 
subject  is  in  inverse  ratio  to  his  confidence  that  he  has  closed  the 
discussion  once  and  for  all,  the  whole  subject  of  consanguinity 
demands  a  generation  of  students  possessed  of  far  more  know- 
ledge than  the  present  to  solve  the  problem.  The  fact  of  the 
physical  degeneracy  of  sundry  mixed  populations  in  the  New 
World  is  painfully  evident  to  the  student  of  man,  and  the 
amount  of  vitality  which  remains  to  them  has  to  be  ascertained 
in  the  great  tontine  which  regulates  the  vital  statistics  in  this 
planet. 


VI.— Sir  J.  Y.  Simpson's  Selected  Obstetrical  and  Gynsecological 

Works.i 

A  NEW  edition  of  Simpson's  works,  long  out  of  print,  became 
almost  a  necessity  when  the  great  obstetrician  had  been   taken 

^  Selected  Obstetrical  and  GyncRcological  Works  of  Sir  James  Y.  Simpson, 
Bart.,  M.D.,  D.CL.,  Late  Professor  of  Midwifery  in  the  University  of  Edinburgh, 
Edited  by  J.  Watt  Black,  M.A.,  M-D.    Ediuburgli,  1871. 


74  Heviews.  [J"an., 

from  us,  and  the  first  volume,  fitly  edited  by  one  who  was  privi- 
leged to  be  his  assistant  for  many  years,  now  lies  before  us. 
This  is,  in  the  main,  a  reprint  of  the  articles  collected  by 
Priestley  and  Storer,  with  some  judicious  omissions,  and  with 
the  addition  of  a  portion  of  his  lecture-notes,  which,  if  they 
serve  no  other  purpose,  will  remind  Simpson's  old  pupils  of  the 
hours  passed  in  the  class-room  in  Edinburgh,  where  the  con- 
tents of  the  "  boards"  which  formed  so  marked  a  feature  of  his 
tuition  were  so  eagerly  scanned.  For  this  reason,  for  the  many 
memories  they  evoke,  we  think  that  Dr.  Black  has  acted  wisely 
in  inserting  them ;  but  independently  of  this  sentimental  con- 
sideration, which  can  appeal  to  Edinburgh  men  alone,  the  notes 
are  valuable  as  giving  some  insight  into  the  clear  and  logical 
nature  of  their  author's  mind.  They  form  a  terse  and  vigor- 
ous synopsis  of  all  that  is  known,  or  rather  was  known  at  the 
time  of  their  compilation,  of  the  topics  they  discuss,  and  our 
obstetric  teachers  would  do  well  to  study  the  method  of  tuition 
used  by  so  great  a  master  in  their  art. 

What  can  we  say  of  the  remainder  of  the  book  ?  Here  we 
have  the  labours,  so  far  as  written  work  went,  on  which  Simp- 
son^s  vast  reputation  was  founded,  and  those  who  did  not  know 
him  personally,  who  had  not  the  opportunity  of  seeing  for  them- 
selves, as  no  one  who  ever  came  into  contact  with  him  could 
fail  to  see,  what  a  marvel  of  enthusiasm  and  energy  he  was,  will 
naturally  look  to  these  writings  for  the  explanation  of  a 
celebrity  unparalleled  in  the  history  of  medicine.  All  who  were 
honoured  with  Simpson's  acquaintance  will  at  once  admit  that 
a  knowledge  of  him  gleaned  from  his  works  alone  must  neces- 
sarily be  a  most  imperfect  one.  Indeed,  his  most  remarkable 
characteristics  are  not  shown  in  them.  His  great  fault  pro- 
bably was  the  want  of  the  system  and  method  so  essential  for 
success  in  literary  work.  Had  he  added  these  qualities  to  his 
genius,  he  Avould  probably  have  left  behind  a  still  larger  and 
more  enduring  reputation.  But,  even  as  it  is^  the  stranger 
will  find  no  want  of  material  for  study,  and  will  experience  no 
difficulty  in  understanding  why  the  author  of  these  papers  had 
gained  for  himself  such  widespread  fame. 

A  mere  glance  at  the  index  will  show  how  vast  was  the 
field  over  which  Simpson's  researches  extended.  The  quality 
of  his  mind  was  peculiarly  unfitted  for  steady  and  continuous 
work.  Some  subject  presented  itself  to  him  in  which  he 
became  interested.  He  laboured  at  it  with  hearty  good  will 
for  a  time,  always  illuminating  it  with  the  light  of  his  genius 
as  no  one  else  could,  and  then  he  strayed  to  '*  fresh  fields  and 
pastures  new."  The  result  is  a  number  of  separate  essays,  on 
all  sorts   of  subjects,  of  which  it  would  be  simply  impossible 


1873.1     Simpson's  Obstetrical  and  Gyncecological  Works.      75 

to  attempt  anything  like  an  exhaustive  review.  We  have  in 
this  volume  alone,  and  it  is  only  the  first  of  a  series,  no  less 
than  eighty-eight  different  papers,  some  of  them  of  great 
length,  many  of  them  starting  subjects  quite  original;  and  these 
are  only  the  selected  essays,  the  editor  having  omitted  many 
that  he  deemed  of  secondary  interest.  It  is  curious,  on  look- 
ing over  them,  to  note  how  greatly  they  have  influenced 
obstetric  practice,  to  observe  how  much  of  the  immense 
advance  which  this  branch  of  the  profession  has  made  of  late 
years,  can  be  directly  traced  to  these  writings.  It  would  be 
hopeless  to  try  to  show  this  forth  within  the  limits  of  one 
short  article.  All  we  can  do  is  to  refer  briefly  to  some  of  the 
leading  contributions,  which  either  were  most  celebrated  at  the 
time  of  their  publication,  or  have  had  the  most  influence  on 
the  present  state  of  obstetric  practice. 

The  first  division  of  subjects  refers  to  pregnancy,  and  it  com- 
mences with  a  well-known  essay  on  its  duration.  In  it  are 
collected  pretty  well  all  the  known  facts  on  this  subject,  com- 
mencing with  the  celebrated  Gardner  peerage  case,  which  gave 
rise  to  so  much  difference  of  opinion  amongst  the  leading  obste- 
tricians of  the  day.  After  relating  several  cases  of  protracted 
utero-gestation,  the  facts  of  which  were  such  as  to  leave  little 
doubt  as  to  their  authenticity,  and  the  longest  of  which  ex- 
tended to  313  days,  Simpson  tabulates  and  discusses  the  cases 
recorded  by  Murphy,  Merriman,  and  Reid.  Some  of  these  facts 
vary  curiously  from  those  observed  by  more  recent  writers; 
thus,  out  of  186  cases  recorded  by  Murphy,  no  less  than  35  were 
delivered  after  the  282nd  day  from  the  cessation  of  menstruation; 
while  in  the  recent  table  published  by  Attfield,  out  of  30  cases 
very  carefully  observed,  with  the  exception  of  two,  of  which  the 
dates  were  doubtful,  all  were  below  that  period.  It  is,  we 
believe,  now  a  pretty  generally  received  opinion  that  280  days, 
which  is  commonly  reckoned  as  the  usual  period  of  gestation,  is 
too  high  an  average,  and  that  a  calculation  of  275  days  is  less 
likely  to  prove  wrong.  In  Simpson's  tables,  a  large  proportion 
of  the  cases,  from  12  to  16  per  cent.,  terminated  from  267  to 
273  days  after  the  last  menstruation.  Simpson  distinctly 
admits,  what  is  now  rarely  questioned,  the  possibility  of  preg- 
nancy being  occasionally  considerably  prolonged,  even  to  30  or 
35  days  beyond  the  average  period,  and  brings  forward  as  an 
argument  in  favour  of  possible  protraction  the  researches  of 
Lord  Spencer  and  Tessier  on  the  length  of  utero-gestation  in 
the  cow,  where  the  exact  period  of  conception  was  known. 
Finally,  he  starts  here,  for  the  first  time,  his  well-known  hypo- 
thesis of  fatty  degeneration  of  the  decidua  being  the  determin- 
ing cause  of  labour. 


70  Revieivs.  [J 


an. 


The  only  other  section  we  need  remark  on  is  that  in  which 
the  oxalate  of  cerium  is  recommended  as  a  remedy  for  the  sick- 
ness of  pregnancy.  Although  still  often  used,  and  sometimes 
of  decided  service,  it  is  certainly  not  found  entirely  to  answer 
Simpson's  expectations  with  regard  to  it.  The  paper  is,  how- 
ever, interesting  as  illustrating  Simpson's  habit  of  seeking 
experimentally  for  new  and  valuable  drugs,  which  sometimes 
produced  a  happy  hit  among  many  failures,  a  habit  which 
eventually  led  to  the  great  discovery  with  which  his  name  is 
most  associated. 

In  the  next  section,  which  concerns  the  foetus,  the  two  most 
important  papers  are,  one  which  refers  to  the  disease  of  the 
fcEtus  itself,  and  another  which  treats  of  diseases  of  the  placenta, 
and  their  secondary  effects  in  interfering  with  the  nutrition  and 
respiration  of  the  foetus,  and  thus  causing  its  death.  Neither  of 
these  subjects  had  received  much  attention  at  the  time  Simpson 
wrote  ;  that  on  the  disease  of  the  foetus  is  still  almost  on  a  level 
Avith  our  present  knowledge.  The  greater  portion  of  it  treats 
of  foetal  peritonitis,  bringing  forward  a  number  of  cases  where 
post-mortem  examinations  had  been  made  on  still-born  cliildren, 
in  which  the  products  of  inflammation  had  been  found  more  or 
less  abundantly  in  and  about  the  peritoneum.  With  regard  to 
its  cause,  Simpson  is  inclined,  and  no  doubt  rightly,  to  attribute 
a  prominent  place  to  syphilitic  taint,  and  he  lays  down  the 
practical  axiom  that,  when  a  mother  gives  birth  to  several  dead 
children  in  succession,  in  whom  traces  of  peritonitis  are  found, 
syphilis  may  with  certainty  be  assumed  to  exist  in  one  or  other 
parent. 

An  interesting  chapter  on  this  subject  is  that  in  which 
Simpson  discusses  the  reproduction  of  rudimentary  limbs  on  the 
stump  of  intra-uterine  amputations.  This  curious  fact,  which 
is  far  from  rarely  witnessed  in  such  cases,  Simpson  explains  by 
supposing  that  the  intra-uterine  amputation  took  place  at  a 
period  of  foetal  life  when  "  the  physiological  powers  of  the  young 
human  being  are  more  assimilated  to  the  reparative  and  other 
powers  of  animals  of  a  lower  type  in  the  animal  scale,"  and 
that,  therefore,  the  attempts  at  reformation  of  the  lost  parts 
resembled  the  reproduction  of  lost  portions  commonly  observed 
in  many  invertebrate  animals,  such  as  the  salamander  and  the 
triton. 

Disease  of  the  placenta,  and  its  effects  on  the  life  and  nutri- 
tion of  the  foetus,  was  always  a  favourite  subject  with  Simpson, 
and  was  one  of  the  first  through  which  he  brought  his  name 
into  public  notice.  Until  he  took  it  up  comparatively  little  had 
been  done  in  the  matter ;  since  that,  however,  a  good  deal  of 
attention  has  been  paid  to  it,  and  the  waitings  of  Barnes,  Druitt, 


i872.]      Si  MI  son's  Obstetrical  and  Gynecological  Works.      77 

Spaeth,  Hyrtl,  and  many  other  pathologists,  have  thrown  much 
light  on  douhtful  points,  have  still  further  proved  the  important 
influence  which  a  morbid  state  of  the  placenta  has  on  the  health 
of  the  foetus,  and  have  in  various  respects  corrected  the  views 
held  by  Simpson. 

With  regard  to  congestion  of  the  placenta,  and  its  frequently 
attendant  extravasation  of  blood  into  the  substance  of  the  organ, 
Simpson  makes  the  observation  that  it  is  a  much  more  frequent 
cause  of  death  of  the  foetus  in  the  earlier  than  in  the  later 
months  of  pregnancy,  although  even  between  the  seventh  and 
ninth  months  it  is  a  not  uncommon  cause  of  premature  labour 
occurring  in  successive  pregnancies.  This  remark  has  been 
quite  recently  confirmed  by  the  researches  of  Hegar,  of 
Fribourg.  Simpson  is  inclined  to  attach  considerable  im- 
portance to  placentitis,  the  existence  of  which  he  considers 
unquestionable.  More  recent  writers,  however,  throw  doubt  on 
the  existence  of  placentitis  as  a  pathological  condition,  attribut- 
ing the  phenomena  ascribed  to  it  to  secondary  changes  taking 
place  in  extravasated  blood- clots,  or,  to  quote  the  words  of 
Robin,  "  What  has  been  taken  for  inflammation  of  the  placenta 
is  nothing  else  than  a  condition  of  transformation  of  blood-clots 
at  various  periods ;'  what  has  been  regarded  as  pus  is  only 
fibrine  in  the  course  of  disorganization,  and  in  those  cases  in 
which  true  pus  has  been  found  the  pus  did  not  come  from  the 
placenta,  but  from  an  inflammation  of  the  tissues  of  the  uterine 
vessels  and  an  accidental  deposition  in  the  tissues  of  the 
placenta."  With  regard  to  fatty  degeneration,  the  importance 
of  which  has  year  by  year  been  more  fully  established,  and  the 
precise  changes  connected  with  which  have  been  very  fully 
worked  out  by  Robin,  it  is  worthy  of  remark  that  in  his  earliest 
writings  on  the  subject  of  placental  disease,  published  as  early 
as  1836,  Simpson  suggested  that  the  stearoid  matter  frequently 
seen  in  diseased  placentae  might  in  reality  be  the  results  of  the 
transformation  of  blood-clots,  a  view  maintained  by  Scanzoni, 
but  opposed  by  other  writers. 

In  noticing  Simpson's  labours  on  this  subject  we  must  not 
forget  his  original  suggestion  that  the  administration  of  various 
alkaline  salts,  especially  the  chlorate  of  potass,  might  improve 
the  chances  of  the  foetus  surviving  in  cases  of  placental  disease, 
by  efi*ecting  a  better  oxygenation  of  the  blood,  and  thus  making 
a  smaller  aerating  surface  to  do  more  work.  Probably  the  plan 
is  not  quite  so  serviceable  as  its  originator  believed,  and  its 
assumed  modus  operandi  is  very  open  to  doubt ;  but  tl^ose  who 
have  tried  it  are  generally  inclined  to  admit  its  occasional 
utility.  At  any  rate,  it  has  the  merit  of  being  the  first  definite 
attempt    to   influence    the   health    of    the   foetus   through    the 


78  Reviews.  [Jan., 

maternal  blood,  a  line  of  experiment  which  may  yet  lead  to 
valuable  results. 

Passinj^  over  several  papers,  inchiding  the  interesting  case  in 
which  a  decomposed  and  softened  foetus  was  pushed  through  a 
contracted  pelvis,  where  the   Ca3sarian  section  would  otherwise 
have  been  necessary,  we  come  to  the  celebrated  dissertation  on 
*'  Placenta  Pra^via."     This  is  one  of  Simpson's  most  important 
contributions    to    obstetric   medicine,  and   is    composed   in  his 
happiest  style.     Many  of  our  readers  will,  doubtless,  remember 
the  sensation   produced  by  the  bold   and  thoroughly  original 
proposal   that   in  certain  severe  cases    of  placenta  pra^via   the 
placenta  itself  should  be  removed,  and  the  somewhat  bitter  con- 
troversy to  which  it  gave  rise.     Increased  knowledge    of  the 
anatomy  of  the  placenta,  and  of  the  circumstances  under  which 
it  comes  to  be  implanted  on  the  cervical  orifice,  teaches  us  that 
many  of  the    views  upheld  in  the  paper  are  now  untenable, 
especially  those  which  explain  the  facts  of  the  cessation  of  the 
haemorrhage  on  the  detachment  of  the  placenta,  by  the  supposi- 
tion that  the  blood  comes  in  great  part  from  the  detached  surface 
of  that  organ,  and  not   from  the  uterine  vessels.     We  believe 
that,  latterly,  Simpson  himself  had  to  a  great  extent  altered  his 
opinion   on    this   point,  while    still   maintaining   his    practical 
advice  with  regard  to  the  removal  of  the  placenta.     Admitting 
this,  it  is   still  impossible  to  read  the  essay  without  profound 
admiration  of  the  ingenious  reasoning  on  the  facts,  so  far  as 
they  Avere    then   known,    and   of  the   extraordinary   erudition 
displayed  in  searching  for  examples  in  authors  whose  existence 
had  been  almost  forgotten.     The  reader  will  do   well  also  to 
study  the   sort  of  essay  within  an  essay  which   treats  of  the 
means  by  which  nature  seeks  to  control  hsemorrhage  after  evacua- 
tion of  the  uterine  contents.  This  is  thrown  in,  as  it  were,  amongst 
the  other  material  of  the  monograph,  and  yet  it  forms  probably 
the  most  suggestive  and  lucid  explanation  in  existence  of  the 
means  by  which  post-partum  haemorrhage  is  prevented.     Greatly 
as  recent  researches  have  obliged  us  to  modify  Simpson's  views, 
it  must  be  admitted  that  he  was  the  first  to  recognise  the  fact 
that  the  supposed  danger  of  complete  placental  separation  was 
imaginary,  and  to  deduce  from  it  a  new  method  of  treatment. 
This  the   more  recent    writings    of  Jacquemier,    Barnes,    and 
Cohen  of  Hamburg,  have  enabled  us  to  explain  with  greater 
accuracy,    and    the    practice   recommended    by   the  two  latter 
physicians  is,  no  doubt,  at  once  more  scientific  and  more  practi- 
cable than  the  separation  of  the  placenta  en  7nasse.     Still,  it  is 
unquestionable  that  their  procedure  is  but  a  modification  of  the 
plan  first  w^orked  out  and  practised  by  Simpson.     It  ought  to 
be  noticed  also,  when  talking  of  this  paper,  how  persistent  and 


1872.]      SiMPSON^s  Obstetrical  and  Gynaecological  Works.     79 

unfair  were  the  misrepresentations  to  which  it  gave  rise.  To 
read  the  criticisms  which  have  been  made  on  it  it  would 
appear  that  Simpson  recommended  complete  detachment  of 
the  placenta  in  all  cases  of  placenta  prsevia.  Nothing  can 
be  farther  from  the  truth.  Over  and  over  again  he  positively 
states,  in  language  so  clear  that  it  is  difficult  to  understand 
how  it  could  have  been  misunderstood,  that  the  plan  is  to 
be  reserved  for  those  rare  and  exceptionable  cases  only  in 
which  the  ordinary  methods  of  treatment  are  impracticable 
and  unsafe. 

The  next  important  paper  is  "  On  the  Sex  of  the  Child  as  a 
cause  of  Difficulty  in  Labour."  It  is  one  which  is,  perhaps,  more 
interesting  in  a  physiological  than  in  a  practical  point  of  view. 
Full  of  the  most  elaborate  statistical  deductions,  it  must  have 
required  much  work  in  its  production,  and,  although  it  is  based 
on  statistics  the  details  of  which  may  be  open  to  question,  the 
general  accuracy  of  the  conclusions  arrived  at  can  scarcely  be 
doubted. 

Passing  over  several  papers  of  interest,  such  as  that  on  turn- 
ing, with  its  recommendation  of  bringing  down  one  knee  only  ; 
on  difficult  labour  from  dorsal  displacement  of  the  child's  arm  ; 
and  on  intra-uterine  hydocephalus ;  we  come  to  one  of  Simp- 
son's most  important  essays,  that  on  *^  Turning  as  a  substitute 
for  Craniotomy."  When  this  was  written,  craniotomy  was  not 
regarded  with  quite  as  much  horror  as  it  now  fortunately  is, 
and  the  proposal  of  an  alternative  operation  which  might  occa- 
sionally obviate  the  necessity  for  resorting  to  it  was  not  received 
with  as  much  favour  as  it  undoubtedly  merited.  Although 
turning  in  contracted  pelvis  is  not  a  new  thing,  since  it  had 
been  practised  by  many  of  the  most  distinguished  accoucheurs  in 
the  last  century,  such  as  Pugh,  Smellie,  and  Perfect,  and  with 
remarkable  success,  still  it  had  practically  fallen  into  oblivion. 
Simpson's  remarkable  essay  not  only  again  directed  the  atten- 
tion of  the  profession  to  its  value,  but,  for  the  first  time,  dis- 
tinctly showed  the  precise  reasons  why  a  child  brought  footling 
might  sometimes  pass  through  the  pelvis  alive,  when  it  could 
not  be  pulled  through  with  the  head  first.  His  demonstration 
of  the  fact  that  the  base  of  the  foetal  skull,  in  consequence  of  its 
being  narrower  than  the  occiput,  passes  where  the  latter  will 
not,  and  of  the  greater  power  of  traction  thus  gained,  of  the 
adaptation  of  the  narrowest  diameter  of  the  skull  to  the  con- 
tracted diameter  of  the  pelvis,  and  of  the  greater  safety  with 
which  the  child's  head  bears  compression  in  the  transverse 
diameter,  were  all  new  facts  in  obstetrics,  recognised  by  him 
for  the  first  time,  and  very  forcibly  insisted  on  as  arguments  in 
favour   of  the  practice  he  proposed.     Nowadays  the  value  of 


Bo  tieviews,  [Jan., 

tuniing  in  sucli  cases  is  admitted  by  the  highest  authorities, 
and  it  is  daily  being  more  and  more  resorted  to.  Tlie  number 
of  foetal  lives  saved  by  it  is  now  so  great  that  it  is  hardly 
necessary  to  bring  forward  any  argument  in  its  favour.  It  is 
worthy  of  remark,  however,  tliat  in  spite  of  all  the  attention 
the  subject  has  received,  scarcely  any  fresh  light  has  been 
thrown  on  it  since  the  publication  of  this  paper,  so  thoroughly 
and  completely  had  Simpson  worked  it  out  in  all  its  bearings. 
All  that  he  left  for  future  obstetricians  to  do  was  to  illustrate  the 
advantages  of  this  recommendation  by  proving  how  frequently 
they  had  resorted  to  it  with  success.  The  bitter  discussions  that 
this  paper  gave  rise  to,  in  consequence  of  the  use  made  in  it  of 
statistics  from  the  Dublin  School  of  Midwifery,  Avill,  no  doubt, 
be  fresh  in  the  memory  of  many  of  our  readers.  In  such  a  feud 
Simpson  w-as  an  adversary  not  readily  discomfited,  and  he  cer- 
tainly had  no  cause  to  consider  himself  worsted  in  the  fight.  Still 
it  is  much  to  be  regretted  that  so  fierce  a  battle  of  words  should 
ever  have  arisen,  the  more  so  as  this  and  similar  discussions  led 
those  who  did  not  know  him  to  believe  that  he  was  of  a  quarrel- 
some disposition  and  addicted  to  controversy.  Such  an  impression 
is,  as  all  who  knew  him  well  will  admit,  a  thoroughly  erroneous 
one.  The  fact  is  that  one  who  wrote  so  much  and  on  so  wide  a 
range  of  subjects,  who  started  so  many  novel  theories,  could 
hardly  fail  to  meet  with  many  who  differed  with  him  in  opinion  ; 
and  although  he  was  always  ready  to  support  his  own  views 
with  characteristic  force  and  energy,  still  he  at  least  never  per- 
mitted controversies  to  merge  into  private  enmity,  and  his 
personal  sweetness  of  disposition  always  made  him  ready  to  hold 
out  the  hand  of  friendship  to  his  strongest  opponents. 

The  section  on  the  puerperal  state  commences  with  a  short 
but  suggestive  paper  on  death  after  delivery  from  entrance  of 
air  into  the  veins.  The  subject  is  one  of  much  importance, 
which  has  scarcely  as  yet  received  any  attention,  and  it  is  not 
impossible  that  it  may  yet  be  found  to  account  for  some  other- 
wise inexplicable  cases  of  sudden  death.  He  (Simpson)  noticed 
in  the  cases  recorded  a  peculiar  reddish  rash  upon  the  cheeks, 
which  had  already  been  observed  in  those  recorded  by  Dr. 
Warren,  of  Boston,  and  which  he  believed  might  be  due  to 
direct  oxygenation  of  the  blood  in  the  capillary  vessels.  The 
mechanism  by  which  such  an  accident  might  occur  is  discussed, 
and  the  ingenious  hypothesis  is  started  that  the  uterus,  by 
alternate  contractions  and  relaxations,  might  act  as  a  sort  of 
force  pump,  especially  if  the  os  was  obstructed  by  a  clot,  and  so 
drive  any  air  there  might  be  in  its  cavity  into  the  open  mouths 
of  the  uterine  sinuses.  The  explanation  is  certainly  not  an 
unreasonable  one,  and  might  account  for  an  accident  not  other- 


i872.J     Simpson's  Obstetrical  and  Gyncecological  JVorks.      Bl 

wise  easily  explicable.  The  precise  way  in  which  the  air  proves 
fatal  is  not  discussed,  and  is  well  worthy  of  study.  The  theory 
advanced  by  Bertin,  in  his  learned  but  little  known  work  on 

*  Embolism/  seems  to  us  to  afford  the  best  explanation  of  a  diffi- 
cult problem.  He  conceives  that  the  air  bubbles  become 
arrested  in  the  pulmonary  capillaries,  the  extreme  points  at 
which  they  have  been  found  in  post-mortem  examinations,  and 
so  prevent  the  access  of  air  into  the  lungs.  They  thus  form,  in 
fact,  true  gaseous  emboli,  and  cause  death  in  precisely  the  same 
manner  as  when  the  pulmonary  circulation  is  arrested  by 
fibrinous  thrombosis  and  embolism. 

Another  very  important  essay  is  that  entitled  '  Puerperal 
Arterial  Obstruction  and  Inflammation,'  which  deals  with  a 
class  of  cases  still  not  sufficiently  studied,  but  of  great  practical 
importance  in  the  puerperal  state.  The  changes  which  the 
blood  undergoes  in  pregnancy,  the  still  further  alteration  effected 
in  it  when  delivery  is  over  and  involution  has  commenced,  often 
lead  to  a  variety  of  pathological  conditions,  the  importance  of 
which  is  being  daily  more  and  more  appreciated.  It  is  interest- 
ing to  see  how  many  opinions,  now  pretty  generally  received, 
were  foreshadowed  by  Simpson  long  before  they  had  attracted 
the  attention  of  the  profession.  Thus  so  long  ago  as  the  year 
1847,  the  same  year  in  which  Virchow  published  his  essay  on 

*  Inflammation  of  the  Arteries,'  and  five  years  before  the  late 
Dr.  Kirkes  wrote  his  well-known  paper  on  the  same  subject, 
Simpson  had  published  a  remarkable  case  in  the  proceedings  of 
the  Edinburgh  Obstetrical  Society,  in  commenting  on  which  he 
proposed  the  following  questions  : 

"  1 .  "Was  the  obstruction  of  the  artery  or  arteries  in  this  case 
produced  by  any  mechanical  cause,  as  one  of  the  vegetations  sepa- 
rated from  the  cardiac  valves  carried  along,  in  the  case  of  the  arm 
for  example,  to  the  bifurcation  of  the  humeral  artery,  and  impacted 
there  ?  2.  Was  it  not  rather  the  result  of  an  original  puerperal 
arteritis  ?  3.  Or  might  it  be  the  effect  of  an  effusion  of  coagulable 
lymph  from  phlebitic  inflammation  on  the  coats  of  the  artery,  a 
secondary  phlebitic  deposit,  or  living  arterial  membrane  ?  " 

Here  we  have  a  very  distinct  intimation  that  he  had  realised 
clearly  the  chief  phenomenon  of  embolism,  the  carrying  of  an 
embolus  along  the  current  of  the  blood. 

In  the  first  section  of  his  paper  arterial  obstruction  is  chiefly 
dealt  on,  and  the  causes  likely  to  give  rise  to  it,  with  illustrative 
cases  gathered  from  various  authors,  are  very  fully  entered  into. 
The  fifth  section  deals  with  obstruction  of  the  pulmonary  arteries, 
the  importance  of  which,  as  a  cause  of  the  appallingly  sudden 
deaths  sometimes  met  with  in  the  puerperal  state,  have  caused 
much  attention  to  be  directed  to  it  of  late  years.  When  the 
97— XLix.  6 


8^  Ueviews.  [Jan., 

paper  was  written  the  subject  was  comparatively  new,  and  only 
a  few  isolated  cases  were  on  record  in  which  this  cause  of  death 
had  been  recognised.  In  spite  of  this  Simpson  had  clearly 
realised  its  importance,  and  had  pointed  out  that  all  the  previous 
theories  of  sudden  death  in  the  puerperal  state  would  require 
to  be  revised,  and  that  the  so-called  cases  of  "  shock,"  "  syncope," 
and  "  idiopathic  syncope,"  terms  devised  as  a  cloak  for  ignor- 
ance, and  meaning  nothing,  might  generally  be  traced  to 
obstruction  of  the  pulmonary  arteries,  or  its  chief  branches. 
Many  facts  connected  with  the  natural  history  of  pulmonary 
obstruction,  which  recent  researches  have  more  or  less  distinctly 
proved,  are  hinted  at  in  the  paper.  Thus,  the  important  pre- 
disposing influence  of  blood  alterations  due  to  the  puerperal  state 
is  pointed  out,  the  possibility  of  spontaneous  thrombosis  in  the 
pulmonary  arteries  themselves,  without  any  primary  embolism, 
is  recognised,  and  the  fact  that  life  may  be  prolonged  for  a 
considerable  time  after  the  formation  of  the  obstructing  clot  is 
admitted.  All  these  we  now  know  much  more  about,  but  in 
estimating  the  importance  of  this  paper  we  should  not  forget 
how  novel  the  subject  then  was,  and  how  little  light  previous 
researches  had  thrown  upon  it. 

The  section  on  gynaecology  commences  with  a  short  but  inter- 
esting paper  on  defective  and  excessive  involution  of  the  uterus 
after  delivery.  No  one  who  sees  much  of  female  disease,  now 
doubts  the  important  influence  of  these  two  states,  especially 
the  former,  in  causing  various  morbid  phenomena  after  delivery. 
Defective  involution  is  of  very  frequent  occurrence,  and  originates 
a  large  number  of  somewhat  obscure  cases,  in  which  uterine 
disorders  can  be  distinctly  traced  to  a  previous  confinement. 
Superin volution  is  not  so  often  recognised,  and  is  probably  a 
much  rarer  occurrence.  The  reader  will  find  recorded  in  this 
paper  some  interesting  cases  in  which  amenorrhsea  after  delivery 
was  distinctly  traced  to  this  cause,  and  in  which  the  uterus 
was  reduced  to  much  the  same  state  as  is  not  unfrequently 
observed  in  connection  with  amenorrhoea  in  the  young  female, 
when  the  uterus  has  not  increased  in  size  at  puberty,  and  has 
retained  its  undeveloped  or  infantile  state. 

The  next  paper  on  the  uterine  sound  is  of  extreme  importance. 
There  can  be  no  doubt  that  the  use  of  this  instrument  has 
greatly  aided  the  remarkable  advances  which  gynaecology  has 
made  in  the  last  quarter  of  a  century,  perhaps  quite  as 
much  or  more  than  the  speculum.  It  is  certainly  to  the  possi- 
bility of  making  a  precise  investigation  into  the  actual  state  of 
the  uterus  and  its  appendages  that  we  owe  the  immense  pro- 
gress recently  made  in  this  branch  of  medical  science.  As 
Simpson  has  so  clearly  pointed  out  in  his  paper,  so  long  as  the 


1872.]     Simpson's  Obstetrical  and  GyncBCological  Works.      83 

physician  had  to  trust  to  functional  symptoms  alone,  he  must  have 
been  constantly  misled,  as  the  same  symptoms  are  common  to  so 
many  and  such  different  uterine  disorders.  That  an  immense 
advance  took  place  along  with  the  introduction  of  the  speculum 
into  practice  is  certain,  but  it  will  doubtless  be  admitted  that 
this  was  not  entirely  from  what  we  directly  learned  by  the  in- 
strument, useful  as  it  is,  especially  in  enabling  us  to  apply  certain 
methods  of  treatment  to  the  uterus  itself.  Much  of  it  can  be 
traced  to  the  increased  carefulness  with  which  physical  exami- 
nations are  made,  and  to  the  greater  frequency  with  which  they 
are  practised.  The  uterine  sound,  however,  has  been  per  se  of 
immense  value.  By  it  we  are  enabled  to  diagnose  accurately 
certain  conditions  about  which  we  were  previously  either  alto- 
gether ignoraut,  or  which  could  not  be  made  out  with  certainty. 
It  would  be  beyond  the  scope  of  this  article  to  attempt  to  prove 
this  at  length,  but  every  one  conversant  with  female  disease  will 
recall  many  instances.  Thus  to  take  one  or  two  examples  only, 
we  need  only  remember  how  little  we  knew  or  could  know 
accurately  about  such  conditions  as  defective  involution  after 
delivery,  the  various  flexures  and  displacement  of  the  uterus, 
the  dififerential  diagnosis  of  uterine  and  ovarian  tumours,  and 
the  like,  to  be  convinced  of  the  enormous  value  of  the  instrument. 
Had  Simpson,  therefore,  done  nothing  else  than  familiarise  the 
profession  with  this  important  diagnostic  aid,  he  would  have 
done  enough  to  cause  his  name  to  be  remembered  with  honour. 
The  essay  itself  is  well  worthy  of  careful  study,  as  an  exhaustive 
account  of  the  uses  of  the  instrument,  and,  although  the  first, 
it  still  remains  by  far  the  best  monograph  on  the  subject  in 
existence.  It  has,  however,  the  fault  of  advocating  a  free  use  of 
the  instrument,  which  certainly  would  not  be  safe  in  careless  or 
iminstructed  hands.  Invaluable  as  it  is  as  an  aid  to  correct 
diagnosis,  it  is  beyond  doubt  that  when  carelessly  or  roughly 
used  the  uterine  sound  is  capable  of  doing  considerable 
damage,  and  there  are  probably  few  gynaecologists  who  have 
not  occasionally  seen  some  considerable  inflammatory  mischief 
following  its  introduction  in  unsuitable  cases.  The  possibility 
of  an  instrument  doing  harm  when  used  improperly  is  no 
argument  against  its  proper  application ;  but  a  word  of  caution 
on  this  point  can  hardly  be  out  of  place,  especially  as  Simpson's 
paper  contains  no  evidences  of  any  possible  ill  effects  that  might 
follow  its  employment. 

Another  instrument  devised  by  Simpson  is  discussed  in  the 
next  short  paper,  viz.  the  small  exploring  needle,  with  which  his 
old  pupils  must  be  familiar.  It  is  a  most  useful  contrivance  for 
clearing  up  the  diagnosis  in  certain  doubtful  cases,  and  is  less 
known  than  its  merits  deserve.     Then  follows  an  article  on 


^4  Reviews.  [jaii.j 

the  usG  of  the  medicated  pessaries,  a  most  useful  means  of  treat- 
ment largely  employed  by  Simpson,  and  now  extensively  used. 
After  this  are  two  short  notes  on  the  very  important  subject 
of  intra-uterine  medication.  This  has  of  late  attracted  much 
attention,  both  in  this  country  and  in  America.  Its  value,  in 
properly  selected  cases,  can  hardly  be  over  estimated,  and  it  is 
to  be  regretted  that  Simpson  had  not  then  investigated  the 
matter  more  than  these  brief  notices  would  indicate.  It  is  to 
be  remarked,  however,  that  he  had  apparently  anticipated  a 
method  of  treatment  recently  strongly  recommended  by  Courty, 
of  Montpellier,  that  of  introducing  a  stick  of  lunar  caustic  into 
the  uterine  cavity,  and  leaving  it  there  to  melt  and  flow  over  the 
mucous  membrane ;  and  also  that  he  had  very  clearly  realised 
the  proper  explanation  of  the  risks  of  intra-uterine  injections  of 
fluids,  as  the  following  sentence  shows : 

"  He  considered  solid  substances  and  powders  as  much  more  safe 
applications  to  the  interior  of  the  uterus  than  any  form  of  fluid 
injection.  The  occasional  danger  arising  from  the  latter  was  not,  he 
believed,  so  much  from  their  passing  along  the  Fallopian  tubes  into 
the  peritoneal  cavity  as  from  their  sometimes  over- distending  the 
uterus,  and  Assuring  and  tearing  through  the  mucous  surface,  and 
getting  into  the  circulation." 

In  the  next  paper,  treating  of  ''  Dilatation  and  incision  of  the 
cervix  uteri  in  cases  of  obstructive  dysmenorrhoea,"  we  come 
upon  very  delicate  ground.  It  is  to  be  feared  that  Simpson's 
enthusiasm  and  parental  fondness  for  an  operation  he  had  him- 
self devised,  somewhat  biassed  his  judgment  in  this  matter. 
Certain  it  is  that  incision  of  the  cervix  is  not  now  practised 
with  anything  like  the  frequency  it  used  to  be,  and  all  will,  we 
think,  admit  that  an  increased  acquaintance  with  it  does  not 
justify  the  high  opinion  which  many  have  had  of  it.  That  it  is 
occasionally  of  decided  benefit  in  obstinate  cases  resisting  other 
treatment  is  beyond  all  question.  But  it  is  equally  certain  that 
it  should  not  be  resorted  to  indiscriminately,  and  never  without 
insisting  on  perfect  rest  and  great  care  after  its  performance. 
When  we  hear  of  its  being  done  in  the  consulting-room,  of 
patients  being  sent  home  without  any  precautions  to  restrain 
possible  haemorrhage,  or  without  any  restriction  as  to  exercise, 
we  can  scarcely  be  surprised  at  the  occasional  disastrous  results 
which  are  said,  from  time  to  time,  to  have  happened. 

We  are  glad  to  learn  that  increased  experience  induced  Simp- 
son to  modify  his  practice  in  this  respect,  as  Dr.  Black  has  very 
properly  pointed  out  in  the  following  note  inserted  at  the  end  of 
the  chapter : — 

"  In  consequence  of  the  gratifying  results  sometimes  produced  by 


1872.]     Simpson's  Obstetrical  and  Gynecological  Works.      85 

incision  of  the  cervix  uteri  in  obstructive  dysmenorrhoea  and  sterility, 
that  operation  became  an  extremely  favorite  one  with  Simpson. 
Certain  risks  connected  with  it,  however — and  in  particular  its 
liability  to  be  followed  by  pelvic  inflammation — inclined  him  ulti- 
mately to  a  rigorous  selection  of  cases,  and  to  the  enjoining  of 
recumbency  several  days  after  the  performance  of  the  operation." 

The  next  paper,  on  "Retroversion  of  the  unimpregnated 
uterus/'  is  interesting  because  its  subject  is  to  this  day  a  fruitful 
cause  of  dispute  among  gynaecologists.  There  is  certainly  no  other 
uterine  disease  about  which  such  varying  opinions  are  held,  and 
such  diverse  treatment  practised.  Those  who  believe  in  the  all- 
importance  of  uterine  flexions,  and  in  the  paramount  necessity 
of  straightening  and  retaining  the  uterus  in  its  rectified  position, 
necessarily  stand  on  a  very  different  platform  from  the  decidedly 
larger  number  of  physicians  who  believe  in  the  secondary  nature 
of  flexions,  and  who  teach  the  importance,  above  all  things, 
of  remedying  the  causes  which  have  given  rise  to  them.  While 
those  who  try  to  shape  a  medium  course  between  the  two 
occupy,  as  we  believe,  a  safer  stand  point  with  regard  to  the 
disease. .  Into  this  questio  vexata  it  is  not  our  intention  to  enter, 
especially  as  this  subject  has  been  discussed  at  some  length  in 
the  last  number  of  the  '  Review.'  It  may,  however,  be  well  to 
recapitulate  briefly  the  opinions  advanced  in  this  the  first  im- 
portant essay  on  the  subject,  which,  in  the  clash  of  modern  war- 
fare on  uterine  deviations,  may  have  been  somewhat  neglected. 
There  can  be  no  doubt  that  the  flexionists,  if  we  may  be  per- 
mitted so  to  call  them,  may  claim  Simpson  as  one  of  their 
school.  While,  however,  he  distinctly  asserts  that  the  symp- 
toms accompanying  flexions  are  primarily  due  to  the  displace- 
ments, and  that  the  congestion  and  other  phenomena  are  the 
results  and  not  the  cause  of  the  condition,  he,  at  the  same 
time,  clearly  admits,  what  many  of  the  school  are  so  apt  to  over- 
look, that  the  symptoms  are  by  no  means  necessarily  always 
met  with.  Nothing  can  be  clearer  than  his  words  on  this 
point : — 

**  The  functional  symptoms  that  I  have  enumerated  may  make  us 
suspect  the  existence  of  retroversion  of  the  uterus,  but  retrover- 
sion may  be  present  without  most,  or  almost  any  of  them ;  and  they 
maybe  present  with  other  diseases  besides  retroversion." 

These,  it  will  be  observed,  are  precisely  the  arguments 
brought  forward  by  those  who  do  not  believe  in  the  necessarily 
important  effects  of  deviations.  After  a  very  clear  account  of  the 
differential  diagnosis  of  displacement,  and  of  the  use  of  the 
uterine  sound  in  helping  us  to  arrive  at  it,  Simpson  proceeds 
to  consider  the  treatment.     It  is  this  part  of  the  paper  which 


86  Reviews.  [Jan., 

will  certainly  be  found  most  fault  with,  as  he  advocates  an 
almost  purely  mechanical  treatment,  and  that  of  a  kind  which 
increased  experience  has  led  us  now  rarely  to  resort  to.  It  was 
the  recommendation  of  the  intra-uterine  pessaries  here  described 
and  figured  which  caused  Simpson's  practice  in  this  respect  to 
be  so  unfavorably  criticised.  All  that  can  be  said  about  it  is 
that  if  Scotch  uteri  could  bear  such  treatment  with  impunity, 
they  must  have  been  very  differently  constituted  from  similar 
organs  in  other  parts  of  the  world.  But  if  half  of  the  tales  told 
be  true,  the  bad  results  which  followed  their  use  were  neither 
few  nor  far  between.  Happily  they  are  now  but  rarely  em- 
ployed by  any  who  know  much  of  their  action,  and  in  very 
exceptional  cases  only,  and  we  learn  from  a  footnote  that  Simp- 
son had,  of  late  years,  chiefly  used  a  modification  of  Hodge's 
pessary  instead.  But  the  student,  taking  this  paper  as  his 
guide  in  treating  flexions,  as  many  may  be  reasonably  expected 
to  do,  would  certainly  not  learn  from  it  that  such  intra-uterine 
appliances  were  anything  but  perfectly  safe  and  manageable. 

Next  we  have  a  series  of  papers  treating  of  fibroid  tumours  of 
the  uterus,  their  course,  termination,  and  treatment,  including 
under  this  heading  the  ordinary  pedunculated  fibroid  polypi. 
The  chief  value  of  these  papers  consists  in  their  recommendation 
of  the  sponge  tent  as  a  means  of  dilating  the  cervix  uteri.  This 
is  certainly  one  of  the  most  useful  and  ingenious  of  Simpson's 
inventions,  and  we  are,  by  their  use,  enabled  to  diagnose  and 
successfully  treat  a  class  of  cases  formerly  quite  beyond  our 
reach.  Nor  have  recent  researches  done  much  to  improve  the 
original  instruments,  as  the  laminaria  tents,  although  very 
serviceable  under  certain  circumstances,  are  not  so  suitable  in 
cases  in  which  complete  and  wide  dilatation  of  the  cervix  is 
required. 

We  must  pass  over  for  want  of  space  the  remaining  papers, 
although  there  is  much  in  them  that  is  novel  and  original,  such  as 
those  on  "  Vaginismus,"  and  on  "  Fistulae  resulting  from  pelvic 
abscess."  That  on  ovariotomy  will  always  be  of  interest,  not  be- 
cause of  anything  in  it  that  is  not  now  well  known,  but  because 
it  shows  clearly  how  prescient  Simpson  was  in  recognising  and 
advocating  the  value  of  the  operation  at  a  time  when  its  oppo- 
nents were  far  more  numerous  than  its  friends.  It  is  impossible 
to  bring  these  necessarily  imperfect  remarks  to  a  close  without 
once  more  expressing  our  admiration  for  the  originality  and  pro- 
found erudition  displayed  in  this  book,  which  will  always  be  the 
worthiest  and  most  enduring  memorial  of  its  author's  unrivalled 
talent. 


1872.]  Deformities  of  the  Human  Body,  87 


VII.— The  Deformities  of  the  Human  Body.^ 

This  reissue  of  some  lectures  previously  published  in  the 
'Lancet^  has  been  made^  so  the  preface  informs  us,  in  compli- 
ance with  frequent  requests.  As  descriptions  of  orthopaedic 
pathology  they  are  good,  and  they  give  most  of  the  main  points 
in  the  treatment  of  deformities  correctly  and  clearly ;  but  they 
are  too  incomplete,  too  sketchy,  to  merit  the  title  of '  A  System 
of  Orthopaedic  Surgery/  which  the  author  has  applied  to  his  re- 
issue. The  book  represents,  no  doubt  fairly  enough,  the 
author's  views  in  orthopaedy,  but  it  gives  imperfect  information 
of  the  progress  this  branch  of  surgery  has  made  on  the  Conti- 
nent and  in  America.  This  might  have  been  usefully  intro- 
duced when  preparing  the  work  for  separate  publication.  The 
book  is  marred  also  by  attempts  to  depreciate  the  labours  of 
others  practising  the  same  branch  of  surgery  —  a  kind  of 
rivalry  too  prevalent  in  the  medical  profession. 

The  author  has  divided  his  treatise  into  three  parts,  the  first 
devoted  to  contractions  of  the  limbs,  the  second  to  affections  of 
the  joints,  and  the  third  to  deformities  of  the  trunk  and  neck. 

In  discussing  the  causes  of  deformities  the  modicum  of 
knowledge  which  we  have  at  present  is  correctly  stated; 
"nervous  irritation,"  with  arrest  of  development,  being,  of 
course,  held  responsible  for  most  congenital  deformities,  the 
modus  operandi  of  the  former  cause  being  still  as  mysterious  as  it 
was  when  Marshall  Hall  endeavoured  to  clear  away  the  darkness 
that  surrounds  it.  Oddly  enough,  when  speaking  of  congenital 
malformations,  our  author  mentions  "  intestinal  irritation  from 
worms"  and  dentition.  The  first  is  probably  an  oversight ;  but 
for  ascribing  congenital  deformity  to  dentition,  Marshall  Hall's 
comprehensive  use  of  the  term  is  relied  on,  that  authority  be- 
lieving that  the  period  of  nervous  irritation  which  sometimes 
accompanies  the  growth  of  the  teeth  may  begin  at  or  before 
birth.  It  is  unfortunate  that  in  this  age  of  unbelief  there  are 
those  who  doubt  the'.connection  between  the  irritation  of  dentition 
and  reflex  cerebro-spinal  action,  but  it  is  no  part  of  our  present 
object  to  discuss  the  correctness,  probable  or  otherwise,  of  this 
doctrine. 

Hereditary  predisposition  is,  doubtless,  a  real  and  very 
curious  cause  of  clubfoot.  Arrest  of  development  is  a  more 
satisfactorily  comprehended  source  of  deformity.  Several  forms, 
even  talipes,  being  simply  the  continuance  of  an  early  stage  of 

1  The  Deformities  of  the  Human  Body :  a  System  of  Orthopcedic  Surgery. 
Being  a  Course  of  Lectures  delivered  at  St.  George's  Hospital.  By  Beenaed  E. 
Beodhuest,  F.R.C.S.    London.     Large  8vo,  pp.  259. 


88  Reviews.  [Jan., 

foetal  development,  which,  by  want  of  further  progress  in  the 
formation  of  the  limb,  becomes  its  permanent  condition.  The 
immediate  cause  of  this  arrest  of  development  still  remains  un- 
known, but  that  it  is  an  efficient  agent  there  is  no  doubt. 

In  describing  the  pathology  of  rickets  it  is  somewhat  vexing  to 
find  our  author'attributing  the  pliability  of  rickety  bones  to  simply 
the  softening  of  the  hard  bone  by  absorption  of  the  earthy  salts. 
Virchow  and  KoUiker  have  demonstrated  that  the  softness  of 
rickety  bones  is  due  as  much  to  arrested  development  of  their 
ossification  as  to  reabsorption  of  their  earthy  salts. 

The  production  of  rickety  bones  is  a  very  complex  process. 
The  primary  cartilage  remains  in  one  part  unchanged;  in 
another  it  is  transformed  into  fibrous  tissue  or  into  true  bone ; 
and  this  may  become  further  altered  by  a  form  of  osteo-myelitis. 
Hence,  in  rickety  bones  all  these  forms  of  development  are  pre- 
sent side  by  side.  In  treating  rickets,  the  author's  directions 
are  very  judicious.  He  rightly  insists  on  the  necessity  for  re- 
cognising rickets  as  a  morbid  condition,  affecting  not  merely 
the  osseous  tissues,  but  all  the  tissues  of  the  body,  and  urges 
the  propriety  of  treating  the  local  deformities  before  general  dis- 
turbance, denoted  by  night  sweats,  tendency  to  diarrhoea,  and 
other  symptoms  of  disordered  functions  throughout  the  body 
have  disappeared;  for  when  morbid  action  subsides,  develop- 
ment goes  on  rapidly,  the  flexible  bones  soon  become  strong  and 
rigid,  and  it  is  then  too  late  to  bend  them  back  to  their  normal 
shape.  There  is,  however,  one  omission  that,  perhaps,  it  is  not 
unnatural  an  orthopaedic  surgeon  should  make,  namely,  to  point 
out  that  limbs  that  are  slightly  but  still  clearly  distorted,  con- 
stantly regain  their  proper  form,  without  the  aid  of  any  surgical 
appliance  whatever.  Advanced  cases  can,  of  course,  be  only  success- 
fully treated  with  instruments.  For  example,  when  the  amount  of 
bend  in  the  tibia  is  slight,  and  has  not  long  existed,  the  simple 
precaution  of  removing  all  vertical  pressure  from  the  bone  by 
preventing  the  child  from  standing  on  his  legs  until  his  rickety 
diathesis  is  altered,  suffices  to  restore  the  tibia  completely  to 
its  natural  shape.  Possibly  the  "continuous  extension"  of  tlic 
weight  of  the  feet  on  the  curved  tibia  is  an  efficient  cause  in 
restoring  the  straightness.  This  natural  tendency  should  never 
be  lost  sight  of,  even  when  it  must  be  aided  by  supports. 

The  reunion  of  cut  tendons  is  accurately  described  as  taking 
place  in  two  ways, — namely,  by  direct  junction  of  the  divided 
surfaces,  and  indirectly  by  the  formation  of  a  plastic  material, 
on  the  ductility  of  which  the  surgeon  depends  when  giving 
appropriate  length  to  contracted  muscles.  Mr.  Brodhurst,  in 
this  description,  gives  very  briefly  and  clearly  the  results  of  earlier 
observations  specially  directed   to  investigating  the  nature  of 


1872.]  Deformities  0/  the  Human  Body.  89 

this  interesting  process,  but  the  researches  of  Strieker  and  his 
assistants  on  the  changes  of  fibrin  and  connective  tissues  in 
inflammation  might  have  been  advantageously  referred  to. 

Three  chapters  are  devoted  to  the  diflerent  forms  of  talipes. 
These  forms  are  well  described,  and  are  illustrated  by  good  draw- 
ings, but  the  directions  for  applying  the  forces  to  overcome  the 
distortion  are  little  more  than  sufficient  to  indicate  that  these  aiFec- 
tions  are  curable.  Certainly  no  novice  could  undertake  the  treat- 
ment of  clubfoot  from  these  lectures.  For  instance,  *'  the  treat- 
ment of  talipes  equinus  consists  of  the  restoration  of  the  shape  of 
the  foot  by  the  division  of  the  tendo  Achillis,  and  the  subsequent 
gradual  extension  of  the  new  material  which  is  deposited  be- 
tween the  divided  ends  of  the  tendon,  until  the  foot  can  be  well 
and  sufficiently  flexed  upon  the  leg."  This,  no  doubt,  is  cor- 
rect enough  so  far  as  it  goes,  but  few  cases  of  talipes  equinus  are 
absolutely  simple,  as  there  is  usually  a  shortened  plantar  fascia 
and  a  retracted  metatarsus.  Division  and  extension  of  the 
tendo  Achillis  would  only  remedy  part  of  the  deformity  in  such 
cases.  The  means  of  encountering  these  numerous  little  difficul- 
ties that  cannot  be  explained  in  general  works  of  surgery  we 
expect  to  find  duly  set  forth  in  a  special  work  on  orthopeedics. 

The  author,  in  treating  of  the  means  for  arresting  pain  in 
diseased  knee-joint  by  the  division  of  the  hamstring  tendon, 
has  given  some  very  instructive  cases,  and  in  the  course  of  his 
remarks  Mr.  Brodhurst  lays  great  stress  upon  it  as  a  mode  of 
relieving  continued  pain  and  of  promoting  the  restoration  of  the 
joint.  It  is,  we  think,  a  proceeding  hardly  enough  employed  by 
surgeons.  In  such  cases  tenotomy  is  evidently  an  adaptation  of 
the  principle  of  "  rest." 

In  treating  of  anchylosis,  both  fibrous  and  bony,  or  "false^' 
and  "true,"  as  they  are  denominated,  Mr.  Brodhurst  has  hardly 
included  in  his  teachings  the  methods  successfully  employed  by 
others  for  combating  these  rigidities.  No  mention  is  made  of 
Sayre  of  New  York,  whose  very  remarkable  success  in  restoring 
motion  to  rigid  hip-joints  was  probably  well  known  to  Mr. 
Brodhurst,  for  Sayre's  earlier  cases  were  published  in  New  York 
as  long  ago  as  1863,  and  in  consequence  of  an  erroneous  quota- 
tion by  Bauer  of  New  York,  they  were  republished  in  the 
*New  York  Medical  Journal'  of  1869,  in  extenso,  with  corrobo- 
rative testimony  of  their  perfect  success  from  the  surgeons  who 
had  been  present  at  the  operations,  or  had  examined  the  patients 
afterwards. 

The  concluding  chapters  are  devoted  to  spinal  curvatures,  but 
either  the  space  at  the  author's  command,  or  want  of  the 
revision  that  the  earlier  divisions  of  his  subject  have  received, 
render  this  the  less  satisfactory  part  of  his  book. 


90  Reviews.  [Jan., 

We  hope  that,  should  it  become  advisable  to  put  forth  a  new 
edition  of  these  lectures,  they  may  undergo  a  complete  revision, 
and  receive  the  necessary  amplifications  to  render  them  worthy 
of  the  title — '  A  System  of  Orthopaedy.' 


VIII.— Physiology  of  Blood-Crystals. 

It  is  somewhat  startling  to  find  a  book  of  nearly  300  pages 
devoted  exclusively  to  the  consideration  of  the  red  colouring 
matter  of  the  blood,  a  subject  which  ten  years  ago  received  only 
a  passing  notice  in  the  best  works  on  physiology.  The  great 
development  of  this  subject  is  attributable,  first,  to  the  discovery 
of  the  fact  that  blood  is  capable,  under  certain  circumstances, 
of  undergoing  crystallisation,  leading  to  a  vast  number  of  re- 
searches on  the  form  of  the  crystals  in  man  and  animals,  on 
their  composition,  and  on  the  conditions  favouring  their  produc- 
tion ;  and,  secondly,  to  the  application  of  the  spectrum  analysis 
to  the  examination  of  the  blood,  which  has  opened  up  a  wide 
field  of  great  interest.  The  value  of  the  facts  obtained  can 
scarcely  be  estimated  at  present,  but  there  can  be  little  doubt 
that  some  aid  will  be  obtained  from  them  in  medico-legal  inves- 
tigations, and  perhaps  it  may  one  day  become  possible  to 
ascertain,  with  absolute  certainty,  to  what  animal  a  minute 
crust  of  dried  blood  originally  belonged. 

The  first  notice  of  blood-crystals  appears  to  have  been  by 
Hiinefeld,  in  a  prize  essay  published  in  1840,  who  observed 
tabular  crystals  in  the  cracks  of  the  balsam  on  the  glass  slide 
on  which  he  had  mounted  some  human  and  pig's  blood;  he 
was,  however,  unable  to  explain  their  nature.  They  were  then 
observed  by  Leydig,  in  1848,  in  Nephelis  and  Elepsine.  The 
real  merit  of  the  discovery  is  due  to  Reichert,  who  saw  them,  in 
1849,  in  the  placenta  of  a  guinea-pig ;  and  though  attributing 
their  colour  to  the  mechanical  admixture  of  pigment,  yet  recog- 
nised their  form  and  organic  nature,  and  named  them  tetrahe- 
dral  albuminous  crystals  (Albuminat-krystalle).  They  were 
subsequently  seen  by  Kolliker,  who  called  them  globulin  crys- 
tals, and  by  Budge,  who,  in  1850,  described  the  blood-crystals 
of  man,  which  he  obtained  from  the  stomach  of  the  leech.  None 
of  these  authors,  however,  followed  up  their  observations,  and  it 
was  reserved  for  Otto  Funke  not  only  to  rediscover  the  crystals, 
but  to  show  how  they  may  be  obtained  at  will.  He  stated  in 
1851  ('  Zeits.  f.  Rat.  Med.),  that  if  to  a  few  drops  of  blood 
which  have  been  allowed  partially  to  evaporate  a  little  water  be 

^  Die  BlutJcrystalle.  Untersucliuugen.  Von  W.  Peeyee.  Mit  di*ei  farbigen 
Tafeln.     Jena,  1871.     8vo,  pp.  263. 


1872.] 


Physiology  of  Blood- Crystals,  91 


added,  the  borders  of  the  small  masses  of  corpuscles  will  be  seen 
to  undergo  a  sudden  change,  so  that  whilst  some  of  the  corpus- 
cles disappear,  the  others  retain  their  thick  contours,  and  become 
angular,  elongated,  and  well-defined  rods.  They  thus  form  the 
embryoes,  so  to  speak,  of  an  immense  number  of  crystals  which 
are  too  small  to  permit  their  shape  to  be  defined,  but  which 
gradually  elongate,  whilst  their  diameter  increases  but  little,  if 
at  all,  and  form  prismatic  spherules  which  in  part  assume  a 
jointed  character,  and  ultimately  cover  the  whole  field  with  a 
close  network  of  decussating  or  acicular  crystals."  He  obtained 
blood-crystals  from  the  horse,  dog,  and  fish,  and  in  the  follow- 
ing year  (1852)  made  the  remarkable  discovery  that  in  the  fish 
the  crystals  did  not  arise  from  the  metamorphosis  of  the  whole 
blood-corpuscle,  but  of  only  a  part,  each  crystal  being  contained 
within  the  blood-corpuscle.  In  the  same  year  Bisegger  and 
Bruch  observed  the  same  phenomena  in  the  blood  of  the  rat. 
Funke  further  insisted  on  the  fact  that  the  crystallising  sub- 
stance was  not  the  albuminous  principle  of  the  corpuscle  alone, 
but  the  globulin  in  combination  with  haematin.  The  expression 
hsemato-globulin,  already  frequently  employed,  was  first  limited 
by  Berzelius  in  1840  to  designate  the  red  colouring  matter  of 
living  blood  as  opposed  to  the  colouring  matter  obtained  by 
artificial  means,  which  he  named  heematin.  Lehmann  applied 
the  term  haemato-crystallin  to  the  crystallisable  red  constituent 
of  the  blood-corpuscles.  Schlossberger,  in  1860,  called  it  hsemo- 
globulin,  and,  when  crystallised,  hsemocrystallin.  The  expres- 
sion liBemoglobin,  which  has  the  advantage  of  brevity,  was  in- 
vented by  Hoppe  Seyler  in  1864.  Bertin,  in  1856,  called  the 
red  colouring  matter  chromatin,  and  entertained  the  singular 
opinion  that  the  crystals  were  really  colourless,  but  owed  their 
colour  to  their  refracting  properties.  Stokes,  in  1864,  called 
the  red  colouring  matter  of  the  blood  cruorine,  and  distinguished 
between  scarlet  and  purple  cruorine ;  the  former,  M.  Preyer 
states,  is  the  somewhat  impure  coloured  oxy-hsemoglobin,  the 

formula  of  which  he  gives  as  Og  — Hb  or  ^  >  Hb;  the  latter  is 

non-oxygenated  or  reduced  hsemoglobin  (Hb).  Stokes'  terms 
have  hitherto  only  found  acceptance  in  England,  the  French 
having  adopted  the  German  phraseology.  In  Germany,  the 
terms  red  colouring  matter  of  the  blood  and  hsemoglobin  are 
used  promiscuously  to  indicate  the  coloured  iron  containing 
crystals  of  albumen  obtained  from  the  blood  (Blutrothstoff 
Hamoglobin,  Blutroth,  Roth,  Blutfarbstoff). 

Teichmann^s  iisemin  crystals,  which  are  identical  with  Leh- 
mann's  hsematin  when  this  is  in  the  crystallised  condition,  and 
with  Virchow's  hamatoidin  when  this  is  found  crystallised  in  old 


92  Reviews.  [Jan., 

blood  extravasation,  and  Preyer's  hamatoin  crystals,  may  all  be 
called  blood-crystals,  since  tbey  are  obtained  from  blood,  but 
are  not  rightly  so  named,  since  they  are  really  all  products  of 
disintegration. 

The  colouring  matter  of  the  blood-haemoglobin,  as  M.  Preyer 
prefers  to  call  it,  occurs  in  the  blood  of  all  Vertebrata  (appear- 
ing as  early  as  the  third  day  of  incubation  in  the  fowl),  and  of 
some  Invertebrata,  as  well  as  in  the  greater  number  of  the 
muscles  of  warm-blooded  animals,  though  there  is  still  some 
doubt  as  to  whether  the  colouring  matter  obtained  from  the 
latter  is  not  really  due  to  the  blood  circulating  through  them. 
By  spectrum  analysis  M.  Preyer  has  demonstrated  its  presence 
to  a  very  small  extent  in  thick  layers  (4 — 6  centimeters  in 
depth)  of  the  serum  of  the  ox,  sheep,  calf,  horse,  and  pig,  a 
faint  absorption  stria  appearing  on  the  right  and  close  to 
Frauenhofer's  line  D.  He  thinks  it  quite  probable  that  it  is 
not  naturally  present  in  the  liquor  sanguinis,  but  is  derived 
either  from  the  disintegration  of  a  few  blood-corpuscles  during 
the  formation  of  the  clot,  or  from  the  presence  of  a  few  corpus- 
cles still  floating,  but  escaping  observation,  in  the  serum. 

A  substance  presenting  all  the  characters  of  hsemoglobin, 
though  it  does  not  appear  to  have  been  submitted  to  the  spec- 
troscopic test,  has  been  obtained  by  Rollett  from  the  red  blood 
of  the  larva  of  Chironomus  plumosus,  and  this  is  so  far  of  inte- 
rest as  proving  that  haemoglobin  can  be  directly  prepared  from 
plants  by  the  animal  organism,  these  gnats  being  exclusively 
vegetable  feeders.  Preyer  has  shown  that  the  red  blood  of  the 
Lumbricidae,  which  has  long  been  known  to  contain  iron  and 
albumen,  presents  the  characteristic  striae  of  haemoglobin  in  the 
spectroscope,  and  these  animals,  like  the  former,  subsist  on 
plants.  Haemoglobin  has  also  been  shown  to  be  present  in  the 
Phyllopod  Crustacean  Cheiroceplialus  diapTianus,  and  recently, 
by  E-ay  Lankester,  in  the  blood  and  muscles  of  Planorbis  and 
many  other  mollusks.  Leydig  has  demonstrated  it  in  Nephelis, 
and  other  Annelids  probably  contain  it ;  but  the  blood  of  in- 
sects, though  capable  of  crystallising  in  stable  crystals,  does  not 
appear  to  possess  any  colouring  matter  allied  to  haemoglobin. 
This  substance  has  not  been  found  in  any  of  the  Protozoa, 
Coelenterata,  or  Echinodermata,  nor  does  it  exist  in  plants. 

To  obtain  blood-crystals  in  quantity,  various  methods  have 
been  suggested.  M.  Preyer  enumerates  no  less  than  six :  by 
water,  and  the  transmission  of  oxygen  and  carbonic  acid  gases 
and  the  addition  of  a  little  alcohol ;  by  freezing ;  by  the  injec- 
tion of  cold  water  into  the  vessels  of  an  animal  whilst  it  is  being 
chloroformed  to  death ;  by  dissolving  the  red  corpuscles  with  a 
solution  of  the  tauro-  and  glycochojate  of  soda  \  by  the  addition 


1872.]  Physiology  of  Btood^Orystah.  ^^ 

of  one  volume  of  water  and  then  of  one  fourth  of  a  volume  of 
alcohol  to  the  deiibrinated  blood  and  exposure  to  cold;  and 
lastly,  his  own  plan,  which  is  as  follows : 

The  blood  is  received  into  a  capsule  or  saucer,  where  it  is 
allowed  to  coagulate,  and  placed  aside  in  a  cool  place  for 
twenty-four  hours.  The  serum  with  the  white  corpuscles  and 
fat,  if  any,  are  removed,  and  the  clot,  after  fine  division,  re- 
peatedly washed  with  cold  distilled  water.  The  fragments, 
hardened  by  freezing,  are  placed  on  a  filter  and  a  stream  of  cold 
distilled  water  allowed  to  play  over  them  until  the  filtrate  gives 
scarcely  any  precipitate  with  solution  of  corrosive  sublimate. 
Water  at  a  temperature  of  from  86°  F.  to  107°  F.  is  now  poured 
over  the  clot,  and  being  filtered  is  received  into  a  large  cylinder 
standing  in  ice.  To  a  small  quantity  of  the  red  solution  alco- 
hol is  added  drop  by  drop,  till  a  precipitate  begins  to  appear, 
and  thus  an  estimate  is  obtained  of  the  quantity  required  to  be 
added  to  the  whole.  The  crystals  appear  in  great  abundance 
in  the  course  of  a  few  hours.  They  must  be  washed  with  ice- 
cold  water  containing  a  few  drops  of  alcohol,  and  then  appear 
to  be  almost  if  not  perfectly  pure.  The  blood  of  the  horse  is 
that  which  is  by  far  the  best  adapted  for  the  preparation  of  very 
large  quantities  of  the  purest  haemoglobin  crystals. 

The  modes  in  which  minute  quantities  of  blood  may  be  crys- 
tallised are  various.  One  of  the  simplest  is  that  discovered  by 
Max  Schultze,  who  observed  that  the  blood  of  the  guinea-pig, 
kept  at  14°  F.,  dissolves,  and  that  from  the  solution  crystals 
separate  on  evaporation.  No  crystals,  however,  can  be  obtained 
in  this  manner  from  the  blood  of  man,  calf,  or  rabbit,  though 
Preyer  has  found  they  are  furnished  by  the  blood  of  the  horse. 
Bojanowski  obtained  hsemoglobin  crystals  by  the  evaporation  of 
the  watery  extract  of  the  blood-clot  of  a  rabbit  by  passing  the 
interrupted,  and  A.  Schmidt  by  passing  the  constant,  current 
through  the  blood  of  man,  the  cat,  dog,  and  guinea-pig.  Pas- 
teur obtained  an  abundance  of  crystals  from  blood  placed  in  a 
flask  to  which  air  that  had  been  passed  through  a  red-hot  tube 
was  admitted,  and  which  was  then  allowed  to  stand  for  some  weeks 
at  70°  F.  Bernstein  obtained  blood-crystals  from  defibrinated 
blood  through  which  air  charged  with  a  small  quantity  of  chlo- 
roform had  been  conducted,  whilst  A.  Schmidt  showed  that  the 
mere  addition  of  alcohol  to  the  blood  of  a  dog  sufficed  to  pro- 
duce crystallization.  Ether  acts  in  the  same  way.  Funke, 
Bojanowski,  and  others,  have  suggested  various  other  plans  for 
procuring  small  quantities  of  blood-crystals,  but  M.  Preyer  re- 
commends the  following  as  being  the  most  expeditious  : — A  few 
cubic  centimetres  of  defibrinated  blood  is  mixed  with  sufficient 
water   to   furnish   a   clear  solution.     A   drop  of  the  mixture, 


94  Reviews,  [Jau., 

covered  with  a  tliin  piece  of  glass,  and  evaporated  in  the  cold, 
will  often  yield  crystals ;  but  if  not,  then  alcohol  to  about  the 
amount  of  one  fourth  of  the  volume  of  the  solution,  is  to  be 
added,  and  placed  on  ice  in  a  platinum  or  silver  capsule ;  crys- 
tals will  then  speedily  form.  In  regard  to  the  mode  of  formation 
of  the  crystals,  M.  Preyer  thinks  that  Beale  is  in  error  in  stating 
that  he  has  seen  a  single  blood-corpuscle  (of  the  blood  of  a 
guinea-pig)  become  converted  into  a  crystal.  In  his  experience 
it  has  always  required  the  ha3moglobin  of  several  corpuscles  to 
form  one  crystal. 

The  colouring  matter  itself  in  the  circulating  blood  is  pro- 
bably not  free,  but  combined  with  an  alkali ;  it  could  not  other- 
wise exist  in  solution,  for,  on  the  one  hand,  hsemoglobin  is  very 
insoluble,  and,  on  the  other,  the  red  corpuscles  are  amongst  the 
least  watery  of  all  the  soft  parts  of  the  body ;  moreover,  there  is 
evidence  that  it  exists,  as,  indeed,  investigation  with  the  highest 
powers  shows,  in  the  granular  condition  in  the  corpuscles,  for  the 
blood  corpuscles,  when  examined  with  a  Nicol's  prism,  are  cer- 
tainly not  doubly  refracting,  whilst,  however  finely  the  crystals 
of  hsemoglobin  may  be  pulverised,  the  dust  so  obtained  is  indu- 
bitably doubly  refracting.  The  stroma  or  colourless  portion  of 
the  living  blood-corpuscle  appears  to  be  combined  with  the 
haemoglobin,  and,  so  to  speak,  fixes  it.  Yet  this  union  is  so 
feeble  that  very  slight  influences,  which  may  be  rather  of  a  che- 
mical or  mechanical  nature,  will  lead  to  their  separation,  and 
occasion  the  formation  of  crystals.  In  every  case  an  alteration 
in  the  structure  of  the  corpuscles  is  produced,  rendering  them 
no  longer  capable  of  retaining  their  haemoglobin;  removal  of 
the  gases  of  the  blood,  agitation  with  fragments  of  metal,  the 
addition  of  water,  the  variations  of  temperature,  and  other  crys- 
tallizing agents  act  in  this  way ;  the  red  colouring  matter  sepa- 
rates from  the  stroma  of  the  blood  and  undergoes  solution  in  the 
liquor  sanguinis ;  in  order  that  it  may  crystallize  out  from  this, 
however,  a  second  chemical  agent  is  required — the  addition  of 
some  acid,  which,  if  not  added  from  without,  is  probably  formed 
in  the  blood,  for  Zuntz  has  shown  that  after  the  withdrawal  of  the 
body  the  alkalescence  of  the  blood  steadily  diminishes  ;  in  other 
words,  acids  are  developed.  With  this  diminution  of  alkalescence 
the  capacity  of  the  blood  to  undergo  crystallization  steadily  in- 
creases. It  is  probable  that  all  the  chemical  agents  used  to 
induce  crystallization,  as  ether,  alcohol,  ozonized  turpentine,  the 
transmission  of  oxygen,  promote  the  formation  of  an  acid  or 
acids,  whilst  in  some  methods  acids  (oxalic  acid)  are  directly 
added  to  the  blood.  If,  then,  the  hsemoglobin  be  admitted  to 
be  combined  with  an  alkali,  there  can  be  little  doubt  that  this 
alkali  is  potash,  and  the  relations  both  of  the  corpuscles  and  of 


1872.]  Physiology  of  Blood-Crystals.  95 

solutions  of  haemoglobin  in  potash  render  it  probable  that  the 
colouring  of  the  matter  of  the  living  blood  exists  in  the  form  of 
a  very  soluble  hacmoglobinate  of  potash,  which  combines  with 
and  retains  a  certain  quantity  of  carbonic  acid,  quite  indepen- 
dently of  the  degree  of  tension  of  this  gas  in  the  atmosphere 
surrounding  the  blood. 

M.  Preyer  next  proceeds  to  consider  the  crystalline  forms 
assumed  by  the  haemoglobin,  and  gives  an  excellent  table  di- 
vided into  seven  columns,  of  which  the  first  gives  the  name  of 
the  animal ;  the  second,  the  form  of  the  crystals ;  the  third,  the 
system  to  which  the  crystals  belong ;  the  fourth,  the  place  where 
the  corpuscles  are  formed,  whether  within  or  without  the  cor- 
puscles ;  the  fifth,  the  solubility  in  water ;  the  sixth,  the  faci- 
lity or  otherwise  with  which  the  crystals  form ;  and  lastly,  a 
column  of  remarks,  including  the  name  of  the  discoverer,  a 
reference  to  the  paper  in  which  it  was  first  mentioned,  and 
to  illustrations  of  the  same  crystalline  forms  by  other  writers. 
The  crystalline  forms  assumed  by  the  blood  of  no  less  than 
forty-six  animals  is  here  given,  including  all  the  domestic  ani- 
mals and  the  more  easily  accessible  birds,  reptiles,  and  fish. 
The  crystals  obtained  by  H.  Landois  from  many  insects  he  ex- 
cludes from  this  table,  on  the  ground  that  they  have  not  been 
proved  to  be  really  haemoglobin.  Of  the  six  systems  of  crys- 
tals, the  table  shows  that  five  have  been  stated  to  be  represented 
in  the  different  forms  of  haemoglobin,  namely,  the  regular 
(tesseral),  the  tetragonal,  the  rhombic,  the  monoklinic  (klino- 
rhombic,  monoklinohedric),  and  the  hexagonal.  The  triklinic 
(klino-rhomboidic)  has  not  hitherto  been  seen  by  any  one.  It 
may  easily  be  shown,  in  addition,  that  haemoglobin  crystals  really 
never  belong  to  either  the  regular  or  to  the  tetragonal  systems, 
since,  on  the  one  hand,  all  haemoglobin  crystals  are  doubly  re- 
fracting, which  is  not  the  case  with  any  crystals  belonging  to 
the  regular  system ;  and,  on  the  other  hand,  it  has  been  recently 
shown  that  the  crystals  from  the  blood  of  the  guinea-pig  do  not 
belong  to  the  tetragonal  system.  The  monoclinous  system  may, 
in  like  manner,  be  excluded,  as  Funke  is  the  only  author  who 
has  placed  the  haemoglobin  crystals  of  man  and  of  the  cat  in 
this  system,  and  his  statenlents  have  not  been  supported  by 
others.  There  remains,  then,  only  the  rhombic  and  hexagonal 
systems,  and  to  one  or  other  of  these  all  blood  crystals  belong. 

In  regard  to  the  optic  relations  of  haemoglobin  crystals  they 
are  always  perfectly  transparent  from  whatever  quarter  derived, 
and  always  doubly  refractile.  They  have  a  silky  lustre,  are 
pleochromatic,  and  their  colour  varies  from  that  of  venous  to 
that  of  arterial  blood. 

The  spectrum  of  pure  oxy-haemoglobin  crystals  invariably 


D6  HevieiDs.  [Jan., 

exhibits  two  very  characteristic  absorption  strise  in  the  yellow 
and  green,  which  are  visible  when  only  l-10,000th  heat  is  pre- 
sent in  solution  in  water.  These  strise  increase  in  breadth  and 
intensity  with  the  increase  of  proportion  of  haemoglobin  in  the 
solution,  whilst  at  the  same  time  there  is  a  considerable  ab- 
sorption of  the  violet  rays,  and,  when  very  strong  (0'6  per  cent.), 
of  the  red  also,  the  two  strise  coalescing  into  one  black  band. 
AVith  still  stronger  solutions  all  the  spectrum  is  absorbed,  with 
the  exception  of  a  band  of  orange  and  one  of  green,  these  colours 
being  alone  transmitted.  Two  years  after  the  discovery  of  the 
absorption  bands  of  oxy-ha^moglobin,  Stokes  pointed  out  that 
the  presence  or  absence  of  loosely  combined  oxygen  made  con- 
siderable difference  in  the  character  of  the  spectrum.  Haemo- 
globin free  from  oxygen  presents  only  a  single  absorption  band 
with  ill-defined  borders  between  D  and  E,  a  portion  of  the  red 
and  nearly  all  the  violet  being  absorbed.  Such  a  solution  is 
best  obtained  by  the  addition  of  a  very  small  quantity  of  sul- 
phide of  sodium  to  a  solution  of  oxy-haemoglobin,  or  by  agita- 
tion of  the  blood  with  fine  iron  filings. 

Remarkable  alterations  occur  in  the  absorption  striae,  when 
haemoglobin  undergoes  decomposition.  A  stria  then  appears  in 
the  orange,  which  was  previously  transmitted  with  the  greatest 
intensity  (m.ethaemoglobin).  M.  Preyer  gives  two  beautiful 
chromographs  of  the  spectra,  not  only  of  the  solutions  above  men- 
tioned, but  of  those  resulting  from  the  action  of  acids  and 
alkalies,  &c.,  on  the  blood. 

The  hardness  of  the  blood-crystals  varies  in  different  animals, 
but,  as  a  rule,  they  are  soft,  and  readily  break  down  when 
pressure  is  made  upon  the  covering-glass.  When  one  of  the 
long  prismatic  crystals  is  fractured  transversely  the  surfaces  are 
uneven  and  splintery.  The  specific  gravity  of  haemoglobin  has 
not,  as  yet,  been  ascertained,  but  it  probably  amounts,  when 
dry,  to  between  1*3  and  1'4.  All  the  forms  of  haemoglobin 
hitherto  investigated  are  soluble  in  water,  though  the  degree  of 
solubility  varies  to  a  considerable  extent ;  and  whilst  some  are 
hygroscopic,  some  few,  as  that  of  the  crow,  dissolve  with  diffi- 
culty in  cold  water.  According  to  Hoppe  Seyler,  100  c.c.  of 
water,  at  5""^  C,  dissolve  two  grammes  of  the  haemoglobin  of  the 
dog,  and  the  solubility  increases  rapidly  with  the  temperature. 
Lehmann  states  that  one  part  of  dry  crystals  from  the  guinea- 
pig  dissolves  in  597  parts  of  water.  The  crystals  of  the  squirrel 
also  dissolve  with  difficulty. 

Haemoglobin  crystals  are  insoluble  in  alcohol,  in  ether,  in 
etherial  and  fatty  oils,  in  benzole,  turpentine,  chloroform,  amyl, 
alcohol,  and  in  bisulphide  of  carbon. 

Their  solubility  in  water  is  increased  by  the  addition  of  a 


1872. J  Physiology  of  Blood-Crystals.  9? 

small  quantity  of  most  alkalies  and  alkaline  salts^  but  tliese 
after  a  few  days  occasion  decomposition.  Acids  have  little  in- 
fluence in  increasing  the  solubility,  but  soon  occasion  decompo- 
sition. 

Haemoglobin  constitutes  an  exception  to  Graham's  theory, 
since,  though  a  crystallizable  substance,  it  will  not  diff'use 
through  parchment  paper ;  and  the  opposite  results  obtained  by 
A.  Schmidt  may  be  attributed  to  the  imperfection  of  the  septum 
employed.  This  fact  is  of  considerable  importance  in  regard  to 
the  views  of  Schmidt  on  the  escape  of  a  fibrino-plastic  substance 
from  the  corpuscles  when  these  are  placed  in  an  albuminous 
fluid,  as  of  hydrocele,  when  it  was  supposed  that  the  globulin 
exuded  from  the  corpuscles  combines  with  the  crystallizable 
hgemoglobin.  M.  Preyer,  however,  shows  that  haemoglobin  is 
not  in  the  slightest  degree  fibrino-plastic.  As  regards  the  effects 
of  heat  upon  the  crystals,  M.  Preyer  shows  that,  if  thoroughly 
dried,  they  are  capable  of  supporting  the  temperature  of  boiling 
water  without  undergoing  decomposition,  and  the  colouring 
matter  of  the  blood  of  the  guinea-pig  only  begins  to  break  up  at 
a  temperature  of  320^^  to  330°  Fahr.  The  moist  crystals,  how- 
ever, decompose  much  sooner,  with  production  of  methsema- 
globin.  Watery  solutions  of  perfectly  pure  dog's  haemoglobin 
began  to  be  turbid  at  176°  F. 

The  composition  of  haemoglobin  has  been  very  carefully  ana- 
lysed by  C.  Schmidt  and  Hoppe  Seyler.  M.  Preyer  himself 
appears  only  to  have  estimated  the  iron  and  sulphur.  The  fol- 
lowing appears  to  be  the  mean  of  various  observations  : 


Carbon 

.     54-00 

Hydrogen 

Nitrogen 
Iron     . 

.  7-25 
.  16-25 
.       0-42 

Sulphur 
Oxygen 

.  0-63 
.     31-15 

100-00 
The  simplest  rational  formula  deducible  from  this  is — 

C60oH96oNi54FeiS30i79. 

One  molecule  of  haemoglobin  requires  to  form  non-coagulable 
combinations,  three  molecules  of  soda ;  its  equivalent  weight  is, 
therefore,  4444,  or  u^^^-^. 

Oxo-h«moglobin  reacts  feebly  acid. 

M.  Preyer  then  proceeds  to  consider  at  length  the  action  of 
various  substances  on  the  blood,  a  work  that  must  have  been 
extremely  laborious,  and  is  very  complete;  it  includes  the 
action  of  hydrochloric,  nitric,  sulphuric,  phosphoric,  chromic, 
boracic,  oxalic,  acetic,  formic,  valerianic,  carbonic,  and  many 
97 — xLix.  7 


98  lieviews.  [Jan., 

other  acids,  of  which,  perhaps,  the  last  is  the  most  important 
and  interesting.  He  divides  the  acids  into  four  groups,  of 
which  the  first,  like  phosphoric  and  sulphurous  acids,  produce 
no  precipitation  in  solutions  of  hsemoglobin,  but  only  a  change 
of  colour ;  the  second,  like  metaphosphoric  acid,  produce,  both 
in  cold  and  warm  solutions,  precipitation  and  decomposition  ;  the 
third,  like  nitric  and  hydrochloric  acids  when  very  dilute,  only 
produce  a  change  of  colour,  but  when  stronger,  a  precipitation 
and  decomposition ;  the  fourth  give  no  precipitate  in  the  cold, 
but  coagulum  occurs  on  warming,  and  to  this  carbonic  acid  and 
weaker  acids  belong. 

The  action  of  the  various  alkalies  is  more  uniform  than  that 
of  the  acids.  Since  oxy-hsemoglobin  is  an  acid,  its  solubility  in 
alkalies  is  easily  intelligible,  soluble  chemical  compounds  being 
formed,  not  differing  in  colour  if  the  alkaline  solution  be  weak, 
nor  in  the  spectrum  it  produces.  If,  however,  the  solutions  be 
more  concentrated,  or  if  the  more  dilute  solutions  are  warmed, 
the  blood-red  colour  changes  to  brown,  or  when  seen  in  thin 
layers,  into  green ;  it  is,  therefore,  dichromatic,  and  a  process  of 
decomposition  sets  in,  the  rapidity  of  the  progress  of  which  is 
dependent  on  the  energy  of  the  base;  potash  acting  more  speedily, 
then  soda,  ammonia,  baryta,  and  lime.  In  the  spectrum  the  two 
hsemoglobin  striae  have  vanished,  and  instead,  a  blurred  absorp- 
tion line  occurs  in  the  orange  constituting  the  spectrum  of  the 
oxy-hsematin  alkali.  The  solution  does  not  coagulate  on  heat- 
ing, but  remains  clear,  even  at  the  boiling  point. 

The  details  of  the  action  of  a  large  number  of  salts  are  given 
by  M.  Preyer,  as  well  as  those  of  both  reducing  and  oxidizing 
agents,  the  spectra  being  in  many  instances  given  in  coloured 
lithographs. 

Though  haemoglobin  gives  some  of  the  reactions  of  albu- 
minous compounds,  as  the  xantho-proteinic  and  that  with 
Millon's  reagent,  he  will  not  admit  that  it  belongs  to  that 
series,  but  considers  that  albumen  splits  off  from  it,  as  it  were, 
in  consequence  of  the  action  of  the  reagent. 

Spectrum  analysis  constitutes,  perhaps,  the  most  satisfactory 
test  of  the  presence  of  blood  known ;  it  is,  without  doubt,  one 
of  the  most  remarkable  instances  of  the  delicacy  of  modern 
methods  of  research.  M.  Preyer  states  that  though  he  has  not 
been  able  to  distinguish  the  spectrum  of  a  single  red  corpuscle, 
yet  a  very  few  enable  it  to  be  clearly  perceived,  though  he  esti- 
mates that  each  corpuscle  only  contains  the  0*000,000,000,0^ 
of  a  gramme  of  hgemoglobin.  If  on  examination  two  absorption 
striae  appear,  some  reducing  agent,  as  solution  of  sulphide  of 
sodium,  must  be  added ;  the  reduction  band  then  appears,  and 
this  can  be  again  resolved  into  two  by  agitation  with   air  or 


1872.] 


Physiology  of  Blood^Crystals. 


oxygen.  An  attempt  should  always  be  made  to  obtain  hsemin 
crystals^  and  before  the  presence  of  blood  is  positively  affirmed, 
iron  should  be  demonstrated. 

A  long  chapter  of  M.  Preyer's  work  is  taken  up  with  an 
account  of  the  combinations  of  hsemoglobin  with  oxygen,  car- 
bonic oxide,  nitric  oxide,  nitrides,  cyanides,  &c.,  containing 
points  of  interest  that  we  have  no  space  to  give. 

The  products  of  the  decomposition  of  the  colouring  matter  of 
the  blood,  which  is,  perhaps,  the  most  complex  substance  in 
nature,  may,  of  course,  be  regarded  as  almost  infinite,  but  the 
most  important  of  those  containing  carbon  may  be  arranged  in 
three  groups,  albuminous  coiwpowids,  colouri7ig  matters,  and 
acids,  M.  Preyer  shows  that  though  the  term  globulin  has  been 
commonly  used  to  distinguish  the  albuminous  substance  that 
can  be  obtained  from  haemoglobin,  yet  that  different  substances 
have  been  described  under  this  name.  He  prefers  the  term 
globin  to  designate  the  albuminous  part  of  hsemoglobin,  and 
states  that  it  is  the  purest  form  of  albumen  known,  as  it  leaves 
no  ash  on  being  burned. 

The  colouring  matters  are  numerous.  Some  few  are  pro- 
duced in  the  living  body  from  the  red  blood-corpuscles,  though 
they  cannot  be  formed  from  them  artificially.  Five  of  the 
coloured  products  of  decomposition  of  hsemoglobin  are  crystal- 
lizable,  namely,  ha^min,  hsematoin,  ha)matoidin,  hsematochlorin, 
and  hsematolutein.  All  others,  if  we  except  the  biliary  colouring 
matters,  are  uncrystallizable ;  to  these  last  belong  methajmo- 
globin,  hsematin,  hsemathion,  and  other  less  known  pigments. 

Hsemin,  and  what  was  formerly  called  hsematin,  are  iden- 
tical. 

In  regard  to  the  physiological  significance  and  importance  of 
the  red  colouring  matter  of  the  blood  little  can  be  said. 

The  scattered  and,  as  it  v/ere,  accidental  occurrence  of  red 
blood  in  the  lower  animals  might  lead  us  to  suppose  that  the 
colour  was  an  unessential  feature,  and  when  present,  might 
even,  as  in  the  case  of  the  larva  of  the  Chironomus,  be  injurious 
to  the  animal  possessing  it,  by  rendering  it  a  more  conspicuous 
mark  for  the  attacks  of  its  enemies.  When,  however,  we  come 
to  see  how  constant  this  tint  is  in  the  blood  of  the  whole  verte- 
brate series,  it  is  impossible  to  avoid  arriving  at  the  conviction 
that,  like  the  green  tint  of  vegetables,  it  is  of  some  service, 
though  we  are  not  at  present  in  a  position  to  explain  what.  M. 
Preyer  suggests  that  it  may  stand  in  connection  with  the  heat- 
producing  and  heat-maintaining  powers  of  the  blood.  The  colour 
may  be  seen  in  the  heart  of  the  chick  at  the  third  day  of  deve- 
lopment, but  no  observations  have  as  yet  thrown  any  light  on 
the  place  of  origin.     Dr.  Furbringer  has  made  a  series  of  expe- 


100  tieviews.  [Jan., 

riments  under  Preyer's  direction,  in  which  mixtures  of  peptones 
and  albuminates  were  made  with  oxide  of  iron,  but  he  uniformly 
failed  in  obtaining  a  blood-red  colour.  Nevertheless  the  obser- 
vations of  Virchow,  that  lymph  exposed  to  the  air  reddens,  is 
worthy  of  particular  note. 

In  conclusion,  we  cannot  part  from  M.  Preyer  without  ex- 
pressing our  commendation  of  the  excellent  manner  in  which 
his  essay  has  been  prepared.  It  may  be  regarded  as  exhausting 
all  the  facts  hitherto  discovered  on  this  subject,  and  at  the  same 
time  as  paving  the  way  for  new  researches,  which  no  one  is 
better  able  than  himself  to  undertake. 


IX.— Sir  H.  Thompson  on  Practical  Lithotomy  and  Lithotrity.^ 

It  has  been  well  said  that  the  medical  books  which  are  most 
valuable  are  those  which  are  written  by  men  the  results  of 
whose  ripe  experience  and  extended  practice  have  placed 
them  in  a  position  wherein  the  temptations  to  go  into  print  are 
diminished  just  in  proportion  to  the  success  and  value  of  their 
labours.  This  is  just  the  class  of  books  which  are  nowa- 
days the  least  forthcoming.  The  Tom  Tiddler's  ground  of  the 
publishers'  lists  is  occupied,  not  to  say  crowded,  with  the  pro- ' 
ductions  of  aspirants  to  fame  rather  than  past  masters  in  the 
art,  and  the  volumes  of  the  wise  and  learned  make  no  more,  or 
hardly  so  much,  show  in  the  advertising  column  as  the  cloth- 
bound  handbills  of  pretenders.  It  is  not  to  be  wondered  at  if 
the  man  of  established  position  steps  hesitatingly  and  doubtfully 
into  the  jostling  arena. 

As  students  of  the  art  and  science  of  medicine  and  surgery, 
we  are  all  the  more  pleased,  however,  when  we  have  an  oppor- 
tunity of  studying  the  doings  and  reading  the  thoughts  of  an 
experienced  teacher.  The  sentiments  of  early  veneration  seem 
again  to  be  recalled  from  the  past  of  our  primeval  student  life, 
when  the  opinions  of  the  professor  carried  an  overpowering 
authority,  and  sank  with  great  weight  into  the  very  foundations 
of  our  knowlege,  to  form  the  buttresses  which  were  destined  to 
withstand,  more  or  less  perfectly,  the  waves  of  conflicting 
opinion,  and  the  ever  changing  tides  of  fashion. 

We  feel  again,  when  we  approach  such  a  work,  like  the 
scholar  in  Faust : 

1  Practical  Lithotomy  and  Lithotrity ;  or,  an  Inquiry  into  the  hest  modes  of 
Eernoving  Stone  from  the  Madder.  By  Sir  Heney  Thompson,  Surgeou-Extra- 
ordinary  to  H.M.  the  King  of  the  Belgians ;  Professor  of  Clinical  Surgery  and 
Surgeon  to  University  College  Hospital.     Second  edition. 


1872.]  Practical  Lithotomy  and  Lithotrity.  10] 

"  Ich  bin  allhier  erst  kurze  Zeit, 
Unci  komnae  voll  Ergebenlieit, 
Einen  Mann  zu  sprecheu  und  zu  kennen, 
Den  Alle  mir  mit  Ehrf  urcht  nennen." 

With  the  advantage  of  the  prestige  of  such  feelings  the 
volume  before  us  presents  itself.  It  speaks  "  ex  cathedra,"  and 
we  sit  at  once  at  the  feet  of  Gamaliel.  If  we  approve,  we  are 
conscious  that  we  add  but  little  to  elevate  the  chair  from  which 
the  utterances  issue ;  if  we  differ,  we  feel,  as  it  were,  compelled 
to  do  so  with  deference,  and  to  utter  our  protestations  "  with 
bated  breath." 

We  shall,  notwithstanding,  endeavour  to  handle  as  freely  as 
may  be  permitted  to  the  chartered  waywardness  of  the  critic's 
nature,  the  doings  and  maxims  which  we  find  in  Sir  Henry 
Thompson's  work,  of  which,  like  other  good  things,  it  may  be 
said,  that  indiscriminate  praise  would  savour  of  the  condemna- 
tion of  contempt  as  much  as  immoderate  blame  would  suggest 
the  influence  of  motives  not  impartial.  We  hope  and  shall 
strive  not  to  be  betrayed  into  either  one  or  the  other,  not  to  feel 
one  whit  lowered  by  the  acknowledgment  of  the  master's  ex- 
cellences, not  one  jot  lifted  up  by  obtaining  a  vantage  ground 
from  which  to  look  down  upon  them. 

There  is  a  disadvantage  attendant  upon  publishing  new  books 
and  new  editions  upon  a  trite  and  well-worn  subject,  which  has 
engaged  the  attention  of  the  best  surgical  intellects  for  cen- 
turies. 

If  we  were  asked  to  designate  a  subject  in  which  it  would  be 
difficult  to  arrive,  in  these  days,  at  anything  which  was  at  the 
same  time  both  new  and  true,  we  should  probably  say  litho- 
tomy. So  well  has  the  ground  been  turned  over  here,  and  so 
tempting  is  the  field  for  every  labourer  of  eminence  to  put  in 
his  spade  and  leave  his  mark,  that  we  have  arrived  at  the  pass 
that  surgeons  of  great  position  have  not  thought  it  beneath 
their  reputation  to  strive  for  the  credit  that  might  be  due  to  a 
variation  in  the  size,  shape,  and  direction  of  an  incision,  which 
can  have  but  very  small  influence  upon  the  total  result  of  cases. 
In  the  first  section  of  his  work,  accordingly,  as  might  have  been 
expected,  the  author  [has  produced  little  which  would  justify 
an  ambitious  publication.  We  find  a  recapitulation  of  the  his- 
tory of  the  operations,  the  description  and  figuring  of  the  dif- 
ferent varieties  of  instruments,  especially  the  gorgets,  together 
with  a  reproduction  of  the  outline  of  the  pelvic  opening,  with 
the  relation  to  it  of  the  superficial  and  deep  incisions  in  perineal 
lithotomy,  which  we  well  remember  as  figuring,  years  ago,  on 
the  demonstrator's  black  board  in  the  dissecting  room,  like  the 
red  outlines  of  muscular  attachments  which  have  since  been 


102  Reviews.  [Jan., 

utilised  as  the  characteristic  feature  of  one  of  the  most  used 
manuals  on  the  hones. 

In  the  hands  of  Sir  Henry  Thompson,  however,  it  must  be 
said  that  the  outlines  of  the  perineal  walls  and  the  relative 
position  of  the  incisions  in  the  various  modes  of  perineal  litho- 
tomy, have  been  illustrated  in  such  a  manner  as  to  give  to  the 
student  a  more  clear  conception  of  the  somewhat  confusing 
differences  of  these  operations  than  in  any  other  description 
with  which  we  are  acquainted.  The  essential  peculiarities  of  the 
lateral,  the  bilateral  of  Dupuytren,  the  medio-bilateral  of  Civiale, 
the  median,  Italian,  or  Allarton's  method,  and  the  incisions 
made  by  Buchanan,  are  all  very  distinctly  set  forth,  compared, 
and  contrasted,  in  a  clear,  methodical,  and  orderly  manner,  and 
the  accessory  instruments  of  Teale,  Corbet,  and  Avery,  and  the 
expanding  staff  employed  by  Wood,  all  receive  acknowledgment 
at  the  hands  of  the  author. 

The  author,  however,  takes  care  to  express  his  opinion  that 
most  of  these  contrivances  rank  rather  as  surgical  curiosities  than 
as  valuable  aids  ^to  the  operator  ;  and  he  inclines  strongly,  in  com- 
mon with  most  "experienced  lithotomists,  to  a  partiality  for  the 
most  simple  instruments,  handled  with  the  *^  tactus  eruditus" 
which  it  is  the  privilege  of  the  surgical  expert  to  dilate  upon 
with  so  much  unction  as  "  the  priceless  and  incommunicable 
heritage  of  experience,'^^ 

The  curved  external  incision  made  by  Buchanan  in  his 
operation  (which  was  also  employed  by  Wood)  'does  not  excite 
any  especial  remark  from  the  author,  although  undoubtedly 
giving  more  room  in  a  limited  space  than  straight  incisions. 
He  considers  Buchanan's  operation  to  be  essentially  a  median 
operation,  though  upon  what  grounds  does  not  appear,  since 
the  superficial  cut,  as  well  as  the  incision  in  the  left  lateral  lobe 
of  the  prostate,  are  both  certainly  placed  in  the  area  of  lateral 
incisions. 

The  illustrations  in  this  part  of  the  work  are,  like  the  text 
and  description,  of  a  high  order  of  accuracy  and  clearness. 
Especially  we  would  call  attention  to  Fig.  20,  in  which  the 
manner  of  holding  the  knife  and  hands  in  performing  the  deep 
incisions  of  the  lateral  operation  is  excellently  shown  by  Bagg. 
Upon  this  point  much  has  been  said  and  written  as  to  the 
manner  of  Listen,  of  whom  Sir  Henry  was  one  of  the  pupils, 
but  he  has  not,  apparently,  considered  this  trivial  peculiarity 

^  This  privilege,  however,  we  must  observe,  "en  passant,''  scarcely  justifies  the 
departure  from  the  reading  and  grammar  of  ordinary  mortals  which  we  find  in  the 
footnote  at  page  66  in  Sir  Henry's  work.  "Tactus  cruditum"  must  surely  he  due 
to  the  imperfection  of  the  subordinate  mechanical  aids,  rather  than  to  the  regu- 
lating intelligence  concerned  in  the  printing  and  publishing. 


1872.]  Practical  Lithotomy  and  Lithotrity.  103 

worth  making  a  coil  about.  In  enumerating  the  parts  cut  in 
median  lithotomy,  we  find  the  usually  correct  anatomy  of  the 
author  at  fault  in  the  omission  of  the  anterior  insertion  of  the 
sphincter  ani  which  passes  forward  over  the  central  tendon 
in  muscular  males,  even  as  far  as  to  overlap  the  fibres  of  the 
accelerator  urince.  These  fibres  are  undoubtedly  severed  in  the 
median  operation,  and  very  frequently  in  the  lateral  when  the 
median  raphe  is  closely  approached  or  transgressed. 

In  speaking  of  \\iq  pre-rectal  method  of  Nelaton,  the  author 
justly  considers  that  "it  is  difficult  to  admit  that  it  possesses 
claims  to  be  regarded  as  a  new  type,  or,  indeed,  that  it  mani- 
fests much  improvement  on  any  old  one"  (p.  67).  He  looks 
npon  it  as  a  modification  of  the  bilateral  with  the  incisions 
placed  further  back,  with  the  design  of  leaving  the  bulb  un- 
touched. 

In  the  few  cases  in  which  this  method  has  been  followed  in 
this  country,  the  results,  we  believe,  have  not  been  satisfactory. 

In  children  "the  lateral  operation  is  generally, and, no  doubt, 
correctly,  held  to  maintain  its  superiority,  as  a  rule,  over  other 
methods,"  though  the  median  and  medio-bilateral  are  both  ad- 
missible. "  But,  especially  where  the  stone  is  large,  the  lateral 
operation  affords  the  opportunity  of  making  a  freer  opening,  and 
in  a  direction  in  which  the  incision  is  less  liable  than  that  of  the 
median  to  injure  the  seminal  ducts  "  (p.  69).  The  author  re- 
commends the  employment  of  one  knife  only,  to  obviate  the 
difficulty  of  placing  the  beak  of  a  second  knife  in  the  exact 
opening  made  by  the  first.  The  deep  incision  should  be  made 
with  clearness  and  decision,  and  with  sufficient  freedom  to  admit 
the  tip  of  the  operator's  finger  with  tolerable  ease,  otherwise  he 
may  drive  the  neck  of  the  bladder  along  the  staff,  or  slide  the 
finger  into  the  cellular  interval  between  the  bladder  and  rectum. 
In  the  performance  of  the  median  operation  in  children.  Sir 
Henry  uses  a  tapering,  blunt  gorget,  with  a  probe  point,  to  pass 
into  the  median  groove  of  the  staff. 

Of  the  two  or  three  modes  of  performing  the  high  or  supra- 
pubic operation,  the  author  prefers  that  practised  by  Civiale, 
done  by  the  aid  of  the  "  sonde  a  dard  "  passed  into  the  bladder ; 
a  curved  and  probe-pointed  "  apotieurotome''^  to  divide  the 
lineaalba;  and  the  blunt-hooked  gorget,  "  or  ^or^ere^  suspen- 
seur^  to  hold  the  fundus  of  the  bladder  in  its  place  after  it  is 
opened,  and  to  protect  the  peritoneum,  upon  which  its  laterally 
convex  surface  is  laid,  during  the  extraction  of  the  stone  along 
its  concave  surface. 

Chapter  V  treats  of  the  very  important  subject  of  The  Causes 
of  Death  following  Lithotomy.  In  doing  so,  the  author  states 
that  it  has  been  the  custom  to  re^jard  the  fatal  contingencies  of 


104  Reviews.  [Jan., 

all  ages  in  the  mass  without  making  distinction  between  adult 
cases  and  those  of  children ;  and  he  remarks  with  great  justice 
that  "  nothing  can  be  more  deceptive  than  a  method  of  dealing 
with  the  results  of  lithotomy,  whether  numerically  or  otherwise, 
by  which  cases  of  all  ages  are  treated  indiscriminately  in  one 
category  "  (p.  76). 

We  were  certainly  under  the  impression  that  this  distinction 
had  been  for  years  almost  universally  understood  among  lithoto- 
mists,  but  would  not  venture  to  gainsay  positively  the  assump- 
tion implied  by  the  author  that  such  a  tacit  understanding,  if  it 
existed  at  all,  was  first  by  him  declared,  "  in  taking  views  of 
the  question  which  differ  somewhat  from  those  generally  held 
respecting  it." 

In  adults  he  places  first  among  the  causes  of  death,  as  the 
most  frequent,  "  inflammation  of  the  tissues,  especially  of  the 
loose  cellular  tissue  around  the  neck,  base,  and  sides  of  the 
bladder,  always  of  a  destructive  character,  and  generally  with  a 
tendency  to  extend  to  the  neighbouring  peritoneum.  This  is 
caused  by  mechanical  violence,  by  want  of  reparative  power, 
from  erysipelas,  and  some  have  supposed  by  urinary  infiltration 
through  the  deep  incisions. 

He  states  (page  77),  "  The  great  majority  of  authors  affirm 
that  infiltration  of  urine  is  the  most  common  cause  of  death,  a 
statement  that  I  venture  not  only  to  call  in  question,  but  to  re- 
gard as  the  source  of  serious  error  in  practice."  This  error,  he 
goes  on  to  show,  is  that  of  making  the  deep  incision  extremely 
limited,  and  not  beyond  the  limit  of  the  prostate  in  any  direc- 
tion, so  as  to  prevent  the  possibility  of  urinary  infiltration  into 
the  post-prostatic  areolar  tissue.  The  consequence  which  has 
resulted  is  the  tendency  in  the  present  day  to  incur  the  danger 
which  attends  an  attempt  to  drag  the  calculus  through  an  open- 
ing of  insufficient  size.  What  the  author  terms  "  the  purely 
anatomical  view  now  in  the  ascendant,"  of  limiting  the  incisions 
to  a  safe  topographical  area,  has,  in  his  opinion,  led  to  "  the 
vital  attributes  and  dispositions  of  .the  organs  involved  "  not 
being  sufficiently  regarded,  and  hence  the  no  less  dangerous 
injury  which  results  from  violence  inflicted  by  the  forceps  and 
stone  upon  the  neck  of  the  bladder,  and  from  powerful  traction 
upon  it,  which  often  irreparably  damages  the  loose,  delicate, 
cellular  connections  permitting  of  the  varying  conditions  of  size 
required  by  its  function  as  a  reservoir  of  urine. 

He  proceeds  to  say,  however  (page  79),  "  Let  it  not  be  ima- 
gined from  these  remarks  that  any  one  can  deprecate  more 
strongly  than  myself  the  making  of  an  incision  in  the  prostate 
more  deeply  than  the  size  of  the  stone  demands,  but  I  am  very 
certain  that  it  is  safer  to  extend  the  incision  when  the  stone 


1872.1  Practical  Lithotomy  and  Lithoirity.  105 

cannot  be  extracted  without  exerting  violence,  than  to  inflict  the 
injury  which  such  a  proceeding  necessarily  involves." 

He  considers  that  the  advocacy  of  small  incisions  by  Scarpa 
and  Sir  B.  Brodie  as  the  sole  or  chief  means  of  preventing  infil- 
tration, has  greatly  influenced  professional  opinion  on  this  sub- 
ject ;  and  he  quotes  from  the  writings  of  Martineau,  who  cut 
eighty-four  cases  consecutively  (including  many  children)  with 
only  two  deaths  (but  who  was  afterwards  much  less  fortunate), 
and  of  Cheselden  himself — their  approval  of  the  practice  of  en- 
larging the  opening  by  the  secondary  use  of  the  knife,  guided 
by  the  blades  of  the  forceps,  rather  than  that  of  using  undue 
violence  in  extracting.  The  latter  eminent  lithotomist,  however, 
also  recorded  his  appreciation  of  the  susceptibility  of  the  neck 
of  tlie  bladder  to  great  dilatation,  which  may  be  safely  accom- 
plished if  not  done  too  rapidly  and  forcibly.  And  hereupon  Sir 
Henry  alludes  in  forcible  but  just  terms  to  the  contemptible 
vanity  felt  by  some  operators  of  achieving  a  rapid  operation  in 
the  eyes  of  the  bystanders,  and  thus  producing  rupture  and  not 
dilatation. 

He  further  observes :  "  I  am  strongly  inclined  to  think  that 
in  many  hands  the  forceps,  and  not  the  knife,  is  the  most 
deadly  instrument  employed  in  lithotomy  ;^'  and  he  fortifies  his 
position  by  quoting  from  Pouteau,  who  wrote  a  century  ago  to 
Frenchmen,  "I  am  persuaded  that  the  thoughtless  anxiety  to 
acquire  this  false  glory,  that  the  public  attaches  to  rapidity 
in  operating,  has  killed  more  patients  than  any  other  evil 
manoeuvre." 

Keith,  of  Aberdeen,  and  Humphry,  of  Cambridge,  both  suc- 
cessful operators,  add  testimony  in  these  pages  to  the  import- 
ance of  employing  sufficient  time  and  gentleness  in  extracting 
the  stone,  and  Sir  Henry  shrewdly  remarks  that,  while  operators 
are  apt  to  attribute  success  almost  entirely  to  various  peculiari- 
ties of  the  instruments  or  methods  used,  "  one  and  all  agree  in 
the  vital  importance  of  extracting  the  stone  with  great  care  and 
gentleness,  and  of  giving  time  in  abundance  to  this  part  of  the 
operation."  It  must  always  be  borne  in  mind,  however,  that 
the  degree  of  force  used  by  the  operator  in  extracting  depends, 
not  so  much  upon  the  opinions  they  express  in  recording  their 
accomplishments,  as  upon  the  nature  and  degree  of  the  resist- 
ance offered  to  extraction,  and  upon  their  accurate  perception, 
and  perhaps,  somewhat,  upon  their  actual  possession  of  the 
wrist  and  arm  power  which  they  may  be  tempted,  almost  un- 
consciously to  themselves,  and  still  more  to  the  spectators,  to 
put  forth  in  any  individual  case.  The  varying  relations  of  the 
size,  shape,  and  character  of  the  stone  to  the  age  and  develop- 
ment of  the  patient^  and  the  form  and  direction  of  the  incision, 


106  Reviews.  [Jan., 

as  well  as  of  the  extracting  forceps,  make,  with  the  coolness, 
temper,  and  power  of  the  surgeon,  a  complete  problem  of  forces 
which  vary  in  their  effects  upon  the  implicated  viscera  with  each 
individual  case  ;  while  the  recuperative  power  of  the  patient,  and 
his  greater  or  less  tolerance  of  violence,  add  still  further  to  the 
uncertainty  which  hangs  over  the  ultimate  result  in  all  cases  of 
lithotomy. 

The  cause  of  death  placed  by  the  author  next  in  order  is 
rapidly  spreading  inflammation  produced  by  urinary  infiltration 
into  the  cellular  interspaces  between  the  pelvic  viscera,  Avhen 
they  liave  been  opened  up  by  too  deep  incisions.  Here  we  have 
the  Charybdis  of  the  foregoing  Scylla.  But,  says  Sir  Henry, 
this  occurs  less  frequently  than  is  usually  supposed.  The 
broken-up  cellular  connections,  the  sloughs  bathed  in  seropuru- 
lent  and  urinous  fluid,  and  the  peritonitis  which  have  been 
found  after  extraction  of  a  large  stone,  are  due,  he  thinks,  in 
most  cases,  primarily  to  inflammation  leading  to  urinary  extra- 
vasation, and  not  to  these  phenomena  occurring  in  the  reverse 
order.  Infiltration,  he  argues,  by  no  means  necessarily  occurs 
when  urine  passes  over  newly  made  sections  of  so-called  cellular 
spaces,  which  really  do  not  exist  except  when  made  by  the 
operator;  and  he  asks,  "How,  if  it  were  a  fact  that  these  cellu- 
lar interspaces  could  not  be  cut  (in  lithotomy)  without  the 
gravest  risk  to  life,  could  forty  or  fifty  cases  have  been  operated 
on  without  a  single  casualty?"  We  find,  however,  tliat  in  his 
able  advocacy  of  '^  a  doctrine  which  he  supposes  to  be  opposed 
to  the  generally  received  notions  on  this  subject,"  Sir  Henry 
has  entirely  omitted  to  take  into  consideration  the  influence  of 
the  levator  ani  in  obstructing  the  free  escape  of  urine  from  the 
bladder  to  the  surface  of  the  wound,  as  well  as  that  of  the  posi- 
tion in  which  the  patient  reclines  after  operation,  in  directing 
the  flow. 

If  the  sub-prostatic  portion  of  the  levator  ani  be  cut  at  all  by 
the  incisions,  and  is  not  cut  freely  enough,  it  is  evident  that  by 
its  subsequent  involuntary  and  sustained  contraction  under  irri- 
tation for  the  few  days  after  the  operation,  the  urine  will  be 
prevented  from  passing  freely  out  of  the  wound,  and  will  be 
directed  above  the  muscle  towards  the  dangerous  proximity  of 
the  peritoneum  through  the  deep  pelvic  fascia,  a  direction  down- 
wards and  backwards,  towards  which  it  has  already  a  tendency 
from  the  action  of  gravity.  It  is  well  known  that  the  smallest 
obstacle  has  a  tendency  to  effect  the  most  important  changes  in 
the  course  of  fluids  of  all  kinds. 

If,  during  the  section,  the  muscle  be  much  relaxed  (as  may 
well  happen  under  chloroform),  it  is,  like  all  muscles,  apt  to 
yield  undivided  before  the  edge  of  the  knife,  and  so  it  may  easily 


1872.]  Practical  Lithotomy  and  Lithotrity,  107 

happen  that  it  is  not  cut  to  nearly  the  same  extent  as  the  more 
resisting  prostate  and  its  fascia ;  its  subsequent  contraction  after 
the  operation  then  leads  to  all  the  mischief.  But  if  the  capsule  of 
the  prostate  is  not  divided  at  all  posteriorly, its  firm,  close-grained, 
and  resisting  texture  prevents  the  flow  of  urine  in  this  dangerous 
direction,  and  turns  it  forward  through  the  anterior  opening  of 
the  levator  into  the  wound.  The  deduction  which  obviously 
offers  itself  to  us  through  these  considerations  is,  that  if  the 
levator  ani  be  cut  at  all  it  ought  to  be  cut  freely,  but  that  an 
operation  certainly  may  be  done  in  Avhich  neither  it  nor  the 
posterior  part  of  the  prostatic  capsule  are  cut  at  all.  The  latter 
Idnd  of  operation  would  include  all  the  median  and  the  more 
limited  of  the  lateral  operations,  which  are  combined  with  dila- 
tation of  the  prostate,  and  the  former  the  free  lateral  and  bilate- 
ral operations.  Another  obvious  inference  seems  to  be  that  the 
former  class  of  operations  is  adapted  for  the  smaller  stones  in 
the  adult,  and  the  latter  for  the  larger.  And  here  we  have 
again  an  important  practical  classification  of  these  operations. 
On  the  other  hand,  the  greater  advantages  of  lithotrity  in  case 
of  small  stones  will,  in  future,  lessen  very  much  the  relative 
importance  of  that  cutting  operation  which  is  in  the  adult 
proper  for  small  stones  only.  With  respect  to  the  argument 
drawn  by  the  author  from  the  significant  fact  of  the  rarity  of 
the  bad  consequences  of  urinary  infiltration  in  children,  he  docs 
not  seem  fully  to  have  appreciated  the  bearing  of  the  milder 
and  less  irritating  character  of  the  urine  in  them,  and  the  fact 
that  the  levator  ani,  from  the  smaller  size  of  its  anterior  open- 
ing, and  its  relative  direction  from  the  obliquity  of  the  pelvis,  is 
unavoidably  cut  freely  in  the  lateral  operation. 

In  the  cause  of  death  placjed  third  in  ordei,  we  have  pelvic 
cellulitis  from  erysipelas,  and  unhealthy  inflammation  in  a  weak 
subject.  We  find,  then,  under  another  numeral  division,  in- 
flammation of  the  mucous  membrane  of  the  bladder  and  kidneys, 
the  latter  ushered  in  by  rigors,  leading  to  suppression  of  urine, 
and  terminating  in  death  within  a  few  days  or  hours.  From 
simple  cystitis  the  author  traces  the  occurrence  of  that  gradual 
and  insidious  form  of  peritonitis  which  affords  the  very  few 
examples  of  recovery  which  do  take  place  after  peritonitis. 

Phlebitis  and  pyscmia  are  placed  low  in  the  list  of  frequency- 
after  lithotomy  in  this  country,  but  it  is  found  to  be  in  Bengal, 
we  believe,  one  of  the  most  frequent  causes  of  death  after 
lithotomy. 

Shock,  as  distinguished  from  rapidly  fatal  cases  of  blood 
poisoning  and  hsemorrhagic  exhaustion,  is  a  rare  result.  Hae- 
morrhage (secondary)  and  exhaustion  (as  most  frequently 
caused  by  bleeding)  are  coupled  together  ;  and  tetanus  is  placed 


108  Reviews.  [Jan._, 

the   eighth  and  last  of  the  causes  of  death  after  lithotomy  in 
adults. 

The  most  frequent  cause  of  death  in  children  is  considered  by- 
Sir  Henry  Thompson  to  be  peritonitis,  which  he  explained  as 
the  consequence  of  the  bladder  being  more  an  abdominal  than  a 
pelvic  organ,  and  more  completely  and  intimately  invested  by 
the  peritoneum. 

The  peritonitis  is  not  usually  induced,  as  in  the  adult,  by 
extension  through  the  cellular  tissue  at  the  neck  of  the  bladder, 
but  is  the  direct  consequence  of  undue  manipulation  of  instru- 
ments in  the  bladder  itself.  Crosse,  and  Fletcher,  of  Gloucester, 
both  give  instances  of  such  fatal  results  by  the  prolonged  use  of 
a  sound  only  searching  for  stone. 

From  this  it  results  that  lithotomy  is  not  so  successful  during 
the  first  three  or  four  years  as  between  six  and  ten  years  of  age. 

Among  the  difficulties  which  are  peculiar  to  the  age  of  the 
patient  treated  of  in  Chapter  VI  (page  99),  are  those  which 
arise  from  the  soft,  yielding,  and  lax  tissues  which  form  and 
connect  the  pelvic  structures. 

The  staff  is  liable  to  be  pushed  out  of  the  urethra  between 
the  bladder  and  rectum,  if  not  carefully  directed  along  the 
sharper  upward  curve  which  the  urethra  takes  in  children 
behind  the  triangular  ligament.  The  only  absolute  safeguard 
against  cutting  for  stone  upon  a  staff  which  has  not  reached  the 
bladder  at  all  known  to  the  author  "  is  to  require  clear,  audible, 
or  tactile  proof  of  contact  between  the  stone  and  the  staff  on 
which  the  patient  is  to  be  cut."  He  explains  that  the  stone 
may  be  found  with  a  sound,  and  then,  directly  afterwards, 
altogether  missed  by  the  staff  in  consequence  of  the  different 
shape  of  the  instrument  (p.  100).  Another  difficulty  is  the 
facility  with  which  the  membranous  urethra  may  be  separated 
from  the  prostate  in  children  in  an  attempt  to  dilate  with  the 
finger,  or  in  consequence  of  repeated  cuts  or  notches  made  in 
the  attempt  to  pass  the  knife  into  the  groove  of  the  staff,  as 
pointed  out  by  Sir  W.  Fergusson. 

Rigidity  of  the  neck  of  the  bladder  and  enlargement  of  the 
prostate  are  difficulties  found  at  the  other  extreme  of  life.  To 
meet  the  former,  a  second  cut  is  recommended  by  the  author 
(following  the  practice  of  the  late  Mr.  Liston)  on  the  opposite 
side  or  lobe  of  the  prostate.  The  latter  difficulty  he  is  not  dis- 
posed to  rank  high  in  the  scale  either  of  difficulty  or  danger, 
since  deep  incisions  into  an  enlarged  prostate,  or  even  removal 
of  a  considerable  portion  of  its  substance,  are  almost  compara- 
tively free  from  danger.  He  recommends  the  gorget  as  a  safe 
and  efficient  instrument  for  extending  the  deep  incision  in  such 
cases,  because  it  forms  a  guide  to  the  forceps,  and  keeps  out  of 
the  way  of  extraction  any  projecting  lobes  or  tumours. 


1872.]  Practical  Lithotomy  and  Lithotrity,  109 

The  difficulties  arising  from  a  deep  perineum,  caused  by  the 
bony  formation  of  the  pelvis,  or  the  superficial  deposit  of  fat, 
and  those  from  a  narrow,  deformed,  and  ricketty  pelvis,  are 
briefly  dismissed;  while  those  from  unusual  distribution  of 
arteries,  as  the  accessory  pudix,  lying  close  to  the  side  of  the 
prostate,  and  others,  receive  little  more  than  a  bare  mention. 

The  third  class  of  difficulties  are  those  which  depend  upon 
peculiarities  of  the  stone,  or  its  relations  to  the  bladder  itself. 
Notwithstanding  the  usual  acceptance  of  the  dictum  of  Crosse, 
of  Norwich,  that  after  moderate  dimensions  are  exceeded, 
danger  and  difficulty  in  extraction  are  in  proportion  to  the  size 
of  the  stone,  ^.  e.,  to  the  extent  of  the  incisions  and  the  force 
employed,  the  lateral  operation  in  Crichton's  practice  showed 
remarkable  success  in  such  cases.  Out  of  eleven  cases  of  stone 
weighing  four  ounces  and  upwards  to  eight  or  nine  ounces,  all 
in  elderly  and  aged  men,  only  two  died.  His  method  was 
marked  by  freedom  of  incision  and  care  in  extraction.  In  two 
cases  only  was  the  stone  broken  up  during  extraction. 

The  author  gives  woodcuts  of  three  instruments  for  crushing 
and  breaking  up  large  calculi  after  lithotomy,  and  states  that  he 
has  been  impressed  in  witnessing  their  use,  1st,  with  the 
liability  to  injure  the  bladder  in  the  requisite  manipulation 
and  2nd,  in  the  removal  of  the  numerous  angular  fragments ; 
3rd,  with  the  danger  of  leaving  a  small  fragment  in  the  bladder 
unless  carefully  washed  out. 

He  considers  that  in  a  case  where  there  were  two  stones 
locked  together,  each  very  large,  weighing  together  12J  ounces, 
the  bladder  habitually  contracted  upon  them,  and  the  urine 
trickling  off  continually,  the  recto-vesical  operation  would  have 
given  the  best  chance  of  success,  as  permitting  the  largest 
opening  with  the  smallest  amount  of  risk. 

Among  the  unusual  examples  of  encysted  calculi  given  in  the 
book  is  one  of  a  very  remarkable  character  in  a  man  aged  fifty- 
one  years,  operated  on  four  times  by  Dr.  Humphry,  of  Cam- 
bridge, before  the  encysted  condition  of  .one  of  the  stones  was 
clearly  made  out.  The  recto-vesical  operation  finally  enabled 
Dr.  Humphry  to  reach  the  cyst,  which  was  just  above  the 
entrance  of  the  right  ureter ;  and,  by  opening  the  sac  with  a 
hernia  knife,  to  extract  a  stone  about  the  size  of  a  walnut. 
Death  unfortunately  occurred  two  days  after,  from  peritonitis. 
In  a  second  case  of  the  same  unusual  character.  Dr.  Humphry 
emptied  the  cyst  of  a  softish  material  with  a  scoop,  and  the 
patient  recovered.  One  other  encysted  stone  was  successfully 
removed  by  Cadge,  of  Norwich,  two  by  Crichton,  and  one  by 
Lawson.     One  case  was  operated  on  by  the  author,  in  a  gentle- 


llO  lieviews.  [Jan., 

man  aged  seventy-four  years,  who  died  one  month  after  the 
removal  of  numerous  phosphatic  fragments  and  an  unsuccessful 
attempt  to  remove  an  encysted  uric  acid  stone  (p.  121). 

In  Sir  Henry's  opinion,  the  spasmodic  or  hour-glass  con- 
striction of  the  bladder,  mentioned  by  Louth,  Brodie,  and 
Gross,  is  exceedingly  rare.  He  alludes,  however,  to  an  example 
of  this  condition  in  the  museum  of  the  Royal  College  of 
Surgeons,  in  which  a  stone  is  lodged  above  the  pubis  and  held 
there  by  this  peculiarity  in  the  form  of  the  viscus,  in  such  a 
way  that  it  could  not  possibly  have  been  removed  by  perineal 
lithotomy. 

Three  well-authenticated  cases  of  adhesion  of  the  stone  to 
the  vesical  mucous  membrane,  and  incorporation  of  some  fibres 
of  the  latter  in  its  substance,  are  given  by  him  from  the  practice 
of  Messrs.  Nunn,  Van  der  Byl,  and  Henry,  of  the  Middlesex 
Hospital. 

Wound  of  the  rectum  accidentally  in  the  operation  is  not 
uncommon,  and  does  not,  even  when  large,  in  Sir  Henry's 
opinion  (coinciding  with  that  of  the  best  authorities),  necessitate 
the  immediate  division  of  the  sphincter  ani,  recommended  by 
some.  It  had  best  be  left  alone,  and  treated  afterwards,  if 
necessary,  as  a  recto-vesical  fistula. 

Removal  of  a  portion  of  an  enlarged  prostate  during  litho- 
tomy has  been  effected  by  Dr.  Keith  nine  or  ten  times,  as  well 
as  by  Key  and  Civiale,  and  no  bad  results  have  ensued  beyond 
a  little  delay  in  healing  in  some  cases.  On  the  other  hand,  it 
has  often  benefited  the  patient.  In  effecting  it.  Sir  Henry 
recommends  the  use  of  probe-pointed  scissors  rather  than  the 
knife  or  by  tearing. 

In  the  cases  in  which,  by  an  oversight  of  the  operator, 
fragments  or  whole  stones  have  been  left  in  the  bladder,  he 
recommends,  if  they  are  small,  the  use  of  the  lithotrite ;  if  large, 
redilatation  of  the  wound.  In  those  in  which  phosphatic  in- 
crustation of  the  Avound  proves  very  troublesome,  the  use  of  an 
acidulated  wash  with,  hip  bath,  seconded,  if  necessary,  by  the 
employment  of  the  forceps  or  scoop. 

In  dealing  with  the  perineal  fistula,  which  occasionally 
remains  after  lithotomy,  the  author  considers  that  the  plan  of 
keeping  a  catheter  tied  in  the  urethra  is  not  successful,  in  con- 
sequence of  the  urine  invariably  making  its  way  by  the  side  of 
the  instrument,  and  the  purulent  discharge  which  is  excited  by 
its  irritation.  He  prefers  to  pass  a  catheter  each  time  the 
patient  needs  it. 

Sexual  impotence  after  lithotomy,  which  rarely  occurs,  and 
has  been  attributed  to  division  of  the  seminal  duct.  Sir  Henry 
considers  to  be  rather  caused  by  inflammatory  plastic  affusion 


I 


1872.]  Practical  Lithotomy  and  Liihotrity.  Ill 

in  the  prostate  and  its  appendages,  or  from  sloughing,  brought 
on  by  violent  extraction. 

Incontinence  of  urine  happens  more  frequently  in  cases 
under  the  age  of  puberty,  and  often  no  clear  explanation  of  its 
cause  can  be  given.  One  case,  following  the  extraction  of  a 
large  stone,  was  cured  by  the  author  by  cauterisation  of  the  neck 
of  the  bladder. 

An  unfortunate  accident  which  occasionally  occurs,  viz., 
inability  to  find  a  stone  in  the  bladder  when  the  incisions  are 
made,  may  result  from  a  small  stone  being  washed  out  of  the 
wound  by  the  gush  of  urine.  This,  the  author  judiciously 
remarks,  ought  not  to  happen,  because  so  small  a  stone  ought  to 
be  crushed,  and  not  cut  for.  Sacculated  bladder  and  cysts 
account  for  some  of  these  cases. 

In  others^  no  stone  has  ever  existed  ;  polypoid  growths, 
phosphatic  encrustations,  hardened  and  rugose  vesical  walls, 
and  even  the  brim  of  the  pelvis  or  spine  of  the  ischium,  have 
given  rise,  when  struck  by  the  sound,  to  the  sensation  of  a 
foreign  body  or  rough  stone.  Such  cases  have  been  recorded 
with  praiseworthy  candour  by  Paget,  of  Leicester,  and  Gutter- 
idge,  of  Birmingham.  Sir  Henry  Thompson  is  of  opinion,  after 
several  experiments,  that  such  sounds  or  sensations  are  not  at 
all  comparable  with  the  click  or  note  elicited  upon  the  sound  by 
any  calculus  which  he  himself  ever  encountered  in  the 
bladder.  We  suppose  that  he  does  not  intend  to  include  in  this 
remark  cases  of  real  phosphatic  incrustation. 

Besults  of  litJiotomy. — Chapter  VII.  The  more  prevailing 
use  of  lithotrity  in  modern  days  has  modified  very  much  the 
statistical  results  of  lithotomy  in  the  more  grave  and  severe 
cases  to  which,  in  adults,  it  is  now  restricted. 

With  much  perseverance,  labour,  and  diligence,  the  author  has 
collected  nearly  2000  cases,  the  authenticity  and  conditions  of 
which  rendered  them,  in  his  opinion,  fair  cases  for  argumenta- 
tive deduction. 

The  most  favorable  results  (with  all  cases  taken  together, 
young  and  old)  are  those  from  the  records  of  Addenbrooke's 
Hospital,  Cambridge,  viz.  183  cases  with  13  deaths,  or  about  1 
in  14.  Next  comes  the  Leicester  Infirmary,  90  cases  with  8 
deaths,  or  about  1  in  11.  Then  the  Birmingham  Hospital,  102 
cases  with  10  deaths,  or  about  1  in  10.  The  hospitals  at 
Norwich  and  Oxford  yield  about  1  in  8J  to  1  in  8,  while  the 
London  and  Leeds  hospitals  average  from  1  in  7  to  1  in  7^. 

The  author  points  out,  how^ever,  that  the  proportion  of  chil- 
dren in  the  Norwich  and  Cambridge  hospitals  is  rather  higher 
than  the  average,  implying  some  explanation  of  their  better 
results ;  while,  on  the  other  hand,  Guy's  Hospital  has  also  an 


112  Reviews.  [Jan., 

unusually  large  proportion  of  young  cases,  and  yet  the  results 
were  1  in  7.  He  then  tabulates  the  cases  which  he  has  col- 
lected, in  groups  of  years,  according  to  the  age  of  the  patient 
operated  on  (p.  1412),  and  obtains  thus  the  result  that  out  of 
377  cases  between  the  ages  of  six  and  eleven  years  (inclusive), 
the  deaths  were  only  16,  or  about  1  in  23  J  ;  while  of  473  cases 
aged  between  one  and  five  years,  the  deaths  were  ZS,  or  1  in 
14^-  cases;  at  between  the  ages  of  seventeen  and  twenty  (inclu- 
sive), the  death  rate  rises  to  1  in  7,  indicating  the  increased 
susceptibility  of  the  generative  and  urinary  organs  attending 
upon  the  development  of  puberty.  The  next  favorable  death 
rate  is  between  the  ages  of  thirty  and  thirty-eight,  viz.  1  in  10^; 
then  from  twelve  to  sixteen,  1  in  9^ ;  while  the  most  fatal,  as 
might  have  been  expected,  is  in  extreme  old  age,  seventy-one  to 
eighty-one,  viz.  1  in  3^;. 

The  great  group  of  infancy  and  boyhood  up  to  puberty  at 
sixteen  years,  comprising  more  than  half  the  entire  number  of 
cases,  shows  a  total  mortality  of  1  in  15i,  while  that  which  is 
taken  from  all  ages  after  this  important  vital  change  gives  a 
mean  proportion  of  one  death  in  every  five  cases  ;  a  very  striking 
difference,  to  the  disadvantage  of  adult  years,  in  this  operation. 

Sir  Henry  anticipates,  in  the  future,  even  a  larger  proportion 
of  fatal  cases  in  adult  lithotomy,  from  the  selection  of  all  the 
more  favorable  cases  and  smaller  calculi  for  the  less  dangerous 
operation  of  crushing.  Lithotomy  will  be  performed  on  selected 
bad  cases,  while  lithotrity  will  at  the  same  time  become  respon- 
sible for  some  difficult  and  unhealthy  cases,  and  will  have  a 
higher  death  rate  per  cent,  than  at  present ;  but  that  a  more 
favorable  sum  total  of  stone  cases  will  be  the  effect  of  a  more 
prevalent  recourse  to  crushing. 

From  Allerton's  record  of  cases  treated  by  the  median  opera- 
tion, the  author  calculates  the  mortality  at  1  in  11  cases  at  all 
ages;  but  he  considers  that  this  operation,  being  reserved 
usually  for  stones  known  or  believed  not  to  be  large,  should 
yield  a  better  result  than  lateral  lithotomy. 

He  states  that  his  own  experience  of  the  median  method  is 
not  favorable,  troublesome  bleeding  often  occurring,  and  the 
rectum  being  easily  wounded,  either  by  the  knife  or  tearing  in 
extraction.  On  these  grounds  (which,  we  must  observe,  are 
scarcely  sufficient)  he  has  discarded  it  entirely  for  the  lateral 
operation. 

The  death  rate  of  the  supra-pubic  operation  is  calculated  by 
Dr.  Humphry,  of  Cambridge,  from  104  authentic  recorded  cases, 
to  be  1  in  3'. 

In  the  careful  analyses  of  cases  given  by  the  author,  one 
thing  strikes  the  reader  as  being  conspicuous  by  its  absence. 


1872.]  LoMBROSO  on  Pellagra.  113 

and  that  is  a  detailed  account  of  the  cases  of  lithotomy  operated 
on  by  himself.  This  is  the  more  remarkable  when  contrasted 
with  the  copious  and  detailed  notes  of  204  cases  of  lithotrity 
given  to  the  reader's  inspection  at  the  end  of  the  second  section 
of  the  volume  treating  of  that  subject. 

A  critical  reflection  upon  the  reasons  for  this  remarkable 
omission  has  given  occasion  for  the  expression  of  an  unfavorable 
surmise  which  we  have  heard  but  will  not  here  express ;  but 
which  Sir  Henry  would  have  done  well,  we  venture  to  suggest, 
to  have  avoided  in  the  last,  as  we  hope  he  will  do  so  in  future 
editions  of  his  valuable  work. 

That  portion  of  the  volume  which  treats  of  lithotrity  assumes, 
in  Sir  Henry's  hands,  an  interest  and  importance  which  forbid 
an  attempt  to  criticise  it  in  the  present  pages,  for  want  of  space 
to  accord  to  it  attention  commensurate  with  its  value.  We 
propose  to  refer  to  it  in  our  next  number. 


X.— Lombroso  on  Pellagral 
As  long  as  the  theory  of  Liebig  on  alimentary  matters, 
dividing  them  into  plastic  and  calorific,  was  held  irrefutable, 
and  before  the  attention  of  pathologists  was  drawn  to  the 
importance  of  chronic  zymosis  in  producing  poisons,  our  Italian 
brethren,  who  are  so  deeply  interested  in  pellagra,  were  right, 
probably,  in  assigning  the  first  place,  among  modern  etiologists 
of  the  disease,  to  Lussana.  In  view  of  the  conjectures  of  some 
speculators,  his  generality  of  attributing  it  to  insufficient  plastic 
alimentation  seemed  to  the  admirers  of  common  sense  to  come 
nearest  to  the  truth.  The  maize,  which  is  the  staple  food  of 
the  Lombard  peasantry,  was  pronounced  even  when  sound,  but 
especially  when  damaged,  to  contain  too  little  nitrogenous 
matter  for  a  labourer's  dietary  ;  and  hence  the  inference,  that 
the  proper  cure  for  pellagra  is  flesh  food  and  a  more  nutritious 
grain-stuff  than  maize.  The  obvious  imperfection  in  this 
argument  is  that,  while  insufficient  nutriment  is,  unhappily, 
very  common  in  most  lands,  and  maize  is  very  extensively  used 
in  warm  climates,  yet  pellagra,  on  the  other  hand,  is  confined 
to  a  certain  number  of  well  defined  districts  in  North  Italy. 
In  these  its  ravages  are  very  melancholy,  and  when  the  traveller, 
through  parts  where  it  is  most  developed — say  the  plains  of 
Caprino  or  Rivoli — sees  the  fields  absolutely  left  uncultivated 

^  Studi  Clinici  ed  Esperimentali  sulla  Pellagra.  Del  Dott.  Cesaee  Lombeoso. 
Memoria  Premiata  dal  R.  Istituto  Lombardo.     Bologna,  1871. 

Clinical  and  Experimental  Observations  on  the  Pellagra.  By  Dr.  C^SAR  LoM- 
BE080.  '  A  Prize  Essay  of  the  Royal  Institution  of  Lombardy.     1871. 

97— XLix.  •  8 


114  Reviews,  [Jan., 

through  the  incapacity  of  the  pellagrosed  inhabitants,  he  feels 
that  the  root  of  the  evil  has  yet  to  be  struck.  And  he  will  hail 
with  peculiar  pleasure  the  direction  to  this  object  of  the  newest 
means  of  investigation  possessed  by  science.  In  answer  to  a 
prize,  offered  by  the  Royal  Institution  of  Lombardy,  Dr.  Lorn- 
broso  has  aimed  at  specialising  more  accurately  the  immediate 
cause  of  the  disease,  as  distinguished  from  those  general  causes 
which  weaken  the  resisting  force  of  poor  populations,  and  make 
them  more  liable  than  the  robust  and  well-fed  to  suffer  from 
injurious  influences.  And  we  think  the  step  he  has  made  is  an 
important  one. 

Though  he  has  not  succeeded  in  absolutely  isolating  a  poison 
capable  of  producing  such  deleterious  results,  he  has  found 
evidences  of  its  existence  in  damaged  maize.  It  is  associated 
always  with  the  growth  oi penicillum  glaucum  (blue  mould)  on 
this  breadstuff,  and  with  the  consequent  or  antecedent  fermen- 
tation thereof;  it  is  capable  of  solution  in  alcohol  and  water, 
resists  the  destructive  agencies  of  cooking  heat,  and  of  panifi- 
cation,  and  is  rendered  inert,  as  far  as  experimented  upon,  only 
by  boiling  with  quick  lime.  The  penicillum  glaucum  is,  however, 
not  itself  the  poison  ;  for,  when  grown  on  other  substances,  it 
seems  to  be  practically  innocuous.  This  poison,  experimented 
upon  in  its  alcoholic  solution,  produced,  when  administered  to 
well-fed  persons  for  a  short  period,  eructation,  pyrosis,  languor, 
sleepiness,  diarrhoea,  nausea,  unnatural  appetite,  thirst,  lumbar 
pain,  sweating,  giddiness,  itching  of  the  skin.  In  less  well-fed 
individuals  the  symptoms  Avere  more  certainly  produced,  and 
were  more  severe.  The  above  named  were  intensified,  especially 
the  cutaneous  symptoms ;  there  was  discoloration,  burning, 
and  desquamation.  The  nervous  phenomena  were  serious ; 
there  was  dilatation  of  the  pupil,  ptosis,  giddiness,  irritability 
with  loss  of  affection,  and  hysterical  crying.  There  was  also 
exhibited  in  some  of  them  that  strange  desire  for  plunging  into 
water  (hydromania),  which  so  often  characterises  cases  of 
pellagra.  These  symptoms  were  brought  on  sometimes  after 
four  doses,  sometimes  not  till  after  sixteen  doses,  but  were  absent 
in  about  one  sixth  of  the  subjects  experimented  upon.  The 
same  damaged  maize,  when  given  for  still  longer  periods  to 
chickens,  brought  on  emaciation,  loss  of  plumage,  rejection  of 
food,  diarrhoea,  langour,  and  death ;  iu  rats,  emaciation,  red- 
dening of  the  skin,  muscular  spasms,  choreic  movements,  and 
death.  The  poison  is  thus  shown  to  be  of  the  nature  of  common 
poisons,  and  not  to  have  the  power  of  zymosis  or  reproduction, 
like  morbid  infections ;  it  acts  in  proportion  to  its  dose  and  to 
the  length  of  continuance,  and  produces  a  different  series  of 
phenomena  in  different  individuals. 


1872.]  LoMBROso  on  Pellagra.  115 

Now  this  is  just  what  happens  in  pellagra ;  short  or  partial 
exposure  to  the  exciting  causes  (as  in  the  case  of  temporary- 
residents)  does  not  induce  it;  different  persons  suffer  in  different 
ways ;  even  different  localities  suffer  in  different  ways  ;  thus,  in 
the  district  of  Verona,  anomalies  of  the  pupil,  lumbar  pain,  and 
affections  of  the  capillaries  of  the  skin  are  most  frequent,  while 
maniacal  and  scorbutic  complications  are  rare.  In  the  Milanese, 
on  the  other  hand  (in  whose  magnificent  hospital  strangers  have 
commonly  been  introduced  to  pellagra),  the  epileptic  and 
idiotic  forms  are  those  most  usually  seen.  In  Pavia,  con- 
tractions of  the  limbs  ;  at  Trent,  albuminuria  and  consumption  ; 
at  Reggio,  scurvy  ;  in  Tuscany,  pterigium.  In  almost  all,  how- 
ever, there  is  exhibited  that  singular  union  of  a  cutaneous 
disease  with  deficiency  of  nervous  power,  which  is  characteristic 
of  pellagra.  The  cutaneous  symptoms  sometimes  take  the  form 
of  eczema  or  herpes,  but  more  usually  consist  of  a  darkening 
of  the  skin  of  the  whole  body.  In  this  variety  of  symptoms,  with 
a  general  pathological  relation  to  one  another,  the  resemblance 
of  the  disease  to  the  experimental  poisoning  is  obvious.  Exact 
proof  of  identity  could  only  be  had  by  using  unjustifiable  tests; 
but  as  evidence  is  gained  of  a  poison  which  will  produce 
somewhat  similar  phenomena,  and  that  poison  can  be  shown  to 
be  especially  widely  diffused  in  places  where  pellagra  is  preva- 
lent, the  argument  is  sufficiently  complete  to  sanction  its  present 
acceptance  and  justify  deductions  therefrom. 

Dr.  Lombroso's  observations  and  experiments  both  show  that 
it  is  not  the  occasional,  but  the  habitual,  use  of  the  mouldy 
maize  which  induces  pellagra ;  and  this  is  an  answer  to  the 
question  why,  considering  the  liability  of  all  bread  stuffs  to  decay, 
the  disease  is  not  more  widely  spread.  Our  peasantry  are,  per- 
haps, supplied  oftener  than  is  right  with  musty  flour,  but  they 
do  not  prefer  it  for  the  "  nutty  ^'  flavour  of  penicillum  glaucum, 
like  some  Piedmontese  villagers.  They  are  free  also  from  the 
belief,  which  Dr.  Lombroso  found  general,  that  baking  would 
cure  flour  hoAvever  unwholesome.  Again,  in  most  sane  popula- 
tions, we  should  expect  the  farmer  to  sell,  if  possible,  his 
damaged  grain,  while  he  has  the  best  ground  for  his  own  use ; 
whereas  it  seems  that  the  Lombard  does  not  send  it  to  market, 
partly  because  it  is  of  low  value,  partly  for  fear  he  should  be 
detected  in  having  stolen  it :  and  he  does  not  give  it  to  the  fowls 
because  it  makes  them  ill — so  he  eats  it  himself!  It  really 
requires  a  special  combination  of  circumstances  to  produce  such 
a  mental  phenomenon.  These  circumstances  are,  in  the  first 
place,  the  climate,  which  is  sufficiently  warm  to  grow  maize,  but 
not  sufficiently  regular  to  ripen  it  with  certainty  as  (within  the 
tropics),  so  a  great  deal  of  the  crop  is  often  spoiled.     Then  the 


116  Reviews,  [Jan., 

Northern  Italian  is  hereditarily  a  hoarder,  and  does  not  mind 
how  hard  he  works  and  lives,  especially  the  latter,  if  he  can 
secrete  a  penny  by  it.  But,  above  all  things,  the  English 
philanthropist  will  probably  accuse  the  barbarous  custom  of 
letting  land  on  the  metaire  system,  according  to  which  the  rent 
is  paid  by  a  certain  share  of  the  crop.  A  temptation  is  offered, 
greater  than  an  avaricious  man  can  resist,  to  cut  too  soon,  and 
store  the  pilfered  grain  in  ill-ventilated  corners,  where  it  soon 
gets  musty,  and,  if  brought  out  and  confessed  to,  would  convict 
the  possessor  of  fraud.  So  he  eats  it,  and  is  poisoned  accordingly. 
Curiously  enough.  Dr.  Lombroso  does  not  see  the  unsuitability 
of  this  southern  custom  to  an  uncertain  climate ;  he  seems  to 
consider  it  the  normal  condition  of  land  tenure.  But  if,  as  he 
urges,  the  Government  is  to  take  any  action  in  arresting  the 
ravages  of  pellagra,  we  are  convinced  that  in  no  direction  could 
they  promote  beneficial  reform  so  surely  as  in  discouraging  the 
metaire  system,  and  facilitating  the  granting  of  leases.  Properly 
ripened  maize  is  such  an  economical  food  that  they  must  think 
twice  and  again  before  they  throw  any  impediments  in  the  way 
of  its  cultivation. 

The  post-mortem  appearances  in  those  who  have  died  pella- 
grose  indicate  an  atrophic  degeneration  of  all  the  soft  tissues, 
distinguished  more  than  usual  by  pigmentation.  This  is  com- 
bined with  local  hypersemia,  and  special  affections  of  the  brain 
and  heart.  The  pia  mater  is  thickened,  and  the  cardiac  muscles 
softened  and  discoloured  brown,  much  more  commonly  than  in 
an  equal  number  (sixty -six)  of  other  victims  of  chronic  disease. 

In  its  old  haunts,  pellagra  would  seem  to  have  much  increased 
during  the  present  generation.  In  Lombardy  the  numbers 
affected  were  reckoned  in  1839  as  20,282;  in  1856,  as  38,777. 
In  Venetia  it  would  seem  to  be  checked  by  the  better  condition 
of  the  inhabitants,  and  their  seafaring  habits ;  in  Bologna  by  the 
use  of  wine.  But  Dr.  Lombroso  notices  its  increase  north- 
ward at  Trent,  and  the  occurrence  southwards  of  as  many  as 
twenty-two  cases  in  the  Campagna  di  Roma — namely,  at  Pales- 
trina  and  Capranica.  He  also  points  out  that  the  mat  dehidago 
of  certain  parts  of  Spain  presents  the  same  symptoms,  apparently 
referable  to  the  same  cause  ;  and  that  in  the  barracks  of  Paris  in 
1831,  in  the  Belgian  prisons  in  1846,  in  British  India  in  1835 
(described  by  Malcolmson  of  Madras),  and  again  in  the  Crimea 
in  1855,  there  were  observed  peculiar  congestions  of  the  ex- 
tremities, associated  with  nervous  symptoms,  which  seemed 
traceable  to  damaged  breadstuffs.  So  that  every  lustrum  makes 
pellagra  more  and  more  our  business — tua  res  agitur,  cum 
proximus  ardet  TJcalegon. 


1872.1     On  Niuralgia  and  Functional  Nervous  Diaorders.    117 


XI.— On  Neuralgia  and  Functional  Nervous  Disorders.^ 
Although   two   authors  of   the   eminence  of  Dr.  Handfield 
Jones  and  Dr.  Eulenburg  have  written  books  under  the  title  of 
'  Functional  Nervous  Diseases/  yet  we  are  not  by  any  menus 
sure  that  the   title  is  a  good  one.     Nor  is  the  matter  of  title 
only  a  matter  of  taste ;  on  the  contrary,  any  haziness  in  this 
respect  is  likely  to  cloud  the  pages  which  follow  and  any  in- 
convenience in  naming  of  the  subject  will  make  itself  seen  in 
the  arrangement  of  the  subject  itself  and  in  the  manner  of  its 
treatment.      For    illustration's    sake,    let    us    apply    the    same 
kind  of  title  to  affections  of  other  parts,  for  instance,  of  the 
respiratory  system.      Should  we  be  satisfied  with  the   title  of 
functional  diseases  of  the  respiratory  system,  or  again  of  the 
abdominal  or  nutritive  system  ?    A  treatise  on  functional  diseases 
of  the  respiratory  system  would  contain  a  long  and  very  inter- 
esting chapter  on  cough,  another  on  expectoration,  another  on 
haemoptysis  and  so  forth  ;  but  should  we  not  all  perceive  that 
neither   cough,  expectoration,  nor   haemoptysis  were    diseases, 
but  were  rather  symptoms,  and  should  we  not  feel  that  to  apply 
the  name  disease  to  a  symptom  was  to  introduce  confusion  at 
the  outset  ?     Or,  to  look  at  the  matter  from  another  side,  such 
chapters  might  not  contain  an  account  of  all  coughs  and  all 
expectorations  but   only  of   such    coughs  and    such    expecto- 
rations    as   were    seen   in   'functional'    disorders,    the    word 
'functional'   being   then  used  in  the  loose] sense    of  transient 
disorders,   or   disorders    not   depending   upon    any   permanent 
lesions.      Such    an    interpretation   however   is    not    likely    to 
be    acceptable  to  either  of  the   distinguished    authors  we  have 
mentioned.     They  would  probably  say  that  they  wished  to  con- 
template   the    various    changes    in    living    phenomena   which 
primarily  depend  upon  alterations  in  the  nervous  system ;  such 
a  change  in  muscular  action,  for  instance,  as  depends  not  upon 
change    in  muscle  itself  but  upon  alterations  of   its  nervous 
supply,  and  so  forth.     But  would  not  discourses  of  this  kind  be 
better  named  if  they  were  entitled  '  Symptoms  of  Nervous  Dis- 
eases,' or  the  *  Clinical  Aspects  of  Nervous  Diseases,'  which  would 
signify  that  the  subject  was  considered  rather  from  a  clinical 
point  of  view    than  from  that   of   pathological  anatomy.     In 
truth,  however,  it  is  impossible  to  consider   the  symptoms  of 
nervous  diseases  apart  from  their  pathological  anatomy,   apart, 
that  is,  from  the  changes   of  which  they  are  the  expression. 

^  1.  Nettralgia,  and  the  Diseases  that  resemble  it.  By  F.  E.  Anstie,  M.D.,  &c. 
London  and  New  York. 

2.  Lehrhuch  d.  functionellen  NervenhranJcheiten.  Von  Dr.  Albeet  Eulen- 
BUEG.     Berlin. 


118  Reviews.  [Jan., 

Where  do  symptoms  end  and  where  does  pathological  anatomy 
begin  ?  or  where  do  the  phenomena  of  life  end  and  those  of 
physiological  anatomy  begin  ?     Take   again  our  illustration  of 
diseasesof  the  respiratory  system;  of  these,  cough  is  a  symptom, 
so  is  expectoration,  but  is  cavernous  breathing  a  symptom  or  is 
fine  crepitation  ?     Whether  these  latter  are  to  be  called  symp- 
toms or  not,  they  are  nevertheless  nothing  more  nor  less  than 
pathological  anatomy,  and  the  surgeon  who  examines  the  lungs 
or  heart  by  the  usual  physical    means  is  doing  no  less  than 
making  an  imperfect  autopsy  before  the  time.     In  affections  of 
the  skin  again  the  dermatologists  who  describe  symptoms  do 
in  the  main  describe  what  can  strictly  be  called  their  patho- 
logical anatomy.     So  by  such  arguments  we  seem  to  come  to 
this,  that  symptoms  are  changes  which  we  can  see,  and  patho- 
logical variations  are  changes  which  we  cannot  see  ;  a  distinc- 
tion which  scarcely  appears  to  be  essential.     Whether  a  certain 
change  is  to  be  called  a  symptom  or  not,   whether,  that  is.  Dr. 
Jones    or  Dr.Eulenburg   are  to  deal    with  it   or  not,   depends 
only  upon  the  degree  to  which  physical  exploration  has  been 
carried  at  the  time  of  writing ;  and,  indeed,  in  no  books  do  we 
find  a  greater  effort  to    supplement  the  seen  by  imaginative 
conceptions  of  the  unseen.     This  confusion    always  gives  us 
some    sense    of   discomfort   in    dealing   with    these    otherwise 
admirable  works.      If  any    one  will   say  that   to    demand   a 
distinction    between    diseases  and  symptoms   is    to   return    to 
ontological  conceptions  and   to  desert  the  truer  ways  of  regis- 
tering sequences,  we  would  reply  that  vagueness  is  not  a  neces- 
sary   consequence   of  the  demolition  of   symmetrical  falsities ; 
on  the  contrary  in  the  midst  of  the  bewilderment  of  ruin  we  are 
the  more  bound  to  know  exactly  what  bearings  we  have.     What 
then   do  we  mean   by  the  word  disease  ?     Without  giving  an 
exhaustive  and  short  definition  in  reply,  we  may  explain  that 
by  a  disease  we  mean  not  a  symptom  but  a  group  of  symptoms 
which  repeats  itself  with  something  like  uniformity,  both  as 
regards  the  mutual  relations  of  its  component  symptoms,  and 
as  regards  its  relation  as  a  whole  to  other  groups    occurring 
under  like  but  not  identical  conditions.     As  a  matter  of  fact, 
we  find  that  symptoms  do  group  themselves  with  consistency 
and  uniformity  in  most  or  all  instances,  as  we  find  that  the 
groups  of  phenomena  which  constitute  animal  life  group  them- 
selves uniformly,  producing  new  dogs  and  cats,  new  horses  and 
snakes  which  we  can  recognise  as  part  of  our  past  experience. 
Were  it  otherwise  we  should  find  it  almost  impossible   to  de- 
scribe human  sufferings  at  all,  and  the  body  of  English  physic 
would  only  be   a  mass  of  undigested  instances  like  the  body  of 
English  law.     It  is  clear  however  that  we  must  include   the 


1872.]    On  Neuralgia  and  Functional  Nervous  Disorders.      119 

pathological  phenomena  with  the  symptomatic,  as  a  naturalist 
must  combine  description  of  species  with  their  comparative 
anatomy ;  a  dog  is  not  merely  an  animal  having  certain  external 
relations  with  the  world  but  also  a  certain  internal  structure 
upon  which  this  outer  structure  depends  and  with  which  it  is 
in  essential  unity.  A  disease,  therefore,  is  a  collection  not  only 
of  external  phenomena  but  of  internal  phenomena  likewise, 
the  degree  in  which  these  latter  are  phenomena  to  our  senses 
depending  only  upon  our  powers  and  opportunities  of  investi- 
gation for  the  time  being. 

When  therefore  we  find  a  series  of  variations  from  the 
normal  state,  whether  these  be  deep  or  superficial,  and  if  these 
variations  tend  to  recur  in  something  like  the  same  order  in 
different  persons  we  designate  the  series  by  a  name  and  call  the 
whole  a  disease.  To  take  some  selected  members  from  such 
groups  and  to  compare  them  is  quite  justifiable,  but  as  we  do 
it  we  thereby  break  up  this  conception  of  a  disease  as  a  whole. 
For  instance,  cutaneous  anaesthesia  is  seen  both  in  locomotor 
ataxy  and  also  in  myelitis,  which  two  names  represent  each  of 
them  a  tolerably  definite  and  recurring  group  of  phenomena ; 
we  may  separate  in  our  own  minds  the  anaesthesia  from  each 
and  from  many  other  states,  and  consider  the  history  and 
modes  of  this  symptom  taken  thus  separately,  but  we  are  not 
then  describing  a  disease ;  on  the  contrary  we  have  dismem- 
bered several  diseases  to  obtain  our  subject,  just  as  to  obtain  a 
study  of  stamens  we  should  dismember  a  number  of  flowers. 
But,  the  reader  will  say,  surely  this  is  a  refinement  upon  terms 
and  upon  mere  terms,  to  which  we  answer  both  ^  yes '  and  '  no/ 
What  can,  in  the  first  place,  be  more  absolutely  necessary  for 
accurate  reasoning  than  a  minutely  precise  limitation  of  the 
meaning  of  the  words  which  we  use.  Such  precision  in  argu- 
ment is  as  necessary  as  is  the  accuracy  of  the  engraver  in  the 
currency  of  bank  notes.  If  no  two  persons  attribute  the  same 
value  to  the  tokens  which  they  use  how  can  any  definite 
understanding  be  preserved?  But  again  there  is  something 
more  than  mere  wording  in  the  matter ;  there  is  a  danger  to  the 
truth  of  the  very  conceptions  themselves,  and  it  is  this  danger 
which  at  first  led  us  to  make  these  reflections.  Dr.  Anstie  has 
made  it  quite  clear  to  us  that  a  great  deal  depends  upon  the 
term  to  be  applied  to  neuralgia,  whether  indeed  this  morbid 
change  is  to  be  called  a  disease  or  whether  it  is  to  be  called  a 
symptom  ;  for,  independently  of  the  accuracy  of  conversation,  we 
cannot  doubt  that  to  change  our  term  from  symptom  to  disease 
in  speaking  of  neuralgia  is  in  some  subtle  but  very  wide-reach- 
ing and  important  way  to  change  also  much  of  our  familiar 
thought  about  that  affection.     The  thing  itself  is  presented  to 


120  '  Reviews.  [Jan., 

our  minds  much  as  before,  but  our  conceptions  of  it  and  the 
relations  which  it  seems  to  boar  to  other  things  undergo  a 
transformation.  It  is  now  become  the  centre  of  a  group  of 
subsidiary  phenomena,  to  which  group,  as  a  whole,  the  name 
neuralgia  is  applied  ;  before,  it  was  itself  but  a  dependent  among 
other  symptoms.  The  consequences  of  regarding  ;  neuralgia  as 
an  accidental  rather  than  as  a  primary  event  are  shown  in  Dr. 
Anstie's  volume  to  have  been  unfortunate  both  from  a  nosolo- 
gical and  from  a  therapeutical  point  of  view.  Nosologists  have 
neglected  to  give  it  any  adequate  definition  and  have  allowed  it 
to  remain  confused  with  other  and  diiFerent  disorders ;  while 
therapeutists  in  like  manner,  regarding  it  as  a  symptom,  have 
preferred  to  treat  it  as  an  outlier  of  some  more  general  ailment, 
rather  than  to  direct  their  attention  to  it  as  a  main  elements 
and  connoting  other  members  of  a  uniform  group  of  changes. 
No  better  example  of  the  difference  of  the  two  points  of  view 
can  be  had  than  that  which  is  offered  by  the  two  books  before 
us.  Dr.  Eulenburg  criticises  Dr.  Anstie's  opinions  somewhat 
adversely  and  Dr.  Anstie  complains  that  he  is  misunderstood ; 
so  indeed  he  is  for  the  two  writers  approach  neuralgia  from 
different  points  of  view  ;  Dr.  Eulenburg  approaches  it  with  the 
confusion  of  mind  which  is  reflected  in  the  title  of  his  work, 
while  Dr.  Anstie,  whether  right  or  wrong,  has  taken  a  distinct 
side  in  the  matter  and  proclaims  that  neuralgia  is  a  disease  as 
angina  pectoris,  asthma,  or  epilepsy  are  diseases.  In  fact,  we 
are  reminded  of  the  position  Dr.  Russell  Reynolds  took  up  in 
his  work  on  epilepsy,  the  drift  of  which  was  and  is  that,  although 
convulsion  like  epilepsy  is  a  symptom,  yet  that  epilepsy  like  neu- 
ralgia is  a  disease,  because  it  consists  of  convulsions  occurring 
in  definite  ways  in  different  people  and  having  tolerably  con- 
stant relations  to  other  phenomena. 

A  shrewd  observer  once  said  to  the  writer,  *  When  I  was  a 
boy  people  used  to  have  headaches  and  toothaches  but  now  all 
the  world  has  neuralgia.'  From  this  superfine  inaccuracy  Dr. 
Anstie  desires  to  rescue  us,  and  he  has  written  a  very  forcible, 
acute  and  practical  book  to  prove  that  neuralgia  is  not  to  be  taken 
merely  as  a  fine  word  for  pains  and  aches  of  whatever  kind  and  of 
whatever  origin,  but  that  the  term  is  to  be  restricted  to  a  cer- 
tain group  of  phenomena  of  which  a  pain  is  the  chief,  which 
occur  in  a  uniform  way  in  different  persons  and  which  bear  in 
their  entirety  some  tolerably  constant  relation  to  other  groups  of 
changes  presenting  themselves  in  the  same  person  or  in  his 
kindred.  The  principal  attribute,  he  says,  of  all  these  groups 
is,  that  they  spring  directly  from  a  defect  in  some  part  or  parts 
of  the  central  nervous  system,  which  latter  may  have  suftered 
under  some  injurious  influence,  or  which   has  more  probably 


I 


1872.]     On  Neuralgia  and  Functional  Nervous  Disorders.      121 

inherited  some  implicit  weakness.     Neuralgia  occurs  in  various 
nerve  districts,  or  is  replaced  by  motor  or  other  functional  dis- 
orders, not  because  the  central  weakness  differs  in  kind,  but 
because  the  points  of  least  resistance  differ  in  different  persons 
or  vary  with  the  years  and  circumstances  of  the  same  person. 
As  to  the  state  of  the  centres  thus  imperfectly  resisting  and  of 
the  parts  which  are  weakest  opinions  differ,  but  Dr.    Anstie 
expresses  a  strong  belief  on  this  the  speculative   portion  of  his 
treatise.     Whether  he  accepts   Dr.   Radcliffe's  theory   of  pain 
and  spasm  in  its  completeness  is  not  quite  evident,  but  he  is 
strongly  convinced  that  the  central  derangement  which  allows 
of  the  establishment  of  a  morbid  point  of  least  resistance  is  due 
to  defective  nutrition,   and  that  the  appearance  of  pain  is  not 
due  to  an  excited   state  of  nerve   in  the  sense   of  over   acti- 
vity accompanied  by  hypereemia,  but  on   the  contrary  is   due 
to  a  state  of  under  activity  or  atrophy  accompanied  by  anaemia. 
He  also  contends,  as  we  have  said,  and  seems  to  prove  that  this 
pain  is  due  to  a  defect  in  the  nervous  centre  rather  than  in  the 
course  of  the   nerve    springing  from    such    centre.     Our  own 
impression  is   that  Dr.  Anstie  is  original  in  this  hypothesis ;  we 
have  not  looked  the  matter  up  but  the  hypothesis  struck  us  as 
original  when  first  proposed  in  '  Reynolds'  Medicine'  and  it 
certainly  is  not  accepted  as  the  usual  teaching.     Neuralgia  has 
always  been  spoken  of  as  an  affection  of  the  nerve  in  its  course 
and,  in  many  or  most  cases,  as  an  irritation  of  such  nerve  in  its 
length  by  an  irritant  either  physical  or  chemical — by  a  morbid 
growth,  say,  by  cold,  or  by  some  acid  or  other  injurious  sub- 
stance circulating  in    the  blood.     Dr.  Anstie,  with   a  boldness 
which  at  first  seems  rather  surprising,  attacks   this  belief  root 
and  branch.     He  says  I  do  not  believe  much  in  your  peripheral 
irritants  ;  gout  is  gout,  rheumatism  is  rheumatism,  syphilis  is 
syphilis  and  none  of  them  are  neuralgia.      Neuralgia  is  very 
rarely  set  up  by  any  peripheral  cause  but,  like  insanity,  depends 
upon  a  local  and  inherited  defect  in   a  particular  centre  or  in 
several  nerve  centres.     Toothache,  he  contends,  is  toothache  and 
no  more,  unless  it  occur  in  a  person  predisposed  to  neuralgia  when 
it  may  hit  the  latent  blot  and  set  up  a  true  neuralgia  or  tic 
douloureux  ;  while  the  pains  of  locomotor  ataxy,  again  when 
duly  considered  with  regard  to  their  central  causation,  are  in 
favour  of  his  view   and  not  against  it.     On  the  other  hand  con- 
sider, he  says,  the  vast  number  of  persons  liable  to  peripheral 
irritations,  such  as  cabmen  who  are  exposed  to  all  weathers,  and 
compare  this  number  with  the  few  among  them  who  suffer  from 
any  consequent  neuralgia.      In  fact,  setting  aneurisms   aside, 
which  present    some  difficulty.  Dr.    Anstie's    astonishment   is 
reserved  rather  for  the  rarity  of  neuralgia  as  a  consequence  of 


122  Reviews.  [Jan., 

any  action,  irritant  or  other,  attacking  a  sensory  nerve  in  its 
course.  And  in  the  main  we  are  tempted  to  concur  with  Dr. 
Anstie.  On  due  consideration  it  certainly  does  seem  that  the 
accidental  causes  of  neuralgia  bear  but  a  small  proportion  to 
the  inherited  causes,  though  we  think  this  may  be  pressed  too 
far  as  we  do  undoubtedly  meet  with  important  cases  of  the 
former  kind.  For  a  good  example  we  may,  indeed,  refer  to  a 
case  reported  by  Dr.  Anstie  himself  in  the  fourth  volume  of 
the  *  Clinical  Society's  Transactions  ' ;  in  which  case  severe 
trigeminal  neuralgia  was  set  up  in  a  person,  not  predisposed,  by 
overwork  of  the  eyes.  As  a  rule,  however,  the  more  we  inquire 
the  more  we  shall  convince  ourselves  that  neuralgia  is  a  matter 
of  hereditary  predisposition  rather  than  of  individual  conditions, 
and  we  find  an  illustration  of  this  in  a  manuscript  note  of  our 
own  upon  the  freedom  from  neuralgia  in  many  women  in  whom 
flooding,  leucorrhoea  and  the  like  had  led  us  too  confidently  to 
expect  it.  Our  own  view  of  neuralgia,  which  though  less 
definite  than  that  of  ,,Dr.  Anstie  is  perhaps  worth  recording,  has 
long  been  that  neuralgia  occurred  in  persons  of  certain  consti- 
tution to  whom  arsenic  is  especially  wholesome,  and  that  it  is 
therefore  associated  with  some  skin  affections  such  as  certain 
forms  of  eczema  and  psoriasis,  with  asthma,  gastralgia  and  some 
other  disorders  which  also  acknowledge  arsenic  as  their  master. 
Here  Dr.  Anstie  is  with  us  also,  but  he  has  gone  a  step  further 
in  telling  us  the  seat  of  the  defect  in  such  persons.  Both  from 
the  point  of  view  of  classification  and  also  from  the  anatomical 
side  Dr.  Anstie's  remarkable  book  is  full  of  light  and  instruc- 
tion. Anatomically  speaking,  to  place  the  defect  in  trigeminal 
neuralgia,  for  instance,  in  the  medulla,  is  true  in  the  sense  of 
having  much  explaining  power.  The  simultaneous  or  succes- 
sive occurrence  of  disturbances  in  nerves  rooted  in  the  same 
parts  are  thus  explained.  Take,  for  example,  that  of  a  lady  now 
under  our  own  care  who  suffers  at  once,  or  within  short  periods, 
from  intense  trigeminal  neuralgia,  from  cardiac  disturbance, 
from  spasmodic  dyspnoea  and  from  trophic  palsy  of  the  lung 
with  bronchitis  and  pneumonic  conditions  of  a  capricious  kind. 
Take  again  another  case  of  a  lady  whose  lungs  present  the  same 
liability  to  trophic  disturbance  and  who  was  for  some  years 
subject  to  occasional  alarming  attacks  of  painless  stoppages  of 
the  heart  with  sudden  faintness,  the  phenomena  being  identical 
with  those  experimentally  induced  by  irritation  of  one  branch  of 
the  vagus,  and  having  now  definitely  retired  in  favour  of  spas- 
modic asthma.  This  lady  has  no  trigeminal  neuralgia  but  this 
affection  occurs  in  others  of  her  family,  she  herself  is  liable  to 
distressing  flushes  of  the  cheek  and  ear,  and  her  son  has  had 
many  unaccountable  attacks  of  swollen  face  without  pain,  com- 


1872.]    On  Neuralgia  and  Functional  Nervous  Disorders.      123 

ing  and  going  in  apparent  caprice ;  he  has  had  also  several 
attacks  of  congestion  and  erythema,  Hke  erysipelas  but  non- 
febrile  or  nearly  so,  around  the  right  eye.  Such  cases  as  these 
are  readily  explained  on  Dr.  Anstie's  hypothesis,  for  a  defect  in 
one  small  central  district  would  make  itself  felt  in  these  several 
peripheral  directions.  The  next  question  which  occurs  to  us^ 
one  upon  which  some  conflict  will  probably  arise,  is  con- 
cerning the  state  of  the  nerve  or  its  centre  during  a  neuralgic 
paroxysm.  The  conflict  will  probably  lie  between  the  advocates 
of  hypersemia  or  excessive  action  and  those  of  ansemia  or 
deficient  action.  We  are  disposed  to  think  with  the  publican  in 
Silas  Marner  that  there  is  truth  on  both  sides,  and  that 
although  Dr.  Radcliffe  may  be  right  in  claiming  anaemia  or 
defective  action  as  a  common  state  of  a  neuralgic  nerve,  on  the 
other  hand  a  state  of  hypera^mic  irritation  may  be  present  in 
other  cases. ^  We  have  evidence  in  either  of  perturbed  nerve 
tension  and  with  this  loss  of  tone  we  should  anticipate  loss  of 
normal  function.  In  either  case,  as  Dr.  Handfield  Jones  and 
others  have  clearly  seen,  to  expect  heighte^ied  function  is 
absurd,  and  the  term  hypera3Sthesia  becomes  either  etymologi- 
cally  or  scientifically  abominable  or  both.  It  seems  to  us 
that  distinction  sufficient  is  not  made  between  the  local  state  and 
the  general  state.  It  is  not  only  conceivable  but  likely  that  a 
hypersemic  and  irritated  state  of  nerve  root  may  coexist  with 
signs  of  general  anaemia  and  debility,  and  this  likelihood 
scarcely  receives  full  recognition  at  Dr.  Radcliffe^s  hands.  On 
the  other  hand  Dr.  Anstie  has  erred,  as  it  seems  to  us,  in 
stating  too  roundly  that  neuralgic  patients  are,  as  a  rule,  the  sub- 
jects of  debility.  That  they  have  a  weak  spot  in  their  organiza- 
tion is,  of  course,  a  truism,  and  that  in  persons  having  this  weak 
spot  exhausting  causes  will  bring  on  an  attack  is  likewise  pretty 
obvious ;  but  we  daily  see  neuralgics  who  not  only  present  the 
ruddiness  and  muscle  which,  as  Dr.  Anstie  says,  may  be  decep- 
tive, but  we  see  them  to  be  men  and  women  of  full  and  real 
vigour  not  only  of  the  body  in  general  but  of  the  nervous 
system  likewise.  An  intimate  friend  of  the  present  writer,  who 
suffers  from  attacks  of  intense  ophthalmic  neuralgia  and  who  is 
the  son  of  an  asthmatic  is  a  fine  example  of  a  strong  and 
enduring  constitution  and  of  a  mental  keenness  and  persever- 
ance far  beyond  the  average.  Of  course  he  may  have,  and  his 
symptoms  prove  that  he  must  have,  one  weak  place,  but  who  has 
not '{     However  the  existence  of  such  a  weak  place  is  not  made 


1  It  seems  certain  that  trigeminal  neuralgias  are  accompanied  sometimes  with 
vaso-motor  spasm  and  ansemia,  and  in  other  cases  with  vaso-motor  palsy  and 
hyperajmia.    Injection  of  the  fundus  of  the  eye  in  hemicrania  we  have  often  noted. 


124  Reviews.  [Jan., 

likely  in  any  degree  by  the  facts  of  his  general  health  and 
powers.  Even  of  abdominal  neuralgia,  which  Dr.  Anstie  says 
(p.  83)  occurs  in  subjects  ^^  almost  invariably  in  a  state  of  marked 
and  evident  debility/'  we  know  several  subjects  whose  health 
and  mental  vigour  are  otherwise  excellent.  Many  such  instances 
rise  into  our  memories,  and  many  likewise  in  whom  general 
debility,  nervous  or  other,  is  but  the  consequence  of  the  harassing 
pain.  At  the  same  time  we  acknowledge  to  the  full  the  value  of 
the  common  cases  to  which  Dr.  Anstie  calls  our  attention  in  a 
most  vivid  and  instructive  way,  cases  in  which  the  neuralgia 
is  but  one  evidence  among  others  of  general  debility  and  in 
which  we  find  other  grave  faults  of  the  nervous  system  likewise. 
A  series  of  such  cases  illustrating  the  coexistence  of  neuralgia 
with  other  manifestations  of  itself,  with  angina  pectoris,  with 
gastralgia,  with  epilepsy  and  with  insanity  is  given  by  the 
author  on  page  114.^  Among  these  affections  phthisis  also 
holds  a  prominent  place,  and  this  coexistence  is  of  especial 
interest  to  the  present  writer,  who  holds  that  there  is  a  kind 
of  phthisis  which  is  a  neurosis,  and  which  is  to  be  classed  with 
several  other  disturbances  of  tissue  nutrition  which  owe  their 
origin  to  a  palsy  or  defect  of  trophic  nerves.^  Another  very  im- 
portant correlation  of  failure  is  found  in  the  concurrence  of  chorea 
on  the  same  family  trees  with  neuralgia  and  its  allies,  a  fact  which 
we  have  long  noted;  this  concurrence  is  one  of  the  several  clinical 
peculiarities  of  chorea  which  may  be  added  to  those  mentioned 
by  Dr.  West^  as  bearing  against  the  ingenious  theory  of  its 
embolic  origin,  as  proposed  by  Dr.  Hughlings  Jackson. 

From  these  interesting  correlations  we  learn  once  more  the 
important  lesson  that  no  true  classification  of  disease  can  be  based 
on  any  other  than  a  hereditary  scheme,  that  it  cannot  attain  even 
a  provisional  completeness  until  the  affinity  of  diseases  is  ascer- 
tained from  a  study  of  their  coexistence  and  sequence  in  the 
same  person  and  his  blood  relations.  There  is  also  the  curious 
touchstone  of  arsenic  which  has  so  potent  an  action  for  good  in 
many  nervous  affections.  We  who  have  worked  round  to  an  in- 
vestigation of  the  neurotic  diathesis  from  another  point  of  view, 
were  led  to  it  by  following  out  the  tracks  of  arsenic.  We 
found  that  this  drug  is  not  a  curer  of  skin  diseases  as  such,  but 
of  certain  kinds  only,  which  kinds,  we  afterwards  found,  deve- 
loped themselves  in  families  and  individuals  who  presented 
likewise  a  tendency  to  nervous  disorders  such  as  those  above 

^  Dr.  Anstie  has  strengthened  this  argument  in  a  very  interesting  paper  in  the 
*  British  Medical  Journal'  for  Nov.  11th,  1871,  where  he  deals  with  the  connec- 
tion of  asthma,  angina  pectoris  and  gastralgia. 

2  Vide  '  Med.  Times,'  Nov.  18th,  1871. 

^  'The  Lumleian  Lectures,'  "Nervous  Diseases  of  Childhood."     1871. 


1872.]     On  Neuralgia  and  Functional  Nervous  Disorders.     125 

enumerated  and  who  were  often  to  be  distinguished  even  in 
health  by  a  peculiarity  of  character  and  physical  attributes. 
We  began  therefore  many  years  ago,  to  extend  the  use  of 
arsenic  in  such  persons  and  families  whether  they  presently 
suffered  from  skin  affections,  or  from  asthma,  gastralgia,  super- 
ficial neuralgia, .  angina  pectoris,  chorea  or  even  epilepsy  and 
phthisis.  To  the  occasional  treatment  of  epilepsy  by  arsenic 
we  were  led  by  the  study  of  two  very  instructive  cases  in 
which  epilepsy  alternated  with  eczema  and  psoriasis  respec- 
tively, and  in  which  arsenic  was  found  to  have  almost  as  great 
curative  powers  in  the  former  as  in  the  latter  diseases. 

With  regard  to  the  incidental  causes  which  call  forth 
attacks  in  the  potentially  neuralgic  Dr.  Anstie  gives  us 
much  very  interesting  information.  On  two  principal  heads 
especially  he  expresses  himself  vigorously,  and  in  a  way 
which  is  full  of  instruction  to  the  clinical  physician.  These 
two  heads  are,  1,  the  effect  of  advancing  years  with  their 
corresponding  tissue  failure  and,  2,  in  earlier  life,  the  ter- 
rible harm  inflicted  upon  the  nervous  system  during  its  rela- 
tively weak  and  unstable  youth,  by  artificially  strained  re- 
ligious emotion,  by  peripheral  sexual  irritation,  by  false  and 
stimulating  art  and  literature,  or  by  all  or  several  of  these 
acting  together.  The  book  is  full  of  sayings  which  betray 
something  more  than  the  mere  physician,  which  distinguish  the 
author  also  as  a  cultivated  and  observant  man  of  the  world  ;  such 
as  the  following :  "  It  is  a  comparatively  frequent  thing,  for 
example,  to  see  an  unsocial  solitary  life  (leading  to  the  habit 
of  masturbation)  joined  with  the  bad  influence  of  an  unhealthy 
ambition  prompting  to  premature  and  false  work  in  literature  or 
art"  (p.  61).  There  never  was  a  time  when  this  could  more 
truly  be  said  than  the  present.  Or  again  :  "  The  truth  is  that 
the  young  people  who  make  music  or  painting  an  excuse  for 
idleness  respecting  other  matters  are  invariably  imposters, 
even  ^in  that  which  is  their  own  supposed  forte"  (p.  215).  On 
the  other  hand  Dr.  Anstie  makes  some  wise  reflections  on  the 
duty  of  imbuing  the  susceptible  and  ardent  mind  of  youth 
with  a  serious  view  of  art.  If,  he  says,  music  or  any  other 
art  be  chosen  and  made  a  serious  study,  "  a  certain  definite 
time  being  set  apart  for  it,  and  thoroughness  being  insisted 
upon  "  we  should  have  "an  admirable  vent  for  the  emotional 
effervescence  of  commencing  sexual  life ;"  while  the  lazy  and 
conceitedmanner  in  which  young  gentlemen  and  ladies  now  dabble 
in  "  accomplishments"  is  "  intensely  pernicious."  No  words 
of  ours  are  needed  to  enforce  these  warnings  ;  perhaps  this  gene- 
ration will  hear  them  when  they  come  not  from  the  pulpit  but 
from   the  hospftal,  not  as    moral  warnings  against  luxurious 


126  Reviews.  [Jan., 

sensations  and  frivolous  heated  joys,  but  as  interpretations  of 
natural  laws  which  never  sleep  but  are  surely  forging  sharp 
arrows  against  those  who  neglect  them.  Secondly,  we  are  told 
more  clearly  than  we  have  been  told  before,  how  the  tissue 
degenerations  of  advancing  years  favour  the  onset  of  neuralgias, 
and  in  this  Dr.  Anstie  fij:ids,  with  reason,  a  great  support  to  his 
belief  that  neuralgia  is  a  diminution  and  not  an  excitement  of 
nerve  action.  The  neuralgias  of  the  period  of  bodily  decay 
"  are  of  very  bad  prognosis." 

"  A  neuralgia  which  first  develops  itself  after  the  arteries  and 
capillaries  have  begun  to  change  decidedly  in  the  direction  of  athe- 
roma, is  extremely  likely,  even  if  apparently  cured  for  a  time,  to 
recur  again  and  again  with  ever  increasing  severity  and  to  hauiit 
the  patient  for  the  remainder  of  his  days." 

"  Eor  this  purpose  I  am  in  the  habit  of  insisting  on  the  great  im- 
portance of  sphygmographic  examination  for  all  neuralgic  patients 
who  have  passed  middle  age.  When  we  get  the  evidence  which  is 
furnished  by  the  formation  of  a  distinctly  square-headed  radial 
pulse  curve,  even  though  there  be  no  palpable  cord-like  rigidity  of 
superficial  arteries,  we  are  bound  to  be  exceedingly  cautious  of 
giving  a  favourable  prognosis'  (p.  171). 

Many  are  the  attractive  topics  which  further  suggest  them- 
selves during  the  perusal  of  this  volume;  among  others,  the 
difference  between  Anstie  and  Eulenburg  as  to  the  true  place 
of  migraine  among  neuralgias  proper.  Our  own  experience 
bears  out  the  statement  of  Anstie  that  migraine  is  but  a  phase 
of  ophthalmic  neuralgia.  On  this  point  we  may  refer  also  to 
a  thesis  on  migraine  privately  published  last  year  by  Mrs. 
Garrett  Anderson,  who,  while  upholding  the  true  view  of 
migraine  as  a  neurosis  among  neuroses,  and  not  as  a  symptom 
of  dyspepsia,  yet  would  put  the  seat  of  the  pain  in  the  central 
encephalic  ganglia.  An  interesting  case  has  lately  come  under 
our  care  in  which  the  appearance  of  severe  migraine  was  the 
first  indication,  and,  as  yet,  continues  to  be  the  most  distressing 
consequence  of  a  fibrous  tumour  of  the  uterus.  Dr.  Anstie 
concludes  his  description  of  neuralgias  by  an  effective  contrast 
between  them  and  pains  which  are  not  neuralgia.  Of  them 
are  myalgic  pains,  pains  of  chronic  alcoholism,  of  rheumatism, 
of  syphilis,  of  dyspeptic  headache  and  so  forth.  Here  the 
author,  who  regards  neuralgia  as  a  disease,  shows  more  discrimi- 
nation than  Eulenburg,  who,  using  the  word  neuralgia  in  the 
sense  of  a  symptom,  gathers  arthritic,  syphilitic,  saturnine  and 
every  sort  of  pain  into  his  net.  We  could  dwell  long  upon  the 
momentous  chapter  on  treatment  did  space  permit,  for  here  Dr. 
Anstie  develops  in  its  fullest  sense  the  important  doctrine  that 
clinical  observation  is  only  justified  by  its  results  in  the  alle- 


1872.]    On  Neuralgia  and  Functional  Nervous  Disorders.     127 

viation  of  suffering.  Anstie  and  Eulenburg  both  speak  at  length 
of  the  constant  galvanic  current  and  come  to  the  conclusion 
which  we  ourselves  support,  that  it  is  the  most  effectual  of  all 
remedies  for  the  superficial  neuralgias,  having  at  least  as  much 
curative  power  as  the  hypodermic  morphia  and  often  as  much 
power  also  for  immediate  palliation.  Cases  do  however  occur 
in  which  it  fails,  as  in  one  of  ophthalmic  neuralgia  with  a 
gray  lock  of  hair  now  under  our  own  care,  in  which  the  cur- 
rent has  failed  to  give  the  slightest  relief.  Our  own  experience 
is  that  if  the  current  is  to  cure  it  will  prove  its  intention  by 
giving  some  degree  of  immediate  relief  at  the  first  sitting. 
Anstie  seems  to  speak  a  little  too  slightingly  of  electricity  in  its 
other  forms  and  of  the  spark  in  particular.  Both  authors 
remark  upon  the  success  of  quinine  in  supraorbital  neuralgia 
which  is  so  curious  a  contrast  with  its  frequent  failure  in  other 
varieties.  Both  authors  also  give  its  due  meed  of  praise  to 
arsenic.  As  to  hypodermic  morphia  there  is  little  now  to  be 
said,  but  we  think  that  the  treacherous  tendency  of  morphia  in 
some  cases  to  keep  up  the  neurosis  it  pretends  to  control  is  not 
recognised.  Our  own  experience  is  full  of  such  cases,  for 
example,  we  remember  one  of  most  intense  cervico-bracheal 
neuralgia  in  which  morphia  had  been  used  with  brilliant  palli- 
ative effects  for  some  time,  the  paroxysms  however  recurring  as 
frequently  as  ever  and  with  more  severity  if  not  cut  short. 
This  brave  lady  at  our  urgent  request  laid  the  morphia  aside 
and  the  disease,  which  during  the  use  of  morphia  had  resisted  all 
other  treatment,  then  gradually  disappeared.  In  visceral  neu- 
ralgias or  neurotic  disorders,  such  as  paroxysmal  vomiting,  we 
have  noticed  the  same  impotence  of  other  remedies  during  the 
regular  use  of  hypodermic  morphia.  On  the  other  hand,  of 
course  we  have  numerous  cases  in  which  this  means  brings 
about  an  instant  or  rapid  cure  ;  should  the  operation,  however, 
fail  after  a  fair  trial  to  cure,  we  are  convinced  that  it  should 
not  be  continued  for  purposes  of  palliation  in  cases  where  a 
cure  is  to  be  anticipated.  In  the  neuralgia  of  decaying  life, 
when  all  remedies  have  failed,  it  may  of  course  be  continued 
as  a  palliative  for  years,  as  here  no  cure  is,  perhaps,  to  be  hoped 
for.  Eulenburg  speaks  highly  of  the  results  of  the  hypodermic 
use  of  narcein  in  an  inveterate  case  of  prosopalgia  as  it  not 
only  relieved  but  cured  the  patient.  As  to  omissions,  we  are 
surprised  to  find  that  Anstie  scarcely  mentions  muriate  of 
ammonia,  a  remedy  which  in  our  hands  has  proved  of  striking 
benefit.  In  a  series  of  fifty  cases  of  neuralgia  treated  by  this 
drug,  we  obtained  decided  relief  in  thirty  and  prompt  cure  in 
twenty-three;  some  of  these  latter  were  very  remarkable  instances 
and  the  whole  series  is  the  more  valuable  as  before  the  commence- 


128  Reviews.  [Jan., 

ment  of  our  stricter  investigations  we  had  little  belief  in  this 
efficacy  of  the  medicine.  We  have  found  it  indeed  at  least 
as  valuable  in  true  neuralgia  as  in  myalgia,  or  more  so.  The 
only  other  matter  to  which  we  can  now  refer  is  that  of  the  use 
of  local  remedies.  Of  these  Eulenburg  speaks  in  terms  which 
scarcely  rise  even  to  the  level  of  contempt.  He  utterly  rejects 
them  as  being  always  and  everywhere  valueless.  Dr.  Anstie 
does  not  go  so  far  as  this  but  allows  that  chloroform,  belladonna, 
opium,  aconite  &c.,  have  some  value  as  helpers.  Nor  can  we 
at  all  admit  that  Eulenburg  is  justified  in  his  exclusiveness. 
We  admit  that  it  would  be  poor  work  to  play  about  with  local 
remedies  and  to  forget  hypodermic  morphia,  galvanism  or 
arsenic,  but  we  do  certainly  contend  that  these  latter  chief  mea- 
sures may  be  supplemented  by  the  use  of  liniments  and  unguents 
with  much  advantage.  We  remember  one  case  of  supraorbital 
neuralgia  which  was  promptly  cured  by  aconitine  ointment,  to 
the  patient's  great  delight,  when  hypodermic  morphia  and 
quinine  had  failed,  and  we  think  our  readers  will  bear  us  out 
in  saying  that  the  application  of  opiates  upon  spongio  piline 
and  of  belladonna,  aconite,  or  chloroform  liniments,  often  serve 
good  purpose  as  palliatives. 

As  we  pass  on  from  then  euralgias  to  other  nervous  dis- 
orders we  turn  altogether  to  the  thoughtful  and  complete  work 
of  Eulenburg.  This  book  is  so  full,  so  well  condensed  and  so 
clearly  written,  that  we  would  fain  say  more  upon  it  than  is 
now  possible.  Dr.  Eulenburg  handles  all  these  questions  with 
so  much  mastery  and  so  much  knowledge  that  we  must  urge  all 
who  study  them  to  obtain  his  work  at  once,  as  no  physician 
however  accomplished  can  fail  to  find  great  profit  in  it,  and  we 
ourselves  must  confess  that  Dr.  Eulenburg  has  laid  us  under  a 
deep  obligation.  Where  he  is  u  lable  to  solve  a  difficulty  he 
states  it  distinctly,  and  so  brings  us  up  to  the  limits  of  knowledge, 
that  we  have  provided  for  us  the  exact  standpoint  for  future 
work.  Take,  for  example,  his  able  discussion  of  a  point  which 
was  among  the  first  on  which  we  sought  to  know  his  conclu- 
sions. We  turned  early  to  his  chapters  on  Cutaneous  and 
Muscular  Anaesthesias  to  see  how  he  would  interpret  the  obscure 
phenomena  of  hysterical  palsy,  of  tabes  dorsalis  and  the  like. 
The  whole  difficulty  is  admirably  handled,  as  it  appears  to  us, 
being  adequately  discussed  yet  without  diffuseness.  It  is 
impossible  for  us  to  make  quotations  from  paragraphs  all  of 
which  hang  so  closely  together,  but,  on  the  question  of  conduction 
of  sensation  in  the  cord,  Eulenburg  leans  to  the  side  of  Schiff, 
who  believes  that  this  property  resides  both  in  the  gray  matter 
and  in  the  posterior  columns,  but  with  a  difference,  the  gray 
substance  being  a  conductor  only  of  general  sensibility,  while 


1872. J     On  Neuralgia  and  Functional  Nervous  Disorders.     129 

the  perception  of  special-touch  impressions  is  carried  by  the 
columns.  He  confesses  however  that,  although  this  view  of 
Schiff  clears  up  some  clinical  cases,  it  is  unequal  to  the 
explanation  of  others.  We  must,  we  say  again,  be  content 
to  do  no  more  than  indicate  the  kind  of  discourse  to  be  found  in 
these  sections,  the  results  being  too  indefinite  to  be  shown  by 
short  extracts.  The  disorders  of  sensation,  superficial,  visceral 
and  special  being  extensively  and  minutely  dealt  with  in  340 
pages,  as  many  more  are  devoted  in  the  second  part  of  the 
volume  to  the  disorders  of  motion.  In  this  division  all  possible 
palsies  are  in-vestigated  as  well  as  convulsions  and  cramps,  and 
with  the  same  skill  as  before.  We  are  struck  not  only  with 
the  extensive  reading  of  the  author  and  his  industrious  com- 
parison of  cases,  clinical  and  experimental,  but  also  with  the 
variety  and  aptness  of  his  own  experience.  On  subjects  the 
most  obscure  he  has  interesting  and  appropriate  instances  of  his 
own  to  bring  forward,  and  he  rarely  sums  up  the  results  of 
therapeutics  without  giving  the  reader  a  sense  of  his  own  parti- 
cipation in  these  results,  without  putting  a  backbone  into  the 
mass  of  scattered  testimony  which  would  otherwise  be  too  in- 
coherent for  practical  purposes,  and  without  showing  that  he  has 
himself  tested  the  methods  of  treatment  of  which  he  speaks  and 
has  therefore  a  right  to  give  to  each  its  due  appreciation. 
Thus  the  book  differs  essentially  from  the  mere  compilations 
which  may  not  fall  short  of  it  in  industry,  or  in  a  kind  of  acumen, 
but  which  do  not  come  from  the  hand  of  practised  and  for- 
tunate observers.  The  author's  remarks  upon  electric  reaction 
and  upon  its  therapeutical  uses  seem  to  us  to  be  everywhere 
acute  and  thoroughly  grounded  upon  investigation.  Under  the 
head  of  spinal  palsies  we  turned  to  consult  the  author  about  the 
recent  statements  of  Schiff',  which  have  so  much  disturbed  the 
current  teaching  concerning  the  transmission  of  motor  impulses 
along  the  spinal  cord.  We  find  the  difficulty  adequately  dealt 
with,  and  Eulenburg  scarcely  sees  how  we  are  to  avoid  accepting 
Schiff's  assertions :  1st.  That  functional  defect  of  the  antero- 
lateral columns  does  not  cut  off  motor  conduction,  and  that 
isolated  disease  in  them  does  so  only  in  so  far  as  it  involves  the 
anterior  nerve-roots;  and  2nd.  That  motor  conduction  is  only 
arrested  when  either  the  anterior  nerve-roots  are  severed,  or 
when  the  gray  matter  is  severed  in  its  whole  thickness. 
Eulenburg  thinks  Schiff"s  evidence  seems  as  yet  stronger  than 
that  of  his  opponents,  and  we  are  not  to  shrink  from  the  con- 
clusions of  advancing  physiologists  merely  because  they  throw 
our  present  opinions  into  confusion.  We  would  draw  attention 
in  the  next  place  to  the  excellent  account  of  the  mode  in  which 
palsy  of  the  bladder  occurs  in  spinal  disorders,  for  we  believe 
97— XLix.  9 


1^0  Reviews,  [Jan., 

that  the  explanation  given  will  enlighten  many  of  our  readers 
as  it  has  enlightened  ourselves.'  Unlike  Schiif's  new  views 
about  motor  conduction,  Budge's  new  views  about  the  innerva- 
tion of  the  bladder  throw  a  fresh  light  upon  bladder  spasms  and 
palsies,  and  perhaps  upon  faecal  and  seminal  acts  and  disorders, 
which  will  not  only  clear  up  obscure  cases  but  will  compel 
many  of  us  to  alter  our  established  opinions  upon  these  disorders. 
Starting  from  the  later  researches  of  Budge  upon  the  motor 
nerves  of  the  bladder,  which  proved,  as  many  of  us  were  aware, 
that  those  nerves  spring  from  the  pedunculus  cerebri,  pass 
through  the  restiform  body  and  the  anterior  columns  of  the  cord, 
and  issue  with  the  third  and  fourth  sacjal  nerves,  the  author 
goes  on  to  say,  what  is  certainly  new  to  ourselves  at  any  rate, 
that  there  is  no  muscle  in  the  bladder  deserving  the  name  of  a 
sphincter,  but  that  every  muscle-fibre  iii  the  bladder  is  in  favour 
of  the  expulsion  of  urine.  The  only  muscles,  according  to 
Budge,  which  prevent  its  flow  are  the  constrictor  urethrse  and 
the  bulbo-cavernosus.  The  motor  nerves  of  these  muscles  spring 
likewise  from  the  pedunculus  cerebri,  have  the  same  course  as 
the  motor  nerves  of  the  bladder  and  issue  from  the  cord  with 
the  third,  fourth  and  fifth  sacral  nerves  in  the  course  of  the 
pudic  nerve.  An  especially  important  point  is,  that  these 
muscles  are  under  the  influence  of  a  reflex  tone  established  in 
the  lower  part  of  the  cord,  the  centripetal  elements  of  which  are 
the  sensory  nerves  of  the  bladder  whicli  run  in  the  posterior 
roots  of  the  third,  fourth,  and  fifth  sacral  nerves.  Section  of 
the  cord  at  any  part  above  these  nerves  invariably  sets  up 
ischuria  and  decided  dilatation  of  the  bladder ,  but  never  incon- 
tinence  ;  and  this  ischuria  depends  not  upon  the  division  of  the 
motor  nerves  of  the  bladder  alone,  but  also  upon  the  increased 
reflex  irritability  which  heightens  the  reflex  tone  of  the  urethral 
muscles.  Incontinence  sets  in  as  a  secondary  event  and  is  due 
to  hydrostatic  pressure  which  then  increases  so  far  as  to  over- 
come these  muscles.  But,  on  the  other  hand,  incontinence  can 
be  directly  produced  by  section  either  of  the  anterior  or  posterior 
roots  of  the  third,  fourth  and  fifth  sacral  nerves,  as  in  the 
former  case  the  motor  nerves,  and  in  the  latter  the  nerves  which 
establish  reflection  upon  the  urethral  muscles  are  severed. 
Eulenburg  goes  on  to  show  how  well  this  explanation  suits, 
among  other  things,  the  bladder  disorder  of  tabes  dorsalis,  in 
which  we  find  at  one  time  ischuria,  at  another  incontinence, 
both   occurring  somewhat    capriciously  but   never  in   a   very 

1  As  we  write  these  lines  (Nov.  25th,  1871),  we  receive  the  current  number  of 
the  '  British  Medical  Journal'  and  in  it  we  see  that  Dr.  Althaus  communicates 
these  new  views  of  Budge. 


1872.]     On  Neuralgia  and  Functional  Nervous  Disorders.     131 

severe  degree.  Like  the  ataxy  itself  the  bladder  disorders 
depend  upon  injury  to  the  centripetal  nerves  passing  from  the 
bladder  to  the  cord,  by  which  both  the  voluntary  and  reflex 
innervation  of  the  urethral  muscles  is  changed  in  the  direction 
either  of  irritation  or  debility.  A  like  explanation,  probably, 
is  true  concerning  the  constipation  followed  by  incontinence  of 
fseces  which  is  so  often  seen  in  tabes,  though  the  precise 
mechanism  of  these  symptoms  is  as  yet  undiscovered,  it  being 
especially  hard  to  disbelieve  in  a  sphincter  ani.  Eulenburg  has 
nothing  more  to  say  concerning  reflex  paralyses  than  has  been 
said  already  by  Brown-Sequard  on  the  one  hand  and,  on  the 
other,  by  Jaccoud.  He  agrees  with  most  physiologists  that 
Brown-Sequard's  view  can  no  longer  be  upheld.  For  our  own 
part,  as  regards  the  so-called  urinary  paraplegia,  we  as  yet  would 
prefer  the  explanation  of  Leyden,  who  believes  that  the  paraplegia 
is  due  to  a  neuritis  propagated  from  the  bladder  to  the  cord. 
This  we  believe  to  be  the  true  explanation  of  the  few  cases  in 
which  the  spinal  disorder  can  be  proved  to  be  secondary  to  the 
disease  of  the  bladder,  and  this  state  of  things  we  were  able  to 
demonstrate  in  the  only  case  of  undoubted  urinary  paraplegia 
which  of  late  years  has  come  under  our  care.  Very  well 
marked  inflammatory  products  were  found  matting  the  sacral 
nerves  together  and  burying  them  with  the  bladder,  peritoneum 
and  other  tissues,  in  a  thickened  mass ;  the  cord  itself  was 
softened.  On  turning  to  the  chapters  on  spasms  and  convul- 
sions, and  among  these  first  to  the  sections  on  epilepsy,  we 
find  Eulenburg  holds  the  opinion  that  epileptic  convulsions 
may  take  their  rise  either  in  an  aneemic  brain,  or  in  a  brain  in  a 
state  of  venous  hypersemia.  This  view,  according  to  the 
observations  of  the  present  writer,  is  supported  by  the  evidence 
of  the  ophthalmoscope  and  Eulenburg  agrees  with  us,  likewise, 
in  attaching  great  importance  to  Nothnagel's  discovery  of  a 
'^cramp-point  "  close  to  the  fourth  ventricle,  a  point  which  also 
corresponds,  we  would  add,  to  the  supposed  centre  of  the  vaso- 
motor nerves.  Eulenburg  also  draws  our  attention  to  the  fact 
that  irritation  of  a  sensitive  nerve  (say,  the  sciatic)  may  not 
only  set  up  contraction  of  the  arteries  of  the  pia  mater 
(Nothnagel)  but  also  their  dilatation  by  a  reflex  paralysis 
(Loven).  He  adds  that  it  is  tolerably  clear  from  the  experi- 
ments of  Nasse  (Centralblatt,  18T0,  No.  8)  that  deficiency  of 
oxygen  is  insufficient  to  call  forth  convulsions,  and  that  these 
depend  rather  upon  the  accumulation  of  injurious  products,  such, 
perhaps,  as  carbonic  oxide,  carbonic  acid  or  other  waste  gases. 
Ursemic  convulsions  on  the  other  hand  do  not,  he  thinks,  depend 
upon  the  accumulation  of  waste,  but  he  holds  with  Traube  that 
they  are  the  consequence  of  oedema  of  the  brain  with  increased 


132  Rei)iews.  \_Ja\)., 

pressure.  Like  epilepsy,  uiTcmic  convulsions  may  occur  either 
in  a  brain  deficient  of  all  blood,  or  in  a  brain  overloaded  with 
venous  blood.  Under  the  head  of  asthma  we  find  that 
Eulenburg  notices,  as  does  Anstie,  the  intimate  connection  of 
this  disease  with  trigeminal  neuralgia  and  with  angina 
pectoris.  These  clinical  facts  taken  with  others  seem  to  point 
to  the  medulla  and  region  of  the  fourth  ventricle  as  a  *  vital 
knot '  in  more  senses  than  one  ;  as  not  only  is  the  respiratory 
centre  here  with  the  cardiac  sensory  centre,  but  hereabouts  are 
the  vaso-motor  centre  and  the  cramp-point;^  here  is  the  centre 
of  the  trigeminus,  and  here  these  are  all  met  also  by  the  sensory 
nerves  from  the  chief  organ  of  digestion,  the  stomach.  In  dis- 
cussing the  pathogeny  of  asthma  we  notice  that  Eulenburg 
fully  accepts  Salter's  hypothesis  of  a  bronchial  spasm  depending 
upon  affection  of  the  vagus,  but  he  believes  that  spasms  of  the 
diaphragm,  of  the  other  inspiratory  muscles  habitual  and  acces- 
sory, and  perhaps  of  the  glottis,  are  also  concerned  in  the  attacks. 
If  this  be  so  it  harmonises  many  observations  which  at  first 
sight  seem  contradictory.  We  had  marked  many  other  para- 
graphs in  this  excellent  and  valuable  treatise  which  we  had 
hoped  to  quote  or  to  discuss,  but  reluctantly  we  pass  them  over 
in  the  hope  that  we  have  said  enough  to  direct  our  readers  to 
the  source  itself.  As  regards  the  printing  of  the  volume,  though 
this  is  done  in  good  type  and  style  yet  there  is  an  abundance  of 
mere  printers'  errors  which  are  not  to  be  excused  on  the  plea  of 
the  author's  absence  during  the  drawing  of  the  proofs,  and 
which  are  unworthy  of  Hirschwald.  It  may  be  that  we  are 
too  much  of  purists  in  this  matter,  but  we  certainly  were  a  little 
disappointed  to  find  that  Dr.  Anstie's  work  also  in  this  respect 
falls  below  the  standard  we  look  for  in  the  Clarendon  Press. 

T.  Clifford  Allbutt. 


^  Salter  was  the  first,  or  one  of  the  first,  to  point  out  the  connection  hetweeu 
asthma  and  epilepsy. 


I 


1872.]  133 


38i6Iio9frapf)ual  ^erorir. 


Notes  on  Comparative  Anatomy.^ — The  present  year  has 
been  prolific  in  the  publication  of  Manuals  of  Comparative  Anatomy, 
which  science  appears  to  have  gone  through  several  periods  of  con- 
struction and  of  reconstruction  during  the  past  ten  or  twenty  years. 
At  the  present  time  it  is  positive  observation  and  not  theory  that 
is  cultivated,  and  the  older  works  have  given  place  to  a  new  series, 
of  which  the  one  before  us  is  an  example. 

Dr.  Ord's  work,  written  in  a  remarkably  laconic  spirit,  is  evidently 
destined  for  purely  scholastic  purposes.  It  is  about  the  last  work  in 
the  world  which  a  learner  would  dawdle  over,  while  as  a  simple  aide- 
memoire  it  is  of  the  highest  possible  utility.  Its  use,  however,  will, 
we  fear,  be  chiefly  confined  to  Dr.  Ord's  own  class  in  Comparative 
Anatomy  at  St.  Thomas's  Hospital,  for  which  it  was  especially  pre- 
pared. The  classification  adopted  by  the  author  is  naturally  the  first 
thing  to  which  the  critic  turns,  and  we  discern  with  pleasure  that 
the  author  has  with  great  discretion  confined  himself  to  the  promid- 
gation  of  a  very  safe  and  generally  accepted  system. 

The  author's  initial  distinctions  between  not  living  matter  and 
living  beings  are  highly  lucid.  They  comprise  an  amplification  (in  part 
after  Nicholson)  of  the  well-known  distinctions  established  by  Pro- 
fessor Owen — distinctions  which,  in  spite  of  the  contrary  arguments  of 
Professor  Eeay  Greene,  have  not  been  formally  disproved  up  to  the 
present  time.  In  fact,  it  is  with  satisfaction  that  we  perceive  that 
Dr.  Ord  is  enabled  to  formulate  accurate  and  clear  distinctions  between 
animals  and  plants. 

Some  of  the  author's  descriptions  are  not  clear.  Por  example, 
when  speaking  of  the  Cetacea,  the  following  passage  occurs — 

"  Line  of  centra  altogether  fish-like  in  look.  Anterior  extremity, 
scapula  flattened,  with  small  distinction  of  parts.  Acromion  and 
coracoid  mostly  imperfectly  marked.  No  clavicle.  Digits  often 
have  more  than  three  phalanges ;  are  enclosed  in  common  skin  or 
web,  and  have  no  nails.  Pelvis  represented  by  a  pair  of  bones  not 
attached  to  spinal  column.  They  support  penis  or  clitoris,  and  as  is 
suggested,  correspond  to  ischia." 

^  Notes  on  Comparative  Anatomy  :  a  Syllalus  of  a  Course  of  Lectures  delivered 
at  St.  Thomas's  Hospital.  By  William  Miller  Oed,  M.B.,  M.R.C.P,  London, 
1871. 


134  Bibliographical  Record.  [J 


an., 


The  first  four  statements  here  are,  we  consider,  rather  vague,  and 
whilst  the  absence  of  the  clavicle  and  the  *'  greater^'  number  of  digits 
than  three  may  be  taken  as  admitted  statements,  the  fact  that  Baloena 
Aiistralis  and  some  Balcenopteroe  have  four  digits,  with  a  rudimentary 
fifth  one,  might  have  been  noticed.  But  the  statement  in  reference 
to  the  pelvic  l3ones  rather  surprises  us.  We  were  under  the  impres- 
sion that  while  the  ischial  bones  were  alone  present  in  the  Belphmida, 
the  pubis,  femur,  and  tibia  found  representative  ossicles^  in  some  of 
the  whalebone  whales,  and  that  Eschricht  and  Eeinhardt  had  made 
this  especially  interesting  discovery.  An  examination  of  the  skele- 
tons of  Baloenoptera  rostrata  and  Sibhaldii,  now  in  the  Hull  Philo- 
sophical Society's  Museum,  will  further  throw  light  on  this  subject. 
If  such  an  error  can  be  found  to  exist  with  respect  to  the  large  bones, 
we  are  afraid  of  the  fate  of  the  little  ones  in  Dr.  Ord's  hands.  We 
imagine  that  a  hasty  glance  at  the  429th  page  of  Owen^sbookmust  have 
led  Dr.  Ord  to  take  the  definition  of  the  Odontocete  family  for  that  of 
the  Cetacean  order,  and  thus  to  confuse  the  part  with  the  whole. 

There  are  few,  however,  of  this  class  of  errors  in  the  work,  which 
doubtless  will  be  of  great  use  as  a  class-book.  The  latest  researches 
of  Mr.  W.  Kitchen  Parker  on  the  development  of  the  "  shoulder 
girdle"  are  very  properly  introduced.  We  think  that  for  students' 
purposes  a  list  of  the  great  bones  of  the  skeleton,  indicating  their 
general,  and,  when  necessary,  their  special  homologies,  would  be 
convenient  in  a  future  edition.  The  bones  which  are  absent  in  any 
of  the  great  groups  of  animals  might  be  indicated  in  italics,  or  in 
some  other  convenient  manner. 

Dr.  Ord^s  classification  of  the  Invertebrate  group,  which  he  con- 
siders as  "  very  probably  equal  in  value  to  the  whole  of  the  verte- 
brata,^'  is  remarkably  lucid,  and  as  the  latest  discoveries  made  in  respect 
of  the  lowest  forms  of  life  are  included  by  him,  this  portion  of  the 
work  will  be  of  the  highest  value  to  the  student.  In  fact,  the  sys- 
tem on  which  Dr.  Ord  has  proceeded,  that  of  presenting  a  "'chart  on 
which  a  few  principal  centres  of  life  are  clearly  indicated"  is  highly 
convenient  for  those  who  would  "get  up"  an  examination  quickly. 
Whether  the  modern  system  of  teaching  Comparative  Anatomy  and 
zoology  ^'  by  type,"  as  opposed  to  ^^  by  definition,"  is  the  ^^best,  is 
another  question  altogether.  The  masters  of  zoological  science  in 
the  last  and  the  present  generation,  were  not  taught  according  to  this 
method.  They  had  before  them  the  Linnean  maxim.  Omnis  vera 
cognitio  cognitione  specifwa  initiaUir^  and  the  result  has  been  a 
thorough  and  accurate  knowledge  of  species.  This  of  much  greater 
importance  to  train  and  discipline  the  mind  than  the  mere  selection 
of  scattered  types.     We  never  yet  found  two  comparative  anatomists 

^  Escliriclit  and  Reinliardt,  '  Oin  Nordhvalen/  4to,  1861,  p.  151,  pi.  ii ;  Oweu, 
'Anatomy  of  Vertebratep/  vol.  ii,  pp.  307  and  429;  Flower,  'Osteology  of 
Mammalia,'  p.  303. 


1872.]         Jones'  Anatomy  and  Nicholson's  Zoology.  135 

who  agreed  with  each  other  what  the  types  really  are,  if  6.^.  the  order 
Perissodactf/la  ;  and  if  this  be  the  case  in  well-known  orders  of  the 
mammalian  class,  what  confusion  may  we  not  expect  to  find  amongst 
the  less  known  Invertebrata  ? 

Some  of  the  definitions  of  the  various  theories  of  the  origin  of 
animal  life  as  expressed  by  Dr.  Ord  are  remarkably  lucid.  He  says  : — 
"In  the  organisation  of  animals  at  least  two  factors  (1),  the  ori- 
ginal type,  (2)  their  habits,  their  history,  and  changes  or  addition  of 
structure  are  therewith  correlated."  This  is  the  same  as  the  saying  of 
Professor  Huxley,  that  every  animal  is  the  resultant  of  two  forces, 
the  one  teleological  and  the  other  morphologiieal.  The  distinction 
between  the  centripetal  and  the  centrifugal  forces  which  operate  in 
the  production  of  living  things  is  here  well  pointed  out.  Dr.  Ord  is 
is  wrong,  however,  in  assigning  to  Lamarck  instead  of  to  De  Maillet 
the  origin  of  the  theory  of  progressive  development  as  usually  under- 
stood ;  and  we  think  that  a  more  distinct  definition  of  the  variations 
of  opinion  between  the  Derivationites  on  the  one  hand  and  the  l)ar- 
winites  on  the  other,  which  Professor  Owen  at  the  end  of  his  famous 
third  volume  has  manifestly  pointed  out,  might  have  been  introduced. 
The  definitions  of  Lamarckism  and  Darwinism  given  are  not  at  all 
clear.  That  there  is  as  much  "  innate ''  tendency  on  the  part  of 
species  to  vary  supposed  by  Darwin  as  by  Lamarck,  we  are  bound  to 
admit.  A  learned  author  has  even  proposed  to  term  Darwinism 
^'  Subjective  Transmutation,^'  and  to  reserve  the  name  "  Objective 
Transmutation''  for  Lamarckism.  Such  expressions,  while  they  are 
more  correct,  are  infinitely  more  lucid  than  those  given  by  Dr.  Ord. 
Nevertheless,  there  is  no  doubt  that  the  present  work  will  be  useful, 
as  it  is  undoubtedly  convenient  as  a  pocket  volume  for  the  student 
during  the  delivery  of  lectures. 

Jones'    Comparative    Anatomy    and    Nicholson's    Zoology.^— 

The  former  of  these  two  treatises  has  had  an  existence  of  thirty 
years,  and  been  a  favorite  during  a  generation  with  some  thousands 
of  students.  It  has  stood  alone  as  a  manual  of  comparative  ana- 
tomy with  just  so  much  physiology  as  would  interest  its  readers 
generally  who  were  not  specially  occupied  with  that  science.  It  has 
recommended  itself  to  all  by  its  easy,  agreeable  style,  and  particu- 
larly by  its  numerous  and  most  excellent  wood  engravings.  In  these 
valuable  features  and  in  the  general  scope  of  information  conveyed 
it  has  had  no  rival;  and  the  demand  for  a  fourth  edition  during  the 
current  year  indicates  for  it  a  prolonged  existence.  How  far  this 
existence  shall  be  lengthened  out  must  depend  on  its  capacity  of 

^  1.  General  Outline  of  the  Organisation  of  the  Animal  Kingdom,  and  Manual 
of  Comparative  Anatomy.  By  Thomas  Rtmee  Jones,  F.R.S.,  &c.  Foui-th 
edition,  illustrated  by  571  engravings.     Loudon,  1871.     Pp.  886. 

2.  Advanced  Text-hooTc  of  Zoology  for  the  Use  of  Schools.  By  H.  AlLEYNE 
Nicholson,  M.D.,  &c.    Edinburgh  and  Loudon,  1870.    Pp.  340. 


136  Bibliographical  Uecord.  [J 


an., 


rejuvenescence — it  must  not  grow  old  in  its  substance-matter.  We 
regret,  however,  to  state  that  our  survey  of  its  contents  forces  upon 
us  the  conclusion  that  it  is  waxing  old,  and  that  if  it  is  yet  to  remain 
a  text  book  of  the  subjects  it  professes  to  teach,  it  needs  the  hand  of  a 
young  and  skilful  reviser. 

Compared  with  the  early  editions  this  last  contains  much  additional 
matter,  but  it  is  not  up  to  the  science  of  the  day ;  and,  to  judge 
from  the  works  referred  to  as  authorities  for  its  statements,  the  author 
lacks  much  in  the  knowledge  of  recent  work  done  in  zoology  and 
comparative  anatomy  by  the  present  best  known  students  in  those 
sciences.  Moreover,  the  additions  made  are  too  much  in  the  form 
of  accretions  to  the  original  matter,  and  not  assimilated  therewith 
as  they  should  be.  These  defects  and  deficiencies  will  not  be  so 
much  felt  by  the  reader  seeking  for  general  information  in  the  sub- 
ject-matter of  the  w^ork,  but  they  will  seriously  lessen  its  value  to  the 
student  preparing  for  examinations,  at  which  the  latest  scientific 
results  are  required  to  be  known. 

Dr.  Nicholson's  advanced  text-book  of  zoology  is  intended  for 
upper  schools,  and  is  admirably  adapted  for  its  object.  We  had 
occasion  to  review  the ."  Manual  of  Zoology'"'  by  the  same  author  in 
the  number  of  this  Review  for  October,  1870,  and  to  commend  it 
for  its  general  excellence.  The  work  now  before  us  may  be  looked 
upon  as  an  abridgment  of  the  foregoing,  retaining  the  same 
characters,  giving  like  descriptions,  but  abbreviated,  and  illustrated 
by  the  same  woodcuts. 

The  descriptive  anatomical  details  are  clearly  given  and  techni- 
cality avoided ;  but  to  aid  the  beginner  unacquainted  with  zoological 
and  anatomical  terms,  a  good  glossary  is  appended  to  the  book, 
explaining  their  use  and  giving  their  derivation.  In  all  respects  this 
treatise  is  an  excellent  introduction  to  zoology,  sufficient  for  all 
readers  not  making  the  science  a  special  study. 

Animal  Plagues.i — Mr.  Fleming  occupies  a  position  which  affords 
him  special  opportunities  for  the  study  of  the  class  of  diseases  to 
which  the  term  epizootics  has  been  recently  applied  ;  but  his  book  is 
precisely  what  it  professes  to  be,  namely,  a ''  Chronological  History  of 
Animal  Plagues  from  B.C.  1490  to  a.d.  1800. 

In  his  '^Introduction,"  which  is  by  no  means  the  least  interesting 
portion  of  his  book,  he  shows  how  "  the  commencement  of  what  we 
may  call  veterinary  medicine ""  may  be  traced  to  the  superstitions  of 
the  primitive  herdsmen,  whose  parallel  may  now  be  traced  in  the 
nomadic  races  who,  with  their  countless  flocks  and  herds,  roam  over 
the  steppes  of  Central  Asia.     The  Egyptians,  Greeks,  Eomans,  and 

^  Animal  Flagues :  their  Jlistori/,  Nature,  and  Prevention.  By  Geoege 
Fleming,  F.R.G.S.,  &c.,  President  of  the  Central  Vcteriniiry  Medical  Society. 
Loudon,  1871. 


1872.]  Fleming^s  Animal  Plagues,  137 

other  nations — pastoral  and  agricultural — all  resorted  to  incantations 
and  sacrifices  for  the  ciire  of  the  diseases  of  themselves  and  of  their 
animals. 

Passing  over  our  autlior^s  allusions  to  some  of  the  special  forms  of 
belief  regarding  plagues  and  pestilences  held  in  the  time  of  Homer, 
and  subsequently  in  the  early  period  of  Eome,  we  come  to  his 
researches  on  the  ''  many  superstitious  customs,  having  reference  to 
the  preservation  of  our  domestic  animals,  that  appear  to  have  been 
derived  from  the  early  traders  with  Britain — the  Phoenicians/'  in 
which  he  shows  that  traces  of  the  worship  of  Bael,  Bel,  or  Belus, 
were  until  recently,  and  we  believe  still  are,  practised  in  the  High- 
lands of  Scotland  and  in  Ireland  (and  he  might  have  added  in  Cornwall). 
It  seems  strange  to  the  hard-headed  philosophers  of  the  present 
day — the  followers  of  J.  S.  Mill  and  Herbert  Spencer,  Tyndall  and 
Huxley — that  it  has  been  left  to  our  own  time  to  see  the  close 
connection  between  dirt  and  disease,  and  to  recognize  the  fact  that 
it  is  not  to  the  special  anger  or  displeasure  of  our  all-wise  and  all- 
merciful  Creator,  but  to  agencies  of  a  physical  nature,  commonly 
under  our  own  control,  that  epidemic  and  epizootic  diseases  are 
ours.  Scarcely  five  years  have  elapsed  since  '^  processions  of  Greek 
and  Turkish  priests  steered  bare-footed  through  the  plague-swept 
streets  of  Constantinople,  the  former  uttering  loud  appeals  for 
deliverance  from  the  scourge,  and  the  latter  calling  upon  Allah  to 
protect  them,  though  they  were  opposing  the  most  urgent  sanitary 
measures,  as  contrary  to  the  teachings  of  the  Koran  ;'^  and  about 
the  same  period  (1865)  a  catholic  archbishop  in  our  own  country 
maintained  from  the  pulpit  that  the  cattle  plague,  then  just  imported 
into  Britain,  was  directly  due  to  God^s  displeasure  at  our  great  love 
for  animals  !  while  a  clergyman  of  the  Church  of  England  similarly 
asserted  that  the  origin  of  the  malady  was  to  be  traced  to  "  our 
national  and  carnal  love  of  beef.^^  The  great  majority  of  our 
readers  will,  we  are  confident,  agree  with  Mr.  Fleming^s  observation  that 
"  such  doctrines  are  unworthy  of  Christians,  and  carry  us  back  to 
ages  when  the  perpetration  of  the  most  atrocious  crimes,  and  the 
cold-blooded  slaughter  of  whole  tribes  of  men,  women  and  children 
were  laid  to  the  favour  or  dis-favour  of  the  God  of  mercy  and 
love.^^ 

The  Introduction  concludes  with  some  valuable  remarks  on  the 
bearing  of  the  study  of  "  animal  plagues,'^  upon  human  medicine, 
agriculture,  history  and  political  economy.  "  The  losses  ^''  (says 
Mr.  Fleming)  "  from  only  two  exotic  bovine  diseases  (contagious 
pleuro-pneumonia  and  foot-and-mouth  disease)  have  been  estimated 
to  amount,  during  the  thirty  years  that  have  elapsed  since  our  ports 
were  thrown  open  to  foreign  cattle,  to  5,549,780  head,  roughly 
estimated  at  £83,616,854;  while  the  late  invasion  of  "cattle 
plague/'  which  was  suppressed  within  two  years  of  its  introduction, 


138  Bibliographical  Record.  [Jan., 

has  been  calculated  to  have  caused  a  money  loss  of  from   five  to 
eight  millions  of  pounds." 

We  regret  that  our  limited  space  prevents  us  from  noticing  this 
useful  and  interesting  volume  so  fully  as  it  deserves.  It  contains  a 
vast  field  of  antiquarian  matter  relating  to  the  diseases  of  almost  all 
kinds  of  animals — epizootics  affecting  bees,  silkworms,  fishes,  birds 
of  various  kinds,  and  mice,  cats,  dogs,  deer,  pigs,  sheep,  cattle  and 
horses. 

If  we  had  been  as  well  acquainted  as  (thanks  to  the  laborious 
investigations  of  our  author)  we  now  are  with  the  early  history  of 
the  diseases  of  our  domestic  animals,  we  might  have  derived  much 
consolation  from  the  reflection  that  the  cattle  plague  was  no  new 
disease ;  that  it  had  raged  with  more  or  less  severity  over  many 
parts  of  Europe  in  the  first  half  of  the  eighteenth  century,  and  that  it 
had,  on  at  least  two  other  occasions,  made  sad  havoc  amongst  our  own 
cattle,  without  leading  to  more  than  temporary  losses  and  troubles. 

When  and  where  this  fearfully  contagious  and  most  destructive  dis- 
ease originated  is  not  clearly  known.  Kanold,  a  German  historian  of 
his  own  time,  states  that  in  1709  its  first  beginning  or  appearance 
in  Europe  arose  in  that  part  of  Tartary  which  lies  on  the  border  of 
Asia  j  "  but  (he  adds)  whether  it  was  originally  generated  in  this 
corner  of  Europe,  or  whether  it  was  brought  there  from  Asia,  or 
yet  whether,  perhaps,  it  was  an  endemic  disease,  as  the  plague  of 
man  is  in  Turkey,  I  am  unable  to  decide.'^  In  1711  we  find  that  it 
had  spread  over  a  great  part  of  Eussia,  and  from  thence  into  Prussia, 
Hungary,  Austria,  Bavaria,  Moldavia,  Switzerland  and  Italy.  How 
long  this  disease  prevailed  is  not  definitely  known,  but  we  learn 
that  in  Holland  alone,  from  1713  to  1723,  it  destroyed  200,000 
cattle.^'  The  celebrated  anatomist  Lancisi,  who  studied  the  disease 
in  Italy,  has  given  an  excellent  description  of  it.  He  fully  recognized 
the  hopelessness  of  medical  treatment,  and  "  advised  that  every 
diseased  animal  should  be  instantly  destroyed  with  the  pole-axe,  so 
that  no  infected  blood  may  escape  to  the  ground/'  in  fact  the 
present  stamping-out  system. 

In  the  summer  of  1714  the  disease  was  carried  from  Holland  to 
England,  and  according  to  a  poet  of  that  day,  John  Morphewd,  the 
"  German  cattle  plague  '^  came  in  with  the  accession  of  the  German 
dynasty  in  England. 

This  pestilence  was  entirely  suppressed  by  means  of  the  stamping- 
out  process  within  a  few  months  of  its  appearance  in  this  country. 
It  has,  however,  been  computed  that  'Hhe  number  of  cows  and 
bulls  lost  by  this  disease  in  the  counties  of  Middlesex,  Essex  and 
Surrey  were  5,418,  and  of  calves  439/'  while  ^^from  1711  to 
1714  no  fewer  than  1,500,000  died  of  the  plague  in  Western 
Europe.'' 
In  1735  the  cattle  plague  was  agam  introduced,  as  we  learn 


]872.]  Fleming's  Animal  P la ffues.  139 

from  Mr.  Fleming,  into  Italy,  and  during  the  inteival,  from  its 
original  appearance  in  Europe  to  this  date,  it  had  probably  never 
been  quite  extinguislied  in  Poland  or  Germany.  Prom  this  time  up 
to  the  end  of  the  eighteenth  century,  this  "  bovine  scourge  "  was 
never  absent  from  some  part  of  Europe,  it  having  been  extended 
and  perpetuated  by  the  almost  continuous  wars  that  were  then 
occurring.  The  hostile  armies  were  accompanied  by  infected  droves, 
and  the  contagion  was  thus  spread  far  and  wide. 

In  171^5  the  cattle  plague  was  again  carried  into  England,  and  on 
this  occasion  it  extended  to  Ireland  and,  as  some  writers  think,  to 
Scotland. 

In  November  of  that  year  we  find  that  Dr.  Mortimer  read  a  paper 
on  this  disease  before  the  Eoyal  Society,  in  which  he  fully  describes 
the  symptoms,  the  appearances  after  death,  and  the  treatment. 
After  reading  his  prescriptions,  we  cannot  help  sympathising  with 
the  unfortunate  cows  which,  for  shortness  of  breath,  took  "  whale- 
oil  and  treacle,  each  a  pint ;  flower  of  brimstone,  four  ounces,  in  a 
mash  of  malt  twice  or  thrice  a  day;"  '^ while  for  running  of  the 
nose,^^  we  are  told  that  ^^  pouring  a  pint  of  warm  vinegar,  with  an 
ounce  of  salt,  into  the  nostrils,  has  proved  successful  in  making  the 
cow  sneeze.'''' 

Subsequent  epidemics  occurred  during  the  last  century  in  1769 
and  in  1799,  and  induced  the  legislature  to  pass  various  enactments 
to  arrest  their  progress  and  also  the  introduction  anew  of  the 
malady.  These  were  of  great  service ;  but  the  strongest  measures 
for  stamping  it  out  remained  for  adoption  in  the  last  great  epidemic 
a  few  years  ago. 

Although  the  disease  we  have  been  describing  is  for  its  virulence 
known  jjar  excellence  as  the  cattle  plague,  contagious  and  infectious 
disorders  of  various  kinds  have  from  the  earliest  times  prevailed 
among  the  lower  animals. 

These  observations  on  the  ^'cattle  disease^''  will  suffice  to  show 
the  great  amount  of  study  Mr.  Eleming  has  devoted  to  this  subject. 

We  have  looked  in  vain  throughout  the  whole  of  his  volume  for  a 
description  of  any  cattle  disease  resembling  the  Texas  disease,  to 
which  we  called  attention  in  a  recent  number  of  this  Eeview,  and 
which  is  remarkable  for  its  resemblance  to  yellow  fever.  We  learn 
from  an  American  correspondent  that  a  full  Eeport  of  the  Texas 
Cattle  Disease  is  now  printed  by  order  of  Congress,  and  that  it  will 
be  immediately  published;  and  we  trust  that  we  shall  have  an 
early  opportunity  of  reviewing  it  in  these  pages. 

Buchan's  Introductory  Text-Book  of  Meteorology, i— The  author 

1  Introductory  Text-hooJc  of  Meteorology.  By  Alexandee  Buchan,  M.A., 
F.R.S.E.,  Secretary  of  the  Scottish  Meteorological  Society;  President  of  the 
Botanical  Society  of  Edinburgh ;  and  Honorary  Member  of  the  Austrian  Meteoro- 


140  Bibliographical  Record,  [J 


an, 


of  this  work  is  well-known  even  in  medical  circles  as  an  indefatigable 
worker,  and  as  a  most  careful  observer  in  a  science  which  is  especially 
related  to  that  of  medicine.  It  was^  therefore,  with  no  ordinary 
degree  of  interest  that  we  opened  the  "Text-book  of  Meteoro- 
logy/' expecting  to  find  its  contents  of  sterling  quahty ;  nor  have 
we  been  disappointed.  No  branch  of  his  subject  has  been  neglected 
by  Mr.  Buchan,  and  he  has  treated  it  with  all  the  acumen 
which  is  certain  to  accompany,  and  to  reward,  accurate  and 
long-continued  observation.  Having  devoted  the  first  chapter 
of  his  work  to  an  historical  sketch  of  the  science,  the  author  at 
once  proceeds  to  a  consideration  of  the  nature  and  distribution 
of  atmospheric  pressure,  including  a  description  of  the  barometer, 
its  principle  and  uses.  To  the  concluding  words  of  this  part 
of  the  subject — "  the  chief  disturbing  influences  at  work  in  the 
atmosphere  are  the  forces  called  into  play  by  its  aqueous  vapour" — 
we  are  inclined  to  take  exception,  remembering  that  this  element  is 
largely,  indeed  altogether,  dependent  on  one  even  more  powerful — 
namely,  caloric.  Chapters  IV — YII  inclusive,  treat  of  tempera- 
ture, as  determined  by  thermometers  of  various  kinds,  as  influenced 
by  solar  and  terrestrial  radiation,  as  distributed  over  the  earth-'s 
surface,  and  as  related  to  atmospheric  pressure.  Under  the  second 
head  allusion  is  made  to  medical  climatology  in  a  brief  but  accurate 
manner.  The  relation  of  temperature  to  atmospheric  pressure 
forms  an  appropriate  introduction  to  the  subject  next  taken  up — the 
moisture  of  the  atmosphere.  This  is  made  to  include  hygrometry ; 
mist,  fog  and  clouds;  and  rain,  hail  and  snow.  The  matter  of 
the  chapters  which  treat  of  these  important  topics  is  particularly 
good.  We  would,  however,  offer  one  or  two  suggestions.  Thus, 
i]\Q  ^'oxdi"  evaporomeier^'  sttm^  more  correct  than  "  etmpometer" 
used  by  our  author ;  and  we  think  that  cirrus,  rather  than  cirro- 
stratus,  is  essentially  the  cloud  which  leads  to  the  appearance  of 
parheha,  paraselene,  and  halos.  Again,  Mr.  Buchan  attributes  the 
relative  greater  amount  of  rainfall  of  the  east  of  Europe  in  summer 
to  the  more  westerly  direction  of  the  wind  at  that  season.  We 
would  suggest  as  a  more  probable  cause  the  increased  frequency  of 
heavy  thunder-storms  over  the  Continent  in  the  hot  months.  In 
Chapter  XI  we  pass  on  to  the  consideration  of  wind.  This  branch 
of  meteorology  is  fully  investigated  in  accordance  with  the  principle 
laid  down  in  Buys-Ballot's  celebrated  law  of  wind  and  pressure.- 
As  this  is  the  case,  some  statements  rather  inaccurate  in  expression 
surprise  us  the  more.  Such  are  the  following:  "the  wind  blows 
from  a  region  of  higher  to  a  region  of  lower  pressure''  (page  132)  — 
there  being  no  qualifying  description  of  the  way  in  wliich  it  does 
so  j  "  the  surface  winds  blow  out  of  this  space  in  every  direction," 

logical  Society.  Edinburgh  and  London,  1871.  Octavo,  pp.  218.  With  iUustra-« 
tions  and  tinted  plates, 


187.2.]  Medical  Botaiiy  of  the  Souihcrn  Slates.  Ill 

([)nge  13  i J  i.e.  in  anticy clonic  curves.  The  first  of  tlicsc  sentences 
is  corrected  at  page  186^  and  more  fully  at  page  140.  Much  valuable 
information  as  to  climate  in  given  in  chapter  XII,  on  local  and 
other  winds.  The  essay  on  "Storms"'^  in  the  next  chapter  is  all 
that  can  be  desired,  and  is  illustrated  by  some  very  pretty  diagrams. 
We  regret  that  atmospherical  electricity  has  had  so  little  space 
allotted  to  its  consideration.  The  work  concludes  with  some  general 
observations  on  "  Weather/^  and  a  brief  allusion  to  systems  of 
storm-warnings.  Some  very  valuable  tables  for  use  in  meteorological 
investigations  are  appended,  and  render  the  book  far  more  complete 
than  its  modest  title  of  an  '^Introductory  Text-Book^'  would  lead 
one  to  suppose  it  to  be. 

Dr.  Porcher  on  Medical  Botany  of  the  Southern  States.'— 
The  copy  of  this  treatise  has  come  to  us  by  favour  of  Prof.  Henry, 
of  the  Smithsonian  Institute.  It  is  a  book  abounding  in  informa- 
tion and  replete  with  suggestions  of  new  vegetable  medicines  of 
much  promise.  The  first  part  of  the  title  is,  however,  calculated 
to  mislead ;  it  is  too  wide  and  general  for  the  contents  of  the 
volume,  and  might  well  be  omitted  in  favour  of  the  second  division. 
Eor  the  substance  matter  of  the  work  is  medical  botany,  with  notes 
on  the  economical  and  agricultural  value  and  management  of  some 
of  the  most  important  plants  and  trees. 

We  learn  from  the  preface,  that  the  book  owes  its  origin  to  the 
late  civil  war  in  the  United  States,  the  author  being  charged  by  the 
then  Confederate  Government  with  the  duty  of  collecting  information 
respecting  the  vegetable  productions  of  the  Southern  States,  with 
the  special  view  of  obtaining  home  supplies  of  drugs  and  of  mate- 
rials for  agricultural  and  economical  purposes,  in  the  absence  of  the 
accustomed  imports  denied  them  by  reason  of  the  blockade  of  their 
ports.  In  its  preparation  Dr.  Porcher  has  also  kept  *'  in  view  the 
wants  of  emigrants  and  those  abroad  who  wish  to  be  acquainted  with 
respect  to  the  agricultural  capacities  of  this  extended  section  of  the 
country.^' 

Much  diligence  is  shown  by  the  number  of  books  and  of  botani- 
cal collections  consulted;  and  the  large  amount  of  matter  compiled 
by  this  writer  is  an  earnest  of  the  immense  harvest  to  be  reaped  from 
the  study  of  the  vegetable  productions  of  the  immense  area  of 
country  comprised  wdthin  the  Southern  States,  a  tract  presenting 
wide  variations  of  climate  and  of  geological  formation,  an  extended 
sea-coast,  an  interior  mountain  range,  with  vast  forests  and  an  almost 
boundless  expanse  of  prairie  and  of  alluvial  country  in  the  course  of 
the  many  large  rivers  that  flow  through  it. 

*  Resources  of  the  Soutliern  Fields  and  Forests,  Medical,  Economical,  and 
Agricultural ;  being  also- a  Medical  Botany  of  the  Southern  States,  ivith  practical 
information  on  the  useful  'pro'perties  of  the  Trees,  Flants,  and  Shrubs.  By 
Feancis  Petee  Poechee,  M.D.,  &c.  New  edition.  Revised  and  largely  aug- 
mented.    Charleston,  1869.     Pp.  733. 


14-2  Bibliogy^aphical  Record.  [j 


an., 


In  treating  his  subject  the  author  has  adopted  the  natural  system 
of  botany,  as  laid  down  by  Dr  Lindley. 

The  economical,  agricultural,  and  commercial  value  of  several  im- 
portant plants  is  brought  under  notice  by  lengthy  dissertations,  the 
propriety  of  portions  of  which,  in  some  cases  at  least,  is  doubtful  in 
a  treatise  of  this  kind.  It  is  certainly  not  the  sort  of  treatise  an 
agriculturist  would  turn  to  for  practical  guidance  in  the  details  of 
cultivation,  nor  a  manufacturer  for  learning  the  processes  of  his  art; 
and  hence,  in  our  opinion,  many  farming  and  manufacturing  exposi- 
tions might  well  be  omitted.  We  may  cite^  as  examples  of  uncalled- 
for  detail,  the  accounts  of  indigo  planting  and  preparation ;  of  grape 
growing  and  the  making  of  wine ;  of  oak  bark  and  tanning ;  of  the 
cultivation  of  the  mulberry  and  the  rearing  and  management  of  silk- 
worms ;  of  the  cultivation  and  manufacture  of  cotton  and  tobacco  ; 
and  of  the  growth  and  various  uses  of  Indian  corn. 

To  the  information,  indeed,  conveyed  in  these  longer  articles  no 
exception  can  be  taken ;  the  fault  we  have  to  find  is,  that  the  work 
before  us  is  not  the  appropriate  vehicle  for  its  communication,  and 
we  hope  that  in  another  edition  Dr  Porcher  will  find  cause  for  cur- 
taihng  these  long  articles,  and  be  enabled  to  occupy  the  space  so 
saved  by  more  full  and  definite  histories  of  the  medical  plants  and  of 
their  virtues.  Such  information  will  be  much  more  appreciated,  in 
relation  to  the  many  important  medicinal  plants  belonging  to  the 
Mora  of  the  Southern  States ;  some  of  which  have  already  attained 
celebrity  in  Europe,  but  others  of  which  are  very  imperfectly  known, 
although  probably  equally  deserving  confidence  and  repute. 

The  author,  indeed,  has  fallen  into  the  besetting  sin  of  compilers, 
in  exercising  too  little  discrimination  in  the  quotation  of  opinions. 
Thus,  relative  to  the  uses  of  plants,  he  appeals  frequently  to  the 
notions  entertained  by  the  old  physicians,  some  of  them  dating  from 
the  early  part  of  the  eighteenth  century ;  and,  again,  to  crude  and 
unconfirmed  statements  of  many  unknown  writers  in  the  ephemeral 
literature  of  the  day.  The  reference  to  the  former  revives  tradi- 
tional marvels  of  the  efficacy  of  very  common  and  almost  inert 
plants,  whilst  that  to  the  latter  affords  no  reliable  knowledge,  and 
often  suggests  what,  prima  facie,  is  most  improbable.  An  odd  ex- 
ample for  the  curious  in  philology  occurs  at  page  240,  where  a 
writer  in  a  newspaper  is  quoted,  who,  in  speaking  of  the  sumach 
tree,  derives  its  name — which,  it  would  seem,  he  would  write  shoe- 
mach — from  its  value  in  making  shoemakers'  wax  ! 

Although  a  critical  examination  of  this  treatise  may  find  blemishes, 
a  debt  of  gratitude  is  due  to  Dr.  Porcher  for  a  volume  replete  in  in- 
formation valuable  to  the  medical  profession  at  large,  but  particu- 
larly to  those  of  its  members  resident  in  the  United  States. 


1872.1  Silvester  on  the  Spleen.  143 

Silvester  on  the  SpleenJ — In  this  able  pamphlet  Dr.  Silvester  has 
started  an  entirely  new' theory  as  to  the  nature  of  the  spleen. 

In  a  brief  history  of  the  views  held  concerning  this  organ,  he 
he  remarks  that  most  of  the  theories  with  regard  to  it  can  be  classed 
under  one  or  other  of  the  two  following  heads  : — 1.  That  it  is  the 
imperfectly  developed  left  homologue  of  the  liver.  2.  That  it  is 
an  originally  mesial  symmetrical  organ,  having  no  connection  with 
the  liver  either  in  structure  or  function.  With  the  latter  view  he 
entirely  dissents.  With  regard  to  the  former,  he  observes  that  one 
great  difficulty  in  considering  it  as  the  left  homologue  of  the  liver, 
is  the  fact  that  it  is  ductless,  and  has  never  been  shown  to  secrete 
bile. 

Nevertheless,  he  inclines  to  this  view,  and  regards  the  spleen  as 
the  left  homologue  of  only  a  portion  of  the  liver.  We  will  now  en- 
deavour to  give  as  shortly  as  possible  an  outline  of  his  theory  and 
the  grounds  upon  which  he  bases  it. 

He  thinks  that  while  the  alimentary  canal  from  the  mouth  to  the 
end  of  the  cesophagus,  and  from  the  commencement  of  the  large 
intestine  to  the  anus,  is,  undoubtedly,  mesial,  and  bilaterally  sym- 
metrical, as  is  shown  from  the  division  of  the  palate,  the  raphe  of 
the  tongue,  &c.,  and  from  the  fact  that  these  portions  of  the  diges- 
tive tract  are  suppHed  with  double  arteries,  yet  the  intermediate  por- 
tion with  the  organs  attached  is  only  in  reality  the  right  half  of  a 
bilateral  symmetrical  set  of  organs.  Of  the  left  set  of  these  organs 
the  cardiac  portion  of  the  stomach,  the  spleen,  and  vermiform  ap- 
pendix, are  the  only  traces,  the  spleen  being  the  left  homologue  of  a 
portion  of  the  liver,  and  the  vermiform  appendix  that  of  the  small 
intestine. 

The  stomach,  small  intestine,  and  liver  are,  therefore,  not  mesial 
and  symmetrical,  but  lateral  organs ;  for  he  considers  that  were  the 
stomach  fully  developed  according  to  his  hypothesis,  the  cardiac 
portion  of  it  would  be  furnished  with  a  valvular  apparatus  similar 
to  that  of  the  pyloric  end,  and  that  to  this  would  be  attached  a  left 
small  intestine  with  a  left  pancreas  and  liver. 

This  theory  he  chiefly  bases  on  the  law  of  symmetry,  and  on  the 
fact  that  the  stomach,  Kver,  and  small  intestine,  are  only  suppHed  by 
single  not  by  double  arteries,  whereas  were  they  mesial,  bilaterally 
symmetrical  organs,  they  would  with  this  method  of  blood-supply 
form  an  exception  to  the  rule  observed  in  all  other  laterally  symme- 
trical organs,  which  are  always  supplied  with  double  arteries,  one 
arising  from  each  side  of  the  aorta. 

He  also  gives  an  outline  of  the  different  forms  of  stomach  in  the 


1  The  Discovery  of  the  Nature  of  the  Spleen.     By  Henky  SllVESTEE,  B.A., 
M.D.  London. 


l44  Bihliogra2)hical  Hecord.  [Jan., 

vertebrate  series,  to  show  that  tliis  organ  is  merely'  separated  into 
right  and  h)ft  portions  distinct  in  structure  and  function,  and  is  not 
merely  a  dilated  })art  of  a  mesial  canal. 

He  furthermore  adduces  several  other  facts  in  support  of  his 
theory ;  for  instance,  the  situation  of  foetal  liver  in  the  right  hy})0- 
chondriac  region,  rather  than  in  the  middle  line ;  the  absence  of  a 
double  portal  system,  one  for  each  side  of  the  abdomen ;  the  facts 
that  the  lacteal  system  of  the  left  side  of  the  body  is  smaller  than 
that  of  the  right  side,  and  is  not  connected  with  the  small  intes- 
tine ;  that  there  is  only  one  umbilical  vein,  although  there  are  two 
umbihcal  arteries,  &c. 

We  mentioned  above  that  the  author  considered  the  spleen  to 
be  the  left  homologue  of  only  a  portion  of  the  liver,  and  this  state- 
ment needs  explanation.  Dr.  Silvester  shows  that  the  liver  is  a 
complex  gland,  composed  of  at  least  two  sets  of  apparatus,  a  biliary 
and  a  glycogenic,  and  he  thinks  that  there  may  be  a  third  set  with 
functions  similar  to  those  of  the  spleen. 

The  function  of  the  spleen  is  evidently  that  of  purifying  the 
blood  by  producing  certain  changes  in  its  constitution — as  is  shown 
by  the  enormous  hypertrophy  of  the  organ  in  certain  cases  of  blood 
poisoning, — and  also  that  of  forming  colourless  blood-corpuscles,  as 
exemplified  in  the  greatly  increased  number  of  these  cells  present  in 
the  blood  of  the  splenic  veins. 

But  the  spleen.  Dr.  Silvester  argues,  both  from  ^Uie  sraallness  of 
its  size,  and  from  the  small  proportion  of  the  entire  blood  of  the 
body  which  passes  through  it,  is  incapable  of  producing  by  itself  the 
entire  amount  of  these  corpuscles.  Now,  their  number  is  found 
largely  increased  in  the  hepatic  vein  also,  and,  therefore,  he  thinks 
that  the  liver  as  well  as  the  spleen  is  employed  in  their  production. 

He  asserts  also  that  a  fibro-cellular  structure  supporting  blood- 
vessels, such  as  forms  the  substance  of  the  spleen,  may  be  observed 
in  the  liver,  and  with  this  ])ortion  of  that  organ  he  thinks  the  spleen 
is  the  left  homologue.  If  this  be  the  case,  which,  indeed,  we 
consider  not  improbable,  the  extirpation  of  the  spleen  without  ill 
effects  to  the  system  may  be  accounted  for  from  the  fact  that  one  of 
two  smaller  glands  is  able  to  perform  the  functions  of  both,  when 
the  other  is  absent  from,  disease  or  other  cause;  as,  for  instance, 
in  the  absence  of  one  kidney  the  other  can  perform  the  amount  of 
work  proper  to  the  two. 

Dr.  Silvester's  opinion  that  the  spleen  is  a  sanguiferous  gland 
coincides  with  that  of  most  modern  observers,  but  we  think 
that  the  bilateral  theory  of  the  liver,  stomach,  and  small  intestine, 
requires  greatly  stronger  evidence  to  support  it  than  has  been,  or 
than,  in  our  opinion,  can  be  adduced.  In  this  essay.  Dr.  Silvester 
brings  forward  facts  in  comparative  anatomy  to  support  his  theory, 
by  showing  that  in  certain  cases,  one  of  two  bilateral  organs  may 


I 


3.872.]  Silvester  on  the  Spleen.  145 

be  developed  to  an  extent  very  different  from  the  other.  He  cites, 
in  illustration,  the  left  incisor  of  the  male  narwhal,  which  reaches  the 
length  of  six  or  eight  feet,  while  the  right  remains  of  an  ordinary 
size ;  the  left  ovary  and  oviduct  in  birds,  which  alone  are  functionally 
developed,  the  right  being  obstructed  at  an  early  stage ;  the  differ- 
ence in  size  between  the  right  and  left  lung  in  ophidia. 

But  in  all  these  cases  evidence  of  the  normal  type  of  the  organs 
is  shown,  either  in  certain  stages  of  their  development  in  the  very 
individual  in  which  they  afterwards  become  abnormal,  or  even  in 
other  species  of  the  class  to  which  these  abnormal  individuals 
belong  the  type  fully  exemplified  in  its  normal  development. 

But  Dr.  Silvester  can  adduce  no  evidence  of  this  sort  to  show 
that  the  digestive  tract  from  the  end  of  the  oesophagus  to  the  com- 
mencement of  the  large  intestine  is  formed  upon  a  double  bilaterally 
symmetrical  type,  for  in  no  species  in  the  whole  animal  kingdom  is 
there  any  trace  of  two  pyloric  orifices  or  of  two  separate  small 
intestines,  and  we  may  not  rashly  assume  simply  from  a  law  of  sym- 
metry that  such  is  the  type  of  these  portions  of  the  digestive 
apparatus. 

Moreover,  we  do  not  consider  that  the  distribution  of  blood  to 
these  organs  by  single  arteries  can  be  considered  as  very  weighty 
evidence  in  favour  of  the  view  that  they  are  not  originally  mesial 
and  symmetrical ;  for  the  aorta  itself  in  the  early  stages  of  develop- 
ment is  divided  near  its  origin  into  two  branches,  and  a  right  and 
left  aorta  are  actually  present  throughout  life  in  the  lower  vertebrata, 
although  in  mammalia  the  right  branch  is  early  obliterated,  and  the 
left  is  alone  functionally  developed. 

Besides,  the  arguments  concerning  the  division  of  the  stomach 
into  right  and  left  portions,  simcUirally  and  functionally  distinct^ 
may  be  adduced  in  reality  in  opposition  to  the  bilateral  theory  ;  for 
this  hypothesis  would  be  more  probable  were  the  two  portions  of  the 
stomach  similar  in  structure  and  function ;  for  how  can  one  organ  be 
the  homologue  of  another  from  which  it  differs  in  both  these  points  ? 
But  we  do  find  differences  of  structure  and  functions  in  different 
portions  of  the  length  of  the  alimentary  canal,  which  render  it 
more  probable  that  the  cardiac  portion  of  the  stomach  is  a  dilatation 
of  the  upper  portion  of  a  mesial  canal,  and  not  a  lateral  homologue 
of  the  pyloric  portion.  This  view  is  confirmed  by  comparative 
anatomy,  for  in  the  lowest  fishes  the  alimentary  canal,  including  the 
stomach,  is  quite  straight,  and  there  is  no  appearance  of  a  division 
into  right  and  left  portions,  but  the  cardiac  portion  is  a  dilated  con- 
tinuation of  the  oesophagus.  On  the  whole,  we  incline  to  the  view 
that  the  spleen  and  the  digestive  apparatus  are  originally  mesial 
organs,  and  this  view  is  not  shaken  by  the  possibility  of  a  portion 
of  the  liver  being  devoted  to  the  same  functions  as  the  spleen.  Por 
it  is  probable  that  the  thyroid  gland  and  supra-renal  capsules  have 

97— xLix.  10 


146  iiihliographical  Record.  [Jan., 

much  the  same  functions  as  the  spleen,  which  has  by  some  modern 
anatomists  been  chissed  with  them ;  at  the  same  time  it  is  certain 
that  tlie  spleen  is  not  homologous  with  them,  and,  therefore,  it 
follows  that  the  spleen  need  not  be  regarded  as  homologous  with  a 
portion  of  the  liver,  because  they  both  perform  similar  functions. 

Space  forbids  us  to  enter  further  into  the  arguments  for  and 
against  the  theory  examined.  We  conclude,  then,  by  stating  our 
opinion  that,  although  Dr.  Silvester  has  come  to  a  true  conclusion 
with  regard  to  the  functions  of  the  spleen,  yet  his  theory  concerning 
the  structural  relations  and  homology  of  that  organ  is  incorrect. 

We  advise  those  interested  in  the  subject  to  study  the  pamphlet, 
which  certainly  has  the  merit  of  being  both  original  and  ingenious. 

The  Year  Book  of  Pharmacy.^— This  volume  is  one  of  great  value 
and  interest,  and  will,  we  trust  be  the  precursor  of  a  series  of  the 
same  excellent  quality.  It  contains  abstracts  of  papers  relating  to 
pharmacy,  materia  medica,  therapeutics,  and  chemistry,  contributed 
to  British  and  foreign  periodicals  during  the  year  ending  Jane,  1870; 
and  after  these  abstracts  comes  an  account  of  the  proceedings  at  the 
Pharmaceutical  Conference  held  at  Liverpool  last  year.  Among  the 
most  striking  features  of  this  book  we  have  particular  pleasure  in 
pointing  out  the  fruit  of  scientific  research,  and  the  just  and  honor- 
able view  of  the  duties  of  the  pharmaceutist  which  it  exhibits.  A 
very  long  notice  would  be  required  to  do  thorough  justice  to  the 
merits  of  this  volume;  but  we  may  rapidly  indicate  its  chief  contents 
by  giying  a  list  of  those  subjects  which  are  treated  with  considerable 
fulness.  Amongst  these  w^e  reckon  the  peculiarities  of  foreign  phar- 
macy (p.  27) ;  discoveries  and  experiments  in  materia  medica  (pp. 
67,  96 — 146) ;  novelties  in  physiological  and  pathological  chemis- 
try, such  as  the  sulpho-carbolates  and  preparations  of  chloral  (p. 
147);  chemical  analysis,  apparatus,  and  manipulation  useful  in 
pharmacy  (p.  157);  and  miscellaneous  notes  and  observations  (pp. 
177  and  258).  The  bibliographical  notices  of  chemical  and  phar- 
maceutical works  are  useful  and  well  written,  but  the  last  hundred 
pages  or  so  of  the  volume  present  matters  of  really  unusual  interest. 
"  A  Century  of  Old  Books'"'  relating  to  pharmacy  and  allied  subjects 
engages  the  attention  of  some  eight  reporters,  and  we  are  bound  to 
say  that  the  notices  of  these  old  books  are  far  the  most  singularly 
entertaining,  and  withal  instructive.  Though  there  are  a  few  useful 
hints  to  be  got  from  some  of  the  old-fashioned  prescriptions  and 
formulae,  yet  there  are  certainly  some  scores  of  humorous  recipes 
which  it  is  difficult  to  do  anything  with  but  laugh  at.  Take,  for 
instance  (p.  32),  a  German  receipt  of  the  year  1693  for  the  Extrac- 
tum  carnis,  Liehig,  of  that  period.     To  prepare  Extractum  mumim 

^  Year-hooJc  of  Pharmacy.  Issued  by  the  Britisli  Pharmaceutical  Conference. 
Pp.  596.     London,  1870. 


1872.]  Lonsdale  s  Life  of  Heysham.  147 

you  are  directed  to  ''  Take  of  the  mummy  of  a  healthy  mau^  either 
liaiiged  or  broken  on  .the  wheels  that  is^  of  the  flesh  of  the  thighs, 
arms,  and  other  parts,  c[.  s.  This,  having  been  once  exposed  to  the 
rays  of  the  moon  and  sun,  cut  into  small  pieces,  and  sprinkle  with 
powdered  myrrh,  or  a  little  aloes ;  afterwards  macerate  twice  for 
some  days  in  tincture  of  elder  or  juniper.  Dry  the  pieces  in  the 
air,  exhaust  them  with  spirit  of  wine,  distil  off  the  spirit,  and  you 
have  the  extract  remaining."  Though  there  are  many  other  things 
comic  and  curious  culled  from  the  one  hundred  old  books  exhibited 
at  the  Pharmaceutical  Conference  at  Liverpool  (a  treatise  of  just 
900  pages  entirely  devoted  to  nutmegs  was  included  in  the  series), 
yet  there  are  other  matters  of  weightier  and  permanent  interest  to 
which  the  reader's  attention  is  here  called. 

On  the  whole  we  can  cordially  recommend  this  book  to  all  persons 
interested  in  the  proper  development  of  pharmacy,  and  anxious  to 
know  how  scientific  chemistry  is  helping,  and  may  help  forward  a 
true  and  complete  knowledge  of  materia  medica. 

Lonsdale's  Life  of  Heysham.^ — Many  a  life  is  written  and  many  a 
name  dragged  from  the  land  of  forgetfulness,  when  the  claims  for  a 
biography  are  most  questionable,  and  charity  towards  the  reading 
public  would  be  better  observed  by  leaving  the  inevitable  obhvion 
undisturbed.  To  many  the  name  of  the  subject  of  this  memoir  will, 
we  apprehend,  be  unknown ;  but  the  readers  of  the  biography  will 
be  thankful  to  Dr.  Lonsdale  for  making  them  acquainted  with  the 
history  and  work  of  Dr.  Heysham. 

It  seems,  indeed,  late  in  the  day  to  resuscitate  the  history  of  a 
man  dead  some  thirty-seven  years,  but  Dr.  Lonsdale  may  find  apo- 
logies for  so  doing,  both  in  the  fact  of  his  own  early  reminiscences 
of  the  man  and  of  his  respect  for  his  character,  and  in  the  desire  to 
secure  to  him  the  honour  of  collecting  the  materials  for  constructing 
the  Carlisle  tables,  which  have  for  many  years  formed  the  basis  for 
estimating  the  value  of  life,  in  use  by  the  principal  Life  Assurance 
Associations,  although  their  originator  may  have  been  largely  forgotten. 

The  rescue  of  Dr.  Heysham's  name  from  oblivion  is,  therefore,  a 
commendable  proceeding,  and  the  readers  of  the  '  life'  will  have  no 
cause  to  regret  its  being  written.  It  is,  indeed,  a  most  interesting 
biography,  not  laden  with  eulogy  of  its  subject,  but  bringing  him 
before  the  world  as  a  living,  busy  man,  determined  to  play  his  part 
and  do  his  best  in  the  sphere  of  life  in  which  he  found  himself 
placed. 

The  reader  is  carried  back  to  modes  of  life,  to  a  state  of  society, 

^  The  Life  of  John  Heysham,  M.I).,  and  his  Correspondence  with  Mr.  Joshua 
Milne  relative  to  the  Carlisle  Bills  of  Mortality.  Edited  by  Heney  Lonsdale, 
M.D.     London,  1870.     Pp.  173. 


llB  Bibliographical  Record.  [Juii.j 

and  to  a  professional  phase  of  existence^  each  and  all  so  unlike  what 
obtain  at  the  present  time,  that  it  seems  hard  to  believe  so  great  a 
change  to  have  occurred  within  less  than  a  century.  The  j)icture  of 
the  times,  of  the  men  and  their  manners,  is  drawn  by  a  well- trained 
scholarly  hand,  and  cannot  fail  to  interest  and  entertain. 

After  a  brief  notice  of  his  family  history  we  are  introduced  to  the 
young  Heysham  as  a  country  apprentice,  roughing  it  in  a  manner 
that  would  be  destructive  of  many  of  the  carefully  nurtured  youths 
who  now  enter  the  profession.  After  five  years^  training  in  Mr.  Par- 
kinson's surgery,  his  next  move  w-as  to  Edinburgh,  and,  in  the 
absence  of  other  means  of  locomotion,  this  journey  of  170  miles  had 
to  be  performed  on  horseback.  At  Edinburgh  he  studied  physic 
under  Monro,  Cullen,  Black,  and  others  of  fame,  and  obtained  his 
doctor's  degree  in  1777.  After  a  visit  to  Holland  he  settled  the 
following  year  in  Carlisle,  where  he  spent  the  remainder  of  what  may 
be  described — 'except  so  far  as  the  works  he  engaged  in,  and  of 
which  the  results  remain — as  an  uneventful  life.  We  find  him  the 
friend  and  associate  of  the  leading  people  of  the  old  city  and  its 
neighbourhood,  interesting  himself  in  the  public  matters  of  the 
locality,  aiding  various  schemes  of  pubhc  utility,  and  performing 
very  assiduously  the  duties  of  a  magistrate.  The  sketch  of  the 
worthy  doctor  in  this  last  capacity  will  be  read  with  much  amuse- 
ment, and,  we  may  add,  with  some  wonderment ;  for  it  would  seem 
that  the  performance  of  his  magisterial  duties  was  a  source  of  consi- 
derable income,  eking  out  very  materially  the  comparatively  small 
return  of  £400  a  year  derived  from  practice. 

Following  the  custom  of  his  time,  he  drank  freely,  though  no 
drunkard.  He  associated  on  terms  of  equality  with  various  fellow- 
citizens  who  held  a  sort  of  pre-eminence  as  "  three-bottle  men,''  and 
both  he  and  they  "  lived  to  a  great  age,  and  enjoyed  life  to  the  very 
last." 

Dr.  Heysham  had  considerable  claims  as  a  naturalist.  Erom  his 
early  days  he  was  ardently  given  to  the  pursuit  of  natural  history, 
and  from  his  own  researches  obtained  an  intimate  acquaintance  with 
the  fauna  and  flora  of  Cumberland.  Ornithology  appears  to  have 
been  the  favorite  branch  with  him.  Unfortunately  he  did  not  collect 
and  publish  his  observations  as  he  might  have  done,  and  excepting 
some  fifty  pages  in  Hutchinson's  quarto  ^  History  of  Cumberland,'  no 
record  of  them  exists. 

However,  his  chief  claim  to  fame  rests  on  his  assiduity  in  collect* 
ing  from  the  bills  of  mortality  of  Carlisle  those  data  which  form  the 
basis  of  the  celebrated  Carlisle  tables.  His  intimate  knowledge  of 
the  people  and  of  the  circumstances  influencing  their  longevity,  gave 
precision  to  statistics  which  could  not  otherwise  have  possessed  such 
value  as  fitted  them  for  the  purpose  to  which  they  were  applied  by 
Mr.  Joshua  Milne,  the  actuary  of  the  Sun  Life  Assurance  Society, 


1872.]  Ancient  Works  on  Syphilis.  149 

by  whose  labours  they  were  reduced  to  the  form  available  for  the 
valuation  of  life. 

In  an  appendix  Dr.  Lonsdale  gives  the  correspondence  between 
Pleysham  and  Milne  relative  to  the  information  collected  and  the 
circumstances  of  the  construction  of  the  Carlisle  tables.  Such  cor- 
respondence will  especially  commend  itself  to  actuaries  of  life  offices. 
The  details  of  Dr.  Hey  shames  life,  and  of  the  state  of  provincial 
gaiety  prevailing,  will  interest  not  only  the  professional  but  likewise 
the  general  reader.  The  manner  in  which  Dr.  Lonsdale  has  per- 
formed his  part  cannot  be  too  highly  praised. 

Ancient  Works  on  Syphilis.^ — However  it  may  be  accounted  for, 
there  are  signs  just  now  portending  of  a  new  revival  or  second  re- 
naissance in  old  medical  lore  at  the  hands  of  the  syphilographers. 
So  little  is  it  the  result  of  general  conviction  that  we  must  fain  credit 
them  on  the  occasion  with  an  earnestness  all  their  own.  No  greater 
advance,  it  must  be  confessed,  has  been  recently  achieved  in  medi- 
cine than  that  which  refers  to  syphilis^  as  its  remote  and  natural  con- 
sequence, a  variety  of  visceral  lesions.  Long  ignored,  we  acknow- 
ledge them  at  length ;  and  it  is,  no  doubt,  in  a  very  high  degree 
satisfactory  to  find  the  view  confirmed,  or  shall  we  not  rather  say 
anticipated,  by  those  who  have  long  ago  preceded  us. 

But  perhaps  it  is  on  too  narrow  grounds  that  we  rest  this  novel 
fascination.  When  we  find  so  many  truths  of  earnest  disputation  in 
our  day  to  have  been  settled  long  since  by  these  authors,  when  we 
think  upon  these  contestations,  the  uncertainty  of  each  and  all  par- 
ticulars, and  find  them  resolved,  in  a  sense  that  accords  with  our 
ultimate  experience,  by  so  many  mediseval  physicians,  it  is  easy  to 
account  for  admiration,  even  carried  sometimes  to  excess  by  observers 
among  ourselves  who  have  most  experienced  the  cost  of  inquiry,  and 
suffered  the  toil  of  investigation.  The  incorrectness  of  these  ancient 
authors  in  point  of  clinical  remark  bears  no  degree  of  comparison 
with  what  they  have  faithfully  recorded. 

Physiology  in  those  days  was  so  wondrous  low,  the  Galenic  doc- 
trines so  obtrusive  and  predominant,  that  httle  might  be  looked  for 
of  a  sound  complexion  in  a  maze  of  tedious  futilities ;  but  the  con- 
trary is  really  the  case ;  the  clinical  sense  was  not  often  betrayed, 
nor  was  their  pathology  so  wholly  wide  of  the  mark  as  might  have 
been  expected  beforehand.     As  regards  these  mediaeval  writers,  after 

1  Feacastor,  La  Syphilis,  A.D.  1530.  Le  Mai  Fran^ais,  extrait  du  livre  *  De 
Contagionibus,'  A.D.  1546.  Traduction  et  Commentaires.  Par  Dr.  Alfred 
FouRNiER,  Medecin  des  Hopitaux,  &c.     Paris,  1870. 

Jacques  de  BExnENCOURT.  Nouveau  Careme  de  Penitence  et  Piirgatoire 
d' Expiation,  a  Vusage  des  malades  offectes  du  Mai  Francais  ou  Mai  Venerien. 
Ouvra::re  suivi  d'un  dialogue  oil  le  mercure  et  le  gaiac  exposent  leurs  vertus  et 
leurs  pretensions  rivalcs  a  la  gueiisou  de  la  dite  maladie,  a.d.,  1527.     Idem,  Idem. 


150  Bibliographical  Record.  [J 


an. 


years  of  clinical  stady,  and  the  sifting  of  a  thousand  minutiae  with 
all  the  machinery  of  statistics,  and  the  microscope  ever  at  hand, 
strange  were  it  indeed  if  we  stood  not  now  at  a  level  to  judge  them  at 
their  desert.  What  gives  much  weight  to  the  collection  before  us 
is  that  the  author  is  no  mere  humanist,  nicely  versed  in  classical  and 
medical  reading,  but  one  who  is  firmly  established  in  repute  as  a 
master  of  clinical  study.  Of  high  and  surpassing  scholarship  there 
is  no  pretension  made,  the  tone  is  of  moderate  pitch,  and  somewhat 
too  apologetic,  perhaps,  for  one  who  undertakes  the  advocacy  of  the 
forsaken.  Let  us  say  that  the  aim  is  practical,  and  directed  toward 
skill  in  medicine.  We  shall  but  glance  at  the  work  of  Eracastor ; 
that  is  to  say,  his  celebrated  poem.  Born  in  1483,  from  mere  ten- 
derness of  age  he  could  hardly  realise  in  fullest  extent  the  great 
strong  agitations  of  the  outbreak  which  alarmed  and  surprised  his 
contemporaries.  The  poem  bears  date  a.  d.  1530,  but  he  was  engaged 
many  years,  no  doubt,  in  the  performance.  The  prose  works  of 
Fracastor  have  scarcely  a  minor  value  or  an  inferior  degree  of  interest. 
We  pass  on  to  an  author  far  less  or  not  at  all  known  to  our  genera- 
tion. The  work  of  Bethencourt  was  the  earliest  published  in  Prance 
upon  the  same  disease.  Strange  to  say  it  was  printed  a.  D.  1527, 
though  the  manuscript  dates  from  a.  d.  1525,  very  much  in  arrear 
of  other  countries.  The  disease  had  then  prevailed,  he  says,  some 
thirty  years  or  so ;  it  had  spread  with  great  rapidity,  affecting  a  vast 
number  of  persons.  If  we  are  to  believe  this  author,  at  the  time  he 
wrote  it  was  of  more  frequent  occurrence  than  all  other  diseases 
combined.  The  work  of  Jacques  de  Bethencourt  is  a  small  volume 
of  120  pages  ;  it  is  written  in  Latin.  As  laid  before  the  reader,  it 
has  been  subject  to  wholesome  retrenchment.  The  French,  or  as  he 
prefers  to  call  it,  the  Venereal  disease,  arises  from  sexual  intercourse, 
but  also,  in  rare  instances  and  exceptionally,  from  chaste  and  inno- 
cent contact.  Always,  however,  in  these  conditions  it  is  initiated  by 
the  like  sores  as  are  wont  to  betray  its  origin  in  the  common  path  of 
contagion;  that  is  to  say,  primaries  arise  in  natural  course  from 
infection  by  secondaries.  The  instance  he  gives  of  this  is  the  sore 
that  comes. in  the  mouth  of  the  infant  infected  by  its  nurse.  lie 
distinguishes  consecutive  symptoms ;  the  further  from  its  origin  the 
more  it  changes  its  ''  physiognomy.''''  He  notices  the  Protean  type 
of  the  disorder;  it  is  composed,  he  says,  of  so  many  maladies.  It  is 
also  at  times  hereditary.  Many  years  it  lies  in  abeyance  and  is  occult ; 
a  man  that  has  had  it  is  like  a  fouled  cask  for  ever,  he  is  subject  to 
sudden  outbreaks  and  complications  that  sound  men  escape  from. 
It  is  worse,  he  says,  in  those  well  advanced  in  age.  Among  the 
viscera  the  brain  is  the  most  liable  to  be  affected,  next  tlie  liver;  the 
heart  is  much  protected,  it  occurs  therein  but  rarely.  The  bones 
suffer,  though  not,  indeed,  at  first,  while  the  cartilages,  ligaments, 
and  tendons  are  implicated  far  less  often,  and  in  an  inferior  degree 


1872.]  On  Epidemic  of  ''  Red  Fever  J*  151 

the  contrary  is  the  case  witli  the  nerves  and  also  the  membranous 
parts.  The  muscular  web  is  very  much  concerned ;  the  pain,  in- 
deed, is  chiefly  found  about  the  middle  of  the  limb.  Spleen,  kidneys, 
lungs,  and  fatty  tissue  have  more  immunity.  Sometimes  there  is 
oedema,  pulmonary  ulceration,  consumption,  small  ulcers  in  the 
trachea,  the  pharynx,  and  also  the  oesophagus.  There  is,  indeed,  a 
world  of  curiosity  in  this  small  book  of  Bethencourt.  He  would 
seem  to  believe  in  a  reiteration  of  the  complaint.  Not  the  least 
interesting  part  of  the  work  is  the  dialogue  or  disputation.  How 
can  you  tax  me,  says  Mercury,  with  such  defects  ?  When  I  am 
given  for  psora,  for  tinea,  and  phthiriasis,  do  you  then  find  these 
ulcerations  of  the  throat,  of  the  palate,  nasal  fossae,  and  uvula  of 
which  you  now  accuse  me  ?  Do  you  find  the  same  of  the  foulness 
of  the  breath  ?  Bethencourt  declares  himself  for  mercury,  but  it 
must  be  given  with  much  scruple  and  conscientious  care.  It  is 
truly  a  sort  of  purgatory  which  the  patient  has  to  pass  through. 

Remarlcs, — It  is  only  the  external  use  of  the  drug  which  comes  in 
question.  Is  the  disease  old?  is  the  patient  broken  in  health  or 
aged  ?  then  your  dose  of  mercury  must  be  small,  the  treatment  more 
prolonged.  The  same  with  the  guiaicum,  it  is  given  according  to 
the  Indian  method ;  but  can  the  patient  bear  this  forty  days'  fast, 
this  strict  and  trying  regimen  ?  In  many  cases  it  will  have  to  be 
refused.  The  collection  of  these  handy  books  will  comprise  John  de 
Vigo  and  Thierry  de  Hery,  and  we  are  also  promised  selections  from 
Leonicenus,  Torella,  Yillalobos,  Ulrich  von  Hiitten,  Massa,  Tallopius, 
Fernel,  and  others. 

Poggio  on  Epidemic  of  ''Red  Fever"  orDengue.i — The  red  fever 
is  that  which  was  known  to  the  people  as  tracazo  or  stroke,  as  it 
occurred  in  Andaluzia  and  other  provinces  of  Spain  during  the  years 
A.D.  1865-7.  This  does  not  appear  to  have  been  its  first  occurrence 
in  the  peninsular.  In  Cadiz  and  Seville,  during  the  past  century, 
A.D.  1764-8,  there  is  described  by  Spanish  writers  a  notable 
epidemic  of  the  same  type,  then  called  la  piadosa,  the  piteous  disease. 
Elsewdiere  it  has  been  termed  la  pantomina ;  it  is  the  polka  of 
Brazil,  the  dandy  fever  of  Saint  Thomas.  In  the  West  Indies  it  is 
more  familiar  to  experience  than  elsewhere  (see  Historia  de  una 
epidemia  padecida  en  Curazao  y  la  Kahana,  por  el  Br.  B.  Jose 
Garcia  Arholeya,  Cadiz,  1854,  page  141.)  It  is  called  the  Colo- 
rado, by  the  Spanish  population  in  these  islands,  as  well  as  on  the 
American  continent.  The  author  last-named  describes  it  well,  but 
has  not  distinguished  it  from  scarlatina.     As  occurring  in  Santa  Ee 

^  La  calentura  roja  ohservada  en  sus  apariciones  epidemicas  de  los  anos  1865  y 
1867.    For  D.  Ramon  Heenandez  Poggio.    Madrid,  1871. 

The  Red  Fever  as  observed  in  the  Epidemics  1865  and  1867-  By  Don  Ramon 
Heenandez  Poggio.    Madrid,  1871.     Large  8vo,  pp.  74. 


153  Bibliographical  Record.  [Jan., 

de  Bogota,  it  is  treated  of  by  a  rrencli  physician,  Leblond,  at  the 
close  of  the  past  century  (see  Observations  sur  la  fiievre  jaune  et  sur 
les  maladies  des  tropiques,  Paris,  1805,  page  44).  In  S.  Cruz  de 
Teneriffe  and  the  Canary  Islands,  it  was  studied  by  our  author, 
A.D.  1865.  This  is  the  dengtte,  breakhone  fever,  rheumatic  scarla- 
tina of  the  English  and  American  writers.  Cook  and  Stedman  among 
the  English ;  Dutrouleau,  Barmer,  Thaly,  Ballot  among  the  Erench, 
have  written  of  it.  The  further  descriptions  are  much  scattered  in 
our  literature,  but  there  is  a  good  though  brief  summary  in  Aitken's 
text- book.  A  great  variety  of  names  have  been  applied  to  the 
complaint,  but  the  Erench  generally  agree  to  call  it  the  red  fever. 
Nor  has  this  been  done  without  protest,  for  one  of  their  authors, 
D.  E.  Thaly,  has  remarked  that  as  found  prevailing  among  the 
negroes  there  is  no  such  redness  to  be  seen,  but  simply  an  interrup- 
tion of  tint — a  very  apparent  variation  in  the  skin.  Martinique, 
Goree  in  Africa,  and  the  Isle  of  Bourbon  have  been  the  chief  fields 
of  observation  respecting  this  fever  for  the  Erench.  It  has  been 
also  described  by  Dr.  James  Mellish,  in  Calcutta,  under  the  name 
of  inflammatory  epidemic  fever.  It  is  not  unknown  in  British  India 
and  on  the  American  continent.  The  circumstance  that  Sydenham 
has  called  scarlatina  the  red  fever  will  ever  hinder,  we  suppose,  the 
Erench  designation  from  being  acceptable  to  us.  There  is  small 
doubt  that  the  dengue  is  contagious,  though  much  favoured  in  its 
development  by  atmospheric  conditions,  the  most  apparent  being 
heat  and  moisture.  An  example  is  given  from  the  record  of  1764, 
of  its  infection  being  carried  by  the  breeze  to  a  vessel  hugging  the 
shore  from  Cadiz  to  Cape  St.  Yincent,  while  some  others  further  off 
escaped  (page  36).  In  this  distressing  but  rarely  fatal  complaint, 
Dr.  Poggio  regards  the  eruption  as  a  most  essential  feature ;  it  is 
not  accidental,  a  mere  epi-phenomenon.  Its  absence  in  certain  cases, 
or  in  a  certain  group  of  cases,  must  be  considered  on  the  same 
footing  as  an  exanthema  sine  exanthemate. 

He  describes  the  eruption  as  occurring  from  the  second  to  the 
fourth  day,  generally  after  a  remission  obtained  from  the  anterior 
febrile  oppression  through  diaphoresis ;  at  the  same  time  there  is 
felt  great  debility  and  prostration  of  the  vital  powers,  which  is  a 
notable  feature  in  the  malady,  as  it  is  just  the  same  as  in  influenza. 
The  implication  of  the  mucous  tract  is,  however,  far  less  than  in 
the  latter,  and  this  suffices  to  distinguish  them.  The  desquamation 
is  extensive  and  considerable.  In  the  Canary  Islands  the  eruption 
assumed  chiefly  the  form  of  scarlatina;  in  Cadiz  that  of  roseola.  The 
pains  are  severe,  sometimes  beginning  in  the  joints  of  the  toes, 
sometimes  in  the  region  of  the  spine.  Early  lumbar  distress,  great 
cerebral  oppression,  and,  as  well  as  the  rheumatic  pains,  various 
hysteriform  phenomena  attend  the  disorder.  More  rarely,  as  in 
Teneriffe  and  Africa,  bilious  and  typhoid  conditions  complicate  it 


1872.1  Dr.  Fox  on  Cold  in  Hyperpyrexia.  153 

and  render  the  prognosis  less  favorable.  Imminent  danger  attends 
the  employment  of  the  lancet^,  evacuants  check  and  prolong 
the  evolution  of  the  complaint.  Head  oppression  and  nervous 
disturbance  are  best  combated  by  valerian,  camphor,  asafoetida, 
ether,  ammonia,  and  even  by  Dover's  powder  repeated  in 
moderate  doses.  A  yellow  condition  of  the  skin  and  other  signs  of 
hepatic  congestion  are  best  dealt  with  by  an  ipecacuanha  emetic. 
Demulcents,  lemonade,  various  tisanes,  especially  that  of  the  lime 
flower,  tilleul  of  the  Trench,  with  a  warm  bottle  to  the  feet  will 
generally  carry  the  patient  through  the  disorder  till  the  stage  for 
giving  tonics  arrives,  and  these  may  be  begun  as  soon  as  the  stomach 
allows  of  it,  with  generous  and  supporting  food.  The  malady  is 
sufficiently  grave  to  endure  three  weeks,  and  relapses  are  not 
unfrequent.  We  regard  this  work  as  a  valuable  addition  to  the 
history  of  this  strange  exotic.  It  contains  ample  references,  and 
the  tone  is  thoughtful  and  philosophical  throughout. 

Dr.  Fox  on  Cold  in  Hyperpyrexia.^ — The  profession  will  be  very 
pleased  to  have  Dr.  Wilson  Poke's  very  suggestive  and  practical  lec- 
tures, as  originally  published  in  the  '  Lancet,'  reprinted  in  the  present 
form  as  a  book.  Indeed,  this  volume  is  more  than  a  reprint,  for  it 
contains  additional  details  of  the  illustrative  cases,  '^tables  of  the 
observations  made  on  the  temperature  during  the  treatment  by  cold 
applications,  and  also  during  their  later  stages,''  two  charts  of  tem- 
perature and  one  of  sphygmographic  tracings,  the  history  of  a  case 
previously  treated,  and  a  tabular  outline  of  twenty-two  cases  of 
hyperpyrexia  recently  published. 

These  lectures  indicate  a  course  to  be  profitably  pursued  in  deve- 
loping a  system  of  scientific  and  rational  therapeutics.  It  is  true, 
indeed,  that  Dr.  Currie,  at  the  beginning  of  this  century,  advanced 
far  on  the  same  road,  and  erected  a  basis  for  the  development  of  a 
system  of  treatment  by  cold  water,  but  he  lived  in  advance  of  his 
time,  and  his  contemporaries  were  possessed  of  too  many  theoretical 
notions  derived  from  the  old  doctrine  of  fluxions  to  give  heed  to  his 
experience,  and  were  too  timid  to  test  it  for  themselves. 

With  Dr.  Fox's  chnical  records  in  hand,  it  will  be  interesting  to 
turn  to  Currie's  old  volumes,  and  to  compare  the  experience  and 
views  of  these  two  physicians.  Every  reader  of  Dr.  Fox's  brochure 
will  be  persuaded  that  we  have  a  potent  therapeutical  agent  in  cold 
water,  suitable  not  only  for  desperate  cases,  such  as  he  particularly 
refers  to,  but  also  to  a  wide  category  of  diseases  in  which  the  ther- 
mometer indicates  a  pyrexial  state. 

The  practitioners  of  hydropathy  ought,  indeed,  to  have,  ere  this, 
satisfactorily  laid  down  physiological  principles  for  the  application  of 

'  On  the  Treatment  of  Hyperpyrexia,  as  illustrated  in  Acute  Articular  Rheu- 
matism, hy  means  of  the  external  application  of  cold.  By  WiiiSON  Fox,  M.D.,  &c, 
London,  1871.    Pp.  78, 


154  Bibliographical  Record.  [Jan., 

cold  and  also  of  hot  water,  but  empiricism  and  boarding-house 
economics  have  too  much  beset  their  practice  and  vitiated  their 
experience. 

In  the  history  of  cold  as  a  remedial  agent  we  must  also  not 
forget  Dr.  Chapman,  who  has  zealously  advocated  its  application  in 
numerous  diseases.  His  enthusiasm,  indeed,  has  jeopardised  his 
cause;  but  at  a  future  time,  when  the  uses  of  cold  have  been 
established  on  a  physiological  and  pathological  basis,  Dr.  Chapman's 
name  will  be  referred  to  as  that  of  a  prime  mover  in  forcing  their 
consideration  upon  the  profession.  The  manner  in  which  Dr.  Fox 
has  handled  the  subject  of  cold  in  hyperpyrexia,  in  these  lectures, 
will,  in  our  opinion,  constitute  a  turning  point  in  rational  thera- 
peutics. 

Trousseau's  Clinical  Medicine.'— It  will  be  gratifying  to  the 
subscribers  of  the  Sydenham  Society  to  have  this  fourth  volume  of 
these  justly  celebrated  lectures  placed  in  their  hands;  and  from  the 
date  of  issue  hitherto  maintained,  to  anticipate  the  early  completion 
of  the  work.  The  present  part  is  occupied  by  lectures  on  dyspepsia, 
gastritis,  and  chronic  ulcer  of  the  stomach ;  on  diarrhoea  in  adults 
and  children;  on  lactation  and  dentition;  on  dysentery  and  con- 
stipation ;  '  on  fissure  of  the  anus,  and  intestinal  occlusions ;  on 
hepatic  colic  and  calculus ;  hydatic  cysts  and  malignant  jaundice; 
on  syphilis  in  infants ;  on  gout  and  on  nodular  rheumatism ;  on  rheu- 
matic gout,  and  on  acute  articular  rheumatism  and  ulcerating 
endocarditis. 

The  contents,  therefore,  are  rather  miscellaneous  ;  but  the  student 
may  be  sure  of  a  thoroughly  practical  consideration  of  the  several 
subjects,  and  of  great  clearness  in  the  enunciation  of  the  pathological 
truths  and  inferences  put  forward.  Tlie  examination  of  the  special 
teaching  of  Trousseau  must  be  made,  as  occasion  offers,  in  the 
discussion  of  those  subjects  respecting  which  he  has  displayed  the 
most  originality  in  thought  and  in  observation. 

Senac  on  Hepatic  Colic. i— Whether  justly  or  unjustly,  it  is 
frequently,  one  might  very  well  say  usually,  the  case,  that  when  a 
work  emanates  from  some  physician  residing  at  a  health-resort — be 
it  distinguished  as  a  sea-side,  or  a  potable  saline  or  mineral  water 
resort,  or  simply  as  a  place  remarkable  for  the  beauty  of  its  scenery 
and  the  salubrityof  its  climate — the  object  of  such  work  is  supposed 
to  be,  principally,  to  advocate  and  advertise  the  same  as  a  residence 
for  invahds,  with  the  very  natural  desire  of  promoting  the  pros- 
perity of  the  place,  and  of  advancing  the  well-doing  of  the  local 

1  Lectures  on  Clinical  Medicine.  By  A.  Teousseau,  M.D.,  &c.  Translated 
from  the  edition  of  1868  by  John  Rose  Coemack,  M.D.,  &c.  New  Sydenham 
Society,  1871.     Pp.  470. 

2  Du  Traitment  cles  Coliques  Kepatiques.  Par  le  Dr.  H.  Senac,  Medeciu  a 
Vichy,  1870. 


1872.] 


Senac  on  Hepatic  Colic. 


155 


medical  men  generally,  and  that  of  the  writer  in  particular  :  we  say- 
that,  whether  justly  or  unjustly,  this  is  the  usual  idea  with  which 
such  publications  are  received,  and  it  was  with  some  such  feeling  we 
took  up  Dr.  Senac's  volume  of  260  pages — a  volume  that  is  well 
printed  on  but  indifferent  paper,  and  with  the  thinnest  of  covers. 

A  glance  at  the  introduction,  which  is  a  long  one — twenty-three 
pages — and  at  some  parts  of  the  body  of  the  work,  soon  assured  us 
that  Dr.  Senac^s  book  merits  a  higher  position  than  is  usually 
accorded  to  the  class  of  publications  before  mentioned. 

The  first  paragraph  of  the  introduction  gives  the  ground  on 
which  the  author  has  based  his  observations.  He  says,  "Le  travail 
que  nous  offrons  au  public  medical  est  base  sur  les  resultats  d^une 
pratique  de  onze  annees,  a  Vichy,  station  thermal  ou  affluent,  de 
toutes  parts,  les  malades  atteints  de  Coliques  Hepatiques." 

The  last  paragraph  of  the  introduction  suffices  to  show  the 
motives  he  was  influenced  by  when  carrying  on  his  work,  and  the 
object  he  aims  at.  ^'Appelons  de  tons  nos  voeux  les  travaux 
d'hommes  plus  autorises  et  qui  viennent  corroborer  les  notres  ou  les 
contredire,  si  nous  avons  vu  mal,  ou  mal  apprecie.  Et  puissions- 
nous  avoir  etc  assez  heureux  pour  contribuer,  dans  le  mesure  de  nos 
forces,  II  faire  avancer  Part  de  guerir  vers  le  but  de  nos  eff'orts  :  la 
verite.'''' 

Beyond  this,  the  introduction  also  serves  as  a  sort  of  "  key  "  to 
what  may  be  expected  to  be  found  in  the  four  chapters  into  which 
the  book  is  divided  ;  and  this,  not  only  as  regards  the  writer^s  own 
views  of  the  nature  of  the  affections  he  designates  "  Coliques  Hepa- 
tiques/^  but  also  as  to  the  various  theoretical  points  on  which  he 
ventures  to  differ  from  other  authorities. 

The  first  chapter,  which  has  several  divisions,  is  devoted  to  a 
description  of  symptoms  :  it  includes  the  prodromatic  symptoms — 
symptoms  present  at,  during,  and  after  "  la  crise  hepatique  :''  then 
follows  au  appendix  to  the  chapter  with  an  interpretation  of  the 
symptoms,  an  illustrative  case,  and  the  author^s  conclusions. 

The  second  chapter  gives  the  etiology  of  the  condition,  and 
recounts  the  various  predisposing  and  determining  causes :  this 
chapter,  too,  has  sub-heads,  and  an  appendix.  In  the  latter  we  find 
a  description  of  "  la  nature  arthritique  des  Cohques  Hepatiqucs." 

The  third  chapter  is  headed  "  Eapports  des  Coliques  Hepatiques, 
avec  diverses  manifestations  arthritiques."  In  this  part  of  the 
work  there  are  given  numerous  cases  under  the  somewhat  obscure 
description  of  "  Observations.'^  The  general  divisions  of  the 
chapter  arc  devoted  to  "  Lithiase  Urinaire,"  "  Calculs  Urinaires," 
"  Gravelle  Urinaire/'  "  Goutte,''  "  Ehumatisme,''  "  Asthme,'' 
"  Arthritides.'''  Like  the  two  preceding  chapters  this  one  has  also 
an  appendix. 

The  fourth  and  last  chapter  is  a  very  long'^one  and  is  devoted  solely 


156  Bibliographical  Record.  [Jan., 

to  treatment.  It  contains  a  lengthy  and  painstaking  account  of  every- 
thing Dr.  Senac  has  tried  for  the  relief  of  all  the  various  states  and 
conditions  described  in  thq  preceding  portion  of  the  book.  Every 
chapter,  it  will  have  been  observed,  has  had  its  appendix,  and  it  is 
not  until  we  come  to  this  supplementary  part  of  chapter  number 
four,  at  page  206,  that  we  find  the  treatment  by  Vichy  baths,  Vichy 
water  and  air,  specially  referred  to  and  described. 

The  volume  is  intended,  as  expressed  by  the  author  in  his  intro- 
duction, to  be  an  essentially  practical  one,  and  consequently  the 
reader  must  be  prepared  to  find,  or  rather  not  to  find,  any  of  those 
interesting  accounts  of  experimental  physiology  with  whicli  such 
works  as  Ererichs,  Fauconneau  Dufresne,  Budd,  and  Murchison,  are 
interspersed.  Dr.  Senac  confines  himself  to  observations  on  certain 
purely  functional  disorders  of  the  liver,  and  what  he  believes  to  be 
resultant  conditions :  his  treatment  of  these  states  may  be  looked 
upon,  as  a  whole,  as  being  determined  principally,  if  not  entirely, 
by  symptoms. 

Undoubtedly  the  book  may  be  read  profitably  by  every  practitioner; 
but  we  fail  to  see  that  it  has  opened  up,  in  a  satisfactory  manner, 
any  new  ground  in  connection  with  that  long  Hst  of  dyspeptic 
ailments  with  which  deranged  hepatic  function  is  so  very  usually 
associated. 

Liverpool  Medical  Reports.^ — We  have  so  recently  noticed  the 
fourth  volume  of  these  reports  that  we  have  really  nothing  to  add 
to,  or  to  take  away  from,  the  observations  we  then  made  with  regard 
to  the  merits  and  defects  of  this  publication. 

The  fifth  volume,  like  its  predecessors,  has  about  a  third  of  its 
pages  occupied  with  abstracts  from  the  proceedings  of  the  Liverpool 
Medical  Institution,  the  Microscopical  Section  of  the  Medical  Institu- 
tion, and  the  Liverpool  Northern  Medical  Society. 

The  original  articles  are  practical  in  their  character,  but  very 
brief,  and  consist  of  contributions  by  Dr.  Skinner,  Dr.  W.  Carter, 
Dr.  Wallace,  Dr.  J.  C.  Brown,  Dr.  Cleaver,  Dr.  W.  Little,  Dr. 
Weaver,  Mr.  G.  E.  Walker,  Dr.  Lyster,  Dr.  De  Zouche,  Mr. 
Higginson,  Mr.  Wood,  Dr.  T.  E.  Glynn,  and  Mr.  Abraham. 

We  think  the  articles,  generally,  do  not  compare  unfavorably 
with  those  in  former  volumes  ;  and  the  illustrations,  of  which  there 
are  several,  deserve  to  be  spoken  of  in  terms  of  high  praise.  The 
volume,  in  point  of  paper  and  printing,  is  exceedingly  well  got  up. 

Physiological  Anatomy  and  Physiology  of  Man.^— After  a  lapse 
of  about  five  years  Dr.  Beale  has  at  length  brought  out  Part  II  of  the 

'  The  Liverpool  Medical  and  Surgical  Reports.  Edited  by  P.  M.  Braidwood, 
M.D.,  and  Heginald  Haeeison,  F.R.C.S. 

^  The  Physiological  Anatomy  and  Physiology  of  Man.  By  R.  B.  Todd,  \V. 
Bowman,  and  Lionel  S.  Beale.  A  new  edition  by  the  list-niuned  author. 
Part  II  of  vol.  i,     London,  1871.     P|).  152. 


1872.] 


The  ^Medical  (Jourier^  of  Lisbon.  \d1 


first  volarae  of  his  edition  of  ^^Todd  and  Bowman's  Human  Physio- 
logy and  Anatomy/'  This  part  treats  of  the  tissues,  their  develop- 
ment, nutrition,  and  microscopic  anatomy,  and  contains  a  full 
description  of  all  the  more  simple  tissues^  together  with  chapters  on 
cartilage,  bone  and  fat. 

In  it,  with  the  aid  of  numerous  and  well-drawn  plates,  Dr.  Beale 
exemplifies  his  theory  on  the  method  of  development  and  nutrition 
of  tissue  by  the  germinal  matter  or  bioplasm,  but  space  forbids  us 
entering  into  an  argument  on  the  details.  Coming  from  the  hands 
of  such  a  skilful  and  accurate  microscopical  observer,  the  work  is  of 
course  very  valuable ;  but  it  is  much  to  be  regretted  that  so  much 
time  is  allowed  to  intervene  between  the  appearance  of  each  part. 
At  the  present  rate  of  progress,  by  the  time  the  work  is  completed, 
the  earlier  parts  will  of  necessity  become,  to  a  great  extent,  out  of 
date,  and  therefore  comparatively  useless,  owing  to  the  rapid  strides 
now  made  in  our  knowledge  of  the  subjects  of  which  it  treats. 

The  ''  Medical  Courier"  of  Lisbon.i_We  hail  with  much  pleasure 
the  appearance  of  a  review  in  Portugal,  which  seems  calculated  to 
fill  up  the  gap  made  by  the  cessation  in  1869  of  the  Escholiaste 
Medico.  The  present  undertaking  has  for  sponsors  the  medical 
gentlemen  Clemente  dos  Santos,  J.  Ferraz  de  Macedo,  J.  T.  da  Silva 
Amado,  J.  M.  Alves  Branco.  In  the  two  first  numbers  we  find  a 
communication  of  singular  interest  concerning  that  curious  affection 
the  African  lethargy,  in  which  the  patient  appears  enwrapped  for 
weeks  and  even  for  months  in  one  long  sleep.  There  is,  however, 
a  degree  of  intermittence  in  the  disorder.  It  affects  principally,  if 
not  exclusively,  the  black  race.  It  would  appear  not  to  be  due  to 
miasmatic  influences ;  and  some  attribute  it  to  the  lymphatic  con- 
stitution of  the  blacks.  Sr,  Perreira  Eibeira  of  the  Portuguese 
medical  service-  da  idtramar,  who  has  resided  some  time  in  the  islands 
San  Thome  and  Principe,  and  who  has  raised  this  subject  for  discus- 
sion, seems  inclined  to  attribute  the  affection  in  great  degree  to 
hehnmthiasis.  We  cannot  say,  however,  that  he  has  thrown  much 
hght  upon  the  subject ;  nor  do  we  learn  much  that  is  useful  and 
edifying  from  the  long  debate  that  ensued  in  the  Society  of  Medical 
Sciences.  A  certain  mystery  seems  to  hang  over  the  affection  from 
want  of  wider  experience.  Sr.  Eibeira  is  of  opinion  that  when  the 
disease  is  confirmed  there  is  little  to  be  done  for  it.  One  case  which 
he  observed  of  such  sleep,  in  the  island  of  Principe,  lasted  more  than 
a  year;  another  treated  by  him  in  hospital,  in  the  island  of  San 
Thome,  lasted  more  than  six  months.  The  same  gentleman, 
Sr.  Eibeira,  addresses  the  Society  of  Medical  Sciences  on  the  conjee- 

^   O  Correlo  Medico  de  Lishoa.     Publica9ao  quinzenal.     1  do  Jullii,  1871. 
The  Medical  Courier  of  Lisbon.     Fortnightly  medical  review,  from  1st  July, 
1871. 


158  Bibliographical  Record.  [J 


an., 


tural  enfeeblcment  of  the  therapeutical  action  of  quinine  in  paludal 
fevers  from  the  previous  employment  of  the  drug  in  the  same  patient 
as  prophylactic.  We  observe  also  in  the  records  of  the  meetings 
of  the  society  a  discussion  on  the  waters  of  Penedo  (Villa  Pouca  de 
Aguia) .  These  waters  contain  lithium  and  arsenic ;  they  gain  on 
public  favour,  competing  with  those  of  Yidago ;  they  seem  of  use 
for  dyspepsia,  squearaishness  of  stomach,  chlorosis  and  hypertrophy 
of  Kveror  spleen.  We  cannot  but  wish  well  to  this  journal,  which, 
up  to  the  present  date,  seems  conducted  with  skill  and  good  sense. 

Transactions  of  Clinical  Society.^ — This  fourth  volume  of  the 
^Clinical  Society^s  Transactions,'''  maintains  the  high  character 
remarked  in  former  volumes,  as  a  record  of  well-observed  and 
narrated  cases,  many  of  them  of  great  pathological  interest.  On 
the  whole,  moreover,  therapeutical  memoranda  abound  more  in  the 
present  than  in  some  past  volumes;  although  the  value  of  the 
Society,  as  an  organization  for  the  advancement  of  therapeutics 
especially,  remains  yet  to  be  demonstrated. 

Besides  the  President's  address,  the  volume  contains  forty-two 
communications,  of  which  rather  above  a  third  refer  to  lesions 
falling  more  especially  within  the  province  of  the  surgeon. 

The  annual  address,  delivered  by  Dr.  Gull,  the  President, 
exhibits  that  general  readiness  of  perception  and  clearness  of 
opinion  which  would  be  looked  for  from  that  highly  skilled  and 
popular  physician.  He  expresses  his  desire  to  see  further  de- 
veloped the  Society's  scheme  of  appointing  committees  to  in- 
vestigate particular  clinical  and  therapeutical  questions,  rightly 
considering  that  by  associated  action  much  more  can  be  effected 
than  by  the  work  of  individuals ;  that  "  by  putting  positive 
questions  to  nature,  we  are  more  likely  to  find  out  her  secrets 
than  by  waiting,  however  patiently,  for  her  own  revelation  of 
them ;"  and  that  experience  in  medicine  being  fallacious,  because 
it  is  limited  and  imperfect,  the  concurrent  action  of  several 
trained  minds  affords  the  best  available  means  for  counteracting 
this  defect. 

After  noticing  the  wide  and  unexplored  fields  demanding 
clinical  research,  he  proceeds  to  remark  on  the  advancement  of 
therapeutics  as  the  end  to  be  aimed  at  by  the  Society,  and 
advocates  observation  on  the  natural  course  or  history  of  disease, 
interference  by  drugs  being  deferred  until  a  healthy  equilibrium 
be  restored  by  physiological  and  mechanical  rest.  "  It  seems 
probable  (he  urges)  that  a  large  number  of  acute  diseases  may  be 
sufficiently  treated  by  following  these  indications  of  rest  only." 

In  this  present  age,  and  the  existing  state  of  public  opinion, 

'  Transactions  of  the  Clinical  Society  of  London.  Vol.  iv.  London,  1871. 
Pp.  200. 


1873.]  Dr.  King  Chambers*  Harveian  Oration.  159 

this  "  sweet  do-nothing "  plan^  if  acceptable  to  philosophic 
physicians,  will  find  little  favor  with  the  world  at  large,  and  par- 
ticularly with  the  victims  of  acute  disease,  who,  if  denied  tangible 
doses  by  the  regular  doctor,  will  call  for  the  globules  or  drops  of 
the  homoeopath,  or  for  the  decided  doses  of  the  irregular  practi- 
tioner. 

The  various  readers  of  the  '  Transactions '  will  naturally 
value,  almost  as  variously,  the  forty-two  communications  recorded 
in  them ;  nevertheless  there  are  some,  doubtless,  which  will  more 
generally  commend  themselves  to  notice  by  their  originality  or 
novelty,  or  by  their  connection  with  topics  that  are  especially  the 
popular  theme  of  the  day.  As  examples  of  communications, 
challenging  attention  on  one  or  other  of  these  grounds,  we  may 
mention  the  records  of  cases  of  skin-grafting,  the  case  of  recovery 
from  tetanus,  the  case  of  vaccino-syphiKs,  and  the  cases  of  skin 
disease  treated  by  phosphorus.  Those  last-named  have  much 
more  than  ephemeral  interest,  inasmuch  as  they  exemphfy  a 
mode  of  scientific  therapeutic  research  from  which  much  may  in 
time  be  gathered.  They,  indeed,  constitute  a  continuation  of  a 
series  of  experimental  inquiries  by  Dr.  Broadbent,  relative  to  the 
hypothesis  that  '^chemical  groups  form  therapeutical  groups,*^ 
the  first  portion  of  which  was  published  in  Vol.  II  of  the 
Society^s  ^  Transactions.* 

In  conclusion,  we  may  congratulate  the  members  of  the  Clinical 
Society  upon  the  contents  of  the  volume  issued  at  their  charge, 
and  recommend  its  possession  to  those  who  are  not  members. 

Dr.  King  Chambers'  Harveian  Oration.! — In  this  little  book  the 
reader  will  recognize  the  same  independence  and  vigour  of  thought 
and  clearness  of  diction  which  characterise  the  works  of  the  distin- 
guished author. 

The  brochure  contains  the  Harveian  oration,  delivered  at  the 
Eoyal  College  of  Physicians  of  London,  in  June,  1871,  and  two  sup- 
plements or  sequels.  In  the  former  portion  the  special  subject  is  the 
modern  theory  of  disease,  which  represents  disease  as  "  a  mode  of 
living,  as  an  imperfect  form  of  undeveloped  vitality,  as  a  loss  of 
something  present  in  health."  In  the  sequels  he  opens  up  to 
discussion  a  much  wdder  and  more  varied  field  of  argument, 
dealing  with  many  of  the  principal  medical  and  medico-social 
topics  of  the  day.  In  so  doing  he  has  adopted  the  form  of  a 
dialogue  between  several  individuals  of  supposed  different  positions 
of  life,  and  of  diverging  views  respecting  the  matters  discussed. 
The  dialogue  is  well  sustained,  and  the  conclusions  arrived  at,  if 
not  all  beyond  cavil,  are  always  both  ingenious  and  plausible. 

^  jRestorative  Medicine :  an  Harveian  Annual  Oration.  By  Thomas  King 
Chambees,  M.D.     With  two  Sequels.     Philadelphia,  1871.    Pp.  85. 


160  Bibliographical  Record.  [Jan.^ 

In  the  oration,  Dr.  Chambers  notices,  in  turn,  the  several 
theories  of  disease  promulgated  since  medicine  has  been  cultivated 
as  a  science  in  connection  with  the  tlierapeutical  doctrines  dependent 
thereon.  Coming  down  to  the  present  date,  he  finds  that  the 
prevailing  idea,  as  illustrated  in  the  new  articles  of  medicine 
introduced,  and  the  mode  of  treatment  in  vogue,  is  that  of  sup- 
porting and  conserving  or  of  holding  up.  In  short.  Dr.  Chambers 
finds  consolation  from  the  review  of  the  present  tendencies  of  physic, 
seeing  therein  the  progressive  acceptance  of  that  "  restorative 
medicine^''  with  which  his  name  has  become  identified. 

This  small  book  comprises,  within  its  few  pages,  a  collection  of 
subjects,  medical  and  social,  which  wnll  occupy  men's  thoughts,  and 
awaken  discussion  for  many  years  to  come.  Dr.  Chambers  has, 
in  regard  to  most  of  the  questions  raised,  a  decided  opinion,  and 
every  reader  of  his  arguments  will  respect  those  opinions ;  but  this 
is  not  the  place  to  attempt  an  examination  of  them.  And  with 
respect  to  his  doctrine  of  restorative  medicine,  this  has  been 
developed  in  treatises  of  much  greater  magnitude  and  of  more  special 
purpose ;  and  cannot  be  equally  advantageously  examined  in  con- 
nexion Avith  a  brochure  like  the  present,  written  as  much  for  the 
perusal  of  the  non-medical  as  of  the  medical  reader.  At  the  same 
time  let  it  be  understood  that,  in  these  observations,  we  would  in  no 
wise  depreciate  the  value  of  this  smaller  production  of  his  pen,  for  no 
one  can  read  it  without  awakening  reflection,  and  furnishing  sugges- 
tions worthy  of  note. 

Hamilton  on  Fractures  and  Dislocations.^ — Hamilton's  treatise  is 
so  well  known  and  appreciated  in  this  country  that  any  lengthened 
description  of  this  fourth  edition  is  unnecessary.  The  author  has 
evidently  taken  pains  to  keep  up  with  the  progress  of  surgery  in 
relation  to  the  subject  of  his  work,  and  has  materially  improved  both 
the  letterpress  and  illustrations  of  the  present  edition. 

In  the  treatment  of  fractured  clavicle  two  novel  methods  are 
described  and  illustrated,  in  both  of  which  the  tension  of  the  mus- 
cular fibres  of  the  pectoralis  major  is  proposed  to  be  employed  for 
the  maintenance  of  the  fragments  in  situ.  The  method  devised  by 
Dr.  E.  M.  Moore,  of  Eochester,  New  York,  is  termed  the  "I'igure- 
of-eight  from  the  elbow,"  and  is  thus  described  : 

"  The  end  of  the  middle  finger  rests  upon  the  ensiform  cartilage 
while  the  elbow  is  pressed  against  the  side  of  the  body.  A  single 
band,  two  and  a  half  yards  long  and  eight  inches  wide,  has  its  centre 
laid  against  the  point  of  the  elbow  and  folded  around  the  arm ;  the 

1  A  Practical  Treatise  on  Fractures  and  Dislocations.  By  Feancis  Hastings 
Hamilton,  A.M.,  M.D,,  LL.D.,  Professor  of  the  Practice  of  Surgery  with  Opera- 
tions in  Belleviie  Hospital  Medical  College;  Surgeon  to  Bellevue  Hospital,  New- 
York,  &c.  Fourth  edition,  revised  and  improved.  Illustrated  with  322  wood- 
cuts. 


1872.]  Hamilton  07i  Fractures.  161 

extremity  which  appears  in  front  is  now  carried  upwards  over  the 
front  of  the  corresponding  shoulder,  obliquely  downward  across  the 
back  to  the  opposite  axilla,  and  through  the  axilla  to  the  front.  The 
other  extremity,  emerging  behind  between  the  elbow  and  the  body, 
is  carried  obliquely  upward  to  the  sound  shoulder,  and  forward  over 
this  shoulder  to  be  tied  the  opposite  extremity  of  the  shawl  or 
bandage  coming  from  the  axilla.  The  forearm  is  then  placed  at  an 
acute  angle  and  suspended  by  a  narrow  sling  passing  under  the 
wrist." 

Dr.  Lewis  Sayre  (who  lately  visited  this  country)  employs 

"  Two  strips  of  adhesive  plaster  about  three  and  a  half  inches  wide 
for  an  adult ;  one  long  enough  to  encircle  first  the  arm  and  then  the 
body  completely ;  the  other  of  sufficient  length  to  reach  from  the 
sound  shoulder  over  the  point  of  the  elbow  of  the  broken  limb,  and 
across  the  back  obliquely  to  the  point  xyi  starting.  The  first  strip  is 
looped  around  the  arm  just  below  the  axillary  margin  and  pinned  or 
stitched,  with  the  loop  sufficiently  open  to  avoid  strangulation.  The 
arm  is  then  drawn  downward  and  backward  until  the  clavicular  por- 
tion of  the  pectoralis  major  is  put  sufficiently  on  the  stretch  to  over- 
come the  sterno-cleido-mastoid,  and  thus  draw  the  sternal  fragment 
of  the  clavicle  down  to  its  place.  The  strip  of  plaster  is  then  carried 
completely  around  the  body  and  pinned  or  stitched  to  itself  on  the 
back.  The  second  strip  is  then  applied,  commencing  on  the  front  of 
the  shoulder  of  the  sound  side,  thence  it  is  carried  over  the  top  of 
the  shoulder  diagonally  across  the  back,  under  the  elbow,  diagonally 
across  the  front  of  the  chest  to  the  point  of  starting,  where  it  is  se- 
cured by  pins  or  threads.  A  longitudinal  slit  is  made  in  the  plaster 
to  receive  the  point  of  the  elbow." 

Several  illustrations  are  given  of  these  methods,  and  Hamilton 
speaks  well  of  Sayre^s  method,  though  he  prefers  his  own,  which 
consists  of  an  axillary  pad  with  a  sling  from  the  opposite  shoulder, 
the  forearm  being  enclosed  in  a  sleeve  and  fastened  across  the  body. 

We  notice  that  in  the  treatment  of  Colles'  fracture  of  the  radius 
Hamilton  does  not  refer  to  Gordon's  splints,  which  have  come  into 
very  general  use  in  Ireland,  and  are  employed  in  many  London 
hospitals.  They  are  described  and  figured  (though  not  very  accu- 
rately) in  the  last  edition  of  Druitt's  '  Vade  Mecum.'  The  chapter 
on  the  treatment  of  fractures  of  the  femur  was  always  very  elaborate, 
and  it  now  includes  all  the  varieties  of  suspension  apparatus  for  this 
injury  which  appear  to  be  such  favorites  in  America,  though  they 
have  not  superseded  the  simple  "  long  splint"  in  this  country.  In 
the  treatment  of  fractured  patella  we  note  that  Hamilton  does  not 
agree  with  Mr.  Hutchinson  in  dispensing  with  all  elevation  of  the 
limb. 

The  chapter  on  dislocations  of  the  femur  has  undergone  consider- 
able modification,  owing  to  the  introduction  of  the  views  of  Dr. 
Bigelow,  of  whom  the  author  remarks,  "  Since  Sir  Astley  Cooper 

97— xLix.  11 


162  Bibliographical  Record.  [Jan., 

wrote,  probably  no  man  has  thrown  so  much  light  upon  the  subject 
of  liip-joint  accidents,  or  contributed  so  much  towards  an  accurate 
and  systematic  plan  of  treatment,  as  the  distinguished  Boston  sur- 
geon/' Dr.  Bigelow's  views  depend  chiefly  upon  the  importance 
he  attaclies  to  the  ileo-femoral  or  Y  ligament  in  relation  to  disloca- 
tion of  the  hip-joint.  The  regular  dislocations  are  those  in  which 
the  ilio-femoral  ligament  has  not  been  ruptured,  and  the  irregular 
dislocations  where  it  has  been  torn.  In  order  to  reduce  the  disloca- 
tion the  ligament  must  be  relaxed,  and  the  reduction  effected  by 
rotation  of  the  Hmb ;  this  method  of  reducing  the  dislocation  upon 
the  dorsum  ilii  is  to  flex  the  thigh  upon  the  abdomen,  abduct,  and 
tlien  rotate  outwards;  or  to  flex,  then  adduct  and  rotate  a  little 
inwards  to  disengage  the  head  of  the  bone  from  behind  the  socket, 
then  to  abduct  and  pull  directly  upwards.  The  same  directions 
apply  to  the  dislocation  in  the  sciatic  notch.  In  the  dislocation 
on  the  thyroid  foramen  Bigelow's  directions  are :  "  Flex  the  limb 
towards  a  perpendicular  and  abduct  it  a  little  to  disengage  the  head 
of  the  bone ;  then  rotate  the  thigh  strongly  inward,  adducting,  and 
carrying  the  knee  to  the  floor/'  on  which  the  patient  is  presumed  to 
be  lying.  In  addition  to  the  ordinary  dislocation  of  the  head  of  the 
femur  several  anomalous  dislocations  are  described,  but  Hamilton 
does  not  adopt  without  reserve  Bigelow's  statement  that  in  all  these 
the  ilio-femoral  ligament  is  completely  ruptured. 

Space  will  not  allow  of  our  making  further  extracts,  but  we  can 
hardly  say  too  much  in  commendation  of  a  work  which  has  properly 
become  a  medical  classic. 

Geographical  Distribution  of  Heart  Disease  and  Dropsy  in 
England  and  Wales.i — It  is  a  praiseworthy  undertaking  on  Mr. 
Haviland's  part  to  endeavour  to  represent  the  geographical  distribu- 
tion of  disease  in  England  and  Wales,  and  every  reader  of  the  pre- 
sent essay  will  at  once  be  conscious  that  it  is  also  an  undertaking 
that  involves  great  labour  and  requires  much  skill.  The  portion 
now  under  notice  is  put  forward  as  the  first  of  a  series  of  ten  parts, 
to  be  produced  from  time  to  time  until  the  work  is  complete,  the 
next  promised  section  being  on  the  geographical  distribution  of 
cancer. 

The  plan  as  struck  out  by  Mr.  Haviland  is  of  great  magnitude, 
and  its  production  a  matter  of  great  cost ;  we  hope,  therefore,  the 
profession  will  afford  its  enterprising  author  the  full  encouragement 
he  needs,  and  which  also  he  most  richly  deserves.  The  undertaking 
is  novel,  an  honour  to  British  medicine,  and  calculated  to  promote 
the  pursuit  of  a  department  of  pathology  hitherto  greatly  neglected. 

•   The  Geographical  Distribution  of  Seart  Disease  and  Dropsy  in  England  and 
Wales.    Illustrated  ly  a  large  Coloured  Map.     By  Alfkbd  Hayiland.  M.R.C  S 
&c.  &c.     Pp.  61.  *  '' 


1872.]     Heart  Disease  and  Dropsy  in  England  and  Wales.    163 

To  return,  however,  to  the  portion  now  before  us.  Tlie  data  and 
conclusions  will  require,  in  our  opinion,  very  considerable  revision. 
The  investigation  is  very  honestly  and  ably  entered  upon,  but  we  are 
not  satisfied  with  the  data  relied  on.  These  are  derived  from  the 
returns  of  the  Registrar- General  for  the  decenniad  1851-60.  Whilst 
recognising  the  general  value  of  these  returns,  we  are  not  prepared 
to  receive  them  in  evidence  of  the  geographical  distribution  of  dis- 
ease. The  looseness  and  inaccuracy  of  the  returns  of  causes  of 
death  are  circumstances  well  known  to  all  medical  men.  These 
defects  will,  we  trust,  in  course  of  time  be  progressively  diminished, 
and  we  should  assign  a  higher  value  to  the  returns  for  the  decen- 
niad 1861-70  than  to  those  used  by  Mr.  Haviland. 

It  seems  to  us,  moreover,  that  the  author  has  kept  too  promi- 
nently in  his  mind  the  meteorological  conditions  of  localities  as  most 
influential  in  the  production  of  heart  disease  and  dropsy.  He  par- 
ticularly insists  on  the  salutary  effects  of  winds,  giving  preference  in 
respect  to  these  to  the  west  and  south-west  winds ;  and  he  certainly 
shows  cause  for  the  views  he  entertains,  considered  generally,  for 
some  curious  exceptions  occur  respecting  which  no  satisfactory 
explanation  appears.  Indeed,  the  inspection  of  the  map  suggests 
other  causes  for  the  prevalence  of  the  diseases  considered  besides  the 
much-prized  free  exposure  to  the  wind.  One  such  other  cause 
occurs  to  the  mind  as  probably  to  be  found  in  the  soil  and  drainage ; 
and  another  one  certainly  obtains  in  the  social  and  sanitary  condi- 
tions and  habits  of  the  residents  in  particular  localities.  This  latter 
is,  in  fact,  one  which  Mr.  Haviland  has  been  compelled  to  fall  back 
upon  in  some  instances  where  his  usual  explanation  is  at  fault. 

Moreover,  in  reference  to  some  localities  he  is  not  sufficiently 
acquainted  with  their  geographical  conditions  and  their  geographical 
features.  In  illustration  of  this  remark  we  would  refer  to  his  notice 
of  the  West  Midland  Counties  division.  Admitting  rheumatism  to 
be  the  most  frequent  cause  of  heart  disease,  a  direct  relation  should 
obtain  between  the  two  with  regard  to  prevalence ;  and  in  examining 
this  relation  no  one  could  acquiesce  in  ignoring  all  other  determining 
causes  of  rheumatism  other  than  free  ventilation  by  winds,  knowing 
how  largely  rheumatism  is  due  to  certain  occupations  and  to  accidental 
circumstances  quite  unconnected  with  site  and  exposure  to  winds. 

We  are  well  acquainted  with  a  district  in  which  rheumatism 
abounds,  and  with  it  heart  disease;  and  yet  this  locality  appears  on 
the  map  as  fourth  in  order,  having  an  average  below  that  prevailing 
in  the  country  at  large.  Indeed,  we  suspect  that  Mr.  Haviland^s 
statistics  lose  force  as  he  extends  his  inquiries  to  smaller  groups  of 
population,  for  it  is  with  such  that  accidental  conditions  assume 
the  most  significance,  and  tend  to  diminish  the  value  of  statistical 
calculations. 

Some  general  deductions  are  worth  noting.     It  is,  for  example, 


]64  Bibliographical  Record,  [Jan., 

clear  that  heart  disease  kills  more  females  than  males,  except  in  the 
first  ten  years  of  existence,  and  that  the  mortality  from  it  among  the 
population  advances  in  each  succeeding  decade ;  "  each  decade  has 
a  relative  mortality  nearly  double  of  the  one  which  precedes  it." 
Again,  the  mortality  from  heart  disease  is  greater  in  places  where 
the  mortality  from  all  causes  is  less ;  and  further,  it  is  less  on  the 
coast  of  the  country  than  inland,  and  generally  less  where  there  is 
free  exposure  to  the  winds  than  where  places  are  sheltered  from 
them.  Another  deduction  is  that  "the  high  mortahty  districts"  have 
an  agricultural  population  greatly  in  excess  of  the  average  for 
England  and  Wales."  Lastly,  in  Mr.  Haviland's  opinion,  rheuma- 
tism is  endemic  in  many  parts,  and  that  this  condition  depends  on  a 
local  materies  morhi.  In  this  opinion  the  hereditary  character  of 
rheumatism  and  of  heart  disease  is  lost  sight  of. 

Notes  on  Skin  Diseases.^— It  is  enough  to  note  the  appearance  of 
this  new  edition  of  this  excellent  though  brief  history  of  skin  dis- 
eases and  their  treatment.  We  hope  that  the  success  of  the  venture 
will  not  induce  Dr.  Liveing  to  make  many  additions,  and  thereby 
change  its  character  from  a  convenient  pocket  companion  to  an 
ambitious  volume,  to  occupy  a  place — and  it  may  be  a  nearly  for- 
gotten place — on  the  library  shelves.  This  undesirable  transforma- 
tion has  not,  we  are  happy  to  say,  been  yet  made,  and  we  are  again 
pleased  to  commend  the  little  volume  to  all  our  readers,  especially  to 
those  engaged  in  practice  whose  memory  requires  from  time  to  time 
refreshing. 

Nouveau  Dictionnaire  de  Medecine,  &c.2 — The  subscribers  to  this 
very  comprehensive  Dictionary  of  Medicine  and  Surgery  will  receive 
with  pleasure  this  thirteenth  volume,  although  it  advances  them  but 
a  small  way  on  the  road  to  completion,  the  articles  in  the  alphabeti- 
cal order  adopted  reaching  only  from  Em  to  Erg.  Certainly  some 
most  important  subjects  fall  within  this  brief  alphabetical  range; 
such  are  the  articles  Encephale,  Endemic,  Endocardites,  Entozoaires, 
Epaule,  Epidemic,  Epilepsie,  and  Epithelium.  There  are  also  some 
very  considerable  essays  on  Epistaxis,  Erectile  tumours.  Ergot  of  rye, 
and  Ergotism. 

The  diseases  of  the  encephalon  are  treated  of  by  the  general 
editor,  M.  Jaccoud,  aided  by  M.  Hallopeau.  The  long  article  on 
endocardium  and  endocarditis  comes  also  from  the  prolific  pen  of 
M.  Jaccoud.  Mr.  Alfred  Luton  is  the  writer  of  the  complete  essay 
on  entozoa ;  M.  Paul  Lorain  of  the  two  articles  on  endemics  and 

1  Notes  on  the  Treatment  of -Skin  Diseases.  By  Robebt  Liveing,  M.D.,  &c. 
Second  Edition,  with  Additions.     London,  1871.     Pp.  104. 

^  Nouveau  Dictionnaire  de  Medecine  et  de  Chirurgie  pratiques,  illustre  de  figures 
intercalees  dans  le  texte.     Tome  xiii.     Em — Erg.     Paris,  1870. 


1872.]      Treatment  of  Women* s  and  Children's  Diseases.      165 

epidemics ;  M.  Yoisin  of  that  on  epilepsy,  and  M.  Panos  of  the 
surgical  article  on  the  shoulder. 

Tliere  is  no  doubt  about  the  ability  and  talent  of  the  contributions 
to  this  dictionary,  but  it  is  a  question  how  far  such  colossal  literary 
undertakings  are  desirable.  The  time  taken  to  complete  such  is  so 
great  that  the  value  of  the  earlier  volumes  must  have  materially 
deteriorated,  particularly  in  so  changing  and  advancing  arts  as 
medicine  and  surgery,  before  tlie  conclusion  of  the  series.  Prance 
is  especially  the  country  of  such  undertakings,  and  much  credit  is 
due  to  the  enterprise  exhibited  in  their  production;  but,  after  all, 
should  a  contributor  live  to  see  the  com])letion,  and  to  be  able  to 
regard  with  patriotic  satisfaction  the  array  of  thirty  or  more  bulky 
tomes  on  his  library  shelves,  he  must  still  be  beset  with  the  convic- 
tion that  much  of  the  system  of  medicine  and  surgery  before  him 
possesses  chiefly  an  historic  interest,  and  does  not  represent  the 
science  and  art  of  the  day. 

We  heartily  wish  M.  Jaccoud  health  and  vigour  to  complete  the 
great  task  he  has  undertaken,  and  can  congratulate  him  on  the 
general  excellence  of  the  many  articles  that  have  been  contributed, 
whether  under  his  supervision  or  by  his  own  hand. 

Handy-Book  of  the  Treatment  of  Women's  and  Children's  Diseases.^ 

— The  translation  of  this  little  book  has  been  well  made,  and  the 
subject-matter  of  the  book  will  have  interest  to  those  practitioners 
who  desire  to  know  the  peculiarities  of  German  therapeutics.  More- 
over, the  notice  of  remedies  and  the  formulse  will  prove  suggestive 
to  the  reader  in  search  of  additions  to  his  armamentarium.  Nume- 
rous and  much  varied,  indeed,  are  the  prescriptions  set  forth,  some 
of  them  placebos  and  herb  preparations  such  as  are  to  be  seen  in  the 
dispensatories  of  the  last  century ;  whilst  others  again  are  as  potent, 
derived  from  the  chemical  laboratory.  Descriptions  are  also  given  of 
various  operations  for  surgical  lesions  of  females,  as,  for  instance,  of 
ovariotomy ;  but  we  regard  these  as  rather  encumbrances  of  the 
treatise,  being  far  from  explicit  enough  to  be  a  guide  to  a  would-be 
operator.  They,  moreover,  do  not  represent  the  present  improved 
methods  of  operation,  particularly  those  pursued  in  England  and  the 
United  States,  where  this  department  of  surgery  has  been  most 
advanced. 

Dr.  "Nicol  deserves  credit  for  his  part  of  the  work,  but  we  cannot 
comprehend  why  he  selected  this  manual  for  appearance  in  an 
English  dress.  It  is  not  the  work  of  a  representative  man  in  Ger- 
man medicine,  but  of  a  compiler  of  *^  Handy -Books,''  previously 
known  among  students  by  the  preparation  of  similar  treatises  on 

^  Handy- Book  of  the  Treatment  of  Women's  and  Children's  Diseases,  accord- 
ing to  the  Fienna  Medical  School.  With  Prescriptions.  By  Dr.  Emil  Dillin- 
BEfiGEE.    Translated  by  Pateick  Nicol,  M.D.     London,  1871.    Pp.  208. 


166  Bibliographical  Record.  [Jan., 

medical  and  surgical  diseases.  The  success  of  tliose  former  produc- 
tions may  have  been  a  sufficient  inducement  to  Dr.  Dillinberger  to 
produce  one  also  on  diseases  of  women  and  children  for  the  medical 
tyros  of  Vienna,  but  this  gives  no  explanation  for  Dr.  Nicol  taking 
up  such  a  production  for  translation  for  English  students  and  medi- 
cal men,  in  whose  hands  so  many  superior  treatises  on  the  same 
subjects  are  to  be  found. 

Manual  of  Practical  Therapeutics.^ — This  new  edition  of  Dr. 
Waring's  Manual  of  Therapeutics  will  be  welcomed  by  practitioners 
generally ;  particularly  when  it  is  known  that  the  work  has,  to  a 
great  extent,  been  re-written,  in  order  to  make  it  convey  adequately, 
without  useless  augmentation  of  size,  the  results  of  modern  inquiries 
into  the  use  and  operations  of  medicines.  Chloral,  bromide  of  mer- 
cury, iodide  of  methyl,  bichloride  of  methylene,  protoxide  of  hydro- 
gen, sandal-wood  oil,  apomorphia,  and  other  new  remedies,  are 
noticed  in  this  new  edition ;  and,  likewise,  a  more  complete  account 
is  given  of  several  drugs  that  have  of  late  advanced  in  public  estima- 
tion. Space,  also,  has  been  found,  even  with  a  decreased  number  of 
pages,  for  articles  on  the  hypodermic  and  endermic  methods  of  treat- 
ment, and  to  additions  to  that  on  antidotes,  setting  forth  the  most 
approved  methods  of  treatment  in  cases  of  poisoning.  There  is,  in 
short,  an  amount  of  information  on  therapeutical  matters  that  may 
well  stagger  the* practitioner  who  first  opens  the  pages  of  this  trea- 
tise; but  at  the  same  time  the  inquiring  reader  who  looks  to  it  for 
reference  will  value  it  accordingly,  as  putting  before  him,  in  a  con- 
densed form,  the  opinions  and  the  results  of  observations  of  a  mul- 
titude of  medical  men  respecting  the  many  drugs  which  have  esta- 
blished a  claim  to  recognition  as  aids  in  treatment ;  however,  the 
practitioner  will  especially  appreciate  this  work  as  presenting  to  him 
therapeutical  information  without  that  mass  of  natural  history,  che- 
mical and  manufacturing  details,  which  usurp  in  books  on  materia 
medica  so  large  an  amount  of  space,  but  possess  so  little  interest  to 
him  after  having  duly  ridded  his  mind  of  them  at  his  examination^ 

The  composition  of  the  book  is  a  marvel  of  industry  and  of 
patient  research  after  information  in  all  quarters. 

Dr.  Einger's  Therapeutics.2 — This  treatise  on  therapeutics  at 
once  assumed  the  first  position  among  kindred  works  on  the  subject 
in  the  EngHsh  language.  Medical  men  could  at  a  glance  learn  the 
reputed  properties  of  drugs,  their  action  on  the  human  frame,  the 
indications  for  their  use,  and  the  mode   of   using   them,  without 

^  A  Manual  of  Practical  Therapeutics,  considered  cliiefiy  loith  reference  to 
Articles  of  the  Materia  Medica.  By  Edwaed  John  Waking,  M.D.,  &c.  Third 
Edition.     London,  1871.     Pp.  875. 

■^  A  Handbook  of  Therapeutics.  By  SYDNEY  RlNQEE,  M.D.  Second  Edition. 
Loudon,  1871.     Pp.  483. 


1872.]  Transactions  of  the  Pathological  Society.  167 

stumbling  over  much  irrelevant  matter,  as  met  with  in  the  mongrel 
contents  of  an  ordinary  treatise  on  Materia  Medica.  Another  good 
feature  in  Dr.  Ringer's  volume  is,  that  it  is  not  made  up  of  excerpta 
of  opinions  and  of  results  of  experience  collected  from  a  host  of 
books  and  periodicals — of  opinions  and  results,  by  the  way,  ofttimes 
of  no  weight  by  reason  of  deficient  critical  power  on  4he  part  of  their 
recorders — but,  on  the  contrary,  presents  a  careful  and  critical 
digest  of  the  views  and  experimental  inferences  of  observers  selected 
as  most  competent  to  put  them  forward. 

In  our  review  of  this  work,  in  the  number  for  April,  1870,  we 
took  occasion  to  advert  to  the  imperfection  of  the  arrangement 
followed  with  reference  to  many  articles  treated  of.  We  find  the 
same  defect  in  the  present  edition,  and  it  is  one  probably  inseparable 
from  the  mode  of  dealing  with  the  several  subjects  pursued  by  the 
author.  He  appears  to  form  therapeutical  groups  of  medicines, 
where  possible ;  but  where  this  plan  fails,  the  arrangement  adopted 
is  not  clear.  The  reader  who  would  refer  to  the  properties  and 
action  of  any  particular  medicine  must,  therefore,  depend  on  the 
index  appended  at  the  end  of  the  book. 

In  the  review  alluded  to,  the  general  features  and  merits  of  the 
treatise  were  enlarged  upon,  and  it  is,  therefore,  unnecessary,  in 
noticing  this  second  edition,  to  revert  again  to  them.  At  the  same 
time,  it  will  be  satisfactory  to  the  reader  to  know  that  the  "  present 
edition  has  been  carefully  revised,  and  much  additional  matter  has 
been  incorporated  with  it ; "  yet,  we  observe,  without  increasing  the 
number  of  its  pages. 

It  is  right  also  to  note  that  a  copious  posological  table  is  appended, 
and  also  a  dietary  for  invalids,  giving  numerous  recipes  for  articles 
of  nourishment  required  in  the  sick  room. 

In  conclusion,  we  have  great  pleasure  in  recommending  this 
treatise  on  therapeutics  to  our  readers  as  a  useful  practical  produc- 
tion, and  one  creditable  to  British  medicine. 

Transactions  of  the  Pathological  Society  of  London.' — These  two 
copious  volumes  of  '  Transactions  '  bear  witness  to  the  vitality  of  the 
Pathological  Society  of  London,  and  to  the  activity  and  industry  of 
its  members.  They  likewise  sustain  the  reputation  gained  by  the 
transactions  of  past  years,  and  afford  a  large  repertory  of  facts  that 
may  be  turned  to  the  best  account  by  pathological  students. 

The  form  and  character  of  the  contents  of  these  records  of  the 
Society^s  work  are  so  well  known  as  to  render  description  un- 
necessary, whilst  at  the  same  time  the  nature  of  the  contents  precludes 
critical  analysis. 

The  reports  of  the  Committee  on  some  of  the  morbid  growths 

1  Transactions  of  the  Pathological  Society  of  London,  comprising  the  Report  of 
the  Proceedings  for  the  Sessions  1869-70  and  1870-71.     Forming  vols,  xxi  and  xxii. 


168  Bibliographical  Record.  [J 


an., 


exhibited  will  always  be  referred  to  with  interest,  as  at  times  clearing 
up  obscure  points  in  morbid  anatomy ;  or,  if  they  do  not  succeed  in 
this,  as  opening  up  fresh  questions,  and  indicating  new  lines  for 
research. 

Ever  and  anon  there  is  a  tendency  on  the  part  of  members  to 
indulge  in  the  luxury  of  a  pathological  essay,  instead  of  making  the 
exhibition  and  history  of  a  morbid  specimen  the  goal  of  their 
ambition. 

There  can  be  no  objection  to  such  papers,  considered  as  contribu- 
tions to  medicine,  from  careful  and  intelligent  observers  and 
thinkers  ;  at  the  same  time,  the  multiphcation  of  such  papers  would 
change  the  character  of  the  work  of  the  Society,  and  deprive  it  of  its 
special  claim  to  recognition  as  an  independent  Society  with  an 
avowed  but  limited  object. 

The  Pathological  Society  has  from  its  institution  been  a  popular 
association ;  its  list  of  members  shows  that  it  still  retains  its 
popularity,  and  its  volumes  of  transactions  give  proof  that  it 
deserves  it. 

Dr.  Hartshorne's  Essentials  of  Medicine.^ — It  is  a  year  since  we 
noticed  the  second  edition  of  this  handbook  of  medicine;  the 
appearance  of  another  edition  wdthin  so  short  a  time  may  be  taken 
as  evidence  that  the  treatise  is  much  appreciated.  Although  we 
had  to  remark  on  some  deficiencies  and  a  few  errors,  our  opinion 
of  the  former  edition  was  very  favorable.  Of  this  third  issue  the 
same  good  opinion  may  be  expressed,  and  we  are  pleased  to  find  the 
author  has  taken  note  of  our  remarks,  and  made  the  corrections  and 
additions  we  ventured  to  suggest. 

^  Journal  of  Anatomy  and  Physiology.^ — We  have  before  us  the 
last  published  number  of  this  most  valuable  scientific  Journal  of 
Anatomy  and  Physiology,  which,  with  reference  to  those  subjects, 
brings  English  scientific  journalism  to  a  level,  at  the  least,  with  the 
prohfic  periodical  productions  of  the  German  press.  Much  honour 
and  praise  are  due  to  Professors  Humphry  and  Turner  for  their 
enterprise  in  starting,  and  for  maintaining,  their  journal  in  its  high 
scientific  character.  They  deserve  the  fullest  encouragement  from 
the  anatomists  and  physiologists  of  this  country.  Indeed,  the 
number  of  contributors  to  its  pages  shows  that  its  value  as  a  vehicle 
for  the  more  advanced  researches  in  the  sciences  it  is  devoted  to  is 
largely  appreciated. 

The  present  number  sustains  the  high  character  recognised  for  the 

1  JEssentials  of  the  Principles  and  Practice  of  Medicine.  A  HandhooJc  for 
Students.  By  Heney  Hartshoene,  M.D.,  &c.  Third  Edition,  thoroughly  Re- 
vised.    Philadelphia,  1871.     Pp.  487. 

2  The  Journal  of  Anatomy  and  Physiology/.  Conducted  by  Professors  Hum- 
phrey and  TuENEE.     November,  1871. 


1872.]  Journal  of  Anatomy  and  Physiology.  169 

Journal  by  those  that  have  preceded  it.  It  contains  seventeen 
communications  and  a  "  Eeport  on  the  Progress  of  Physiology.^' 
The  papers  deal  with  questions  on  both  human  and  comparative 
anatomy  and  physiology,  and  some  among  them  address  themselves 
to  medical  men  who  would  not  arrogate  to  themselves  a  special 
scientific  position,  but  who  make  it  their  business  to  learn  the 
advances  of  physiology  in  their  bearings  upon  practice. 

Omitting  articles  that  are  chiefly  of  interest  to  comparative 
anatomists,  we  may  note  the  presence  of  papers  on  "  The  Brain  of 
an  Idiot/'  on  ^' The  Action  of  Inorganic  Substances  when  intro- 
duced directly  into  the  Blood  ;"  on  "  The  Relation  of  the  Tempera- 
ture of  the  Air  to  that  of  the  Body ;''  on  "  Uterine  Contrac- 
tions during  Pregnancy  /'  and  ou  "A  new  Schema  of  the  Circula- 


Jan.,  1872.]  171 


(Bvisinhl  Communuatione?* 


I.— On  the  Proper  Management  of  Tedious  Labours.     By  Dr.  G. 
Hamilton,  Palkirk. 

{Continued  from  No.  96.) 

In  resuming  the  consideration  of  this  subject,  I  would  remark  th?it 
I  have  always  considered  it  of  great  importance,  when  a  labour 
threatens  to  become  lingering,  to  ascertain  with  precision  the  position 
of  the  head,  and,  if  possible,  also  the  form  of  the  pelvis.  Both 
these  are  important  guides  if  the  forceps  should  be  required.  When 
labours  have  been  easy,  I  confess  to  having  often  not  paid  much 
attention  to  the  positions ;  and  this  has,  no  doubt,  led  me,  in  the 
following  rough  and  ready  arrangement  of  vertex  presentations,  to 
differ  somewhat  from  that  usually  followed  by  authors.  Mine,  in 
fact,  has  relation  to  the  use  of  the  forceps,  theirs  to  the  whole  labour, 
as  well  as  to  both  easy  and  difficult  labours.  Setting  aside  cases 
where  the  head  has  already  turned  into  the  hollow  of  the  sacrum,  or 
where  the  face  is  to  the  pubes,  I  would  divide  vertex  presentations 
into  six  kinds,  regulated  by  the  position  of  the  ear  placed  anteriorly 
at  the  time  when  the  use  of  the  forceps  is  required.  Though  more 
numerous  than  usual,  these  positions  are  very  simple.  They  are — 
1st,  face  to  right  side,  with  ear  to  the  right  of  symphysis;  at,  or 
very  near,  symphysis  ;  and  on  the  left  of  it.  2nd.  With  the  face  to 
the  left  side,  and  the  ear  the  reverse  of  these.  We  have  here,  there- 
fore, six  positions,  of  which  the  most  favourable  is  the  first,  and  the 
least  favourable  the  sixth.  Generally  speaking,  also,  those  with  the 
face  to  the  left  are  less  favourable  than  when  it  is  to  the  right, 
evidently  because  the  rectum  occupies  a  certain  space  on  the  left 
side.  Although  the  first  position  of  authors  (with  ear  and  face  to 
right  side)  is  by  far  the  most  common,  taking  all  kinds  of  labours, 
I  do  not  find  that  it  is  so  when  I  have  to  apply  the  forceps.  By  far 
the  most  common  situation  in  which  I  have  then  founds  an  ear  has 
been  at  or  very  near  the  symphysis,  with  the  face  sometimes  to  the 
one  side,  sometimes  to  the  other  (my  2nd  and  4th  positions) ;  and 
this,  and  the  other  positions,  I  shall  immediately  have  to 
show,  become  almost  indispensable  guides  in  the  proper  use  of  the 
instrument.  It  is  easy  to  see  why  an  ear  near  the  symphysis 
is  more  common  than  the  other  positions,  when  a  certain  amount  of 


172  Original  Communications.  [Jan., 

arrest  has  taken  place,  because  the  ear  may  have  been  placed 
originally  at  the  sym])hysis  in  my  1st,  2n(l,  4th,  and  5th  positions,  or 
it  may  have  passed  into  this  from  my  3rd  and  6th.  When  I  require 
it,  therefore,  it  is  there  that  I  generally  seek  for  an  ear,  which  in  the 
great  majority  of  cases  is  my  principal  guide  in  forceps  cases;  for  I 
agree  with  Smellie  and  Burns  in  thinking  that,  "  when  the  forceps 
are  applied  along  the  ears  and  sides  of  the  head,  the  blades  are  nearer 
to  one  another  and  have  a  better  hold''  than  when  applied  over  the 
occipital  and  frontal  bones,^  or,  indeed,  anywhere  else.  A  knowledge 
of  these  positions  also  shows  what  cases  are  likely  to  be  most  re- 
tarded, because,  if  a  revolution  of  the  head  have  to  be  made,  the 
further  it  has  to  travel  the  greater,  probably,  will  be  the  detention. 
Hence,  my  3rd  and  6th  (on  the  wrong  side  of  the  symphysis,  as  I 
have  called  it)  are  on  each  side  generally  the  most  lingering,  and 
most  frequently  require  interference  and  rectification. 

Continuing  my  narrative,  I  have  now  to  state  that  the  second  class 
of  cases  in  which  I  have  had  to  apply  the  forceps  is  one  in  which" 
the  head  is  higher  up  than  in  the  first,  the  ear  near  the  symphysis, 
wdth  the  face  mostly  to  the  right  side,  but  where  the  head,  although 
the  pelvis  is  roomy  enough,  though  flat,  obstinately  refuseS;,  from  the 
vis  a  tergo  alone,  to  take  the  turn  into  the  sacrum.  This  kind  of  case 
I  have  mentioned  in  my  paper  in  this  Journal  in  1853  as  having 
particularly  attracted  my  attention,  especially  from  the  arrest  having 
occurred  repeatedly  in  the  same  female — in  ons  case  as  many  as  ten 
times  out  of  twelve  labours.  The  forceps  here  are  generally  pretty 
easily  applied ;  the  head  yields  to  their  joint  rotation  and  traction, 
often  with  a  jerk,  and,  after  the  face  gets  into  the  hollow  of  the 
sacrum,  the  delivery  is  quickly  completed.  The  case  will  frequently 
have  been  so  remarkably  intractable  before  this  rotation  has  been 
applied,  and  so  easy  of  management  afterwards,  as  to  astonish  one 
not  prepared  for  it.  Indeed,  it  is  so  simple  as  to  have  been  eff'ected 
by  Dr.  Montgomery  with  his  hand  alone.  This  I  have  almost  never 
been  able  to  do,  but  with  the  straight  forceps  rotation  is  often  easy 
and  most  effectual,  nature  unaided,  if  allowed,  going  through  the 
rest  of  the  labour  without  impediment.  Short,  squat  females  are 
peculiarly  liable  to  this  kind  of  detention.  Soon  after  I  settled  in 
practice  I  lost  twins,  where  the  patient,  a  primipara,  had  this  make. 

My  opinion,  at  the  time  I  published  the  paper  referred  to,  was, 
that  this  description  of  labour  constituted  a  larger  proportion  of 
forceps  cases  than  I  am  now  inclined  to  hold.  I  think  the  third 
class,  which  I  have  now  to  refer  to,  is  more  common  and  more  im- 
portant, and,  as  I  shall  attempt  to  show,  it  admits  of  a  special  treat- 
ment which  requires  a  modification  in  our  ideas,  both  theoretical  and 
practical,  of  the  utmost  moment. 

^  •  Smellie's  Obstetrical  Plates,'  p.  13. 


1872.]        The  Proper  Management  of  Tedious  Labours.       173 

This  third  class  consists  of  cases  where  an  ear  is  found  to  be  more 
or  less  easily  within  reach  of  the  finger,  at  or  near  the  symphysis 
pubis,  on  either  side,  and  with  the  face  either  to  the  right  or  the  left 
side,  which  do  not  naturally  take  the  turn,  and  cannot,  without  the 
apphcation  of  more  force  than  it  is  advisable  to  apply,  be  made  to  take 
the  turn,  into  the  hollow  of  the  sacrum. 

As  a  proper  view  of  these  most  important  and  often  very  serious 
cases  involves  a  consideration  of,  1st,  the  powers  and  operation  of 
the  forceps  as  an  instrument ;  2nd,  of  the  mechanism  of  labour  in 
relation  to  this  instrument;  and  3rd,  of  the  kind  and  form  of 
forceps  best  fitted  to  effect  our  objects,  I  shall  make  a  few  remarks 
on  each  of  these  points.  After  this  has  been  done,  my  observations 
on  this  subject  will  be  greatly  simplified,  and  made  much  more 
intelligible. 

And  first,  as  to  the  powers  and  operation  of  the  forceps  as  an 
instrument.  On  this  department  of  the  subject  the  observations  of 
Dr.  Barnes^  are  the  most  recent  and  minute  that  I  have  met  with, 
and  on  these,  therefore,  I  would  beg  to  make  a  few  remarks ;  and 
in  doing  so,  though  I  shall  have  to  say  that  I  differ  from  some  of 
the  conclusions  at  which  Dr.  Barnes  has  arrived,  I  yet  must  express 
the  interest  with  which  I  have  read,  and  the  instruction  I  have 
derived  from,  many  of  his  papers  on  obstetrical  subjects.  Dr.  Barnes 
says, 

"  Three  distinct  powers  can  be  developed  in  the  forceps.  First, 
by  simply  grasping  the  head  and  drawing  upon  the  handles,  it  is  a 
'  tractor.'  Secondly,  the  forceps  consisting  of  two  blades,  having  a 
common  fulcrum  at  the  joint  or  lock,  we  can,  by  a  certain  manipula- 
tion, use  it  as  a  douUe  lever.  Thirdly,  if  the  blades  are  long  enough 
and  strong  enough,  and  otherwise  duly  shaped,  the  forceps  becomes 
a  compressive  power  capable  of  diminishing  certain  diameters  of  the 
child's  head." 

And  again  he  says  : 

"  First,  as  to  its  tractile  powers.  In  order  to  draw,  the  instrument 
must  take  hold.  How  does  it  take  hold  ?  You  may,  at  first  sight, 
suppose  that  this  is  accomplished  by  grasping  the  handles ;  but  in 
the  case  of  the  ordinary  forceps,  especially  the  short-handed  forceps, 
there  is  little  or  no  compressive  power,  so  that  the  hold  cannot  be 
due  to  the  handles.  The  hold  is  really  due  to  the  curvature  of  the 
blades,  which  fit  more  or  less  accurately  upon  the  globular  head, 
and  the  compression  of  the  bows  of  the  blades  against  the  soft  parts 
of  the  mother,  supported  by  the  bony  ring  of  the  pelvis.  This  may 
be  made  clear  by  a  simple  experiment.  Take  an  india-rubber  ball, 
slightly  larger  in  diameter  than  a  solid  ring  ;  place  the  ball  upon  the 
ring,  then  seize  the  ball  through  the  ring  by  the  forceps ;  the  blades 

1  See  '  Med.  Times  and  Gazette,'  July  27th,  Sept.  7th  and  21st,  1867,  pp.  85, 
249,  313,  quoted  in  *  Braithwaite's  Retrospect,'  vol.  Ivi. 


174  Original  Communications.  [Jan., 

will  be  opened  out  by  the  ball ;  then  drawing  upon  the  handles,  even 
without  squeezing  them  together,  you  will  see  the  blades  pressed 
firmly  upon  the  ball  by  gradual  wedging,  as  the  greatest  diameter  or 
equator  of  the  ball  comes  down  into  the  ring.  Just  so  is  it  with  the 
child's  head  and  the  pelvic  brim  and  canal.  The  blades  are  held  in 
close  apposition  to  the  head  by  the  soft  parts  and  pelvis  of  the 
mother.  In  many  cases  this  outward  pressure  upon  the  bows  of 
the  blades  is  enough  to  account  for  traction." 

And  again  : 

"  Thus,  just  as  the  pressure  of  the  soft  parts  and  the  pelvis  is  a 
main  agent  in  fixing  the  forceps  upon  the  head,  so  is  it  in  moulding 
the  head  to  allow  of  its  passing.  Indeed,  I  think  this  pressure 
almost  entirely  accounts  for  the  alteration  of  form  the  head  under- 
goes when  the  English  forceps  is  applied." 

With  many  of  these  propositions  and  conclusions  I  confess  my- 
self unable  to  agree,  for,  first,  excluding  the  pressure  of  the  mother's 
parts  altogether,  if  I  take  a  croquet  ball  ten  inches  in  circumference, 
put  it  in  a  cotton  bag,  and  attach  this  to  a  spring  balance,  I  can 
easily,  using  my  forceps,  figs.  1,  2,  p.  179,  with  both  hands,  make 
the  index  of  the  balance  stand  at  62  lbs.  before  they  slip.  Again, 
instead  of  finding  the  compressive  power  "  inconsiderable  in  almost 
all  the  English  forceps,^'  I  find,  when  I  drive  two  strong  nails  into 
a  board,  say  eighteen  inches  asunder,  and  attach  the  spring  balance 
to  one  nail,  and  pass  a  loop  of  strong  cord  over  the  other,  so  that 
the  two  blades  of  the  forceps  can  be  made  to  act,  the  one  on  the 
balance  and  the  other  on  the  loop  of  cord,  that  I  can  with  my  two 
hands  make  the  index  stand  at  70  lbs.  with  my  forceps,  figs.  1,  2 ; 
at  62  lbs.  with  the  instrument  I  have  used  until  lately  for  thirty 
years;  and  at  64^  lbs.  with  the  short  forceps,  fig.  3.  As  the  index 
gives  the  power  represented  by  only  one  of  the  blades,  and  its  oppo- 
site must  be  the  same,  we  have  here  respectively  140  lbs.,  124  lbs., 
and  128  lbs.,  for  the  powers  of  these  three  instruments.  Now,  let 
any  one  try  to  lift  a  weight  of  140  lbs.  with  both  his  hands,  and  he 
will  realise  the  compressive  power  of  the  forceps.  Exerting  nearly 
all  my  strength,  I  am  barely  able  to  lift  it.  If  anything  like  this 
force  were  not  diff'used  over  a  considerable  surface,  and  restrained 
within  certain  limits  by  the  width  between  the  blades,  the  head  of 
the  child  would  inevitably  be  crushed,  and  its  life  sacrificed  instead 
of  saved,  by  the  use  of  the  instrument. 

And  here  it  may  be  noted  that  the  proper  use  of  the  forceps  forms 
not  quite  such  a  "  gentle^'  operation  as  it  has  been  represented  by 
some  authorities.  "  Eorce,^^  says  Dr.  Ramsbotham,  "  is  a  word 
which  should  be  expunged  from  the  vocabulary  of  obstetrical 
phrases."  ^  This,  I  think,  is  a  mistake ;  only  it  requires,  in  applying 
the  force,  that  we  should  know  well  what  we  are  doing.    In  general,  I 

^  *  Obstetric  Medicine  and  Surgery/  p.  338. 


1872.]        The  Proper  Management  of  Tedious  Labours,       175 

would  say  that  Dr.  Eamsbotham  is  correct  as  to  the  introduction  of 
the  forceps ;  but  in  extraction  nature  uses,  and  we  often  require  to  use, 
very  considerable  force,  and  this,  I  am  satisfied,  can  be  appHed,  if 
not  too  much  prolonged,  with  perfect  safety  to  mother  and  child.  It 
is  prolonged  pressure  that  is  especially  hurtful  to  both,  and  this 
whether  it  be  applied  by  means  of  the  forceps  or  by  the  resistance 
to  the  vis  a  tergo  by  the  bony  unyielding  maternal  canal.  When 
the  hand  has  to  be  introduced  into  the  uterus  in  turning,  we  get, 
during  a  pain,  an  idea  of  the  power  nature  brings  into  operation. 
In  my  early  practice  I  have  seen  force  used  in  the  introduction  of 
the  forceps  which  was  altogether  unwarranted,  and,  I  now  believe, 
unnecessary.  Knowledge  and  skill  are  here  the  chief  desiderata,  and 
especially  a  correct  diagnosis ;  but  force,  and  very  considerable  force, 
must  occasionally  be  used  in  extraction.  This  need  not  alarm  us 
much,  when  Dr.  Haughton  tells  us  that  the  expulsive  powers  of 
nature  in  parturition  amount  to  something  like  a  quarter  of  a  ton,^ 
even  though  this  estimate  is  held  by  Dr.  Mathews  Duncan  to  be 
much  exaggerated. 

Let  us  now  further  inquire  what  are  really  the  powers  brought 
into  operation  by  us  when  we  use  the  forceps.  Dr.  Barnes  says, 
"  we  can,  by  a  certain  manipulation,  use  it  as  a  double  lever  "  but 
it  again  seems  to  me  that  we  never,  properly  speaking,  use  the  forceps 
as  a  double  lever,  except  when  we  grasp  the  head,  and  in  the  sense 
that  all  pincers  are  double  levers,  having  their  fulcra  at  the  joint. 
But  this  is  not  the  real  power  exerted  in  the  common  mode  of  using 
the  forceps,  for  the  instrument  is  then  used  more  as  a  double  hook 
or  loop  than  as  a  lever.  The  leverage  power  is  exerted,  in  such  a 
case,  simply  in  laying  hold  of  the  head,  not  in  extracting  it.  This 
will  become  evident  if  we  imagine  an  unyielding  band  passed  round 
the  blades  of  the  forceps  when  placed  on  the  head.  In  such  a  case 
no  leverage  power  might  be  used  at  all,  and  yet  the  child  might  thus 
be  supposed  to  be  extracted  by  the  forceps,  acting  as  two  hooks,  or 
combined  as  a  loop,  passed  round  the  head  or  round  the  croquet 
ball.  The  leverage  exerted  by  the  hands  on  the  handles  of  the 
instrument,  therefore,  simply  represents  the  power  conferred  on  us 
by  this  imaginary  band  when  we  are  exerting  traction.  When  we 
employ,  in  delivery,  leverage  power,  we  act,  properly  speaking,  not 
with  a  double  but  with  a  single  lever,  and  this  is  effected  by  con- 
verting, as  it  were,  the  forceps  and  head  of  the  child  into  a  single  bar, 
the  one  end  of  the  bar  thus  being  the  head  stopped  in  its  passage. 
By  working  on  the  other  end  the  head  may  gradually  be  dislodged, 
but  the  power  employed  is  mostly  traction,  for  the  leverage  power 
usually  exerted  in  extraction  is  remarkably  small.  It  consists,  indeed, 
nearly  altogether,  as  Dr.  Barnes  says,  in  using  "slight  movements 


On  the  Muscular  Forces  employed  in  Parturition.' 


176  Original  Communications.  [Jan., 

of  laterality  or  oscillation."  I  shall  presently  have  to  show  that  in 
my  practice  I  liave  used  the  leverage  power  of  the  forceps  in  a  much 
more  efficient  way ;  and  this,  in  fact,  is  by  far  the  highest  power 
possessed  by  the  instrument. 

As  this  point  is  im})ortant  in  relation  to  my  practice,  I  may  illus- 
trate it  by  the  following  example : — If  we  take  a  large  malleable  iron 
headless  nail,  which  will  bend  somewhat',  and  drive  it  partially  but 
firmly  into  a  tree,  this  may  be  supposed  to  represent  the  head  of  the 
child.  In  extracting  this  wedge  we  can  employ  three  methods  : — 1st, 
laying  hold  of  the  wedge  with  a  pair  of  sharp-pointed  pincers  or 
double  lever,  we  can  extract  it  by  simple  traction,  and  in  this 
way  we  can  also  deliver  the  child,  but  the  power  employed  is  not 
great ;  2nd,  we  can  extract  it  or  the  child  by  uniting  with  the  trac- 
tion a  motion  from  side  to  side,  which  is  traction  and  leverage  com- 
bined. This  is  more  powerful  than  the  first,  but  the  leverage  power 
obtained  is  not  great.  3rd,  We  can  extract  by  laying  hold  of  the 
wedge,  and  forcing  the  pincers  and  it  to  move  in  part  of  a  circle 
round  the  tree.  The  force  employed  here  is  in  great  part  leverage, 
and  is  much  greater  than  in  either  of  the  other  two,  and,  as  I  shall 
immediately  have  to  show,  it  is  that  which  I  now  mainly  employ  in 
cases  embraced  under  my  third  class.  If,  after  extraction,  we  look 
at  the  wedge  and  the  hole  from  which  it  has  been  drawn,  what  do 
we  find  ?  This  certainly,  that  the  edge  of  the  hole  in  the  tree,  on 
the  side  on  which  we  made  the  revolution,  is  depressed  or  indented, 
because  it  has  served  as  our  fulcrum,  and  the  part  of  the  wedge 
which  was  in  the  tree  has  been  somewhat  bent,  because  it  had  not 
strength  to  resist  the  leverage  of  the  bar  (consisting  of  pincers  and 
part  of  the  nail)  brought  to  bear  on  it.  Precisely  the  same  thing 
takes  place  in  extracting  the  child  in  my  mode  of  operating.  It 
must  be  noticed,  however,  that  the  forceps  do  not  press  upon,  or 
make  a  fulcrum  of,  the  parts  of  the  mother,  exactly  in  the  same  way 
as  the  pincers  never  come  in  contact  with  the  wood  of  the  tree. 
We  see  something  like  the  same  process  brought  into  operation 
when  a  smith  extracts  with  his  convex-shaped  pincers  z.  projectiyig 
nail  from  the  shoe  of  a  horse,  only  that  he  makes,  at  a  certain  stage 
of  the  extraction,  the  shoe  his  fulcrum.  At  first,  however,  the  cases 
are  identical,  and  every  one  knows  what  immense  advantage  the 
leverage  he  employs  gives  him  in  the  extraction.  This  will  give  an 
idea  of  the  mode  in  which  I  now  frequently  use  my  forceps ;  or  it 
may  be  likened  to  the  power  we  see  acquired  when  a  smith  uses  a 
bar  in  turning  a  vice  (known  as  the  "  rack-and-pinion^'  modification 
of  leverage) ;  only,  in  my  case,  the  forceps  embrace  the  head,  whereas 
in  the  case  referred  to  the  bar  used  for  procuring  leverage  is  hiserted 
in  a  hole. 

In  the  second  place,  in  trying  to  clear  up  this  part  of  the  subject, 
I  shall  make  a  few  remarks  on  what  I  have  observed  to  be  the  me- 


1872.]        The  Proper  Management  of  Tedious  Labours.        177 

chanism  of  labour  in  .  the  class  of  cases  I  am  now  treating  of.  The 
generally  received  opinions  on  this  subject  are  well  stated  by  Dr. 
Barnes,^  in  speaking  of  the  application  of  his  long  double-curved 
forceps.     He  says : 

"  The  pelvis  has  been  compared  to  a  screw.  !•  think  a  better 
idea  may  be  formed  of  its  mechanical  properties  by  comparing  it 
to  a  rifled  gun,  and  the  child's  head  to  a  conical  bullet.  But  even 
then  the  comparison  is  not  complete,  for  the  pelvis,  unlike  a  gun, 
is  a  curved  tube.  Now,  just  as  the  head  must  traverse  the  pelvis 
in  a  helicine  course,  determined  by  the  relation  of  form  between 
pelvis  and  head,  so  is  it  natural  that  an  instrument  designed  to  grasp 
the  head  should  be  so  modelled  as  to  be  fitted  to  follow  this  helicine 
course  during  introduction  and  extraction.  This  indication  a 
well-modelled  long  forceps  fulfils.  No  single-curved  forceps  can 
fulfil  it." 

Now,  I  contend  that  the  pelvis  in  labour  is  not  necessarily  a 
screw  or  rifled  curved  tube.  I  maintain  that,  in  many  cases,  it  is  a 
plain  curved  tube  without  any  rifling ;  and  I  prove  this  assertion  by 
stating  that  I  am  constantly  in  the  habit  of  placing  a  blade  of  the 
forceps  on  an  ear  near/  at,  or  even  above  the  symphysis  pubis,  and 
that  neither  it  nor  the  opposite  blade  ever  rotates  or  materially  alters 
its  central  position  till  the  head  of  the  child  is  just  being  born.  The 
one  blade,  and  ear  move  steadily  under  and  round  the  symphysis 
pubis,  while  the  other  blade  and  ear  sweep  along  or  near  to  the 
central  line  of  the  sacrum,  until  the  child's  head  has  passed,  or  is 
just  on  the  point  of  passing,  the  os  externum — often  the  former, 
but  sometimes  the  latter.  It  is  princi])ally  by  using  the  forceps  as 
a  lever  that  this  can  be  effected,  and  the  appositeness  of  the  illus- 
tration I  have  given,  in  which  the  nail  is  supposed  to  be  extracted 
from  the  tree  as  we  walk  round  it,  will  become  apparent.  In  point 
of  fact,  I  often  make  the  handles  of  the  forceps  go  through  even 
more  than  a  semicircle  in  this  mode  of  extraction.  I  have  con- 
stantly practised  this,  to  me,  entirely  novel  operation  for  twelve  or 
fifteen  years ;  and  it  appears  to  me,  from  its  simplicity,  from  its 
safety,  and  from  the  otherwise  diificult  class  of  cases  to  which  it  can 
be  applied,  to  be  one  of  the  most  important  in  obstetrics.^ 

Of  course,  double-curved  forceps  could  not  be  employed  as  I  have 
used  mine ;  they  could  not  perform  the  curve  1   have  described 

■•  Loc.  cit.,  and  '  Braithwaite's  Retrospect,'  vol.  Ivi,  p.  312. 

2  My  son,  who  practises  in  Asliton-under-Lyne,  writing  me  in  September  last 
as  to  some  forceps  cases  he  has  had,  says,  "  In  one  the  head  occupied  your  No.  5 
position,  that  is,  with  the  ear  to  the  symphysis  and  the  occiput  to  the  right.  The 
woman  was  of  a  squat  make,  and  had  previously  been  delivered  with  forceps  with 
great  difficultj-.  After  the  blades  had  been  applied  over  the  cars,  I  tried,  as  an 
experiment,  the  effect  of  a  straight  pull,  with  no  result-  I  then  gave  the  head  a 
slight  turn,  when  it  was  easily  brought  down  into  the  hollow  of  the  sacrum  and 
delivered,  making  the  sweep  of  a  large  segment  of  a  circle,  and  never  changing 
the  position  of  the  forceps  until  the  head  was  born." 

97 — XLix.  12 


178  Original  Communications.  [Jan., 

without  injuring  the  mother.  In  other  words,  they  necessarily  lose 
the  advantage  of  the  leverage  power  I  have  referred  to.  We  cannot, 
so  to  speak,  go  round  the  tree  with  them. 

On  the  other  hand,  if  the  pelvis,  in  these  instances,  is  not  the 
screw  spoken  of,  where  can  be  the  necessity  of  the  curve  in  the 
forceps  to  fit  into  it  ?  On  this  point  I  shall  have  something  more  to 
say  immediately.  But,  in  point  of  fact,  I  cannot  "^o  round  the 
tree'^  with  mi/  forceps,  unless  when  they  are  applied  and  maintained, 
as  it  will  be  observed  they  are  in  this  class  of  cases,  with  the  flat 
part  of  the  blades  to  the  pubes  and  sacrum.  The  advantage  thus 
gained  as  to  space  will  be  at  once  seen  by  looking  at  the  mea- 
surements of  forceps  and  parts.  Tor  example,  I  find,  in  an  ordi- 
nary female  pelvis,  the  width  of  the  arch  formed  by  the  rami  of 
the  pubes  to  be,  at  its  lower,  middle,  and  upper  portions,  re- 
spectively 3 1,  24,  and  If  inches;  while  my  forceps  measure,  from 
blade  to  blade,  at  the  widest  part,  2  J^  inches,  and  across  each 
blade  1^  inch.  It  will  thus  be  seen  that  even  their  range  (and 
the  blades  are  f  ths  of  an  inch  closer  than  most  others)  is  extremely 
limited  when  the  flat  of  the  blades  is  towards  the  ischia ;  while  when 
the  flat  of  the  blades  is  towards  the  sacrum  and  pubes,  the  bones 
admit  of  their  going  to  nearly  the  top  of  the  arch. 

I  come  now,  therefore,  naturally  to  speak  of  the  forceps  I  have 
employed,  or  which  can  be  employed,  in  delivering  in  this  third  class 
of  cases,  as  I  propose  should  be  done.  As  I  have  already  men- 
tioned, I  have  used  for  upwards  of  thirty  years  only  the  late  Dr. 
Ziegler's  straight  forceps,  and  until  lately  only  one  pair  of  these. 
Shortly  after  Dr.  Ziegler  invented  his  instrument  I  called  upon 
him  in  Edinburgh,  and  he  recommended  me  to  get  the  forceps 
which  were  then  being  made  by  Young,  of  Edinburgh.  These  con- 
sisted of  the  two  blades  which  are  now  so  well  known,  and  also  of 
a  shorter  blade,  which  Dr.  Ziegler  thought  could  occasionally  be  ad- 
vantageously substituted  for  one  of  these.^  This  forceps  is  thirteen 
inches  long,  and  is  a  most  admirable  instrument.  Its  ingenuity, 
simplicity,  and  great  utility,  have  hardly  yet,  I  think,  been  justly 
appreciated  by  the  profession,  arising,  perhaps,  a  good  deal,  in 
Scotland  at  least,  from  the  circumstance  that  the  brilliant  reputa- 
tion of  Sir  James  Simpson,  who  shortly  afterwards  designed,  and 
of  course  recommended,  an  instrument  of  his  own,  overshadowed 
and  kept  in  the  background  this,  in  my  opinion,  the  best  of  all 
forms  of  the  forceps  I  have  seen.     My  original  instrument,  after 

^  I  have  hitherto  managed  to  dispense  with  this  addition,  but  1  think  it  may 
be  found  useful,  for  example,  where  one  blade  has  been  fixed  near  the  symphysis, 
and  a  projecting  promontory  of  sacrum  prevents  the  other  from  locking  with  it. 
In  such  cases  I  have  managed  by  applying  the  blade  next  the  sacrum  first, 
throwing  it  well  back.  In  one  case  of  this  kind  I  got  hold  of  the  head  without 
the  blades  locking,  and  drew  it  down  sufficiently  to  allow  them  to  do  so.  The 
blades,  applied  over  the  cheek  and  ear,  and  opposite  parietal  bone,  hold  very  well. 


1873.]        The  Proper  Management  of  Tedious  Labours.        179 

long  use,  I  found  to  have  certain  defects,  and  on  that  account  I 
have  now  laid  it  aside;  but  although  I  have  done  so,  I  look 
upon  it  with  wonderful  respect,  as  a  servant  that  has  been  most 
useful  to  me  in  many  trying  situations. 

The  defects  of  this  instrument  I  have  found  to  be,  that  it  was 
barely  long  enough  in  certain  cases  that  have  occurred  to  me,  that 
it  is  not  strong  enough  to  be  used  as  a  lever  in  my  mode  of  de- 
livery or  even  with  powerful  traction,  that  the  hinge  has  not  sufficient 
"  play'^  to  allow  the  blades  easily  to  lock,^  and  that  the  open  fenestra 
in  blade  No.  1  is  apt,  when  much  leverage  is  used,  slightly  to  injure 
the  cheek  or  side  of  the  head  of  the  child  next  the  pubes.  Mr. 
Young  has  constructed  me  two  instruments  to  remove  these  defects, 
and  the  one  which  I  consider  the  better  of  the  two  is  represented  in 
figs.  1,  2,  the  figures  being  one  fourth  their  proper  size. 


Fm.  1.  Fig.  2.  Fig.  3. 

Fig.  1.  Ziegler's  forceps  modified,  front  view. 
„     2.         „  „  »»  side  view,   showing  play  of   hinge,  closed 

fenestra  in  blade  No.  1,  and  prolonged  fenestra  in  No.  2.     (One 
fourth  proper  size.) 
„     3.  Short  double  curved  forceps,  in  use  forty  years  since. 

Mr.  Young,  who  introduced  this  improvement  into  Ziegler's  instrument,  tells 


180  Original  Communications.  [Jan., 

The  following  are  the  dimensions  of  different  forceps  : 


Over  all. 

From 

middle  of 

hinge  to end 

of  blades. 

Greatest 
inside 

width  of 
blades. 

Between 
tips  of 
blades. 

Sir  J.  Simpson's  double- curved  forceps 

Dr.  M.  Duncan's  ditto  ditto 

J)r.  Ramsbotham's  ditto  ditto 

Dr.  Bcaty's  straiglit  ditto     . 

Dr.  Ziegler's   ditto    ditto   (figs.    1,   2, 

page  179) 

Short  forceps  (fig.  3,  page  179)     . 

Inches. 
13i 
12^ 
121 

12i 

13f 
lU 

Inches. 
8i 

81 
6f 

Inches. 
3 

2g 
3 

2| 
2| 

Inches. 
1 
1 
1 

H 

1 
U 

Comparing  the  above  forceps,  I  would  remark,  1st,  that  Ziegler's 
(figs.  1,  2)  are  longer  than  any  of  the  others,  and,  I  believe,  also 
stronger.  2nd,  That  Sir  J.  Simpson's,  which  come  nearest  to  them 
in  length,  have  two  projecting  horns,  nine  and  a  half  inches  from  the 
extremities  of  the  blades,  which  must,  I  should  think,  limit  their  in- 
troduction to  this  length,  whereas  those  wanting  these  horns  may 
be  easily  locked  even  within  the  parts  of  the  patient,  if  necessary. 
These  appendages  were  added,  no  doubt,  to  give  additional  trac- 
tion power,  but  this  is  amply  secured  by  the  great  strength  of 
those  I  am  using,  3rd,  Mine,  inside  the  blades,  measure  two  inches 
and  five  eighths,  and  the  others  one  eighth,  two  eighths,  and  three 
eighths  of  an  inch  more.  Now  this,  again,  may  become  important 
in  difficult  cases,  for,  as  Burns  properly  remarks  ('  Midwifery,'  p.  503), 
*'  forceps  whose  blades  could  come  considerably  within  three  inches 
of  each  other  may,  in  a  particular  degree  of  contraction,  act  better 
and  require  less  exertion"  than  others.  4th,  With  a  width  of  three 
inches  between  the  blades  the  instrument  may  be  simply  a  double 
hook  or  tractor,  while  with  two  and  five  eighth  inches  it  may  lay 
hold  of  the  head,  and  enable  us  to  use  it  and  the  head  as  a  lever. 
5th,  Dr.  Beaty  w^ell  observes  (^  Braithwaite's  Eetrospect,'  vol.  li, 
p.  361),  that  the  '^elongate  curve"  (which  is  given  by  the  lesser 
width  between  the  blades  of  Ziegler's  forceps)  renders  the  introduc- 
tion of  forceps  more  easy.  6th,  The  solid  blade  in  figs.  1,  2,  will, 
I  think,  be  found  a  great  improvement,  not  only  by  preventing,  as  I 
have  said,  injury  to  the  skin  of  the  child,  but  also  by  facilitating 
their  introduction;  and,  when  smeared  with  india-rubber  paste, 
making  the  large  friction-surface  that  lays  hold  of  the  scalp  really  of 
considerable  importance.  In  fact,  the  forceps  when  thus  assisted  in 
laying  hold  of  the  skin,  become  almost,  as  it  were,  an  instrument 
combining  the  properties  of  the  forceps  with  what  was  aimed  at  by  Sir 
James  Simpson  in  his  air-tractor.     In  fine,  I  think  my  instrument, 

me  that  he  has  done  the  same  with  Sir  James  Simpson's,  from  whom  I  think  he 
said  he  got  this  "  wrinkle." 


1872. J        The  Proper  Management  of  Tedious  Labours.        181 

from  wanting  projecting  parts,  and  thus  being  less  liable  than  double- 
curved  ones  to  injure  the  mother;  from  the  ease  with  which  it  can  be 
introduced  and  locked ;  from  its  great  length,  which  allows  us  to  reach 
all  kinds  of  cases ;  and  from  its  great  strength,  which  enables  us 
firmly  to  lay  hold  of,  move,  and  mould  the  head,  is  superior  to  any 
other  I  have  seen. 

I  have  remarked  that  straight  forceps  can  alone  be  used  so  as  to 
gain  the  leverage  power  which  I  have  indicated,  and  also  that  they 
must  have  their  blades  placed  antero-posteriorly  in  relation  to  the 
pelvis.  If  we  inspect  the  bony  pelvis,  I  think  we  see  the  reason  of 
this,  as  well  as  the  advantages  which  are  thus  gained.  The  outlet 
of  the  pelvis  has  been  described  as  an  irregular  oval  space,  with  its 
long  diameter  placed  from  before  backwards.  I  would  rather  incline 
to  describe  it  as  two  irregular  spaces,  the  posterior  always  oval  and 
the  anterior  often  so,  running  into  each  other  at  the  point 
formed  by  a  line  drawn  between  the  two  spinous  processes  of  the 
ischia  {c  c'),  as  seen  at  a  and  b,  figs.  4  and  5.  It  is,  I  think,  in  the 
anterior  space  that  the  head  in  my  second  and  third  classes  mostly 
gets  fixed,  and  we  may,  I  think,  perceive  that  mere  traction  must 
often  have  very  great  difficulty,  or  that  it  may  be  found  impossible. 


Fig.  4.  Fia.  5, 

Pelves,  showing  anterior  space,  A ;  posterior  ditto,  b  ;  ischial  spines,  c,  c'. 

with  this  alone,  to  move  it,  unless  we  either  turn  it  round  or  throw 
it  to  a  certain  extent  back  (sometimes  conjoining  the  two  movements) 
into  the  posterior  space  b.  This  is  what  I  do  in  delivering  in  the  way 
I  have  mentioned,  as  may  easily  be  shown  by  performing  the  trifling 
but  very  striking  experiment  of  placing  the  forceps  in  the  bony  pelvis, 
and  making  them  describe  under  the  symphysis  pubis  the  semicircle,  or 
more,  I  have  alluded  to.  I  have  been  called  in  by  brother  practi- 
tioners, using,  as  I  did,  Ziegler's  forceps,  who  have  yet  been  unable 
to  deliver  under  these  circumstances  after  hours  of  traction,  where  I 
have  succeeded  at  once  by  altering  the  position  and  direction  of  the 
instrument — applying  leverage,  and  thus  throwing  the  head  back 


182 


Original  Communications, 


[J 


an. 


into  the  posterior  space.  My  friends,  I  dare  say,  have  been  apt  to 
think  that  I  possessed  a  superior  instrument  to  what  they  used,  but 
the  true  secret  of  my  success  consisted  in  the  different  mode  in  which 
I  used  it. 

Although  the  anatomical  peculiarity  I  have  referred  to  is  at 
once  seen  by  glancing  at  the  photographs,  figs.  4  and  5,  yet,  as  this  is  a 
point  of  great  practical  importance,  it  ma}'^  be  useful  to  illustrate  it 
still  further  by  some  measurements  of  pelves  I  have  got  taken,  with- 
out any  particular  selection.  In  the  following  table  the  peculiarity 
adverted  to  is  seen  by  looking  at  the  difference  in  the  measurements 
in  the  first  and  second  columns ;  and  some  other  measurements  have 
been  added,  to  show  the  general  capacity  of  each  pelvis,  as  well  as 
to  illustrate  some  other  points.  Nine  of  the  pelves  are  normal,  and 
two  are  somewhat  distorted. 


Between 

Between 

Between 
tlie  pro- 

Transverse 

From 
hollow  of 
sacrum  to 

pubes. 

Lower  part 
of  pubic 

Upper  part 
of  pubic 

Noa. 

the  ischial 

the  tubera 

montory  of 

diameter 

spines. 

ischii. 

the  sacrum 
and  pubes. 

of  l)rim. 

arch. 

arch. 

Inches. 

Inches. 

Inches. 

Inches. 

Inches. 

Inches. 

Inches. 

1-1 

r  3| 

3| 

4| 

5| 

5i 

2f 

1 

2. 

^ 

3f 

3^ 

3f 

4f 

4| 

3 

1| 

3. 

rf 

4 

^ 

4| 

5 

5i 

3| 

If 

4. 

4| 

4| 

3| 

5f 

4i 

3i 

1 

5. 

-  ^ 

■  ^i 

H 

n 

5f 

^ 

3f 

If 

6. 

(fig.  4) 

4f 

^ 

5f 

5i 

3| 

If 

7. 

^f 

44 

4| 

5i 

5i 

3| 

1| 

8. 

(fig.  5) 

4 

3i 

3| 

H 

K 

-  ^ 

3f 

4 

H 

5i 

2f 

H 

10. 

"S 

<     ^ 

5 

2| 

5 

4| 

3| 

1 

11. 

^  % 

'     2| 

3f 

2| 

4| 

4i 

3 

i| 

s 

^ 

In  the  numbers  from  1  to  7  in  this  table  we  see  that  the  difference 
of  the  measurements  between  the  ischial  spines  andbetween  the  tubera 
ischii  goes  on  gradually  increasing  from  one  eighth  of  an  inch  to 
an  inch.  In  No.  6  (fig.  4),  the  difference  is  only  half  an  inch,  and 
yet  the  oval  form  of  both  spaces  is  seen  to  be  very  decided.  In  such 
a  pelvis  as  No.  7,  where  the  difference  is  an  inch,  the  anterior  space 
may  almost  be  spoken  of  as  a  trap,  from  which,  if  the  foetal  head 
got  in,  it  would  have  great  difficulty  in  escaping.  In  Nos.  8  (fig.  5) 
and  9  the  proportions,  it  will  be  observed,  are  reversed,  and  the 
head  would  therefore  in  these  pass  out  of  the  anterior  space  with 
the  greatest  ease. 

The  third  column,  giving  the  measurements  of  the  conjugate 
diameters,  shows  at  once  in  what  cases  the  uterus  would  be  likely  to 
be  caught  by  the  head  and  pelvis,  and  where  even  the  head  alone 
would  have  difficulty  in  passing. 

The  fifth,  sixth,   and  seventh  columns  show  the  capacity  of  the 


1872.1        The  Proper  Management  of  Tedious  Labours,       183 

pelves  for  allowing  the  use  of  the  forceps  with  **  leverage,"  as  I  have 
described  the  operation. 

Having  given  these  explanations  of  what  seem  to  me  the 
mechanism  of  labour,  and  of  the  powers  and  proper  form  of  the 
forceps,  I  can  now,  I  think,  with  greater  profit,  say  a  few  words  as 
to  how  I  came  to  use  the  instrument  in  the  way  I  have  described. 
But  in  truth  I  can  hardly  do  this  in  a  systematic  manner,  for  I  may 
say  it  grew  up  rather  than  was  invented  by  me ;  and  I  confess  I  did 
not  at  first  see,  as  I  afterwards  have  done,  the  novelty  and  importance 
of  the  changes  implied  by  it.  Perhaps  the  first  thing  that  particu- 
larly attracted  my  attention  was  the  different  position  in  these 
deliveries  required  to  be  occupied,  in  the  bed,  by  the  attendant. 
Formerly  (the  patient  lying  on  her  left  side)  she  used  to  sit,  say  a 
little  higher  than  the  middle  of  the  bed,  gently  elevating  the 
patient's  right  knee.  Now,  I  required  that  she  should  sit  on  the 
pillow,  on  a  line  with  the  patient's  head,  and  I  usually  found  that 
I  had  to  make  great  exertions  to  get  her  to  keep  the  patient''s  right 
knee  and  leg  out  of  my  way,  I  myself  going  into  the  bed  and  fol- 
lowing the  course  taken  by  the  forceps.  I  found  myself  always 
crying  "  Up,  up,  still  further,"  till  the  nurse  sometimes  lost  patience, 
saying  she  could  do  so  no  more.  This,  of  course,  arose  from  the 
much  greater  curve  which  I  was  now  making  the  handles  of  the 
forceps  take.  This,  in  point  of  fact,  is  so  great,  that  I  often,  as  has 
been  stated,  find  the  handles  of  the  instrument,  at  the  termination 
of  delivery,  almost  parallel  with  the  abdominal  parietes  of  the  patient. 
In  November,  1861,  I  delivered  with  the  forceps  a  lady  (primi- 
para)  lying  in  a  bed  which  stood  in  the  midst  of  the  room,  and  I 
noticed  that  I  introduced  my  forceps  while  sitting  on  the  right  hand 
side  of  the  bed,  that  as  the  delivery  progressed  I  went  round  the 
foot  of  the  bed,  that  when  the  delivery  was  completed  I  was  stand- 
ing at  about  the  middle  of  the  left-hdiwdi  side  of  the  bed,  and  that 
in  the  last  stage  of  the  delivery  I  had  changed  the  position  of  my 
hands  in  grasping  the  handles,  and  was  then  drawing  the  instrument 
forwards  and  upwards.  I  did  this,  as  I  mentioned,  with  Ziegler's 
forceps ;  but  had  I  been  using  such  an  instrument  as  I  commenced 
practice  with  (fig.  3),  it  is  manifest  that  the  discovery  of  such  an 
operation  being  possible  never  could  have  been  made. 

Let  me  now  give  a  single  case  illustrative  of  these  remarks,  in 
which  I  used  one  of  the  new  instruments  made  for  me  by  Mr, 
Young. 

December  30th,  1870. — Was  called  about  1  p.m.  to  Mrs.  G — , 
who  has  a  midwife  with  her,  and  states  that  she  has  been  in  labour 
since  7  a.m.  Is  of  the  squat  figure  I  have  referred  to  as  having 
tedious  or  very  difiicult  labours.  States  that  she  has  had  thirteen 
children  (the  first  twins),  of  whom  five  were  stillborn,  three  of  these 
being  delivered  with  the  forceps.     The  head  was  at  the  brim  of  the 


184  Original  Communications.  [Jan., 

pelvis,  the  uterus  easily  dilatable,  and  the  os  uteri  about  twice  the 
size  of  a  crown-piece.  Pains  regular,  but  rather  feeble.  On  ex- 
amination the  pubes  and  promontory  of  the  sacrum  were  found  to 
project  inwards,  and  between  these  and  the  head  the  uterus  was 
caught.  My  first  care  was  to  get  rid  of  this  obstacle,  which  I  suc- 
ceded  in  doing,  first,  by  using  two  fingers  in  pushing  up  the  uterus 
in  front ;  and  secondly,  as  this  failed,  by  introducing  my  hand  and 
extricating  the  engaged  part  of  the  uterus  posteriorly.  After  a  few 
endeavours  of  this  kind  the  uterus  slipped  over  the  head,  the  latter 
immediately  descending  a  little  into  the  pelvis.  The  head  was  stil), 
however,  so  high  up  that  it  was  with  difficulty  the  tip  of  one  ear 
could  be  felt  a  little  to  the  right  of  the  sy^iphysis  pubis.  The  face, 
I  thought,  was  to  the  right  (which  I  afterwards  ascertained  to  be  the 
case),  but  of  this  I  was  not  at  the  time  quite  certain.  After  the  head 
had  come  a  little  further  down  into  the  pelvis  I  tried  to  apply  my  new 
forceps,  and,  by  directing  the  handle  of  the  blade  No.  1  ^  well  back- 
wards, I  succeeded  in  placing  it  over  the  ear  next  the  pubes.  The 
other  blade  easily  slipped  into  its  place  on  the  opposite  side,  and 
these  gave  me  a  remarkably  firm  hold  of  the  head.  I  used  simply 
traction  at  first,  assisting  each  pain,  until  the  perinseum  began  to  be 
pressed  upon,  when  I  turned  the  instrument  forwards  and  upwards 
(supporting  the  perinseum  with  my  left  hand),  until  the  handles  had 
revolved  round  the  lower  part  of  the  pubes.  "When  the  head  was 
born  the  instrument  remained,  as  when  applied,  nearly  in  the  mesial 
line  of  the  woman's  body.  One  blade  was  over  the  right  ear  and 
cheek,  and  the  other  over  the  opposite  ear  and  parietal  bone.  There 
was  a  very  slight  excoriation  over  the  left  parietal  bone  ;  the  anterior 
solid  blade  had  merely  compressed  the  skin  and  made  it  look 
slightly  grayish.  The  umbilical  cord  was  round  the  neck,  and  the 
child  for  some  time  failed  to  breathe.  By  at  once,  however,  apply- 
ing my  mouth  to  that  of  the  child  and  inflating  the  lungs,  and  com- 
pressing the  sides  of  the  chest  in  conjunction  with  this  (as  I  have 
recommended  and  described  in  the  '  Edin.  Med.  Jour.'  for  May, 
1855),  the  child  soon  began  to  breathe  and  cry,  and  both  it  and  the 
mother  did  well. 

In  my  notes  I  find  the  following  remarks  on  this  case  : — Here  the 
length  and  strength  of  my  new  instrument  gave  me  great  advantage, 
for  it  must  be  remembered  that  in  such  labours  strength  is  equivalent 
to  length.  I  think  my  old  instrument  would  have  been  constantly 
slipping  until  the  head  advanced,  and  hence  losing  most  valuable 
time.  And  time  here,  as  far  as  the  child  was  concerned,  was  of 
immense  importance,  for,  had  the  labour  been  prolonged  even  a  very 
little  more,  the  child  must  have  been  lost.  From  the  time  I  saw 
this  woman  till  her  delivery  something  more  than  an  hour  elapsed. 
I  should  say  that  probably  another  half  hour,  and  certainly  another 
hour,  in  the  passages  would  have  killed  the  child.  As  it  was,  not  an 
instant  of  time  had  to  be  lost  in  order  to  save  it ;  and  here  I  would 

'  I  call  the  blade  with  closed  fenestra  No.  1. 


1872.]        The  Proper  Management  of  Tedious  Labours.        185 

remark  that  slapping  the  buttocks,  clipping  in  cold  or  warm  water, 
&c.,  would  have  been  bad  practice.  In  such  extreme  cases  inflation, 
as  the  major  remedy,  should  instantly  be  used,  for  then  even  seconds 
of  time  are  precious.  In  delivery,  the  force  applied  was  at  first 
almost  pure  traction,  and  at  last  it  became  almost  pure  leverage.  At 
first  I  tried  to  turn  the  head  into  the  hollow  of  the  sacrum ;  but 
finding  this  not  to  succeed,  I  let  the  instrument  take  its  own  course, 
the  head  passing  the  os  externmn  with  the  blades  nearly  antero-pos- 
teriorly.  Looking  at  it  as  a  whole,  I  think  we  have  here  a  key  to  the 
success  which  has  attended  my  mode  of  practice,  for  it  is  easy  to  see 
how  enormously  a  want  of  decision  and  knowledge  must  in  these 
trying  cases  increase  the  mortality  to  both  mother  and  child.  Even 
though  the  ear  was  at  the  brim  of  the  pelvis,  and  so  high  up  that  it 
could  barely  be  touched,  the  simplicity  of  the  whole  operation,  and 
the  ease  with  which  it  was  performed,  seemed  to  me  very  remarkable. 
Once  the  anterior  blade  had  been  placed  over  the  ear,  I  seemed  to 
take  almost  no  heed  as  to  all  the  rest.  The  posterior  blade  at  once 
took  its  proper  place,  and  locked  without  giving  me  either  trouble 
or  thought  (for  this  is  the  rare  quality  in  Ziegler^s  forceps,  that  they 
lock  of  themselves) ;  as  the  head  advanced  I  did  not  know,  and  I 
did  not  care,  what  turn  it  would  take,  or  whether  it  would  take  any, 
for  my  forceps  were  adapted  to  all  contingencies ;  so,  as  it  were,  I 
almost  let  them  take  their  own  way,  only  watching  the  handles,  which 
at  once  told  me  what  was  being  done.  If  they  should  keep  antero- 
posterior, then  leverage  was  the  power  I  had  mostly  to  trust  to ;  if 
they  became  transverse,  the  curve  they  could  go  through,  or  the 
lateral  oscillation  that  could  be  employed,  I  knew  was  very  limited, 
and  traction  then  would  mostly  be  the  power  available.  With  such 
simple  rules  as  our  guides,  it  seemed  to  me  almost  impossible  for  a 
person  of  the  most  ordinary  competency  to  go  wrong. 

But  if,  from  timidity  or  other  cause,  I  had  allowed  the  uterus  to  be 
caught  at  the  brim  for  an  hour  or  two  more,  and,  as  a  consequence, 
the  head  to  be  arrested  and  the  parts  to  become  swollen,  and  had 
then  introduced  a  curved  instrument  within  the  uterus,  and  had  set 
out  with  a  conviction  that  it  must,  and  a  determination  that  it  should, 
describe  a  screw-like  course  in  delivery,  how  very  different  might 
have  been  the  results  to  mother  and  child.  Looking  at  the  difficulties 
of  such  cases,  so  managed,  I  think  there  can  be  little  wonder  that 
most  writers  on  obstetrics  have  expressed  a  salutary  dread  of  "  long-- 
forceps  ■"  deliveries,  or  that  some  should  even  have  preferred  to  them 
opening  the  head.^ 

^  The  following  extract  from  Dr.  Barnes's  paper  abeady  referred  to,  containing 
instructions  for  the  use  of  this  instrument,  is  so  suggestive  that,  though  long,  I 
think  I  shall  be  excused  quoting  it : 

"Introduction  of  the  first  blade. 

"  First  stage. — One  or  two  fingers  of  the  left  hand  are  passed  inside,  in  at  the 


186  Original  Communications,  [J; 


in. 


The  double  curve  appears  to  have  been  first  given  to  the  forceps 
by  Levret,  so  as  that  it  might  fit  into  the  shape  of  the  sacrum,  and, 
when  the  face  has  already  got  into  the  hollow  of  the  sacrum,  a  short 
instrument  of  this  kind  suits  very  well.  The  curve  has  been  retained 
on  the  longer  instruments  used  since  then  on  different  grounds — as 
far  as  I  can  understand,  because  it  gives  a  larger  surface  for  laying 
hold  of  the  head ;  because  the  head  at  the  brim  can  be  better  reached 
with  it  j  because,  as  Dr.  Barnes  says,  it  fits  into  the  natural  screw- 
like form  of  the  pelvis.  These  and  other  reasons  I  have  heard  given 
for  retaining  the  double  curve,  but  I  have  never  yet  seen  a  case  in 
which  I  would  have  preferred  this  to  the  straight  instrument.^  In 
this  I  think  the  Dublin  school,  where  Dr.  Beaty's  straight  forceps 
are  mostly  used,  is  right.  Dr.  Barnes  says  he  formerly  used  straight 
forceps,  but  has  latterly  laid  them  aside,  in  consequence  of  finding 
that  they  injured  the  perinseum.  On  this  point  I  can  only  repeat 
what  I  have  already  stated,  that  I  have  never  had  in  my  whole  prac- 

pcrinajum  and  between  the  cervix  uteri  and  the  head.  Then,  bearing  in  mind  the 
relative  forms  of  the  instrument,  the  head,  and  the  pelvic  canal,  the  point  of  tlie 
blade  is  passed  along  the  palmar  aspect  of  the  fingers,  at  first  nearly  directly  back- 
wards towards  the  hollow  of  the  sacrum. 

*'  Second  stage. — The  handle  is  now  raised  so  as  to  throw  the  point  downwards 
upon  the  left  side  of  the  head.  As  the  point  of  the  blade  must  describe  a  double 
or  compound  curve — a  segment  of  a  helix — in  order  to  travel  round  the  head-globe, 
and  at  the  same  time  to  ascend  forwards  in  the  direction  of  Carus's  curve,  so  as  to 
reach  the  brim  of  the  pelvis,  the  handle  rises,  goes  backwards,  and  partly  rotates 
on  its  axis. 

"  Third  stage. — The  handle  is  now  carried  backwards  and  downwards  to  com- 
plete the  course  of  the  point  around  the  head-globe  and  into  the  left  ilium.  Slight 
pressure  on  tlie  handle  ought  to  suffice.  This  will  suggest  movement  to  the  blade ; 
the  right  direction  will  be  given  by  the  relation  of  the  sacrum  and  head.  The 
blade  is  now  in  situ;  the  shank  is  to  be  pressed  against  the  coccyx  by  the  back  of 
the  operator's  left  hand  whilst  he  is  introducing  the  second  blade. 

^'Introduction  of  the  second  blade. 

"  First  stage. — Two  fingers  of  the  left  hand,  the  back  of  which  is  supporting 
the  first  blade  against  the  perinseum,  are  passed  into  the  pelvis  between  the  os 
uteri  and  the  side  of  the  head  which  lies  nearest  the  right  ilium.  The  instrument 
held  in  the  right  hand  lies  nearly  parallel  with  the  mother^s  left  thigh,  or  crossing 
it  with  only  a  slight  angle.  The  point  of  the  blade  is  slipped  along  the  palmar 
aspect  of  the  fingers  in  the  vagina,  across  the  hank  of  the  first  blade  in  situ,  in- 
side the  perinajum  towards  the  hollow  of  the  sacrum. 

"  Second  stage. — As  the  point  has  to  describe  a  helicine  curve  to  get  round  the 
head-globe,  and  forwards  in  the  direction  of  Carus's  curve,  the  handle  is  now  de- 
pressed and  carried  backwards  until  the  blade  lies  in  the  right  ilium.  When  ifc 
has  reached  this  position  the  handle  will  be  found  near  the  coccyx,  nearly  in  oppo- 
sition to  the  first  blade." — "  Locking,"  &c.  &c., '  Braithwaite's  Ret.,'  1867,  vol.  Ivi, 
p.  353. 

1  The  fallacy  and  viciousness  of  Dr.  Barnes's  argument  and  illustration,  that  a 
screw  must  require  another  screw  to  fit  into  it,  must  be  apparent  when  we  notice 
the  ease  with  which  the  straight  forceps  follow  the  natural  rotations  of  the  head 
when  it  does  turn,  as  well  as  from  observing  their  superiority,  as  to  simplicity 
and  safety,  when  extensive  rotations  are  required.  In  the  latter  1  would  lay 
it  down  as  a  rule,  from  my  own  experience,  tliat  a  double-curved  forceps  never 
should  be  used. 


1872.]        The  Proper  Management  of  Tedious  Labours.       187 

tice  rupture  of  the  perinseum ;  and  that,  when  using  the  forceps,  if 
I  find  any  unpleasant  distension  of  it,  I  take  them  off,  and  support 
the  parts  with  the  palm  of  my  right  hand  (not  the  left,  as  recom- 
mended by  some  authors),  pushing  the  head  strongly  forwards  and 
somewhat  upwards,  as  recommended  by  the  late  Professor  Hamilton, 
or,  in  other  words,  "  shelling  it  out,"  as  this  mana3uvre  has  been 
appropriately  named  by  Dr.  Barnes.  As  far,  therefore,  as  I  can 
judge,  I  would  say  that  the  instrument  I  now  use  (figs.  1,  2)  is  fit 
for  the  management  of  any  case  I  have  ever  met  with,  and  certainly 
it  can  be  used  in  many  where  the  double-curved  forceps  are  wholly 
inadmissible. 

My  4th  class  consists  of  such  cases  as  cannot  be  reduced  to  the 
1st,  2nd,  or  3rd  classes,  which  may  arise  from  a  variety  of  causes. 
To  some  of  these  I  shall  now  advert ;  and  here  I  must  repeat  the 
opinion  I  have  already  expressed,  that,  with  increased  knowledge 
and  experience,  and  the  use  of  better  instruments  than  we  formerly 
had,  we  may  reasonably  hope  the  number  of  such  will  in  future 
be  considerably  diminished.  Let  us  take,  for  example,  such  a  case 
as  I  have  recorded  in  the  'Ed.  Med.  Jour.,'  Oct.,  1861,  p.  320, 
where  the  ear  was  at  the  symphysis  and  the  face  to  the  left  (my 
5th  position).  In  this  case  I  could  not  get  the  face  to  rotate 
to  the  left,  and  was  therefore  obliged  to  push  up  the  head,  rotate 
the  face  to  the  right,  and  then  deliver.  If  I  met  with  such  a 
case  now  I  would,  of  course,  at  once  endeavour  to  use  the  forceps 
as  a  lever  in  the  manner  described,  and  my  impression  is,  that 
with  my  stronger  instrument  I  should  succeed.  Supposing  we 
fail,  however,  the  principle  of  rotation,  as  I  have  pointed  out  in 
the  article  referred  to,  can  be  resorted  to  with  great  advantage,  and 
to  an  extent  (with  straight  forceps)  that  would  astonish  many 
practitioners.  Sir  James  Simpson  used  to  be  much  interested  in 
this  subject,  and  I  recollect  relating  to  him  a  still  more  interesting 
example  of  this  kind.  The  case  had  been  a  long  time  under  the 
care  of  an  ignorant,  and,  what  was  even  worse,  an  obstinate  midwife, 
who  persisted  in  the  vain  endeavour  to  make  unaided  nature  effect 
the  delivery.  When  I  saw  the  woman  I  found  the  parts  dreadfully 
swollen,  and  the  case  fast  assuming  all  the  characters  of  "  impac- 
tion.''  With  considerable  exertion  I  found  that  the  ear  and  face 
were  to  the  left  of  the  symphysis  (my  4th  position),  and  succeeded  in 
fixing  the  forceps  over  this  ear  and  the  head,  but  could  neither  turn 
the  face  into  the  hollow  of  the  sacrum  nor  make  it  advance  down- 
wards. I  then,  as  in  the  last  case  referred  to,  pushed  the  head  above 
the  brim,  and  rotated  it  so  as  to  place  an  ear  and  the  face  to  the 
right  of  the  symphysis  (my  1st  position),  and  still  I  could  not 
deliver.  I  then  resorted  to  podalic  version,  and  by  that  means  saved 
the  child.     The  mother,   however,  succumbed   to   peritonitis  ^   in 

'  Curiously  enough,  the  husband  of  this  patient  again  maiTied  a  woman  who  hai> 


188  Original  Communications.  [Jan., 

three  or  four  days  afterwards.  Besides  showing  the  extent  to  which 
rotation  can  easily  be  carried,  this  case  is  one  among  many  others 
confirming  the  doctrine  that  the  base  of  the  child^s  head,  when 
brought  down  first,  will  sometimes  pass  easier  through  a  narrow 
pelvis  than  if  the  vertex  had  presented.  With  my  later  ideas  as  to 
the  mechanism  of  labour,  and  of  the  powers  of  the  forceps,  I  would 
give  my  adhesion  to  this  general  principle  with  reservation ;  and  I 
would  say,  as  the  result  of  my  own  experience,  that  podalic  version 
should  never  be  resorted  to  until  the  forceps  (with  rotation  to  the 
right,  should  the  face  be  to  the  left)  have  failed.^ 

When  I  am  absolutely  compelled  to  apply  the  forceps  within  the 
uterus,  the  rule  I  follow  is  still,  if  I  can,  to  place  them  over  the  ears, 
which  mostly  requires  that  the  anterior  blade  (No.  1)  should  be 
thrown  well  back  on  the  perinseum ;  or,  if  I  cannot  do  this,  or  can- 
not exactly  ascertain  where  the  ear  lies,  I  then  lay  hold  of  the  head 
wherever  I  can  (sometimes  placing  blade  No.  1  posteriorly  before 
introducing  No.  2)  ,2  and  advance  it  until,  by  examination,  I  find  its 

always  to  be  delivered  with  forceps,  for  though  the  pelvis  is  broad,  the  pubes 
project  very  much  inwards.  I  therefore,  contrary  to  my  general  practice,  have  to 
apply  the  instrument  diagonally.  The  last  time  I  delivered  her  I  noticed  there 
was  so  much  room  at  the  sides  that  when  I  placed  the  first  blade  at  the  right 
obturator  opening  it  fell  backwards,  and  had,  therefore,  to  be  held  in  position  till 
the  other  blade  was  fixed.  Usually,  my  first  blade  is  held  quite  firm  between 
pubes  and  head. 

^  I  therefore  could  not  agree  with  Sir  James  when,  in  the  Obstetrical  Society, 
he  said  ('  Edin.  Med.  Journ,,'  Oct.,  1862,  p.  378) — "  When  it  became  necessary  to 
shorten  the  labour  he  believed  that  it  did  not  matter  very  much  whether  the 
operation  had  recourse  to  were  extraction  by  the  forceps  or  version ;  that  it  was 
the  speedy  delivery  of  the  patient  from  all  her  sufferings  and  struggles,  and  not 
the  special  kind  of  operation,  that  was  her  source  of  safety."  This,  however, 
relates  merely  to  the  safety  of  the  mother,  while  it  is  the  duty  of  the  accoucheur, 
if  possible,  to  save  both  mother  and  child.  Dr.  Figg,  late  of  Bo'ness, 
Stirlingshire,  who  used  to  contend  that  all  vertex  presentations  ought  to  be  con- 
verted into  footling  ones,  was  present,  and  spoke  on  this  occasion ;  and  Sir  James, 
in  the  above  extract,  seems  to  give  countenance  to  the  doctrine  that  in  a  case  of 
tedious  labour  it  is  immaterial  whether  podalic  version  be  resorted  to  or  the 
forceps  applied.  I  can  only  express  on  this  point  my  very  decided  opinion, 
that  an  ordinary  vertex  presentation  gives  the  easiest  of  all  labours,  and  ought 
not,  therefore,  as  a  general  rule,  to  be  interfered  with;  and  that  when  the 
labour  has  become  tedious,  any  practitioner  w^ould  be  guilty  of  very  bad  practice 
indeed  if  he  converted  it  into  a  footling  case  before  he  had  exhausted  the  powers 
of  the  forceps.  Sir  James's  obstetric  practice  seems  at  this  time  to  have  been  in 
an  unsettled  or  a  transition  state,  for  whereas  formerly,  at  the  Edinburgh  Maternity 
Hospital,  which  was  chiefly  under  his  direction,  the  forceps  deliveries  had  been  1 
in  472,  he  (November,  1861)  stated  during  this  discussion  that  he  then  was  using 
the  forceps  once  in  perhaps  every  15  or  20  cases.  He  also  stated  that  "  he  had 
never  doubted  that  the  chief  danger  from  delay  began  when  the  first  stage  was 
completed,  and  an  arrest  of  the  labour  took  place  when  the  fatal  head  had  begun 
to  be  compressed  in  the  maternal  canals." 

2  My  reason  for  generally  introducing  blade  No.  1  first  anteriorly  i«,  that  after 
it  has  been  placed  in  position  the  other  usually  at  once  slips  into  its  place,  A  pro- 
jecting promontory  will  sometimes,  however,  prevent  this.  The  projecting  pubes 
will  sometimes  also,  as  I  have  said,  cause  the  blades  to  be  diagonal.     I  very  rarely 


1872.]        The  Proper  Management  of  Tedious  Labours.        189 

exact  position,  when  I  then  know  precisely  how  to  proceed.  At  the 
same  time  that  the  forceps  draw  the  head  through  the  os  uteri, 
I  find  it  most  useful,  with  the  fingers  of  the  left  hand,  to  push 
the  uterus  up  over  the  head.  In  these  high  operations  the  length 
and  strength  of  my  present  instrument  give  me,  I  think,  very  great 
advantages. 

Cases  with  the  face  to  the  pubes,  occurring  in  primiparse,  have 
given  me  some  trouble.  My  732nd  case,  as  I  have  stated,  was  of  this 
kind,  and  I  lost  the  child,  and  in  an  earlier  part  of  my  practice  I 
recollect  the  game  thing  happening  in  another  instance.  It  was 
interesting  to  me,  therefore,  since  I  have  been  using  my  new  instru- 
ment, to  meet  with  a  case  exactly  similar.  It  was  under  the  care  of 
a  midwife,  who  called  me  to  assist  her.  I  found  the  head  jammed 
in  the  parts  very  tightly,  and,  as  I  could  not  at  first  ascertain  with 
precision  the  position,  1  placed  the  blades  antero-posteriorly,  and 
used  as  much  leverage  as  the  case  would  allow.  In  doing  so  I 
suddenly  felt  the  handles  jerk  round  and  become  transverse.  Taking 
the  instrument  off  and  examining,  I  now  found  that  an  ear  was 
slightly  to  the  left  of  the  symphysis,  with  the  face  to  that  side  also.^ 
lieapplying  the  instrument  I  again  used  leverage,  when  the  head 
made  another  jerk  round,  placing  the  face  in  the  hollow  of  the 
sacrum,  and  delivery  took  place  immediately.  Here,  again,  I  was 
much  impressed  with  the  great  power  my  new  instrument  and  mode 
of  delivery  gave  me,  and  I  w^as  much  pleased  with  the  firm  hold  the 
india-rubber  on  the  inside  of  the  blades  (which  I  had  lately  been 
using)  seemed  to  give.  The  simplicity  of  the  operation  especially 
struck  me,  for  it  was  nature,  and  not  I,  that  took  the  turns.  I 
found,  on  examination,  that  the  solid  blade  (No.  1)  had  at  first 
been  place  over  the  left  eyelid  and  cheek,  which  were  a  little  red  and 
swollen,  but  not  in  the  least  degree  excoriated.  This  disappeared  in 
a  few  days,  and  mother  and  child  did  excellently. 

After  all,  of  course  it  will  occur  that  in  some  instances  the  dis- 
proportion between  head  and  pelvis  is  so  great  that  delivery  cannot 
be  effected  with  the  forceps,  though  I  am  now  inclined  to  think,  if 
the  case  has  been  well  managed,  and  absolute  deformity  of  pelvis  or 
hydrocephalus  be  absent,  this  is  much  rarer  than  is  generally 
imagined.  In  such  cases,  if  the  mother  has  not  previously  been  too 
much  exhausted,  podalic  version  naturally  presents  itself  to  us  as 

indeed  find  myself  placing  them  transverse  at  first  if  the  head  is  high  up.  But 
at  first,  in  such  cases,  I  am  content  with  any  good  hold. 

^  In  the  •  Edin.  Med.  Journ./  for  October,  1861,  in  mentioning  my  732nd  case, 
with  face  to  pubes,  I  state  that  I  found  I  could  not  move  the  face  to  the  right, 
and  was  equally  siu'prised  to  find  that  it  comparatively  easily  took  the  turn  to  the 
left,  in  this  difi'ering  from  what  usually  occurs  in  vertex  presentations.  The 
present  case,  it  will  be  observed,  did  the  same,  which,  on  consideration,  seems  to  me 
the  natural  course,  for  the  rectum  prevents  the  occiput  from  revolving  to  the 
left,  while  the  spaces  on  the  right  posteriorly  and  the  left  anteriorly  are  free.  I 
think  it  is  worth  while  keeping  this,  as  a  rule,  in  mind. 


190  Original  Communications,  [Jan., 

another  resource  before  perforation.  From  the  line  of  practice 
which  I  have  followed,  I  have  had  so  much  less  experience  in  podalic 
version  than  most  hospital  accoucheurs/  that  I  cannot  venture  to 
speak  practically  on  the  subject  with  great  confidence.  I  would 
remark,  however,  that  in  such  cases,  where  the  head  is  very  large 
and  refuses  after  version  to  enter  the  pelvis,  or  where  it  is  caught 
high  up  and  does  not  advance  after  prolonged  traction,  it  is  perhaps 
the  best  practice,  if  the  want  of  beat  in  the  funis  indicates  the  child''s 
death,  at  once  to  use  the  perforator.  In  the  case  immediately  pre- 
ceding my  series  of  731  cases  I  did  this,  the  child  being  almost  a 
monstrosity  in  point  of  size.  In  another  case,  where  I  had  to  assist 
two  brother  practitioners,  I  did  the  same,  the  cervical  vertebrae 
having  given  way  before  it  was  resorted  to.  In  the  first  case  the 
mother  died  also,  from  peritonitis,  while,  in  another  case  still,  I  was 
called  by  two  practitioners  to  assist  them,  and  found  the  head  alone 
in  utero,  and  the  mother  moribund.  Such  examples,  conjoined  with 
the  mortality  to  the  children  in  cases  under  my  own  care,  already 
referred  to,  have,  I  confess,  given  me  a  great  dread  of  turning  and 
high  footling  cases. 

Even  when  the  face  has  come  into  the  hollow  of  the  sacrum, 
in  muscular  primiparse,  the  difficulty  in  delivery  must,  I  think, 
often  be  so  great  that  the  pressure  on  the  cord  will  kill  the  child. 
Here  I  have  found  the  two  dangers  to  be  injury  to  the  spine  from 
traction,  and  death  from  compression  of  the  cord.  Although  speak- 
ing only  theoretically,  I  would  hope  that  both  of  these  may  be  in 
most  instances  overcome.  The  statement  of  Professor  Busch,  of 
Berlin,^  that  he  had  applied  the  forceps  in  such  cases  and  saved 
most  of  the  children,  is  certainly  most  encouraging  for  the  use  of  this 
instrument,  though  I  have  never  myself  so  used  it.  Dr.  Meigs  also 
advocates  the  use  of  the  forceps  in  the  same  kind  of  cases.  The 
statement,  also,  that  the  introduction  of  a  catheter  or  tube  into  the 
child's  mouth,  or  even  expanding  the  parts  with  the  fingers,  has 
enabled  it  to  breathe  until  delivery  could  be  effected,  would  seem  to 
point  out  that  the  joint  admission  of  air  to  the  child  and  traction 
applied  to  the  head,  are  the  desiderata  required.  It  has  struck  me 
that  this  might  be  effected  in  two  ways.  On  this  same  subject  I  said, 
in  the  'Edin.  Med.  Jour.,'  May,  1855,  p.  404,  that  possibly  a  vectis, 
more  curved  than  usual,  might  be  found  useful  in  such  cases.  I  got 
one  made  and  tried  it,  but  the  curve  prevented  its  introduction. 

^  In  note  in  No.  96,  page  202,  we  find  in  the  '  Glasgow  Maternity  Eeport  * 
12  versions  to  882  deliveries. 

'  "  Turning  with  the  feet  foremost  was  performed  in  forty-four  cases,  with  the 
highly  favorable  result  that  only  three  children  lost  their  lives  from  the  effects  of 
the  operation.  Professor  Busch  ascribes  this  unusually  small  mortality  among  the 
children  thus  delivered  to  the  circumstance  of  his  instantly  applying  the  forceps 
the  moment  the  head  experienced  any  hindrance  when  passing  through  the  pelvis." 
— *  Brit,  and  For.  Med.-Chir.  Rev.,'  1838,  p.  579. 


1872.]         The  Proper  Management  of  Tedious  Labours.      191 

Latterly  I  have  reverted  to  the  same  idea,  lessening  the  curve,  and 
getting  a  deep  groove  made  in  the  instrument,  so  that  the  child 
could  easily  breathe  by  it,  at  the  same  time  that  traction  was  being 


Fig.  6  (one  fourth  size).  A  kind  of  spoon,  with  douhle  floor  of  perforated  zinc 
(a),  and  india-rubber  tube  (J)  ;  to  be  introduced  into  the  hollow  of  the  sacrum,  so 
as  to  enable  the  child  to  breathe  while  the  forceps  are  being  used  in  footling  cases. 

applied.  The  great  objection  to  the  vectis  (properly,  of  course, 
a  tractor),  however,  is  its  small  power;  and  therefore  I  have  also 
got  a  little  instrument  made  (fig.  6),  which  perhaps  may  serve 
better  than  a  catheter  to  allow  of  respiration  while  the  forceps  are 
being  used.  I  also  got  made  a  hook  to  fit  on  the  forefinger  of  the 
left  hand  when  introduced  into  the  child's  mouth,  so  that  traction 
and  breathing  might  go  on  at  the  same  time.  The  '^  spoon,"  fig.  6, 
and  the  forceps,  however,  seem  likely  to  be  the  most  useful.  A 
vectis  without  fenestra,  to  give  it  increased  surface,  made  upon  the 
principle  referred  to,  and  smeared  with  india-rubber  paste,  however, 
may  probably  be  found  a  tolerably  efficient  instrument,  from  the 
hold  which  it  will  have  on  the  scalp.  These  suggestions,  however, 
are  theoretical,  but  they  seem  to  me  worthy  of  trial. 

This  paper  has  extended  so  much  beyond  the  limits  I  originally 
assigned  to  it,  that  I  have  left  myself  almost  no  space  to  notice 
objections  I  have  heard  urged  to  the  practice  I  have  been  advocating. 
This  is  the  less  necessary,  however,  first,  because  the  good  sense  of 
almost  all  later  practitioners  seems  to  have  set  them  aside  as  in  a 
great  measure  baseless.  Sir  James  Simpson  setting  the  good  example 
by  telling  us  how  he  had  altered  his  practice.  Who  now,  of  British 
accoucheurs,  will  venture  to  say  that  the  forceps  require  to  be  used 
only  once  in  500  or  700  labours?  or  what  general  practitioner 
would  think  the  use  of  them  excessive  even  once  in  every  twentieth 
or  thirtieth  labour?  This  alone  shows  how  great  has  been  the 
alteration  of  opinion  on  this  subject  during  the  last  twenty  years. 
Secondly,  because  all   these  objections  I  have  heard  of,  I  think. 


193'  Original  Communications.  [Jt 


in. 


resolve  themselves  into  the  fallacy  which  I  had  formerly  to  expose. 
I  then  showed  that  it  was  not  the  forceps,  but  the  delay  and 
tedious  labour,  that  killed  the  child ;  and  so  now,  if  any  minor 
injuries  are  likely  to  accrue  to  mother  or  child,  I  say  again,  it  is  not 
the  forceps,  but  the  tedious  labour,  that  should  be  blamed  for  these; 
and  just,  I  believe,  in  so  far  as  the  forceps  are  promptly  and 
judiciously  used  will  they  be  found  less  frequent.  I  can  most 
faithfully  say,  however,  and  without  the  slightest  reservation, 
that  I  have  observed  in  my  own  practice  no  drawbacks  to  their 
application  of  the  very  slightest  consequence.  This  includes  an 
aliedged  one  to  which  my  attention  has  only  lately  been  directed  by 
a  friend,  as  he  has  found  it  stated  by  Drs.  Barnes,  Pettigrew,  and 
Murphy,  viz.  that  the  use  of  the  forceps  encourages  flooding.  Now, 
after  my  long  and  constant  practice  with  them,  I  should  surely  be 
able  to  speak  pretty  confidently  on  this  point,  and  since  the  subject 
has  been  brought  under  my  notice  I  have  been  trying  to  remember 
any  of  my  forceps  cases  in  which  flooding  had  occurred  (for  most 
assuredly  this  never  had  attracted  my  special  attention),  and  I  can  re- 
collect only  three  that  were  severe.  In  the  first  the  forceps  were  used, 
no  doubt,  but  the  flooding  recurred,  in  the  same  patient,  in  five  out 
of  other  seven  labours,  all  of  which  were  particularly  easy.  In  the 
second  and  third  chloroform  was  also  used,  and  both  patients  had 
flooding  more  than  once  in  their  labours.  In  no  patient  whatever 
delivered  by  me  with  the  forceps  for  the  last  twenty-five  years  have 
I  failed  (and  generally  with  great  ease)  to  restrain  the  flooding  by 
the  method  I  have  recommended,  viz.^  introducing  the  one  hand 
under  the  uterus,  and  compressing  it  between  this  and  the  other 
applied  externally.  In  the  instance  formerly  referred  to,  where  the 
chloroform  excited  the  patient,  it  was  the  chloroform  alone  that  pre- 
vented the  application  of  the  necessary  measures,  and  hence  made 
the  case  formidable. 

I  must  now  take  leave  of  this  subject,  hoping  that  the  details 
my  practice  has  furnished  to  me,  and  the  observations  it  has  enabled 
me  to  make,  may  be  of  use  to  my  professional  brethren.  I  must 
warn  them,  however,  that  it  is  not  alone  by  a  more  frequent  use  of 
the  forceps  that  success  will  be  attained,  if  the  other  rules  which 
have  guided  me  be  neglected.  The  first  stage  of  labour  improperly 
interfered  with,  by  giving  ergot  or  otherwise,  may  exhaust  and  kill 
the  child,  or  the  same  may  be  done  by  allowing  the  second  to  be 
too  much  prolonged ;  so  that  a  frequent  use  -of  the  forceps  and  a 
high  infantile  mortality,  although  at  first  sight  apparently  con- 
tradictory of  my  practice,  might  not  necessarily  be  so.^ 

1  See  '  Edin.  Med.  Journ.,'  October,  1850,  and  October,  1861,  p.  315. 

2  In  the  note  regarding  the  Glasgow  Maternity,  as  given  in  No.  96,  page 
202,  it  will  be  noticed  that  among  the  882  children  born,  version  or  the  forceps 
were  used  29  times,  or  about  1  in  30,  and  yet  the  stillborn  children  amounted  to 
91,  or  more  than  1  in  10. 


18 72. J  On  the  Recent  Progress  of  Uroscopy.  19^ 


II.— On  the  Recent  Progress  of  Uroscopy.     By  Dr.  Karl  Ber- 
THOLD  HoFMANN,  Lecturcr  in  the  University  of  Vienna. 

The  design  of  the  following  paper  is  to  present  an  account  of  the 
progress  that  has  been  made  on  uroscopy^  especially  in  Germany. 
I  shall  therefore  notice  principally  the  works  of  the  German  physio- 
logists_,  taking  it  for  granted  that  most  of  the  Enghsh  works  are 
known  to  our  readers,  while  most  of  the  German  works  are  inacces- 
sible to  the  English  medical  public. 

On  the  formation  and  elimination  of  urea  under  different  condi- 
tions.— By  far  the  most  important  constituent  of  the  urine  is  the 
urea ;  its  synthesis  on  the  one  hand,  and  the  explanation  of  its 
derivation  through  the  retrogressive  metamorphosis  of  the  tissues  on 
the  other  hand,  have  for  a  long  time  occupied  the  attention  of  the 
chemist  and  physiologist. 

During  the  past  year  in  this  direction  two  series  of  researches 
have  been  made.  Basaroff  succeeded  in  forming  urea  from  ammonia 
(NH4O),  and  carbonic  acid  (CO2) ;  and  Bechamps,  for  the  third 
time,  asserts  the  possibility  of  obtaining  urea  by  the  oxidation  of 
albumen. 

In  addition  to  the  old  method  of  artificial  production  of  this  body 
from  the  cyanate  of  ammonia,  Nathansen  has  discovered  two  others 
which  support  the  hypothesis  that  urea  is  to  be  considered  as 
the  amide  of  carbonic  acid.  He  obtained  urea  by  treating  dry 
ammoniacal  gas  with  phosgene  (COCI2),  or  by  heating  carbonic 
ether  with  ammonia  in  excess. 

The  first  process  is  COCI2  +  2NH3  =  CON2H4  +  2HC1. 
The  second,  QO;{Q^B,)^  +  2NH3  =  CON^H^  +  ^C^H.p.i 

In  intimate  connection  with  those  two  methods  stands  the  follow- 
ing method  of  Basaroff.^  He  passes  pure  dry  ammoniacal  gas  and 
carbonic  acid  through  absolute  alcohol.  By  this  is  formed  carbonate 
of  ammonia  (formula:  CO^  +  2NH3  =  (NH2)COoNHJ.  This 
formula,  compared  with  that  of  urea  (00^2114),  contains  one 
molecule  of  water  (H2O)  more,  to  remove  which  he  heats  this  com- 
bination in  an  hermetically  sealed  tube  at  the  temperature  of  130° — 
150°  centigrade. 

Daily  experience  teaches  us  that  when  the  urine  is  in  process  of 
putrefaction  the  carbonate  of  ammonia  which  gives  the  urine  its 
disagreeable  odour  is  got  from  the  reception  of  two  molecules  of 
water  by  one  molecule  of  urea.     Basaroft*,  by  inverting  this  process, 

1  In  the  formulae  given  above  the  equivalents  of  C  and  O  are  taken  twice  as 
large  as  in  less  recent  chemical  works. 

2  A.  Basaroff,  "Directe  Darstellung  des  Harnstoffs  aus  Kohlensaure  und 
Amoniak,"  '  Journal  fur  Pract.  Chemie,'  N.  F.,  Bd.  i,  p.  283. 

97— XLix.  13 


191  Original  Communications.  [J 


an. 


succeeded  in  splitting  up  carbonate  of  ammonia  into  urea  and 
carbonic  acid,  by  heating  the  same  in  an  hermetically  sealed  glass 
tube  at  a  temperature  of  130°  centigrade. 

Less  fortunate  was  Bechamps.^  He  proposed  the  following 
method : — Ten  grammes  of  albumen  (free  from  fat  and  sugar)  are 
mixed  with  sixty  to  seventy-five  grammes  of-  permanganate  of  potash 
and  one  hundred  to  three  hundred  c.c.  water ;  this  is  heated  in  a 
water  bath  until  the  blue  colour  disappears;  then  the  fluid  is 
filtered,  and  acetate  of  lead  added  (excess  of  the  latter  is  to  be 
avoided).  Having  filtered  again,  the  filtrate  is  to  be  treated  with 
sulphuret  of  hydrogen.  The  precipitate  of  sulphuret  of  lead  is  to 
be  filtered,  and  to  the  clear  filtrate  caustic  baryta  and  subnitrate  of 
mercury  added  as  long  as  a  precipitate  is  formed.  The  precipitate 
must  be  separated,  washed,  and  afterwards  decomposed  by  the 
addition  of  sulphuret  of  hydrogen.  The  acid  fluid  is  filtered  once 
more,  and  then  neutralized  with  carbonate  of  baryta  and  evaporated. 
Bechamps  states  that  he  found  in  this  residuum  crystals  of  urea. 

I  am  not  able  •  to  confirm  this  statement  of  the  French  experi- 
menter. Although  I  have  closely  followed  his  directions,  I  have 
not  succeeded  in  obtaining  a  single  grain  of  urea.  My  own  experi- 
ments have  been  made  in  Prof.  Tr.  Schneider's  laboratory.  Some 
time  afterwards  Lowe,  of  New  York,  proved  the  crystals  which 
Bechamps  took  for  nitrate  of  urea  to  be  only  the  crystals  of  nitrate 
of  baryta.  These  two  negative  results  apparently  prove  that 
Bechamps'  latest  assertion  is  just  as  incorrect  as  his  two  former 
ones.  The  superficiality  of  his  work  is  proved  by  the  mere  fact 
that  he  did  not  even  deem  it  worth  the  trouble  to  subject  his  sup- 
posed urea  to  the  elementary  analysis. 

The  generally  conjectured  derivation  of  urea  from  the  albuminates 
is  therefore  not  yet  proved. 

Next  to  the  formation  of  the  urea  physiologists  are  most  interested 
in  the  place  of  its  formation.  Is  the  urea  first  made  in  the  blood, 
and  have  the  kidneys  only  to  eliminate  it  ?  Or  are  the  kidneys  the 
place  where  it  takes  its  origin  ?  To  solve  this  contested  question 
N.  Grehant^  repeated  in  C.  Bernard's  laboratory  the  following 
decisive  experiments.  He  extirpated  both  kidneys  of  a  dog,  and 
found,  after  this  operation,  that  the  blood  contained  more  urea  than 
before.  The  same  results  followed  the  placing  of  ligatures  on  the 
ureters.  Both  experiments  proved  the  accumulation  of  urea  in  the 
blood. 

If  the  blood  of  the  renal  vein  and  artery  of  a  perfectly  healthy 

^  M.  A.  Bechamps,  "  Sur  la  formation  de  I'uree  par  Paction  de  I'hypermanganate 
de  potasse  sur  les  mati^res  albuminoides/'  '  Comptes  rend./  Ixx,  866-69. 

2  N.  Grehant,  "  Recherches  physiologiques  sur  I'excretion  de  I'uree  par  les 
reins/*  •  Bibliotheque  de  recole  des  hautes  etudes/  Sect,  des  sciences  natur.,  i, 
265. 


1872.]  On  the  Recent  Progress  of  Uroscopy.  195 

kidney  be  examined,  it  will  be  found  that  the  venous  blood  contains 
less  urea  than  the  arterial,  which  shows  us  that  some  urea  is  lost 
during  the  passage  of  the  blood  through  the  kidneys.  If  the  two 
ureters  are  tied  so  that  no  urea  can  be  eliminated,  the  blood  in  the 
veins  and  arteries  contains  the  same  per-centage  of  urea.  This  is  an 
indisputable  proof  that  the  urea  is  not  formed  in  the  kidneys,  other- 
wise the  venous  blood  would  contain  more  urea  than  the  arterial. 
The  great  mass  of  urea  in  the  blood  after  the  extirpation  of  the 
kidneys  proves  the  same,  for  if  this  were  not  true  the  production  of 
urea  would  cease  after  the  kidneys  have  been  extirpated.  To  deter- 
mine the  quantity  of  urea  Grehant  used  Millon's  fluid. 

Induced  by  the  observations  of  Grehant,  Cyon  attempted  to  prove 
that  urea  is  produced  in  the  liver.  To  this  end  blood  was  taken 
from  the  carotid  of  a  dog  which  had  not  been  narcotized,  quickly 
defibrinized,  and  a  part  of  it  placed  in  an  apparatus  by  means  of 
which  it  was  to  be  forced  through  the  liver.  These  tubes  were 
introduced  respectively  into  the  ve7ia  cava  inferior,  arteria  hepaticaj 
and  vena2^ortce,  then  the  liver  cut  out  of  the  body  and  placed  in  a 
vessel  heated  to  the  temperature  of  the  blood.  The  first  tube  was 
connected  with  an  aspirator,  the  second  and  third  with  the  above- 
mentioned  apparatus,  in  which  the  blood  was  contained.  The 
circulation  of  the  blood  through  the  liver  could  be  kept  up  by  means 
of  a  connecting  tube,  which  returned  the  blood  on  its  arrival  in  the 
aspirator  into  the  first  vessel,  from  which  it  could  be  again  forced 
through  the  liver.  After  the  blood  had  been  several  times  passed 
through  the  liver  it  showed  a  greater  per-centage  of  urea  than  a  hke 
quantity  of  the  active  blood  of  the  same  animal.  Cyon  draws, 
therefore,  the  conclusion  that  the  liver  is  the  place  of  formation  of 
the  urea.  He  promises,  at  the  same  time,  to  follow  these  short 
communications  with  a  more  elaborate  article.  (Hr.  E.  Cyon, 
"Ueber  Harnstoffbildung  in  der  Leber,'^  '  Centralblatt  fiir  die 
medicinischen  Wissenschaften,'  1870,  No.  37.)   p.  580. 

Dr.  Perls,^  lecturer  at  Konigsberg,  proposed  a  new  method  for 
determining  the  quantity  of  urea  in  the  blood.  Pirst  prepare  a 
watery  solution  of  sulphate  of  copper  of  the  concentration  one  to 
five.  Then  the  blood  which  is  to  be  analysed  is  to  be  diluted  with 
an  equal  quantity  of  water.  For  every  twenty  c.c.  of  this  diluted 
blood,  which  contains  ten  c.c.  pure  blood,  there  is  to  be  used  one 
c.c.  of  the  sulphate  of  copper.  The  result  of  this  reaction  will  be 
a  yellowish-green  fluid,  which,  after  standing  a  few  hours,  forms  a 
precipitate.  This  fluid  is  to  be  filtered,  and  the  filtrate  evaporated ; 
then  an  alcoholic  extract  to  be  made  from  the  residuum,  and  this 
extract  treated  with  nitric  acid,  whereby  nitrate  of  urea  is  formed. 

^  "Neue  Methode  zur  Bestimmung  des  Harnstoffes  im  Blute  imd  in  den 
Goweben/'  *  Med,  Centralb./  1870,  p.  49, 


196  Original  Communications,  [Jan., 

Meissner  asserts  that  by  this  method  he  found,  in  ten  to  twenty 
c.c.  blood  of  rabbits,  whose  kidneys  had  been  extirpated,  four 
centigrammes  of  nitrate  of  urea.  This  also  proves  the  accumulation 
of  urea  in  the  blood  after  nephrotomy. 

Elimination  of  urea  in  starvation  and  in  fever. — As  the  elimina- 
tion of  urea  affords  the  best,  indeed  the  only  means,  of  explaining 
the  atomic  changes  in  the  human  body,  so  the  attention  of  observers 
has  been  called  to  the  investigation  of  its  quantity  under  different 
physiological  and  pathological  conditions.  The  chief  aim  of  these 
observers  has  been  to  make  themselves  better  acquainted,  by  means 
of  the  examination  of  the  urine  and  its  constituents  (especially  by 
the  quantitative  determination  of  the  urea),  with  the  atomic  changes 
which  accompany  starvation  and  fever. 

A  new  investigation  of  Dr.  Nicholson's,  ^'  On  the  Body- weight  and 
Urea  in  a  Case  of  Starvation,"  published  in  the  '  Brit  Med.  Journ.,' 
1870,  No.  470,  confirms  the  previous  experience,  that  with  absti- 
nence the  elimination  of  urea  does  not  cease,  and  that  the  accom- 
panying diminution  of  body-weight  is  in  proportion  to  the  same. 

The  observations  of  the  urine  in  fever,  and  especially  of  the 
quantity  of  its  nitrogenous  constituents,  have  been  made  partly  on 
patients  with  febrile  diseases  and  partly  on  dogs. 

Naunyn^  determined  the  quantity  of  urea  ehminated  by  a  starving 
dog.  The  quantity  was  0*28  gramme  per  hour.  If  in  addition  he 
produced  fever  by  the  injection  of  ichor,  the  dog  excreted  0*42 
grammes  in  the  same  time.  Another  dog,  during  the  starving 
period,  excreted  0*26  gramme  per  hour,  during  the  fever  0*48 
gramme.  The  increase  in  the  total  quantity  of  the  urine  during 
fever  (from  180  c.c.  to  280  c.c.)  leads  Naunyn  to  believe  that  in 
this  condition  not  only  the  nitrogenous  constituents  of  the  organism, 
but  also  the  non-nitrogenous,  are  subject  to  a  greater  oxidation  than 
in  health. 

Naunyn  wished  to  become  certain  whether  or  no  the  increase  of 
urea  during  the  febrile  state  is  the  effect  of  the  raised  temperature  of 
the  body.  To  decide  this  point  he  shut  a  dog  in  an  Obernier^s 
chest,  the  air  of  which  was  perfectly  saturated  with  steam  of  the 
temperature  of  35° — 40°  C.  During  the  six  hours  the  dog  remained 
under  the  influence  of  this  heat  the  temperature  of  the  dog  rose  to 
42*5  C,  and  he  excreted  110  c.c.  urine,  containing  9*716  grammes 
urea.  Outside  of  the  chest,  in  the  same  time,  with  the  same  food, 
the  dog  passed  120  c.c,  containing  6-3 — 7*5  grammes  urea.  This 
seems  to  indicate  that  it  is  the  raised  temperature  which  causes  the 
increased  production  of  urea. 

Unruh's  investigations  on  fever  patients  would  go  to  disprove 

^  Naunyn,  "Ueber  das  Verhalten  des  Harnstoffausscheidung  beim  Fieber," 
'  Berliner  Clinisclie  Wochensehrift,'  1869,  No.  4. 


1872.]  On  the  Recent  Progress  of  Ur  as  copy.  197 

this  hypothesis ;  on  the  other  hand,  Schroder's  observations  on 
typhus  patients  confirm  it. 

Unruh^  makes  the  comparison  between  the  urine  of  patients  with 
fever  and  those  without,  the  same  food  having  been  given  to  both. 
The  patients  without  fever,  one  of  whom  had  a  cancer  of  the 
stomach,  the  other  syphilis,  excreted,  on  an  average,  17*466  grammes 
urea;  those  with  fever  (relapsing  fever,  pneumonia,  typhus  fever, 
acute  synovitis,  rheumatismus  articulorum  febrilis,  trichinosis,  ery- 
sipelas, typlioid  fever,  wound  fever)  eliminated  more  urea.  The 
increase  reached  3*06  —  3*07  times  the  average  quantity  which 
those  without  fever  eliminated.  These  results  agree  with  those  ob- 
tained by  former  observations.  The  quantity  of  uric  acid  and  of 
kreatinine  was  also  increased,  the  increase  of  uric  acid  being  1*6 
times  the  normal  quantity,  and  that  of  kreatinine  nearly  double. 
This  result  confirms  my  experiments  on  kreatinine.^  The  quantity 
of  urine,  with  few  exceptions,  was  decreased.  Unruh  thinks  that 
the  retention  of  water  in  the  system  is  the  cause  of  the  diminution  of 
urine.  Senator  and  Naunyn  consider  the  decrease  to  be  only  appa- 
rent ;  for  fever  patients  taking  less  food,  less  water  is  introduced 
into  the  system,  and,  therefore,  according  to  the  opinion  of  the  last 
two  investigators,  there  cannot  be  so  much  urine  eliminated.  This 
last  objection  is  worthless,  for  Naunyn  explicitly  states  that  the 
patients  had  the  same  food  as  those  without  fever.  According  to 
my  own  observations,  thare  are  many  cases  where  the  patients,  tor- 
mented with  excessive  thirst,  drink  a  much  greater  quantity  of 
water  than  the  food  and  beverage  together  amount  to  which  they 
consume  in  a  healthy  state,  and  hardly  excrete  half  so  much  urine 
as  they  are  accustomed  to  in  a  healthy  condition.  In  these  cases  it 
may  be  that  the  excess  excreted  through  the  lungs  and  skin,  rather 
than  a  retention  of  water  in  the  syetem,  is  the  cause  of  the  decreased 
excretion  of  urine.  This  explanation  is  confirmed  by  the  everyday 
experience  that  in  a  state  of  health  the  quantity  of  urine  diminishes 
if  a  person  perspire  excessively,  because  the  skin  acts  vicariously 
for  the  kidneys. 

Unruh's  investigation  of  the  connection  between  the  increase  of 
urea  and  the  height  of  the  body-temperature  does  not  perfectly 
agree  with  the  observations  of  others ;  he  found,  in  the  beginning 
of  a  very  high  fever,  that  the  quantity  of  urea  is  not  as  great  as  in 
the  following  days,  though  the  temperature  does  actually  increase. 
In  the  stadium  decrementi,  in  spite  of  a  lower  temperature,  a  greater 
quantity  of  urea  is  sometimes  eliminated. 

In  diseases  with  light  fever  Unruh  found  more  urea  than  in  severe 
fever,  e.  g,  in  rheumatism  more  than  in  pneumonia. 

^  Unruh,  *  Virchow's  Arcliiv/  xlvlii,  227  and  f . 

2  Hofmtvnn,  '*  Uebcr  Kreat'uiin,"  '  Vircliow's  Ai*ch.,'  xlviii,  p.  390, 


198  Orifjinal  Communications.  [J 


an. 


Unruli  explains  the  increased  elimination  of  urea  which  continues 
during  the  epicritical  stadium  of  the  fever^  partly  by  the  rapid  dis- 
integration of  the  fevcr^  partly  by  the  accumulation  in  the  organism 
during  the  stadium  incrementi  of  products  which  are  only  entirely 
oxidized  at  the  crisis  of  the  fever.  The  observations  of  Naunyn 
(at  least  in  some  cases)  go  to  disprove  the  hypothesis  that  the 
increased  diminution  of  urea  is  consequent  on  the  greater  height  of 
the  temperature  of  the  body. 

According  to  Unruh's  observations,  the  proportion  between  urea 
and  uric  acid  remained  the  same  in  the  febrile  and  in  the  normal 
state  of  the  organism. 

Chinine  seems  to  have  neither  a  constant  influence  on  the  elimina- 
tion of  urea,  as  the  urea  was  now  increased,  now  diminished  ;  nor, 
in  opposition  to  the  former  opinions  of  Eanke,  can  any  constant 
influence  on  the  uric  acid  be  said  to  have  been  observed. 

L.  Schroder^s^  observations  on  patients  with  typhus  fever  seem 
(as  already  said)  to  confirm  the  theory  that  the  increase  in  the 
urea  is  dependent  on  the  increase  of  temperature.  He  examined  the 
urine  of  two  typhus  patients,  that  of  the  one  during  eight  days, 
of  the  other  during  nine  days,  the  food  given  being  every  day  of  the 
same  quality  and  quantity.  Both  patients  were  treated  on  some 
days  with  cold  baths  and  on  others  without ;  one  of  the  patients 
eliminated  on  the  days  when  he  received  the  bath,  on  the  average, 
33'9  grammes  urea,  on  the  days  when  he  was  not  bathed  41'7 
grammes ;  the  other,  in  the  first  case  19*9  grammes,  in  the  second 
case  29*6  grammes  urea.  The  decrease  of  urea  on  the  days  with 
bath  is,  therefore,  like  the  decrease  in  the  temperature,  very  con- 
siderable. 

According  to  a  short  communicaton  in  the  ^  Centralblatt  fur  die 
medicinischen  Wissenschaften,'  1870,  p.  194,  Professor  Ley  den 
found  the  increase  of  urea  in  fever  =  1 :  1*45. 

0.  Schultzen's^  observations  in  cases  of  febris  recifrrens  con- 
firm the  results  obtained  by  Unruh  and  tliose  previously  obtained 
by  Riesenfeld  and  Huppert,  i.  e.  that  the  increased  elimination  of 
urea  continues  some  time  after  the  temperature  has  begun  to  fall. 
This  observer  attempts  to  explain  the  continuation  of  the  increased 
elimination  of  urea  in  a  manner  differing  from  that  of  his  prede- 
cessors. He  rejects  the  supposition  that  substances  could  be  re- 
tained in  the  body,  which,  being  afterwards  oxidized,  could  increase 
the  quantity  of  urea  eliminated  in  the  epicritical  period,  and  affirmed 
that  no  trace  of  any  such  substance  is  to  be  found  in  the  urine,  and 
that  such  substances  would  have  to  be  present  in  very  great  quan- 
tities.    He  holds  that  this  process  has  its  analogon  in  the  healthy 

^  "  Ueber  Harustoffaiisscheidung/^  *  Deutsclies  Arclnv  f.  Klin.  Mcdizivi/  vi,  4'. 
^  O.  Sclmltzeii,  "Ueber  d.  Stickstoffumsatz  bei  Febris  recurreus,"  'Annaleu  d. 
Charite-Kraukenb.,'  xv,  153  aud  ff. 


1872.]  On  the  Recent  Progress  of  Uroscopy,  199 

organism  where,  after  a  long-continued  consumption  of  albumen^  the 
increased  elimination  of  urea  continues,  even  after  the  quantity  of 
albumen  in  the  diet  has  been  greatly  diminished,  until  the  body 
reaches  a  new  state  of  equilibrium.  The  difference  between  these 
two  cases  is  this,  that  the  albumen  of  the  circulation  (Circulations- 
Eiweiss)  which  is  to  undergo  the  process  of  oxidation  is  derived, 
in  fever,  from  the  increased  quantity  of  albumen  of  the  tissues 
(Organeiweiss)  in  process  of  disintegration,  in  health  from  the 
increased  quantity  of  the  albumen  of  the  food  (Nahrung-Eiweiss) . 
This  increase  in  the  urea  eliminated  (the  chlorides  being  at  the  same 
time  diminished)  is  also  confirmed,  in  seven  cases  of  febris  recurrens, 
by  Meymott  Tidy.^ 

As  can  easily  be  seen  from  what  has  been  brought  forward,  the 
point  in  discussion  remained  open,  i.  e.  whether  a  causal  connection 
exists  between  the  raised  temperature  of  the  body  in  fever  and  the 
increased  elimination  of  the  nitrogenous  products  of  disintegration ; 
and  if  this  is  the  case,  whether  the  increased  temperature  is  the 
cause  of  the  increased  disintegration  of  the  tissues  or  vice  versa. 
M.  Naunyn^  undertook  to  answer  this  question  by  means  of  experi- 
ment. 

It  cannot  be  doubted,  at  least,  the  great  majority  of  observers 
confirm  the  theory,  that  fever  is  accompanied  by  an  increased  elimi- 
nation of  nitrogenous  substances.  It  is  probable  also  that  the 
nitrogeunus  substances  are  subjected  to  an  increased  oxidation  and 
disintegration.  The  above-mentioned  experiment  on  the  dog  en- 
closed in  the  steam- chest  of  Obernier  confirms  Bartel's  experience 
on  men  who  have  remained  in  a  steam  bath  from  ten  minutes  to 
an  hour  and  a  half.  An  increased  elimination  of  urea  was  observed, 
which  probably  resulted  from  a  retention  of  heat  and  a  consequent 
oxidation.  As  a  result  of  these  observations  it  can  reasonably  be 
supposed  that  the  raised  temperature  was  the  antecedent  and  the 
cause  of  the  increased  metamorphosis  of  the  tissues.  He  (Naunyn) 
repeated  the  subcutaneous  injection  of  ichor  on  animals.  He 
reasoned  thus :  if  the  retention  of  heat  be  the  cause  of  the  more 
rapid  disintegration,  no  increased  elimination  of  urea  should  take 
place  during  the  period  between  the  injection  and  the  beginning  of 
the  noticeable  rise  in  temperature,  the  (so-called)  period  of  the 
latent  fever.  But  numerous  observations  taught  him  just  the  con- 
trary— that  already  in  the  period  of  the  latent  fever,  when  no  rise  in 
temperature  could  be  observed,  the  increase  in  the  production  of 
urea  had  already  begun,  being  a  proof  that  this  was  not  consequent 
on  the  increased  temperature  but  on  that  enigmatical  process  which 

1  "  On  the  Urine  in  Relapsing  Fever,"  *  Lancet/  1870,  i,  No.  xxvi. 

2  "  Beitrage  zur  Fieberlchre,"  '  Reichert's  unci  Du  Bois-Reymond's  Arch.,'  1870, 
Heft  ii,  p.  159. 


200  •     Original  Communications.  [Jan.j 

we  call  fever,  and  this  increase  did  not  keep  in  tlie  same  proportion 
to  the  increased  temperature. 

This  seems  to  be  in  harmony  with  the  above-mentioned  observa- 
tions of  Unruh  on  man.  Naunyn  supposed  the  increased  eHmina- 
tion^^urea  to  be  a  result  of  its  accumulation  during  the  crisis  and 
subsequent  less  rapidr-evacuation  after  the  crisis. 

I  will  here  just  mention  that  Burral/  like  Puller,^  found  an  in- 
crease in  the  urea  m  nervous  diseases  accompanied  by  hypochon- 
dria. It  is  a  pity  that  Burral  made  his  conclusions  from  the  mere 
formation  of  a  precipitate  consequent  on  the  addition  of  nitric  acid, 
which  precipitate  could  easily  have  been  confounded  with  one  com- 
posed only  of  urates,  or,  if  this  confusion  did  not  take  place,  may 
only  prove  the  concentration  of  the  urine. 

On  elimination  of  uric  acid. — B.  Naunyn^  and  L.  Eiess  made  ex- 
periments on  the  elimination  of  the  uric  acid,  the  most  important  con- 
stituent of  the  urine  after  the  urea.  They  found  on  dogs  fed  with 
flesh  the  same  proportion  between  urea  and  uric  acid  which  Eanke 
states  as  existing  in  man,  the  similarity  in  these  two  cases  ceasing, 
however,  to  exist  when  the  food  of  the  dogs  consisted  chiefly  of 
non-nitrogenous  substances.  These  two  observers  found,  when  the 
food  contained  proteine  in  only  small  quantities,  no  uric  acid  (and 
also  no  kynurenic  acid),  while  Eanke  and  myself  saw  under  the 
same  conditions  in  the  urine  of  man  the  uric  acid  decrease  in  quan- 
tity, but  not  entirely  disappear.  In  a  state  of  complete  starvation 
we  are  told  that  the  presence  of  uric  acid  was  again  observed  in  the 
urine,  while  we  found  a  continued  diminution.  The  two  observers 
attempted  to  advance  a  proof  that  the  increase  in  the  elimination  of 
the  uric  acid  was  consequent  on  the  decreased  oxidizing  power  of 
the  blood. 

Induced  by  the  supposition,  which  does  not  agree  with  my  analysis, 
of  which  mention  will  be  made  below,  that  in  leucocythsemia  the 
decrease  of  the  red  blood-corpuscles  is  the  cause  of  the  diminished 
oxidating  power  of  the  blood,  and,  therefore,  of  the  increase  of  uric 
acid,  they  tried  to  bring  dogs  under  similar  conditions.  They  made 
the  animals  anaemic  by  means  of  venesection.  Although  by  these 
means  the  oxidizing  power  of  the  blood  must  have  been  lessened, 
still  they  could  not  find  any  sensible  increase  in  the  quantity  of  uric 
acid  eliminated.  They  performed  another  series  of  experiments  for 
the  determination  of  the  quantity  of  uric  acid  in  diabetes. 

Everybody  has  experienced  that,  in  analysing  diabetic  urine,  it  is 
often  impossible  to  obtain  uric  acid  by  treatment  with  hydrochloric 
acid.     Naunyn  and  Eiess  showed  us  a  new  method,  which  gives, 

^  F.  A.  Burral,  *  Amer.  Journ.  of  the  Med.  Soc.,'  July,  53. 
^  'Medico-Cliirurgical  Transactions' for  1858. 

^  "  Ueber  Hariisaureaussclicidung-/'  '  llcicbcrt's  und  Du  Bois-Reymond's  Arch.,' 
1869 


1872.]  On  the  Recent  Progress  of  Uroscopy.  201 

even  in  such  cases^  satisfactory  results.  The  uric  acid  is  to  be  pre- 
cipitated with  acetate  of  mercury,  the  precipitate  to  be  filtered,  then 
suspended  in  water,  and  then  to  be  decomposed  by  the  action  of 
sulphuretted  hydrogen.  The  sulphuret  of  mercury  formed  in  this 
manner  is  to  be  filtered.  The  uric  acid  contained  in  the  filtrate  can 
now  be  determined.  They  found  by  this  method  the  proportion 
between  uric  acid  and  urea  in  diabetes  =  1'99.  After  the  adminis- 
tration of  large  doses  of  opium  the  quantity  of  uric  acid  slightly 
decreased  in  proportion  to  the  urea. 

071  elimination  of  urea  and  uric  acid  as  influenced  hy  muscular 
exertinn. — In  the  '  New  York  Medical  Journal '  of  October  a  short 
article  was  published  on  the  influence  of  muscular  exertion  upon  the 
excretion  of  urea  and  uric  acid,  by  Dr.  Mint,  but  was  in  no 
respect  trustworthy.  Mr.  Weston  is  said  to  have  walked  one 
hundred  miles  in  less  than  twenty-two  hours.  Given  that  this  is 
true,  which  is  open  to  strong  suspicion,  the  figures  for  urea  and 
uric  acid  are,  nevertheless,  of  doubtful  value.  During  the  period  of 
comparative  rest  we  find  the  quantity  of  urea  discharged  191"4< 
grains.  This  quantity  is  evidently  erroneous  for  such  a  brawny 
man  as  Mr.  Weston  must  be,  judging  by  the  pretended  unequalled 
muscular  exertion.  I  obtained  from  subjects  of  mean  strength  the 
average  quantity  of  540  grains  from  subjects  of  weak,  delicate  con- 
stitution, the  average  quantity  of  460  grains.  As  to  the  figures 
obtained  in  the  period  of  the  great  exertion,  the  quantity  of 
463'368  grains,  compared  with  the  nitrogenous  food  (consisting  of 
sixteen  eggs,  one  to  two  bottles  of  beef  essence,  and  two  bottles  of 
oatmeal  gruel),  is  not  to  be  esteemed  an  increase  of  urea,  being  not 
higher  than  the  average  quantity  found  by  me  in  weak  persons 
living  on  ordinary  diet. 

A  comparison  cannot  be  made  between  the  first  and  second 
figures,  unless  we  suppose  that  Mr.  Weston  is  as  great  an  abnormity 
in  the  voiding  of  urine  as  in  walking. 

The  quantity  of  uric  acid  during  the  period  of  exertion  recorded 
by  Dr.  Mint  (forty  grains)  deserves  no  earnest  criticism.  Researches 
like  this  are  not  fit  to  assist  in  bringing  this  delicate  question  to  a 
definite  solution. 

Urine  in  acute  atrophy  of  liver  and  in  intoxication  with  phosphoiiis. 
— A  number  of  analyses  of  the  urine  have  been  made  by  0. 
Schultzen,  L.  Kiess,  and  A.  Yalenta,^  in  another  interesting  group 
of  diseases,  namely,  on  the  molecular  changes  in  acute  poisoning 
with  phosphorus,  and  in  acute  atrophy  of  the  liver.  Schultzen  and 
Eiess2  observed  ten  cases  of  poisoning  with  phosphorus  and  fever  of 

1  "  Ueber  Acute  Phospliorvcrgif  tuiig  mid  Acute  Leberatrophie,"  '  Annaleu  d, 
Charite  Krankenbauses,'  1869,  183  a.  f. 

2  '  Wiener  Med.  Jabrb./  xvni. 


203  Original  Communications.  [Jan., 

acute  atrophy  of  the  liver  in  Professor  Frerich's  Klinik.  The  cha- 
racteristics of  the  urine  in  the  cases  of  poisoning  were  as  follows : — 
The  urea  was  greatly  diminished,  especially  as  death  approached. 
The  place  was  taken  by  other  nitrogenous  substances,  tlie  composi- 
tion of  which  is  not  perfectly  known,  and  which,  as  they  are  also 
precipitated  by  nitrate  of  mercury,  can  be  easily  mistaken  for  the 
urea.  If  the  patient  begins  to  recover,  the  urea  returns,  and  these 
abnormal  substances  vanish. 

The  uric  acid  does  not  disappear,  even  in  the  most  severe  cases 
of  poisoning.  The  urates  precipitated  by  alcohol  are  said  to  give 
crystals  similar  to  those  of  tyrosine.  In  one  case,  ending  with 
recovery,  2"326  grammes  uric  acid  were  eliminated  (in  twenty-four 
hours)  in  3000  c.c.  urine  (sp.  gr.  1021) — a  very  considerable 
quantity.  In  the  same  urine  three  grammes  kreatinine  were  found. 
I  pass  by  the  abnormal  substances  whose  nature  is  not  perfectly 
known,  referring  the  reader  to  the  original. 

Those  of  the  known  substances  which  were  present  were  bile- 
pigment  and  acids  of  the  bile.  Albumen  was  not  constant,  and 
when  it  appeared  was  always  present  in  only  small  quantities.  Sugar 
was  never  present.  The  result  of  these  analyses  seems  to  indicate 
that  the  protein  substances  are  split  up  into  nitrogenoas  and  non- 
nitrogenous  combinations,  but  that  the  combustion  is  not  carried 
far  enough  to  produce  the  final  results  of  a  normal  oxidation  in  the 
healthy  organism.  The  crystalloid  substances  resulting  from  this 
decomposition — for  instance,  the  lactic  acid,  the  peptone-like  matters, 
and  the  uric  acid — are  eliminated  with  the  urine ;  the  colloid  sub- 
stance— for  instance,  the  fats — cannot  pass  through  the  kidneys,  and 
collect  in  the  organism,  inducing  thus  its  fatty  degeneration.  The 
phosphorus  resembles  in  this  respect  the  ferments,  that  even  small 
quantities  of  it  produce  this  derangement  of  the  organism,  and  it 
possesses  also  the  power  of  transforming  great  quantities  of  oxygen 
into  ozone.  Schultzen  and  Eiess  believe  that  the  phosphorus  so 
changes  the  organs  in  which  the  oxidation  takes  place  that  they 
lose  their  power,  and  that  thus  the  oxidation  is  not  completed. 

The  urine  in  acute  atrophy  of  the  liver  differs  from  the  above- 
mentioned  only  in  containing  large  quantities  of  leucine  and  tyrosin, 
which,  in  the  poisoning  with  phosphorus,  either  fail  entirely  or  are 
present  only  in  small  quantities,  and  that  the  albumen  appears  as  a 
constant  constituent  of  the  urine.  It  contains,  moreover,  all  the 
substances  which  we  have  mentioned  as  occurring  in  the  urine  after 
the  poisoning — the  peptone-like  substances  and  an  organic  acid, 
CgHy04,  which  the  authors  call  oxymandelsaure.  The  characteristics 
of  the  urine  in  both  cases  (acute  poisoning  with  phosphorus  and 
liver  atrophy)  seem  to  indicate  that  they  do  not  essentially  differ,  but 
that  the  poisoning  with  phosphorus  takes  a  too  rapid  course  to  show 
us  the  same  final  stage  which  we  observe  in  the  acute  atrophy  of  the 


1872.] 


On  the  Recent  Progress  of  Uroscopy,  203 


liver.  Dr.  Ossikowsky,  who,  in  chronic  poisoning  with  phosphorus, 
found  leucine  and  tyrosin,  supposes  also,  in  a  lately  published  paper, 
an  identity  between  the  two  diseases. 

Urmeiii  Tetanus. — Senator^  had  the  opportunity  of  examining  the 
urine  in  two  cases  of  tetanus  traumaticus.  Passing  over  details, 
the  result  of  his  analysis  was  as  follows  : — The  quantity  of  the 
urine  was  much  diminished  (in  the  first  case  500 — 600  c.c,  in  the 
second  485 — 870  c.c.)  ;  likewise  the  urea  (on  an  average  1  grain 
to  3  grains,  and  21 '8  grains).  This  proves  the  assertion  of  the 
physiologists  that  the  increased  action  of  the  muscles  does  not 
increase  the  quantity  of  urea  eliminated  to  be  true. 

It  was  then  observed  that,  on  the  days  when  the  convulsions  were 
most  violent  and  numerous,  consequently  on  the  days  of  the  most 
violent  muscular  action,  that  the  quantity  of  urea  eliminated  was  not 
the  greatest.  The  small  quantity  eliminated  is  so  much  the  more 
remarkable  inasmuch  as  the  convulsions  were  accompanied  by  a 
high  fever  temperature  (39-4°— 11-0°  and  37'0°— 38-2°).  Creatinine 
as  well  as  uric  acid  was  present  in  small  quantities.  The  result  of 
this  analysis  accords  with  the  observations  of  Nawrocky  and  myself 
that  the  creatinine  is  not  increased  after  violent  muscular  exertion, 
and  therefore  is  only  partly  derived  from  the  disintegration  of  the 
tissues,  and  partly  from  the  food. 

On  Chyliiria. — Hr.  EggeP  had  the  opportunity  of  observing  a  case 
of  chyluria,  a  disease  seldom  to  be  studied  in  Europe,  and  which  is 
alike  enigmatical  in  its  nature  and  in  its  setiology.  The  case  was 
one  of  a  woman,  fifty-seven  of  age,  from  Eio  Grande,  in  Brazil,  who 
had  left  her  native  country  thirteen  years  before.  We  take  from  the 
amanuensis  that  her  health  had  always  been  good,  with  the  exception 
of  headaches,  which  appeared  alternately  in  the  region  of  the  occiput, 
the  temples,  and  the  top  of  the  head,  and  attacks  of  dizziness, 
having  no  connection  in  time  with  the  headaches  (accompanied  at 
the  same  time  by  constipation  and  colics) .  She  bore  three  children ; 
the  birth  and  period  of  confinement  were  in  all  cases  normal.  The 
disease  first  attracted  her  notice  eight  years  ago.  Six  months  after 
a  violent  concussion,  received  in  a  collision  of  railway  trains,  she 
observed  for  the  first  time  that  her  urine  was  milky.  This  first  attack 
lasted  uninterruptedly  during  eight  months.  One  year  later  it  was 
followed  by  a  second,  lasting,  with  interruptions,  for  some  months. 
Two  years  later  by  a  third,  which  continued  for  two  years,  with  free 
spaces  of  weeks  in  length;  and  finally,  fifteen  months  later,  by  a 
fourth  attack,  which  Eggel  observed.  The  urine  w^as  in  quantity 
normal;    specific   gravity    1*10 — 1'14<,  slightly  acid  or   alkaline; 


1  "  Ueber  die  Beschaffenheit  des  Harnes  in  Tetanus,"  *  Vircli.  Arch.,'  xlviii, 
295. 

2  *  Deutsches  Archiv  f.  Clin.  Med.,'  vi,  421. 


204  Original  Communications.  [Jan., 

decomposing  easily,  with  a  weak,  stale  odour  of  ammonium  sulpli- 
hydrate,  the  existence  of  which  could  not  be  chemically  proved.  It 
was  white,  with  a  reddish  tinge ;  milky,  forming  a  one  mm.  thick 
cream-like  surface  layer,  and  an  equally  thick  sediment.  The 
normal  constituents  (unfortunately  only  given  in  percentages)  were 
urea,  2-10— 2-20 ;  uric  acid,  0-03;  salt,  0-35  per  cent.  The 
abnormal  constituents  were  albumen,  0*32 — 0-627  per  cent. ;  fat, 
0-687 — 0*20  per  cent.  Some  cholestearin,  lecitine,  and  traces  of  a 
fibrinoplastic  substance,  but  no  sugar.  The  urine  contained  no 
coagula.  The  sediment  consisted  of  pus  and  blood- corpuscles,  and 
darkly  lined  bodies  of  a  high  refracting  power,  and  enclosiDg  a  few 
glistening  molecules,  which  bodies  were  smaller  than  large  white 
blood-corpuscles.  Neither  epithelium,  casts,  nor  milk-globules  were 
observed.  The  opacity  of  this  urine  was  caused  by  the  finest  mole- 
cules. Beside  this  constitution  of  the  urine,  only  backache,  great 
weakness  (at  the  beginning  of  the  disease)  and  dysuria,  were 
observed. 

The  author,  whose  paper  is  remarkable  for  the  careful  use  he 
makes  of  former  cases,  calls  our  attention  to  the  fact  that  his  case 
also  was  a  chronic  one,  and  that  the  disease  was  not  developed  until 
five  years  after  the  patient  had  left  her  native  country,  where  chyluria 
is  endemic,  and  also  that  the  patient  was  a  lady  of  a  nervous 
temperament.  The  conclusions  arrived  at  by  the  author  were  as 
follows  : — The  abnormal  constitution  of  the  urine  cannot  be  simu- 
lated on  account  of  the  exceedingly  fine  division  and  equal  distribu- 
tion of  the  molecules,  and  has,  as  has  often  been  supposed,  nothing 
whatever  to  do  with  the  secretion  of  the  breasts.  The  fat  in  the 
chylous  urine  is  not  derived  from  the  molecular  changes  in  the 
tissues,  but  from  incomplete  assimilation  of  the  food,  especially  of 
the  fat  contained  in  it,  because  in  the  tropics  the  high  temperature 
of  the  atmosphere  reduces  the  assimilating  power. 

The  chyluria  is  caused  by  the  atrophy  of  the  capillaries  in  the 
kidneys,  not  by  a  disease  of  the  kidney  parenchyma,  nor  rupture  of 
the  lymphatics,  the  lymph  containing  less  fat  than  the  urine,  and 
the  urine  but  few  lymph-corpuscles. 

On  Leucocythemia. — Analyses  of  the  urine  have  been  made  by 
Eeichart,  Salkowsky,  and  myself,  to  obtain  a  more  thorough  know- 
ledge of  the  molecular  changes  in  leucaemia. 

Eeichart^  analysed  the  blood  and  the  urine  of  a  forty -three  year 
old  man,  who,  formerly  addicted  to  drinking,  had  sutfered  for  three 
years  from  dyspnoea,  and  finally,  on  account  of  ascites,  weakness, 
oedema  of  the  lower  extremities,  and  diarrhoea,  came  into  the  hands 
of  the  physician.     The  spleen  extended  twelve  centimetres  over  the 


Jenaisclie  Zeitschr.  Medic.,'  v,  389. 


1872.]  On  the  Recent  Progress  of  Uroscopi/,  205 

median  line  towards  the  right  side ;  its  greatest  breadth  =  twenty- 
four  cent.  The  proportion  between  the  white  and  red  blood-corpus- 
cles (1 — 2  and  1 — 3)  indicated  a  high  degree  of  leucaemia.  In  an 
average  quantity  of  urine  (1100  c.c.)  in  twenty-four  hours,  he  found 
28-30  grains  urea,  and  0*71  grains  uric  acid.  It  seems  that  the  urea 
was  diminished,  though  neither  the  quantity  nor  the  quality  of  the 
food  is  mentioned.  The  uric  acid  was  increased  absolutely  as  well  as 
relatively  to  the  amount  of  urea  (uric  acid,  urea  =  1*31 — 70,  while 
in  normal  urine  the  proportion  stands  1'60 — 80) .  The  mean  quantity 
of  urea  equalled  30 — 40,  and  of  uric  acid  0*50  grains.  This 
increase  of  uric  acid,  confirmed  by  Yirchow  and  all  other  observers, 
seems  to  indicate  that  connection  which  Kanke  was  the  first  to  men- 
tion between  the  state  of  the  spleen  and  the  excretion  of  uric  acid. 
Neither  albumen  nor  hypoxanthine  could  be  detected. 

In  the  case  under  my  examination^  (the  patient  being  a  man  of 
thirty  years  of  age)  a  series  of  analyses  gave  the  following  results. 
The  quantity  of  colouring  matter  of  the  urine  was  increased,  indicat- 
ing neither  a  greater  disintegration  of  the  red  blood-corpuscles  nor 
the  production  of  an  abnormal  pigment  of  greater  colouring  power 
derived  from  hsematine.  The  whole  quantity  of  phosphoric  acid 
was  greatly  diminished  (66*66  per  cent.),  this  diminution  being 
greater  on  the  side  of  the  alkaline  phosphates  than  on  the  side  of 
the  earthy  phosphates.  The  quantity  of  chlorine,  sulphuric  acid, 
and  creatinine  was  normal.  The  urea  also  was  in  this  case  not 
diminished,  in  contradiction  to  a  greater  number  of  cases  where  the 
diminution  was  great.  The  uric  acid  was  absolutely,  relatively,  and, 
in  proportion  to  the  urea,  increased.  Eanke's  supposition  that  the 
decrease  of  the  urea  is  not  dependent  on  the  increase  of  the  uric 
acid  appears  to  be  wholly  confirmed  by  this  case.  The  increase  of 
uric  acid  was  not  in  consequence  of  a  febrile  state  of  the  organism. 
The  normal  quantity  of  urea  conflicts  with  the  supposition  that 
decreased  oxydation  is  the  cause  of  an  incomplete  combustion  of 
uric  acid,  and  therefore  of  its  increased  elimination.  No  hypoxan- 
thine could  be  detected,  but  slight  quantities  of  lactic  acid  and 
albumen  were  present. 

Salkowsky^  made  a  careful  analysis  of  the  urine  in  a  third  case  of 
leucsemia.  A  series  of  observation  during  thirty  days  showed  that 
here,  as  in  other  cases,  the  uric  acid  was  considerably  increased. 
These  analyses  are  followed  by  an  excellent  criticism  of  Hosier's 
method  for  the  detection  of  hypoxanthine ;  he  shows  the  fallacy  in 
this  old  way  of  examination,  and  advances  at  the  same  time  a  more 
accurate  method  as  follows.     The  urine  is  made  strongly  alkaline, 


1  '  Wiener  Med.  Woclienschrift,'  1870,  No.  42. 

2  *  Virchow's  Archiv,'  1870, 1,  174. 


206  Original  Communications.  [Jan., 

and  after  some  hours  the  precipitated  phosphates  filtered  off.  To 
the  filtrate  is  added  an  ammoniacal  solution  of  nitrate  of  silver  as 
long  as  any  precipitate  is  formed.  This  greyish- white  precipitate  is 
collected  in  a  filter,  washed  till  all  the  chlorine  has  been  removed ; 
then  suspended  in  water  and  decomposed  with  sulphuretted  hydrogen ; 
then  heated  to  a  boihng  point,  filtered  while  hot,  and  the  filtrate 
evaporated  to  dryness  in  a  water  bath.  The  residuum  consists  of 
uric  acid,  xanthine,  and  hypoxanthine.  To  separate  the  uric  acid 
from  the  xanthine  and  hypoxanthine  the  residuum  is  dissolved  under 
the  action  of  heat  with  diluted  sulphuric  acid  (1*30).  The  hot 
liquid  is  filtered  off,  and  ammonia  added  in  excess.  After  cooling, 
the  liquid  is  again  filtered,  and  a  precipitate  formed  by  the  addition 
of  an  ammoniacal  solution  of  nitrate  of  silver.  The  precipitate, 
treated  according  to  the  method  of  Neubauer,  gives  the  compound 
nitrate  of  hjjpoxanthine  and  silver. 

Salkowsky  gives  us  also  the  method  of  distinguishing  hypoxan-i 
thine  from  xanthine  and  xanthine-like  substances  (on  which  point 
reference  can  be  made  to  the  original).  By  this  more  accurate 
method  it  w^as  impossible  to  detect  any  trace  of  hypoxanthine  in  the 
urine  in  this  case  of  leucsemia.  Lactic,  formic,  and  acetic  acid  as 
w^ell  as  oxalic  acid  were  found,  but  as  the  same  are  normal  consti- 
tuents of  the  spleen,  their  appearance,  as  well  as  the  increase  of  zinc 
acid,  may  be  caused  by  the  hypertrophy  of  this  organ.  "We  thus 
do  away  with  the  necessity  of  supposing  a  diminished  oxidising 
power  of  the  blood. 

On  Alhmninuria. — The  practical  importance  which  the  presence 
of  even  small  quantities  of  albumen  in  the  urine  has  for  physicians, 
makes  it  desirable  that  we  should  have  an  exact  method  for  its 
detection.  Such  a  method,  resembling  that  of  Mehn,  has  been  given 
us  by  Meymott  Tidy.^  Mehn  precipitates  the  albumen  with  a  mix- 
ture consisting  of  one  part  carbolic  acid,  one  part  acetic  acid,  and 
two  parts  alcohol  of  86  per  cent.  The  carbolic  acid  alone  makes 
the  albumen  insoluble.  The  acetic  acid  prevents  the  precipitation 
of  other  salts,  if  such  should  be  present.  Tidy's  method  differs 
from  this  only,  in  that  he  first  adds  one  cubic  centimetre  alcohol  to  a 
small  sample  of  urine,  and  then  adds  a  solution  of  hke  parts  of  car- 
bolic acid  and  acetic  acid.  The  accuracy  of  this  method  surpasses 
that  of  the  method  with  nitric  acid.  While  the  nitric  acid  method 
detects  the  presence  of  one  part  albumen  in  8000  parts  water,  this 
latter  method  detects  one  part  albumen  in  15,000  water. 

E.  Hefsen^  gives  us  his  observations  on  the  nature  of  the  albumi- 
nates in  the  urine.  In  thirty-one  cases  of  albuminuria  he  seems  to 
have  found  with  certainty  gloWline.  If  the  urine,  namely,  be  strongly 

1  *  Lancet/  1870,  May,  p.  691. 

^  *  Virchow's  Archives,'  vol,  lix,  p.  437. 


1872.]  On  the  Recent  Progress  of  Uroscopy.  207 

diluted  with  water,  it  becomes  opaque,  which  opacity  is  increased  by 
the  influence  of  carbonic  acid,  but  which  disappears  on  the  addition 
of  some  dro])s  of  hydrochloric  or  acetic  acid,  of  some  drops  of  am- 
monia, or  of  a  concentrated  solution  of  common  salt.  He  could 
neither  detect  "  kahalbuminat"  nor  "  paralbumin." 

Hegar  and  Kaltenbach^  observed  the  appearance  of  albumen  in 
the  urine  after  a  prolonged  narcosis  from  chloroform.  The  albumen 
was  detected  by  addition  of  nitric  acid  and  heating ;  besides  this 
epithelial  casts  were  found.  In  thirteen  cases  albumen  was  found  in 
six,  and  failed  in  the  other  seven.  In  several  cases  of  chloroform 
narcosis  I  did  not  succeed  in  proving  the  presence  of  albumen.  The 
patients  were  all  men,  while  the  positive  observations  of  these  two 
observers  were  for  the  most  part  on  pregnant  women.  As  the 
number  of  my  observations  was  but  small,  it  seems  desirable  to  carry 
the  observation  on  this  interesting  point  further. 

M.  G.  Calmettes^  made  experiments  on  the  appearance  of  albumen 
in  the  urine  after  the  injection  of  different  albuminates.  After  the 
injection  of  a  large  quantity  of  a  solution  of  casein  or  milk  (20 — 26 
gr.)  into  the  veins  of  a  rabbit,  he  found  that  several  times  the  urine 
turned  opaque  from  the  action  of  heat  alone ;  in  other  cases  this  did 
not  take  place  until  nitric  or  acetic  acid  was  added.  The  milky 
appearance  in  the  first  case  he  attributed  to  the  presence  of  albu- 
men, that  in  the  second  to  casein.  The  injection  of  white  of  egg 
and  gelatine  seems  to  me  to  give  unreliable  results.  When  white  of 
t^^  was  injected  it  sometimes  itself  appeared  again  in  the  urine  and 
sometimes  albumen  of  the  serum. 

On  the  determination  of  Sugar. — On  glycos^iria  {diabetes). — The 
property  which  Tehling^s  solution  has  of  being  easily  decomposed 
by  the  influence  of  light  and  fermentation,  induced  several  observers 
to  seek  other  methods  of  determining  sugar. 

K.  Knapp,^  induced  by  Liebig,  advances  a  method  of  determining 
the  sugar  by  means  of  cyanide  of  mercury.  Ten  grammes  of  pure 
cyanide  of  mercury  are  dissolved  in  water,  ten  c.c.  of  a  solution  of 
caustic  soda  added  of  the  sp.  gr.  1*145,  and  this  liquid  diluted  to  a 
litre. 

The  determination  is  made  in  a  way  similar  to  that  in  Pehhng-'s 
method.  Porty  c.c.  of  the  above-mentioned  solution  of  quicksilver 
are  put  in  a  porcelain  basin  and  heated  to  boiling.  The  diluted 
urine  is  dropped  in  from  a  burette  till  all  the  mercury  is  precipitated.' 
The  test  solution,  at  first  muddy  and  opaque,  becomes  clear  and  some- 
what yellowish.     The  reaction  is  finished  when  a  drop  of  the  liquid  on 

^  'Deutsches  Arcliiv  fur  Klinischc  Medicin,'  1870,  p.  67. 
^  'Arch,  de  pliysiol.  norm,  and  path.,'  iii,  26. 

^  "  Ueber  eine  neue  Methode  zur  BestimmuBg  des  Traubenzuckers,"  *  Annalen 
der  Chern.  und  Pharm.,'  vol.  Ixxviii,  p.  252. 


208  Original  Communications.  [J 


an 


filter  paper  does  not  take  a  brown  tinge  when  exposed  to  the  action 
of  the  fumes  of  strong  sulphuret  of  ammonia  (Schwef el-ammonium). 
The  end  of  this  reaction  can  be  detected  with  the  greatest  accuracy 
when  the  paper  is  held  before  the  window.  In  the  beginning  of  the 
reaction  the  whole  drop  becomes  brown ;  at  the  end  only  a  narrow 
ring  of  colour  is  formed  at  its  periphery.  Lowy  proposes  a  modifi- 
cation of  Eehling^s  standard  fluid  for  the  volumetric  analysis  of 
sugar.  'Fehling^s  fluid,  as  is  well  known,  moulds  easily,  and  is 
decomposed  by  the  action  of  light.  Lowy  proposes  glycerine  instead 
of  the  Eochelle  salts.  He  gives  the  following  directions  for  his 
standard  fluid  : — Sixteen  grammes  pure  sulphate  of  copper  are  dis- 
solved in  sixty-four  grammes  water,  and  eighty  c.c.  of  a  solution  of 
caustic  soda  of  the  sp.  gr.  1*34  (nearly  112  grammes),  are  added  by 
degrees  to  this  solution ;  finally,  six  to  eight  grammes  pure  glycerine 
are  added.  A  clear  deep-blue  liquid  is  the  result.  This  solution  is 
said  to  remain  perfectly  unchanged. 

Schubert  finally  pro])osed  a  method  which  is  based  on  the  reduc- 
tion of  sugar  by  caustic  potash  in  excess,  even  at  a  low  tempera- 
ture.^ 

^  *  Verliaudluugen  der  Physik.  Med.  Gesellscbaf  t  in  Wiirzburg.' 


1872.]  On  the  Administration  of  Medicines.  200 


III.  —  The  Administration  of  Medicines  in  comparatively  small 
and  frequent  doses.  By  John  Kent  Spender,  M.D.  Lend., 
Surgeon  to  the  Mineral  Water  Hospital,  Bath. 

I  PROPOSE  in  the  present  essay  to  exhibit  the  advantages  of 
administering  certain  medicines,  when  given  by  the  mouth,  in 
comparatively  small  and  frequent  doses. 

The  inquiry  I  am  about  to  enter  upon  is  in  one  sense  old,  in 
another  new.  It  is  quite  an  old  practice  to  administer  a  medicine 
at  frequent  and  definite  intervals  during  the  emergency  of  disease  or 
pain ;  the  natural  impulse  is  to  try  and  cure  extraordinary  suffering 
by  extraordinary  and  rapid  means.  But  it  is  a  new  proposal  to 
establish  this  method  of  practice  as  a  defined  and  regular  thing 
under  defined  and  regular  conditions  :  not  as  a  remedial  method 
merely  for  urgent  distress,  but  as  a  trustworthy  way  of  dealing  with 
particular  phases  of  slow  disease.  I  shall  attempt  to  show,  too, 
that  there  are  certain  deviations  from  health,  neither  very  quick  nor 
very  chronic,  which  can  be  alleviated  or  removed  by  the  same 
method ;  and  that  this  method  has  some  positive  and  unquestionable 
advantages.  The  difficulties  and  hindrances  which  attend  the  prac- 
tice of  it  will  be  enumerated  and  examined ;  and  the  circumstance* 
will  be  pointed  out  which  appear  to  render  this  mode  of  adminis- 
tering medicines  unadvisable,  or  of  inferior  utility  to  the  common 
plan. 

The  title  of  this  essay  requires  one  or  more  postulates  to  start 
from.  What  is  a  small  dose  ?  What  is  a  frequent  dose  ?  Both 
adjectives  are  of  relative  significance,  but  the  former  represents  a 
quantity  varying  necessarily  with  the  medicinal  substance  to  which 
it  is  annexed.  Further,  "  doses^'  are  things  determined  by  the 
variables  of  time,  place,  and  circumstance ;  what  is  specified  in  the 
'  British  Pharmacopceia'  as  a  "  dose,''  should,  I  imagine,  be  regarded 
as  that  moderate  equivalent  of  a  drug  which  can  do  no  harm,  even 
if  it  fails  to  achieve  the  least  appreciable  good.  Accepting  this 
conventional  interpretation  of  the  word  "  dose,"  a  small  dose  would 
mean  any  quantity  below  the  standard,  and  a  large  dose  any  quantity 
above  it.  Even  this  definition  does  not  exhaustively  express  all  we 
wish  to  convey ;  for  a  medicine  may  be  used  in  different  doses  with 
the  avowed  purpose  of  fulfilling  widely  different  ends,  a  small  and  a 
large  dose  of  it  respectively  having  no  specific  or  even  generic  rela- 
tion with  each  other.  So  that  we  must  qualify  our  statement  by 
saying  that  a  small  dose,  or  a  large  dose,  is  one  relatively  small  or 
large  for  the  purpose  which  we  have  in  view. 

Next,  as  to  the  frequency  with  which  a  medicine  is  given. 
This  also  must  be  measured  by  a  standard,  real  or  imaginary ;  and 

97— xLix.  14 


210  Original  Communications,  [Jan., 

the  customary  professional  standard  of  administering  a  medicine  is 
formularised  by  '^  bis  terve  die/'  now  and  then  by  "  quarta  quaque 
hora/'  More  often  than  this  constitutes  a  relative  frequency  which 
requires  me  to  draw  an  arbitrary  line  somewhere ;  and  I  fix  two  hours 
or  less  as  the  interval  at  which  the  doses  of  a  medicine  must  be  given 
in  order  to  bring  it  within  the  scope  of  this  essay.  My  two  postu- 
lates, then,  are  these  :  a  small  dose  signifies  a  dose  of  medicine 
which,  when  given  to  an  adult  person,  is  smaller  than  the  standard 
dose  specified  in  the  '  British  Pharmacopoeia  /  and  a  frequent  dose 
signifies  a  dose  of  medicine  given  (say)  four  or  more  times  at  in- 
tervals which  do  not  exceed  two  hours,  and  which  may  be  less.  And 
I  shall  try  to  demonstrate  the  advantages  which,  under  particular 
conditions,  appear  to  follow  this  plan  of  treatment. 

Every  medicine,  properly  so  called,  represents  a  composite  power, 
physiologic  and  therapeutic.  Its  physiology  can  be  determined 
sometimes  deductively  either  from  its  composition,  or  from  its  mani- 
fest relation  to  the  blood  and  tissues.  Its  therapseia  can  be  pre- 
dicated sometimes  deductively  too ;  more  often  it  is  discovered  by 
experiment  or  by  pure  accident.  But  whichever  element  predomi- 
nates, the  physiologic  or  empiric,  the  fact  remains  that  a  new  com- 
pound, of  greater  or  less  complexity,  is  added  to  the  blood;  and, 
permeating  every  part  of  the  body,  it  modifies  every  nutritional  act 
performed  within  certain  limits  of  time,  i.  e.  until  it  is  wholly  ex- 
creted from  the  body  by  the  excreting  glands.  It  cannot  be  said 
that  the  ^^  syphilised  plasma^'  of  a  syphilitic  subject  can  be  more 
than  evanescently  affected  by  a  single  dose  of  mercury  or  of  iodide 
of  potassium ;  a  ''  dose''  of  benefit  is  received,  but  the  constitu- 
tional vice  of  the  "  syphilised  plasma"  is  so  little  modified  by  that 
single  and  separate  quantity  of  medicine,  that  no  perceptible  altera- 
tion follows,  and  the  vis  morbiflca  is  practically  unchecked.  Why 
must  so  many  ''  doses"  of  medicine  be  given  before  the  syphilised 
plasma  becomes  w^^syphilised  ? 

If  that  number  can  be  counted  (as  it  may)  and  calculated  (as  it 
ought  to  be  if  all  the  data  are  forthcoming),  why  may  we  not 
shorten  the  period  of  our  heahng  process  by  embracing  that  number 
within  a  less  time  ? 

A  whole  series  of  problems  is  opened  up. 

The  number  just  spoken  of  is  probably  determined  by  a  pro- 
found reference  to  the  cyclical  changes  of  the  human  body.  Probably 
so  many  changes  have  to  be  transacted— so  many  currents  to  flow. 
Finally  and  gradually  the  tissues  are  renovated,  and  the  tracks 
of  dynamic  error  are  effaced.  Again,  a  quantity  of  a  particular  me- 
dicine is  \^Q]i^di  poisono2is  or  dangerous,  i.  e,  it  is  poisonous  or  dan- 
gerous if  taken  by  a  person  all  at  once.  Now,  suppose  that  we 
break  up  this  quantity  into  equal  parts — say  five  or  more ;  how  near 
in  time  may  these  parts  be  administered  before  any  dangerous  or 


1872.]  On  the  Administration  of  Medicines.  311 

poisonous  results  are  developed  ?  The  one  large  intoxication  is 
disintegrated  into  five  little  intoxications;  they  crowd  upon  one 
another,  but  each  has  very  nearly  gone  before  a  fresh  one  comes. 
The  excretory  organs  unceasingly  operate  to  expel  what  is  a  foreign 
body — an  alien  body  no  less  than  the  disease  which  it  cures,  though 
by  its  grateful  aid  that  disease  may  be  brought  to  an  end. 

The  key  to  the  principle  which  this  essay  is  intended  to 
illustrate  is,  therefore,  as  follows : — Increase  the  frequency  of  a 
medicine,  not  its  amount.  Given  a  specific  disease,  to  saturate 
the  system  with  its  antidote.  Do  not,  if  possible,  administer  a  me- 
dicine so  as  to  add  its  own  toxical  error  to  the  morbific  error  whicli 
that  medicine  is  designed  to  remove  or  relieve.  And  if  this  evil  be 
occasionally  unavoidable,  shorten  its  duration  within  the  smallest 
practicable  limits.  Withdraw  the  medicine  by  degrees,  and,  before 
it  is  withdrawn  altogether,  see  that  the  counteracting  forces  are 
being  steadily  controlled,  and  at  length  entirely  conquered  or 
eliminated.  Examine  all  the  surrounding  elements  of  hygiene, 
and  neglect  no  auxiliary  means  which  may  help  to  restore  and  main- 
tain the  health. 

The  dynamic  effects  of  small  frequent  doses  of  a  medicine  keep 
pace  with  the  molecular  changes  of  nutritional  force.  The  reno- 
vating momenta  of  the  two  forces  go  on  together,  and  even  assist 
each  other.  The  new  element  is  introduced  into  the  system 
guttatlm  (so  to  speak),  and  carries  with  it  the  many  qualities  whicli 
proverbially  belong  to  quiet  perseverance.  But  the  notorious  fact 
that  nearly  all  substances  so  administered  can  be  detected  in  the 
urine  within  a  few  seconds  afterwards,  proves  that  there  is  an  oppo- 
sition between  those  substances  and  the  principle  of  organic  life, 
even  when  they  are  introduced  with  the  intention  of  putting  it  right 
by  driving  out  or  by  neutralising  something  wrong. 

A  definite  residue  is  appropriated,  dynamically  incorporated  with 
blood  and  tissue.  This  is  really  all  that  is  required ;  but  what  is 
excreted  is  by  no  means  mere  surplusage.  It  is  pushed  out  of  the 
system  partly  because  it  cannot  help  being  excreted  with  the  normal 
excreta,  but  partly  because  it  represents  work  already  transacted  in 
the  system  and  duty  done.  Its  quittance  is  a  declaration  of  irre- 
concileableness  of  essence  between  itself  and  animal  hfe ;  its  mystery 
is  accomplished,  and  so  it  is  cast  out. 

Take  belladonna  as  an  illustration  of  this  doctrine.  Belladonna 
has  a  potent  influence  on  spasm ;  it  quells  and  relaxes  it ;  a 
rhythmic  convulsion  like  asthma,  which  comes  on  at  special  times 
or  on  special  days,  is  held  in  check.  But  no  curative  operation  is 
performed.  The  spasm  is  prevented  only  while  the  belladonna  circu- 
lates in  the  blood.  Omit  the  belladonna  for  a  single  night,  and 
back  the  asthma  comes.  But  the  convulsion  is  not  so  severe  as  if 
the  belladonna  had  never  been  given;  the  neurosis  is  favorably 


2\^  Orlijinal  Communication^,  [Jail., 

modified ;  we  may  legitimately  infer  that  some  of  the  belladonna 
has  been  appropriated  by  nerve-tissue,  and  that  the  morbid  habit  of 
that  tissue  has  been^ro  tanto  controlled. 

Belladonna  poisoning  is  an  awkward  phenomenon  to  look  at; 
but  it  is  devoid  of  real  danger  unless  the  quantity  taken  has  been 
mortally  large.  Leave  the  poisoned  person  alone ;  do  nothing  for 
him  in  the  way  of  antidotes,  and  gradually  will  all  the  functions 
return  without  a  trace  of  damage.  There  will  be  no  ill  afterwards, 
even  of  a  temporary  kind,  except  what  may  come  from  the  inter- 
ruption to  the  healthy  ingestion  of  food. 

Tartrate  of  antimony  often  abolishes  inflammation  in  a  re- 
markable way  when  administered  in  the  method  which  will  be  illus- 
trated presently.  Select  a  case  of  typical  phlegmon — acute  and 
quick — and  administer  one  sixteenth  of  a  grain  of  tartrate  of  antimony 
in  solution  every  hour  for  twelve  hours,  then  every  two  hours  for 
twenty-four  hours  more ;  by  this  time  the  inflammation  will  be  clean 
gone.  Usually  the  patient  will  be  ignorant  that  he  has  been  taking 
medicine  at  all,  so  far  as  any  collateral  effects  are  concerned. 

Now,  when  we  consider  the  action  of  this  method  of  sub- 
duing inflammation,  and  the  contrast  it  offers  to  the  " vi  et  armiii^ 
plan  by  which  it  was  formerly  deemed  necessary  to  knock  down  and 
expel  the  inflammatory  demon,  the  candid  inquirer  must  acknow- 
ledge the  radical  difference.  In  the  old  way  certainly  the  disease 
was  sometimes  knocked  down,  but  the  whole  body  was  knocked 
down  too.  A  fourth  of  a  grain  of  tartrate  of  antimony  given  every 
four  hours  caused  serious  nausea  and  depression  — possibly  syncopal 
disturbance  of  the  heart.  This  was  the  costly  price  at  which  dis- 
ease was  got  rid  of,  and  occasionally  there  was  no  riddance  at  all. 
The  clear  and  accurate  pathology  of  our  own  day  proves  inflammation 
to  be  (without  metaphor)  an  error  of  nutrition — a  neurose  perver- 
sion of  a  natural  process ;  and  how  consonant  it  is  with  philosophy 
and  common  sense  to  try  and  correct  this  error  by  quiet  coaxing 
ways,  by  the  persuasive  influence  of  "  smpe  cadenclo"  the  correcting 
agent  being  thus  not  a  new  disturber  and  disorder  producer,  but  a 
new  beneficence  and  guard. 

As  a  rule,  when  a  medicine  has  been  administered  with  un- 
faihng  regularity  every  hour  or  every  two  hours  (except  in  the  night) 
during  from  one  to  three  days,  it  should  be  discontinued  hj  degrees. 
This  principle  is  exceedingly  important,  and  much  disappointment 
has  come  when  it  has  been  neglected  by  the  patient  or  by  me.  I 
shall  be  able  to  show  its  necessity  when  I  relate  the  safeguards  and 
cautions  which  demand  observance  while  tartrate  of  antimony  is  being 
given  for  the  cure  of  inflammation,  and  iron  for  the  cure  of  erysipelas. 
Inattention  to  it  may  entail  the  labour  of  beginning  our  work 
again,  to  say  nothing  of  lost  time,  and  the  occasional  impossibility 
of  doing  afterwards  what  was  done  once  only  with  difficulty.     Nor 


1872.]  On  the  Administration  of  Medicines.  213 

does  the  subsequent  administration  of  the  medicine  at  longer  inter- 
vals take  it  away  from  the  scope  of  the  principle  enforced.  The 
whole  scheme  is  logically  bound  together,  and  the  end  is  no  less  an 
integral  part  of  it  than  the  beginning.  And  in  practice  it  will  be 
found  to  be  one  of  the  most  delicate  touches  of  art  to  hold  one^s 
hand,  and  to  withdraw  in  a  timely  and  gradual  manner  the  material 
instrument  of  healing. 

Some  practical  difficulties  are  alleged  to  lie  in  the  way.  Trouble 
is  imposed  on  the  attendants  of  a  sick  person ;  there  may  be  a  dan- 
gerous accumulation  of  a  medicine  in  the  system ;  and  a  medical 
man  has  no  means  of  testing  regularity  of  administration.  Now,  it 
is  obvious  that  every  earnest  and  true  scheme  of  therapasia  must 
involve  trouble.  I  do  not  urge  that  a  medicine  be  given  during 
the  night  (11  p.m.  to  7  a.m.),  except  under  the  pressure  of  a  grave 
and  almost  desperate  exigency.  I  do  not  say  that  refreshing  sleep 
is  to  be  disturbed  during  the  day  in  order  to  give  a  specified  dose : 
none  but  a  pedant  would  do  this,  and  no  pedant  ought  to  undertake 
a  nurse^s  duties.  Similarly  no  one  ought  to  minister  to  a  sick  child 
who  has  not  much  judgment ;  for  there  are  certain  medicines  which, 
when  administered  to  children  in  any  sort  of  cumulative  fashion^ 
may  unexpectedly  induce  dangerous  or  alarming  symptoms,  calling 
unmistakably  for  a  suspension  of  the  treatment.  Other  casualties 
may  occur,,  requiring  the  opinion  of  the  medical  adviser ;  or  a  mani- 
fest benefit  from  the  medicine  may  be  so  suddenly  established 
as  to  justify  its  discontinuance^  or  its  administration  at  longer 
intervals. 

Just  as  different  quantities  (or  "doses")  of  a  medicine  may 
signify  so  many  different  ideas,  or  even  represent  so  many  theories  ; 
the  diverse  frequency  in  which  that  medicine  can  be  administered 
may  be  symbolical  of  diverse  methods,  each  constituting  a  separate 
canon.  In  the  former  case,  we  think  primarily  of  the  element  of 
quantity i  the  arithmetical  measure  of  how  much  or  how  Httle ;  in 
the  latter  case,  the  element  of  time  predominates^  and  a  rule  of  stern 
punctuality  has  to  be  observed.  Whatever  may  be  the  determining 
principle  which  guides  the  practitioner  in  prescribing  a  medicine, 
it  is  essential  that  he  have  a  competent  knowledge  of  the  several 
therapeutic  forces  which  that  medicine  embodies,  and  which  ordi- 
narily it  is  capable  of  exercising.  Then,  having  clearly  discerned 
and  identified  his  mark,  he  aims  at  it  with  that  instinctive  precision 
which  governs  the  marksman  in  shooting  his  arrow  or  his  bullet,  the 
cricketer  in  throwing  his  ball^  the  player  in  hurling  his  quoit.  That 
there  is  often  a  waste  or  error  of  force  in  the  execution  of  all  these 
actions,  is  simply  equivalent  to  asserting  that  human  imperfection 
exists  everywhere.  But  all  honest  endeavours  to  reduce  that  im- 
perfection to  its  lowest  amount  form  the  basis  of  sound  know- 
ledge. 


214  Original  Communications,  [Jan., 

I  proceed  now  to  the  illustrations  of  my  paper.  I  begin  with 
the  relation  of  cases  in  which  opium,  or  its  derivative  morphia, 
was  administered  in  *^  comparatively  small  and  frequent  doses  -/' 
some  of  the  cases  are  drawn  from  private,  others  from  dispensary, 
practice.^  All  occurred  in  my  own  practice,  and  were  under  my 
own  professional  care  through  the  whole  course ;  and  of  nearly  all 
notes  were  taken  at  the  time. 

(1.)  P.,  March,  1858. —  Married  female  in  the  middle  rank 
of  life,  set.  60.  Acute  cerebral  rheumatism,  preceded  -by  diarrhoea, 
profuse  sweating  and  collapse.  The  first  thing  I  did  when  called  to 
the  case  was  to  darken  the  patient's  room,  order  plain  milk  diet,  and 
give  one  grain  of  powdered  opium  in  a  pill  every  hour  for  six  hours  ; 
then  every  three  hours  for  twenty-four  hours ;  then  less  frequently 
during  two  or  three  days.  'No  other  medicine  was  prescribed  until 
the  fever  began  to  pass  away ;  quinine  then  helped  the  natural 
progress  towards  cure. 

The  neurological  theory  of  rheumatism  is  reviving;  it  has  been 
ably  advocated  by  Dr.  H.  Day  in  his  recent  ^  Commentaries,'  and  by 
Dr.  Eidge  in  late  numbers  of  the  '  Medical  Times  and  Gazette/  I 
have  always  inclined  to  it  as  the  only  one  adequate  to  explain  all  the 
clinical  phenomena,  and  the  treatment  by  opium — long  ago  strenu- 
ously urged  by  Sir  D.  Corrigan  and  Dr.  Sibson — affords  a  good 
plea  for  the  soundness  of  the  theory.  If  excessive  alvine  flux 
precede  the  rheumatic  affection,  there  is  really  no  other  treatment 
available ;  and,  in  all  other  cases,  opium  can  be  administered  hand 
in  hand  with  alkalies  even  when  pushed  to  the  extent  recommended 
by  Dr.  Puller  ;^  and  a  further  merit  of  opium  is  that  it  favours  the 
escape  of  the  serous  membranes  from  rheumatic  inflammation.  The 
case  just  related  is  typical  of  other  cases  which  have  been  under  my 
care.^ 

(2.)  D.,  May,  1867. — Boy  set.  eleven;  child  of  very  poor 
parents;  spare  and  ill-nourished.  Acute  tubercular  peritonitis; 
sudden  access  of  excruciating  pain,  suggesting  perforation  of  bowel 
or  foecal  abscess  ;  sickness  and  constipation  ;  pinched  features ;  great 
prostration.  A  grain  of  opium  gum  was  administered  every  hour 
for  several  days,  and  he  was  allowed  to  drink  iced  milk  and  barley 
water.     A  thin  hot  linseed  poultice  over  the  abdomen.     The  case 


^  Those  from  private  practice  are  marked  P. ;  those  from  dispensary  practice 
are  marked  D. 

2  *  The  Practitioner/  March,  1869. 

3  Those  who  are  interested  in  the  history  of  the  theories  of  disease  should 
read  a  chapter  (Chapter  VI)  in  Dr.  Pring's  '  Exposition  of  the  Principles  of 
Pathology,  and  of  the  Treatment  of  Diseases,'  Loudon,  1823,  p.  321.  The  cha])ter 
in  question  is  entitled  "  The  Origin  of  Disease  in  the  Nerves."  Dr.  Pring  became 
more  of  a  humoralist  as  he  advanced  in  life,  and  at  the  end  of  this  chapter  it 
will  be  see  a  that  he  distinctly  abandoned  his  early  views. 


1873.  J  On  the  Administration  of  Medicines,  215 

seemed  very  unpromising,  but  eventually  the  boy  pulled  through 
wellj  and  was  heard  of  last  May  as  fat  and  strong.  It  deserves 
note  that  he  was  treated  in  his  own  wretched  home,  and  had  none  of 
the  benefits  of  hospital  nursing. 

Inflammation  of  serous  membranes  would,  in  the  judgment  of 
many  practitioners,  always  clamour  for  the  administration  of  mer- 
cury. In  strong,  healthy  adults,  the  union  of  equal  parts  of 
hyclrargyrum  cum  cretd  with  opium  may  be  a  good  point  of  practice, 
especially  in  inflammation  of  the  csecum  ;  but  the  opium  is  always 
foremost  in  its  virtue,  and  in  almost  every  other  case  should  be  given 
alone.  In  the  so-called  inflammations  of  the  tubercular  diathesis, 
the  bare  mention  of  mercury  is  a  heresy.  It  is  not  only  absolutely 
unnecessary,  but  pernicious  in  all  conceivable  ways ;  a  long  period 
of  bad  health  may  be  engendered  by  it,  possibly  the  development  of 
acute  tuberculosis.  The  opinion  seems  growing  that  all  serous 
inflammations  can  be  safely  treated  without  mercury. 

(8.)  D.,  June,  1869. — Married  woman,  set.  40;  tall  and  thin; 
bore  her  fifth  child  in  March,  1869.  Incessant  vomiting  from 
pyloric  cancer ;  diagnosis  easy,  but  had  been  overlooked  by  medical 
man  who  attended  the  labour,  as  he  attributed  the  vomiting  to  the 
pregnancy.  Of  course  the  prognosis  was  as  hopeless  as  it  invariably 
is  in  malignant  disease,  but  the  vomiting  nearly  ceased  for  more  than 
a  month,  when  powdered  opium  was  continuously  given  in  half 
grain  doses  every  two  hours.  Only  cold  milk  was  allowed  as  food. 
The  vomiting  returned  badly  at  intervals,  but  it  was  always  relieved  by 
opium,  which  was  sometimes  combined  with  the  extract  of  bella- 
donna. Death  from  ascites  and  exhaustion  on  October  12th.  This 
patient  was  treated  at  her  own  home  all  the  time,  but  she  was 
supplied  with  sundry  comforts  by  benevolent  friends. 

I  plead  earnestly  for  the  liberal  administration  of  opium  in  all 
instances  of  malignant  disease  in  which  pain  is  an  urgent  symptom. 
The  penurious  dole  of  a  grain  of  opium  every  night,  or  of  half  a 
grain  now  and  then,  is  a  mock  at  suffering.  I  ask  that  opium  may 
be  administered  freely,  and  yet  not  without  rule  and  careful  measure ; 
I  ask  the  practitioner  not  to  wait  till  pain  clamours  for  medicine,  but 
to  offer  it  readily  as  a  preventive  and  a  comfort.  In  most  cases 
opium  is  assimilated  with  remarkable  success,  and  with  a  total 
absence  of  those  inconveniences  proverbially  associated  with  this 
drug.  It  is  sometimes  better  still  to  give  morphia,  and  now  and 
then  to  order  a  hypodermic  injection  of  morphia  once  or  twice  a  day 
(as  occasion  demands),  auxiliary  to  smaller  doses  of  opium  or 
morphia  by  the  mouth  at  shorter  intervals. 

I  have  found  the  opium  gum  of  signal  advantage  when  it  has  to 
be  given  frequently.  Prescribe  a  grain  (or  -even  more)  every  two 
hours,  and  the  nervous  system  is  kept  in  happy  quiescence ;  and  if 
we  can  ward  off  the  acuter  paroxysms  of  suffering,  the  temptation 


216  Original  Communications.  [Jan., 

is  removed  to  take  opium  in  large  and  irregular  quantities,  or  to 
inhale  chloroform  perhaps  to  a  dangerous  amount.  The  painful 
spasms  which  accompany  the  passage  of  an  urinary  or  renal  calculus 
down  their  respective  ducts  are  well  known  to  be  susceptible  of 
relief  by  opium ;  but  the  best  mode  of  administering  it  is  not  in 
shock-like  quantities  of  heavy  narcosis,  but  by  the  gradually  tran- 
quillising  influence  of  '^  small  and  frequent  doses."  The  phenomena 
of  the  puerperal  state  shall  supply  my  last  illustration  of  the 
therapaeia  of  opium. 

(4.)  P.,  August,  1862. — A  lady,  a3t.  40,  was  delivered  of  her 
fifth  child ;  severe  post-partum  heemorrhage,  as  on  nearly  all  pre- 
vious occasions.  This  (says  Dr.  Barnes)  should  always  make  us 
watchful  for  any  event  of  the  pyaemic  kind.  On  the  fourth  day 
after  labour,  without  warning,  severe  pain  set  in  about  the  uterine 
region,  with  apparent  collapse.  I  was  summoned  almost  imme- 
diately, and  ordered  a  grain  of  powdered  opium  every  hour  for  six 
hours.  The  benefit  was  quick  and  positive ;  pain  went  away,  and 
the  skin  became  warm.  The  same  dose  was  then  given  every  two 
hours  for  a  few  times,  and  afterwards  at  gradually  lengthening 
intervals.     The  recovery  was  uninterrupted  and  complete. 

(II.)  Morphia,  or  the  therapeutic  essence  of  opium,  identical  with 
opium  in  most  of  its  properties,  has  yet  some  special  virtues  of  its 
own. 

I  propose  to  relate,  first,  all  very  illustrative  cases,  and  then  to 
comment  on  those  points  in  the  histories  which  deserve  special 
note. 

(5.)  D.,  May  and  June,  1869. — An  artisan,  set.  40;  tolerably 
healthy  ;  no  history  of  rheumatism  or  of  syphilis.  Severe  sclerotitis, 
which,  in  point  of  duration,  almost  deserved  the  name  of  "  chronic ;" 
probably  slight  iritis.  Only  one  (the  right)  eye  aff'ected.  One 
twelfth  of  a  grain  of  acetate  of  morphia  in  solution  was  adminis- 
tered every  hour  for  three  days ;  every  two  hours  for  ten  days ;  and 
then  gradually  at  wider  intervals.  Two  grains  of  blue  pill  were 
given  every  night  for  the  first  ten  days.  No  aperient  medicine 
was  needed.     The  recovery  of  vision  was  absolute. 

(6.)  P.,  September,  1869.— Lady's  maid,  ait.  23;  healthy,  but 
complexion  somewhat  anaemic.  Acute  conjunctival  catarrh.  One 
sixteenth  of  a  grain  of  morphia  in  solution  was  administered  every 
hour  on  the  first  day,  and  one  twelfth  of  a  grain  every  hour  on  the 
second  day ;  the  same  quantity  every  two  hours  on  the  third  day ; 
and  every  four  hours  on  the  fourth  and  fifth  days.  She  was  then 
quite  well. 

A  number  of  cases  like  this  have  been  treated  by  me  with  perfect 
success  during  the  last  seven  years,  both  in  private  and  public 
practice. 

Other  neuroses  may  be  favorably  modified  by  morphia. 


1872.]  On  the  Administration  of  Medicines.  217 

(7.)  P.,  May,  1863. — A  young  gentleman,  set.  10,  suffering  from 
the  troublesome  sequel  of  whooping  cough ;  cough  incessant,  but 
the  peculiar  spasm  of  the  specific  disease  had  passed  away.  One 
twenty-fourth  of  a  grain  of  acetate  of  morphia  in  solution  was  pre- 
scribed every  two  hours  for  the  first  two  days ;  afterwards  at  longer 
intervals  of  time.  The  cough  was  notably  alleviated  almost  imme- 
diately, and  the  patient  enjoyed  refreshing  sleep  during  the  first 
night.  Scarcely  any  drowsiness  was  produced  by  the  morphia,  nor 
was  any  other  inconvenience  felt ;  not  even  constipation.  Within 
five  days  the  cough  had  nearly  gone. 

(8.)  D.,  May,  1869. — A  female  child,  set.  5  ;  parents  not  very 
poor ;  house  clean  and  healthy.  Whooping  cough,  rather  severe ; 
no  complications.  One  thirty-second  part  of  a  grain  of  morphia, 
with  three  grains  of  bromide  of  potassium,  in  solution  every  two 
hours ;  mother  was  instructed  to  suspend  the  medicine  for  four 
hours  at  any  time  if  unusual  drowsiness  came  on.  No  medicine 
was  given  during  the  night.  The  usual  auxiliary  treatment  as 
regards  diet  and  clothing.  The  paroxysms  of  whooping  cough 
soon  became  less  severe,  and  the  duration  of  the  disease  seemed 
shortened. 

There  are  many  mysteries  about  the  therapeutics  of  morphia  which 
we  have  yet  to  fathom.  I  incline  to  the  opinion  that  the  extraordinary 
and  unexpected  benefits  which  have  been  reaped  from  the  subcuta- 
neous injection  of  morphia  have  partially  overshadowed  the  good 
which  morphia  is  capable  of  affording  when  administered  in  the 
usual  way.  Its  power  over  neuralgias  and  neuroses,  after  they 
have  become  chronic  habitudes,  is  notably  shown  when  prescribed 
in  the  small  recurrent  quantiti^  which  Dr.  Anstie  calls  ''  stimu- 
lant,'^ rather  than  in  the  larger  and  much  less  frequent  quantities 
which  produce  phenomena  approximating  "  narcosis.^''  These  heal 
and  soothe  for  the  vicissitude  which  evoked  them ;  those  are  less 
hasty  to  avert  suffering,  but  their  ultimate  effects  are  equally  sure, 
and  almost  always  more  lasting.  Adopting  Dr.  Inman's  opinion, 
the  drug  thus  given  probably  exerts  a  modifying  influence  on  the 
organic  condition  of  the  affected  part ;  it  may  prevent  a  threatened 
destruction  of  tissue,  and  consequently  relieve  pain.^  But  I  cannot 
agree  with  Dr.  Anstie's  axiom  that  ''  when  a  particular  symptom, 
e.g.  pain,  can  be  relieved  only  by  narcotic  doses  of  any  drug,  the 
medicine  is  probably  altogether  an  improper  one  for  the  case.''  ^  A 
single  dose  of  morphia  may  relieve  (it  is  remotely  possible  that  it 
may  even  cure)  an  obtrusive  neuralgia ;  it  does  so  distinctly 
through  the  medium  of  narcosis ;  but  there  is  nothing  intrinsically 
improper  in  our  eliciting  this  narcosis.     The  narcosis  passes  away  ; 

1  Quoted  by  Dr.  Anstie,  'Stimulants  and  Narcotics,'  p.  118. 
8  Ibid.,  p.  280. 


218  Original  Communications.  [Jan., 

any  possible  evil  arising  of  the  narcosis  passes  away  too ;  and  the 
pain  is  gone,  at  least  for  the  time.  The  probable  (almost  certain) 
return  of  the  pain  proves,  not  that  the  remedy  is  wrong,  but  that  it 
is  achiinistered  in  a  wrong  way.  .Administer  it  in  the  right  way, 
and  it  is  proved  to  be  a  right  remedy  ;  and  it  is  further  proved  to 
be  the  right  remedy  by  the  fact  that  none  other  can  supply  its  place. 
Accepting  Dr.  Anstie's  terminology  as  sound  and  authentic,  I 
base  upon  it  my  proposed  method  of  working.  I  break  up  a 
"  narcotic  ^^  dose  of  morphia  into  fractional  '^  stimulant  "  doses ; 
I  order  these  to  be  given  to  a  patient  with  punctilious  regularity  at 
definite  short  intervals  of  time.  I  never  allow  (if  it  can  be  avoided) 
the  acGumulative  influence  of  ''stimulant"  doses  to  cause  ''narcosis.'" 
I  have  the  power  of  controlling  this  (under  ordinary  circumstances) 
by  lengtliening  the  intervals  or  by  diminishing  the  quantities  ;  and 
I  prefer  the  latter  plan  as  more  truly  in  accordance  with  the  physio- 
logical operations  of  nature :  and  thus  a  typical  narcotic,  like 
morphia,  may  become  a  rational  stimulant  medicine,  rectifying,  by 
its  direct  action,  "  some  deficient  or  too  redundant  natural  action  or 
tendency."  ^ 

It  deserves  note  that  long  ago  Drs.  Bardsley  and  Stokes  recom- 
mended morphia  as  a  remedy  for  chronic  gastritis  to  be  administered 
in  an  order  inversely  to  that  which  I  have  spoken  of;  that  is  to  say, 
one  twelfth  of  a  grain  is  to  be  given  twice  on  the  first  day,  three 
times  on  the  second  day,  and  so  on,  increasing  the  quantity  until 
the  patient  consumes  one  to  one  and  a  half  grains  in  twenty-four 
hours. ^  It  is  not  said  whether  the  medicine  is  to  be  left  off  in  the 
same  gradual  manner  in  which  it  is  begun. 

Digressing  for  a  little  while  to  the  subject  of  the  general  action  of 
morphia,  there  are  plenty  of  facts  which  attest  the  value  of  this 
drug  in  promoting  nutrition.  A  man,  set.  fifty,  is  lying  in  his  bed 
crippled  by  chronic  rheumatoid  arthritis ;  he  is  racked  by  much 
pain;  he  is  sleepless  and  emaciated.  I  persuade  him  to  take  a 
small  dose  of  morphia  five  or  six  times  a  day  for  several  months ; 
and,  besides  the  ordinary  relief  which  might  a  priori  have  been 
expected,  the  skin  becomes  warm,  the  appetite  returns,  the  muscles 
are  better  nourished,  and  at  the  end  of  a  year  he  scrambles  down  to 
my  out-patient  room.  Again,  whenever  a  neuralgia,  apparently 
pure  and  simple,  is  the  one  pressing  symptom  of  distress,  it  is  right 
to  administer  morphia  in  very  frequent  stimulating  doses,  while  we 
are  ripening  other  more  eclectic  methods  of  treatment.  A  delicate 
woman  asks  to  be  cured  of  an  acute  uncomplicated  pleurodynia,  or 
neuralgia  of  the  intercostal  nerves.  What  are  the  therapeutic  ideas 
which  her  case  suggests?     One  physician  would  prescribe  imme- 

^  Dr.  Anstie,  op.  cit ,  p.  161. 

'  Dr.  Waring's  *  Manual  of  Practical  Therapeutics/  p.  469  (second  edition). 


1872.]  On  the  Administration  of  Medicines.  219 

diately  the  dynamic  tonicj  quinine ;  a  second,  the  chemical  blood 
tonic,  iron ;  a  third,  the  nutritional  tonic,  cod  oil ;  and  a  fourth 
might  be  contented  with  the  moderate  instalment  of  an  opiate 
embrocation.  But  her  pressing  need  will  not  be  removed  by  any  of 
these  means  except  in  terms  of  weeks  or  days,  and  she  craves  to  be 
relieved  as  quickly  as  possible.  Now  give  her  minute  and  frequent 
doses  of  morphia,  just  sufficient  to  cause  the  most  trifling  drowsi- 
ness, and  yet  not  enough  to  interfere  with  the  performance  of  life's 
daily  occupations ;  observe  that  the  pain  is  almost  to  a  certainty 
gradually  and  surely  palliated,  and  its  urgency  blunted. ^  Withdraw 
the  medicine  little  by  little ;  while  it  is  being  withdrawn,  begin  to 
introduce  the  nutritional  and  blood  tonics  whixih  are  the  pabula  of 
nerve  tissue,  and  which  are  the  antidotes  to  that  pain  which  signifies 
the  deterioration  of  this  tissue.  And  thus  the  philosophical  order  of 
our  therapoeia  is  sometimes  to  attack  first  the  effect,  and  then  the 
cause ;  and  for  the  plain  reason  that  the  effect  is  peremptory  and 
injurious,  clamouring  for  alleviation  because  of  its  annoyance  and 
damage. 

1  proceed  to  comment  on  my  cases.  Nearly  ten  years  ago  the 
late  Mr.  Z.  Lawrence  illustrated  the  successful  treatment  of  acute 
sclerotitis  and  iritis  by  the  '^antiphlogistic"  power  of  morphia.^ 
His  cases  are  remarkable,  and  are  not  disposed  of  by  recent  criti- 
cism ;^  he  suggests  that,  in  a  certain  class  of  cases,  pain  may  be  the 
cause  of  repletion  of  blood-vessels,  and  he  submits  that  the  action 
of  morphia  may  be  to  reduce  that  nervous  irritability  which  is  the 
primary  cause  of  the  inflammation.  Since  the  publication  of  Mr.  Z. 
Lawrence's  paper  I  have  pursued  the  same  line  of  treatment  in 
cases  of  conjunctivitis  and  sclerotitis;  and  also  in  some  cases  of 
iritis,  combined  with  the  local  use  of  atropia.  I  eliminate  the  latter 
cases  because  the  use  of  atropia  vitiates  them  for  purposes  of  evi- 
dence, and  I  relate  two  examples  which  are  similar  to  a  host  of 
others  that  have  come  under  my  care  during  the  last  nine  years. 

My  own  practice  diff'ers  from  that  advised  by  Mr.  Lawrence  in 
one  specific  point,  though  generically  identical.  The  doses  enume- 
rated by  him  are  administered  never  with  greater  frequency  than 
every  third  hour,  sometimes  every  fourth  hour,  and  the  amount 
of  each  dose  is  comparatively  large  (a  quarter  to  half  a  grain).  I 
strongly  recommend  a  great  reduction  of  dosage,  and  a  proportionate 
increase  of  frequency  in  its  administration.  To  a  child  of  five  years 
old  I  give  one  fortieth  to  one  thirty-second  of  a  grain  of  morphia 
every  second  hour,  with  the  rigorous  instruction  that  the  effect  be 

^  It  is  not  inconsistent  with  my  plan  to  give  a  double  or  a  treble  dose  Tiord 
somni,  and  this  I  usually  do.  In  the  text  I  have  ventured  to  draw  a  model  figure, 
with  whose  head  and  stomach  morphia  is  assumed  to  "  agree." 

2  '  Med.  Times  and  Gazette/  December  31,  1859. 

3  Mr.  Carter  in  the  •  Practitioner,'  July,  1869. 


220  Original  Communications.  [Jan., 

carefully  watched.  For  an  otherwise  healthy  adult  I  often  prescribe 
one  twelfth  of  a  grain  of  morphia  every  hour  for  the  first  twenty-four 
hours  (omitting,  as  usual,  the  eight  hours  of  the  night),  and  one 
tenth  or  one  eighth  of  a  grain  every  two  hours  for  the  subsequent 
two  or  three  days.  The  only  local  application  necessary  is  a  com- 
press of  lint  dipped  in  warm  water  (or  cold  water,  if  the  patient 
prefer  it)  ;  and  the  affected  eye  is  never  allowed  to  be  opened  during 
the  early  stage  of  treatment,  except  for  necessary  inspections  by  the 
medical  man.  The  effect  of  this  simple  scheme  of  therapeutics  is 
usually  very  happy.  The  patient  may  be  scarcely  aware  that  any 
drug  is  being  taken,  as  only  the  slightest  approach  to  narcosis  is 
permitted;  he  is  prudently  confined  to  the  house,  and  he  is  pru- 
dently restricted  in  his  diet;  an  occasional  purgative  also  may  be 
advisable.  But  note  how  quietly  the  vascular  congestion  of  the 
conjunctiva  and  sclerotic  disappears ;  how  the  pain  and  photophobia 
diminish,  and  may  have  gone  entirely  on  the  third  or  fourth  day  of 
the  treatment;  and  sometimes  the  cure  may  be  completed  in  less 
than  a  week  without  any  other  help,  though  it  may  be  expedient 
now  and  then  to  finish  with  quinine  as  a  vaso-motor  tonic,  in  order 
to  gain  a  perfect  victory. 

Justice  to  Mr.  Lawrence's  plan  is  hardly  done  by  distinguished 
ophthalmologists.  It  is  necessary  to  be  clear  about  the  presence  or 
absence  of  syphilitic  taint;  but  if  there  be  the  slightest  uncertainty, 
the  safe  course  is  to  order  a  small  dose  of  blue  pill  once  or  twice 
daily,  as  in  the  history  of  my  own  case  (5). 

The  troublesome  and  importunate  neurosis,  a  cough,  affords  an 
excellent  field  for  the  exercise  of  my  therapeutic  principle.  When 
a  cough  is  a  mere  factor  (though  a  principal  one)  in  some  specific 
disease,  that  disease  requires  to  be  attacked  with  clinical  precision  if 
we  are  to  acquire  a  mastery  over  its  several  factors.  In  the  most 
recent  exposition  of  hooping-cough^  the  writer  politely  dismisses 
the  drugs  which  have  been  propounded  for  its  cure  during  late 
years ;  and  he  emphasises  the  view  long  maintained  by  him,  that 
morphia  is  the  best  remedy,  because  it  is  more  certain  and  uniform 
in  its  action  than  all  others.  I  am  weary  of  treating  hooping-cough 
with  any  medicine  but  morphia,  but  I  think  that  bromide  of  potas- 
sium may  be  usefully  combined  with  it.  Dr.  E.  Smith's  proposal 
is  as  follows  : — "  With  children  under  one  year  of  age  the  dose  of 
the  hydrochlorate  or  acetate  of  morphia  should  be  one  sixty-fourth 
of  a  grain,  repeated  every  four  hours ;  with  children  between  one  and 
three  years  of  age,  one  forty-eighth  to  one  thirty-second  of  a  grain ; 
and  with  those  yet  older,  one  thirty-second  to  one  twentieth  of  a 
grain.     The  dose  selected  should  be  repeated  three  or  four  times, 

^  Dr.  Reynolds's  'System  of  Medicine,'  vol.  i,  pp.  271-86.     The  author  of  the 
article  is  Dr.  E.  Smith. 


1872.]  071  the  Administration  of  Medicines.  2^1 

and  if  no  perceptible  drowsiness  be  induced  it  should  be  increased  a 
step  and  repeated  in  like  manner^  and  again  increased^  if  necessary, 
until  the  dose  has  been  found  which  produces  the  slightest  oppres- 
sion of  the  sensorium ;  the  aim  must  then  be  to  maintain  this  effect 
by  repeating  the  same  dose,  or  by  further  increasing  it  from  time  to 
time.  The  cases  of  slight  hooping-cough  are  extremely  few  in 
which  slight  drowsiness  has  been  produced  and  uniformly  maintained 
for  three  or  days  without  the  spasm  having  subsided,  and  the  cough 
nearly  reduced  to  that  of  a  common  cough  ."^ 

There  is  nothing  so  successful  as  success,  says  the  proverb,  and 
this  is  equally  true  when  we  cannot  explain  the  success.  But  Dr. 
E.  Smithes  success  is  based  upon  reason,  not  upon  empiricism.  As 
before,  I  have  an  amendment  to  make.  It  may  be  wise  in  many 
cases  to  administer  morphia  to  an  infant  with  extreme  tentative  care, 
and  a  dose  may  be  appropriately  given  at  first  every  four  hours. 
But  to  almost  any  child  from  six  months  to  a  year  old  it  is  absolutely 
safe  to  give  a  single  minim  ^  of  the  Liq.  Morphise  Hydrochloratis,  vel 
Acetatis,  every  hour  for  several  hours,  in  order  to  pacify  a  convulsive 
cough.  After  five  or  six  doses  the  medicine  may  be  left  off  for  a 
little  while,  to  be  resumed  either  in  the  same  way  or  (perhaps  better 
still)  in  doses  of  a  minim  and  a  half  every  two  hours.  It  is  presumed 
that  the  infant  is  under  the  incessant  guardianship  of  an  intelligent 
nurse,  that  the  taking  of  food  is  interfered  with  as  little  as  possible, 
and  that  the  general  precautions  expressed  by  Dr.  E.  Smith  are 
punctually  adhered  to. 

Other  medicines  may  cluster  around  morphia  when  used  according 
to  the  directions  now  given,  but  strictly  subordinated  to  it. 

Opium  and  morphia  are,  therefore,  grand  remedies  for  inflamma- 
tion, pain,  convulsion.  Dying  struggles  may  be  alleviated,  some- 
times removed,  by  them,  especially  the  final  agonies  of  laryngeal 
phthisis,  and  of  many  forms  of  malignant  disease.  They  are  parti- 
cularly useful  in  certain  rapid  and  painful  phases  of  rheumatoid 
arthritis.  When  to  give  opium  rather  than  morphia,  or  morphia 
rather  than  opium,  is  not  requisite  here  to  define ;  it  is  a  problem 
which  rarely  puzzles  the  experienced  therapeutist.^ 

(Ill)  Tartrate  of  antimony  may  challenge  all  other  medicines 
for  certainty  of  action ;  and  when  administered  in  the  mode  about 
to  be  recorded,  its  conquest  over  disease  is  not  only  the  most  effec- 
tive, but  the  inconvenience  to  the  system  the  very  smallest. 

(9)  P.,  September,  1866. — A  lady,  set.  38,  was  delivered  of  her 
eighth  child ;  she  suffered  severely  from  flooding.     On  the  afternoon 


1  Op.  cit.,  pp.  282-3. 

■■^  Equivalent  to  ji^th  of  a  grain  of  the  salt. 

^  Among  eccentric  neuroses  I  may  mention  "hay  fever"  as  often  capable  of 
very  great  relief  by  a  drop  dose  of  tincture  of  opium  given  in  water  every  hour. 


^22  Original  Communications.  [Jan., 

of  September  5  th,  fifty -eight  hours  after  delivery,  signs  of  inflamma- 
tion of  the  left  breast  were  noticed.  Six  hours  afterwards,  late  at 
night,  I  was  called  to  see  her  on  account  of  the  violence  with  which 
the  inflammation  had  set  in.  Pifteen  drops  of  antimonial  wine  (equal 
to  one  sixteenth  of  a  grain  of  '  tartar  emetic')  were  given  every  hour 
through  the  night,  and  until  I  saw  the  patient  again  at  eleven  o'clock 
next  morning.  The  inflammatory  hypersemia  was  then  entirely 
gone,  the  breast  was  only  a  little  more  swollen  than  the  other,  and 
there  was  scarcely  any  pain.  There  had  been  not  only  no  vomiting, 
but  no  appreciable  nausea.  The  medicine  was  continued  in  the  same 
dose  every  two  hours  until  the  next  day,  then  every  four  hours  for 
another  day,  and  in  less  than  four  days  from  the  beginning  of  the 
treatment  all  signs  of  inflammation  of  the  breast  had  disappeared.^ 

(10)  P.,  September,  1866. — The  wife  of  a  tradesman  had  a  rapid 
favorable  labour  on  September  25th.  On  the  fourth  day  after  deli- 
very inflammation  of  the  left  breast  was  suddenly  developed.  On 
account  of  general  nervous  excitability  and  a  tendency  to  diarrhoea, 
one  drop  of  tincture  of  opium  was  combined  with  fifteen  drops  of 
antimonial  wine,  and  administered  in  water  every  hour  for  fourteen 
hours.  After  five  doses  had  been  given  profuse  diaphoresis  occurred ; 
coincidently  with  this  the  pain  suddenly  went  away,  and  light  sleep 
followed ;  and  within  three  days  from  the  beginning  of  the  .treatment 
there  was  no  vestige  of  what  had  happened.  The  local  means  used 
were  the  same  as  in  the  last  case. 

I  relate  these  two  cases  as  typical  of  several  others  treated  in  the 
same  or  similar  manner  with  equal  success. 

(11)  D.,  June,  1869. — A  maiden  female  servant,  set.  23,  applied 
to  me  on  account  of  a  threatening  abscess  of  the  breast,  the  result 
of  a  blow.  She  appeared  in  tolerably  good  health.  One  sixteenth 
of  a  grain  of  tartrate  of  antimony  was  given  in  solution  every  hour 
for  three  days  (excluding  the  night) ;  then  every  three  hours  for 
two  days  more.  The  inflammation  quietly  went  away,  and  she  did 
not  attend  after  a  week. 

I  quote  this  case  because  of  its  logical  value.  It  offers  a  ready- 
made  illustration  of  one  of  Mr.  J.  S.  Mills'  four  experimental 
methods,  namely,  the  method  of  difference.  Nothing  was  done  for 
the  patient  but  the  administration  of  the  medicine  specified;  no 
other  medicine  was  ordered,  not  even  an  aperient  dose ;  there  were 
no  local  applications ;  no  alteration  whatever  was  made  in  her  man- 
ner of  life  or  in  her  diet.  The  tartrate  of  antimony  was  the  single 
n^w  element  introduced — the  factor  of  the  artificial  experiment,  all 
the  surrounding  circumstances  being  the  same.  And  it  is  the  very 
nature  of  an  experiment  to  introduce  into  the  pre-existing  circum- 

*  In  this  case  no  local  application  was  used,  except  a  piece  of  hot  wet  flannel 
covered  with  oil- silk. 


1872.] 


On  the  Administration  of  Medicines.  223 


stances  a  change  perfectly  definite.  "  We  choose  a  previous  state  of 
things  with  which  we  are  well  acquainted,  so  that  no  unforeseen 
alteration  in  that  state  is  likely  to  pass  unobserved ;  and  into  this 
we  introduce,  as  rapidly  as  possible,  the  phenomenon  which  we  wish 
to  study,  so  that  in  general  we  are  entitled  to  feel  complete  assur- 
ance that  the  pre-existing  state  and  the  state  which  we  have  pro- 
duced differ  in  nothing  except  the  presence  or  absence  of  that  phe- 
nomenon.''''^  Hence  it  is  susceptible  of  complete  proof  that  the 
tartrate  of  antimony  cured  the  threatened  inflammation  in  the  case 
last  given,  as  nothing  else  was  done  but  this,  and  every  other  cir- 
cumstance remained  unchanged. 

(12)  P.,  August,  1869. — A  maiden  female,  set.  30,  daughter  of 
a  tradesman.  She  had  been  nursing  a  sick  relative,  and  had  used 
the  left  arm  beyond  her  strength.  The  left  breast  was  enormously 
swollen  and  tense,  but  there  was  no  positive  evidence  of  suppuration. 
Twenty  drops  of  antimonial  wine  were  ordered  every  two  hours,  and 
were  continued  perseveringly  for  more  than  a  week.  The  result  was 
only  a  small  limited  abscess  on  the  outside  and  upper  part  of  the 
breast,  which  discharged  and  then  quickly  healed.  Quinine  and 
iron  were  prescribed  in  order  to  renovate  the  general  health. 

This  case  looked  very  unpromising  when  the  treatment  was 
begun ;  both  the  local  malady  and  the  constitutional  weakness  had 
been  neglected.  It  cannot  be  too  often  or  too  clearly  stated  that 
the  formation  of  pus  is  an  absolute  bar  to  the  success  of  the  antimo- 
nial treatment ;  this  treatment  is  then  not  only  useless,  but  hurtful. 
The  opportunity  for  the  application  of  preventive  measures  has 
passed,  and  new  plans  have  to  be  devised. 

In  another  case  of  mammary  inflammation,  which  I  need  not 
quote  at  length,  and  which  conveys  a  very  useful  lesson,  the  anti- 
monial treatment  was  left  off  too  soon ;  worse  still,  a  blood  tonic 
was  prescribed.  So  obstinately  and  quickly  retrograde  was  the  course 
of  the  disease,  that,  although  the  mistake  was  very  early  seen  and 
the  antimony  recommenced,  the  inflammation  never  stayed  its  course 
for  an  instant,  and  the  patient  had  to  endure  a  large  abscess  with 
all  its  sequels. 

(13)  P.,  July,  1869. — The  wife  of  a  farmer,  a  strong,  healthy 
woman,  of  middle  age.  Inflamed  varix  of  right  leg,  exquisitely 
painful ;  much  redness  of  skin  over  inflamed  veins.  The  leg  was 
placed  in  the  recumbent  position ;  a  pledget  of  hot  wet  lint  was 
placed  over  the  course  of  the  vein,  w^hich  was  covered  by  oil-silk. 
Twenty  drops  of  antimonial  wine  were  given  in  water  every  two 
hours ;  no  other  medicine  was  required.  A  great  improvement  was 
visible  in  two  days,  and  within  five  days  no  trace  of  inflammatory 
action  was  left. 

^  '  System  of  Logic,'  3rd  edition,  vol.  i,  p.  399. 


224  Oriyinal  Communications,  [Jaii., 

(14)  P.,  October,  1869. — A  gentleman,  ast.  33,  injured  his  ankle 
by  an  awkward  fall.  Within  a  few  days  a  painful  red  swelling  was 
noticed  on  the  upper  part  of  the  inside  of  the  leg,  just  below  the 
knee.  From  this  red  streaks  of  angeioleucitis  ran  up  the  thigh  to 
the  femoral  glands,  which  had  already  begun  to  swell  and  to  be 
painful.  Health  pretty  good,  but  he  was  rather  feverish.  A  single 
purgative  dose  was  given,  and  then  fifteen  drops  of  antimonial  wine 
in  water  ev^ry  hour  for  four  days,  sixteen  doses  being  taken  every 
day.  The  inflammation  of  the  lymphatics  went  away  almost  directly, 
the  femoral  glands  ceased  to  be  painful  after  two  days,  and  the 
swelling  below  the  knee,  which  was  as  near  suppuration  as  possible, 
began  to  lose  its  inflammatory  characters.  The  antimonial  medicine 
was  continued  every  two  hours  for  three  days,  and,  finally,  every 
three  hours  for  two  days  more.  The  recovery  was  complete.  During 
the  latter  part  of  the  treatment  the  leg  was  bandaged.  It  is  proper 
to  state,  also,  that  during  the  earlier  part  of  the  treatment  the  limb 
was  kept  in  the  recumbent  position.     The  diet  was  not  altered. 

The  cases  now  adduced  are  sufficient  to  exhibit  tartrate  of  antimony 
as* an  "  antiphlogistic^' — to  use  the  old  terminology — of  unrivalled 
efficacy  and  certainty  in  the  treatment  of  certain  external  inflamma- 
tions of  the  pysemic  or  erysipelatous  kind.  I  am  indebted  to  Dr. 
Beatty  and  Dr.  ChurchilP  for  a  knowledge  of  the  curative  power  of 
tartrate  of  antimony  over  inflammation  of  the  breast  when  occurring 
after  parturition.  I  discerned  no  reason  why  the  same  treatment 
might  not  be  employed  when  we  have  to  deal  with  mammary  in- 
flammations unconnected  with  the  parturient  function.  Then  the 
argument  from  analogy  led  me  to  hope  that  kindred  inflammations 
in  other  external  parts  of  the  body  might  be  controlled  and  cured  by 
the  same  method.  The  important  fact  has  been  verified  that  tartrate 
of  antimony  can  achieve  this  triumph  over  disease  without  the  display 
of  any  counterbalancing  inconvenience  or  trouble,  even  of  the  most 
trivial  degree.  A  patient  may  not  perceive  the  slightest  physiologi- 
cal sequence  any  more  than  if  so  many  rations  of  cold  water  had 
been  administered  to  him.  Even  nausea  is  a  pure  ixvOoq,  and 
vomiting  is  a  higher  invOog  still.  I  have  not  found  that  so-called 
weakness,  or  spansemia,  affords  any  valid  barrier^to  this  plan.  Indeed, 
a  weak  person  had  surely  better  take  tiny  doses  of  tartrate  of  antimony 
and  be  cured  of  a  local  inflammation,  than  suffer  the  pain  of  an 
abscess  and  the  drain  of  puriform  or  pyoid  discharge.  Common 
sense  dictates  the  surgical  auxiliaries  of  "rest,''  "position,"  and 
"hygiene;"  but  the  central  fact  is  the  administration  of  the  tartrate 
of  antimony,  without  which  all  other  means  are  shadows. 

Some  inflammations  are  more  easily  curable  by  opium  or  morphia, 
others  by  tartrate  of  antimony.    Whence  is  this  difference,  and  how 

^  Churchill's  Manual  of  *  Diseases  of  Women,'  p.  752,  4th  edit. 


1872.]  On  the  Adm'mistration  of  Medicines.  225 

are  we  to  know  which  drug  to  use  ?  The  question  is  too  large  to 
answer  fully  here,  but  the  presence  or  absence  of  pyrexia  has  some 
determining  influence.  Well-marked  pyrexia,  as  there  was  in  some 
of  the  patients  whose  cases  are  last  related,  should  at  least  suggest 
antimony.  On  the  other  hand,  the  predominance  of  pain  or  of 
nervous  irritability  tells  us  that  opium  or  morphia  should  be  preferred. 
But  there  are  cases  in  which  a  combination  of  tartrate  of  antimony 
and  opium,  or  of  tartrate  of  antimony  and  morphia,  furnishes  results 
of  high  therapeutic  interest. 

What  is  the  value  of  this  method  in  the  management  of  internal 
inflammations?  All  available  evidence  points  to  its  utility;  but 
that  evidence  is  qualified  by  a  host  of  surrounding  "  circumstances,^^ 
which  hopelessly  impair  its  logical  force.  A  simple  naked  pneu- 
monia, if  such  a  pathological  thing  exist,  how  do  we  treat  it  ? 
Ethics  forbid  us  to  experimentalise  when  vital  function  (perhaps  life 
itself)  is  at  stake ;  and  so  we  put  a  patient  in  bed,  make  him  rest, 
surround  him  with  warm  clothes,  compel  him  to  inhale  warm  moist 
air,  "  counter-irritate"  the  skin  of  the  thorax,  supply  him  with  food 
and  wine  in  quantities  and  qualities  easily  assimilated,  and,  finally, 
in  obedience  to  authoritative  dogma,  we  ask  him  to  take  a  little 
medicine  !  But  if  the  tartrate  of  antimony  be  made  to  produce  its 
specific  physiological  effects,  as  in  Dr.  Cheyne's  treatment  of  croup,^ 
we  have  clearer  landmarks  of  what  our  drug  is  doing.  It  cures  now 
because  it  causes  nausea  and  vomiting,  and  by  virtue  of  those  pro- 
cesses; and  we  are  logically  right  in  attributing  to  them  a  portion 
at  least  of  our  success,  if  success  be  attained.  And  our  skill  is 
appropriately  directed  to  the  guidance  and  governance  of  the  phy- 
siological phenomena,  and  their  subordination  to  the  desired  end. 

(lY)  Mercury  may  be  given  sometimes  with  conspicuous  advan- 
tage in  comparatively  small  and  frequent  doses.  When  we  wish  to 
produce  what  is  called  "  mercuriahzation"  with  sureness  and  speed, 
we  can  do  it  by  administering  Hydrargyrum  c.  Cretd  in  a  two-grain 
dose  every  two  hours  better  than  in  a  four-grain  dose  every  four 
hours. 

(15)  D.,  Pebruary,  1869.  —  A  man,  eet.  47,  a  coal-hauler. 
Chronic  syphihtic  laryngitis,  which  suddenly  took  on  an  acute  exa- 
cerbation after  exposure  to  cold  and  probably  to  dissipation.  The 
treatment  was  carried  out  as  just  specified,  and  within  thirty-six 
hours  the  laryngeal  distress  had  subsided.  An  inopportune  change 
of  weather  to  a  keen  damp  wind  helped  the  development  of  a  low 
inflammation  of  the  lungs,  which  proved  fatal  on  the  fourth  day  of 
treatment.  The  mercury  was  left  oft'  as  soon  as  signs  of  pulmonary 
disease  became  manifest,  and  everything  was  done  for  the  man 
secundum  art  em. 

^  '  Cyclop,  of  Practical  Medicine,'  vol.  i,  p.  497. 
97— XLix.  15 


22G  Original  Communications.  [J 


an. 


The  dangerous  inflammation  of  the  larynx  and  epiglottis,  whieh 
is  kindled  by  the  contact  of  a  very  hot  fluid — an  accident  so  liable 
to  happen  to  the  children  of  the  poor — demands  a  treatment  (quoad 
drugs)  swift  and  energetic  in  a  high  degree.  A  half-grain  dose  of 
calomel  may  be  prescribed  at  first  every  half  hour ;  after  six  doses 
the  same  quantity  every  hour,  and  the  quantity  and  frequency  are  to 
be  augmented  or  lessened  according  as  the  urgency  of  the  inflamma- 
tion seems  likely  to  yield.  A  professional  friend  recommends  one 
eighth  of  a  grain  of  bichloride  of  mercury  every  half  hour,  the  me- 
dicine to  be  given  in  solution.  An  unmistakable  collapse  or  a 
hopeless  spasmodic  dyspnoea  indicates  the  further  inutility  of 
medicine. 

(V)  Iron. — This  great  hsematinic  is  sometimes  needed  for  managing 
the  acute  phases  of  disease,  notably  those  of  erysipelas  and  pyaemia.^ 
The  following  case  is  instructive  as  to  the  manner  in  which  the  iron 
must  occasionally  be  given  : 

(16)  P.,  April,  1869. — A  girl,  set.  21,  daughter  of  a  tradesman. 
Severe  erysipelas  of  face  and  scalp;  no  apparent  external  cause. 
After  a  single  purgative  dose  the  administration  of  the  tincture  of 
perchloride  of  iron  was  begun,  and  at  first  in  a  dose  of  5ss  every 
four  hours.  The  case  went  on  well  for  four  days ;  she  then  had  an 
unaccountable  relapse,  and  the  iron  seemed  to  lose  its  beneficial 
effect.  I  ordered  the  same  medicine  to  be  taken  in  a  dose  of  fifteen 
minims  every  two  hours,  both  day  and  night,  each  dose  in  a  half- 
tumblerful  of  water.  The  result  was  quick  and  good,  and  the  medi- 
cine was  continued  in  gradually  diminishing  doses  for  a  whole 
month.  Recovery  was  complete,  and  the  health  became  entirely  re- 
estabhshed. 

However  hard,  dry,  and  brown  the  tongue  may  be  in  a  patient 
suffering  from  an  acute  erysipelas,  we  should  still  resolutely  give  the 
iron.  It  does  not  act  as  a  mere  vulgar  tonic ;  its  use  and  function 
are  probably  much  more  profound,  acting  to  protect  the  blood  from 
devitalization  and  decay. 

In  ordinary  cases  of  chronic  ansemia  and  chlorosis  I  have  not 
found  any  special  result  from  the  administration  of  iron  in  very 
small  and  frequent  doses,  and,  therefore,  the  usual  method  may 
hold  its  ground  without  fear  of  disturbance. 

(VI)  Gallic  acid  is  among  the  first  of  hsemostatics,  but  requires 
to  be  given  in  much  larger  quantities  than  are  sanctioned  by  sys- 
tematic writers. 

(17)  P.,  June,  1869. — A  young  lady,  set.  28,  pale,  but  not  thin; 
a  morning  hsemoptysis  of  variable  amount,  always  soon  after 
awaking ;  cough  in  the  morning,  not  afterwards   during  the  day. 

^  I  may  just  refer  here  to  the  recent  valuable  investigations  of  Dr.  Eussell 
Reynolds  on  the  treatment  of  acute  rheumatism  by  iron. 


1872.]  On  the  Administration  of  Medicines.  227 

No  evidence  of  tubercle  in  the  chest.  I  tried  various  means,  but 
with  no  success  ;  finally,  T  ordered  four  grains  of  gallic  acid  in  a 
pill  to  be  taken  every  hour.  This  was  continued  for  several  days, 
and  then,  as  usual,  left  off  gradually.  No  other  medicine  was  given. 
She  has  expectorated  very  little  blood  since. 

(18)  P.,  July,  1869. — The  'widow  of  a  tradesman,  set.  58.  Very 
profuse  menorrhagia  for  some '  years ;  the  flux  was  now  and  then 
continuous  for  several  days.  Her  former  medical  attendant  had  not 
been  able  to  control  it.  I  prescribed  five  grains  of  galhc  acid  in  a 
pill  every  two  hours,  with  twenty  drops  of  the  fluid  extract  of  ergot ; 
and  further  requested  that  a  quarter  of  a  pint  of  infusion  of  matico 
should  be  injected  into  the  cavity  of  the  uterus  twice  a  day.  The 
plan  succeeded  beyond  my  expectations;  the  recumbent  position 
was  diligently  maintained  for  three  or  four  weeks,  and  great  circum- 
spection exercised  about  the  diet.  Finally  she  got  up  and  walked 
about  as  usual,  and  no  blood  whatever  has  been  lost  since.  In  this 
case  the  suspicion  was  strong  of  the  existence  of  polypus  uteri,  or 
even  of  a  graver  lesion;  and  if  the  menorrhagia  had  not  so  readily 
yielded  to  medical  means,  an  examination  per  vaginam  would  clearly 
have  been  necessary.^ 

In  sudden  and  copious  haemoptysis  Dr.  Symonds  recommends 
scruple  doses  of  gallic  acid,  administered  at  first  every  hour.^  My 
experience  leads  to  the  impression  that,  as  a  haematic  astringent, 
gallic  acid  is  far  superior  to  digitalis  and  ergot,  and  possesses  advan- 
tages of  an  obvious  kind  over  acetate  of  lead.  Gallic  acid  seldom 
constipates  the  bowels ;  but  if  a  very  earl?/  and  certain  astringent 
effect  is  desired,  acetate  of  lead  is  a  more  reliable  agent. 

(VII)  Strychnia  has  been  reported  lately  to  have  an  excellent 
effect  in  the  treatment  of  epilepsy.  It  is  notorious  that  bromide  of 
potassium  sometimes  utterly  fails  in  removing  epilepsy,  or  even  in 
alleviating  the  epileptic  convulsion ;  and  I  seized  the  first  distinct 
opportunity  of  the  failure  of  bromide  of  potassium  in  order  to  try 
the  remedial  efficacy  of  strychnia. 

(19)  D.,  September  and  October,  1869.  — An  agricultural 
labourer,  aet.  23.  Heavy  in  manner  and  thick  in  limb.  He  had 
been  an  out-patient  of  mine  for  nearly  two  years,  but  cod-liver  oil 
and  KBr,  pushed  to  its  utmost  extent,  had  done  very  little 
towards  the  mitigation  of  the  "  fits.^^  During  last  summer  the 
"  fits"  were  as  severe  and  frequent  as  ever.  On  September  8th  he 
again  came  under  my  care,  and  I  ordered  one  forty-eighth  of  a  grain 
of  strychnia  in  solution  to  be  taken  every  two  hours.  Between 
September  8th  and  15th,  the  next  day  of  his  attendance,  there  was 

'  The  urgency  of  this  case  imperatively  forced  me  to  use  three  trustwortliy 
remedies  together,  and  without  delay.  Qua  the  medicinal  properties  of  gallic 
acid,  the  case  is  not,  of  course,  intended  to  be  quoted. 

=*  '  Brit.  Med.  Journal,'  June  13,  1868. 


228  Original  Ccmmunicatiovs.  [Jan., 

not  a  single  "  fit/'  and  this  was  the  first  time  for  more  than  a  year 
during  which  a  week  had  so  passed.  On  the  latter  date  I  increased 
the  dose  of  strychnia  to  one  forty-fourth  of  a  grain.  Between  Sep- 
tember 15th  and  22nd  there  was  one  small  attack  o^ petit  mal.  Again 
the  strychnia  was  increased  to  one  fortieth  of  a  grain.  During  the 
succeeding  week  he  had  two  attacks  of  the  same  kind.  On  Septem- 
ber 29th  the  dose  of  strychnia  ordered  to  be  taken  every  two  hours 
was  one  thirty-eighth  of  a  grain ;  no  toxic  effects  whatever  were 
produced,  and  during  the  whole  of  the  ensuing  week  he  had  no 
"  fit"  of  any  kind.  Between  October  6th  and  20th  the  dose  ad- 
ministered was  one  thirty-sixth  of  a  grain  ;  he  suff'ered  one  convul- 
sion of  the  type  grand  mal  and  three  of  the  iy^^  petit  mal.  I  saw 
the  patient  again  on  the  morning  of  October  27th,  and  his  report 
was  discouraging.  He  had  had  one  major  fit  and  two  of  the  minor 
order  during  the  previous  six  days.  He  continued  to  see  me  once 
a  week  for  another  month;  but  about  the  end  of  November  he 
had  a  very  severe  paroxysm  one  day  when  waiting  in  the  out-patient 
room,  and  he  did  not  afterwards  come.  No  medicine  was  given 
to  this  man  besides  the  strychnia,  and  no  change  was  made  in  his 
habits.  The  case  goes  to  prove  what  has  been  remarked  by  many, 
that  epilepsy  is  sometimes  ameliorated  for  a  while  by  the  mere 
substitution  of  one  empiric  treatment  for  another.  Still,  the  good 
results  of  the  strychnia  in  this  case  were  seen  in  the  warmer  skin, 
brighter  eye,  and  brisker  walk.  The  vaso-motor  nerves  and  capillary 
blood-veesels  seemed  roused  to  a  more  active  function.  Strychnia 
is  one  of  our  best  remedies  for  headache. 

A  short  time  ago  I  had  a  private  case  of  ^^ uterine  paraplegia" 
under  my  care,  which  surprisingly  improved  under  the  use  of  one 
forty-fourth  of  a  grain  of  strychnia  every  two  hours,  but  the  benefit 
ceased  after  a  certain  point  had  been  reached. 

(VIII)  Bromide  of  potassium  may  be  given  in  small  and  frequent 
doses  to  children  when  we  have  to  do  battle  with  convulsions,  the 
origin  of  which  is  for  the  present  beyond  our  scrutiny,  but  which 
plainly  put  life  in  peril. 

(20)  P.,  August,  1869. — A  female  child,  set.  3,  the  daughter  of 
respectable  persons  in  the  middle  rank  of  life.  There  was  a  look  as 
if  rhachitis  had  begun  during  infancy,  but  had  not  gone  on.  There 
had  been  for  some  weeks,  at  very  irregular  intervals,  a  convulsive 
attack  of  a  severe  kind,  engaging  nearly  the  whole  body,  and  accom- 
panied by  apparent  insensibility.  The  action  of  the  bowels  was 
regular;  the  belly  was  not  swollen.  The  auscultation  and  percus- 
sion phenomena  of  the  lungs  and  heart  were  normal,  but  there  was 
doubtful  evidence  of  cerebral  tubercle.  Eour  grains  of  KBr  were 
administered  in  sweetened  water  every  two  hours,  a  total  of  thirty- 
two  grains  being  consumed  every  day.  The  medicine  was  continued 
on  this  plan  for  ten  days,  and  during  this  time  no  ^^fits"  occurred. 


1872.]  071  the  Almlnlstration  of  Medicines,  229 

The  intervals  between  the  doses  of  medicine  were  lengthened  to  four 
hours  for  another  fortnight ;  again  no  "fits."  Tinally  the  medicine 
was  left  off  entirely 4  but  two  or  three  convulsions  of  a  less  severe 
sort  than  formerly  induced  the  mother  to  begin  the  same  treatment 
again,  and  with  equal  success.  The  medicine  has  since  been  dis- 
continued for  a  second  time,  and  without  a  return  of  the  old  malady. 

Like  most  other  practitioners,  I  have  administered  KBr  largely 
for  the  treatment  of  epilepsy.  When  the  salt  was  introduced  for 
this  purpose,  and  after  its  apparent  efficacy  had  been  established,  I 
prescribed  it  according  to  the  common  use,  in  doses  varying  from 
fifteen  to  thirty  grains  three  or  four  times  a  day.  The  proportion 
of  absolute  relief  obtained  was  large,  and  a  more  or  less  quahfied 
relief  was  still  more  common.  After  a  time,  I  took  three  or  four 
cases  just  as  they  came  before  me,  without  any  selection,  and 
administered  KBr  in  an  average  dose  of  ten  grains  every  two  hours 
(eight  doses  daily) .  I  have  no  right  to  say  that  this  method  had 
any  advantage  over  the  other,  or  that  it  did  any  more  good ;  and 
when  no  conspicuous  advantage  of  any  kind  can  be  claimed,  we 
have  no  ground  for  teasing  a  sick  person  with  what  so  ceaselessly 
reminds  him  of  his  infirmity.  Further,  KBr  is  a  medicine  which 
seldom  causes  ill  results  of  the  physiological  order,  and  therefore 
we  have  less  plea  for  deviating  from  the  usual  plan  of  prescribing  it 
in  the  management  of  chronic  neuroses. 

When  it  is  desired  to  produce  a  pseudo- narcosis  with  this  medi- 
cine, it  is  essential,  I  believe,  to  administer  it  in  single  large  doses. 

(IX)  The  niUritmial  tonics,  including  not  only  those  which  feed 
tissue,  but  those  which  promote  oxidation,  may  be  classified  together. 
Iron  has  been  spoken  of  already,  and  I  wish  to  write  now  about 
iodide  of  potassium,  chlorate  of  potash,  and  cod-liver  oil.  Concern- 
ing the  last- mentioned  drug  (or  food),  the  single  conceivable  reason 
for  ever  administering  it  in  small  and  frequent  quantities  would  be 
that  only  in  this  manner  can  it  elude  the  disgusts  of  palate  and 
stomach.  Ten  or  fifteen  drops  might  be  so  disguised  as  to  escape 
rejection,  but  for  this  small  dose  to  do  medicinal  good  it  must  be 
given  very  often;  and  a  reasonable  critic  might  inquire  whether, 
under  these  circumstances,  cod-liver  oil  is  likely  to  be  useful  at  all. 

Yery  rarely,  again,  can  iodide  of  potassium,  be  needed  in  more  than 
four  doses  during  the  twenty-four  hours,  and  each  of  these  may  be 
represented  by  twenty  to  thirty  grains.  I  have  had  only  one  case  of 
which  I  can  say  that  positive  and  enduring  benefit  was  derived  from 
the  administration  of  ten  grains  of  the  salt  every  two  hours,  after 
twenty  grains  every  four  hours  had  been  taken  with  benefit,  which, 
though  great,  was  not  enduring.  It  was  an  example  of  severe 
syphilitic  headache  in  a  woman  of  middle  age. 

There  are  certain  cases  of  aphthous  stomatitis,  which  may  be  con- 
nected with  chronic  phthisis  pulmonalis,  that  are  curable  in  an 


230  Oriyinal  Comtnunications,  [J 


Hll, 


exceedingly  rapid  way  by  frequent  doses  of  Morale  of  potash.  Of 
several  cases  which  have  been  under  my  care,  I  may  allude  to  one  of 
sudden  development,  very  painful  and  bad,  which  was  entirely  cured 
within  four  days  by  fifteen  grains  of  the  salt,  in  solution,  being  taken 
every  two  hours.^ 

Three  medicines  remain,  each  of  the  highest  importance,  and  I 
have  taken  every  legitimate  opportunity  of  administering  them 
according  to  the  principle  propounded  in  this  essay,  and  of  trying 
to  ascertain  its  real  or  supposed  superiority.  The  notes  of  several 
of  these  cases,  however,  are  imperfect,  and  the  references  to  others 
are  not  exact  enough  for  my  present  purpose  ;  consequently,  I  have 
submitted  these  medicines  to  a  new  examination,  and  the  cases 
which  will  be  quoted  presently  are  all  of  recent  occurrence. 

(X)  Arsenic  may  be  administered  in  small  and  frequent  doses, 
with  the  object  of  overcoming  an  unusual  susceptibility  to  its 
toxical  influence.  A  case  (say  of  psoriasis)  is  presented  to  us  for 
which  the  use  of  arsenic  appears  to  be  imperatively  required  \  we 
prescribe  it  accordingly,  and  are  vexed  to  discover  that  an  ordinary 
dose  {e.g.  ii\.v  of  Liquor  Arseuicalis) ,  taken  three  times  a  day  in  solu- 
tion after  food,  causes  in  a  little  while  a  general  eruption  of  so-called 
lichen,  and  perhaps  swelling  of  the  feet  and  hands ;  or  there  may  be 
troublesome  irritation  of  some  of  the  nmcous  membranes. 

(21)  D.,  March,  LSTU. — A  laundress,  £et.  42,  unmarried,  suffer- 
ing from  psoriasis  guttata  over  a  large  area  of  the  body,  but  chiefly 
on  the  legs  and  arms.  She  seemed  well  in  other  respects.  She 
consulted  me  first  on  March  26th ;  I  prescribed  five  drops  oi  Liquor 
Arsenicalis  in  infusion  of  orange  peel  to  be  taken  three  times  a  day. 
In  a  week  she  came  again,  and  displayed  her  arms  and  shoulders 
covered  with  a  thick  and  quasi  lichen ;  she  complained  also  of  some 
neuralgia  in  the  feet.  1  attributed  these  new  symptoms  to  the 
arsenic,  as  no  other  medicine  had  been  given,  and  there  was  nothing  else 
to  account  for  them.  They  went  away  spontaneously  in  three  days. 
On  April  6  th  I  ordered  her  to  take  one  drop  of  the  Liquor  Arsenicalis 
in  plain  water  every  two  hours  (eight  drops  daily).  This  plan  succeeded 
very  well ;  she  took  the  arsenic  in  this  way  for  seven  weeks  without 
any  return  of  the  same  trouble,  and  the  cutaneous  disease  improved 
pari  jjassu. 

Another  case  has  occurred  to  me  not  unlike  this. 

I  venture  to  affirm,  therefore,  the  possibility  of  administering 
arsenic  in  small  and  frequent  doses  for  a  special  disease  requiring  its 
use  without  the  apprehension  of  developing  poisonous  symptoms. 
I  do  not  say  that  the  disease  will  be  cured  more  quickly  ;  that  is 

^  It  is  well  worth  a  record  that  chlorate  of  potash  is  easily  soluble  in  compara- 
tively small  quantities  of  boiling  water,  and  the  salt  is  not  deposited  (or  only  to  a 
most  limited  extent)  wben  the  water  cools.  I  wish  that  the  value  of  this  medicine 
in  certain  forms  oi' phthisis  pulmonalis  was  more  widely  recognised. 


1872.]  On  the  Administration  of  Medicmes.  231 

quite  a  diiferent  matter.  I  have  no  facts  to  warrant  me  in  saying 
that  a  psoriasis  will  be  cured  in  forty  days  instead  of  fifty  days  by 
the  one  plan  of  treatment  rather  than  by  the  other.  It  is  a  question 
of  safety,  not  of  speed.  It  is  possible  that  the  elements  of  greater 
speed  and  greater  safety  may  concur;  but  when  they  really,  or 
apparently  antagonise,  we  properly  esteem  the  latter  as  of  much 
higher  price  tlian  the  former. 

Hence,  when  a  patient  can  take  five  drops  of  Liquor  Arsenicalis 
three  times  a  day  for  a  psoriasis,  or  an  ague,  or  a  neurosis,  without 
suffering  any  obvious  physiological  disturbance,  I  see  no  reason  for 
taking  the  medicine  in  any  other  way,  such  as  two  drops  every  two 
hours,  which  would  be  very  nearly  an  equivalent  quantity.  The 
only  conceivable  apology  for  doing  so  would  be  the  allegation  that 
the  psoriasis,  or  the  ague,  or  the  neurosis,  is  cured  in  a  shorter  time ; 
but  if  this  cannot  be  proved,  the  argument  falls  to  the  ground. 
The  analogy  between  arsenic  and  antimony  is,  in  this  respect,  com- 
plete. We  desire  to  cure  the  disease,  curable  respectively  by  the 
arsenic  and  the  antimony,  without  adding  to  it  what  may  be  called 
the  toxic  disease  of  the  medicinal  agent ;  and  we  are  able  to  do  so 
by  the  method  of  administering  that  agent  in  "  comparatively  small 
and  frequent  doses."*' 

(XI)  Belladonna  is  a  remedy  of  great  power,  but  of  great 
capriciousness.  I  do  not  profess  to  enumerate  here  all  its  capacities 
for  good  and  harm.  I  propose  to  discuss  its  use  for  a  single  pur- 
pose, that  of  alleviating  or  removing  spasm,  and  to  describe  the 
best  manner  of  administering  it  as  an  antidote  to  some  forms  of 
spasm. 

When  belladonna  does  good  to  simple  and  uncomplicated  asthma. 
Dr.  Hyde  Salter's  plan  is  a  very  efficacious  one.  He  recommends 
a  single  large  dose  to  be  given  at  bedtime,  in  order  to  ward  oif  an 
asthmatic  attack  during  the  hours  of  early  morning.^  In  this 
manner  I  have  given  twenty-five  or  thirty  drops  of  the  tincture  of 
belladonna  to  an  asthmatic  person  at  bedtime,  with  very  decided 
success  j  but  the  great  drawback  is  that  one  never  knows  when  to 
expect  success,  nor  why  it  comes  or  does  not  come.  And  further, 
success  at  one  time  by  no  means  guarantees  success  at  another. 

But  that  more  permanent  condition  of  bronchial  spasm,  impro- 
perly called  "  bronchial  asthma,"  is  susceptible  of  much  alleviation 
by  the  administration  of  belladonna  in  "  comparatively  small  and 
frequent  doses.""  It  is  one  of  the  best  medicines  for  this  purpose 
given  in  almost  any  way ;  its  unpleasantnesses  are  never  dangerous, 
provided  that  they  do  not  exceed  a  certain  degree  ;  it  is  immeasura- 
bly superior  to  opium  as  a  remedy  taken  for  any  length  of  time. 

*(22)  D.,  I'ebruary,   1870. — A  man,  set.   55,  a  hawker  of  steel 

1   '  Laucet,'  Jau.  30tli,  1869. 


232  Original  Communications.  [Jan., 

pens.  He  consulted  me  first  in  the  middle  of  February,  with  a 
category  of  complaints  which  pointed  very  strongly  to  the  possibility 
of  intra-thoracic  aneurism ;  indeed,  I  examined  his  chest  at  the  very 
outset  with  this  hypothesis  uppermost  in  my  mind,  but  I  discovered 
no  substantial  evidence  anywhere  for  the  existence  of  aneurism. 
Bronchial  dyspnoea  was  the  prominent  trouble;  there  was  no  appa- 
rent damage  of  heart  or  of  great  blood-vessels.  At  first  I  prescribed 
ten  drops  of  tincture  of  belladonna  every  four  hours ;  then  I  in- 
creased each  dose  to  twelve  drops,  still  at  the  same  intervals,  four 
doses  being  taken  every  day.  In  the  middle  of  March  I  began  the 
plan  of  giving  two  drops  of  the  tincture  of  belladonna  every  hour, 
from  eight  in  the  morning  until  eleven  at  night.  The  man  com- 
plained of  some  dryness  of  throat,  but  no  difficulty  of  vision,  and 
the  dyspnoea  was  much  relieved.  Simply  for  the  sake  of  saving  him 
trouble,  I  allowed  him  to  take  four  drops  of  the  tincture  of  bella- 
donna every  two  hours,  nine  doses  being  taken  daily  (though  some- 
times, through  forgetful ness,  only  seven  or  eight).  He  continued 
this  plan  for  several  weeks,  entirely  of  his  own  accord,  until  perma- 
nently warm  weather  set  in;  the  gradual  and  uninterrupted  improve- 
ment was  very  noteworthy.  No  other  medicine  was  given,  nor  did 
it  seem  to  be  required ;  and  scarcely  any  physiological  derangement 
was  produced  by  the  belladonna. 

It  is  one  of  the  sound  traditions  of  the  practice  of  physic  that 
belladonna  is  a  drug  which  may  be  trusted  for  allaying  abdominal 
spasm  and  neuralgia.  It  is  only  a  sincere  desire  to  keep  my  essay 
within  moderate  limits  that  restrains  me  from  the  relation  of  cases 
in  which  fractional  doses  of  aloes  and  belladonna,  repeated  every 
hour  for  a  number  of  times,  have  overcome  the  pains  and  perils  of 
acute  constipation. 

(XII)  Ligitalis. — I  cancel  some  remarks  in  which  I  had 
attempted  to  give  a  therapeutic  history  of  digitalis,  as  the  researches 
of  Dr.  Tothergill  and  Dr.  Sydney  Einger  have  put  this  subject  on  a 
new  and  authentic  basis,  which  need  not  here  be  described  again.  I 
pass  to  the  question  which  it  is  the  province  of  this  essay  to  discuss. 
May  digitalis  be  beneficially  given  in  comparatively  small  and 
frequent  doses  ?  and  is  there  any  advantage  in  this  plan  ? 

Out  of  several  cases,  more  or  less  alike,  I  choose  one  which  is 
typical  in  its  pathological  and  therapeutic  outlines. 

(23)  D.,  April,  1870. — A  woman,  set.  43,  wife  of  a  cabinet- 
maker, in  tolerably  comfortable  circumstances.  Had  been  now  and 
then  under  my  care  in  past  years  for  minor  ailments.  Applied  to 
me  on  April  2nd,  on  account  of  palpitation  of  the  heart ;  there  was 
no  murmur,  but  a  quick  weak  action,  with  some  physical  signs  of 
dilatation  of  the  left  ventricle.  Health  pretty  good  in  other  respects. 
At  first  I  gave  her  iron  with  iodine,  then  alkalies  with  digitalis  and 
chloric  ether,  afterwards  quinine  and  belladonna.     These  medicines 


1872.]  On  the  Administration  of  Medicines.  233 

were  taken  mostly  three  times  a  day,  but  the  quinine  and  belladonna 
every  two  hours  for  a  short  time ;  no  distinct  benefit  was  realised 
from  anything.  On  Easter-eve,  April  16th,  I  determined  to  give 
digitalis  alone,  five  drops  of  the  tincture  every  two  hours.  On  the 
20th  I  ordered  six  drops  every  two  hours.  Seven  drops  every  three 
hours,  prescribed  on  the  23rd,  disordered  the  stomach,  and  the  digi- 
talis was  discontinued  for  four  days.  Up  to  this  time  the  relief 
afforded  to  the  cardiac  symptoms  was  of  a  very  positive  kind.  On 
the  30th  I  resumed  the  medicine  in  a  tentative  fashion ;  on  May  4th 
she  began  again  to  take  five  drops  of  the  tincture  of  digitalis  every 
two  hours,  and  she  continued  it  with  the  intermission  of  only  a 
few  days  until  the  middle  of  June.  She  speaks  in  the  most  un- 
qualified way  of  the  good  which  she  has  derived  from  the  persistent 
use  of  digitalis,  and  the  objective  signs  and  symptoms  correspond 
thereto. 

Will  any  philosophic  therapeutist  explain  what  is  meant  by  the 
"  cumulative^'  action  of  medicines — and  whether  it  is  possible  for 
medicines  derived  from  the  animal  and  vegetable  kingdoms  to 
'^  accumulate'^  in  the  human  body  ?  Has  such  "  accumulation'' 
ever  been  proved  ?  Digitalis  has  earned  a  bad  name  for  its  supposed 
capacity  to  do  mischief — a  mischief  liable  to  break  out  without  note 
or  signal,  and  to  end,  perhaps,  in  organic  damage.  Now,  behold 
the  woman  whose  case  I  have  just  related.  She  knows  nothing  of 
what  is  administered  to  her;  she  neither  loves  nor  hates  this  drug 
or  that,  and  so  she  takes  digitalis  in  small  and  frequent  doses  for 
several  weeks,  not  only  without  being  poisoned,  but  with  large  and 
grateful  benefit. 

I  am  now  studying  the  action  of  aconite,  veratrimi  viride,  and 
chloral,  prescribed  and  given  according  to  the  method  advocated  in 
this  essay. 

A  careful  review  of  the  subject  leads  us  to  accept  tartrate  of 
antimony  and  opium  (including  its  derivative,  morphia)  as  typical 
medicines  in  their  certainty  and  safety.  As  a  rule,  the  metallic 
salts  are  more  constant  in  their  remedial  effect,  this  constancy  being 
sometimes  almost  mechanical  in  its  accuracy  and  definiteuess.  Being 
more  alien  to  the  human  body  than  the  vast  majority  of  vegetable 
and  animal  proximate  principles,  an  inorganic  substance  taken  into 
that  body  resembles  a  stone  thrown  into  a  given  bulk  of  water, 
where  the  ripples  can  be  calculated  with  mathematical  nicety,  and 
where  we  can  even  announce  when  the  undulating  particles  will 
subside  into  rest.  The  additional  experience  which  nearly  every  day 
brings  enables  me  to  state  that,  within  a  definite  range  of  quantity 
— one  twentieth  to  one  sixteenth  of  a  grain — tartrate  of  antimony 
may  be  adminstered  in  solution  every  hour  to  an  adult  person  with 
the  infallible  result  (barring  extremely  rare  contingencies)  of  hin- 
dering the  development  of  an  early  local  phlegmon.    And  this  being 


234  Original  Communications.  [J 


an., 


so,  surely  it  is  a  mistake  to  call  tartrate  of  antimony  by  the  synonym 
of  '*  tartar  emetic."  It  is  a  wrong  thing  to  affix  a  name  to  a  drug 
which  indicates  a  single  coarse  property,  and  to  bind  that  name  to  it 
so  unalterably  that  its  better  properties  are  hidden,  and  often  scarcely 
thought  of.  Do  we  call  opium  the  "vegetable  stupifier,"  or  calomel 
the  "mercurial  purgative^''?  "In  poison  there  is  physic^' — physic 
which  is  dutiful  and  pliant  to  nearly  all  our  nepds,  if  we  handle  it 
with  delicacy  and  discrimination.^ 

I  have  attempted  to  open  a  new  field  of  research  in  the  history  of 
therapeutics ;  I  am  fully  conscious  how  imperfectly  the  attempt  has 
been  made.  All  discoveries  in  the  art  of  healing  are  dimmed  by  the 
thought  that  in  the  old  days  there  were  some  pains  and  weaknesses 
which  were  not  alleviated  and  cured,  and  which  are  now  controlled 
with  certainty  and  ease.  Even  death  itself  has  sometimes "  come 
without  sufficient  combat  on  our  side  to  beat  it  off;  and  cases  crowd 
on  our  memory  about  the  treatment  of  which,  if  we  had  known  then 
what  we  know  now,  health,  and  even  life  itself,  might  (God  willing) 
have  been  given  back.  But  the  same  cycle  of  regrets  will  have  to 
be  rehearsed  in  future  years.  Nevertheless,  the  science  and  art  of 
medicine  are  so  wide  in  their  scope  as  to  afford  room  for  a  number 
of  inquirers  of  different  bias.  Here  may  be  one  man  who  finds 
delight  in  inventing  new  splints  and  in  discovering  new  ways  of 
reducing  a  dislocation ;  there  may  be  another  man  whose  faculties 
are  directed  to  the  improvement  of  the  obstetric  forceps,  or  to  the 
abbreviation  of  the  pains  of  childbirth  ;  and  now  may  the  energies  of 
many  be  guided  to  the  investigation  of  the  heahug  virtues  of  all 
substances  which  can,  outwardly  or  inwardly,  do  good  to  mankind. 
That  investigation  must  be  rigid  and  austere,  uninfluenced  by  super- 
stitious tradition  or  partiality.  The  boundless  field  for  observation 
and  deduction  ought  to  attract  numerous  workers ;  and  in  prose- 
cuting the  work  there  are  so  many  prompting  motives  of  higli  phi- 
lanthropy that  the  student  may  become,  without  fanaticism,  a  zealot 
and  a  devotee. 

Further,  it  must  be  evident  that  speculative  therapeutics  will 
always  be  in  advance  of  the  actual  materia  medica. 

In  the  busy  quest  after  new  powers  to  conquer  new  diseases,  or  to 
cut  short  old  diseases  more  quickly,  we  are  tempted  to  assign  a  value 
to  those  powers  which  will  not  in  every  instance  bear  a  scientific 
scrutiny.  Too  eagerly  we  deduce  therapeutic  hints  from  the  physio- 
logical disturbance  which  a  drug  produces ;  too  hopefully  we  assume 
that  a  substance  has  healing  virtues,  to  which  some  variety  of  that 
thing  called  Disease  may  or  must  submit.  Every  fresh  medicine  is 
on  its  trial  by  a  thousand  hands.     News  of  its  supposed  achieve- 

^  The  latest  and  most  woudrous  news  about  tartrate  of  antimony  comes  from 
India,  where  it  has  been  given  in  heroic  doses  fur  the  treatment  of  cholera.  See 
pamphlet  by  Mr.  George  Barnard,  Stuff  Surgeon,  Indian  Army,  Calcutta,  1869. 


1872.]  On  the  Administration  of  Medicines.  235 

ments  has  gone  before,  and  in  our  constant  battle  with  pain  imagina- 
tion reinforces  our  strength  before  the  reinforcement  comes.  We 
crave  incessantly  for  more  help,  and  are  deceived  by  therapeutic 
mirages.  We  believe  that  every  human  agony  is  destined  to  be 
mitigated  or  overcome ;  our  firm  silent  creed  is  in  the  mission-work 
of  doing  the  greatest  good  without  in  the  least  denying  the  Christian 
discipline  of  suffering. 

The  therapeutic  method  which  has  been  elucidated  in  this  essay 
is  not  polypharmacy,  so  called,  nor  anything  akin  to  it.  At  the  first 
glance  it  may  seem  polypharmaceutical  to  be  repeating  doses  of  a 
medicine  at  such  frequent  intervals,  but  the  whole  principle  and 
practice  of  the  method  are  built  upon  unity  and  simplicity — the 
repetition  of  a  single  medicine,  administered  in  the  simplest  form. 
And,  as  a  final  remark,  I  urge  that  in  this  manner  we  can  best  study 
the  operations  of  medicines  ;  for  ^however  clearly  a  substance  w4iich 
we  term  a  medicine  works  in  health,  it  may  work  doubtfully  in  dis- 
ease. Clearly  and  doubtfully,  I  mean,  to  our  unaided  understand- 
ing, arising  from  the  very  nature  of  the  problem  which  we  have  to 
solve ;  for  perfect  health  is  a  plentiful  abounding  thing,  which  we 
have  only  to  go  into  the  streets  to  see,  and  health  only  a  few  shades 
short  of  perfect  is  to  be  met  with  on  every  side.  But  the  conditions 
of  7iot-hQdXi\\  are  as  multiform  as  the  persons  who  exhibit  it,  and 
beneath  all  are  the  numberless  phases  of  individual  idiosyncrasy  by 
which  disease  is  modified  or  prolonged;  and  thus  we  hesitate  some- 
times from  not  knowing  whether  our  weapons  are  weak  or  im})roper,^ 
or  whetlier  they  are  blunted  or  nullified  by  the  resistance  which  they 
meet  with.  Now  and  then  we  do  daring  things,  for  death  faces  us, 
and  will  smite  us  with  mortal  defeat  if  we  falter  or  look  back.  Every 
fresh  case  of  illness  is  a  new  labyrinth  to  unravel,  unlike  in  its  com- 
bination and  permutation  of  tracks  all  other  labyrinths  that  we  have 
gone  through  before.  How  grateful  we  should  be  when  Nature 
grants  us  an  Ariadne  to  help  us  out ! 

The  thesis  of  my  essay  includes  "  things  new  and  old  -,"  the  old 
things  I  have  endeavoured  to  establish  on  a  surer  basis,  and  the  new 
things  are  the  fruit  of  personal  experience,  which  remains  now  to  be 
tested  by  the  higher  and  broader  experience  of  others.  I  have  not 
claimed  for  the  practice  of  administering  medicine  in  small  and 
frequent  doses  a  wider  application  than  appears  legitimately  to  belong 
to  it.  I  plead  simply  lor  a  sj/slematic  recognition  of  it  at  appro- 
priate times  and  under  appropriate  circumstances;  I  desire  that  it 

'  That  cry  of  scepticism  about  drugs  which  we  heard  some  years  ago  was  the 
wail  of  iguorance,  not  of  knowledge.  It  was  the  wail  of  that  acute  impatience 
which  will  not  sit  down  to  plain  hard  work  and  test,  step  by  step,  the  fitness  of 
the  tools  it  uses.  Wiiether  a  patient  lived  or  died  it  miglit  bo  the  doctor's  doings, 
but,  i)erhaps,  it  was  all  chance : 

'  "  Casus  niedicusve  levarit 
iEgram  ex  precipiti." — '  Hor.  Sat.,'  lib.  ii,  3,  v.  292. 


236  Original  Communications.  [J 


an, 


may  be  used  with  confidence  as  one  of  the  authentic  methods  of 
medical  art.  If  I  am  not  greatly  mistaken  in  my  interpretation  of 
facts,  the  phenomena  of  inflammation  in  certain  tissues  admit,  in  the 
early  stage,  of  complete  control  by  this  method ;  the  phenomena  are 
arrested,  and  their  pathological  evolution  stopped.  Purther,  it  has 
been  attempted  to  show  that  there  are  particular  phases  of  chronic 
disorder  or  disease  susceptible  of  alleviation  by  the  same  plan.  Let 
the  axiom  ever  be  borne  in  mind  that  usually  the  most  potent  reme- 
tlies  are  the  most  useful.  A  distinguished  medical  writer^  asks 
us  not  to  be  afraid  of  power ;  and  I  know  nothing  which  more  satis- 
factorily proves  mastery  of  craft  than  the  wielding  of  strong  weapons 
of  medicine  as  if  we  were  not  terrified  by  them,  as  if  we  had 
dominion  over  them.  It  has  been  one  of  the  purposes  of  this  essay 
to  show  how  therapeutic  and  even  toxic  power  may  be  guided  to 
beneficial  ends. 

The  scope  of  subject  embraced  by  this  essay  is  not  very  wide ; 
but  the  principle  selected  for  discussion  and  illustration  appears 
capable  of  becoming  a  scientific  law,  which  may  promote  the  highest 
interests  of  the  art  of  therapeutics,  and  so,  indirectly,  enhance  the 
'^  order  and  beauty  which  we  see  in  the  world."^ 

^  Dr.  Barnes,  '  Lectures  on  Obstetric  Operations/  p.  22. 
'  Sir  Isaac  Newton's  '  Opticks/  Query  28. 


1872.]  237 


€f)von(tlt  of  i^leliiral  ^titntt. 


KEPORT   ON  OBSTETRICS  AND   GYNAECOLOGY. 
By  W.  S.  Playfair,  M.D.,  F.E.C.P. 


I. — The  Non-Pregnant  State. 

1.  One-sided   HcEmatometra  in  two   cases  of  Double    Uterus.     By 
Dr.  LuDwiG  Neugebauer. 

2.  On  the    SulpJio-carholafes    as    Oyncecological    Agents.     By  Dr. 
Mack. 

3.  On  the  Mechanical  Treatment  of  Displacements  of  the  Zfnimpreg- 
nated  Uterus.     By  Dr.  Pepper. 

4.  The    Treatment    of  Fibroid  Tumours  of  the   Uterus.     By  Dr. 
Meadows. 

Uterine  Fibroid  Tumours  and  Polypi,  their  Pathology  and  JRe- 
moval.     By  Dr.  Skinner. 

5.  Sudden    Death  in   Patients    suffering  from    Cancer.      By  Dr. 

Barnes. 

6.  Restoration  of  the  Perinceum.     By  Dr.  Matthews  Duncan. 

7.  The  Value  of  Arsenic  in  Menorrhagia  and  Leucorrhea.     By  Dr. 

Aveltng. 

8.  On  Herpetic  Eruptions  of  the  Uterm.     By  Dr.  Noel  Gtjeneatj 
DE  MussY. 

9.  Dilatation   of  the  Cervix  Uteri  by  Graduated  Bougies.     By  Dr. 

Arthur  Edis. 

10.  Termination  of  the  Nerves  in  the  Vagina.     By  M.  Chrschtscho- 

NOYITSCH. 

11.  Diffuse  Ovarian  Fibroid  of  peculiar  construction.      By  Professor 

Waldeyer. 

1.  Dr.  Ludwig  Neugebauer  narrates  two  instances.  In  the  first 
menstruation  began  at  seventeen,  and  was  very  painful.  It  reappeared 
five  times,  a  tumour,  the  size  of  a  fist,  being  felt  above  the  pubis, 
which  increased  monthly.  Amenorrhoea  then  occurred  for  nearly 
two  years,  with  complete  absence  of  pain.  On  the  reappearance  of 
the  catamenia  pain  returned,  the  tumour  on  the  right  extending 
nearly  to  the  umbilicus.  It  was  opened  per  vaginam  by  means  of  a 
pointed  bistoury,  and  the  patient  went  on  well  for  fourteen  days, 
when,  on  the  return  of  the  period,  acute  peritonitis  set  in,  and  the 
patient  succumbed  in  three  days.     No  autopsy  allowed. 

In  the  second  the  tumour  was  not  so  large,  and  was  opened  by 
pushing  the  uterine  sound  through  the  lower  portion  of  the  swelling. 
The  patient  succumbed  on  the  forty-eighth  day.     No  autopsy. 

The  author  gives  references  to  nineteen  similar  cases  ;  the  ages 


238  Chronicle  of  Medical  Science.  [Jan., 

varied  from  fourteen  to  twenty-seven  ;  the  right  side  was  more  fre- 
quently involved.  In  four  no  operation  was  resorted  to.  In  fifteen 
operations,  small  and  large  incisions,  puncture  with  gradual  dilatation, 
&c.,  were  tried;  of  these  eight  recovered  and  seven  died.  The 
prognosis  is  bad  if  nothing  be  done,  but  even  by  operation  50  per  cent, 
die.  He  advocates  large  free  incision,  or,  better  still,  galvano-caustic, 
to  prevent  infection. — Archiv  fur  Gyn'dkol.,  ii,  2,  p.  246,  1871. 

2.  Dr.  Mack  has  employed  the  sulpho-carbolate  of  zinc  with  great 
advantage.  He  uses  it  as  an  injection,  half  a  drachm  of  the  salt  to 
a  pint  of  tepid  water.  As  an  intra-uterine  application,  he  had 
applied  it  both  by  injection  and  with  a  mop  ;  and  it  was  also  bene- 
ficial in  chronic  vaginitis  attended  with  fetid  discharge,  being  used 
in  solution  with  glycerine,  in  doses  often  grains  at  a  time,  applied 
with  a  tampon.  —  Journal  of  Oynceological  Society  of  Boston, 
August,  1871. 

3.  Dr.  Pepper  publishes  a  lengthy  paper  on  displacement  of  the 
uterus,  in  which  he  details  the  anatomy  of  the  uterine  organs,  in  so 
far  as  it  bears  on  the  subject,  and  describes  the  various  forms  of 
uterine  supports,  and  the  indications  for  their  use. 

His  general  conclusions  are  summed  up  as  follows : 
"  (1)  Cases  undoubtedly  occur  in  which  all,  or  nearly  all,  the  symp- 
toms are  due  to  uterine  malpositions,  although  these  may  be  asso- 
ciated with  other  disease ;  and  when  these  displacements  are  corrected, 
a  cure  may  be  said  to  have  been  effected,  so  far  as  the  painful  sen- 
sations are  concerned,  leaving  the  residuary  disease  to  be  treated  and 
removed  at  leisure. 

(2)  In  other  instances  uncomplicated  malpositions  are  capable 
of  giving  rise  to  the  most  severe  local  and  general  disturbances,  and 
their  correction  will  completely  restore  the  patient  at  once  to 
health  and  comfort. 

(3)  Cases  occur  of  displacement  coexisting  with  inflammatory  or 
other  diseases,  in  which,  if,  from  the  irremediable  nature  of  the  mal- 
positions, or  from  other  considerations,  the  entire  attention  be 
directed  to  the  removal  or  mitigation  of  the  coexisting  trouble,  all 
symptoms  will  disappear,  although  the  displacement  remains  as 
maiked  as  at  first. 

(4)  Cases  occur  in  which  inflammatory  disease  as  a  result,  is  asso- 
ciated with  uterine  displacement,  and  although  skilful  treatment 
be  directed  against  the  former  condition,  no  relief  can  be  obtained 
until  the  malposition  is  rectified,  when  the  inflammation  will  subside 
spontaneously. 

(5)  And,  lastly,  I  am  satisfied,  from  repeated  observation,  that 
cases  occur  in  which  inflammation  and  displacement  coexist,  and*that 
the  removal  of  the  inflammatory  hypertrophy  will,  by  lessening  the 
weight  of  the  uterus,  cause  the  malposition  to  be  gradually  corrected. 

Hence  it  would  appear  that  some  mechanical  contrivances  for  cor- 
recting uterine  malpositions  play  an  absolutely  essential,  though  by 
no  means  a  universally  applicable  part,  in  our  successful  treatment  of 
uterine  diseases. — American  Journal  of  Obstetrics,  August,  1871." 

4.  The  chief  object  of  these  papers  is  to  advocate  a  more  frequent 


1872,]  Report  on  Obstetrics  and  GynaBcology,  239 

resort  to  surgical  treatment.  Dr.  Meadows  recommends  a  more 
general  use  of  those  methods  of  dealing  with  fibroids  which  have 
been  so  ably  advocated  and  carried  into  practice  by  Dr.  Matthews 
Duncan.  Dr.  Skinner,  while  admitting  their  usefulness,  advises 
caution  as  to  their  adoption,  and  states  that  the  only  case  in  which 
he  attempted  enucleation  on  Duncan's  plan  terminated  fatally. — Brit. 
Med.  Journ.,  Aug.  26th,  1871,  and  Liverpool  Med.  and  Surg.  Reports. 

[Both  authors  put  themselves  to  some  pains  to  prove  that  we 
possess  no  therapeutical  agent  which  will  effect  the  removal  of  these 
growths.  We  are  not  aware  that  any  one  has  so  stated.  What  has 
been  said  is  that  nature,  in  some  rare  cases,  effects  spontaneously 
what  art  is  powerless  to  accomplish.  It  is,  no  doubt,  difficult  for 
any  one  to  believe  in  a  confessedly  exceptional  occurrence  which 
he  himself  does  not  happen  to  have  seen,  but  that  does  not  prove 
that  others  who  have  reported  such  cases  are  mistaken.  The 
reporter  has  published  some  in  a  paper  "  On  the  Spontaneous 
Absorption  of  Fibroid  Tumours  of  the  Uterus,"  and  since  that  several 
others,  minutely  observed,  have  been  narrated  by  Matthews  Duncan, 
Sedgwick,  Spencer  Wells,  Scanzoni,  and  others,  so  that  the  fact 
seems  beyond  question.  Unless  Dr.  Skinner  considers  nothing  evi- 
dence that  he  has  not  himself  seen,  he  can  scarcely  be  justified  in 
saying,  "  I  have  never  come  across  a  particle  of  evidence  to  lead  me 
to  the  conclusion  that  so  much  as  one  grain  of  a  fibroid  tumour  ever 
was  absorbed  by  a  natural  process." — W.  S.  P.] 

5.  In  a  note  on  this  subject.  Dr.  Barnes  refers  to  Dr.  Todd's 
opinion  that  in  some  of  these  cases  the  death  may  be  due  to  embo- 
lism, from  small  portions  of  the  cancerous  growths  invading  the 
blood-vessels,  and  subsequently  being  swept  into  the  circulation. 
He  has,  however,  searched  without  success  for  these  cancer  emboli 
in  cases  in  which  the  final  symptoms  seemed  to  point  to  pulmonary 
embolism.  In  a  patient  who  died  suddenly  in  St.  Thomas's  Hos- 
pital death  seems  to  have  resulted  from  an  altogether  different 
mechanism.  Extensive  secondary  deposits  were  found  in  the  abdo- 
men. These  so  surrounded  the  aorta,  "that  it  was  no  longer  an 
elastic  tube,  expanding  under  the  heart's  systole  and  then  contract- 
ing, but  a  rigid  tunnel,  utterly  wanting  in  resiliency,  and  with  its 
interior  no  longer  smooth,  but  distorted  by  irregular  projections. 
Such  an  aorta,  accompanied  by  a  vena  cava  similarly  affected,  is 
mechanically  unfitted  to  do  its  work.  Under  very  moderately  in- 
creased emotion  or  exertion,  causing  unusual  action  in  the  heart, 
this  rigid  tube  would  throw  back  upon  the  heart  a  portion  of  the 
column  of  blood  which  the  aorta  ought  to  receive  and  propel.  This 
retrograde  dynamic  disturbance  would  overwhelm  the  feeble  heart, 
and  thus  death  would  follow. — Brit.  Med.  Jour.,  July  16th. 

6.  Dr.  Duncan  details  the  indications  for  operation,  either  after 
laceration  of  the  perinseum  or  in  cases  of  procidentia.  His  method 
of  operating  consists  in  transfixing  the  fourchette,  the  patient 
being  in  the  lithotomy  position,  and  then  cutting  upwards  on  each 
side,  removing  a  long  tape-like  piece  of  integument  rather  less  than 
half  an  inch  in  breadth.     The  raw  surfaces  are  brought  closely  into 


240  Chronicle  of  Medical  Science.  [Jan., 

apposition  by  a  number  of  silver  wires  after  all  oozing  has  ceased. 
Dr.  Duncan  speaks  favorably  of  the  success  of  his  operation. — Edin. 
Med.  Journ.,  November,  1871. 

7.  The  author  had  administered  the  remedy  for  twelve  years  in 
eases  of  monorrhagia  with  great  success.  Besides  the  improvement 
it  effected  in  the  general  health,  he  believed  it  to  possess  a  powerful 
influence  in  lessening  congestion  in  mucous  membranes.  He  confi- 
dently recommends  it  in  all  disorders  of  the  uterus  having  a 
hypersemic  origin.  He  administers  small  doses,  either  in  solution 
or  granules,  increasing  them  from  time  to  time,  and  continuing  them 
for  weeks  or  months  as  the  necessities  of  the  case  requires. — Brit. 
Med.  Journ.,  August  26th,  1871. 

8.  Dr.  De  Mussy  writes  a  lengthy  essay  on  the  constitutional 
origin  of  those  diseases  of  the  uterus  which  have  been  variously 
described  as  uterine  catarrh,  granulations,  erosions,  or  ulcerations  of 
the  cervix  uteri.  These  he  believes  to  be  chiefly  due  to  a  diathetic 
condition  similar  to  that  which  causes  various  skin  eruptions,  and 
closely  allied  to  the  arthritic  diathesis.  The  peculiar  form  of  the 
eruptions  he  believes  to  be  modified  according  to  their  site,  whether 
on  skin  or  mucous  membranes.  He  points  to  the  frequency  with 
which  erythematous  and  eczematous  eruptions  are  met  with  about 
the  vulva  in  cases  of  chronic  and  severe  uterine  catarrh  as  confirming 
his  views,  and  relates  cases  in  which  bronchitis  and  muscular  rheu- 
matism, due  to  the  same  diathetic  state,  alternated  with  the  uterine 
affection.  The  symptoms  described  by  Dr.  De  Mussy  are  precisely 
those  familiar  in  some  cases  of  erosion  and  granular  disease  of  the 
cervix.  The  author  then  proceeds  to  describe  the  various  eruptions 
which  he  believes  he  has  recognised  on  the  cervix  uteri,  such  as  the 
vesicular,  papular,  &c.  In  long-standing  cases  these  become  modi- 
fied, and  merge  into  the  condition  generally  described  as  granular 
erosion  of  the  cervix.  Granulations  of  the  cervix  he  believes  to  arise 
from  tumefaction  both  of  papillsB  and  follicles  of  the  cervix.  He 
next  proceeds  to  describe  the  treatment  he  adopts,  both  constitu- 
tional and  local.  He  is  opposed  to  intra-uterine  medication. — 
Archives  Generales  de  Medecine,  October  and  November,  1871. 

9.  Dr.  Edis  advocates  the  gradual  dilation  of  the  cervix  some  time 
before  the  commencement  of  menstruation,  by  sounds  varying  in  size 
from  that  of  a  No.  8  to  a  No.  12  catheter.  He  considers  this  treat- 
ment preferable  to  the  use  of  any  form  of  intra-uterine  stem  in  cases 
of  anteflexion  causing  painful  menstruation. — Brit.  Med.  Journ., 
November  4th,  1871. 

10.  M.  Chrschtschouovitsch  has  recently  read  a  paper  on  this 
subject  before  the  Academy  of  Sciences  at  Vienna.  The  animals  ex- 
amined were  man,  the  rat,  dog,  and  rabbit,  the  latter  being  the  best 
for  purposes  of  demonstration.  The  results  arrived  at  were  as 
follows : — The  mucous  membrane  of  the  vagina  of  all  animals  con- 
tained numerous  branched  cells,  resembling  connective-tissue-cor- 
puscles, arranged  just  beneath  the  laminated  pavement  epithelium 
with  almost  the  same  regularity  as  in  the  cornea,  whilst  others  are 
scattered  irregularly  through  the  membrane.    The  nerves  penetrating 


1872.] 


Report  on  Obstetrics  and  Gyncecology ,  211 


through  the  muscular  layer  contain  large  bunches  of  medullated 
fibres,  which  here  and  there  contain  ganglion-cells.  From  these 
smaller  trunks  are  given  off,  which  enter  the  proper  mucosa,  or  rete 
Malpighii ;  as  these  press  towards  the  surface  the  medullated  sheath 
is  gradually  lost,  and  the  fibres  either  bend  back  or  join  with  a  fibril 
from  a  neighbouring  trunk,  forming  a  very  superficial  plexus,  or 
apply  themselves  to  the  wall  of  one  of  the  small  vessels  ascending  to 
supply  the  papillae  of  the  membrane.  Some  few  of  them,  destitute  of 
mamillary  sheaths,  may  be  seen  ascending  between  the  epithelial 
cells,  but  do  not  join  with  the  branched  connective  corpuscles  men- 
tioned above.  The  smooth  muscular-fibre  fasciculi  of  the  membrane 
are  surrounded  by  a  very  rich  plexus  of  non-medullated  nerve-fibres, 
from  which  individual  fibres  are  given  oflf,  that  exhibit  here  and  there 
granule-like  enlargements,  and  penetrate  between  the  several  muscle 
cells.  He  thinks  it  probable  that  these  last  are  encircled  by  the 
ultimate  fibrils,  but  has  not  been  able  to  find  any  closer  relation  to 
the  surfaces  of  the  muscle,  as  stated  to  occur  by  Klebs  and  others. — 
Lancet^  November  25th,  1871. 

11.  Professor  Waldeyer,  of  Breslau,  narrates  a  case  of  the  above. 
It  was  about  six  by  four  and  a  half  inches  large,  and  weighed  a  little 
over  two  pounds.  It  was  so  hard  that  it  was  difficult  to  make  a  section, 
almost  brittle,  and  resembled  spongy  bone  or  osteoid  tumour  of  the 
upper  jaw.  It  wanted  only  the  peculiar  grouping  of  the  cells  on  the 
epithelial-like  borders  of  the  trabeculae,  as  in  osteoblastema,  and  the 
solid  homogeneous  condition  of  the  trabecular  tissue  itself,  in  order 
to  constitute  a  complete  resemblance  of  the  tumour  in  microscopic 
appearance  with  the  osteoid  tumour. — Arch.f.  Gyn.,  ii,  3,  1871. 

II. — Pregnat^cy. 

1.  Exfoliation  of  tlie  Bladder.     By  T.  Spencer  Wells,  F.R.C.S. 
Exfoliation  of  the  Bladder.     By  Dr.  Whitehead. 

2.  Obliquely  Distorted  Pelvis.     By  Dr.  SpiEaELBERG. 

3.  Conception  under  unusual  Circumstances.     By  Dr.  Olshausen. 

4.  Well-marked    Ancemia    in    Pregnant    Women.      By    Professor 

GUSSEROW. 

5.  Quadruplets.     By  Dr.  Leopold. 

6.  Case  of  Twin  Compound  Conception  and  Removal  of  Extra-uterine 
Foetus  after  Four  Tears.     By  Mr.  Bleach. 

7.  The  Vomiting  of  Pregnancy.     Bj  Dr.  Hubert. 

8.  A  Case  of  Double  Uterus  with  Concurrent  Pregnancies.     By  Dr. 

J.  Harris  Eoss. 

9.  On  Calcification  of  the  Placenta.     By  Dr.  Prankel. 

10.  The  Amnion  in  relation  to  Foetal  Malpositions.     By  Dr.  Furst. 

11.  Cysts  of  the  Placenta.     By  M.  Jacquet. 

1.  Mr.  Wells  reports  two  cases  of  this  interesting  accident ;  both 
occurred  after  severe  cystitis  following  delivery. 

Mr.  Whitehead  describes  one  from  the  notes  of  Mr.  Clement 
Godson.     In  this  case  the  pregnant  uterus  was  retroverted,  thus 

97— XLix.  16 


24-2  Chronicle  of  Medical  Science.  [Jan., 

impedinpj  the  emptying  of  the  bladder,  and  confirraing  tVie  s\iggcstion 
of  Dr.  Phillips,  as  to  retroversion  being  one  of  the  probable  causes. 

"The  cysts,"  Mr.  Whitehead  observes,  "cannot  be  looked  upon 
as  simply  exfoliations  of  the  raucous  membrane  of  the  bladder, 
as  they  do  not  consist  entirely  of  mucous  membrane.  Muscular 
fibre,  and  even  serous  tissue,  are  often,  if  not  generally,  attached 
to  and  incorporated  with  the  mucous  lining;  and,  further,  we 
have  the  distinct  fibrinous  casts." — Brit.  Med.  Journ.,  July  1st  and 
October  14th. 

2.  Professor  Spiegelberg  gives  the  details  of  two  cases  in  a  most 
elaborate  paper.  In  the  first  it  was  right-sided,  with  synostosis 
of  the  sacro-iliac  synchondrosis  and  shortening  of  the  right  '[eg, 
from  a  fall  at  three  years  old.  In  the  second  inflammation  of  the 
right  sacro-iliac  synchondrosis  and  secondary  atrophy  of  the  pelvis, 
without  synostosis,  resulted.  In  these  two  cases  the  author  ascribes, 
as  the  principal  cause — 

1st.  The  increased  pressure  upon  one  half  of  the  pelvis. 
2nd.  Atrophy  of  the  bones  forming  the  ilio-sacral  joint. 
Either  of  these  may  be  the  original  cause,  the  other  following  as  a 
consequence. — Arch.f.  Gyn.,  ii,  2,  1871. 

3.  Dr.  Olshausen,  of  Halle,  narrates  two  curious  instances  of  con- 
ception occurring  during  the  presence  of  an  intra-uterine  stem. 

In  one  case  menorrhagia  with  anteflexion  existed  in  a  multipara. 
The  stem  was  inserted  on  June  28th,  and  removed  January  15th. 
She  was  delivered  on  the  25th  September,  253  days  from  the  time  of 
its  removal,  of  an  extremely  vigorous  boy,  the  largest  she  had  ever 
borne.  Nausea,  vomiting,  &c.,  had  existed  during  the  latter  half  of 
December  and  in  January. 

In  the  second  case  marked  anteflexion  occurred  after  the  second 
labour,  and  an  intra-uterine  stem  was  worn  for  nine  months.  The 
catamenia  ceased  on  September  8th,  and  the  stem  was  removed 
October  18th.  She  was  confined,  on  the  24th  June,  of  a  vigorous 
girl,  over  eight  pounds  in  weight,  249  days  only  from  the  removal  of 
the  stem. 

In  the  first  instance  the  ovum  was  probably  twenty-seven  days  in 
utero,  and  in  the  second  twenty  days,  before  the  stem  was  with- 
drawn.— Arcliivf.  Gyncdkol.,  p.  278,  1871. 

4.  Professor  Grusserow,  of  Zurich,  gives  the  details  of  five  cases 
of  the  above.  They  all  occurred  in  young  persons  between  twenty- 
four  and  thirty-six  years  old,  who  had  always  enjoyed  good  health 
previously  ;  four  had  already  borne  children.  The  normal  condition 
of  the  blood  during  pregnancy  seems,  in  these  cases,  to  have  been 
greatly  intensified ;  premature  delivery  at  the  height  of  the  disease, 
about  the  eighth  month,  occurring,  and  death  rapidly  ensuing  in 
each  case.  In  three  cases  transfusion  was  employed  without  success, 
as  also  internal  remedies,  with  good  diet,  wine,  &c. 

The  author  advises,  in  similar  cases,  the  induction  of  abortion,  or 
premature  labour  and  transfusion  if  necessary. 

The  organs  generally  were  in  a  very  anaemic  condition,  but  no  well- 
ascertained  cause  for  this  could  be  detected,  the  fatty  degeneration 


1872.]  Report  on  Obstetrics  and  Gyncecology.  243 

being  apparently  the  effect  and  not  the  cause,  the  hydraemic  condi- 
dition  being  also  secondary  ;  in  fact,  an  increased  pathological  degree 
of  the  physiological  condition  of  pregnancy. — ArcMv  f.  GynaeJcoL, 
ii,  2,  1871. 

5.  Dr.  Leopold,  of  Glauchan,  narrates  an  instance  of  the  above  oc- 
curring in  a  multipara  at  the  seventh  month.  The  first  child  presented 
by  the  breech  ;  the  second  was  a  cross  birth,  and  necessitated  turning, 
as  also  the  third ;  the  fourth  was  a  head  presentation.  They  were 
all  born  within  an  hour.  Flooding  occurred,  but  was  arrested  on 
expulsion  of  a  very  large  placenta,  with  two  cords  proceeding  from 
its  margin.  Two  separate  smaller  placentae  were  subsequently  ex- 
pelled, each  with  its  separate  bag  of  membranes ;  only  one  ba": 
existed  in  the  laro;e  one.  The  children  were  all  female,  living,  well 
formed ;  one  died  on  the  twelfth  day,  the  others  on  the  twentieth 
and  twenty-first  day.  The  mother  made  a  good  recovery.  Dr. 
Leopold  asserts  that  out  of  20,000  births  three  cases  of  quadruplets 
have  occurred,  whereas  of  152,395  births  observed  in  Dublin  only 
one  case  is  recorded. — Arch.f.  Gynaelcol.,  ii,  2,  285,  1871. 

6.  Mr.  Beach  relates  an  interesting  and  unusual  case.  The  patient 
aborted  about  the  sixth  week  of  pregnancy,  but,  her  abdomen  con- 
tinuing to  enlarge,  it  was  presumed  that  she  had  been  pregnant  of 
twins,  the  other  still  remaining  in  utero.  Symptoms  of  labour  came 
on  at  term,  but  soon  passed  off.  Menstruation  was  re-established, 
and  the  abdominal  tumour  remained  unaltered.  Four  years  after- 
wards, extra-uterine  pregnancy  having !  been  diagnosed,  an  attempt 
was  made  to  remove  the  foetus  by  abdominal  section,  but  was  aban- 
doned. A  fistula  formed  at  the  site  of  the  wound,  through  which 
the  fostus  could  be  felt.  This  was  enlarged,  and  "  a  partially  decom- 
posed foetus,  weighing  about  seven  pounds,"  was  removed.  The 
patient  made  a  perfect  recovery.  —  Journal  of  the  Gyncecological 
Society  of  Boston,  August,  1871. 

7.  Dr.  Hubert  believes  that  in  certain  cases  the  vomiting  of  preg- 
nancy may  be  traced  to  undue  mobility  or  displacement  of  the 
uterus,  and  proposes  to  treat  it  by  producing  immobility  of  the 
organ  by  suitable  bandages  and  the  use  of  Hodge's  or  Zwancke's 
pessary. — Lyon.  Medicate,  October  15th. 

[Dr.  Hubert  seems  to  be  ignorant  of  the  fact  that  Dr.  Grraily 
Hewitt  has  already  advanced  a  similar  theory. — W.  S.  P.] 

8.  Dr.  Ross  contributes  a  case  of  extreme  interest,  in  which  preg- 
nancy occurred  in  both  sides  of  a  double  uterus.  The  patient  was 
thirty-eight  years  of  age,  and  had  had  six  children,  nothing  peculiar 
having  been  noted  with  regard  to  her  confinements.  On  July  16th, 
1870,  she  miscarried  of  twins,  apparently  between  the  fifth  and  sixth 
month.  During  the  labour  a  second  opening  was  felt  close  to  the 
OS  uteri,  but  its  precise  nature  was  not  then  made  out.  About  a 
week  after  the  labour  she  declared  that  she  was  then  pregnant,  and 
the  presence  of  another  child  was  made  out.  She  was  delivered  of  a 
healthy  female  child  on  October  31st,  fifteen  weeks  and  two  days 
after  miscarrying  with  twins.  After  recovery  a  complete  examina- 
tion was  made.     Two  openings  were  found  in  front  of  the  cervix 


244  Chronicle  of  Medical  Science.  [Jan., 

"Upon  introducing  the  sound  into  the  upper  or  right  aperture,  it 
passed  quite  freely  into  a  cavity  two  inches  and  a  half  deep  to  the 
summit,  where  it  was  cautiously  moved  in  every  direction  with  the 
view  of  discovering  any  communication  that  might  exist  between  this 
and  the  supposed  adjoining  cavity,  and  on  withdrawing  the  instru- 
ment the  same  caution  was  exercised,  and  for  the  same  purpose,  but 
no  such  outlet  or  passage  could  be  detected.  The  sound  was  then 
passed  into  the  lower  or  left  aperture,  and  traversed  quite  easily  a 
cavity  two  inches  and  a  quarter  deep  only,  nearly  parallel  to  the  pre- 
ceding cavity.  Thus,  between  the  two  cavities  there  was  a  vertical 
partition  or  septum  extending  from  the  fundus  to  the  front  of  the 
cervix  uteri,  and  completely  dividing  the  latter  into  two  separate  or 
distinct  cavities."  A  curious  corroborative  proof  of  the  concurrent 
impregnation  in  two  distinct  uterine  cavities  was,  that  the  patient 
had  menstruated  (evidently  from  the  uterus  which  had  thrown  off  its 
contents)  three  times  beeween  her  miscarriage  in  July  and  her 
delivery  in  October. — Lancet,  August  5th,  1871. 

9.  Dr.  Frankel,  in  an  able  paper,  gives  us  the  result  of  his  own 
and  others'  observations.  1.  Calcification  of  the  placenta  follows — 
a,  the  course  of  the  capillaries  and  small  villi,  and  this  is  by  far  its 
most  frequent  course ;  h,  it  is  more  diffuse  and  intermediate  ;  then, 
according  to  Langhaus,  it  takes  its  origin  from  the  epithelial 
layer  of  the  trunk  of  the  villi.  2.  The  more  frequent  capillary  in- 
crustation proceeds  from  the  wall  of  the  vessel,  spreads  on  all  sides, 
and  forms,  as  it  were,  a  mantle  round  the  tube  of  the  vessels,  without 
making  them,  however,  completely  impervious ;  it  begins  generally,  not 
always,  in  the  end  of  the  villi,  and  may  also  appear  in  separate  points 
in  the  trunk.  3.  Diffuse,  not  too  extended,  calcification  is  without 
influence  upon  the  nourishment  of  the  foetus,  whilst  even  in  less  ex- 
tended capillary  petrefaction,  especially  in  the  earlier  months  of 
the  pregnancy,  the  foetal  blood  and  gas  changes  are  prevented,  and 
this  may  lead  primarily  to  the  death  of  the  foetus.  4.  The  calcifica- 
tion of  the  mature  placenta  is  only  an  expression  of  the  com- 
pleted intra-uterine  growth  of  the  foetus.  5.  We  must  regard 
from  a  similar  point  of  view  secondary  calcification  where  the 
foetus  is  withered  and  macerated  from  other  causes. — Arch,  fur 
Gyn.,  ii,  3,  373. 

10.  Dr.  Livius  Fiirst,  of  Leipsic,  narrates  two  cases.  In  place  of 
thread,  string,  or  membranous  formations  of  the  amnion,  he  desires 
to  call  them  all  by  one  common  name — filamentous  adnexa.  He 
describes  the  three  theories  which  are  set  up  for  the  explanation  of 
the  development  of  these  adnexa.  1.  Plastic  adhesions,  which  have  no 
relation  with  inflammation,  but  which  are  produced  by  the  formative 
power  of  the  embryonic  cells.  2.  Foetal  inflammation  with  plastic 
exudation.  It  is  well  known  that  we  find  this  in  the  tissues  as  well 
as  in  the  cavities  and  on  the  surface  of  the  skin  of  the  foetus ;  and 
everywhere,  where  the  plexus  of  vessels  forms  the  basis,  we  find  hy- 
persemia,  exudation,  suppuration,  and  new  formations,  from  normal 
as  well  as  pathological  tissues.  3.  The  third  theory  is  that  which 
assumes,  as  a  cause  of  the  filamentous  adnexa,  obstructed  formation 


1872.] 


Report  on  Obstetrics  and  Gynecology.  2il 


of  the  amnion ;  this  is  specially  advocated  by  C.  and  G.  Brauu, 
whilst  they  point  out  abnormal  folding  and  progressive  pathological 
metamorphosis  as  the  cause  of  the  malformation.  According  to  them 
threads  arise  which  hinder  the  development  of  the  extremities,  either 
partly  or  entirely.  The  most  frequent  cause  of  the  process  is  the 
small  quantity  of  liquor  amnii,  or  too  late  secretion  of  it,  which 
retards  the  separation  of  the  amnion  from  the  foetus,  and  leads  to 
adhesions.  The  author  agrees  with  this  latter  theory. — Arch.  f. 
Oyn.,  ii,  3,  315. 

11.  M.  Jacquet  describes  the  various  forms  of  cysts  that  may  be 
observed  in  connection  with  the  placenta,  especially  some  that  he 
describes  as  found  between  the  placental  villosities,  varying  in  size 
from  that  of  a  pea  to  that  of  a  filbert.  They  seem  to  be  connected 
with  the  vascular  ramifications  of  the  organ,  and  Jacquet  conceives 
them  to  be  formed  from  the  perivascular  sheaths  ;  hence  he  pro- 
poses to  call  them  perivascular  cysts.  He  recognises  four  varieties 
of  cysts  in  connection  with  the  placenta: — 1.  Gelatinous  cysts  de- 
veloped from  the  tissue  existing  between  the  chorion  and  amnion, 
which  have  been  particularly  described  by  M.  Millet.  2.  The  above- 
mentioned  formed  from  the  perivascular  sheaths.  3.  Blood-cysts, 
specially  described  by  M.  Bustaniente,  and  which  probably  are 
developed  in  connection  with  the  placental  sinuses.  4.  The  well- 
known  cysts  of  hydatiginiform  degeneration  of  the  placenta. —  Gaz. 
MSdicale  de  Paris,  October  14th,  1871. 

III. — Labour. 

1.  Conjoint-Extra  and  Intra-Uterine  Foetation  ;  Ccesarean  Section ; 
both  Children  saved.     By  Dr.  E.  P.  Sale. 

2.  On  Catheterization  of  the  Uterus.     By  Professor  Valenta. 

3.  Impaction  as  a  Cause  of  Vesico-vaginal  Fistula.     By  Dr.   S.  C. 

BUSET. 

4.  Observations  on  Craniotomy.     By  Dr.  Carl  Rokitansky. 

5.  The    Management  of  the  Ferinceum   during  Labour.      By  Dr. 
Haet. 

6.  On  Inertia  of  the   Uterus  from  the  presence  of  Fibroid  Tumour. 
By  M.  Depaul. 

7.  On  the  Value  of  the  Artificial  Induction  of  Fremature  Labour  in 
Contracted  Felvis.     By  Dr.  Litzman. 

8.  On  the  proper  Management  of  Tedious  Labour.     By  Dr.  Hamil- 
ton", of  Falkirk. 

1.  This  interesting  case  occurred  in  an  unmarried  negress,  in 
whom  the  existence  of  intra-uterine  pregnancy  was  diagnosed.  The 
symptoms  being  urgent,  gastrotomy  was  determined  on.  A  living 
child,  with  placenta,  was  removed,  when  the  uterus  was  found  to  be 
enlarged  and  to  contain  a  second  child,  a  complication  not  pre- 
viously suspected.  After  consultation  hysterotomy  was  performed, 
and  a  second  living  child  and  placenta  removed.  The  mother  died 
on  the  fourth  day  from  septicaemia.  No  post-mortem  was  allowed. 
Both  children  survived. — New  Orleans  Journ.  of  Medicine. 


246  Chronicle  of  Medical  Science.  [Jan., 

2.  Professor  Valenta,  of  Laibach,  recommends,  after  ten  years' 
experience,  the  introduction  of  the  catheter  as  a  harmless  method  of 
increasing  and  exciting  uterine  pains. 

He  gives  details  of  sixty-eight  cases.  He  advises  the  use  of  an 
English  elastic  catheter,  passed  to  the  left  and  posteriorly.  He  says 
six  and  a  quarter  hours  are  enough  to  regulate  the  pains  until  the  os 
uteri  is  dilated  from  two  to  three  inches ;  if  to  accelerate  labour,  it 
should  be  left  in  until  the  os  is  fully  dilated.  It  is  the  best  method 
of  inducing  abortion  and  premature  labour.  It  can  be  adopted 
vs^hilst  other  measures  are  also  employed,  as  in  placenta  prsBvia,  with 
the  tampon  as  well.  In  primiparaD  it  is  better  before  the  pains  have 
commenced,  in  multiparse  after.  In  deviations  of  the  uterus  the 
stillette  can  also  be  used. —  Wien.  Med.  Fresse^  23 — 39. 

3.  Dr.  Busey  analyses  the  particulars  of  sixty- five  cases  of  vesico- 
vaginal fistulas  reported  by  Dr.  Emmett,  from  which  he  draws  the 
now  pretty  generally  admitted  conclusion,  "  that  though  instruments 
were  employed  in  very  many  of  the  cases,  it  is  perfectly  apparent  that 
the  error  was  in  not  having  resorted  to  artificial  means  sooner.  A 
curious  corroborative  proof  of  this  opinion,  and  of  the  fact  that  vesico- 
vaginal fistula  has  a  direct  relation  to  impaction  and  protracted 
labour,  is  that  out  of  sixty-five  cases  no  4ess  than  fifty  of  the  chil- 
dren were  stillborn. — Amer.  Journ.  of  Obstetrics,  August,  1871. 

4.  Dr.  Karl  Eokitansky,  chief  assistant  in  the  Lying-in  Hospital 
at  Vienna,  states  that  in  ten  years  52,394  births  occurred,  and  of 
these  103  were  craniotomy  cases,  or  1  in  508*7,  eighty-six  being  head 
presentations.  He  discusses  the  merits  of  Braun's  modification  of 
Simpson's  instrument,  which  is  stronger  and  longer  than  Simpson's 
original.  1st,  its  total  length  being  seventeen  inches  eight  lines ; 
2nd,  there  is  a  compression  apparatus  at  the  end ;  3rd,  the  ends, 
when  the  instrument  is  closed,  remain  nine  lines  apart :  4th,  at  the 
upper  end  are  hooks  on  either  side,  to  facilitate  traction. 

In  each  case  perforation  was  first  eff'ected  with  Braun's  trepan. 

Of  the  103,  forty-one  died — a  result  less  successful  than  in 
England. 

He  concludes  that  the  cranioclast  can  be  used  in  much  more 
contracted  pelves  than  the  cephalo tribe,  and  also  more  readily 
where  the  head  follows  the  body.  Excerebration  is  best  performed 
by  Braun's  trepan. — Wien.  Med.  Press,  xii,  8 — 19. 

5.  Dr.  Hart's  paper  is  written  with  the  view  of  confirming  Dr. 
Goodell's  views  on  supporting  the  perinseum,  reported  in  the  Jnly 
number  of  the  'Med.-Chir.  Review ;'  but  the  author  does  not  agree 
with  him  in  his  recommendation  of  hooking  up  the  sphincter  aui 
with  his  fingers  and  pulling  it  towards  the  pubes,  so  as  to  relax 
the  perinsDum.  After  discussing  this  point  he  suggests  the  following 
rules : 

(1)  So  long  as  the  sphincter  ani  is  not  freely  dilated  a  resort  to 
the  bowel  for  the  purpose  of  adjusting  the  relations  of  the  foetal 
head  to  the  maternal  soft  parts  is  not  indicated. 

(2)  If  the  anal  sphincter  is  freely  dilated,  and  if  at  each  recur- 
rence of  the  pain  the  posterior  margin  of  the  perina3um  protrudes 


1872.]  Report  on  Obstetrics  and  Gynaecology.  24i7 

beyond  the  vulva,  pass  one  or  two  fingers  of  either  hand  (as  the 
position  of  the  patient  may  indicate)  into  the  rectum,  and  with  their 
pahnar  surface  press  the  foDtal  head  forward  towards  the  vulva,  and 
at  the  same  time  press  the  fourchette  gently  backwards,  either  with 
the  thumb  or  the  fingers  of  the  other  hand,  so  as  to  bring  the  vulva 
as  nearly  as  possible  within  the  axis  of  the  distending  force. 

(3)  When  it  is  evident  that  the  head  is  advancing  too  rapidly  for- 
the  safety  of  the  parts,  plant  the  thumb  and  fingers  against  it,  so  as 
to  check  farther  progress  until  the  pain  has  subsided,  and  then  pro- 
ceed to  rectify  the  position,  or  to  enucleate  the  head  if  it  be 
practicable  or  expedient  to  do  bo.  — St.  Louis  Med.  and  Surg.  Journ.j 
No.  3,  1871. 

6.  The  author  narrates  a  case  of  labour  in  which  there  was  com- 
plete inertia,  due,  it  was  believed,  to  the  presence  of  an  interstitial 
fibroid  interfering  with  the  action  of  the  muscular  tissue  of  the 
uterus,  and  he  believes  this  to  be  a  prominent  danger  when  such 
growths  exist,  even  when  they  do  not  encroach  upon  the  true  pelvis. 
— Gaz.  Med.  de  Paris,  August  12th. 

7.  Dr.  Litzman  concludes  that  the  induction  of  premature  labour 
is  not  to  be  recommended,  as  the  child  is  either  born  dead  or  survives 
only  a  few  days,  whilst  the  danger  to  the  mother  is  increased,  for 
though  the  child  is  smaller  the  placenta  is  more  firmly  attached,  and 
the  risk  of  puerperal  complications  is  increased,  especially  when  we 
consider  the  bruising  that  ensues  from  artificial  interference. 

He  gives  the  details  of  373  cases,  all  grades  included. 

By  natural  premature  labour  the  maternal  mortality  is  only  6*5 
per  cent.,  whilst  in  artificially  induced  it  is  14'7  per  cent.  More 
living  children  are  born  by  the  latter  method,  but  they  die  in  a  few 
days. 

He  gives  four  groups  of  distorted  pelves : 

1st. — a.  Uniformly  contracted  pelvis,  with  conjugate  diameter  of 
9  to  10  centimetres,  h.  Uniformly  contracted,  with  conjugate 
diameter  specially  narrowed  (9*5  to  8*25  centimetres). 

2ud.  Uniformly  contracted  pelvis,  with  conjugate  diameter  of  9 
centimetres. 

3rd.  Simply  contracted  and  generally  narrowed  pelvis,  with  a  con- 
jugate diameter  of  7"3  to  55. 

4th.  Ditto  5*4,  where  Caesarean  section  is  necessary. — Archivf. 
GynaeJcol,  ii,  2,  1871. 

8.  Dr.  Hamilton  contributes  a  very  valuable  paper,  which  is,  in 
the  main,  an  extension  of  a  former  paper  of  his  on  the  same  subject 
published  in  this  Journal  in  1853.  Dr.  Hamilton  is,  as  is  well 
known,  one  of  the  most  prominent  advocates  of  a  frequent  and  early 
use  of  the  forceps  in  the  second  stage.  His  results  are  most  remark- 
able, and  claim  careful  consideration.  Up  to  December,  1860,  he 
had  in  his  own  practice  731  consecutive  births  without  a  stillborn 
child.  Since  that  he  has  lost  only  one  other  child,  and  that  a  foot- 
ling case.  "  In  other  ivords,  that  every  head  presentation  in  loth 
series  has  yielded  a  living  child. '^ 

"  This,"  says  Dr.  Hamilton,  "  is  such  an  extraordinary  departure 


248  Chronicle  of  Medical  Science.  [Jan., 

from  anything  that  I  know  of  in  the  history  of  obstetrics,  and  pre- 
sents such  a  serious  view  of  the  possible  sacrifice  of  human  life  that 
may  have  hitherto  been  going  on  in  this  department  of  our  profession, 
that  I  am  sure  my  professional  brethren  will  be  not  unwilling  to 
hear  from  me  how  I  think  1  am  able  to  explain  the  very  opposite 
results  that  have  been  obtained  by  me  compared  with  those  of  many 
other  professional  gentlemen,  for  whom  I  entertain  the  highest 
respect." 

With  the  view  of  still  further  showing  the  success  of  his  practice, 
Dr.  Hamilton  then  refers  to  the  annual  reports  of  two  well-known 
lying-in  charities,  in  one  of  which  the  infantile  mortality  ranges  from 
one  in  five  to  one  in  twenty -nine,  in  the  other  from  one  in  eleven  to 
one  in  twenty-seven. 

Dr.  Hamilton  rarely  or  never  interferes  with  the  first  stage  of 
labour.  He  attaches  great  importance  to  having  the  os  uteri  fully 
dilated  before  applying  the  forceps,  and  with  rare  exception  he  never 
applies  them  within  the  uterus.  He  approves  of  gentle  but  firm 
manual  dilation  of  the  os  in  the  second  stage,  if  the  head  has  not 
passed  through  it,  and  has  never  seen  any  ill  effects  follow  this 
practice,  and  has  never  met  with  a  case  of  laceration  of  the  neck  of 
the  uterus.  "  It  is  with  the  commencement  of  the  second  stage  of 
labour  that  our  active  interference  should  generally  begin,  if  we  be 
called  upon  to  interfere  at  all.  If  the  membranes  have  not  been  rup- 
tured and  the  head  is  presenting  fairly,  I  then  do  so  at  once,  and 
gently,  but  firmly,  continue  to  press  up  the  uterus  with  one  or  two 
fingers,  or  with  the  whole  hand  if  necessary,  until  I  have  got  it 
pushed  over  the  head ;  and,  as  previously  observed,  I  like  to  use 
the  forceps  as  seldom  as  possible  before  this  has  been  effected.*' 

Tir.  Hamilton  holds  that  it  is  not  safe  to  the  child  to  allow  the 
labour  to  continue  more  than  two  hours  after  the  head  is  in  the 
pelvic  cavity. 

With  regard  to  the  method  of  application,  he  never,  if  possible, 
applies  the  forceps  except  over  the  ear.  He  never  uses  a  forceps 
with  a  double  curve,  and  he  never  greases  the  instrument  before 
introduction.  He  prefers  not  to  use  chloroform,  as  he  likes  to  have 
the  full  power  of  the  uterus,  and  to  use  traction  to  assist  the  natural 
labour-pains.     {To  he  continued.)— Med.'Chir,  Bev.,  October,  1871. 

[The  more  frequent  use  of  the  forceps  in  the  second  stage  is 
now  becoming  much  more  prevalent.  Dr.  Hamilton's  views  as  to 
the  manual  dilation  of  the  os  will,  doubtless,  not  be  accepted  without 
considerable  hesitation.  The  necessity  of  feeling  the  ear  is  also 
very  open  to  question,  and,  as  Dr.  Barnes  has  well  shown,  and  as 
Grerman  practitioners  have  always  taught,  it  seems  to  be  neither 
necessary  nor  advisable.  Dr.  Hamilton's  results,  however,  are  quite 
unique,  and  speak  in  the  strongest  terms  in  favour  of  his  views.— - 
W.  S.  P.] 


1872.]    Rej)ort  on  Physiological  §•  Pathological  Chemistry.     249 

REPORT  ON  PHYSIOLOGICAL  AND   PATHOLOGICAL 
CHEMISTRY. 

By  Professor  A.  H.  Church,  M.A. 

Mineral  Constituents  of  Food. — The  ash  or  mineral  matter  of  food 
has  scarcely  received  that  attentive  chemical  study  which  its 
important  physiological  bearings  demand.  Messrs.  Lawes  and 
Gilbert,  and  other  experimenters  as  well,  have  shown  how  neces- 
sary it  is  in  feeding  experiments  on  animals  to  supply  phosphoric 
acid  and  certain  bases  when  starch,  gelatine,  sugar,  and  other  proxi- 
mate principles  freed  from  ash,  are  given  to  animals.  Karl  Yoit  has 
just  made  some  important  experiments  in  this  direction,  especially 
with  regard  to  the  relations  of  acids  and  bases.  He  proves  that 
compensations  and  transferences  of  many  kinds  occur  in  the  orga- 
nism when  the  composition  of  the  ash  of  the  food  does  not  corre- 
spond exactly  with  the  mineral  requirements  of  the  blood  or  organs. 
When  an  animal  is  fed  on  bran  (which  leaves  an  acid  ash)  the  excess 
of  phosphoric  acid  appears  in  the  urine,  while  the  blood  is  not  less 
alkaline  than  usual.  The  reaction  of  tl)e  ash  of  the  urine  is,  in  fact, 
either  acid  or  alkaline,  in  accordance  with  the  acidity  or  alkalinity 
of  the  ash  of  the  food.  Voit  caused  some  experiments  to  be  made 
also  on  the  source  of  the  alkalies  in  the  blood  of  the  chick,  and  from 
these  experiments  it  appeared  that  the  white  of  the  egg  furnished 
these  alkalies,  and  in  such  quantity  that,  though  the  ash  of  the  yolk 
of  the  egg  is  acid,  the  ash  of  the  white  and  yolk  together  is  alkaline. 
— N.  Report.  PJiarm.,  xx,  S.  422. 

Extract  of  Meat. — Some  of  the  recent  experiments  on  the  nutritive 
value  of  the  Extractum  carnis  do  not  give  a  high  estimate  of  its 
physiological  importance.  Herr  G.  Bunge,  who  has  been  lately 
investigating  this  subject,  under  the  direction  of  Dr.  Schmiedeberg, 
of  Dorpat,  assigns  a  lower  value  (as  a  nutrient  material)  to  the 
extract  than  to  coffee,  tea,  or  alcohol. — Archiv  fur  die  gesammte 
Physiologie,  Bd.  iv. 

Easy  Formation  of  ^lood- crystals. — To  an  aqueous  solution  of 
blood  add  just  enough  nitrate  of  silver  to  remove  the  chlorine ;  agi- 
tate and  filter.  Then  introduce  an  equal  volume  of  pure  ether  and 
a  little  pure  acetic  acid.  The  materials  having  been  shaken  together, 
the  ether  takes  up  a  peculiar  colouring  matter  (doubtless  an  altera- 
tion product),  which  exhibits  four  absorption  bands,  and  when  evapo- 
rated slowly  yields  abundance  of  needle-shaped  crystals,  which,  how- 
ever, seem  somewhat  different  from  those  previously  studied. — Dr. 
Preyer,  Chem.  Centralhlatty  No.  7,  1871. 

On  HcBmatin. — Hsematin  differs  but  little  in  appearance  from 
hsemin,  from  which  it  is  best  obtained.  To  hsematin  is  given  the 
formula  CggH7()NgFe20iy,  while  hsemin,  which  is  the  hydrochlorate  of 
hsematin,  may  be  represented  by  the  expression  CggH73NgEe20i,^Cl2. 


250  Chronicle  of  Medical  Science.  [Jan., 

]3y  the  action  of  sulphuric  acid  on  hsematin  in  the  presence  of 
water  and  oxygen,  the  iron  combines  with  the  sulphuric  acid,  and 
a  substance  soluble  both  in  sulphuric  acid  and  caustic  potash  is 
obtained.  To  this  substance  is  assigned  the  formula  Cfj^H^^NyO^g ; 
it  is  called  hsematoporphyrin.  When  hsematin  is  acted  on  by  sul- 
phuric acid  in  sealed  tubes,  a  substance  insoluble  in  caustic  potash, 
and  only  slightly  soluble  in  sulphuric  acid,  is  produced.  It  has  been 
called  haematolin,  and  has  the  formula  CggH7gNg07.  "When  a  solution 
of  haemoglobulin  is  reduced  by  hydrogen,  and  decomposed  by 
alcohol  containing  sulphuric  acid  or  caustic  potash  in  absence  of 
oxygen,  a  colouring  matter  is  produced  characterised  by  definite 
absorption  bands.  It  is  called  by  Hoppe-Seyler  haemochromogen. 
On  oxidation  it  forms  hsematin.  Bilirubin  seems  closely  related  to 
haemochromogen,  and  is  probably  formed  from  it  by  the  action  of 
water  and  an  acid  in  absence  of  oxygen. — F.  Hoppe-Seyler,  Med. 
Ghem.  Untersuch.,  1871,  p.  523. 

Blood  and  Urine  in  Chyluria. — The  urine  was  milky  white  in  appear- 
ance, and  contained  over  0*7  per  cent,  of  fat.  The  whole  blood  con- 
tained 017  per  cent,  of  fat,  and  the  serum  0-359  per  cent. — Hoppe- 
Seyler,  Med.  Ghem.  Unters.,  1871,  p.  551. 

Action  of  Carhonic  Oxide  on  Blood-glolules. — Blood  absorbs  car- 
bonic oxide  in  preference  to  oxygen,  and  as  the  affinity  is  greater  the 
oxide  cannot  be  expelled  by  the  oxygen.  The  hsemoglobulin  of  the 
blood  has  a  great  affinity  for  carbonic  oxide,  and  forms  with  it  a  true 
chemical  compound,  which  is  very  stable.  In  cases  of  poisoning 
with  carbonic  oxide,  with  proper  precautions  the  gas  can  be  extracted 
from  the  blood,  and  its  presence  accurately  determined.  As  carbonic 
oxide  preserves  blood,  Bernard  proposes  to  use  it  as  a  means  of  pre- 
serving meat.  The  experiments,  however,  already  tried  in  this 
direction  are  not  very  promising. — Claude  Bernard,  J.  Pharm.  (4), 
xiii,  255. 

Earthy  Matter  in  a  Human  Lung. — In  the  lung  of  a  workman  who 
was  exposed  to  the  dust  of  a  mixture  used  in  the  preparation  of 
ultramarine  3*193  grms.  of  silicate  of  alumina,  0*33  grm.  of 
quartz  sand,  and  0*329  grm.  of  iron  oxide  were  found,  in  227  grms. 
of  lung.  Estimating  the  weight  of  the  lungs  at  1 500  grms.,  they 
would  contain  2986  grms.  of  earthy  matter. 

In  the  lung  of  a  woman  who  had  inhaled  the  dust  of  iron  oxide 
used  in  preparing  books  for  gold  leaf  Grorup-Besanez  found  0*828 
grms.  of  iron  oxide  in  57  grms.  of  lung,  or  equal  to  about  from  21 
to  22  grms.  for  the  whole  lung. — E,  von  Gorup  Besanez,  Ann.  Chem. 
Bharm.,  clvii,  287. 

Variations  in  the  Size  of  the  Red  Blood-corpuscle. — Nearly  all  the 
conditions  which  increase  the  temperature  of  the  body  diminish  the 
size  of  the  blood-corpuscles.  Poisoning  an  animal  by  the  injection 
of  putrid  matter  into  its  vessels,  compelling  it  to  breathe  an  atmo- 
sphere highly  charged  with  carbonic  acid  gas,  or  submitting  it  to  an 
increased  temperature,  are  amongst  the  causes  which  produce  the 
above-named  effect.     The  administration  of   oxygen,   prussic  acid, 


1872.]    Report  on  Physiological  ^  Pathological  Chemistry.    251 

hydrochlorate  of  quinine,  or  alcohol,  produced,  like  the  application  of 
cold,  an  increase  in  the  size  of  the  blood-corpuscles. — Dr.  Manassein,  • 
Chem.  Oentrahlatt,  No.  44,  1871. 

Blood  and  Urine  in  LeuJchcemia. — In  the  urine  urea  and  uric  acid 
were  abundant,  and  nearly  in  their  normal  proportions,  the  amount 
of  uric  acid  bein^  slightly  increased.  The  urine  was  acid — no  albu- 
men present.  No  hypoxanthine  could  be  detected.  In  a  portion  of 
leukhaemic  blood,  after  the  albumen  was  separated,  gelatine  and 
acetic  acid  were  found.  Another  sample  of  blood,  about  thirty 
grins.,  yielded  0"123  grm.  of  gelatin  and  0055  grra.  of  hypoxan- 
thine, as  well  as  formic  and  lactic  acids,  with  a  doubtful  trace  of 
acetic  acid.  It  also  contained  a  new  substance,  alhukalin — a  crys- 
talline body,  for  which  Thaile  obtained  the  formula  C4Hj^NOjjiIl20. 
— Dr.  lieichardt,  Archiv  Pliarm.  (2),  cxlv,  142. 

Decomposition  of  Animal  Substances  containing  Phosphorus. — 
riesh  of  fishes  beaten  into  a  pulp  was  allowed  to  putrefy.  The  gases 
given  off  were  collected  and  examined  for  phosphorus  and  sulphur. 
Sulphuric  acid  was  found  in  abundance,  but  no  phosphoric  acid. — 
P.  Ploesz,  Med.  Chem.  Natur.,  1871,  521. 

Blood-corpuscles  of  Birds  and  Snakes. — The  nuclei  were  separated 
and  examined.  In  birds  and  snakes  the  nuclei  consist  of  the  same 
substance,  but  this  substance  was  not  found  in  ox-blood.  The  sub- 
stance seems  to  resemble  mucin,  but  dift'ers  from  it  in  containing 
2*4  per  cent,  of  phosphorus,  and  not  being  soluble  in  dilute  mineral 
acids. —  P.  Ploesz,  loc.  cit.,  461. 

Subcutaneous  Absorption  of  Starch. — Starch-granules  derived  from 
rice  flour  have  been  found  to  be  absorbed,  not  only  when  injected 
into  the  abdominal  cavity,  but  also  when  introduced  into  the  sub- 
cutaneous connective  tissue.  The  observation  is  due  to  Herr 
Auspitz,  who  thinks  that  the  starch-granules  gain  access  to  the  cir- 
culation, passing  into  the  lymphatic  system  through  the  openings 
between  it  and  the  serous  cavities. —  Wiener  Med.  Jahrbuchern. 

Artificial  Digestion  of  Gasein. — Casein  was  digested  in  pepsine 
solutions  for  periods  varying  from  five  hours  to  eleven  days,  at  a  tem- 
perature of  from  40°  to  45°.  The  greater  part  was  dissolved,  but  a 
portion  always  remained  behind.  The  digested  solution  contained 
pepsine,  peptone,  leucine,  and  tyrosine.  The  author  also  thinks  that 
he  has  obtained  a  definite  compound  of  barium  and  peptone. — N. 
Lubarin,  Med.  Chem.  TJntersuch.,  1871,  463. 

MetamorpJiosis  of  Albuminous  Substances  in  Ruminating  Animals. — 
From  this  paper  it  appears  that  the  whole  of  the  albuminoids  under- 
going decomposition  appear  as  oxidation  products  in  the  excretions. 
The  metamorphosis  of  albumen  is  dependent  on  the  quantity  in  cir- 
culation. "When  albumen  in  the  food  is  deficient  the  body  loses 
albumen.  Drinking  large  quantities  of  water  increases  the  meta- 
morphosis of  nitrogenous  matters.  When  the  quantity  of  nitrogen 
in  the  food  is  increased  the  excretion  of  nitrogen  soon  adapts  itself 
to  this  increase.     The  animals  were  found  to  increase  in  weight 


252  Chronicle  of  Medical  Science.  [J 


an. 


when,  along  with  a  sufficient  quantity  of  albumen,  a  quantity  of  non- 
nitrogenous  substances  were  given. — Stohmann,  Eruehiiug,  and  Rost, 
Chem.  Gent,  1871,  377. 

Properties  of  Egg- albumen. — It  is  well  known  that  the  albumen 
of  eggs,  when  treated  with  acids,  acquires  new  properties,  chemical 
and  polarimetric  ;  alkalies  also  produce  certain  changes.  When  one 
gram  of  caustic  potash  is  added  to  75  c.c.  of  a  one  tenth  solution  of 
egg-white,  and  saturated  immediately  with  acetic  acid,  total  precipi- 
tation of  the  albumen  occurs  without  the  application  of  heat.  This 
does  not  occur  when  the  albumen  is  from  urine.  Animal  charcoal 
removes  albumen  from  its  solution  in  liquids.  Gautier  ('  Jour. 
Pharm,'  (4),  xiii,  p.  16)  remarks  that  egg-albumen  consists  of  two 
albumens,  one  coagulated  at  63°,  the  other  at  74° ;  that  it  is  an  alka- 
line albuminate,  its  coagulation  being  preceded  by  displacement  of 
the  base,  Wurtz's  albumen  being  the  acid  of  this  base. — A.  Petit, 
Jour.  Pharm  (4)  xiii,  14. 

Influence  of  Food  in  the  Production  of  Milk  in  the  Cow. — By 
increase  of  the  albuminous  and  fatty  elements  of  the  food,  an  in- 
crease (up  to  a  certain  maximum)  in  the  quantity  of  milk  is  caused, 
but  this  ceases  sooner  or  later  during  lactation.  Diminution  of  these 
elements  causes  a  diminution  in  the  quantity  of  milk.  The  quantity 
of  casein  and  albumen  does  not  seem  to  be  altered  by  diet. — Kiicher, 
Chem.  Centralht.,  1871, 102. 

The  Albuminoids  of  Milk. — Three  flesh-formers  are  known  to  exist 
in  the  milk  of  many  animals.  The  casein  may  be  removed  by  pre- 
cipitation with  acetic  acid,  the  albumen  by  ebullition,  and  the  third 
albuminoid  by  aqueous  carbolic  acid  or  solution  of  corrosive  subli- 
mate, and,  according  to  M.  Morin,  by  the  addition  of  alcohol  to  the 
whey,  after  it  has  been  freed  from  fat  by  ether,  concentrated,  and  fil- 
tered. M.  Morin  calls  the  substance  he  thus  obtains  "  galactin," 
and  regards  it  as  a  normal  constituent  of  the  gastric  juice,  blood, 
&c.,  and  many  plants.  He  also  detects  it  in  many  morbid  secre- 
tions. As  the  precipitate  which  its  solution  forms  with  tannin  re- 
dissolves  at  60°  C,  the  detection  of  galactin  is  easy. — J.  Pharm. 
(iv),  xiv. 

Excretion  of  Ihe  Nitrogen  of  the  Albuminoids. — Seegen,  in  opposi- 
tion to  Yoit,  concludes  that  the  whole  of  the  nitrogen  derived  from 
the  decomposition  of  albuminous  substances  was  not  excreted  as 
urea  in  the  urine.  By  using  one  method  in  collecting  the  urine  the 
deficiency  of  nitrogen  was  found  to  be  25  per  cent,  of  that  ingested. 
By  Voit's  method  of  collecting,  i.  e.  making  the  animal  micturate 
into  a  vessel  every  two  hours,  the  deficiency  was  only  1  per  cent. 
If  the  increase  in  weight  of  the  animal  was  reckoned  as  muscle,  then 
there  would  be  no  loss,  but  an  overplus  of  4  per  cent.  More  urine 
was  collected  by  Yoit  than  by  Seegen,  who  merely  collected  what 
was  voided  in  the  cage. — J.  Seegen,  Wien  Akad.  Ber.,  Ixiii,  Abt. 
ii,  11. 

Differences  between  Albumen  and  Casein. — By  oxidation  with  an 


1872.]     Report  on  Physiological  S^  Pathological  Chemistry.     253 

alkaline  solution  of  potassium  permanganate  casein  yields  6*5  per 
cent,  of  ammonia,  while  albumen  gives  10  per  cent.,  thus  indicating 
a  considerable  difference  in  chemical  structure  of  these  allied  sub- 
stances.— J.  A.  "Wanklyn,  Pharm.  J.  Trans.  (2),  ii,  QQ. 

Constitution  of  Milh. — Dumas  thinks  that  minute  quantities  of 
substances  difficult  to  recognise  may  exist  in  milk  which  are  essen- 
tial to  nutrition.  As  these  are  certain  to  be  omitted  in  artificial 
substitutes,  the  nutrition  of  children  fed  on  these  substitutes  would 
be  sure  to  suffer. — M.  Dumas,  Arch.  Sci.  Phys.  Nat.  (2),  xli,  105. 

On  the  Mucin  of  the  Submaxillary  Gland. — In  a  paper  by  J.  Obo- 
lensky  ('  Med.  Chem.  Unters.,'  1871,  590—593)  an  account  is  given 
of  this  substance,  first  obtained  by  Staedeler  from  the  salivary 
glands.  Mucin  is  prepared  by  rubbing  down  the  salivary  glands  of 
the  ox  with  pounded  glass,  placing  the  mass  in  water  for  a  night, 
then  filtering  and  again  treating  the  residue  with  water.  Acetic 
acid  in  excess  is  added  to  the  filtrate  and  the  precipitate  washed 
with  water,  acetic  acid,  and  warm  alcohol;  it  is  then  dried.  Mucin 
is  only  obtained  from  the  submaxillary  gland,  and  is  insoluble 
in  acetic  acid.  Mucin  contains  no  sulphur,  and  from  1'06  to 
107  per  cent,  of  phosphoric  acid.  This  probably  exists  as  me- 
tallic phosphates,  adherent  to  the  mucin.  It  yields  about  2*44  per 
cent,  of  pure  ash,  1*64  parts  being  soluble  in  water,  the  rest  in  hydro- 
chloric acid.  The  percentage  composition  of  mucin  free  from  ash 
is  C  52-2,  H7-18,  N  11-87,  O  2875.  Moist  freshly  precipitated 
mucin  swells  in  water,  is  easily  soluble  in  lime  and  baryta  water, 
is  not  precipitated  by  tannic  acid,  ferric  chloride,  or  mercuric  chlo- 
ride. It  is  also  soluble  in  concentrated  hydrochloric  and  nitric  acid 
and  in  sodium  carbonate.  When  treated  with  hot  alcohol  and  dried 
in  the  water  bath  it  scarcely  swells  in  water,  and  is  only  slowly- 
soluble  in  lime  or  baryta  water  or  soda  solution.  Dried  and  pulve- 
rised mucin,  when  heated  with  dilute  sulphuric  acid  for  twenty-five 
minutes,  gives  a  rich  precipitate  of  cuprous  oxide  with  excess  of 
caustic  soda  and  copper  sulphate.  If  heated  longer  the  quantity  of 
the  reducing  agent  diminishes,  and  lastly  disappears.  This,  taken 
along  with  the  insolubility  of  the  reducing  agent  in  absolute  alcohol, 
shows  that  it  is  not  the  same  as  either  grape  sugar  or  milk  sugar. 

Effects  of  Change  of  Climate  on  the  Human  Economy. — Tropical 
climate  causes  loss  of  weight  and  depression  of  both  mental  and 
bodily  energy.  AVith  hard  work  and  diet  of  salt  meat  the  loss  is 
greatly  increased. — Dr.  Alexander  Kattray,  Proc.  Boy.  Soc,  1870, 
p.  529. 

Effect  of  Diet  and  Exercise  on  the  Elimination  of  Nitrogen. — These 
experiments  show  that  there  is  an  increased  elimination  of  nitrogen 
during  the  period  of  rest  after  severe  exercise,  and  that  the  necessary 
amount  offeree  needed  for  great  muscular  work  can  be  obtained  by 
the  muscles  from  fat  and  starch. — Dr.  E.  A.  Parkes,  Proc.  Poy.  Soc, 
1871,  p.  349. 

Urea  a  normal  and  constant  Constituent  of  Bile. — Dr.  0.  Popp 
('  Zeitschr.  f.  Chem.'  (2),  vii,  88)  states  that  urea  is  a  normal  and  con- 


254  Chronicle  of  Medical  Science.  [Jan., 

stant  constituent  of  bile,  and  gives  a  mode  of  extracting  the  urea 
from  bile.  Popp  states  that  bile  from  the  pig  contains  more  urea 
than  that  from  the  ox. 

Sarcolactic  Acid  in  Urine  of  Patient  suffering  from  Trichinosis. — 
Sarcolactic  acid,  recognised  by  its  zinc  salt,  was  obtained  from  the 
urine  of  a  patient  in  the  Frankfort  Hospital  who  was  suffering  from 
trichinosis. — Th.  Simon  and  F.  Wibel,  Deut.  Chem.  Oes.  JBerlin.,  iv, 
139. 

Estimation  of  Urea  hy  Sodium  Hypohromiie. — Gr.  Huefner,  in 
'  Jour.  pr.  Chem.,'  2,  iii,  1,  proposes  a  modification  of  Knop's  process 
for  the  determination  of  urea.  Knop's  solution  was  made  by  placing 
100  grms.  of  sodium  hydrate  in  250  cubic  cent,  of  warm  water, 
leaving  the  solution  to  cool,  and  then  adding  25  cub.  cent,  of  bro- 
mine. 50  cub.  cent,  of  this  solution,  diluted  with  200  cub.  cent,  of 
water,  will  liberate  from  130  to  150  cub.  cent,  of  nitrogen  from  a 
solution  of  ammonium  chloride.  Huefner  proposes  to  modify  Knop's 
process  by  employing  a  gentle  heat  to  complete  the  reaction.  On 
mixing  the  urea  and  the  oxidizing  agent,  nitrogen  and  oxygen  gases 
are  liberated  and  are  collected  in  a  graduated  cylinder.  Aftef 
absorption  of  the  oxygen  the  percentage  of  nitrogen  found  by  expe- 
riment in  urea  by  this  method  closely  corresponds  to  the  theoretical 
amount. 

Pigments  of  Bile  and  Urine. — The  spectroscopic  appearances  of 
the  bile  which  has  given  the  usual  colour  reaction  with  nitric  acid 
are  described,  also  of  the  coloured  solution  obtained  by  exhausting 
bile  with  dilute  hydrochloric  acid.  This  reddish  solution  gives  a 
well-marked  absorption  band  between  Fraunhofer's  h  and  F  lines. 
The  same  band,  and  others  described  by  Jaffe,  were  also  met  with  in 
healthy  urine. — Dr.  Max  Jafi'e',  Arch.  Pharm.  (2),  cxlv,  148. 

Chemical  Composition  of  Pus-corpuscles. — Pus-corpuscles  are  com- 
posed chiefly  of  albuminoids.  These  are— 1,  alkali-albuminates ;  2,  an 
albuminoid  coagulable  at  48° — 49°  ;  3,  an  albuminoid  coagulable  at 
the  ordinary  temperature  of  serum-albumen ;  4,  Eonda's  hyaline 
substance  ;  and,  5th,  an  albuminoid  unaltered  in  water  and  sodium 
chloride,  with  difficulty  soluble  in  hydrochloric  acid.  The  alcoholic 
extract  of  pus  gives  lecithin  and  cerebrin  and  a  substance  similar 
to  it.  The  ash  in  100  parts  amounted  to  1*269,  and  contained — 
NaCl,  0-143;  K2O,  0-655;  MgO,  0087;  NagO,  0262;  CaO, 
0"830 ;  Fe203,  0039.  Phosphoric  acid  and  chlorine  are  also  present. 
The  nuclei  of  pus-corpuscles  give  the  same  reactions  as  mucin.  The 
substance  of  the  nuclei  contains  nitrogen  and  sulphur,  and  is  rich  in 
phosphorus. — F.  Miescher,  Jfec?.  Chem.  Untersuch.,  1871,441. 

Chemical  Composition  of  Pus. — Hoppe-Seyler  agrees  with  Mies- 
cher  in  the  results  obtained  by  the  latter  author. — F.  Hoppe-Seyler, 
Med.  Chem.  Untersuch.,  1871,  486. 

The  Alkaloids  of  Tobacco  Smohe. — The  physiological  action  ol 
tobacco,  when  used  as  a  narcotic,  is  commonly  attributed  to  the 
nicotine  which  it  is  known  to  contain,  although  Zeiss,  nearly  thirty 


1872.]     Report  on  Physiological  ^  Pathological  Chemistry.    255 

years  ago,  could  not  discover  this  alkaloid  iu  tobacco  smoke.  H. 
Vohl  and  H.  Eulenberg  differ  from  this  view  ;  they  find  mere  traces 
of  nicotine  in  many  prepared  snuffs  and  quid-tobaccoes.  The  effec- 
tive constituents  of  tobacco  smoke  appear  to  be  carbonic  oxide,  cya- 
nogen compounds,  and  especially  certain  organic  bases,  which  are 
well  known  as  occurring  amongst  the  products  of  the  destructive 
distillation  of  peat  and  shales.  These  bases  are  oily  bodies  discovered 
by  Aiaderson  and  Greville  Williams,  and  belong  to  the  pyridine 
series.  This  series  commences  with  pyridine,  C5H5N,  and  ends 
with  viridine,  Cj2B[j9N  ;  picoline,  the  second  member  of  it,  is  iso- 
meric with  the  well-known  alkaloid  aniline  or  phenylamine,  a  deriva- 
tive from  indigo  and  coal-tar. — ArcJiiv  der  Pharmacie  (2),  cxlvii, 
S.  130. 

Action  of  Crystallized  Aconitine. — MM.  Grehaut  and  Duquesnel 
detail  some  experiments  made  with  this  substance.  Small  doses  of 
aconitine  destroy  the  motor  power  of  the  nerves,  the  physiological 
action  thus  resembling  that  of  curarine.  Experiments  are  detailed, 
made  both  on  frogs  and  rabbits.  In  the  rabbit  the  action  was  very 
rapid,  one  milligramme  in  half  an  hour  rendering  the  sciatic  nerve  in- 
capable of  conveying  impressions  to  the  muscles,  the  muscles  them- 
selves not  having  lost  their  contractility.  In  this  case  artificial 
respiration  had  to  be  employed. — Compt.  Rend.,  Ixxiii,  209. 

Detection  of  Curarine. — The  method  of  separating  curarine  from 
the  flesh,  blood,  urine  and  faeces,  &c.,  is  described.  When  '00006 
grm.  of  curarine  is  treated  withi — |^  c.c.  of  concentrated  sulphuric 
acid  (raonohydrate)  an  immediate  red  coloration  is  produced,  which 
becomes  darker  on  standing,  and  passes  into  rose-red  after  four 
hours.  Concentrated  sulphuric  acid  and  potassium  chromate  give 
the  same  reaction  as  with  strychnine. — Karl  Koch,  Chem.  Centr., 
1871,  219. 

Synthesis  of  Alkaloids, — The  alkaloid  coniine,  the  active  principle 
of  hemlock  {Conium  maculatum)  has  been  produced  by  Schiff. 
Butyraldelhyde,  when  acted  upon  by  alcoholic  ammonia  at  a  tem- 
perature not  exceeding  100°  Cent.,  produces  two  bases,  one  of  which 
is  dibutyraldine.  By  dry  distillation  of  dibutyraldine,  among  other 
products  coniine  is  produced. 

CgH^^NO  =  HO.-fCgHi.N. 

Dibutyraldine.  Couiine. 

-Schiff,  PJiarm.  J.  Trans.  (3),  1,  605. 

StrycTinine-oxetliyl  Compounds.  —  Compounds  of  strychnine  and 
quinine  with  ethylene  hydroxychloride  (CgH^OHCl)  have  been  pre- 
pared and  examined  by  E.  Messel.  The  formula  of  the  strychnine 
derivative  is  C^^ll,^,^p,,-^C^^fillQ\=Q,^.^^^^^,fi,^C\.  When  the 
solution  of  the  chloride  of  strychnine- oxythyl  was  administered  tp 
medium-sized  frogs  by  subcutaneous  injection  three  to  four  mgrms. 
caused  death.  In  smaller  doses  total  paralysis  of  the  motor  nerves 
was  produced,  which  lasted  for  hours  ;  during  this  time,  however, 
the  muscles  of  the  animal  were  capable  of  contracting  powerfully  on 


256  Chronicle  of  Medical  Science.  [Jan., 

the  application  of  a  direct  stimulus. — Ann.  Ch.   Pliarm.^  clvii,  7 ; 
Jour.  Ghem.  Soc.  (2),  ix,  p.  148. 

Decomposition  of  Solution  of  Morphine  Acetate. — Morphine  ace- 
tate in  solution  undergoes  decomposition  if  kept  for  some  time. 
J.  M.  Maisch  has  made  experimeuts  on  a  solution  of  eight  grains  of 
the  acetate  in  half  an  ounce  of  distilled  water.  On  keeping  for 
several  months  the  solution  became  of  a  pale  brownish  colour,  and 
deposited  a  quantity  of  brown  matter.  A  single  large  crystal  formed, 
which  on  examination  proved  to  be  pure  morphine.  The  liquid 
appeared  still  to  contain  a  small  quantity  of  the  morphine  acetate 
in  solution. — Vliarm.  Journ.  Trans  (3),  1,  664;  Jour.  Chem.  Soc.  (2), 
ix,  p.  148. 

Tissue  Changes  in  Phosphorus  Poisoning. — Voit  attempts  to 
explain  the  fatty  degeneration  of  organs  during  disease  by  a  com- 
parison of  the  results  obtained  in  poisoning  with  phosphorus.  The 
fat  might  be  produced  in  three  ways  : — 1.  Derived  directly  from  the 
food.  2.  Brought  from  other  parts  of  the  body,  as  the  subcuta- 
neous cellular  tissue.  3.  Produced  in  the  cells  of  the  organ  by  the 
splitting  up  of  the  albuminous  bodies  contained  in  them.  By  ex- 
perimenting on  dogs  deprived  of  food  he  found  that  the  fat  could 
not  be  derived  from  the  food  or  from  fat  brought  from  other  parts 
of  the  body.  The  combined  albumen  of  the  organ  undergoes  oxida- 
tion, thus  causing  complete  disorganization  and  destruction  of  the 
tissues. — K.  Voit,  N.  Rep.  JBharm.^  xx,  340. 

Method  of  distinguishing  the  Arsenic  Deposit  in  HeinscVs  Process 
from  Mercury. — In  the  '  Chemical  News,'  xxxiii,  73,  Mr.  James 
St.  Clair  Gray  describes  a  mode  of  distinguishing  the  arsenic  deposit 
in  Eeinsch's  process  from  mercury.  The  method  employed  is  to 
take  the  slip  of  coated  copper  and  rub  it  on  a  flat  piece  of  pure  gold. 
If  mercury  exists  in  the  deposit  on  the  copper  it  will  mark  the  gold 
with  a  clear,  white,  shining  streak,  which  is  removable  by  the  action 
of  nitric  acid. 

Absorption  of  Oxygen  hy  Fish. — It  has  been  found  by  M.  G-rehaut 
that  the  dissolved  oxygen  of  water  is  completely  removed  by  the 
respiration  of  fish  before  they  become  asphyxiated.  This  absorp- 
tion of  oxygen  and  consequent  production  of  carbonic  acid  gas  is  by 
no  means  confined  to  the  bronchise,  but  the  skin  of  the  anima 
seems  nearly  as  eff'ective  in  bringing  about  the  change.  In  con- 
nection with  this  observation  we  may  note  the  recent  experiments 
of  Signor  Panceri  on  the  phosphorescence  of  fish,  which  he  attri- 
butes to  the  penetration  beneath  the  skin  of  dissolved  oxygen,  and 
the  resulting  oxidation  of  the  fat  of  the  subcutaneous  adipose 
tissue. 

Animal  Starch, — In  the  yolk  of  the  hen's  egg  starch  granules  exist. 
During  a  certain  stage  of  incubation  they  are  easily  demonstrated, 
and  appear  as  granules  about  '025  mm.  in  diameter,  giving  the  usual 
optical  characters  of  starch  when  examined  with  polarized  light.  In 
this  state  they  do  not  always  give  a  blue  reaction  with  iodine,  but 


1872.]    Report  on  Physiological  ^  Pathological  Chemistry.     257 

sometimes  turn  red.  During  incubation  three  or  four  successive 
series  of  granules  are  formed,  which  disappear.  The  disappearance 
and  reappearance  of  the  granules  Dareste  thinks  may  be  due  to  the 
transformation  of  the  starch  into  glucose,  and  its  re-formation  from 
this  glucose. — C.  Dareste,  Compt.  Bend.  Ixxii,  845. 

JResearches  on  Alcoholic  Fermentation  and  Nutrition  of  the  Yeast 
Plant. — The  author  points  out  the  different  substances  necessary  for 
the  nutrition  of  the  yeast  plant,  one  of  the  most  important  being 
acid  potassium  phosphate. — Adolph  Mayer,  Pogg.  Ann.,  cxlii,  293. 

Flesh-Juice  of  Phoccena  communis. — The  following  comparison  be- 
tween the  juice  of  the  flesh  of  porpoise  and  the  horse  is  given  in  this 
paper : 

Porpoise.  Horse-flesh. 


Sareine 

.     105 

1-23 

Xanthine 

.  traces 

.        0-11 

Inosite 

.     008 

0-30 

Sarcolactic  acid 

.     7-45 

4-47 

Taurine 

— 

0-70 

— Oscar  Jacobsen,  Ann.  Ch.  Pharm.,  clvii,  227. 

Putrefaction  and  Disinfection. — Hoppe-Seyler  finds  that  1  per 
cent,  of  carbolic  acid  will  put  an  end  to  all  organized  life,  but  that  2 
per  cent,  is  required  to  stop  putrefactive  changes.  The  most  effec- 
tive way  of  destroying  germs  in  the  air  is  found  to  be  by  the  use  of 
sulphurous  oxide  gas,  as  14'3  to  28*6  grms.  of  sulphur  burnt  for  each 
cubic  metre  of  space  entirely  prevents  the  growth  of  fungi. — Hoppe- 
Seyler,  Med.  Chem.  Unters.,  1871,  561. 

Artificial  production  of  Cqlcareotcs  substances,  such  as  exist  in  the 
Organism. — M.Harting('Compt.Bend.'(2),xxiii, p.  361)  has  succeeded 
in  imitating  calcareous  bodies,  such  as  biliary  concretions,  otolites, 
pearls,  spiculas  of  alcyonium,  &c.,  but  has  failed  to  imitate  the  pecu- 
liar calcareous  skeleton  of  the  echinoderms  and  bone.  The  length  of 
time  required  for  the  deposit  seems  to  be  of  primary  importance,  as 
M.  Harting  found  the  calcareous  combination  to  be  formed  in  organic 
fluids  by  double  decomposition  when  the  action  was  retarded  by 
slow  difl'usion.     Mr.  Eainey  has  anticipated  M.  Harting. 

On  the  Purification  of  Fai. — M.  Debrunfant  ('  Compt.  Eend.,'  Ixxi, 
p.  36)  states  that  tainted  meat  is  deprived  of  its  disagreeable  odour 
by  being  fried,  and  after  frying  may  be  used  for  any  culinary  pur- 
pose. Eish  oils  can  be  deprived  of  their  odour  by  heating  to  a  tem- 
perature of  330°.  In  the  kitchen,  fats  may  be  easily  purified  by 
placing  in  a  frying  pan,  raising  the  temperature  to  between  140°  and 
150°  C,  and  then  sprinkling  the  fat  cautiously  with  small  quantities 
of  water ;  the  steam  which  is  evolved  carries  off  the  offensive  fatty 
matters,  which  are  thus  decomposed.  This  process  would,  in  many 
cases,  prove  very  useful,  but  it  is  evidently  an  operation  which  must 
be  conducted  with  considerable  caution. 

Detection  of  Turmeric  in  powdered  Bhuharh  and  Mustard. — Inferior 
rhubarb  may  be  adulterated  with  turmeric  to  improve  its  colour. 
It  can  be  detected  by  agitating  a  small  quantity  of  the  rhubarb  for 

97— xLix.  17 


258  Chronicle  of  Medical  Science.  [Jan., 

a  minute  or  two  in  strong  alcohol  and  filtering ;  to  this  add  a  strong 
solution  of  borax,  and  a  considerable  excess  of  hydrochloric  acid. 
If  pure,  the  filtrate  will  be  light  brown,  the  borax  rendering  it  red- 
brown,  a  tint  at  once  discharged  by  the  hydrochloric  acid.  If  adul- 
terated, the  brown  colour  remains  after  the  addition  of  the  acid. 
The  same  process  is  applicable  to  mustard. — J.  M.  Maisch,  Pharm. 
J.  Trans,  (3),  i,  1027. 


REPORT  ON  TOXICOLOGY,  FORENSIC  MEDICINE, 

AND   HYGIENE. 

By  Benjamin  W.  Richaedson,  M.D.,  E.R.S. 


I. — Toxicology. 

Toxical  studies  on  cJiloral  hydrate. — The  most  important  subject, 
in  a  toxicological  point  of  view,  that  has  been  under  discussion  since 
our  last  report,  has  relation  to  chloral  hydrate.  The  increasing 
employment  of  this  narcotic  by  the  members  of  the  general  public, 
without  the  advice  of  the  professors  of  medical  science,  has  been 
attended  by  several  fatal  occurrences ;  while  in  instances  where  fatal 
results  have  not  taken  place,  peculiar  symptoms  have  followed  the 
frequent  self-administration  of  the  narcotic — symptoms  of  serious 
import,  and  demanding  ready  recognition.  We  have,  consequently, 
devoted  some  labour  to  the  investigation  of  certain  facts  bearing  on 
the  toxicological  history  of  chloral  hydrate,  to  which,  and  the  results 
of  our  inquiries,  we  would  now  direct  attention. 

1.  We  have  endeavoured  to  ascertain  what  is  a  dangerous  and 
what  a  fatal  dose  of  chloral  hydrate.  The  conclusion  at  which  we 
have  been  able  first  to  arrive  on  this  point  is,  that  the  maximum 
quantity  of  the  hydrate  that  can  be  borne,  at  one  dose,  bears  some 
proportion  to  the  weight  of  the  animal  subjected  to  its  influence. 
The  rule,  however,  does  not  extend  equally  to  animals  of  any  and 
every  class.  The  proportion  is  practically  the  same  in  the  same 
classes,  but  there  is  no  actual  universality  of  rule.  A  mouse  weigh- 
ing from  three  quarters  of  au  ounce  to  an  ounce  will  be  put  to  sleep 
by  one  quarter  of  a  grain  of  the  hydrate,  and  will  be  killed  by  a 
grain.  A  pigeon  weighing  weighiDg  twelve  ounces  will  be  put  to 
sleep  by  two  grains  of  the  hydrate,  and  will  be  killed  by  five  grains. 
A  guineapig  weighing  sixteen  ounces  will  be  put  by  two  grains  into 
deep  sleep,  and  by  five  grains  into  fatal  sleep.  A  rabbit  weighing 
eighty-eight  ounces  will  be  thrown  by  thirty  grains  into  deep  sleep, 
and  by  sixty  grains  into  fatal  sleep. 

The  human  subject,  weighing  from  one  hundred  and  twenty  to  one 
hundred  and  forty  pounds,  will  be  made  by  ninety  grains  to  pass 
into  deep  sleep,  and  by  one  hundred  and  forty  grains  into  a  sleep 
that  will  be  dangerous. 


1872.]      Report  on  Toxicology y  Forensic  Medicine,  ^c.  259 

From  the  effects  produced  on  a  man  wlio  had  of  his  own  accord 
taken  a  hundred  and  twenty  grains  of  the  hydrate,  and  who  seemed 
at  one  period  to  be  passing  into  death,  we  were  led  to  infer  that  in 
the  human  subject  one  hundred  and  forty  grains  should  be  accepted 
as  dangerous,  and  one  hundred  and  eighty  as  a  fatal  dose.  Evidence 
has,  however,  recently  been  brought  before  us  which  leads  us  to 
think  that,  although  eighty  grains  would  in  most  instances  prove 
fatal,  it  could,  under  very  favorable  circumstances,  be  recovered 
from. 

Dr.  Hills,  of  the  Thorpe  Asylum,  Norwich,  has,  for  example, 
favoured  us  with  the  facts  of  an  instance  in  which  a  suicidal  woman 
took  no  less  thdco.  four  hundred  and  seventy-two  grains  of  the  hydrate 
dissolved  in  sixteen  ounces  of  water,  and  actually  did  not  die  for 
thirty-three  hours.  Such  a  fact,  ably  observed  as  it  was,  is  startling ; 
but  it  does  not,  we  think,  militate  against  the  rule  that  one  hundred 
and  forty  grains  is  the  maximum  quantity  that  should,  under  any 
circumstances,  be  administered  to  the  human  subject. 

2.  A  second  point  to  which  our  attention  has  been  directed  is, 
what  quantity  of  hydrate  of  chloral  can  be  taken  with  safety  at  given 
intervals  for  a  given  period  of  time,  say  of  tv*^enty-four  hours.  To 
arrive  at  some  fair  conclusion  on  this  subject,  we  calculated  from  a 
series  of  experiments  the  time  required  for  the  development  of 
symptoms  from  different  doses  of  the  hydrate,  the  full  period  of  the 
symptoms,  and  the  time  when  they  had  entirely  passed  away.  Great 
difficulties  attend  this  line  of  investigation ;  but  we  may  state,  as  a 
near  approximation  to  the  truth,  that  an  adult  person  who  has  taken 
chloral  hydrate  in  sufficient  quantity  to  be  influenced  by  it,  disposes 
of  it  at  the  rate  of  about  seven  grains  per  hour.  In  repeated  doses,  the 
hydrate  of  chloral  might  therefore  be  given  at  the  rate  of  twelve 
grains  every  two  hours  for  twenty-four  hours,  with  less  danger  than 
would  occur  from  giving  twelve  times  twelve  (144)  grains  at  once; 
but  w^e  do  not  think  that  amount  ought,  except  in  the  extremest 
emergencies,  to  be  exceeded,  in  divided  quantities. 

3.  A  third  point  to  which  we  have  paid  attention  is,  the  means  to 
be  adopted  in  any  case  when,  from  accident  or  other  cause,  a  large 
and  fatal  dose  of  chloral  hydrate  has  been  administered.  We  can 
speak  here  with  precision.  It  should  be  remembered  that  this  hy- 
drate, from  its  great  solubility,  is  rapidly  diffused  through  all  the 
organism.  It  is  in  vain,  consequently,  to  attempt  its  removal  by  any 
extreme  measures  after  it  has  fairly  taken  effect.  In  other  words, 
the  animal  or  person  under  chloral,  like  an  animal  or  person  in  a 
fever,  must  go  through  a  distinct  series  of  stages  on  the  way  to  reco- 
very or  death ;  and  these  stages  will  be  long  or  short,  slightly  dan- 
gerous or  intensely  dangerous,  all  but  fatal  or  actually  fatal,  accord- 
ing to  the  conditions  by  which  the  animal  is  surrounded.  One  of 
the  first  and  marked  effects  of  the  chloral  is  reduction  of  the  animal 
temperature ;  and  when  an  animal  is  deeply  under  the  influence  of 
the  agent,  in  the  fourth  degree  of  narcotism  of  Dr.  Snow,  the  tem- 
perature of  its  body,  unless  the  external  warmth  be  carefully  sus- 
tained, will  quickly  descend  seven  and  even  eight  degrees  below  the 


260  Chronicle  of  Medical  Science.  [Jan., 

natural  standard.  Such  reduction  of  temperature  is  itself  a  source 
of  danger ;  it  allows  condensation  of  fluid  on  the  bronchial  pulmo- 
nary surface,  and  so  induces  apnoDa,  and  it  indicates  a  period  when 
the  convulsion  of  cold  (a  convulsion  which  sharply  precedes  death) 
is  at  hand. 

We  ofier  these  explanations  in  order  to  indicate  the  first  favorable 
condition  for  the  recovery  of  an  animal  or  man  from  the  effects  of 
an  extreme  dose  of  chloral  hydrate.  It  is  essential  that  the  body  of 
the  animal  be  kept  warm,  and  not  merely  so,  but  that  the  air  inspired 
by  the  animal  be  of  high  temperature.  The  first  eff'ort  to  recovery, 
in  short,  should  consist  in  placing  the  animal  in  a  warm  air.  This 
fact  is  perfectly  illustrated  by  experiment  on  the  inferior  animals. 
In  the  pigeon  an  air  of  95°  Fahr.  is  most  favorable,  in  the  rabbit  an 
air  at  105°  to  110°,  in  the  dog  the  same.  In  man  the  air  to  be 
breathed  should  be  raised  to  and  sustained  at  90°  Tahr.  at  least.i 

The  next  thing  to  be  remembered  in  the  recovery  of  persons  under 
the  fatal  influence  of  chloral  hydrate  is  to  sustain  the  body  by  food. 
I  find  that  even  under  deep  sleep  from  the  narcotic,  although  the 
process  of  waste  is  less  than  is  common  under  natural  conditions  of 
rest,  there  is  still  a  very  considerable  waste  in  progress,  which,  if 
not  made  up,  is  against  recovery.  I  find  also  that  the  digestive  and 
assimilating  powers,  though  impaired  during  sleep  from  chloral,  are 
not  arrested,  but  may  be  called  into  fair  action  with  so  much  advan- 
tage, that  if  two  animals  be  cast  into  deep  sleep  by  an  excessive 
quantity  of  the  narcotic,  and  one  be  left  without  food  and  the  other 
be  artificially  fed  on  warm  food,  one  fourth  of  the  chance  of  recovery 
is  given  to  the  animal  that  is  supplied  with  food.  In  the  human 
subject  warm  milk,  to  which  a  little  lime-water  has  been  added,  is 
the  best  food.  Milk  is  very  easily  administered  mechanically,  and 
it  should  be  administered  in  the  proportion  of  half  a  pint  every  two 
hours. 

4.  The  fourth  point  to  remember  is  to  sustain  the  breathing ;  in 
the  inferior  animals  the  question  of  life  or  death  can  be  made  to  turn 
on  this  pivot.  But  the  artificial  respiration  must  be  carried  out 
with  great  gentleness ;  it  must  not  be  done  by  vehement  movements 
of  the  body  or  compressions  of  the  chest,  but  by  the  simple  process 
of  inflating  the  lungs  by  means  of  small  bellows,  through  the  nos- 
trils. We  have  devised  in  the  course  of  our  researches  various 
instruments  for  artificial  respiration,  viz.  a  small  double-acting 
bellows,  a  small  syringe,  and  a  double-acting  india-rubber  pocket- 
bellows;  and  we  have  lately  made  an  instrument  which  acts  by 
a  simpler  method  still,  i.  e.  we  merely  attach  to  a  single  hand- 
bellows  a  nostril-tube,  and  gently  inflate  the  lungs,  letting  the 
elasticity  of  the  chest-wall  do  the  work  of  expiration.  A  little 
valve  near  to  the  nostril-tube  effectually  stops  all  back  currents 
from  the  lungs  into  the  bellows.      For  the  human  subject,    five 

'  We  have  no  doubt  it  will  be  found,  as  the  chronicle  of  deaths  from  chloral 
hydrate  increases,  that  the  mortality  from  the  agent  will  be  the  greatest  when 
the  thermometrical  readings  are  the  lowest,  and  vice  versa. 


1872.]      Report  on  Toxicology^  Forensic  Medicine,  ^c.         261 

charges  of  air  from  the  bellows  should  be  given  at  intervals  of  five 
seconds  apart. 

The  symptoms  of  acute  poisoning  by  chloral  hydrate  are,  briefly, 
profouud  coma,  great  muscular  relaxation,  apoplectic  breathing,  and 
flushing  of  the  face  and  neck,  with  intermissions  of  pallor.  The  eyes 
are  usually  rolled  upwards  as  under  chloroform,  and  at  times,  as 
impressions  of  motion  are  made  on  the  surface  of  the  body,  there  is 
muscular  tremor,  which  may  pass  into  convulsion.  In  time  the 
extremities  become  cold,  and  the  bronchial  surfaces  become  charged 
with  frothy  mucus,  which  greatly  impedes  the  breathing  and  hastens 
the  final  result. 

The  chronic  symptoms  of  chloral  poisoning  are — sleeplessness, 
unless  the  narcotic  be  taken  in  very  large  doses  ;  great  mental  irrita- 
bility and  muscular  prostration;  uncertainty  of  movement,  with 
tendency  to  fall  forward ;  caprice  of  appetite  and  frequent  nausea. 
In  some  cases  there  is  injection  of  the  conjunctivae,  and  in  other 
cases  yellowness.  The  urine,  in  extreme  cases,  contains  albumen, 
and  the  bowels  are  commonly  constipated,  the  evacuations  being 
white  and  hard.  Chloral  hydrate  does  not  produce  the  ecstatic 
dream  or  delirium  caused  by  opium  or  haschish ;  on  the  contrary,  it 
causes,  through  all  the  stages  of  its  action,  a  sense  rather  of  depres- 
sion than  of  elevation  of  mental  faculty. 

Volumetrical  determination  of  Arsenic. — Mr.  E.  Waitz  has  inves- 
tigated with  care  the  diflferent  methods  for  determining  arsenious 
acid,  viz.  1st,  by  means  of  free  iodine ;  2nd,  by  means  of  dipotassic 
dichromate ;  8rd,  by  means  of  potassic  permanganate ;  as  well  as 
the  method  for  estimating  arsenic  acid  by  means  of  uranic  acetate. 

The  iodine  method  depends,  as  is  well  known,  upon  the  conversion 
of  arsenious  into  arsenic  acid  in  alkaline  solution.  In  an  acid  solu- 
tion arsenious  acid  can  exist  in  the  presence  of  iodine  or  chlorine, 
and  is  only  partly  converted  into  the  higher  oxide.  The  alkali  must 
be  in  the  form  of  a  carbonate,  for  a  caustic  alkali  combines  with  the 
iodine.  The  author's  experiments  show  that  normal  sodic  carbonate 
fixes  iodine,  but  that  the  acid  carbonate  does  not ;  a  solution  satu- 
rated in  the  cold  should  be  used.  This  only  confirms  the  previous 
observations  of  Eresenius.  On  employing  a  standard  solution  of 
arsenious  acid  in  hydrochloric  acid,  the  free  acid  has  first  to  be  neu- 
tralised by  means  of  caustic  soda  or  acid  sodic  carbonate.  With  an 
excess  of  this  latter  salt  good  results  were  obtained. 

Experiments  made  with  a  view  of  converting  precipitated  arse- 
nious sulphide  into  arsenious  acid  by  the  action  of  an  ammoniacal 
solution  of  silver  nitrate  upon  the  sulphide  dissolved  in  ammonia, 
as  well  as  by  means  of  freshly  precipitated  bismuthous  hydrate,  and 
of  substituting  in  this  manner  the  trisulphide — which  can  be  ob- 
tained in  a  state  of  great  purity — for  the  trioxide,  where  unsuccess- 
ful, as  the  reaction  is  never  quite  complete,  owing  to  the  formation 
of  sulpho-salts  of  silver  and  bismuth. 

The  method  first  proposed  by  Kessler  of  determinating  arsenious 
acid  in  an  acid  solution  by  means  of  depotassic  dichromate,  and 
standardizing  back  by  means  of  a  ferrous  sulphate  solution,  gave 


262  Chronicle  of  Medical  Science.  [Jan., 

good  results.  Excess  of  hydrochloric  acid  has  to  be  avoided.  Kessler 
succeeded  in  utilising  arsenious  sulphide  by  treating  it  in  a  hydro- 
chloric acid  solution  with  mercuric  chloride,  a  saturated  solution  of 
which  converts  the  sulphide  slowly  at  the  ordinary  temperature, 
more  rapidly  on  the  application  of  a  gentle  heat  into  the  trioxide. 
The  reaction  is  over  when  the  mass  has  become  white.  The  author's 
experiments  show  further  that  the  mixture  of  trisulphide  and  sulphur 
which  is  obtained  when  a  solution  of  arsenic  acid  is  precipitated  with 
sulphuretted  hydrogen,  cannot  be  converted  directly  into  arsenious 
acid  by  digestion  with  mercuric  chloride,  on  account  of  the  dense 
nature  of  the  precipitate,  but  that  it  is  readily  acted  upon  after  dis- 
solving out  the  trisulphide  by  means  of  dilute  ammonia  and  repreci- 
pitating  with  hydrochloric  acid. 

The  oxidation  of  arsenious  into  arsenic  acid  by  means  of  potassic 
'permanganate  is  never  perfect,  and  a  volumetric  method  based  upon 
this  reaction  was  found  by  the  author  to  be  most  untrustworthy ; 
but  by  adding  excess  of  permanganate — more  than  double  the  amount 
required  according  to  theory — and  standardizing  back  with  a  solu- 
tion of  ferrous  sulphate,  very  accurate  results  were  obtained. 

The  volumetric  determination  of  arsenic  acid  by  means  of  uranic 
acetate  in  the  presence  of  free  acetic  acid  and  an  alkaline  acetate, 
did  not  yield  trustworthy  results. — ZeitscJir.f.  Anal.  Chem.,  x,  158 — 
183  ;  and  Pharmaceutical  Journal,  November  25th,  1871. 

On  the  distinctions  hetiveem  edible  and  poisonous  Mushrooms. — A 
writer  under  the  initials  W.  Gr.  S.,  gives  the  following  concise  account 
of  the  differences  between  the  edible  mushroom  and  the  poisonous 
fungi  resembling  it.  First  and  foremost,  the  true  mushroom  (Aga- 
ricus  campestris)  is  invariably  found  among  grass  in  rich  open  pastures, 
and  never  on  or  about  stumps  or  in  woods.  Many  cases  of  poison- 
ing have  occurred  owing  to  the  supposed  mushrooms  being  gathered 
from  stumps  or  in  woods.  It  is  true  there  is  a  certain  variety  found 
in  woods  and  woody  places  (A.  silvicola),  but  as  far  as  amateurs  are 
concerned  it  is  best  left  alone.  A  second  very  good  point  is  the 
peculiar  intense  purple-brown  colour  of  the  spores  (which  are  analo- 
gous to  seeds)  ;  the  ripe  and  fully  matured  mushroom  derives  the 
intense  purple-brown  colour  (almost  black)  of  its  gills  from  the  pre- 
sence of  these  innumerable  coloured  spores.  To  see  these  spores, 
and  so  become  acquainted  with  the  peculiar  colour,  remove  the  stem 
from  a  mushroom,  and  lay  the  upper  portion  with  the  gills  lower- 
most on  a  sheet  of  writing-paper ;  in  a  few  hours  the  spores  will  be 
deposited  in  a  thick,  dark,  impalpable  powder.  Several  dangerous 
species,  at  times  mistaken  for  this  mushroom,  have  these  spores 
umber-brown  or  pale  umber-brown  in  colour,  and  belong  to  Fhaliota 
or  Seleloma.  There  are  innumerable  varieties  of  the  true  mush- 
room (and  of  the  horse  mushroom),  but  all  are  equally  good  for  the 
table.  Sometimes  the  top  is  white  and  soft,  like  kid  leather;  at 
other  times  it  is  dark  brown  and  scaly.  Sometimes  on  being  cut  or 
broken  the  mushroom  changes  colour  to  yellow,  or  even  bright  red ; 
at  other  times  no  change  whatever  takes  place.  But  observe,  the 
mushroom  always  grows  in  pastures ;  always  has  dark  purple-brown 


1872.]      Report  on  Toxicology,  Forensic  Medicine ^  ^c.         263 

spores ;  always  has  a  perfect  encircling  clothy  colour ;  and  always 
gills  which  do  not  touch  the  stem,  and  a  top  with  an  overlapping 
edge. — The  Garden;  and  The  World  of  Science,  December  10th,  1871. 

Phosphorus  Poisoning  said  to  he  cured  hy  Oil  of  Turpentine. — Dr. 
Lichtenstein  reports  of  a  girl  nineteen  years  old,  who  cooked 
with  a  steak  of  meat  the  heads  of  eight  friction  matches,  and 
partook  of  the  same  for  food.  Soon  after — precise  time  not  given — 
she  was  attacked  with  a  pain  in  the  stomach  and  vomiting  of  phos- 
phorescent matter  mixed  with  coagula  of  blood.  Twelve  drops  of 
01.  Terebinthinae  in  milk  being  administered,  the  pain  in  the  stomach 
and  vomiting  ceased.  Subsequently  the  vomiting  returned,  the  dis- 
charges presenting  traces  of  blood  but  none  of  phosphorus.  An 
emetic  of  Ipecacuan.  and  Tartrate  of  Antimony  was  given,  and  the  tur- 
pentine in  barley  water  continued.  The  vomiting  now  became  almost 
entirely  free  from  blood,  and  at  the  end  of  two  hours  the  only  complaint 
made  was  of  loss  of  appetite ;  no  after  symptoms.  The  case  is  adduced 
by  Dr.  Lichtenstein  as  a  further  evidence  of  the  correctness  of  the 
reports  of  Personne,  Andans,  Kohler,  and  others  in  favour  of  oil  of 
turpentine  as  an  antidote  against  poisoning  by  phosphorus. 

In  a  comment  upon  the  report  of  Dr.  Lichtenstein  and  his  con- 
clusion. Dr.  Schultzen  remarks,  that  during  a  few  years  past  he  has 
observed  in  the  wards  of  the  Berlin  "  Charite"  some  thirty  to  forty 
cases  of  phosphorus  poisoning,  of  which  nearly  one  half  terminated 
favorably,  notwithstanding  no  oil  of  turpentine  was  given.  The 
prognosis  of  a  favorable  event  is  to  be  based  solely  upon  the  occur- 
rence of  free  vomiting,  either  spontaneously  or  induced,  soon  after 
the  poison  has  been  taken.  In  Dr.  Lichtenstein' s  case  vomiting  set 
in  immediately  after  the  phosphorus  was  swallowed,  and,  according 
to  Dr.  Schultzen,  to  this  is  to  be  mainly,  if  not  entirely,  attributed 
the  safety  of  the  patient. — Berlin  Klin.  WochenscJir ;  and  American 
Journal  of  the  Medical  Sciences,  July,  1871. 

Snahe  Poison. — Dr.  Shortt  states  that  the  numerous  experiments 
he  has  conducted  duriog  the  last  four  years,  not  only  in  Madras, 
but  in  most  of  the  districts  of  this  presidency,  lead  him  to  believe 
that  when  an  animal  is  fairly  wounded,  and  has  had  poison  injected 
into  the  wound,  be  the  quantity  small  or  large,  in  man  or  beast, 
death  is  sure  and  certain,  with  this  exception,  that  when  the  poison 
is  long  retained  in  the  poison  sacs,  and  is  thus  to  a  certain  extent 
concentrated  by  the  absorption  of  the  watery  parts,  and  the  quantity 
large,  death  is  almost  instantaneous,  and  it  is  a  question  of  so  many 
minutes;  but  when  the  poison  is  weak  from  frequent  and  rapid 
secretion,  or  the  quantity  small,  death  is  more  prolonged,  and 
it  is  then  a  matter  of  hours.  The  cobra  poison  is  so  active  and 
energetic  that  five  sixths  of  a  grain  of  the  fluid  poison  killed  a  large 
Persian  horse  in  twenty-four  hours  and  twenty-five  minutes,  and  one 
twelfth  of  a  grain  killed  a  full-grown  dog,  weighing  18  lbs.,  in 
twenty-five  minutes.  These  cases,  as  well  as  the  experiments  con- 
ducted by  Dr.  Shortt  and  others,  are,  he  says,  fully  conclusive  as  to 
the  worthlessness  of  ammonia  as  an  antidote. — Ibid, 


264  Chronicle  of  Medical  Science.  [J 


an. 


Three  cases  of  poisoning  hy  Whislcey  in  cJiildren. — Dr.  P.  De 
Marmon,  of  King's  Bridge,  New  York,  reports  in  a  most  able  paper 
three  cases  of  acute  poisoning  by  whiskey  in  young  children,  two  of 
the  cases  ending  fatally.  In  one  case  a  child  aged  five  years  took  a 
tumbler  full  of  whiskey  at  six  o'clock  in  the  evening,  it  was  not  seen 
by  a  medical  man  until  nine  in  the  evening,  it  was  then  comatose, 
the  respiration  was  stertorous  and  82  in  the  minute ;  the  jmlse  was 
full,  irregular,  but  rather  slow  ;  the  temperature  taken  in  the  axilla 
was  93i°  F.  The  action  of  the  bowels  and  of  the  bladder  was 
involuntary  :  death  occurred  nineteen  hours  after  the  ingestion  of 
the  fatal  drink.  In  the  second  case  a  little  girl  five  years  old  took 
a  tumbler  full  of  whiskey  and  beer  at  five  o'clock  in  the  afternoon. 
The  draught  was  given  to  her  by  a  lad  fifteen  years  old.  She 
soon  became  comatose,  and  her  temperature  fell  to  94i°  F.,  her 
respirations  being  80  per  minute,  and  the  beats  of  her  pulse  60. 
The  child  was  kept  warm,  and  was  treated  freely  with  liquor 
ammonise  acetatis,  two  ounces  of  which  was  administered  at  once  in 
an  enema.  In  the  end  recovered.  The  third  case  was  that  of  a 
child,  a  boy  eight  years  old,  who  took  a  quantity  of  whiskey  at  eight 
o'clock  in  the  morning.  This  patient  was  treated  by  another 
physician  with  mustered  emetics :  he  died  twenty  hours  after  the 
ingestion  of  the  poison.  The  post-mortem  revealed  imperfect 
cadaveric  rigidity  and  intense  congestion  of  lungs  ;  the  internal 
bronchial  surface  was  livid,  and  coated  with  bloody  spumous 
mucosities.  The  kidneys  were  also  congested.  The  head  was  not 
examined.  The  liver  was  congested,  and  the  gall  bladder  was  less 
than  half  full. 

Dr.  De  Marmon  in  commenting  on  these  cases  gives  the  following 
suggestions  on  the  subject  of  treatment  in  cases  of  acute  alcoholic 
poisoning. 

1 .  When  called  to  see  a  case  of  poisoning  by  alcohol,  care  must  be 
taken  if  but  a  short  time  has  elapsed  after  the  ingestion  of  the  liquid, 
and  none  has  been  vomited,  to  give  an  emetic  immediately.  Dr. 
De  Marmon  prefers  brown  emetine  to  any  other,  inasmuch  as,  in  a 
dose  of  from  two  or  four  grains  for  an  adult,  it  produces  emesis 
almost  immediately  without  nausea. 

2.  Keep  the  patient  warm,  but  not,  as  some  persons  do,  take  him 
out  of  doors  under  the  pretext  that  fresh  air  will  do  him  good ;  it  is 
a  very  great  mistake,  as  a  man  who  is  only  half  intoxicated  in  a 
warm  room,  may  become  quite  drunk  by  going  out  in  the  cold  air. 

3.  Grive  liquor  ammonisB  acetatis  in  large  and  repeated  doses  to 
fluidify  the  blood  and  re-establish  the  circulation. 

4.  When  the  patient  is  not  seen  until  a  long  time,  say,  from  two 
to  six  or  eight  hours  after  the  alcohol  has  been  taken,  the  comatose 
state,  the  stertorous  respiration,  the  decrease  of  the  pulse,  cold  tem- 
perature, and  accelerated  respiration  are  noticed  ;  it  is  then  probable, 
if  the  patient  has  not  vomited,  that  the  greatest  part  of  the  liquid 
taken  may  have  been  absorbed.  In  this  case  warm  applications,  and 
liquor  ammonisB  acetatis  in  large  and  repeated  doses  must  be  given 
immediately,  an  emetic  being  of  no  use,  for  several  reasons  :  1.  Be- 


1872.]      Report  on  Toxicology ^  Forensic  Medicine ,  ^c,         265 

cause  in  such  bad  cases  and  after  sucli  a  lapse  of  time,  the  stomach, 
cesophagus,  and  pharynx,  are  almost  always  paralysed,  and  the 
emetic  can  have  no  efi'ect ;  2.  Because,  being  usually  given  in  larger 
doses  for  the  purpose  of  producing  emesis,  it  only  adds  to  the  severity 
of  the  case.  The  author  would  say  the  same  of  all  mechanical  means 
used  for  irritating  the  pharynx  and  larynx,  with  the  view  of  pro- 
ducing emesis,  inasmuch  as  these  parts  are,  as  already  said,  paralysed, 
and  the  stomach  pump  being,  if  supposed  necessary,  the  only  avail- 
able means. — JVew  York  Medical  Journal,  December,  1870. 

Case  of  poisoning  with  sugar  of  lead. — Dr.   Maschka  relates  the 
following  case  of  poisoning  with  sugar  of  lead  : 

A  draper,  J.  E/ — ,  69  years  old,  married  a  woman  of  25,  and 
lived  happily  with  her,  the  girl  was  in  love,  however,  with  a  postilion. 
After  J.  It.  had  been  ill  several  days,  and  had  refused  all  advice,  he 
became  so  seriously  ill  that  a  physician  was  obliged  to  be  called  in  on 
the  3 1  st  of  March,  1 868.  At  that  time  he  was  suffering  from  yellow- 
ness of  the  conjunctiva,  loss  of  appetite,  eructation,  accumulation  of 
phlegm  on  the  chest,  and  attacks  of  giddiness.  The  evacuations  were 
normal,  the  thirst  not  increased,  the  pulse  from  80  to  90,  the  tongue 
coated.  The  man  also  felt  weak.  The  physician  ordered  an  emetic 
which  took  effect  several  times,  and  lemonade  and  such  things  were 
given.  On  the  following  day  the  weakness  and  other  symptoms  had 
so  increased  that  sulphate  of  quinine  and  bicarbonate  of  soda  were 
administered  to  the  patient,  on  the  2nd  of  April  he  was  evidently 
better  and  stronger,  ate  some  soup  and  plums,  and  wished  to  leave 
his  bed.  On  the  evening  of  the  same  day  he  became  worse  and  vomited 
several  times  when  Dr.  Maschka  was  summoned.  The  quinine  was 
discontinued  and  lemonade  only  given.  At  eleven  o'clock  the  same 
evening  the  patient  again  became  worse,  and  on  his  second  arrival  the 
physician  found  the  man  dying,  his  eyes  fixed,  his  breathing  short  and 
rattling,  the  pulse  weak, and  the  extremities  cold :  in  a  short  time  death 
ensued.  As  during  the  whole  time  of  the  attendance  neither  colic, 
cramp,  stoppage  nor  contraction  of  the  stomach  had  been  observed, 
neither  any  evacuation  of  blood  seen,  the  physician  considered  the  ill- 
ness and  death  arose  from  want  of  proper  diet,  and  cold,  and  when  the 
report  of  his  death  having  been  caused  by  poisoning  by  sugar  of  lead 
was  spread  he  immediately  denied  the  probability  of  the  report.  As 
the  report,  however,  continued  and  a  great  deal  of  sugar  of  lead  had 
been  found  in  the  house,  kept  nominally  for  killing  vermin  and  cleaning 
the  linen,  suspicions  fell  upon  the  widow  of  the  deceased,  and  twenty 
days  after  death  the  body  was  exhumed.  The  contents  of  the 
stomach  and  bowels  were  chemically  analysed,  and  found  to  be  very 
rich  in  lead  (yielding  in  240  grammes  of  the  contents  of  the 
stomach,  0*45  grammes  of  sulphuret  of  lead.)  The  whole  quantity  of 
sugar  of  lead  taken  just  before  the  increased  symptoms  preceding  the 
death  was  said  to  have  been  20"  12  grammes. —  Wien  Med.  WocJienschr., 
xxi,  14,  1871. 


266  Chronicle  of  Medical  Science,  [Jan., 

II.  Hygiene. 

Dr.  Polli,  of  Milan,  publishes  an  instruction  on  the  method  of 
applying  the  therapeutic  sulphites  for  the  prevention  and  cure  of 
epizootic  diseases,  carbuncular  fever,  bovine  typhus,  cattle  plague. 
The  belief  of  the  value  of  the  sulphites  rests  on  the  theory  that  in 
the  diseases  named  there  is  a  peculiar  morbific  fermentation  of  the 
blood ;  to  arrest  this  decomposition  constitutes  the  cure,  to  prevent 
it  constitutes  the  prophylactic  of  the  disease. 

"With  this  intent  a  remedy  is  needed  which  the  animal  economy 
can  tolerate  even  in  large  doses  without  inconvenience,  which  may 
possess  the  property  of  rendering  the  organization  unsusceptible  to 
the  influence  of  contagious  ferments,  and  which,  while  arresting  the 
effects  of  them,  may  permit  it  to  fulfil  its  healthy  eliminations.  This 
remedy  is  the  combination  of  sulphurous  acid  with  alkaline  and 
earthy  bases.  Sulphite  of  soda,  from  its  solubility  and  cheapness,  is 
the  most  suitable  as  a  curative,  while  hyposulphite  of  soda,  which 
undergoes  oxydation  during  its  passage  into  the  organism,  albeit 
converted  into  sulphate,  is  the  most  convenient  as  the  prophylactic. 

Preservative  treatment. — When  sheep,  oxen,  or  other  animals  are 
liable  to  infection,  either  directly  or  indirectly,  the  preservative 
treatment  should  be  carried  out  in  the  following  manner :  For  every 
ox  a  solution  should  be  made  consisting  of  100  grammes  of  hyposul- 
phate  of  soda  in  1  litre  of  water,  with  the  addition  of  20  or  30  grms. 
of  common  salt  to  render  it  more  palatable  and  to  strengthen  its 
action.  One  half  of  this  solution  should  be  administered  in  the 
morning  and  the  other  half  in  the  evening,  by  means  of  the  bottle ; 
or  it  may  be  given  in  the  form  of  boluses,  after  which  the  animal 
should  be  made  to  take  several  litres  of  water.  No  food  should  be 
given  to  the  animal  for  one  hour  after  the  salt  has  been  administered, 
and  two  hours'  fast  should  be  observed  before  it  is  taken. 

This  treatment  ought  to  be  continued  while  the  epidemic  is  in  the 
vicinity  where  the  cattle  are  kept. 

If  the  animals  under  treatment  suff'er  from  too  profuse  action  of 
the  bowels  the  doses  should  be  modified,  or  not  given  so  frequently, 
as  the  proposed  remedy  is  not  intended  to  be  purgative,  but  to  be  ab- 
sorbed and  conducted  with  the  blood  into  the  whole  economy,  so  as 
to  give  to  the  blood  the  property  of  resisting  morbific  ferments. 

For  sheep  and  goats  the  dose  should  be  reduced  about  one  third ; 
that  is  to  say,  20  grammes  in  the  morning  and  the  same  in  the 
evening  of  the  hyposulphite  in  the  form  of  potion  or  bolus,  with  the 
addition  of  a  little  common  salt  as  before  mentioned. 

During  this  treatment  the  utmost  cleanliness  should  be  observed 
in  the  stables,  plenty  of  fresh  air  admitted,  and  the  purest  water 
and  the  best  food  given  to  the  animals. 

Curative  treatment. — Where  the  epidemic  shows  itself  among 
cattle  all  the  healthy  ones  should  be  immediately  subjected  to  the 
already -named  prophylactic  treatment,  and  to  the  sick  animals  the 
sulphite  of  soda  should  be  administered. 

For  oxen  the  dose  would  be  from  100  to  150  grammes  of  sulphite 


1872.]     Report  on  Toxicology y  Forensic  Medicine ^  ^c.         267 

of  soda  dissolved  in  one  litre  of  water,  together  with  50  grammes  of 
common  salt,  one  half  to  be  taken  in  the  morning  and  the  other  half 
in  the  evening.  If  made  into  boluses  a  plentiful  supply  of  water  should 
be  given  to  the  animal,  and  the  same  regulations  should  be  observed 
as  regards  the  food  as  after  the  administration  of  the  hyposulphite. 

Great  cleanliness  of  the  stables,  keeping  up  of  constant  ventilation, 
pure  water,  and  frequent  renewal  of  the  straw  or  bed,  are  indispen- 
sable requisites  for  the  success  of  the  treatment. 

In  "  L'afta  epizootica"  the  pustules  and  ulcerations  of  the  lips, 
mouth,  and  tongue,  and  also  the  teats  and  clefts  in  the  hoofs  should 
be  washed  and  bathed  frequently  with  tow  dipped  in  a  solution  of 
one  part  of  sulphite  of  soda  and  ten  parts  water,  made  fresh  every 
day.  The  same  treatment  should  be  observed  with  ulcers  after  car- 
buncular  fever  or  the  cattle  plague.  The  most  useful  detergent  when 
the  flesh  is  in  wounds  during  any  epidemic,  is  that  made  of  a  con- 
centrated" solution  of  sulphite  of  soda,  which  can  be  used  in  the 
proportion  of  one  part  of  sulphite  with  six  of  water. 

If  the  animal  is  unable  to  take  the  dose  prescribed  the  same  solu- 
tion must  be  administered,  increasing  it  from  one  third  to  one  fourth 
of  the  salt,  or  diluting  it  with  double  the  quantity  of  water  by  means 
of  clysters,  by  the  straight  gut,  dividing  it  into  four  doses.  During 
the  employment  of  this  remedy  great  care  should  be  taken  to  avoid, 
externally  and  internally,  every  acid  substance. 

The  dose  of  sulphite  of  soda  for  smaller  animals  must  be  reduced 
in  proportion  from  30  to  40  grammes  per  day,  in  two  doses,  and 
administered  with  the  same  rules  as  were  to  be  observed  with  the 
larger  animals. 

The  faeces  of  animals  treated  with  hyposulphites  and  sulphites 
give  off  a  strong  exhalation  of  hydrosulphuric  acid,  which,  although 
disagreeable,  is  not  injurious.  It  may  almost  be  considered  as  a 
purifier  in  the  stable,  since  on  entering  the  respiratory  tract  there  is 
reproduction  of  sulphurous  acid  and  of  sulphites.  If  the  smell  should 
inconvenience  the  attendants  the  stable  might  be  fumigated  with 
chlorine  once  or  twice  during  the  twenty-four  hours.  "With 
this  the  hydrosulphuric  acid  gas  diffused  in  the  atmosphere  is 
destroyed,  and  it  suf&ces  for  this  purpose  to  place  half  a  kilogramme 
of  chloride  of  lime  in  an  earthen  vessel  and  mix  it  with  twice  its  own 
weight  of  water,  and  then  add,  drop  by  drop,  about  one  of  its  weight 
of  oil  of  vitriol ;  the  gas  which  immediately  evolves  and  diffuses 
itself  in  the  air  purifies  it  from  the  sulphuretted  hydrogen  by  direct 
decomposition. 

The  prophylactic  treatment  may  be  carried  on  for  any  length  of 
time  without  injury  either  to  the  flesh  or  the  milk  of  the  animals ; 
the  milk  requiring  less  rennet  to  prepare  it  for  cheese,  and  the  flesh 
remaining  fresh  and  free  from  putrefaction  longer  than  that  of  the 
animals  not  under  treatment. 

As  the  sulphite  treatment  has  not  the  effect  of  destroying  the 
cause  or  the  morbific  ferment,  but  by  means  of  a  particular  action  of 
rendering  the  organic  components  of  the  animal  economy  unassaiL 
able  by  morbific  ferments,  it  will  be  easy  to  understand  its  use  in  all 


268  Chronicle  of  Medical  Science.  [J 


an, 


these  diverse  epidemics,  as  well  as  in  others  which  have  the  common 
characteristic  of  morbific  fermentation. 

In  introducing  modifications  of  this  treatment  it  must  be  remem- 
bered that  the  hyposulphites  of  soda  are  rather  more  purgative  than 
the  sulphites  ;  and  that  in  affections  of  the  blood  the  mucous 
mfembrane  gastro-intestinal  tract  is  always  more  or  less  inclined  to 
hypersecretion. — Istruzione  intorno  al  modo  di  applicare  la  terapeia 
foljitica  nelle  epozoozie^  e  principalemente  nelV  afta  epozootica  {tag- 
lione)  nella  febhre  carhonchiosa  {antrdce)  e  nel  tifo  honino  {peste 
hovina).     Dell  Bott.  Giovanni  Folli. 

On  tlie  relative  powers  of  various  substances  in  preventing  the 
generation  of  animalculcd  or  the  development  of  their  germs,  with  spe- 
cial reference  to  putrefaction. — Dr.  John  Dugall,  under  the  head 
given  above-named,  communicates  one  of  the  best  essays  we  have 
for  some  years  past  read  on  the  question  of  putrefactive  change. 
There  is  in  the  paper  solid  experiment  and  very  little  speculation. 
The  object  of  the  author  was  not  to  inquire  whether  the  minute 
animated  specks,  called  in  general  animalcula),  are  generated  or 
developed,  but  how  their  propagation  could  be  retarded  or  prevented. 
Three  series  of  experiments  were  made,  one  on  vegetable  and  two  on 
animal  matter ;  while  sixty-seven  substances  were  selected  for  the 
trial  of  their  antiseptic  properties.  The  mode  of  experiment  was  as 
follows : — To  three  drachms  of  a  solution  consisting  of  one  part  of 
the  substance  to  be  tested,  in  500  parts  of  water,  was  added  one 
drachm  of  a  filtered  solution  of  hay,  of  the  strength  of  half  a  drachm 
of  dried  hay  to  a  fluid  ounce.  This  mixture  was  put  into  a  phial ; 
when  the  substance  was  volatile  the  phial  was  kept  closed,  otherwise 
it  was  left  open.  The  modi^s  operandi  with  the  animal  substance  was 
similar ;  the  only  diff'erence  being  that  human  urine  was  substitued 
for  infusion  of  hay  in  one  set  of  experiments,  and  a  mixture  of  beef 
juice  and  egg  albumen  in  another,  only  half  a  drachm  of  the  latter 
mixture  being  added  to  three  drachms  and  a  half  of  the  test  solu- 
tions. Three  blank  experiments  were  first  made ;  that  is  to  say, 
three  phials  were  filled  respectively  with  water  and  infusion  of  hay, 
water  and  urine,  and  water  with  juice  of  flesh  and  egg  albumen 
only,  in  order  that  any  contrast  in  the  growth  of  animalculae  in  the 
simple  and  supposed  preventive  solutions  might  be  noted.  All  the 
phials  when  filled  were  placed  in  a  medium  temperature  of  about 
60°  Fahr.  and  exposed  to  a  moderate  light.  In  two  to  six  days  the 
microscopical  examination  of  each  series  with  a  magnifying  power  of 
700  diameters,  was  begun  and  concluded.  The  simple  solutions 
were  found  teeming  with  bacteria,  vibriones,  monads,  amosbsB,  torulse. 
The  results  of  the  test  examinations  of  the  various  test  solutions 
were  necessarily  of  two  kinds,  life  or  no  life ;  the  one  or  other  being 
inferred  from  the  presence  or  absence  of  moving  bodies  only.  No 
notice  was  taken  of  fungi,  which  were  generally  more  or  less  pre- 
sent, especially  in  the  vegetable  solutions.  The  experiments  were 
afterwards  repeated  under  various  forms  of  modification.  The  sub- 
stances used  for  preservation  were  classified  into  fifteen  groups,  viz. 
metallic  salts,  organic  acids,  salts  of  the  alkaline  earths,  inorganic 


1872.]     Report  on  Toxicology,  Forensic  Medicine,  ^c.         269 

acids,  alcohol  and  its  derivatives,  inorganic  bases,  organic  salts,  inor- 
ganic alkaline  salts,  volatile  juices,  aromatic  oils,  organic  bases,  bitter 
extracts,  animal  substances,  aromatic  extracts,  poisonous  vegetable 
extracts,  spirituous  and  aqueous.  Of  all  these  in  tlieir  respective 
groups  sulphate  of  copper  shows  the  highest  average  preventive 
power  amongst  the  metallic  salts,  benzoic  acid  amongst  the  organic 
acids,  chloride  of  aluminium  amongst  the  salts  of  the  alkaline 
earths.  Amongst  the  organic  acids  the  carbolic  holds  a  very  low 
place;  it  occupies  the  "fifth  rank,"  a  position  we  were  fully  pre- 
pared to  see  it  in.  Permanganate  of  potassa  stands  second  in  its 
group,  but  has  a  comparatively  low  average  of  preservative  power. 
Sulphurous  acid  stands  low  in  its  group ;  hydrocyanic  acid  stands 
very  high,  and  so  does  chromic  acid.  This  latter  acid,  says  the 
author,  is  unquestionably  an  antiseptic  of  surpassing  power,  and 
must  ere  long  take  the  foremost  place  as  a  sanitary  agent. 

After  giving  the  details  of  this  inquiry.  Dr.  Dougall  draws  certain 
important  conclusions  from  them.  First,  he  maintains  that  it  does  not 
appear  that  germs  are  the  cause  of  putrefaction  ;  on  the  contrary,  decom- 
position precedes  germs,  and  the  first  inference,  therefore,  is  drawn 
— after  the  teaching  of  Professor  Owen,  on  the  uses  in  nature  of  the 
infusoria — that  the  uses  of  the  animalculsB  are  to  destroy  and  remove 
the  products  of  putrefaction,  in  which  they  find  the  proper  conditions 
and  elements  for  their  temporary  existence.  Secondly,  Dr.  Dougall 
supports  the  old  theory  that  the  cause  of  putrefaction  is  oxygen  ;  and, 
thirdly,  he  suggests  that  the  mode  in  which  certain  substances  pre- 
vent the  appearance  of  putrefaction  and  of  animalculse  is  by  exhaling 
constantly  a  destructive  atmosphere  on  the  myriads  of  animalcules 
which  are  perpetually  remaining  in  the  neighbourhood  of  organic 
matter  ;  the  preventive  matter  either  permanently  destroys  the  ova, 
or  suppresses  development  for  an  indefinite  time,  or  renders  the  soil 
inimical  to  their  growth,  whether  they,  the  ova,  be  considered  as 
lodged  in  the  putrescible  substance  previous  to  the  "addition  of  "  the 
preventive,"  or  as  continuously  depositing  on  it  subsequently. — 
From  paper  read  at  the  meeting  of  the  British  Association  for  the 
Advancement  of  Science,  1871,  and  separately  published. 

III. — Summary. 

The  complete  History  of  the  Welsh  Fasting  Girl,  Sarah  Jacob,  ivith 
Co7nments  thereon  and  Observations  on  Death  from  Starvation.  By 
Eobert  Fowler,  M.D. — This  book,  for  it  is  a  goodly  volume,  supplies  a 
full  history  of  the  painful  case  of  Sarah  Jacob,  and  a  report  of  the  trial 
of  her  parents  for  manslaughter.  Dr.  Powler  has  acquitted  himself 
of  his  task  well,  and  has  introduced  many  points  of  peculiar  interest 
in  a  medico-legal  sense.  His  definitions  of  death  from  acute  as  dis- 
tinguished from  chronic  starvation,  and  of  the  appearances  after 
death,  are  most  judicious,  and  we  had  almost  said  judicial.  As  we 
propose  to  notice  the  work  in  a  separate  article,  it  is  sufficient  to  say 
now  that  the  author  sets  forth  two  propositions : — one^  that  death 
from  starvation  is  equivalent  to  death  from  cold;  two,  that  the  pre- 


270  Chronicle  of  Medical  Science.  [Jan., 

sence  of  fat  in  the  body  and  the  absence  of  attenuation  of  the  intes- 
tines are  conditions  compatible  with  death  from  acute  starvation. 

Process  of  Disinfection  with  Chlorine.  By  M.  Eegnauld. — The 
fumigation  to  which  mattresses  and  bedding  of  all  kinds  more  or  less 
infected  during  contagious  diseases  are  subjected,  is  carried  out  by 
the  author  in  the  following  manner : — 500  grammes  of  a  mixture  of 
hypochlorite  of  lime  and  the  chloride  of  lime  used  in  trade  are  placed 
in  a  linen  bag  holding  about  one  litre,  at  a  temperature  of  100°  C  ; 
the  bag  is  then  closed.  This  bag  is  placed  in  an  earthen  pan  con- 
taining 1  litre  of  ordinary  hydrochloric  acid  and  3  litres  of  water. 
As  soon  as  the  chloride  comes  gradually  into  contact  with  the  liquid 
acid,  all  the  openings  of  the  room  in  which  the  mattresses  and 
bedding  are  suspended  are  to  be  closed,  and  the  infected  things  are 
to  be  exposed  to  the  gaseous  vapours  for  twenty-four  hours ;  the 
doors  and  windows  of  the  room  should  then  be  left  wide  open  for 
forty-eight  hours. 

Ten  vessels  prepared  as  above,  giving  off  500  litres  of  chlorine,  are 
sufficient  to  disinfect  from  twenty  to  twenty-five  mattresses  more  or 
less  infected. — Journal  de  Fharmacie,  Jan.,  1871. 

Case  of  Saturnismus  from  taMng  Snuff  containing  Sugar  of  Lead. 
By  Dr.  Wenz. — A  case  of  much  value  is  communicated  by  Dr.  Wenz, 
of  a  man  forty-nine  years  of  age,  who  had  long  suffered  from  gastric 
disease.  He  was  melancholy  and  misanthropic,  became  indifferent 
to  his  wife  and  children,  and  complained  much  of  having  to  move, 
eat,  write,  dress ;  he  suffered  from  extreme  tremor  of  the  limbs  and 
from  dysuria,  and  had  considerable  atrophy  of  the  muscles  of  the 
shoulder  and  forearm.  The  muscles  supplied  by  the  radial  nerve 
on  the  dorsal  side  of  the  forearm  and  the  interossei  were  specially 
affected  (with  the  exception  of  the  supinator  longus),  and  this  cir- 
cumstance, which  the  electro-therapeutic  treatment  of  the  patient 
suggested,  first  led  to  the  correct  diagnosis  of  lead  poisoning. — 
Wilrteinh.  Corr.  Bh.,  xl,  24,  p.  187,  1870;  and  Schmidt' s  J alirhuc her ^ 
Band  151,  No.  8,  1871. 

Poisoning  loith  Mercury  in  the  form  of  Ointment.  Dy  Dr.  Lei- 
blinger. — In  January,  1869,  three  persons  were  found  dead  in  their 
beds  who  had  some  days  before  rubbed  their  bodies  over  with  an 
ointment  made  from  quicksilver,  as  a  cure  for  itch.  At  the  post- 
mortem the  bodies  were  all  alike  in  this  particular,  that  there  was 
nothing  abnormal  except  several  post-mortem  spots  and  marks  on  the 
skin  arising  from  the  eruption  produced  by  the  acarus.  The  inter- 
nal examination  showed  much  blood  in  the  skull,  extreme  fulness  of 
the  sinuses  with  dark  venous  blood,  abnormal  abundance  of  blood  in 
the  brain,  thyroid,  and  windpipe ;  adhesion  of  both  lungs  with  the 
pleura,  congestion  of  the  lungs  with  dark  blue-red  fluid  and  frothy 
blood,  distension  of  the  stomach,  and  hypersemia  of  the  kidneys, 
liver,  and  spleen.  In  the  visceral  organs,  on  their  being  subject 
to   chemical   analysis,   large  quantities  of  mercury  were  found  to 


1872,]       Report  on  Toxicology,  Forensic  Medicine j  ^c,       271 

be  present. —  Wien.  Med.  Wbchnschr.,  xix,  96,  1869;  and  Sdimidfs 
Jahrhucher,  Band  151,  No.  7,  1871. 

Letters  to  the  '  Times*  on  S^nallpox  Encampments,  and  a  word  on  the 
Contagious  Diseases  Acts.  By  Surgeon- Major  T.  Atchison. — Surgeon 
Atchison  in  this  pamphlet  suggests  as  a  means  of  meeting  smallpox 
successfully  when  it  is  epidemic,  that  instead  of  the  costly,  inju- 
rious, and  tardy  system  of  congregating  the  sick  in  hospital  asylums 
or  improvised  lazarettos,  in  a  hitherto  uninfected  neighbourhood,  the 
simple  plan  resorted  to  in  India  should  be  at  once  adopted.  His 
plan  would  be  to  pitch  tents  in  high  and  airy  situations,  to  quaran- 
tine the  encampment,  and  on  the  subsidence  of  the  disease  to  dis- 
infect or  burn  the  camp. — Pamphlet,  London,  1871. 

On  Fluid  Meat :  a  new  preparation  of  Meat,  especially  adapted  to 
weah  stomachs.  By  Stephen  Darby,  F.C.S. — Mr.  Darby's  fluid  con- 
sists of  animal  flesh  brought  by  artificial  digestion  with  pepsin,  and 
hydrochloric  acid,  to  the  state  of  a  peptone.  Bitter  taste  is  removed 
by  the  addition  of  a  small  proportion  of  fresh  pancreas.  The  fluid 
meat  difiers  from  Liebig's  extract  in  that  it  contains  the  albuminous 
flesh-forming  material  of  meat.  One  ounce  by  weight  is  said  to 
equal  the  quantity  of  extract  obtained  by  boiling  from  twenty 
ounces  of  meat. — Pamphlet,  London,  1871. 

Dangerous  effects  of  a  Hypodermic  Injection,  with  extraordinary 
slowness  of  respiration,  and  recovery.  By  Dr.  Frederick  D.  Lente. — 
In  this  case  a  female  patient,  aged  49,  and  somewhat  intemperate, 
was  treated  with  an  injection  of  two  thirds  of  a  grain  of  morphia, 
and,  this  taking  no  eftect  after  twenty  minutes,  one  third  of  a  grain 
more  was  similarly  injected.  About  ten  minutes  later  the  patient 
suddenly  fell  back  on  her  pillow  and  lapsed  into  complete  insensi- 
bility, the  respiration  falling  to  three  and  a  half  per  minute,  and  at 
one  time  to  one  in  a  half  minute,  the  pulse  getting  up  to  150.  In 
six  hours,  after  profuse  perspiration,  she  began  to  recover,  and  ulti- 
mately did  recover. — New  Yorh  Medical  Journal,  vol.  xii,  No.  5. 

Death  from  Chloral  Hydrate. — A  case  of  death  at  Leicester,  from 
chloral  hydrate  taken  in  an  overdose,  is  reported  in  the  '  Pharmaceu- 
tical Journal '  for  November  25th,  1871.  The  person  poisoned  was  a 
Mrs.  Turner,  and  it  was  proved  that  she  took  the  narcotic  of  her 
own  accord  in  order  to  produce  sleep,  as  she  sufiered  from  neuralgia. 
A  point  of  special  medico-legal  importance  raised  at  the  coroner's 
inquest  was  whether  the  bottle  containing  the  narcotic  ought  to 
have  been  labelled  "  poison"  by  the  druggist  (Mr.  Cox)  who  dispensed 
the  article.  The  evidence  showed  that  chloral  hydrate  is  not  among 
the  substances  obliged  to  be  registered  and  labelled  as  a  poison. 

Adulterations  of  Foods  and  their  Microscopical  Detection.  By  W. 
Morris. — Mr.  Morris  maintains  that  adulterations  of  common  arti- 
cles of  food  still  exist  to  a  great  extent.  Of  forty-seven  samples  of 
coftee,  eighteen  were  found  pure ;  of  the  rest  most  were  half  and 


272  Chronicle  of  Medical  Science »  [Jan., 

some  were  wholly  composed  of  chicory,  being  worth  about  sixpence  a 
pound,  while  the  article  called  coffee  sold  at  one  and  fourpence.  Even 
the  chicory  itself  was  impure ;  in  fifty-seven  samples  half  were  adul- 
terated, the  adulterants  being  roasted  wheat,  acorns,  beans,  carrots, 
and  sawdust.  In  bread,  in  fifteen  out  of  twenty  loaves  he  found 
sulphate  of  copper  added  to  give  whiteness.  Mustard  is  invariably 
adulterated  with  flour. — World  of  Science,  December  22Dd,  1871. 

Drainage  of  Calcutta.  Memarlcs  on  Mr.  GlarTc's  Calcutta  Drainage 
Scheme.  By  David  B.  Smith,  M.D. — Mr.  Clark's  plan  for  the  drain- 
age of  the  capital  of  India  is  to  convey  all  liquid  and  solid  sewage 
into  the  river,  as  we  do  in  London.  Dr.  Smith  considers  this  plan 
a  system  of  excellent  drainage,  but  he  objects  to  the  pollution  of 
river  water  with  solid  faecal  sewage,  and  proposes  that  the  faecal 
sewage  shall  be  separately  collected  and  turned  to  useful  account  as 
manure.  From  his  report,  or  address,  it  appears  that  this  is  already 
done  to  some  extent  in  Calcutta.  His  argument,  in  a  sanitary  point 
of  view,  is  conclusive. — Pamphlet,  Calcutta,  1871. 

The  Phosphate  Process  with  Sewage.  By  Messrs.  Forbes  and 
Price. — These  experimenters  described  their  process  at  the  meeting 
of  the  British  Association  in  Edinburgh  in  August  last.  Their  plans 
are  epitomised  as  follows : — The  process  is  in  operation  at  Totten- 
ham. The  sewage,  after  passing  through  some  depositing  tanks  which 
had  been  constructed  for  the  lime  process,  was  pumped  up  at  the 
rate  of  800  or  1000  gallons  per  minute  along  a  carrier  into  a  tank  a 
hundred  yards  long  and  of  gradually  increasing  breadth.  This  tank 
took  three  hours  to  fill.  As  the  sewage  passed  along  the  carrier 
the  chemicals  were  mixed  with  it  thus : — Two  boxes  were  placed  on 
the  carrier,  one  a  few  yards  further  along  it  than  the  other ;  the  first 
contained  the  phosphate  mixture,  the  second  milk  of  lime.  Men 
were  continually  stirring  the  contents  of  each  box,  which  were 
allowed  to  run  continuously  into  the  sewage  as  it  passed  beneath  the 
boxes.  The  amount  of  the  preparation  added  was  not  determined, 
but  was  certainly  much  less  than  the  proportion  indicated  by  pre- 
vious experiments,  viz.  one  litre  to  500,000  gallons  of  sewage. — 
Poj)ular  Science  Review,  October,  1871. 

The  progressive  Physical  Degeneracy  of  our  Town  Populations.  By 
H.  W.  Eumsey,  M.D. — Dr.  Eumsey,  in  an  excellent  paper  on  this 
subject,  states  briefly  the  leading  causes  at  work  in  deteriorating 
town  populations : 

"  The  destructive  influences  at  work  in  the  dwelling  places  of  the 
million  include  Soil-poisoning,  Water-poisoning,  and  Air-poisoning. 
Tl\\e  physique  of  the  people  tends  inevitably  to  deteriorate — (1)  where 
the  soil  is  wet  or  chemically  bad,  or  where  it  is  sodden  by  decompos- 
ing filth ;  (2)  where  the  water  for  domestic  use  conveys  injurious 
matters,  inorganic  or  organic,  from  the  soil,  or  is  polluted  by  sewage, 
by  the  offal  of  slaughter-houses,  or  by  the  refuse  of  trades  and  fac- 
tories, or  where  it  distributes    lead    from  pipes,  or  metallic  and 


1872.]       Report  on  Toxicology,  Forensic  Medicine,  &;c.       273 

organic  matters  from  roofs ;  (3)  where  the  air  within  dwellings  is 
vitiated  by  the  overcrowding  of  inmates,  by  the  want  of  common 
cleanliness,  by  sewer  gases  which  often  convey  specific  infections,  or 
by  arsenical  fumes  from  wall-coverings ;  and  (4)  where  the  atmo- 
sphere outside  of  dwellings  is  defiled  by  smoke  and  noxious  vapours 
from  mineral  and  manufacturing  processes,  by  middens  and  other 
putrefying  accumulations,  and  above  all,  by  the  exhalations  of  an 
excessive  population,  the  density  of  which  in  some  of  our  worst  town 
districts  is  not  less  than  1000  persons  to  the  acre." 

He  concludes,  from  all  the  facts  he  has  observed,  that  comprehen- 
sive, yet  cautious,  measures  are  necessary  for  the  improved  house 
accommodation  of  the  working  classes  of  our  great  towns  over  larger 
areas  of  habitation ;  that,  as  for  the  overcrowding  of  persons  in  a 
house,  so  also  for  the  overcrowding  of  houses  on  a  given  area,  there 
should  be  a  limit  to  density  of  population  fixed  by  law,  at  all  events 
in  the  building  of  dwelling  houses  on  fresh  ground,  as  well  as  in 
rebuilding  them  on  ground  previously  occupied ;  and  that,  for  the 
success  of  such  measures,  the  establishment  of  superior  administra- 
tive authorities,  with  adequate  powers,  is  as  essential  as  it  is  for  the 
execution  of  measures  intended  to  prevent  the  adulteration  and  to 
secure  the  good  quality  of  food ;  or,  again,  for  those  which  protect 
labour  from  abuses  and  unhealthy  conditions  known  to  sap  the 
vigour  of  the  race. — Paper  read  before  the  Social  Science  Association 
at  Leeds,  October  10th,  1871. 

Is  Consumption  Contagious?  By  D.  Travers  Condie,  M.D. — Dr. 
Condie  relates  at  length  three  observations  of  cases  of  consumption 
which  came  under  his  notice,  and  which  seem  to  favour  the  view  that 
without  any  predisposition  the  disease  may  be  induced,  as  if  by  con- 
tagion, subsequently  to  a  close  association  with  patients  labouring 
under  the  malady.  He  admits,  however,  with  perfect  candour  that 
his  illustrations,  striking  as  they  are,  are  simply  exceptional  cases,  a 
trifling  percentage  of  the  entire  number  of  cases  he  has  treated  in  a 
practice  of  fifty-four  years.—  American  Journal  of  the  Medical  Sciences, 
July,  1871. 


97— XLix.  ^  18 


274  Chronicle  of  Medical  Science.  [Jan., 


REPORT    ON     SURGERY. 

By  Alfred  Poland,  F.R.C.S. 

SELECTIONS  FROM  THE   FOREIGN  JOURNALS. 

I. — Three  Cases   of  Bronchocele  successfully  removed  bt 
Wm.  Warren  Gtreene,  M.D. 

The  subject  of  extirpation  of  the  thyroid  gland  in  part  or  whole 
has  always  engrossed  the  serious  attention  of  the  operative  surgeon, 
and  up  to  late  years  this  operation  has  been  generally  considered  as 
inexpedient,  in  consequence  of  its  danger  and  fatality. 

^ButcJier^  in  his  '  Observations  on  Surgery,'  has  revived  the  opera- 
tion, and  proved  the  possibility  and  the  practicability  of  the  removal 
of  the  gland,  and  with  success.  Its  removal  has  also  been  attended 
with  favorable  results  in  other  countries. 

But  it  is  to  Dr.  Warren  Grreene  that  we  are  indebted  for  the  more 
elaborate  detail  of  this  interesting  and  vital  question  respecting  the 
propriety  of  the  operation.  Our  own  personal  experience  in  the 
matter  so  fully  accords  with  the  views  and  sentiments  expressed  by 
Dr.  Greene,  that  we  cannot  do  otherwise  than  quote  his  very  prac- 
tical suggestions  and  opinions.  Dr.  G-reene  gives  a  full  detail  of  his 
cases,  and  then  makes  the  following  remarks  on  the  operation : 

"I  prefer  to  submit  these  cases  to  the  profession  with  very  little 
comment.  They  are  the  only  ones  in  which  I  have  ever  attempted 
the  excision  of  bronchocele,  and  if  they  are  the  last  I  shall  not  regret 
it ;  for  while  their  issue  has  been  so  fortunate,  I  am  sure  that  no 
man  could  witness  even,  much  less  perform,  these  operations,  and 
envy  the  man  upon  whose  lot  it  fell  to  undertake  them.  Tet,  under 
similar  circumstances,  I  should  not  shrink  from  such  responsibility, 
and  this  for  the  reason  that  the  possibility  of  successful  extirpation, 
even  of  the  worst  cases,  is  established;  and  I  believe  the  operation, 
performed  in  the  manner  I  have  indicated,  may  claim  quite  as  secure 
a  place  among  legitimate  derniers  ressorts  as  amputation  at  the  hip- 
joint. 

"  The  several  steps  of  the  operation,  as  I  perform  it,  are  briefly 
these : 

"  1.  Exposure  of  the  tumour  by  linear  incisions  of  ample  length, 
avoiding  most  sedulously  any  wounding  of  the  tumour  or  its  fascia 
propria. 

"  2.  Division  of  the  fascia  propria  upon  the  director, 

"3.  Its  reflection  and  the  enucleation  of  the  tumour  with  the 
fingers  and  handle  of  the  scalpel,  paying  no  attention  to  haemorrhage, 
however  profuse,  but  going  as  rapidly  as  possible  to  the  base  of  the 
gland  and  compressing  the  thyroid  arteries. 

"  4.  Transfixion  of  the  pedicle  from  below  upwards  with  a  hlunt 
curved  needle  armed  with  a  double  ligature,  and  tying  each  half,  or 


1872.]  Report  on  Surgery.  275 

when  practicable,  dividing  the  pedicle  into  as  many  portions  as  there 
are  main  arterial  trunks,  and  tying  each  portion  separately. 

"  5.  Excision  of  the  gland  and  subsequent  dressing  of  the  wound, 
as  in  ordinary  cases. 

"  In  conclusion^  I  cannot  refrain  from  one  word  of  warning  to  my 
younger  brethren  whose  ambition  may  make  their  fingers  tingle, 
lest  they  should,  in  the  light  of  these  successful  cases,  be  too  easily 
tempted  to  interfere  with  these  growths.  It  is,  and  always  will  be, 
exceedingly  rare  that  any  such  interference  is  warrantable  ;  never 
for  relief  of  deformity  ov  discomfort  merely,  only  to  save  life;  and  if 
it  is  beyond  all  question  determined  in  any  given  case  that  such  an 
operation  gives  the  only  chance  for  snatching  a  fellow  being  from  an 
nntimely  grave,  be  it  remembered  that  accurate  anatomical  know- 
ledge, and  a  perfect  self  control  under  the  most  trying  ordeals 
through  which  a  surgeon  can  pass,  are  indispensable  to  its  best  per- 
formance." 

We  cannot  forbear  quoting  in  full  the  accurate  details  of  the 
operation  as  performed  by  Dr.  Grreene  in  each  of  his  cases,  and  the 
perusal  of  which  may  prove  of  essential  service  to  those  who  may  be 
disposed  to  undertake  the  operation  in  future. 

Case  1. —  On  raising  upon  the  director  the  little  thin  layer  of 
fascia  immediately  investing  the  tumour,  several  veins  were  wounded 
and  bled  profusely ;  this  was  controlled  by  the  fingers  of  an  assis- 
tant, and  the  delicate  envelope  carefully  reflected  from  the  gland ; 
but  although  this  was  done  with  the  utmost  caution  and  gentleness, 
several  other  veins  were  ruptured.  I  now  found  that  the  entire 
growth  was  completely  covered  with  a  network  of  these  vessels  ;  and 
so  thin  and  tender  were  their  walls,  that  the  forceps  tore  and  the 
ligature  cut  their  coats ;  and  now,  although  the  blade  of  the  knife 
had  not  touched  the  surface  of  the  tumour,  so  many  of  these  veins 
were  opened,  that  in  spite  of  all  pressure  that  could  be  made  the 
hsBmorrhage  was  fearful.  I  now  rapidly  separated  the  areolar  attach- 
ments, and  in  a  few  seconds  was  at  the  pedicle,  which  I  found  con- 
taining three  large  arteries  whose  pulsations  were  very  distinct,  and 
which  were  my  guide  for  dividing  the  pedicle  into  three  parts,  which 
I  also  accomplished  with  my  fingers.  I  immediately  tied  each  third 
with  a  ligature  composed  of  eighteen  strands  of  saddlers'  silk,  satu- 
rated with  wax  and  loosely  twisted.  As  I  drew  the  last  cord  all 
haemorrhage  instantly  ceased.  The  pedicle  was  divided  close  to  the 
goitre  and  it  removed.  During  the  dissection  I  found  at  one  point 
the  tumour  quite  firm,  and  adherent  to  the  structure  of  the  vessels ; 
and  while  separating  it,  a  gush  of  venous  blood  indicated  the  rupture 
of  a  large  vessel.  The  finger  of  an  assistant  controlled  it  until  the 
ablation  of  the  bronchocele,  when  on  examination  it  proved  to  be  the 
internal  jugular  vein  wounded ;  this  was  tied  with  a  ligture  of  three 
strands  of  silk  loosely  twisted ;  no  other  vessel  needed  interference. 
The  main  operation  occupied  twenty-two  minutes. 

Case  2. — Having  divided  its  delicate  fascia  propria,  I  proceeded 
with  the  greatest  care  to  separate  the  fascia  and  enucleate  the 
tumour.     This  was  done  almost  entirely  by  the  fingers  and  the  ban- 


276  Chronicle  of  Medical  Science.  [J 


an., 


die  of  the  scalpel.  The  difficulty  of  this  procedure  will  be  appre- 
ciated when  I  state  that  the  deepest  portion  of  the  gland  was  im- 
dedded  in  what  seemed  to  be  a  mass  of  organized  lymph,  through 
the  medium  of  which  it  was  attached  to  the  oesophagus.  So  firm 
was  the  adhesion,  that  I  refrained  from  completing  the  separation 
entirely  with  the  fingers  or  instruments,  lest  I  might  lacerate  the 
tumour  and  produce  severe  haemorrhage.  No  vessels  of  large  size 
were  found  on  the  surface  of  the  growth,  but  two  large  arteries  were 
felt  pulsating  powerfully  at  its  base.  Between  these  I  passed  a  blunt 
curved  needle,  armed  with  a  double  ligature  of  eight  strands  of 
saddlers'  silk,  as  near  as  possible  to  the  oesophagus,  and  yet  separate 
the  vessels.  Each  portion  of  the  pedicle  was  then  firmly  tied, 
and  the  tumour  removed  without  the  loss  of  an  ounce  of  blood. 
Only  two  or  three  small  superficial  vessels  required  ligature. 

Case  3. — Dividing  the  successive  layers  of  fascia  upon  a  grooved 
director,  I  came  directly  down  upon  the  tumour,  and  began  to  reflect 
from  it  its  thin  investment.  Immediately,  as  in  the  first  case,  at 
very  many  points  the  thin  coats  of  superficial  vessels  gave  way,  and 
uncontrollable  oozing  resulted.  Still  the  haemorrhage  was  not  im- 
mediately alarming  until  the  dissection,  which  was  carried  on  by  the 
fingers,  reached  the  calcareous  portion  of  the  tumour  on  the  right 
side.  Here  adhesions  were  encountered  of  considerabe  firmness,  and 
as  they  yielded  to  the  most  careful  eftbrts  I  could  make,  other  large 
branches,  which  had  given  the  aneurismal  thrill,  and  whose  coats 
were  extremely  attenuated,  burst,  and  immediately  we  had  the  most 
fearful  haemorrhage,  such  as  one  who  has  not  seen  it  can  hardly 
realise.  The  only  expedient  was  the  rapid  completion  of  enuclea- 
tion and  seizure  of  the  vessels  at  the  base  of  either  lobe.  This  I 
accomplished  in  a  very  few  seconds,  and  was  enabled  so  to  seize  the 
pedicle  with  the  fingers  as  to  suppress  the  bleeding  measurably  until 
I  could  transfix  it  with  the  blunt  needle,  armed  with  a  double  liga- 
ture ;  this  was  carried  in  the  median  line  from  below  upwards,  close 
upon  the  trachea,  and  either  ligature  tightened  sufficiently  by  a 
single  knot,  to  control  the  haemorrhage  and  give  time  for  examina- 
tion. These  were  subsequently  tied  as  lightly  as  possible,  and  the 
tumour  carefully  severed  from  its  attachments.  Several  small  arte- 
rial twigs,  not  connected  with  the  growth,  were  tied.  The  wound 
was  left  open  for  a  short  time,  and  in  fifteen  minutes  from  the  abla- 
tion of  the  tumour  the  inferior  thyroidal  artery  of  the  left  side 
escaped  from  the  ligature  and  spirted  with  great  violence ;  the  vessel 
was  equal  in  size  to  the  common  carotid,  and  was  seized  and  secured. 
The  entire  left  half  of  the  pedicle  was  transfixed  by  a  tenaculum, 
and  a  new  ligature  was  carried  underneath  both  the  original  one 
surrounding  the  pedicle  and  the  separate  one  around  the  inferior 
thyroid  artery,  and  drawn  as  tightly  as  possible.  Secondary  haemor- 
rhage occurred  on  the  tenth  day,  which  was  controlled  by  digital 
compression  for  seventy-two  hours. — American  Journal  of  Medical 
Science^  January,  1871. 


1872.] 


Report  on  Surgery. 


277 


II. — On  the  Galvano-catjstio  Teeatment  op  Angioma. 

Br.  H.  Ifaas  has  collected  and  tabulated  130  cases  in  which  this 
method  was  carried  out.  The  cases  include  congenital  nsevi  and 
teleangiectasis,  cavernous  venous  angioma,  arterial  racemose  angioma, 
and  mixed  allied  tumours. 

The  following  is  a  table  of  the  results  : — 


Kind  of  Angioma. 

Cured. 

Improved. 

Unknown. 

Deatlis. 

Total. 

Capillary  .... 
Cavernous  (venous)    . 
Arterial  (racemose)    . 
Mixed  angioma 

32 

72 
2 
6 

1 

8 

1 

1 

1 
1 

2 

3 

34 

84 

3 

9 

Total     . 

112 

11 

4 

3 

130 

The  instruments  employed  were : — 

The  loop  wire  in  39  cases  ;  the  porcelain  burner  in  17  cases ;  the 
setaceum  candens,  or  pointed  wire,  in  12  cases ;  and  various  other 
gal vano- cauteries  m  59  cases. 

The  results  of  the  cases  are  shown  in  the  above  table  ;  the  perfect 
cures  amounted  to  somewhat  over  85  per  cent.  Under  the  eleven 
cases  which  were  considerably  improved,  one  was  afterwards  extir- 
pated, and  one  involving  the  finger  to  a  considerable  extent  under- 
went amputation  ;  four  subsequently  returned.  In  four  cases  the 
result  is  not  given,  and  under  the  three  deaths,  the  fatal  occurrence 
was  due  in  one  instance  to  hsBmorrhage  from  the  cicatrix— a  boy 
nineteen  months  old,  which  was  unobserved  and  neglected  ; — the 
second  case,  a  man  aged  thirty-five,  died  four  weeks  after  the  opera- 
tion, from  chronic  trismus  and  tetanus ;  in  the  third  case  the  cause 
of  death  is  not  stated,  but  occurred  some  days  after  the  operation 
in  a  girl  aged  eight  days. — Langenbeck's  ArcTiiv  f.  Klin.  Chir., 
1870,  Bd.  12,  p.  518. 

III. — Obsebvations  on  Ulceeation  of  the  Jugulae  Veins, 

COMMUNICATING   WITH   AN   AbsCESS    OE    OpEN    SoEE. 

Dr.  S.  W.  Gross  has  collected  from  various  sources,  and  given  an 
abstract  of  twelve  cases  of  ulceration  of  the  jugular  veins  with 
haemorrhage  into  the  sacs  of  closed  abscesses,  or  into  abscesses 
several  days  after  their  contents  had  been  evacuated,  o  r  into  acute 
and  chronic  ulcers.  The  majority  of  these  occurrea  in  children  in 
connection  with  grave  forms  of  scarlet  fever,  while  others  were  due 
to  the  extension  of  inflammation  to  the  walls  of  the  vessels  from 
scrofulous  sores  and  abscesses.  All  the  cases  proved  fatal.  Of 
these  twelve  cases,  eleven  aff'ected  the  internal  jugular  vein,  and 
one  the  external.  Nine  cases  were  examples  of  ulcers  of  the  in- 
ternal jugular  vein  from  inflammatory  action  extending  to  its  walls, 
communicating  with  closed  or  open  abscesses  or  ulcers,  and  occur- 


fl7S  Chronicle  of  Medical  Science.  [Jan., 

ring  in  children  after  an  attack  of  scarlet  fever.  The  single  case 
relating  to  the  external  jugular  vein  in  connection  with  the  same 
disease,  presented  the  interesting  feature  of  being  an  example  of 
hsDmorrhage  into  the  cavity  of  closed  abscess,  the  blood  flowing 
therefrom  immediately  upon  an  incision  being  carried  with  it.  The 
above  ten  cases  occurred  in  early  life,  between  two  and  thirteen 
years  of  age.  The  two  remaining  cases  of  ulceration  of  the  internal 
jugular  vein  were  attended  with  fatal  haemorrhage,  due  to  the  exten- 
sion of  the  morbid  action  from  open  scrofulous  abscesses  or  ulcers 
to  the  walls  of  the  vein ;  these  cases  run  a  chronic  course,  and 
occurred  in  adult  subjects. 

The  efficient  cause  of  the  destruction  of  the  coats  of  the  vessels 
was,  in  eleven  instances,  dilFuse  cellulitis  following  their  course,  and 
that  disorder  in  at  least  ten  of  the  cases  must  be  regarded  as  one 
of  the  secondary  expressions  of  the  morbid  poison  of  scarlatina, 
developed  immediately  after  its  termination,  or  during  convalescence 
from  it. 

HsDmorrhage  from  perforation  of  the  jugular  veins  may  be  looked 
for  within  the  first  week  after  the  so-called  resulting  abscess  has 
been  evacuated,  surgically  or  spontaneously.  In  two  of  the  cases 
the  bleeding  was  immediate,  and  in  one  it  was  deferred  to  the 
seventh  day,  but  the  average  date  of  its  appearance  was  the  fifth 
day. 

After  haemorrhage  has  once  occurred  a  fatal  result  may  be  antici- 
pated. In  three  instances  it  was  immediate,  two  of  these  being 
children  who  were  found  dead  in  their  beds  ;  one  was  fatal  in  a  few 
hours,  while  in  six  cases  death  varied  from  thirty  hours  to  five  days 
after  the  first  haemorrhage,  the  average  being  the  third  day,  and  the 
death  due  to  repeated  recurrence  of  loss  of  blood. 

Three  distinct  pathological  processes  are  probably  included  in  the 
perforation  of  veins ;  in  one,  the  vessel  appears  to  have  been  afi'ected 
with  limited  necrosis,  from  the  cutting  off  of  its  vascular  supply — 
an  eschar  of  upwards  of  an  inch  in  extent  having  been  plainly  visi- 
ble before  the  fatal  termination.  In  another  instance,  the  enlarged 
and  softened  internal  jugular  vein  gave  way  from  the  withdrawal  of 
the  contents  of  an  overlapping  abscess,  through  which  it  lost  its 
support.  In  all  the  remaining  instances  the  ulceration  was  due 
to  progressive  inflammatory  charges,  or  diffuse  (suppuative)  phle- 
bitis. 

In  only  two  cases  of  the  entire  number  was  there  thrombosis  of 
the  affected  vessel.  The  appearance  of  the  ulcer  in  the  vein  is  noted 
in  eleven  cases ;  in  that  of  the  external  jugular  vein  the  vein  was  perfo- 
rated like  a  sieve  in  a  space  of  three  quarters  of  an  inch  in  extent ;  in 
one,  there  were  two  openings  in  the  internal  jugular  vein,  of  the  size  of 
a  pea,  and  in  the  form  of  a  slit ;  in  all  of  the  remaining  cases  the  ulcer 
was  single,  two  being  circular,  while  the  rest  were  oblong  or  ovoidal, 
and  varying  from  four  to  twelve  lines  in  length. 

Introduction  of  air  through  the  perforated  vessel  occurred  in  one 
case  only,  and  was  attended  with  alarming  syncope,  but  restoration 
was  effected  by  stimulants. 


3872.]  Report  on  Surgery.  279 

The  practical  lessons  to  be  deduced  are  : 

1st.  That  acute,  destructive  inflammation  of  the  tissues  of  the  neck 
and  deeply-seated  abscesses,  which  has  existed  for  some  time  and 
suddenly  takes  an  acute  action,  may,  if  unchecked  in  their  progress, 
lay  bare  and  perforate  blood-vessels,  and  that  this  result  is  to  be 
feared,  more  particularly  when  diffuse  cellulitis  follows  grave  forms 
of  scarlatina  or  other  acute  specific  diseases. 

2nd.  That  scrofulous  abscesses  and  ulcers  are  not  always  indolent, 
but  may,  under  unfavorable  circumstances — that  is,  in  an  enfeebled, 
broken-down  condition  of  the  system,  rapidly  assume  phagedenic 
action,  and  lead  to  the  same  complication. 

3rd.  That  the  large  arterial  and  venous  trunks  are  more  liable  to 
be  involved  than  their  branches. 

The  treatment  will  be,  first,  to  direct  measures  to  prevent  the 
accident,  by  cutting  short  or  aborting  the  dift'use  cellulitis  during 
the  stage  of  exudation,  by  incisions  carried  through  the  deep  apo- 
neurosis, to  relieve  tension,  care  being  taken  to  arrest  any  haemor- 
rhage by  light  and  agreeable  compression.  During  the  suppuration 
and  mortification  incisions  are  also  imperatively  demanded,  with  the 
use  of  antiseptics ;  attention  to  general  health  by  hygienic  and 
medicinal  measures. 

The  second  object  will  be  to  arrest  haemorrhage  when  the  vessel 
has  been  perforated.  Little  can  be  said,  as  all  the  cases  proved 
fatal.  In  all  instances  in  which  it  is  possible  a  ligature  should  be 
cast  above  and  below  the  dead  portion  of  the  vessel,  in  preference  to 
other  haemostatic  agents.  It  is  perfectly  safe,  and  is  not  open  to 
the  objections  which  can  be  justly  urged  against  compression. 
Should  compressive  treatment  be  deemed  advisable,  an  assistant 
should  place  his  finger  on  the  vein  above  the  opening,  to  prevent 
further  loss  of  blood.  A  small  piece  of  sponge  or  lint  wrung  out  of 
a  dilute  solution  of  perchloride  of  iron  should  then  be  held  in  contact 
with  the  orifice  until  it  adheres,  when  it  is  to  be  supported  by  a 
compress  retained  by  adhesive  strips. — American  Journal  of  Med. 
Science,  April,  1871,  p.  337. 

IV. — On  resection  of  the  oesophagus  in  cases  of  cancer  of  that  tube. 
By  Dr.  Thomas  Bilroth,  in  the  current  '  Archiv  f.  Klin.  Chir.,'  by 
Langenbeck,  1871,  p.  65. 

The  author  remarks  that,  when  examining  persons  who  had  died 
of  cancer  of  the  oesophagus  he  was  struck  with  an  idea  whether  it 
were  not  possible  to  extirpate  that  portion  of  the  oesophagus.  He 
states  that,  as  a  rule,  cancer  of  the  oesophagus  does  not  involve  the 
lymphatic  glands,  but  that  it  remains  chiefly  confined  as  a  purely 
primitive  disease.  In  such  cases  bougies,  oesophageal  tubes,  &c., 
have  to  be  passed,  so  as  to  dilate  the  constricted  part,  and  thus 
prevent  starvation  ;  but  too  often  the  evil  is  rendered  worse  by  such 
proceedings,  in  consequence  of  the  irritation  caused  by  the  frequent 
passage  of  instruments  setting  up  ulceration  and  softening  of  the 
new  growth. 

The  failure  of  oesophagotomy  and  the  opening  of  the  stomach  by 


280  Chronicle  of  Medical  Science.  [Jan., 

abdominal  section  having  proved  hopeless,  he  was  disposed  to  enter- 
tain seriously  the  question  of  resection  of  the  oesophagus,  and 
removal  of  the  disease  itself.  He  considered  that  after  extirpa- 
tion of  a  portion  of  the  entire  circumference  of  the  oesophagus,  the 
lower  end  of  the  tube  must  be  drawn  upwards  through  cicatricial 
contraction,  and  thus  a  ring-like  stricture  remain,  which  could  be 
readily  dilated  by  bougie  without  danger. 

However,  although  there  are  not  over  many  cases  of  cancer  in- 
volving the  oesophagus  high  enough  up  for  the  operation,  still  there 
are  many  in  which  the  operation  might  be  undertaken  in  order  to 
save  life. 

In  order  to  carry  out  this  idea  this  operation  was  performed  on 
dogs,  so  as  to  make  observation  as  to  how  the  cicatrization  would  be 
accomplished.  The  first  operation  was  made  upon  a  middle-sized 
dog,  and  the  animal  seemed  to  be  going  on  favorably  and  satisfac- 
torily, as  far  as  could  be  desired ;  but,  unfortunately,  on  the  fifth 
day,  the  servant,  who  was  in  the  habit  of  feeding  the  dog  by  injec- 
tion of  milk  through  the  oesophagus,  introduced  by  the  wound, 
passed  the  tube  into  the  mediastinum,  and  injected  the  milk  into 
this  space.  The  animal  died,  in  consequence  of  this  error  loci,  from 
mediastinitis  and  pleuritis. 

The  second  case  was  operated  on  in  April  2l8t,  1870.  The  animal 
was  a  large  yellow  dog,  and  was  placed  under  chloroform.  The 
oesophagus  was  laid  bare  on  the  left  side  of  the  neck,  and  was  pretty 
deeply  situated.  With  the  finger  and  the  handle  of  the  scalpel  the 
oesophagus  was  separated  from  the  surrounding  parts  to  the  extent 
of  two  inches.  The  tube  was  then  cut  across  in  toto,  and  one  inch 
and  a  half  of  its  calibre  completely  removed.  The  lower  end  of  the 
tube  was  fastened  by  two  stitches  to  the  integuments  at  the  lower 
end  of  the  wound,  so  as  to  have  a  more  ready  means  of  introducing 
the  oesophageal  tube  in  order  to  feed  the  animal  artificially.  On 
April  26th  a  soft  bougie  was  able  to  be  passed  from  above  through 
the  mouth,  and,  by  the  assistance  of  the  finger  in  the  wound 
carried  downwards  into  the  stomach.  The  sutures  were  removed  at 
the  end  of  a  week.  Subsequently  there  occurred  enormous  mucous 
discharges  through  the  wound,  apparently  coming  up  from  the 
stomach.  By  degrees  this  discharge  subsided  entirely,  and  the 
wound  contracted ;  but  the  wound  did  not  heal  rapidly,  owing, 
probably,  to  the  dog  being  kept  with  other  dogs,  and  allowed  to  par- 
take of  their  food,  so  that  he  could  not  well  swallow  the  bony  and 
fleshy  masses  ;  in  fact,  these  stuck  at  the  wound,  and  had  to  be 
removed  therefrom  with  much  trouble.  At  the  end  of  June  the 
fistula  became  completely  closed.  The  passage  through  the  oesopha- 
gus was  daily  kept  open  by  means  of  bougies  of  the  thickness  of  the 
little  finger.  The  dog  could  eat  meat,  potatoes,  &c.,  and  swallow 
well,  and  became  in  good  condition.  On  July  26th  the  dog  was 
killed  by  cyanide  of  potassium.  The  preparation  is  delineated  in  a 
plate  accompany  the  communication ;  and  Bilroth  remarks  that  it 
shows  that  his  proposition  on  the  healing  process  after  resection  was 
correct,  viz.  that  there  was  a  simple,  fine,  ring-like  cicatrix,  scarcely 


1872.] 


Books,' ^c,  received  for  Review.  281 


half  a  line  broad,  which  remained  amenable  to  extension.  Bilroth 
says,  in  conclusion,  "  I  should  feel  justified,  after  such  results, 
to  undertake  the  operation  of  resection  of  the  oesophagus  in  certain 
cases." 

Amputation  of  Hedundant  Scrotum, — Dr.  Henry,  Surgeon  to  the 
New  York  Dispensary,  would  revive  a  method  of  treating  varicocele 
originated  by  Sir  Astley  Cooper,  but  which  has  long  since  fallen  into 
disuse  both  in  this  country  and  elsewhere.  Eor  the  purpose  of  the 
operation  he  has  devised  a  "  scrotal  forceps,"  whereby  its  perform- 
ance is  said  to  be  rendered  easier  and  safer. 

The  treatment  consists  simply  in  enclosing  within  the  blades  of 
the  forceps  or  clamps  so  much  of  the  skin  of  the  scrotum  as  can  be 
spared  with  advantage,  cutting  it  off  with  a  pair  of  strong  scissors, 
stitching  up  the  incision  closely,  and  then  removing  the  clamp 
and  dressing  the  wound  on  ordinary  principles.  That  such  an  ope- 
ration cannot  be  free  from  danger — danger  of  cellular  inflammation — 
seems  certain ;  and  so  long  as  we  have  safe  and  simple  means  of 
dealing  with  varicocele  by  obliterating  the  veins,  there  can  be  no 
advantage  in  returning  to  a  more  severe  and  hazardous  method  of 
treatment.  After  all  that  can  be  said  in  favour  of  the  removal  of 
redundant  skin,  it  may  very  well  be  asked  whether  this  does  more  to 
effect  a  cure  of  the  disease  than  can  be  accomplished  by  cold  spong- 
ing and  a  well-adjusted  suspensory  bandage.  For  it  deals,  not  with 
the  enlarged  or  tortuous  veins,  which  are  the  cause  of  the  mischief, 
but  only  with  the  pendulous  scrotum,  which  they  have  produced. 
We  are  inclined,  therefore,  to  think  that  the  operation  which  is  at 
present  in  use  for  obliterating  the  veins,  and  which  has  been  carried 
to  a  great  degree  of  perfection,  is  not  only  the  simplest  and  safest, 
but  that  it  goes  most  directly  to  the  root  of  the  malady,  and  is  the 
most  likely  to  lead  to  a  permanent  and  satisfactory  cure. 


BOOKS,  PAMPHLETS,  &c.,  RECEIVED  FOR  REVIEW. 


A.  System  of  Medicine.  Edited  by  J.  of  the  Privy  Council.  With  Appendix. 
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Ill,  containing  Local  Diseases  (continued).  Introductory  Notes  on  Lying-in  Institu- 
London  and  New  York,  Macmillan  and  tions,  together  with  a  Proposal  for  Organ- 
Co.  1871.  pp.  995.  izing  an  Institution  for  Training  Mid- 
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Rose   Corraack,  M.D.,  &c.     New  Syden-  pp.  110. 

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A  New  Operation  for  Bony  Anchylosis  ditism,  and  a  proposal  to  Stamp  out  Small- 

of  the  Hip-joint  with  Malposition  of  the  pox  and  other  Contagious  Diseases.     By 

Limb,  by  Subcutaneous  Division   of  the  Sir  James  T.  Simpson,  Bart.,  M.D.,  &c. 

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Churchills.     1871.     pp.  68.  Fecundity,    Fertility,     Sterility,     and 

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On  the  Treatment  of  Hyper  pyrexia,  as 
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On  the  Treatment  of  Pulmonary  Con- 
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Fistula,  Haemorrhoids,  and  other  Dis- 
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The  Science  and  Practice  of  Surgery. 
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Pulmonary  Consumption :  its  Nature, 
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Essentials  of  the  Principles  and  Practice 
of  Medicine.  A  Handbook  for  Students 
and   Practitioners.     By   H.   Hartshorne, 


uuuiis,-  c^c.j  receivea  jor  Kevtew. 


283 


;.D.,  &c.    Third  Edition,  thoroughly  re- 

sed.  Philadelphia,  H.  C.  Lea.  London, 
rubner  and  Co.     1871.     pp.  487. 

A  Practical  Treatise  on  Fractures  and 
islocations.  By  Frank  H.  Hamilton, 
[.D.,  &G.  Fourth  Edition.  Illustrated 
ith  322  woodcuts.  Philadelphia,  H.  C. 
ea.  London,  Triibner  and  Co.  1871. 
p.  789. 

Transactions  of  the  Pathological  Society 
:  London.  Vol.  XXII.  London.  1871. 
p.  361. 

Centenary  Address  delivered  before  the 
ociety  of  the  New  York  Hospital.  By 
ames  W.  Beekman.  1871.  pp.  44  ;  and 
ppendix  "On  the  Structure  and  Economy 
f  Hospitals,  particularly  Military  ones," 
p.  20.     Published  by  the  Society. 

St.  Andrew's  Medical  Graduates'  Asso- 
iation.  Transactions.  1870.  Edited  by 
iconard  W.  Sedgwick,  M.D.  London, 
Ihurchills.     1871.     pp.  316. 

National  Disease.  Kemarks  upon  the 
*revailing  Epidemic  of  Smallpox ;  its 
lause  and  "Prevention,  &c.  London,  Long- 
Qans.     pp.  85. 


Des  Impulsions  dans  la  Folie  et  de  la 
^lie  Impulsive.  Par  Dr.  H.  Dagonet. 
?aris.  Bailliere  et  Fils.     1870.     pp.  74. 

Mode  d' Invasion  et  de  Propagation  de 
yholera,  etudie  a  Smyrne.  Par  le  Dr.  W. 
^hapeaud.  Constantinople.   1871.  pp.  188. 

Notizen  und  Erinnerungen  eines  Am- 
)ulanzohirurgen.  Von.  W.  MacCorraac. 
lus  dem  Englischen  iibersetzt,  und  rpit 
Juniertlvungen  versehen,  von  Dr.  Louis 
)tromi3yer.  Hannover,  Haln.  1871.  pp. 
82. 


Pamphlets. 

On  an  Aspirator  for  use  in  Parace»tesis, 
nvented  by  Dr.  V.  RasmussexJ,-  of  Copen- 
lagen.     By  J.  W.  Moore,  M.D.,  &c. 

Epidemic  Cholera.  By  E.  Ambrose  Fitz- 
gerald, Surgeon,  Bengal  Medical  Service. 

Experimental  Research  on  the  Anta- 
gonism between  the  Actions  of  Physo- 
itigma  and  Atropia.  By  Thomas  R.  Fraser, 
M.D.,  F.R.S.E.,  &c. 

On  Decapitation  as  a  Mode  of  Delivery 
in  Cases  of  Shoulder  Presentation,  in  which 
Version  catmot  be  safely  effected.  By 
George  Kidd,  M.D.,  &c. 

Darwinism:  being  an  Examination  of  Mr. 
St.  George  Mivart's  '  Genesis  of  Species.' 
By  Chauncey-Wright. 

Sugar  Formation  in  the  Liver.  By 
John'C.  Dalton,  M.D.     New  York. 

On  Intermittent  Malaise.  By  Dr.  Henry 
A  dans. 

Or.  the  Induction  of  Premature  Labour 
as  a  Remedy  for  Eclampsia,  &c.  By  Samuel 
C.  Eusey,  M.D.     Washington.     1870. 


Some  Simple  Sanitary  Precautions 
against  Cholera  and  Diarrhoea,  &c.  By 
M.  A.  B.     London. 

The  Public  Medical  Libraries  of  Phila- 
delphia. By  Richard  J.  Dunglison,  M.D. 
Philadelphia.     1871. 

On  the  Relative  Powers  of  various  Sub- 
stances in  Preventing  the  Generation  of 
Animalculse,  &c.,  with  special  reference  to 
the  Germ  Theory  of  Putrefaction.  By 
John  Dougall,  M.D.     London.     1871. 

On  Chloroform  in  its  Medico-Legal 
Bearings.     By  Charles  Kidd,  M.D. 

Inaugural  Address  at  the  Twenty-second 
Annual  Meeting  of  the  American  Medical 
Association.  May,  1871.  By  Alfred  Stille, 
M.D.,  President.     Philadelphia.     1871. 

Hindu  View  of  Cholera.  A  Lecture,  by 
Golab  Sing,  M.D. 

A  Review  of  Darwin's  Theory  of  the 
Origin  and  Development  of  Man.  By 
James  B.  Hunter,  M.D.     New  York. 

Epidemic  and  Specific  Contagious  Dis- 
eases :  Considerations  as  to  their  Nature 
and  Mode  of  Origin.  By  H.  Charlton 
Bastian,  M.D.,  &c. 

Journal  of  the  Scottish  Meteorological 
Society.     July;  1871. 

The  Morningside  Mirror.  Edinburgh. 
1870-71. 

An  Analysis  of  the  Post- Mortem  Appear- 
ances in  235  Insane  Persons.  By  James 
C.  Howden,  M.D.     1871. 

On  Clinical  Education  :  the  Introductory 
Address  at  the  Queen's  Hospital,  1871-2. 
By  Furneaux  Jordan,  F.R.C.S.  London, 
Churchills.  , ,    " 

Plastics  and  Orthopaedics.  A  Report  re- 
published from  the  '  Transactions  of  the 
Illinois  State  Medical  Society'  for  1871. 
By  David  Prince,  M.D. 

On  a  Means  of  Arresting  the  Spread  of 
Smallpox.     By  John  Day,  M.D.     Geelong. 
..On  Fluid  Meat:    a  New  Preparation  of 
■  Meat.     By  Stephen  Darby. 

Remarks  on  Mr.  Clark's  Calcutta  Drain- 
age Scheme.     By  David  B.  Smith,  M.D. 

Mr.  Spencer  Wells's  Note-Book  for  Cases 
of  Ovarian  and  other  Abdominal  Tumours. 
Third  Edition. 

Inti'oduetoiy  Lecture  to  the  Course  of 
Pathological  Anatomy  at  the  University  of 
Pennsylvania.  By  Joseph  G.  Richardson, 
M.D.,  &c. 


La  Calenlura  Roja  observada  en  sus 
Apari^iones  Epidemicas.  Por  D.  R.  Her- 
nandez Poggio.     Madrid.     1871. 

Suir ultimo  Stadio  del  Colera  Asiatico,  o' 
stadio  di  morte  apparente  dei  colerosi  e  sul 
modo  di  farli  risorgere.  Memoria  del  Prof. 
Filippo  Pacini.     Firenze.     1871. 

Ein  Apparat  fiir  kiinstliche  Respiration 
und  dessen  Anwendung  zur  Heilzwecken. 
Von.  Dr.  Ignaz  Hanke.     Wien.     1870. 

Welche  Zelle  in  den  Pepsindriisen  en- 


284 


Books,  3fC.,  received  for  Review.  [Jan.^  1872 


thalten  das  Pepsin.   Von  Ernst  Friedinger. 

Sopra  un  Caso  di  etnisezione  del  Mitiollo 
Spinale  nell'  Uomo.  Lettera  del  Prof,  Pietro 
liurresi  al  Prof.  M.  SchifF. 

Clinica  Medica  di  Siena.  Diretta  dal 
Prof.  P.  Burresi.  I.  Sugli  Effetti  Tera- 
peutici  della  Inalazione  d'Ossigeno.  II. 
Percussione  del  Cuore. 


Eeports,  Journals,  Reviews,  ^c. 

Sixth  Eeport  of  the  Quekett  Micro- 
scopical Club,  and  List  of  Members.  July, 
1871. 

Report  of  the  Joint  C'lmmittee  on  State 
Medicine  on  tlie  Report  of  the  Royal  Sani- 
tary Commission. 

Report  of  the  Royal  Lunatic  Asylum  of 
■Montrose. 

Report  of  the  Association  of  Certifying 
Medical  Officers  for  the  Year  1871-2, 
•with  Annual  Address  by  the  President. 

AVeekly  and  Quarterly  Returns  of  Births 
and  Deaths,  &C.,  from  the  Registrar- 
General. 

The  Dublin  Quarterly  Journal  of  Medi- 
cal Science.     August  and  November,  1871. 

The  Edinburgh  Medical  Journal.  August 
to  December. 

The  Journal  of  Mental  Science.  October, 
1871. 

The  Journal  of  Anatomy  and  Physiology. 
Second  Series.     No.  IX.     November,  1871. 

Food  Journal.     October  to  December. 

Food,  Water,  and  Air.  Edited  by  Arthur 
Hill  Hassall,  M.D.  (Published  monthly.) 
Nos.  1  and  2. 

Archives  of  Ophthalmology  and  Otology. 
Edited  bv  Drs.  Knapp  and  Moos.  Vol.  I 
and  Vol.  il,  Part.  1.    New  York.    1870-71. 

The  Journal  of  Psychological  Medicine. 


New 
July 


Edited  by  W.  A.  Hammond,   M.D 
York,  July,  October,  1871. 

The  New  York  Medical  Journal, 
to  November. 

The  Medical  Record.  New  York. 
September  to  November. 

The  Medical  World  :  a  Monthly  Journal 
of  Medicine,  &c.  Edited  by  Dr.  Reuben  A. 
Vance,  M.D.  New  York.  July  to  October, 
1871.  J  .     . 

The  Australian  Medical  Gazette.  June, 
July,  August. 

The  American  Journal  of  the  Medical 
Sciences.     October,  1871. 

The  Garden  :  an  Illustrated  Journal  of 
Gardening.  (A  new  weekly  periodical.) 
No.  I. 

Archiv  fiir  Gynaekologie.  Band  ii, 
3  Heft.     Berlin.     1871. 

Archiv  fiir  Puthologische  Anatomie  und 
Physiologic.     Von.  R.  Virchow.     Band  53. 

Schmidt's  Jahrbucher  der  Gesammten 
Medicin.  Band  151.  August — October, 
1871. 

Monatsschrift  fiir  Ohrenheilkunde.  July, 
August,  September,  October. 

Deutsches  Archiv  fii.  ^''^.nisf^he  Medi- 
cin.    Band  ix.    Heft  1.     September,  1871. 

Medizinische  Jahrbiicher  herausgegeben 
von  der  K.  K.  Gesellschaft  der  Arzte. 
Redigirtvon  S.  Strieker.  Jahrgang,  1871. 
Ill  Heft.     Williams  and  Norgate.     pp.  52. 

Archires  Generales  de  Medecine.  July, 
August,  September,  October,  November. 

Ga.'^ette  flebdomadaire  de  Medecine  et 
de  Chirurgie.  August,  September,  October, 
November. 

L'Abeille  Medicale :  Revue  Hebd'-oma- 
daire  de  Medecine  et  de  Chirurgie,  Jiily — 
October.  i  *. 

L' Union  Medicale.  August,  Sept^mbe^j, 
October.      •  y 

0  Correio  Medico  de  Lisboa.  September 
to  November,  1871. 


CORRIGENDA  AND  ADDENDA. 

No.  XCVI,  p.  467,  line  26,  instead  of  "  as  many  cases  of  cholera  did  not  sub- 
sequently follow  in  the  city,"  read  "  as  no  case  of  cholera  subsequently  occurred 
in  the  city  itself." 

Id.,  p.  468,  line  11,  dele  "but  was  not  successful  in  1857."  This  sentence  conveys 
a  wrong  impression,  inasmuch  as  the  partial  evacuation  spoken  of  was  not  pat  in 
force  at  all  in  1857,  but  for  the  first  time  in  1866.  ^ 

Dr.  Schleisner,  in  noting  the  above  errors  In  hi*,  paper,  takes  occasion  to  state 
that  the  same  measures  have  been  taken  at  Copenhagen  in  the  presence  of  cholera 
in  various  parts  of  northern  and  eastern  Europe  during  the  past  voar  n871),'jand 
have  been  followed  by  complete  success.   To  show  that  the  city  euj  nmity 

due  to  other  causes  than  the  preventive  measures  described  i 
Schleisner  reeals  the  fact  that  in  the  epidemic  of  1853,  when  the  I 

at  150,000,  there  were  7219  cases  of  cholera,  and  as  many  as  4/ 
from. 

In  the  present  number,  p.  69,  line  26,  instead  of  "  American,"  r  ' 


n^ 


< 


THE 

BRITISH    AND    FOREIGN 

MEDICO-CHIRURGICAL  REVIEW. 

APEIL,    1872. 
analytical  anti  OTntical  l^ebiebs. 


I. — Reynolds's  System  of  Medicine.^ 

The  nature  of  this  work  precludes  a  general  criticism,  each 
separate  portion  standing  on  its  own  merits,  and  apparently 
never  being  sacrificed  to  or  aggrandized  at  the  expense  of 
another. 

*'  Diseases  of  the  Digestive  System"  are  continued  in  articles 
by  Dr.  Squarey,  "  On  Diseases  of  the  Mouth,  Fauces,  Pharynx, 
and  CEsophagus."  Here  is  condensed  a  fair  resume  of  the  usual 
teaching  at  metropolitan  schools  on  the  affections  of  these  parts. 
We  confess,  however,  to  a  sense  of  disappointment  that  the 
opportunity  afforded  for  discussion  of  the  lesions  of  a  visible 
mucous  membrane  was  not  taken,  so  as  to  place  before  us  the  more 
recent  views  on  catarrhal  and  other  morbid  states  of  this  tissue. 
The  mouth  shares  with  the  eye  the  privilege  of  exhibiting 
normal  and  abnormal  processes  in  action ;  so  that  we  are  not 
referred  to  fatal  cases  and  post-mortem  appearances  for  our 
information  as  to  what  is  going  on.  We  trust  this  omission 
may  be  made  up  by  a  general  article  on  "  Inflammation,"  or 
something  of  the  sort,  in  the  fourth  volume. 

We  really  must  beg  Dr.  Squarey's  pardon  while  we  make 
his  writings  the  text  of  another  complaint.  It  concerns  a  fault 
which  runs  through  not  only  his  essay,  but  more  or  less  the 
whole  volume  ;  and  not  only  the  whole  volume,  but  all  English 
medical  literature.  In  treating  of  therapeutics,  no  order  is 
observed,  and  no  comparison  is  made  of  the  different  activity  of 
reagents.  If  the  writer  thinks  them  all  equally  useless,  let  him 
have  the  courage  to  say  so,  and  to  leave  the  page  blank  for 
other  purposes.  If  he  has  confidence  in  their  efficacy,  let 
him  not  say,  this  " /7^al/ "  be  given,  or  that  "m«y"  be  used. 


^  A  System  of  Medicine,    Edited  by  J.    Russell  Reynolds,  M.D.,   F.R.S. 
Vol.  iii,  containing  Local  Diseases  {continued).     1871. 

98— XLix.  19 


286  Reviews,  [April, 

one  after  another  to  a  dozen  drugs,  but  let  him  urge  instantly 
the  importance  of  pressing  one  to  its  logical  consequence.  Let 
us  not  have  such  uncertain  sounds  as  in  the  following  paragraph 
about  Ulcerative  Stomatitis : 

"  Of  the  topical  applications,  powdered  alum,  nitrate  of  silver, 
nitrate  of  mercury,  and  hydrochloric  acid  may  be  named,  and  of 
these,  alum,  either  used  as  a  powder  or  in  the  form  of  a  wash,  will 
generally  be  found  quite  sufficient ;  but  if  the  ulcers  be  slow  to  heal, 
their  surface  should  every  now  and  then  be  cauterized  with  nitrate 
of  silver.  Gargles  of  chlorate  of  potash,  from  five  grains  to  one 
scruple  to  the  ounce,  or  even  stronger,  may  be  used,  other  means 
failing  (! !)" 

Does  the  author  really  mean  that  the  use  of  chlorate  of  potash 
should  be  postponed  till  such  a  painful  application  as  nitrate  of 
mercury  has  been  premised  ?  It  is  a  loose  mode  of  expression, 
sadly  common,  which  we  would  gladly  see  reformed. 

"  Enteralgia"  is  an  essay  by  Dr.  Wardell,  of  Tunbridge 
Wells,  on  a  disease  very  important  from  its  frequency,  and 
from  the  likelihood  of  its  symptoms  being  misunderstood.  The 
scattering  through  several  volumes  of  the  various  neuralgies 
which  are  pathologically  related  to  each  other,  such  as  hemi- 
crania,  hepatalgia,  sciatica,  colic,  lumbago,  angina  pectoris,  &c., 
has  this  advantage,  that  they  are  not  forgotten  in  the  formation 
of  a  diagnosis ;  for,  by  the  catenation  of  literary  ideas,  they  are 
associated  in  the  mind  with  conditions  which  they  resemble, 
and  are  likely  to  be  mistaken  for.  Dr.  Wardell  rightly  holds 
that  pain  in  the  abdomen,  which  is  variously  called  belly-ache, 
gripes,colic,  spasmus  intestinorum,  ileus  spasmodicus  [Sauvages) , 
spasmus  ventriculi  ( Wiessner),  &c.,  to  be  a  true  neuralgia. 
And  in  its  pathology  he  recognizes  several  distinct  classes  of 
causes — first,  those  which  mechanically  distend  the  bowel,  such 
as  the  sudden  secretion  of  a  large  quantity  of  flatus  from  the 
blood,  which  partially  paralyzes  the  peristaltic  movements,  as 
retained  urine  paralyzes  the  bladder  ;  secondly,  those  which 
paralyze  by  reflex  action,  such  as  harmful  ingesta;  thirdly, 
those  whose  depressing  influence  is  conveyed  through  the  blood, 
as  in  lead  poisoning ;  fourthly,  where  the  nerve  tissue  is  im- 
perfectly nourished,  as  in  anaemia  andnervosism  ;  fifthly,  where 
the  mind  withdraws  from  the  corporeal  substance  the  normal 
use  of  the  involuntary  nerves,  as  in  emotional  hysteria  and 
melancholia;  sixthly,  organic  lesions  of  the  cerebro-spinal 
axis  (?) ;  seventhly,  "  reflex"  or  misplaced  pains  from  lesions 
of  parts  normally  insensitive,  as  the  uterus  or  kidneys.  We 
do  not  mean  to  say  that  Dr.  Wardell  has  thus  formulized  the 
causes,  but  we  have  taken  the  liberty  of  orderly  arranging  and 
condensing  his  pages  on  the  pathology  of  enteralgia.     Recog- 


1872.] 


Reynolds's  System  of  Medicine.  287 


nizing  its  intermittent  and  neuralgic  character,  and  with  such 
just  views  of  its  etiology,  it  is  strange  that  Dr.  Wardell  does 
not  in  the  paragraphs  about  treatment  make  his  science  hear 
fruit.  He  tells  us  of  anodynes  and  the  usual  list  of  antispas- 
modics (we  will  not  repeat  this  list  here  ;  it  is  described  pithily 
by  Sydenham  as  "Qua?cunque  foetent''^) — but  why  is  no  mention 
made  of  cinchona,  quinine,  and,  above  all,  of  arsenic  ?  The 
writer  must  surely  have  heard  of  these  remedies  being  adminis- 
tered, and  if  he  does  not  approve  them  should  say  so. 

"  Enteritis,"  by  Dr.  Bristowe,  is  a  model.  The  subject 
is  a  most  difficult  one  to  treat  satisfactorily  in  a  work  of  the 
kind  represented  by  the  ^  System  of  Medicine ;'  but  we  must 
say  that  the  author  has  completely  succeeded.  The  word,  or 
its  equivalent,  inflammation  of  the  bowels,  is  of  ancient  date, 
and  from  the  earliest  times  until  now  has  had  a  loose  and 
various  application  :  so  that  there  was  the  constant  temptation 
to  include  matter  which  has  been,  or  will  be,  properly  handled 
under  more  precise  headings  ;  or,  on  the  other  hand,  to  treat 
too  lightly  the  clinical  importance  of  the  fact  of  the  ilia  being 
really  inflamed  as  a  consequence  or  part  of  the  special  affections 
elsewhere  noticed.  Dr.  Bristowe  has  avoided  both  these  pitfalls. 
While  leaving  catarrhal  and  croupous  conditions  of  the  mucous 
membrane  to  be  discussed  under  "  Diarrhoea"  and  "  Dysen- 
tery," he  has  yet  pointed  out  the  necessity  for  remembering 
that  the  bowels  really  are  liable  to  those  interstitial  changes 
whose  commencements  Ave  group  together  as  "  inflammation," 
and  which  may  lead  consequently  to  persistent  modifications  of 
the  tissue ;  and  while  identifying  many  of  the  post-mortem 
appearances  anciently  assigned  to  enteritis  as  really  due  to  the 
objective  causes  of  enteritis,  has  deduced  most  valuable  thera- 
peutical inferences  from  the  frequency  of  its  presence.  He  well 
points  out  that  intestinal  obstructions  may  last  for  many  weeks, 
even  in  an  absolute  degree,  without  destroying  life ;  whereas,  if 
the  bowel  becomes  inflamed,  the  duration  of  the  case  is  usually 
measured  by  days.  Its  rapid  fatality  is  doubtless  due  in  a 
serious  measure  to  the  perturbative  treatment  still  often  adopted 
in  cases  of  obstruction,  and  therefore  the  author  gives  a  solemn 
and  earnest  warning  against  the  use  of  purgatives  or  any  other 
mode  of  moving  the  bowels  about. 

"  It  has  been  shown  quite  conclusively,  principally  by  experience 
derived  from  the  after-treatment  of  strangulated  hernia,  that  it  is 
always  dangerous  to  endeavour  to  propel  faecal  matters  through  an 
enteritic  length  of  bowel,  that  in  most  cases  the  eff'ort  is  useless  so 
far  as  their  effectual  propulsion  is  concerned,  while,  by  the  augmented 
muscular  and  excretory  action  which  is  thus  produced  in  the  bowel 

1  '  Diss.  Epist.  de  Affect.  Hysterica,'  120. 


288  Reviews.  '  [April, 

above,  the  diseased  tract  below  becomes  more  and  more  softened, 
congested,  and  inflamed,  not  unfrequently  becomes  ruptured,  and,  at 
the  least,  has  its  progress  towards  recovery  delayed.  And,  indeed, 
when  one  considers  the  great  length  of  time  during  which  constipa- 
tion may  continue  with  little  or  no  influence  on  the  general  health, 
how  long  patients  with  impassable  stricture  of  the  bowel  may  con- 
tinue to  survive,  it  must  be  obvious  that  the  constipation  of  a 
disease  of  so  short  a  duration  as  enteritis  is  not  of  itself  a  source  of 
danger.  Clearly,  if  the  patient  is  to  get  well,  his  recovery  must,  in 
the  first  instance,  be  dependent  on  the  recovery  by  the  diseased 
bowel  of  its  healthy  tone  and  capability  of  peristaltic  action  ;  and  to 
this  end  our  efforts  must  be  directed." 

The  article  on  "  Obstruction  of  the  Bowels/'  by  the  same 
author,  may  be  considered  as  a  part  of,  or  natural  complement 
to,  the  former.  It  discusses  the  most  frequent  cause  of  enteritis, 
and  its  pages  on  pathology  and  treatment  are  largely  influenced 
by  the  views  which  we  have  already  quoted.  As  might  have 
been  expected,  surgical  interference  is  looked  upon  as  a  very 
fragile,  if  not  broken,  reed.  The  authorities  quoted  are,  as  a 
rule.  Dr.  Brinton,  Dr.  Barlow,  and  Dr.  Fagge^  especially  the 
first  named, 

"  Ulceration  of  the  Bowels,"  also  by  Dr.  Bristowe,  in  its 
pathological  part  usefully  contrasts  the  different  appearances 
presented  by  ulcers  arising  from  tuberculosis,  typhoid  fever,  and 
other  causes.  The  remarks  on  therapeutics  seem  to  be  in- 
tentionally meagre,  as  by  pointing  rather  to  principles  than  to 
details,  the  moral  might  be  enforced  that  the  treatment  should 
be  of  the  initiatory  disease,  not  of  the  secondary. 

Then  follow  four  pages  on  "  Cancerous  and  other  Growths 
of  the  Intestines,"  the  subject  having  only  a  pathological  and 
no  clinical  interest. 

"  Diseases  of  the  Caecum  and  Appendix  Vermiformis  ^'  gives 
a  full  account  of  the  acute  evils  resulting  from  inflammation  and 
ulceration  of  those  parts,  typhlitis  and  perityphlitis.  But  we 
miss  what  we  should  have  been  glad  to  have  had,  namely,  in- 
formation about  the  chronic  ailments  of  this  part  of  the  intestinal 
canal.  Even  the  result  of  typhlitic  ulceration  in  chronic  fistula 
is  scarcely  alluded  to ;  and  atonic  sluggishness,  dilatation,  and 
other  defects  of  defsecation  indubitably  referable  to  the  caecum, 
are  passed  over  in  complete  silence.  We  look  upon  this  as  a 
serious  omission ;  for  led  by  the  index  to  this  volume,  the 
student  would  be  in  danger  of  learning  that  constipation  was  a 
disease  of  the  small  intestines,  and  that  its  only  injurious  result 
was  ileus.  We  would  suggest  to  the  editor  that  the  *  System  of 
Medicine  '  will  be  very  incomplete  without  an  article  on  de- 
ficiencies of  defeecation,  under  some  heading  which  will  involve 
a  thorough  examination  of  the  subject,  without  robbing  former 


1872.] 


Reynolds's  System  of  Medicine,  289 


contributors.  We  should  have  been  glad  also  to  have  heard 
something  about  neuralgia  of  the  csecum,  the  chronic  form  of 
which  is  by  no  means  rare,  and  important  from  the  paralytic 
distension  of  the  part  which  it  causes,  simulating  tumour  and 
faecal  masses. 

In  the  succeeding  essay  on  "  Colic,"  Dr.  Begbie  tells  us  that 
it  is  "  a  disease  which  is  to  be  distinguished  from  "  enteralgia 
or  neuralgia  of  the  bowels.  We  should  have  been  glad  to  know 
"  How  ?" — for  his  page  on  the  pathology  of  the  ailment  appears 
to  exhibit  them  as  identical.  The  article,  and  especially  its 
etymological  part,  would  have  been  better  devoted  to  showing 
that  the  symptoms  described  by  former  writers,  and  by  the 
current  writer  himself,  have  no  pathological  connection  with  the 
colon  or  function  of  defsecation  at  all.  When  he  tells  us  that 
the  adjectival  expressions  "  Colica  Hepatica,"  ''  Colica  Neph  • 
ritica,"  "  Colica  IJterina,"  are  "  eminently  faulty,  and  it  is  de- 
sirable that  their  use  should  be  entirely  abandoned,"  we  feel 
that  he  is  bound  to  make  out  a  much  stronger  case  in  favour  of 
the  substantive  "  Colica,"  derived  (as  he  derives  it)  from  Colon, 
than  he  has  done,  before  he  allows  it  a  superiority  over  the 
localizing  epithets  he  falls  foul  of.  Inasmuch  as  "  Dolor 
Colicus  "  is  entered  by  Dr.  Wardell  among  the  synonyms  of 
enteralgia  not  100  pages  back,  we  think  this  essay  might  have 
been  omitted  altogether. 

The  same  may  be  said  of  "  Colitis,"  the  post-mortem  appear- 
ances of  which  there  is  allowed  to  be  no  possibility  of  dis- 
tinguishing from  the  results  of  dysentery,  and  the  symptoms  of 
which  no  attempt  is  made  to  differentiate  in  the  page  devoted 
to  it. 

In  reviewing  the  first  volume  of  this  work  we  remarked  on 
the  fact  of  "Dysentery"  and  diarrhoea  being  treated  of  as  if  they 
■were  only  tropical  and  epidemic  diseases.  Another  article 
here  on  "  Dysentery,"  by  Dr.  Warburton  Begbie,  is  designed  to 
remedy  our  complaint;  which  it  does,  and  adds  some  interesting 
historical  facts  concerning  a  plague  which  will  always  attract 
the  attention  of  mankind.  We  should  have  been  glad  to  have 
read,  either  in  this  article  or  in  another  supplementary  one, 
something  about  a  form  of  dysentery  very  fatal,  though  in  the 
view  of  a  mere  morbid  anatomist  of  inferior  moment,  namely, 
that  which  affects  suckling  and  teething  infants  from  improper 
food. 

We  think  it  is  judicious  in  the  editor  to  insert,  even  in  a 
strictly  medical  work,  an  article  on  "  Diseases  of  the  Rectum 
and  Anus."  The  question  of  diagnosis  often  occurs  to  the 
physician  in  respect  of  them  ;  they  are  often  capable  of  relief  by 
purely  medical  remedies,  at  the  same  time  with  the  medical 


290  Reviews.  [April, 

diseases  they  are  concurrent  with ;  and,  indeed,  surgical  in- 
terference so  often  does  them  harm,  that  the  purest  of  the  pure 
will  welcome  this  pithy  practical  resume  by  Mr.  Curling  of  what 
his  life-long  experience  selects  as  the  most  important  points  of 
the  subject. 

As  the  separate  essays  are  not  placed  in  strictly  anatomical 
order,  we  have  not  noticed,  till  arrival  at  the  rectum  excluded 
all  hope,  the  absence  of  the  duodenum  from  the  list  of  viscera 
whose  morbid  states  are  commented  upon.  To  judge  by  the 
already  published  volumes,  one  would  suppose  that  congenital 
malformation,  the  occasional  presence  in  it  of  a  worm  which  has 
never  been  seen  by  an  Englishman,  and  its  perforation,  which 
are  incidentally  alluded  to  in  discussing  others  matters,^  are  the 
only  diseases  affecting  the  duodenum  independently  of  the  ilia. 
Its  special  physiological  relations  to  digestion,  the  frequency 
with  which  catarrhs  of  the  part  are  induced  by  meteorological 
changes,  its  common  atony  from  psychical  causes,  its  causation 
of  jaundice,  its  problematical  connection  with  emaciation,  its 
neuralgia  (vulgarly  called  "  liver "),  its  acute  ulceration  after 
burns,  the  special  symptoms  by  which  cancer  here  is  differen- 
tiated, of  all  which  we  cannot  discover  any  mention,  would  make 
up  an  excellent  article  in  the  inevitable  appendix. 

"  Intestinal  Worms,"  by  Dr.  Kansom,  is  written  co7i  amove 
on  a  most  enticing  subject.  Can  we  pay  the  author's  literary 
talents  a  higher  compliment  than  to  say  that  he  has  con- 
densed all  that  is  important  into  twenty-five  pages  ?  The 
history  of  these  disgusting  guests  of  ours  always  reads  like  a 
fairy  tale.  The  lamp  of  science,  which  has  remorsely  scattered 
the  shreds  of  poetry  from  so  much  of  our  forefathers'  physical 
notions,  has  only  added  to  the  wonder  excited  by  the  story  of 
their  lives.  They  are  shorn  of  the  mysterious  interest  which 
their  apparent  origin  by  spontaneous  generation  once  gave 
them,  only  to  become  tenfold  more  romantic  by  the  strangest 
travels  and  changes  of  residence  in  the  shape  of  eggs,  larvae,  and 
perfect  animals.  Though  a  great  number  of  "  tales  of  horror  " 
related  concerning  what  were  of  old  considered  intestinal  worms 
are  shown  to  be  deserving  of  scepticism,  yet  a  nearer  and  deeper 
source  of  interest  is  opened  up  by  the  facts  of  social  life  which 
our  lowly  fellow-creatures  reveal.  "Every  person  who  is  shown 
to  be  infested  by  those  very  common  Entozoa  Ozyuris  vermicu- 
laris  or  Trichocephalus  dispar  is  thereby  demonstrated  to  have 
swallowed  minute  portions  of  his  own  or  another  person's 
faeces."  With  that  sentence  Dr.  Ransom  concludes ;  and  we 
think   that  the  curdling  of  the  blood  which  it  will  produce  in 

'  Viz.  in  vol.  iii,  p.  72,  vol.  iii,  p.  202,  and  vol.  ii,  913. 


1872.] 


E/EYNOLDs's  System  of  Medicine.  291 


the  reader  is  an  effective  substitute  for  the  sensational  matter 
concerning  Trichina  spiralis,  of  which  it  has  been  determined 
by  the  editor  to  make  a  separate  article. 

Dr.  Ransom  does  not  think  there  is  sufficient  evidence  for 
attributing  to  the  intestinal  parasites  found  in  the  stools  the 
more  severe,  especially  cerebral,  symptoms,  with  which  they  are 
credited  by  writers  up  to  the  present  generation.  Microscopic 
investigation  finds  these  creatures  to  be  so  common  without  any 
signs  at  all  of  their  presence,  and  the  indubitable  local  pheno- 
mena are  so  often  unaccompanied  by  loss  of  health,  while  at  the 
same  time  the  severe  symptoms  so  generally  are  explicable  by 
other  causes,  that  he  would  condone  their  serious  offences  as 
not  proven.  However  it  must  be  allowed  that  loss  of  sleep  from 
anal  titillation,  abnormal  lustfulness,  innutrition  and  bad  temper 
are  no  slight  evils,  and  we  cannot  rank  as  superfluous  any  atten- 
tion paid  to  proper  means  of  avoiding  them.  It  is  a  happiness 
to  reflect  that  these  means  are  far  from  being  abhorrent  to  our 
better  tastes  :  cleanliness,  good  cookery,  the  self-respect  of  not 
doing  in  private  what  one  abstains  from  in  public,^  and  the 
careful  supervision  of  children,  are  Avortliy  of  advocacy  for  so 
many  other  reasons  than  the  exclusion  of  worms,  that  we  see 
no  difficulty  in  connecting  their  complete  extinction  with  the 
future  advance  of  civilization.  It  is  interesting  as  a  matter  of 
sanitary  police  to  learn  that  complete  submersion  in  water  for 
a  few  days  kills  the  ova  of  the  thread- worm  {Oxyiiris  vcr- 
inicular is),  i\\ov[^  they  retain  their  vitality  through  desiccation, 
freezing,  or  a  considerable  rise  of  temperature ;  that  it  is  through 
human  excrement  that  pigs  are  infected  with  cysticerci,  and 
that  they  revenge  themselves  on  their  poisoners  by  supplying  in 
cysticercous  or  "  measly  "  pork  the  larvae  of  human  tapeworm. 
The  obvious  inference  is  the  importance  of  letting  wet  sewage 
stand  for  a  time  before  it  is  distributed  on  plants  eaten  raw, 
and  of  preventing  human  and  porcine  ordure  from  becoming 
dust  to  be  blown  about  by  the  wind.^ 

"  Peritonitis  "  by  Dr.  Wardell  is  a  difficult  matter  to  review, 
and  still  more  difficult  to  write.     The  difficulty  consists  in  what 

1  "One  would  not  surely  be  nasty  when  alone.  "  (Chesterfield's  'Letters  to  his 
Son.') 

2  It  seems  likely  also  that  carnivorous  animals  contribute  to  the  distribution  of 
taenia  ;  the  larvae,  swallow^ed  by  them  in  raw  pork  or  beef,  may  pass  alive  through 
their  digestive  canal  and  adhere  to  green  vegetables  cultivated  for  food.  A  few 
years  back  we  attended  a  boy  of  four  years  old  for  tapeworm ;  and  having,  in  a 
case  so  exceptionally  young,  the  opportunity  of  accurate  information  on  the  daily 
habits,  we  were  able  to  trace  the  probable  source  of  the  worm  to  the  child's 
habitually  eating  the  nasturtiums  grov/ing  in  a  sculptor's  yard,  which  was  fre- 
quented by  the  suburban  dogs  as  a  privy.  The  danger  of  the  tcenia  echinococcus 
being  thus  introduced  is  still  more  serious,  as  is  urged  in  the  article  on  "  Hydatids 
of  the  Liver." 


292  Reviews.  [April, 

is  technically  termed  "  making  points."  An  idiopathic  form  of 
the  disease  is  exceedingly  problematical,  and,  if  it  exist,  is  cer- 
tainly of  minor  importance.  It  cannot  therefore  be  made  the 
typical  example,  with  which  in  illustration  to  compare  other 
forms.  Without  denying  the  possibility  of  its  being  primary, 
or  absolutely  incapable  of  connexion  with  a  foregoing  or 
coetaneous  disease.  Dr.  Wardell  occupies  his  pages  by  steadily 
going  through  the  several  instances  in  which  affections  of  the 
underlying  parts  cause  inflammation  of  the  peritoneal  sac, 
extracting  with  great  judgment  the  bulk  of  his  matter  from  the 
several  special  authorities  on  the  diseases  of  those  parts.  The 
pages  on  therapeutics  are  more  ex  cathedra,  and  in  prompt  and 
decided  tones  urge  the  duty  of  promptitude  and  decision  of  pur- 
pose in  the  selection  of  those  agents  which  are  the  most  effective 
auxiliaries  in  combating  the  rapid  progress  of  serous  inflam- 
mation. Bloodletting,  both  local  and  general,  is  advocated  for 
patients  of  the  sthenic  type,  and  its  application  recommended 
to  follow  immediately  on  the  recognition  of  the  lesion — "  as  soon 
as  possible  after  the  pulse  has  become  hard  and  quick,  the  pain 
urgent,^'  Sec. 

Dr.  Wardell  mentions,  but  does  not  commend,  the  use  of  cold, 
externally  iri  the  way  of  water  compresses  and  evaporating 
lotions,  and  internally  by  iced  enemata.  Doubtless  as  an 
universal  remedy  it  would  seem  hazardous,  but  some  cases  not 
yet  defined  appear  to  have  done  well  in  the  hands  of  Dr.  Aber- 
crombie,  Dr.  Sutton  of  Greenwich,  and  M.  Smoler  of  Prague. 
We  would  suggest  that  probably  thermometric  observations  on 
the  general  temperature,  applied  to  the  disease,  would  throw 
light  on  this  point  of  therapeutics. 

After  bloodletting  has  been  premised,  opium  is  advised  in 
unsparing  doses  without  delay  or  hesitation.  So  far  we  have 
gone  along  with  the  author  without  a  check.  But  here  we  are 
pulled  up  by  an  unpleasant  change  of  manner  apropos  of  mer- 
cury :  he  begins  a  clause  on  this  most  serious  question  thus — 
"  If  ^^  wish  to  influence  the  system  by  mercurials,  one  grain  of 
opium,  and  three  grains  of  calomel,  &c.,  &c."  "If"  ! ! — Why 
the  very  point  the  reader  prays  to  have  decided,  is  whether 
mercurialization  checks  serous  inflammation  or  not.  And  when 
he  is  held  capable  of  determining  that  momentous  question, 
surely  he  may  fix  the  quantity  without  hesitation.  A  sentence, 
which  passing  over  the  weightier  matter,  merely  tells  us  that 
three  grains  of  calomel  every  four  or  six  hours,  or  two  grains 
and  a  half  of  calomel  every  second  hour,  accompanied  by 
inunction  with  linimentum  hydrargyri,  will  mercurialize  the 
patient,  is  simply  frivolous.  The  only  excuse  we  can  make  is  that 
a  page  or  so  on  the  question  of  mercury  has  dropped  out  in 


1872.]  Keynolds^s  System  of  Medicine.  293 

arranging  the  type.  Let  us  have  it  in  the  "  Errata"  next 
volume. 

After  a  few  short  articles  on  irremediable  pathological  states 
of  the  peritoneum  by  Dr.  Bristowe,  we  have  one  by  the  same 
physician  on  ''  Ascites."  In  the  treatment  of  that  disease  we 
are  happy  to  notice  that  tonics,  such  as  quinine,  iron,  and  cod- 
liver  oil  are  commended  with  a  view  of  expediting  the  absorption 
of  fluid. 

"  Hepatalgia  "  might  have  been  with  advantage  fused  with 
'*  Enteralgia."  For  it  is  evident  that  the  deep  situation  of  the 
liver  within  the  body  must  render  it  next  to  impossible  to 
localize  such  an  impalpable  a  thing  as  pain  in  the  hepatic  nerves. 
Even  Valleix,  whose  business  as  a  systematic  writer,  and  French 
birth,  naturally  dispose  him  to  differentiation,  discredits  its  exist- 
ence as  a  separate  malady.  We  should  be  sorry,  however,  if  the 
reader  fail  to  see  one  sentence  at  the  end  of  the  article,  which 
gives  the  experience  of  the  author  on  the  use  of  chloride  of 
ammonium  in  painful  affections  of  the  right  hypochondrium, 
when  accompanied,  as  they  not  rarely  are,  by  functional  hepatic 
disturbance. 

The  sheets  on  "  Jaundice"  and  "  Biliary  Calculi"  are  centos 
of  the  established  works  of  the  present  day  on  those  subjects, 
but  they  supply  us  with  less  of  the  author's  opinion  than  we  had 
hoped  to  see  from  one  of  such  wide-spread  Indian  experience 
as  Dr.  Goodeve. 

Dr.  Maclean's  essay  on  "  Suppurative  Inflammation  of  the 
Liver'^  is  redolent  throughout  of  personal  experience,  and  has  a 
corresponding  value  to  the  practitioner.  We  are  not  alluding 
merely  to  the  cases  of  diagnosis  which  he  relates  so  pithily  and 
well,  but  more  especially  to  his  remarks  on  treatment.  Without 
hesitation  he  tackles  the  important  questions  of  bleeding  and 
mercury,  which  he  unhesitatingly  condemns.  He  does  this  on 
the  real  ground  of  personal  experience,  for  his  argument  from 
Cohnheim^s  researches,  on  the  identity  of  white  blood- cells  with 
pus-corpuscles,  is  rather  beside  the  mark.  He  continues, ''  Bleed- 
ing and  the  administration  of  mercury  being  thus  objectionable, 
what  remains  ?  I  answer.  Ipecacuanha.  For  years  past  in  my 
lectures  at  Netley,  I  have  urged  the  free  use  of  this  invaluable 
remedy,  not  only  in  dysentery,  but  in  suppurative  inflammation 
of  the  liver.  I  give  it  in  the  same  large  and  efficient  doses  as 
in  dysentery,  from  20  to  25  grains,  and  even  more,  &c."  When 
an  abscess  has  formed.  Dr.  Maclean  raises  a  warning  voice 
against  unnecessary  surgical  interference.  He  says  he  has  tried 
by  valve-like  openings,  by  drawing  off  small  portions  of  the  pus 
at  a  time,  by  closing  the  opening  with  collodion,  and  by  canulae 
provided  with  stop-cocks,  to  prevent  air  entering  into  the  cavity. 


294  Reviews.  [April, 

but  all  in  vain.  He  suggests,  and  indeed  has  used  successfully, 
the  syringe  recently  introduced  by  Dr.  Bowditch  of  Boston  for 
evacuating  the  pleura.  But  these  expedients  failing,  his  incli- 
nation evidently  is  to  leave  the  evacuation  of  the  abscess  to 
Nature,  who  working  from  inside,  at  her  leisure,  with  the  choice 
of  the  convenient  spot,  and  the  opportunity  of  making  several 
holes,  or  one,  as  suits  best,  has  an  indubitable  advantage  over 
the  shrewdest  diagnosticator.  Another  non  nocere  with  which 
we  may  credit  Nature,  is  that  she  will  probably  not  puncture 
the  gall-bladder  by  mistake,  an  accident  which  Dr.  Maclean  has 
witnessed  in  France. 

The  article  on  "  Fatty  Liver"  by  Dr.  Warburton  Begbie  is 
very  valuable,  especially  to  junior  practitioners,  by  the  warning 
which  it  indirectly  but  earnestly  puts  forth  against  over-treatment. 
The  portion  on  the  "  pathological  import"  of  the  lesion  shows 
clearly  that  the  feature  which  gives  it  the  name  is  the  least 
important  of  all.  "  It  is  not  to  be  lost  sight  of,"  says  the  writer, 
"that  the  presence  of  fat  in  the  liver-cells  is  not  morbid;  but 
that  the  increased  or  excessive  amount  of  fat  in  the  organ  con- 
stitutes disease.  Deposition  of  fat  in  the  liver-cells  is  a  natural 
physiological  process — one  which  is  continually  at  work,  and 
the  activity  of  which,  with  its  subsequent  reabsorption  of  the 
fatty  matters  is  determined  by  the  nature  of  the  food,  whether 
rich  in  fat  or  not,  and  the  consequent  impregnation  of  the  blood 
with  the  same  material."  Attention  is  directed  to  a  diagnostic 
mark  of  this  condition,  first  observed  by  Dr.  Addison,  namely, 
that  it  occurs  mostly  in  suet-pudding-faced  individuals  : — "  It  is 
earliest  observable  in  the  integuments  of  the  face  and  backs  of 
the  hands.  To  the  eye,  the  skin  presents  a  bloodless,  almost 
semi-transparent,  and  waxy  appearance  ;  when  this  is  associated 
with  mere  pallor,  it  is  not  very  unlike  fine  polished  ivory;  but 
when  combined  with  a  more  sallow  tinge,  as  is  now  and  then 
the  case,  it  more  resembles  a  common  wax  model.  To  the  touch 
the  general  integuments,  for  the  most  part,  feel  smooth,  loose, 
and  often  flabby ;  whilst  in  some  well-marked  cases  all  its 
natural  asperities  would  appear  to  be  obliterated,  and  becomes 
so  exquisitely  smooth  and  soft  as  to  convey  a  sensation  resem- 
bling that  on  handling  a  piece  of  the  softest  satin." 

With  respect  to  "  Cancer  of  the  Liver,"  which  is  handled 
by  Dr.  Warburton  Begbie,  the  main  points  are  diagnosis  and 
prognosis.  It  is  of  the  utmost  importance  to  both  patient  and 
physician  to  ascertain  whether  he  has  to  deal  with  an  uniformly 
fatal  disorder  or  with  one  of  the  seven  curable  or  the  three  less 
rapidly  destructive  lesions  which,  according  to  Frerichs,  may  be 
mistaken  for  it — viz.  (1),  waxy  liver,  (2)  syphilitic  hepatitis, 
(3)  liver  depressed  from  habit  of  tight  lacing,  (4)  hydatid  dis- 


1872.]  Reynolds's  System  of  Medicine.  295 

ease  of  liver,  (5)  hepatic  abscesses,  (6)  dilatation  of  the  bile- 
ducts  and  gall-bladder,  (7,  8,  and  9)  cancer  of  the  omentum, 
cancer  of  the  stomach,  and  cancer  of  the  right  kidney,  (10)  ac- 
cumulation of  feculent  masses  in  the  transverse  colon.  For  the 
means  of  diagnosis  we  are  referred  to  the  articles  containing 
separate  descriptions  of  the  affections  themselves.  Now  Ave 
must  warn  Dr.  Begbie,  that  is  a  mode  of  giving  information 
most  objectionable,  not  only  to  a  reviewer,  but  to  a  general 
reader  also.  A  peevish  expression  escapes  him  as  he  sees  the 
prospect  of  looking  in  the  index  for  the  references  to  ten  arti- 
cles. But  what  is  he  likely  to  "  say  in  his  haste,"  when  in 
the  first  of  these  he  reads  (page  967)  no  detailed  comparison  of 
the  two  lesions  ;  when  on  syphilitic  hepatitis  (No.  2)  there 
appears  to  be  no  article  at  all ;  nor  is  there  on  No.  3,  the  lesion 
not  being  named  in  the  index  ?  By  the  time  that  No.  4  is 
arrived  at,  calm  thought  is  out  of  the  question.  Besides  which, 
some  of  the  matter  probably  referred  to  is  not  yet  published, 
some  is  in  former  volumes  and  by  different  authors.  This  is  a 
glaring  instance  of  the  difficulties  engendered  by  the  anatomical 
classification  of  disease,  and  the  impossibility  of  avoiding  repe- 
tition without  injuring  the  usefulness  of  the  work. 

A  propos  of  "  Hydatid  Disease  of  the  Liver,"  Dr.  Warburton 
Begbie  has  some  interesting  remarks  on  the  geographical  dis- 
tribution of  the  echinococcus :  these  would  be  a  guide  to  the 
adoption  of  means  to  prevent  its  spread,  if  it  is  found  dependent 
on  varieties  of  social  habits.  Now,  recent  investigations  seem 
to  have  made  it  certain  that  this  parasite  of  the  interstitial 
structure  of  man  is  the  larva  of  a  very  small  tape-worm,  not  a 
quarter  of  an  inch  long,  which  attains  its  perfection  in  the  intes- 
tines of  the  genus  Canis.  But  how  do  dogs  get  hold  of  the 
larva  ?  After  we  have  extirpated  the  wolves  that  "  tore  up 
the  liver  and  lights  "  of  our  Red  Riding-hoods,  do  their  domes- 
ticated cousins  still  devour  our  entrails  ?  No ;  but  the  taenia  echi- 
nococcus is  found  in  the  larva  state  in  the  sheep  as  well  as  in 
man,  and  it  is  from  the  offal  of  butchers'  slaughter-houses  that 
dogs  probably  get  infected.  The  inference  is  obvious,  that  in 
proportion  to  the  proper  management  of  these  sources  of  infec- 
tion the  disorder  is  rare. 

"  Diseases  of  the  Pancreas"  is  a  careful  resume  by  Dr. 
Wardell  of  the  more  cautious  handlers  of  this  obscure  subject. 
The  rasher  speculations  of  Dr.  Dobell  do  not  appear  to  find 
favour,  as  they  are  not  alluded  to ;  and  the  statement  that 
"  there  are  no  medicines  which  have  a  special  power  of  counter- 
acting its  maladies"  would  seem  to  indicate  an  active  unbelief 
in  the  modern  therapeutics  of  the  gland. 

We   now   arrive   at    Diseases    of   the  Respiratory  System. 


296  Reviews.  [April, 

Dr.  Morell  Mackenzie's  sedulous  prosecution  of  the  pathology 
and  therapeutics  of  the  larynx  makes  him  the  most  suitable 
person  to  undertake  the  lesions  of  that  part.  It  is  a  well- 
defined  subject  for  a  monograph,  and  we  are  glad  that  he  takes 
the  whole  of  it,  which  it  is  scarcely  necessary  to  say  is  effectively, 
fully,  but  always  pithily  discussed.  A  certain  tincture  of 
egotism  was  inevitable,  and  is  not  ungraceful,  in  one  who  has 
been  so  much  before  the  public  in  relation  to  the  organs  of  voice. 
Sir  William  Jenner  on  "  Emphysema  of  the  Lungs"  is  still 
more  worthy  of  unqualified  commendation.  Since  the  time 
Avhen  he  gave  the  public  his  observations  in  the  ^  Medico- 
Chirurgical  Transactions,'  on  the  degenerations  of  the  pulmo- 
mary  tissue,  he  has  made  this  disease  one  of  his  specialities,  and 
has  at  his  leisure  examined  and  compared  with  nature  all  that 
has  been  published  by  authors  of  note,  as  his  list  of  authorities 
consulted  shows.  And  what  is  the  result?  An  exhaustive 
collection  of  conflicting  opinions,  an  elaborate  subdivision  of 
forms  on  minute  diiferences,  winding  up  with  a  list  of  drugs 
which  "  may  be  administered"  ?  No — six-and-thirty  pages 
from  which  not  a  word  can  be  spared,  and  which  therefore 
impress  themselves  upon  the  memory  with  a  sharpness  of  outline 
equalled  only  by  the  aphorisms  of  Hippocrates.  The  pathology 
is  illustrated  by  three  striking  woodcuts,  just  enough  to  be 
remembered  and  to  bring  before  the  mind  of  the  practitioner 
what  is  inside  the  chest  he  is  examining.  Care  is  taken  in  the 
selection  of  epithets  to  convey  as  much  of  the  true  state  of 
knowledge  on  the  subject,  and  as  little  fallacious  assumption  as 
possible.  What  can,  for  example,  be  more  graphic  than  the 
division  of  vesicular  emphysema  into  "  large-lunged "  and 
"small-lunged"  ?  Autopsies  immediately  recur  to  the  mind  in 
which  the  pale  lungs  crowded  out,  like  opaque  soapsuds,  as  the 
sternum  was  removed ;  others  in  which  equally  emphysematous 
pulmonary  tissue  fell  back  black  and  flabby,  and  left  a  hollow 
space  ;  and  we  feel  prepared  immediately  by  our  clinical  recalled 
experiences  to  endorse  the  following  pithy  sentences : 

"  General  large-lunged  vesicular  emphysema  is  a  very  serious 
disease.  The  symptoms  directly  due  to  it  are  grave  ;  the  diseased 
conditions  dependent  on  it  for  their  origin  are  frequently  fatal. 

"  Thus  a  large  proportion  of  cases  of  heart  disease  have  their 
starting  point  in  large-lunged  vesicular  emphysema. 

"  It  rarely  occurs  in  a  marked  form  before  the  middle  of  life,  and 
more  commonly  afi'ects  fat  people.  Lungs,  the  subject  of  this  form 
of  vesicular  emphysema,  are  larger  and  drier  than  healthy  lungs. 

"  The  parts  uncoloured  by  pigment  are  paler  than  healthy  lung. 

"  The  lungs  overlap  the  pericardium  to  a  considerable  extent,  and 
meet  above  it  even  to  near  the  top  of  the  sternum  ;  they  have  a  down- 


1872.] 


Reynolds's  System  of  Medicine.  297 


cushion-like  feel,  and  retain  the  impression  of  the  fingers.  "When 
the  thorax  is  opened  they  contract  less  that  healthy  lungs  do  under 
like  circumstances. 

''  Large-lunged  vesicular  emphysema  is,  in  the  great  majority  of 
cases,  preceded  by  attacks  of  bronchitis,  by  congestion  of  the  lungs, 
by  dry  winter  cough,  or  by  chronic  bronchitis ;  that  is  to  say,  by 
diseases  having  as  immediate  consequences  toughening  and  thick- 
ening of  the  tissues  of  the  lungs,  and  severe  cough ;  in  other  words, 
diminished  elasticity  of  the  lungs,  and  powerful  expiratory  efforts 
with  closed  glottis." 

In  the  few  concluding  words  of  the  extract  which  we  have 
made,  as  a  specimen  of  style,  are  contained  all  that  the  author 
thinks  needful  on  a  discussion  often  much  protracted  in  syste- 
matic works,  namely,  whether  expiration  or  inspiration  is  the 
final  determining  cause  of  the  breaking  up  of  the  pulmonary 
tissue.  We  are  glad  to  see  the  controversy  is  not  deemed  worth 
entering  into,  as  any  medical  student  who  has  shirked  the 
lectures  on  the  mechanism  of  respiration,  will  probably  in  his 
boyhood  have  found  out  the  way  to  burst  an  old  pair  of  bellows 
by  converting  the  tube  into  a  pop  gun. 

In  what  follows  on  small-lunged  emphysema  the  wrinkled 
and  shrivelled  subjects  of  the  disease  with  their  small  immovable 
chests,  and  the  length  of  time  they  remain  under  our  care,  no 
better  and  no  worse,  are  vividly  depicted. 

The  therapeutical  part  of  this  monograph  is  particularly  good  ; 
no  drug  is  recommended  without  a  reason  for  its  use  being  given 
in  the  physiological  action  which  it  introduces,  not,  of  course, 
each  time  that  it  is  named,  but  in  some  part  of  the  rules  for 
treatment. 

The  pages  on  "  Asthma"  have  a  melancholy  interest.  The 
gentle-hearted  and  accomplished  author  is  dead — "  dead  ere  his 
prime" — and  from  the  consequences  of  the  disease  which  he  so 
graphically  describes,  and  the  treatment  of  which  no  one  was  so 
well  qualified  to  weigh,  for  he  himself  was  the  balance  and  the 
test-tube. 

The  culminating  point  of  the  article  is  the  "  Pathology  of 
Asthma."  To  this  lead  the  description  of  the  symptoms, 
physical  signs,  causes,  and  indirectly  the  diagnosis ;  and  from 
it  the  treatment  and  prognosis  are  deduced.  It  is  not,  there- 
fore, exhibiting  a  brick  to  show  what  a  house  is  like,  but  rather 
giving  an  idea  of  a  temple  by  its  pediment,  to  quote  this  part  as 
representing  the  whole  monograph.     Dr.  Salter  says : 

"Our  views  respecting  this  (the  pathology)  must  be  greatly  in- 
fluenced by  our  views  of  the  immediate  condition  in  asthma.  My 
belief  is  that  the  immediate  and  essential  condition  of  the  asthmatic 
paroxysm  is  a  state  of  contraction  of  the  bronchial  tubes.     What 


298  Reviews.  [April, 

proof  have  we  of  this  ?  In  the  first  place,  the  sudden  induction  and 
remission  of  the  asthmatic  paroxysm  is  consistent  with  its  depending 
on  muscular  spasm  ;  in  the  second  place,  there  is  abundant  proof 
that  the  air  in  the  lungs  is  locked  up,  and  can  neither  be  got  in  or 
out ;  there  is  evidently  plenty  of  air  in  the  chest,  percussion  is  even 
hyper-resonant ;  the  patient  is  as  unable  to  drive  air  out  as  to  draw 
it  in,  can  neither  inspire  nor  expire,  cannot  discharge  breath  enough 
to  whistle  or  blow  at  a  candle  or  blow  his  nose.  The  muscles  of  re- 
spiration tug  and  labour  to  fill  and  empty  the  chest,  but  the  chest- 
walls  remain  almost  immovable ;  the  inspiratory  muscles  cannot 
raise  them,  the  expiratory  cannot  depress  them.  On  listening  to 
the  chest,  we  find  corroborative  evidence  of  the  stagnation  of  the 
air.  The  respiratory  murmur  is  in  a  great  degree  lost.  This 
absence  of  respiratory  sound,  accompanied  by  violent  respiratory 
effort,  is  one  of  the  most  striking  and  suggestive  of  the  facts  of 
asthma.  How  can  we  explain  it,  except  by  supposing  that  there  is 
some  bar  to  the  ingress  and  egress  of  air,  and  what  can  this  bar  be, 
unless  it  is  spasm  of  the  bronchial  tubes  ?  It  cannot  be  inflamma- 
tory thickening  of  the  mucous  membrane  lining  them ;  for  the 
sudden,  almost  instantaneous,  establishment  and  remission  of  the 
dyspnoea  is  incompatible  with  this.  It  cannot  be  mucous  plugging 
of  the  tubes ;  for  the  attack  will  often  come  and  go  without  any  ex- 
pectoration whatever.  But  we  have  still  more  positive  and  precise 
evidence  of  circumscribed  narrowing  of  the  air-tubes  in  the  musical 
sounds  that  are  present  in  asthmatic  breathing.  This  symptom  has 
all  the  certainty  and  precision  that  characterize  physical  phenomena, 
and  shows  that  the  air-tubes  are  the  seat  of  constrictions  that  throw 
the  air  passing  through  them  into  vibrations,  and  convert  them  into 
musical  instruments ;  and  since  these  musical  sounds  are  multitu- 
dinous, the  points  of  constriction  must  be  many  ;  and  since  they  are 
constantly  varying  in  character,  the  constrictions  of  the  tubes  must 
be  undergoing  similar  change.  Lastly,  the  effects  of  remedies  and 
their  nature  tell  the  same  tale,  and  point  to  muscular  spasm  as  the 
immediate  essential  condition.  The  most  powerful  remedies  of  asthma 
are  what  are  called  cerebro-spinal  depressants,  such  as  emetics, 
tobacco,  &c.,  remedies  whose  direct  effect  is  to  relax  muscular  spasm." 

Dr.  Salter's  last  sentences  may  seem  perhaps  at  variance  with 
our  having  previously  said  that  he  deduced  the  treatment  from 
the  pathology  ;  but  the  fact  is  he  is  speaking  above  only  of 
medicines  for  the  alleviation  of  the  paroxysm,  and  that  what  we 
refer  to  are  the  real  therapeutical,  or  curative,  remedies.  In 
prescribing  these,  the  author  makes  a  contribution  to  rational, 
as  distinguished  from  empirical,  medicine,  which  shows  how 
truly  philosophical  a  high  class  of  mind  is  when  most  practical, 
and  how  truly  practical  when  most  philosophical. 

He  divides  the  curative  treatment  into — first,  the  treatment  by 
air,  that  is,  by  locality ;  second,  dietetics  ;  third,  avoidance  of 
exciting  causes.     If  vere  scire  est  per  causas  scire,  still  more 


1872.]  Rky^^olms's  Si/stem  of  Medicine.  299 

surely  vere  curare  est  per  causas  curare^  and  we  look  upon  the 
latter  as  the  characteristic  feature  of  the  rational  medicine  of 
the  present  day.  The  aim  is  to  try  and  find  out  what  is  the 
megacosmic  or  external  cause  of  the  patient  exhibiting  cer- 
tain morbid  phenomena,  and  to  divide  the  attention  between 
the  removal  of  that  cause  and  rendering  the  suiferer  able  to 
endure  it  without  injury.  In  the  instance  of  asthma  Dr. 
Salter  claims  no  more  than  the  first  intention,  observing  that 
his  recommendations  resolve  themselves  essentially  into  the 
avoidance  of  the  provocations  of  the  attacks  ;  their  applicability 
depending  upon  what,  in  each  particular  case,  is  the  special 
exciting  cause.  We  must,  however,  remind  the  reader,  not 
alas !  the  author  himself,  that  in  diseases  of  habit,  of  which 
functional  nerve  diseases  are  the  very  types,  each  day  that  the 
paroxysm  is  postponed  becomes  in  itself  an  element  of  cure,  and 
that  in  direct  proportion  to  the  length  of  the  interval  so  is  the 
power  of  future  resistance  of  the  affected  body. 

As  a  therapeutical  classification  derived  from  pathology,  Dr. 
Salter  distinguishes  secondary  asthma  into  bronchitic,  gastric, 
and  cardiac  ;  but  he  distinctly  pronounces  for  an  idiopathic  form 
of  the  disorder  as  the  best  marked,  most  typical,  and  character- 
istic, and  at  the  same  time  the  most  severe.  He  points  out 
the  analogy  between  it  and  epilepsy,  as  essentially  nervous  in- 
termittent diseases. 

The  views  of  Dr.  Hughes  Bennett  on  the  pathology  of 
tubercle  are  well  known,  and  those  who  wish  to  read  them  pro- 
nounced in  a  condensed  form  ex  cathedra  will  find  what  they 
require  in  a  contribution  from  that  physician  on  "Phthisis 
pulmonalis."  Those  who  expect  other  aspects  of  the  question, 
as  looked  at  by  Virchow,  Niemeyer,  Sanderson,  and  others,  to 
be  sufficiently  displayed  in  a  '  System  of  Medicine,'  will  be 
disappointed.  We  cannot  agree  with  the  writer  that  the 
differences  between  them  are  merely  verbal.  All,  however,  will 
be  satisfied  that  the  therapeutics  represent  the  best  common- 
sense  inferences  which  can  be  drawn  from  a  general  view  of  the 
scientific  explanations  of  the  origin  and  progress  of  the  disease. 
To  treat  the  patient's  body  as  a  whole,  to  restore  that  which  is 
deficient  in  it,  in  respect  of  both  substance  and  function,  and  to 
shun  the  obvious  external  causes  of  aggravation  may  be  stated 
to  include  the  whole  of  the  remedial  measures  which  Dr. 
Bennett  considers  useful.  And  with  them  we  may  be  fairly 
satisfied,  for  by  such  help  the  evil  is  so  mitigated  that  one  ex- 
perienced physician  gives  statistical  evidence  of  the  average 
duration  of  life  in  consumptives  being  actually  doubled ;  while 
the  Registrar- General  for  Scotland  reports  a  decrease  of  one 
third  in  the  annual  number  of  deaths  from  phthisis.     We  would 


300     *  Reviews.  [April, 

not  attach  too  much  importance  to  the  eixactitude  of  the 
numerical  results  obtained,  but  they  certainly  exhibit  a  marked 
diminution  in  the  gravity  of  the  disease  during  the  last  twenty- 
five  years,  that  is  to  say  during  the  period  in  which  this  mode 
of  treatment  has  more  and  more  prevailed. 

Dr.  Beigel  has  in  an  article  on  *^  Cancer  of  the  Lungs"  made 
the  most  of  an  unpromising  subject  by  industriously  collecting 
all  that  has  been  written  about  it  for  several  years. 

The  really  learned  articles  of  the  whole  book,  however,  are 
the  next,  on  '^Pneumonia,"  by  Dr.  Wilson  Fox.  The  notes  and 
appendices  alone  (where  counting  is  easiest)  contain  upwards  of 
six  hundred  references  to  authorities  for  various  statements, 
while  the  text  also  in  some  parts  bristles  with  names  of  various 
degrees  of  familiarity.  And  let  it  not  be  understood  that  this 
is  a  heterogeneous  collection  of  quotations,  like  the  works  of  a 
second-rate  seventeenth-century  writer ;  all  are  carefully  selected, 
so  as  not  to  be  repetitions,  and  where  known  are  such  as  must 
command  respect.  This  array  of  colleagues  in  research  some- 
what overshadows  the  author's  own  name  both  as  a  witness  and 
as  a  judge  in  the  important  questions  here  debated  before  the 
reader.  Without  any  affectation  of  modesty  he  certainly  does 
keep  himself  in  the  background,  and  we  think  it  right  to  notice 
this,  because  when  we  do  become  conscious  that  the  author  is 
relating  his  own  experience,  we  are  struck  with  the  peculiar 
healthy  vigour  of  observation  which  it  displays,  and  when  we 
are  specially  pleased  with  some  judicious  apothegm  we  are 
usually  led  to  infer  from  the  style  that  it  is  the  author's  own. 
Yet  he  does  not  shrink  from  his  responsibilities  ;  the  names  of 
clinicists,  such  as  Graves  and  Chambers,  whose  position  as  summers 
up  of  evidence  is  similar  to  his  own,  rarely  appear,  nor  do 
those  of  systematic  writers,  such  as  Watson  and  Aitken ;  but 
any  one  whose  statistics  are  valuable  is  immediately  pressed 
into  the  service.  It  is  evident  that  we  here  possess  a  mono- 
graph of  the  thoughts  of  the  current  generation  on  the  subject 
that  will  be  absolutely  essential  as  a  mine  of  reference  for  all 
who  are  discussing  it  for  many  years  to  come.  We  cannot 
expect  another  to  go  so  thoroughly  into  it  for  a  long  time. 

As  to  treatment  everybody  of  course  quotes  pneumonia  as  the 
chief  battle-field  where  opposite  principles  of  therapeutical 
pathology  have  fought  for  the  mastery.  Its  frequency,  the 
facility  of  diagnosis,  and  the  gravity  of  the  symptoms  seem  to 
have  commended  it  for  this  purpose  to  all  parties.  And  they  are 
right  in  their  selection,  when  the  reckoning  of  the  value  of  a 
treatment  is  made  according  to  the  rough  average  mortality  on 
a  large  scale.  But  when  you  come  to  judge  of  the  immediate 
action  of  a  remedy  upon  this  or  that  part  of  the  disease,  or  upon 


1872.] 


Reynolds's  System  of  Medicine,  301 


its  duration  in  individual  cases.  Dr.  Fox  well  points  oat  that  no 
malady  can  well  he  chosen  less  suited  to  afford  logical  proof,  by- 
means  of  statistics,  of  the  relative  value  and  the  curative  effects 
of  any  system  of  treatment.  An  acute  disease  with  a  natural 
tendency,  under  favourable  circumstances,  to  terminate  spon- 
taneously by  a  sudden  crisis  occurring  at  periods  varying  from 
the  third  (?  the  second)  to  the  seventh  or  eleventh  days,  presents 
the  most  singular  elements  of  fallacy  in  reasoning  from  the 
phenomena  following  active  interference.  The  author's  reason- 
ings on  therapeutics  are  therefore  rational,  rather  than  statistical, 
and  he  is  quite  open  to  allow  the  occasional  advantage  of  a 
treatment  whose  general  adoption  has  proved  injurious.  Even 
the  unpopular  venesection  is  liberally  spoken  of,  and  allowed  to 
have  saved  life  in  cases  of  apncea  occurring  early  in  the  disease. 
The  external  application  of  cold  water  to  reduce  the  pyrexia,  is 
a  treatment  we  would  gladly  know  more  about.  Dr.  Fox  gives 
only  one  instance  of  its  employment,  and  that  an  unsatisfactory 
one ;  and  the  immediate  distress  it  causes  to  the  patient  is  not 
encouraging ;  but  still  from  experience  of  it  in  other  pyrexias 
we  know  it  to  be  safe  and  to  be  worthy  a  fair  trial. 

We  may  observe  here  that  Dr.  Fox  speaks  about  this  method 
of  treatment  as  if  the  low  temperature  were  the  only  element  to 
be  considered — for  he  introduces  the  ice  bag  as  an  equivalent 
for  aqueous  compresses.  But  it  should  not  be  forgotten  that  warm 
water  also,  and  probably  more  generally  than  cold,  has  been 
thought  beneficial;  indeed  by  some  in  the  shape  of  "jacket- 
poultices  "  is  considered  a  sort  of  panacea  for  pneumonia.  It  is 
possible,  therefore,  that  the  temperature  may  be  of  less  impor- 
tance than  the  medium  of  its  application.  It  should  not  be  for- 
gotten that  tepid  baths  were  used  in  Greece  for  pneumonia  by 
even  such  an  expectant  physician  as  Hippocrates. 

We  may  remark  in  favour  of  the  wet  tepid  treatment  of  pneu- 
monia that  its  virtues  are  most  visible  when  employed  in  the 
most  serious  varieties  of  the  disease,  namely,  the  secondary 
pneumonias  —  broncho-pneumonia,  lobular  pneumonia,  &c. 
Now  fierce  and  vigorous  therapeutics  always  vaunt  their  most 
startling  victories  over  frank  idiopathic  cases,  which  are  shown 
by  statistics  to  be  much  less  fatal  in  their  nature,  as  may  be  read 
in  Dr.  Fox's  words. 

That  destruction  of  the  lung  tissue  by  its  conversion  into  an 
impermeable  fibrous  structure  which  has  been  variously  sermed 
''Cirrhosis,"  "Sclerosis,"  "  Scirrhus,"  "  Induration,"  "Inter- 
stitial Pneumonia,"  "  Melanotic  Phthisis,"  "  Fibroid  Phthisis  " 
(the  last  two  names  being  an  attempt  to  combine  an  anatomical 
and  a  clinical  momenclature),has  its  titles  here  compounded  for 
by  the  compromise  of  "  Chronic  Pneumonia."  And  Dr.  \^  ilsou 
98— xLix.  20 


302  Reviews.  [April, 

Fox  again  appears  as  the  collector  of  the  material  required  to 
illustrate  the  subject.  He  confines  himself  strictly  to  such  forms 
of  chronic  induration  of  the  lung  as  may  be  reasonably  pre- 
sumed to  have  been  caused  by  processes  in  which  tubercular 
changes  have  had  no  share.^  In  this  sense  the  disease  is  of 
great  rarity,  and  examples  of  it  can  only  be  found  in  isolated 
cases  scattered  in  different  journals  and  in  monographs  on 
diseases  of  the  lungs.  At  the  same  time  it  has  from  some 
accidental  circumstances  excited  lately  considerable  interest 
among  practitioners,  and  we  may  therefore  not  be  considered 
impertinent  if  we  allot  more  space  to  it  than  its  comparative 
importance  to  mankind  would  justify. 

Let  it  be  understood  that  the  adoption  of  the  name  is  not  a 
meaningless  ceremony,  or  to  prevent  a  disease  being  utterly 
anonymous  when  all  its  previous  titles  had  been  rejected  as  unsuit- 
able. It  is  upheld  that  this  condensation  of  the  pulmonary  tissue, 
without  tubercle,  or  other  heterogeneous  formation,  is  really  the 
result  of  a  pneumonia  which  has  passed  into  a  chronic  stage. 
Other  accounts  of  its  origin  are  fairly  and  favorably  set  before  the 
reader — namely,  first  Sir  D.  Corrigan's  view  of  it  as  a  growth 
of  fibrous  tissue  analogous  to  "  cirrhosis"  of  the  liver,  indepen- 
dent of  any  inflammatory  process ;  secondly,  that  it  is  a  primary 
"  fibroid  degeneration"  of  the  alveolar  walls.  To  the  first  Dr. 
Fox  would  reply  that  the  interior  of  the  air-sacs  almost  inva- 
riably, if  not  constantly,  exhibit  an  accumulation  of  the  products 
of  inflammation,  as  is  shown  in  the  woodcuts  inserted  in  the 
text.  Further,  the  change  in  the  liver  takes  place  mainly 
through  an  increase  of  fibrous  tissue  between  the  acini ;  whilst 
in  the  lung,  though  some  thickening  be  found  in  the  inter- 
lobular septa,  the  most  important  pathological  alterations  are 
those  which  occur  in  the  walls  of  the  pulmonary  alveoli,  which 
certainly  are  not  interstitial  tissue,  but  correspond  rather  to  the 
terminal  extremities  of  gland-ducts.  In  short,  in  a  cirrhotic 
liver  the  fibrous  thickening  is  perilobular;  in  an  indurated  lung 
it  is  intralobular.  To  the  suggestion  that  this  alteration  in  the 
alveolar  walls  is  a  jprimary  lesion,  as  implied  by  the  words 
'*  fibroid  degeneration,"  Dr.  Fox  also  demurs  on  account  of  the 
deficiency  of  sufficient  positive  evidence  for  admitting  such  a 
class  of  lesions  into  our  nosological  categories.  He  says  that 
during  many  years  of  much  attention  to  the  subject  he  has 
never  seen  any  pathological  specimens  supporting  such  a  view, 

^  The  autlior  classes  all  cases  as  tubercular  which  present  granulations — grey, 
or  soft,  or  cheesy — in  the  lungs  or  other  organs.  The  question,  "  What  is  a 
tubercle  ?"  is  as  vital  an  one  to  future  pathology  as  "  What  is  a  pound  ?"  to  poli- 
tical economy.  Dr.  Fox  announces  that  he  will  shortly  enter  the  lists  with  an 
answer. 


1872.] 


Reynolds^s  Sijstem  of  Medicine.  303 


and  nearly  all  the  cases  which  have  fallen  under  his  own  oh- 
servation  "  have  been  connected  with  previous  chronic  pneu- 
monia associated  with  the  presence  of  tubercles." 

The  reader  is  probably  familiar  with  the  tale  of  the  aged 
divinity  clerk  (the  bearer  of  the  silver  poker  before  the  uni- 
versity preacher)  at  Oxford,  who  on  his  death -bed  told  his  me- 
dical attendant,  "  Ah,  sir,  1  have  for  fifty-five  years  been  hear- 
ing, at  St.  Mary's,  the  excellent  gentleman  in  the  afternoon 
contradicting  the  learned  gentleman  in  the  morning  ;  yet,  thank 
God,  I  remain  a  Christian."  He  will  be  reminded  of  this,  and 
perhaps  also  have  a  struggle  to  maintain  faith  in  the  revelations 
from  professional  chairs,  when  he  reads  in  an  article  by  Dr. 
Bastian,  which  immediately  succeeds  those  by  Dr.  Fox,  "  It 
seems  expedient  to  me  to  do  away  altogether  with  the  name 
*  chronic  pneumonia,'  as  an  appellation  for  the  pathological 
changes  in  question."  Dr.  Bastian  gives  his  reasons,  which 
may  be  shortly  described  as  the  reading  in  a  reverse  direction 
of  the  phenomena  on  which  Dr.  Fox  grounds  his  argument. 
Cases  which  the  one  calls  the  rule  the  other  calls  the  exception, 
and  both  are  disposed  to  draw  into  their  meshes  instances  from 
previous  observers  which  have  an  indeterminate  clinical  history. 
The  truth  of  the  matter  is  that  the  post-mortem  appearances 
do  not  decide  the  questions  at  issue,  and  the  disease  is  too  rare 
to  furnish  clinical  evidence  of  its  primary  nature. 

We  will  not  presume  to  give  any  opinion  upon  the  subject, 
and  think  it  may  be  well  left  undecided  till  some  practical  point 
be  found  to  hinge  upon  it.  Perhaps  we  may  be  allowed  to 
suggest  that  it  would  have  been  as  well  if  the  editor  of  the 
'  System  of  Medicine'  had  been  actuated  by  corresponding 
feelings  to  spare  the  public  these  unripe  fruits,  and  to  let  the 
contending  opinions  balance  one  another  outside,  rather  than 
within,  his  limited  sheets.  The  110  pages  of  close  print  occu- 
pied by  the  four  articles  entitled  "  Chronic  Pneumonia,"  "  Sy- 
philitic Affections  of  the  Lung,"  ^'  Brown  Induration  of  the 
Lung,"  and  "  Cirrhosis  of  the  Lung,"  none  of  which  possess 
the  slightest  clinical  interest,  might  with  great  advantage  have 
made  way  for  several  subjects  the  omission  of  which  can  be 
excused  only  by  want  of  space.  We  would  specify,  as  suggested 
by  this  part  of  the  work,  "  Coryza,"  "  Ozaena,"  "  Ulcer  of  the 
Nose,"  *'  Epistaxis,"  "  Acute  Capillary  Bronchitis"  (which  is 
in  the  article  on  bronchitis  merged  in  bronchial  catarrh),  '*  Dis- 
ease of  the  Bronchial  Glands"  (in  its  local  aspects),  ''  Disease 
of  the  Thymus,"  "  Miller's  Asthma,^"  "  Grinder's  Rot,"  and 
other  lesions  of  the  lungs  by  dust,  "  Foreign  Bodies  in  the  Air- 

^  We  do  not  mean  Dr.  Miller's  Asthma  thymicum,  but  that  peculiar  to  the 
trade. 


304  Reviews.  [April, 

passages,"  "  Hydatids  of  the  Lung,"  "  Pulmonary  Extravasa- 
tion" ;  Avhile  in  the  earlier  portion  of  the  volume  we  miss  "  Lead 
Colic,"  "  Constipation,"  "Neuralgia  Ani,"  "  Peritoneal  Abscess 
and  False  Anus,"  "  Hydatids  of  Peritonaeum,"  "  Disease  of  the 
Omentum,"  and  "  Obesity."  We  do  not  see  either  where  dis- 
eases of  the  ductless  glands,  such  as  "  Goitre,"  are  to  come  in, 
for  they  cannot  be  said  to  belong  to  the  "  blood-glandular  sys- 
tem,^' the  lesions  of  which  are  promised  in  the  fourth  volume. 
We  think  also  that  a  *  System  of  Medicine'  cannot  be  called  com- 
plete in  the  present  day  without  at  least  a  short  review  of  in- 
struments of  precision,  the  'scopes  and  'graphs  and  'meters  and 
tests  of  various  sorts,  which  much  require  valuation  and  classifi- 
cation. We  are  the  less  reticent  of  our  wants,  inasmuch  as  we 
foresee  an  inevitable  fifth  volume  looming  in  the  distance. 

The  sesquipedalia  verba  used  in  the  modern  naming  of  the 
diseased  womb  and  skin  will  assuredly  require  a  volume  to  them- 
selves, instead  of  being  disposed  of,  as  Dr.  Reynolds  proposes,  in 
the  fourth,  in  the  wake  of  the  circulatory,  the  blood-glandular, 
and  the  urinary  systems. 

The  next  contribution  is  by  Dr.  G rally  Hewitt  on  "  Apneu- 
matosis,"  which  he  defines  as  a  "  condition  of  the  lung-tissue 
characterised  by  the  return  of  certain  of  the  air-cells  to  a  quasi- 
foetal  state,"  to  distinguish  it  from  "Atelectasis,"  which  is  the 
non-expansion  of  the  air-cells,  or  the  retention  of  the  foetal  state. 
It  is  a  clear,  sensible  monograph,  and  the  only  defect  we  can 
lay  our  finger  on  is  that  the  author  confines  his  pathology  and 
treatment  of  the  lesion  solely  to  the  case  of  children,  thus  pass- 
ing over  in  silence  that  discipline  of  the  thorax  in  boyhood 
which  is  so  important  to  the  health  of  the  patient  in  adult 

"  Bronchitis,"  by  Dr.  Frederick  Roberts,  seems  written  rather 
against  the  grain.  The  author  has  not  gone  into  his  subject 
con  amove,  and  consequently  has  neither  contributed  anything 
which  bears  the  stamp  of  personal  observation,  nor  collected  the 
harvest  grown  by  others.  This  produces  a  painful  vagueness, 
of  which  the  following  sentence  may  be  taken  as  a  haphazard 
specimen : — 

"  If  plethora  exists,  this  must  be  reduced  by  appropriate  diet  and 
general  management,  and  the  use  of  watery  purgatives." 

The  reader  for  practical  instruction  cannot  but  ask.  What  is 
plethora  1  What  are  its  signs  ?  Does  it  ever  "  exist"  ?  What 
diet  is  appropriate  ?  and  why  is  the  management  to  be  "  gene- 
ral "  instead  of  also  "  appropriate  "  ?  Are  "  watery  purgatives" 
those  which  are  soluble  in  water  or  are  they  hydragogues  ?  Then, 
to  wind  up,  we  are  told  that  "  a  course  of  mercury  is  said  to 
have  a  very  favourable  influence  over  some  cases  of  chronic 


1872.] 


Reinolds's  System  of  Medicine,  305 


bronchitis."  Surely  nothing  but  harm  can  follow  from  the 
administration  of  teaching  like  that  to  junior  practitioners. 
They  are  not  told  who  says  it,  what  sort  of  favourable  influence 
mercury  exerts,  nor  in  what  sort  of  case,  and  the  result  can  only 
be  either  promiscuous  drugging  or  a  general  disrespect  for  the 
valuable  parts  of  the  author's  writing. 

In  less  than  fifty  pages  Dr.  Anstie  has  managed  to  convey 
a  vast  amount  of  valuable  matter  on  the  diseases  of  the 
pleura,  viz.  "  Pleurodynia,"  *'  Pleurisy,"  "  Hydrothorax,"  and 
"  Pneumothorax,"  the  titles  of  his  papers.  In  the  first  the 
main  point  is  the  removal  of  stitch  in  the  side  from  the  category 
of  rheumatic  ailments  and  its  reception  among  the  neuralgies. 
This  considerably  affects  both  prognosis  and  therapeusis,  ren- 
dering the  expectation  of  future  allied  ailments  more  correct 
and  the  treatment  more  decided. 

In  "  Pleurisy"  the  author  fixes  with  uncompromising  decision 
the  status  of  the  disease  in  modern  pathology.  He  points  to 
two  facts  eminently  characteristic  of  recent  investigation  as 
modifying  in  a  sovereign  manner  our  thoughts  and  practice  in 
relation  to  this  disease  :  lirst,  the  increasing  certainty  that 
primary  acute  pleurisy  is  but  rarely  fatal ;  and  secondly,  the 
discovery  that  those  chronic  cases  which  are  merely  the  prolon- 
gation of  the  acute  primary  variety,  may  be  safely  treated  with 
an  energy  which  helps  greatly  to  abridge  the  course  they 
naturally  tend  to  run.  With  our  present  means  and  new  maxims 
of  treatment  it  is  not  too  much  to  say  that  primary  chronic 
pleurisy  has  lost  its  most  important  features  and  its  peculiar 
terrors  ;  and  the  only  reason  for  regarding  pleurisy  of  chronic 
type  in  any  special  way  is  the  fear,  that  underneath  the  appa- 
rently mere  local  affection  there  may  lurk  the  taint  of  a  consti- 
tutional diathesis,  such  as  tuberculosis  for  example  ;  while  the 
regular  result  of  an  acute  inflammation  of  this  serous  membrane 
is  an  illness  of  one  week  to  three,  ending  in  trifling  local  lesions 
of  no  injury  to  the  patient's  subsequent  health  and  strength. 
The  cases  which  last  longer  are  those  where  external  circum- 
stances have  been  especially  adverse,  the  patient  neglecting 
ordinary  instinctive  precautions,  either  from  obstinacy,  or  insen- 
sibility, or  from  the  slight  nature  of  the  early  symptoms.  This 
is  of  course  more  likely  to  happen  in  the  slighter  cases ;  the 
protraction  of  the  severe  sort  is,  we  fear,  justly  to  be  laid  to  the 
charge  of  the  doctor.  On  the  other  hand,  secondary  pleurisy,  of 
which  our  predecessors  would  seem  to  have  taken  less  account, 
exhibits  a  much  greater  variety  of  type,  and  is  a  much  more 
serious  subject  for  prognosis.  The  vital  significance  of  this  class 
depends  on  two  factors — the  virulence  of  the  original  disease 
and  the  power  of  resistance  which  the  organism  has  so  far  pre- 


306  Reviews.  [April, 

sented  to  it.  The  main  points  which  the  history  of  pleurisies 
secondary  to  acute  fevers  present,  are  the  protracted  course,  the 
tendency  to  become  prevalent,  and  the  frequent  end  either  in 
death  or  in  constitutional  disease,  especially  tuberculosis.  The 
form  of  pleurisy  which  is  secondary  on  acute  or  subacute  diseases 
of  other  viscera  are  of  very  various  types.  Pneumonia,  for 
instance,  in  numberless,  perhaps  almost  in  all,  cases,  is  attended 
with  a  certain  amount  of  fibrous  pleurisy  :  but  fortunately  this 
is  usually  limited  to  a  circumscribed  development  of  plastic 
lymph,  which  acts  as  its  own  cure  ;  while  that  which  is  conse- 
quent on  Bright's  disease  is  always  an  untractable  ailment ;  but 
still  its  history  differs  greatly  according  to  circumstances.  Where 
it  is  the  immediate  consequence  of  the  acute  albuminuria  of 
scarlatina,  the  collected  fluid  is  rapidly  changed  to  pus,  and  the 
least  disastrous  result  in  a  chronic  empyema,  with  too  often  a 
fatal  termination.  A  different  type  of  pleurisy  may  be  often  seen 
occurring  as  a  complication  of  the  amyloid  form,  still  oftener  of 
the  cirrhotic  (contracting)  form  of  renal  lesion.  There  is  not 
here  the  same  proneness  to  the  production  of  pus,  but  rather  to 
the  collection  of  a  copious  fibro-serous  (chiefly  serous)  fluid. 

This  short  abstract  of  what  Dr.  Anstie  gives  as  the  history  of 
pleurisy  shows  clearly  enough,  to  those  used  to  modern  medical 
logic,  what  his  treatment  of  it  is.  He  denounces  in  no  measured 
term^s  bloodletting,  mercury,  blisters,  and  says  that  in  poultices, 
the  subcutaneous  injection  of  morphia,  and  rest,  we  have  quite 
sufficient  to  counteract  all  the  risks  and  pains  of  ordinary 
pleurisy.  When  these  means  have  been  insufficient  to  prevent 
severe  fits  of  orthopnoea,  or  the  time  for  their  agency,  say  three 
or  four  weeks,  has  gone  by  without  a  renewal  of  the  power  of 
absorption.  Dr.  Anstie  would  proceed  at  once  to  paracentesis 
thoracis.  He  says  truly  that  a  new  era  has  upsprung  in  the 
treatment  of  pleurisy  since  the  recent  development  of  this  opera- 
tion. Till  lately  it  was  a  clumsy  proceeding,  which,  notwith- 
standing all  skill,  admitted  air  into  the  pleural  cavity,  gave  rise 
to  suppuration  at  great  risk  of  life,  often  established  a  fistulous 
opening,  and  was  therefore  only  spoken  of  as  a  last  resource,  and 
had  its  chances  of  success  diminished  by  being  performed  too 
late.  The  best  that  the  '  Enclyclopsedia  of  Practical  Medicine' 
can  say  of  it  in  the  year  1834  is,  "  Still,  even  the  few  cases  in 
which  either  complete  recovery  or  relief  for  a  considerable  time 
has  followed  it,  prevent  us  from  despairing."^  It  is  startling 
to  contrast  this  lugubrious  expression  with  the  statement  by 
Bowditch  that  since  1850  he  has  performed  the  operation  "  250 
times  in  154  persons,  without  once  seeing  any  evil,  or  even  any 

^  'Encyclopaedia  of  Pract.  Med.,'  vol.  iii,  p.  399. 


1872.] 


Reynolds's  System  of  Medicine.  307 


very  distressing  symptoms  resulting  from  it ;  while  on  the  other 
hand  it  has  saved  a  large  number  of  lives  which  must  otherwise 
have  been  sacrificed."  What  paved  the  way  to  this  eminent 
success  was  the  invention  at  the  date  given  of  his  excellent 
suction  instrument  by  Dr.  Morill  Wyman.  The  most  important 
advance  that  has  been  made  is  the  employment  of  apparatus 
which  allows  of  the  operation  being  made  either  simply  explo- 
ratory, or  carried  on  at  once  to  evacuation  of  the  fluid.  Dr. 
Anstie  quotes  the  approbation  of  a  large  number  of  the  best 
practical  men  of  the  day,  not  as  a  logical  argument,  but  simply 
as  adding  tone  to  the  trumpet  blast  with  which  he  thinks  it 
"  pardonable  and  even  necessary"  to  proclaim  the  downfall  of 
those  timid  and  vacillating  rules  of  conduct  which  text-books 
have  hitherto  prescribed.  For  these  he  would  substitute  the 
following : 

"  If  at  the  end  of  fourteen  or  twenty  days  for  a  child,  or  three 
weeks  to  a  month  for  an  adult,  from  the  initial  symptoms,  the  fluid 
does  not  show  real  signs  of  diminution,  paracentesis  should  be  per- 
formed ;  and  this  rule  is  absolute,  both  for  primary  and  secondary 
pleurisies,  except  where  the  case  is  hopeless  on  other  grounds." 

By  "  Hydrothorax  "  Dr.  Anstie  means  a  passive  non-inflam- 
matory effusion  of  serum,  due  either  to  mechanical  obstruction 
of  circulation  or  to  blood  poisoning.  By  this  etiology  he 
designedly  draws  as  clear  a  line  as  possible  between  it  and 
pleurisy,  for  a  reason  which  cannot  but  appear  to  everybody 
most  practical.  As  he  says,  "  The  tendency  of  the  best  modern 
practice  in  regard  to  hydrothorax  may  be  said  to  be  nearly  the 
reverse  of  that  with  regard  to  pleurisy."  Reference  is  intended 
to  the  uselessness  of  paracentesis,  except  in  very  few  instances, 
to  such  cases,  and  on  the  other  hand  to  the  beneficial  effects  of 
diuretics  and  hydragogue  purgatives.  The  singular  number 
would  have  been  suitable  to  the  latter  word,  for  he  says,  "  I 
only  recommend  one,  viz.  elaterium,  which  is  incomparably 
superior  to  all  others."  That  sentence  is  very  characteristic ; 
it  seems  to  protest  against  that  vagueness  of  prescription  which 
we  have  already  denounced  in  this  article,  bidding  the  student 
more  powerfully  than  in  words  to  have  but  few  drugs,  but  to 
take  good  care  that  those  few  are  efficient  and  well  proved. 
The  Thucydidean  heedlessness  of  grammar  which  in  the  two 
sentences  quoted  almost  provokes  a  smile,  gives  a  quaintness  to 
the  diction  which  makes  it  all  the  more  forcible. 

While  on  the  subject  of  diction  we  may  be  allowed  to 
suggest  that  the  use  of  the  conventional  term  "  effusion "  is 
somewhat  unsuitable  to  the  correct  pathology  which  Dr.  Anstie 
has  evidently  adopted,  and  makes  less  clear  the  therapeutics 
thereupon  grounded.     "  Collection  "  would  be  an  improvement. 


308  Reviews.  [April, 

for  in  fact  the  amount  of  serum  continuously  effused  is  not  in- 
creased, but  its  reabsorption  is  arrested,  and  to  the  recovery  of 
this  reabsorption  the  treatment  is  directed. 

The  four  pages  on  "  Pneumothorax  "  say  shortly  what  has 
often  been  said  before  at  greater  and  melancholy  length. 


II. — The  Dynamics  of  Nerve  and  Muscle.^ 

More  than  twenty  years  ago,  as  he  tells  us  in  his  preface, 
Dr.  Radcliffe  was  not  a  little  puzzled  by  seeing  what  happened 
to  a  rabbit  after  death  by  strychnia.  The  animal  at  death  was 
propped  up  against  the  side  of  a  box,  touching  the  ground  only 
by  the  tips  of  its  toes,  with  its  legs  rigidly  stretched  out,  and 
with  its  neck  and  body  arched  backwards  until  the  head  almost 
touched  the  tail^  and  so  it  remained  until  the  putrefactive  un- 
stiifening  of  the  muscles  caused  it  to  fall  down.  The  contrac- 
tion, which  had  fixed  the  body  in  this  position  before  death, 
had  not  been  relaxed  by  death  ;  the  spasm  before  death  and 
the  rigidity  after  death  seemed  to  be  confounded  one  with  the 
other.  Dr.  Radcliffe  upon  this  began  to  ask  himself  whether 
the  interpretation  of  the  spasm  might  not  be  found  on  the  side 
of  death  rather  than  on  the  side  of  life  ;  whether  the  spasm 
might  not  be  in  very  deed  a  transition  step  towards  rigor  mortis, 
and  result  from  the  abstraction  of  something  from  tlie  muscle, 
and  not  from  something  imparted  to  it  or  awakened  in  it ; 
whether,  in  fact,  it  might  not  be  a  physical  rather  than  a  vital 
phenomenon. 

This  was  a  bold  speculation  twenty  years  ago.  Now  that  the 
doctrine  of  the  conservation  of  energy  and  the  correlation  of 
forces  has  penetrated  into  physiology,  and  educated  medical 
men  are  familiar  with  the  deductive  calculations  of  Meyer  and 
the  experimental  investigations  of  Joule,  by  which  heat  is 
weighed  in  the  balance,  and  are  competent  to  that  scientific 
exercise  of  the  imagination  by  which  molecular  motion  and 
motion  in  mass  are  realized  as  mutually  convertible,  the  one  into 
the  other,  it  is  not  difficult  to  conceive  that  "  vital  force  "  may 
be  correlated  with  the  cosmic  forces  generally,  and  to  admit  that 
vital  motion  may  be  simply  another  mode  of  motion ;  but 
twenty  years  ago  the  case  was  different,  and  the  question  was 
calculated  to  startle  those  to  whom  it  was  addressed  by  Dr. 
Kadcliffe  after  he  had  answered  it  for  himself.  Whether  we 
agree  or  not  with  Dr.  Radcliffe  in  his  latest  conclusions  on  this 
subject,  as  expressed  in  the  book  before  us,  this  credit  at  any 

^  The  Dynamics  of  Nerve  and  Muscle.     By  Dr.  C.  B.  Radcliffe. 


1872.]  The  Dynamics  of  Nerve  and  Muscle.  309 

rate  is  due  to  him  of  having  formed  a  daring  conception,  and  of 
having  perseveriiigly  laboured  to  demonstrate  its  truth ;  he  has, 
moreover,  in  the  course  of  his  work  largely  contributed  to  the 
establishment  of  correct  ideas  as  to  the  real  nature  of  pain  and 
spasm,  and  of  more  rational  and  successful  methods  of  relieving 
these  conditions. 

Dr.  Radcliffe's  theory  of  muscular  action  was  originally  this. 
In  some  way  or  other  the  natural  electricity  present  in  muscle 
during  rest  produces  this  state  of  rest  or  relaxation  by  keeping 
the  muscular  molecules  in  a  state  of  repulsion,  and  contraction 
results  from  the  discharge  of  this  electricity,  allowing  the  attrac- 
tion of  the  molecules  to  come  into  play.  In  other  words, 
muscle  is  inherently  elastic,  and  tends  to  contract;  during  rest 
the  mutual  attraction  of  its  molecules  is  antagonised  by  the 
natural  electricity,  much  in  the  same  way  as  cohesive  attraction 
in  bodies  generally  is  by  heat,  and  its  contraction  is  determined 
by  the  removal  of  this  antagonistic  force.  Dr.  Radcliffe's  earlier 
idea  as  to  the  form  of  electricity  present  in  muscle  was  derived 
from  Du  Bois-Raymond's  demonstration  of  a  galvanic  current 
from  end  to  side  of  the  muscular  fibre,  and  he  supposed  it  to  be 
current  or  galvanic  electricity ;  later,  he  was  led  to  consider  the 
condition  of  muscle  at  rest  to  be  one  of  charge,  the  electricity 
being  tensional,  this  modification  in  his  opinion  being  gradually 
brought  about  by  consideration  of  the  fact  discovered  by 
Matteucci,  that  muscular  contraction  is  accompanied  by  an 
electrical  discharge  analogous  to  that  of  the  torpedo.  In- 
vestigating this  new  hypothesis  experimentally,  he  came  upon 
the  fact  that,  not  one,  but  two  kinds  of  charge  were  present  in 
muscle,  positive  and  negative  electricity,  a  state  of  things 
which  appeared  to  him  to  be  inconsistent  with  the  mutual  re- 
pulsion of  the  molecules  in  virtue  of  charge  with  similar 
electricity.  This  does  not  appear  to  us  quite  in  the  same  light ; 
we  do  not  well  see  how  a  charge  of  one  kind  only  could  be  ex- 
pected to  sustain  any  degree  of  tension  without  being  equili- 
brated by  an  opposite  charge ;  and  one  only  of  the  charges  being 
within  the  fibre,  might,  from  the  author's  old  point  of  view, 
have  induced  the  required  molecular  repulsion.  Our  difficulty 
would  have  been  that  tensional  electricity  is  a  phenomenon  of 
surface  rather  than  of  substance.  The  great  facts,  however, 
remained — that  muscular  fibres  in  a  state  of  rest  were  in  a  state 
of  high  electric  tension ;  that  the  act  of  contraction  was  coinci- 
dent with  torpedo-like  discharge,  and  the  condition  of  contrac- 
tion associated  with  a  lowered  electrical  tension.  Dr.  Radcliffe 
held  to  the  idea  that  this  proved  relation  between  the  relaxed  or 
contracted  condition  of  muscle  and  the  high  or  low  electrical 
tension  in  the  fibres  was  something  more  than  a  mere  accident ; 


310  Reviews.  [April, 

that  in  one  way  or  another  they  stood  in  the  relation  of  cause 
and  effect,  and  the  new  theory  presented  for  our  acceptance  is 
the  result.  This  is,  that  muscular  fibre  may  be  compared  to  a 
Leyden  jar;  the  sheaths  are  non-conductors;  a  charge  of  one 
kind  of  electricity  generated  on  the  outside  of  the  sheath  by  the 
reaction  of  the  blood  there  circulating  induces  a  charge  of  the 
opposite  kind  on  the  inside ;  the  fibres  are  kept  in  a  state  of 
relaxation  or  elongation  by  compression  of  the  sheaths,  arising 
from  the  mutual  attraction  between  the  two  opposite  charges, 
one  on  the  outside,  the  other  on  the  inside,  as  in  a  Leyden  jar ; 
contraction  results  when  this  compression  is  withdrawn  by  the 
act  of  discharge.  It  is  remarkable  in  how  many  points  this 
theory  is  consistent  with  facts,  and  affords  explanation  of  them. 
In  the  first  place,  the  muscular  sheath  is  a  non-conductor  in  a 
high  degree.  Then  all  the  tensional  electric  phenomena  and 
all  the  current  phenomena  of  muscular  fibre  are  explained  by  it ; 
and  not  only  so,  but  they  can  be  reproduced  upon  a  model  of 
muscular  fibre,  of  which  the  core  is  wood,  the  sheath  gutta 
percha,  coated  inside  and  out  by  tinfoil.  The  Leyden  jar  con- 
dition, moreover,  explains  the  difficulty  of  detecting  the  charge 
in  muscular  fibre,  and  the  retention  of  the  charge  by  the  fibre, 
though  uninsulated.  Finally,  the  elongation  and  contraction 
of  the  fibre  can  be  in  some  degree  imitated  in  a  narrow  band  of 
india  rubber  covered  on  its  two  surfaces  by  a  thin  metallic 
coating;  when  this  band  is  charged  like  a  Leyden  jar  it  can  be 
seen  to  elongate,  presumably  under  the  pressure  caused  by  the 
mutual  attraction  of  its  two  surfaces,  and  to  contract  when 
discharge  occurs  and  the  pressure  is  removed.  Not  only  in 
these  respects  has  the  theory  the  support  of  fact,  but  the 
phenomena  of  electrotonus  are  explained  by  it ;  the  increased 
contraction  referred  to  "  exalted  irritability "  is  apparently 
simply  an  elastic  return  of  the  fibres  from  an  increased  elonga- 
tion, due  to  increased  charge.  If  we  hesitate  to  accept  Dr. 
Radcliffe's  theory,  it  is  certainly  not  because  he  has  failed  to 
establish  any  one  of  these  points.  So  far  he  has  made  out  his 
case,  and  his  experiments  and  conclusions  must  constitute  a 
valuable  contribution  to  our  knowledge  of  the  phenomena  of 
muscular  action,  and  must  be  taken  into  account  in  any  attempt 
to  explain  it.  We  shall  follow  briefly  his  arguments  as  they 
are  employed  in  the  book  before  us. 

The  history  of  animal  electricity  need  not  detain  us,  interest- 
ing as  it  is,  nor  will  it  be  necessary  to  enter  in  detail  upon  the 
electrical  phenomena  manifested  by  nerve  and  muscle  while  at 
rest,  and  when  passing  into  a  state  of  action.  It  is  familiarly 
known  that  when  the  two  poles  of  a  galvanometer  are  applied, 
one  to  the  side  the  other  to  the  end  of  a  band  of  living  muscular 


1872.]  The  Dynamics  of  Nerve  and  Muscle.  311 

or  nerve-fibre,  a  current  passes  through  the  instrument.  By 
the  new  quadrant  electrometer,  now  for  the  first  time  applied 
by  Dr.  Radcliffe  to  the  investigation  of  the  tensional  phenomena 
of  muscle  and  nerve,  it  is  similarly  shown  tliat  while  at  rest 
living  nerve  and  muscle  furnish  supplies  of  free  electricity,  the 
sides  exhibiting  positive  charge,  the  ends  negative  charge  ;  the 
tension,  like  the  current,  increasing  with  the  distance  from  the 
line  of  junction  of  the  two  surfaces. 

When  a  muscle  or  nerve  passes  from  a  state  of  rest  to  a  state 
of  action  we  have,  on  the  one  hand,  almost  complete  disappear- 
ance of  the  muscle  or  nerve  current,  as  shown  long  ago  by  Du 
Bois-Raymond,  and  an  almost  complete  disappearance  of  all 
tensional  signs  of  electricity,  as  ascertained  by  Dr.  Radcliffe; 
and  on  the  other  hand,  electrical  discharge,  as  seen  from  the 
following  long-known  and  familiar  experiment : — If  the  nerve 
of  a  prepared  frog's  leg  be  placed  across  the  muscles  of  another 
prepared  frog's  leg,  or  across  the  nerve,  or  if  the  connection 
between  the  two  be  only  a  piece  of  cotton  wick  moistened  with 
salt  and  water,  when  the  nerve  of  leg  No.  2  is  pinched,  not  only 
are  the  muscles  of  this  leg  thrown  into  action,  but  those  also 
of  leg  No.  1.  The  force  transmitted  from  the  contracting  muscles 
to  the  nerve  lying  across  them,  as  shown  by  the  contraction  of 
the  muscles  to  which  it  is  distributed,  can  scarcely  be  anything 
but  electricity,  and  we  have  thus  simultaneously  with  muscular 
action  disappearance  of  electricity  from  its  fibres  and  discharge 
from  its  surface,  and  the  same  may  be  said  of  nerve.  This  is 
scarcely  capable  of  explanation  on  any  other  supposition  than 
that  the  condition  of  muscle  and  nerve  during  rest  is  one  of 
charge. 

If,  now,  we  suppose  the  sheath  of  the  muscular  fibre  to  be  a 
non-conductor,  and  the  contained  sarcous  material  to  have 
decidedly  better  conducting  properties,  which  is  a  not  im- 
probable inference  from  the  relative  conductivity  of  muscle 
and  tendon,  a  charge  of  positive  electricity  generated  on  the 
outside  of  the  fibre  by  the  reactions  between  the  blood  and  tissue 
will  induce  a  charge  of  negative  electricity  on  the  inside  of  the 
sheath,  as  in  a  Ley  den  jar,  and  this  condition  will  explain  all 
the  electrical  phenomena  just  enumerated.  The  negative  elec- 
tricity of  the  contents  of  the  muscular  sheath  will  be  conducted 
by  the  sarcous  matter  to  the  extremity  of  the  fibres,  and  there 
manifested  on  the  application  of  the  electrometer ;  along  the 
line  of  junction  of  the  ends  and  sides  the  two  opposite  charges 
will  neutralise  each  other,  and  the  tension  will  be  nil,  the 
further  away  from  this  line  the  higher  the  tension,  positive  or 
negative.  The  current  obtained  when  the  galvanometer  is  em- 
ployed instead  of  the  electrometer  must  be  taken  as  due  to  the 


313  Reviews.  [April, 

continued  generation  of  free  electricity,  which  will  go  on  while 
the  muscle  is  living.  We  have  here  to  allow  a  certain  number 
of  things  to  be  taken  for  granted;  as,  for  example,  that  the 
shortness  of  the  circuit  consequent  upon  the  minuteness  of  the 
muscular  fibre,  may  make  it  difficult  to  obtain  evidence  of  tension 
and  of  discharge  without  rendering  tension  impossible,  but  this 
we  do  advisedly,  and  the  more  readily  because  several  points 
are  capable  of  illustration,  and  it  may  be  said  of  demonstration, 
by  means  of  the  model  of  a  muscular  fibre  constructed  in  accord- 
ance with  this  view  of  its  different  parts,  as  already  mentioned. 
Unless  some  fatal  difficulty  presents  itself,  it  is  a  good  thing  to 
take  an  hypothesis  and  try  it.  If  a  certain  place  is  paved  with 
good  intentions,  we  may  say  that  science  is  built  up  of  over- 
thrown hypotheses,  each  one  of  which  has,  in  its  day,  been 
useful  and  valuable,  and  in  its  fall  has  served  as  a  stepping- 
stone  to  something  higher. 

Now,  admitting  simply  the  fact  of  discharge,  there  are  many 
reasons  for  considering  the  discharge  from  muscle  as  it  enters 
upon  contraction  to  be  closely  analogous  to  the  discharge  from 
the  electric  organs  of  the  torpedo.  The  nerves  to  these  organs 
are  from  the  motor  tract.  When  the  nerves  are  divided  the 
organs  are  paralysed  ;  when  the  distal  end  of  the  divided  nerve 
is  pinched  they  are  excited,  but  they  are  thrown  into  violent 
action  by  strychnia.  The  elaborate  structure  of  the  electric 
prisms  and  their  free  supply  of  blood  show  that  the  electricity 
is  generated  on  the  spot,  and  not  communicated  from  the  nerve- 
centres;  they  are  exhausted  by  prolonged  exercise,  and  ob- 
viously they  are  during  repose  in  a  state  of  charge,  and  the 
action  of  the  nerves  is  to  effect  discharge.  If  we  go  farther,  and 
admit  the  comparison  between  muscular  fibre  and  the  Ley  den 
jar,  we  bring  the  electrical  shock  of  the  torpedo  out  of  the 
category  of  exceptional  phenomena,  and  we  can  even  see,  not 
only  an  analogy  between  this  and  the  muscular  discharge,  but 
an  analogy  in  point  of  structure  between  the  electrical  organ 
and  muscle. 

Up  to  this  point,  then,  theory  and  facts  go  fairly  well  together  ; 
but  there  are  other  phenomena  by  which  further  to  test  the 
theory.  When  the  two  hind  legs  of  a  frog,  separated  from  the 
body,  but  remaining  united  by  all  the  structures  of  the  part,  or 
only  by  the  exposed  and  isolated  lumbar  nerves,  are  made  to  form 
part  of  a  galvanic  circuit  by  placing  the  positive  pole  on  one  foot, 
the  negative  on  the  other,  the  current  will  necessarily  pass  up  one 
leg  and  down  the  other — against  the  course  of  motor  impulses 
through  the  nerve  in  the  former,  with  it  in  the  latter ;  it  will 
be  "  inverse"  in  the  one,  "  direct"  in  the  other.  In  this  ex- 
periment it  is  found  (1)  that  contraction  of  the  muscles  occurs  at 


1872.] 


The  Dynamics  of  Nerve  and  Muscle,  313 


the  moment  of  closing  and  opening  the  circuit,  or  at  one  only  of 
these  moments ;  (2)  that  the  muscles  remain  relaxed  while  the 
current  is  passing  through  them ;  (3)  that  the  contractions  last 
longer  in  the  limb  in  which  the  current  is  upward  or  *^  inverse" 
than  in  the  limb  in  which  it  is  downward  or  "  direct."  Certain 
differences  are  observed  when  the  nerves  are  exposed,  and  when 
the  two  legs  are  united  by  all  the  structures,  namely,  that  in  the 
course  of  the  experiment,  when  contractions  no  longer  occur,  both 
at  the  closing  and  at  the  opening  of  the  circuit,  but  at  one  only  of 
these  events,  the  two  legs  will  contract  together  at  the  closing  of 
the  circuit  when  the  nerves  are  7iot  exposed,  whereas  when  they 
are  isolated  one  leg  will  contract  at  the  closing  of  the  circuit 
only,  namely,  that  in  which  the  current  is  direct  or  downward, 
the  other  in  which  the  current  is  inverse  or  upward  at  the  open- 
ing only.  The  explanation  of  this  difference  is  that  nerve,  being 
a  worse  conductor  than  muscle,  is  traversed  by  the  current  only 
when  it  is  isolated ;  when,  therefore,  the  two  legs  remain  united 
the  current  will  traverse  the  muscles  in  preference  to  the  nerves, 
and  muscular  fibres  contract  most  readily  and  energetically 
when  the  impulse  is  strongest,  irrespective  of  the  direction  of 
the  current,  and  this  will  be  when  the  circuit  is  closed.  When 
the  limbs  are  united  only  by  the  isolated  nerves,  the  electricity 
has  no  other  channel,  and  nerve  is  called  into  action  most 
readily  when  the  current  coincides  with  the  habitual  course 
of  impulses  in  it,  which  will  happen  differently  in  the  two 
legs.  This  is  beautifully  demonstrated  by  making  a  metallic 
bridge  from  the  muscles  of  one  leg  to  those  of  the  other  when 
the  nerves  are  isolated,  providing  a  passage  for  the  current, 
which  allows  it  to  avoid  the  badly  conducting  nerves.  The 
contractions  now  occur  just  as  in  the  legs  connected  by  the 
structures.  The  way  being  now  clear,  we  may  follow  Dr.  Rad- 
cliffe  in  his  explanation  of  the  principal  facts  under  considera- 
tion. First,  then,  it  is  shown  to  be  probable  that,  as  contrac- 
tions occur  only  at  the  making  and  breaking  of  the  circuit,  and 
not  while  the  current  is  passing,  the  contractions  are  due  not  to 
the  primary  current,  but  to  the  instantaneous  extra  currents  of 
high  tension  discovered  by  Faraday  to  be  developed  when  the 
circuit  is  closed  or  opened.  Then  it  is  demonstrated  that  the 
longer  duration  of  contractions  under  the  "  inverse"  current  has 
no  direct  relation  with  the  direction  of  the  current,  but  with  a 
charge  of  positive  electricity  associated  with  this  current,  and, 
vice  versa,  the  shorter  duration  of  contractions  under  the 
"  direct"  current  is  due  to  an  associated  "  negative"  charge. 
This  point  is  too  interesting  and  important  to  be  passed  over 
without  reference  to  the  experiments  by  which  it  is  established. 
The  electrometer,  then,  is  applied  to  different  points  along  the 


314  Revieivs.  [April, 

two  legs  through  which  a  current  is  passing  from  foot  to  foot, 
the  legs  heing  insulated  ;  it  is  found  that  a  positive  charge  is 
present  in  the  limb  to  which  the  positive  pole  is  applied,  by 
which,  therefore,  the  current  enters,  and  in  which,  consequently, 
it  is  inverse  or  upward,  and  a  negative  charge  in  the  other  limb, 
the  tension  in  each  case  being  highest  at  the  foot,  i.  e.  near  the 
pole,  falling  gradually  to  zero  midway  between  the  poles.  Under 
these  circumstances  contractions  can  be  elicited  for  60'  in  the 
muscles  through  which  the  current  passes  upwards,  and  in  which 
the  charge  is  positive,  but  for  15'  or  20'  only  in  the  other  limb, 
through  which  the  current  passes  downwards,  and  in  which  the 
charge  is  negative.  So  far  the  difference  might  be  due  either  to 
the  direction  of  the  current  or  the  nature  of  the  charge  ;  but  the 
direction  of  the  current  remaining  the  same,  the  kind  of  charge 
can  be  varied ;  if  the  positive  pole  be  put  in  communication 
with  the  earth  by  a  wire  the  positive  electricity  will  run  off  to 
the  ground,  and  both  legs  will  be  charged  with  negative  elec- 
tricity from  the  negative  pole.  In  this  case  the  contractions 
cease  in  both  within  15'  or  20'.  Conversely,  if  the  negative 
electricity  be  run  off,  and  a  positive  charge  be  allowed  to  spread 
itself  over  both  limbs,  the  contractions  in  both  will  last  an  hour 
or  more ;  that  is  to  say,  the  direction  of  the  current  remaining 
the  same,  the  duration  of  contractility,  or,  as  Dr.  Radcliffe  prefers 
to  call  it,of  impressibility  alters  according  as  the  charge  associated 
with  it  is  positive  or  negative,  and  a  reversal  of  the  course  of 
the  curreut  makes  no  difference  in  the  duration  of  muscular 
impressibility,  provided  the  kind  of  charge  be  made  to  remain 
the  same.  Can  anything  be  more  conclusive  ?  And  this  posi- 
tive charge,  which  is  thus  conservative  of  the  muscular  impressi- 
bility, is  also  to  a  certain  extent  restorative  of  it,  and  is  the 
cause  of  the  fact  that  contractions  which  have  ceased  under  the 
direct  current  are  removed  under  the  inverse.  We  have  only 
to  go  one  step  farther,  and  see  how  all  this  fits  in  with  the 
theory  that  muscular  fibres  are  like  so  many  Leyden  jars.  The 
positive  charge  associated  with  the  inverse  current  is  only  an 
exaggeration  of  the  natural  positive  charge  on  the  outside  of 
the  fibres,  and  so  favours  the  continued  activity  of  the  muscle. 
The  negative  charge  reverses  the  normal  condition  by  substi- 
tuting an  external  negative  charge  and  an  induced  internal 
positive  charge,  and  so  is  unfavorable  to  continuance  of  activity. 
Finally,  it  is  easily  understood  how  the  extra  currents  of  high 
tension  accompanying  the  making  and  breaking  of  the  voltaic 
circuit  may  discharge  the  natural  electricity  of  the  muscular 
fibres,  and  so  cause  the  contraction,  just  as  a  Leyden  jar  is  dis- 
charged by  passage  of  a  discharge  across  it. 

We  come  now  to  the  condition  induced  in  a  nerve  by  the 


1872.]  The  Dynamics  of  Nerve  and  Muscle.  315 

passage  of  a  voltaic  current  through  a  part  of  its  length,  called 
electrotonus.  The  facts  to  be  considered  are,  that  during  the 
passage  of  the  voltaic  current  the  nerve  current,  as  shown  by  a 
galvanometer,  one  pole  of  which  is  applied  to  the  cut  end,  the 
other  to  the  side  of  another  part  of  the  nerve  in  the  usual  way, 
is  apparently  increased  when  its  direction  coincides  with  the 
direction  of  the  voltaic  current  (an-electrotonus),  while  the 
impressibility  of  the  nerve  is  suspended;  diminished  when  its 
direction  is  opposed  to  that  of  the  voltaic  current  (cath-electro- 
tonus),  the  nerve  being  more  impressible.  The  word  apparently 
is  here  necessary,  for  a  source  of  error  underlies  the  statements 
hitherto  made  both  as  to  the  nerve-current  and  as  to  the  nerve 
impressibility  in  electrotonus.  With  respect  to  nerve-current,  as 
the  phenomena  of  electrotonus  are  reproducible  with  dead  nerve 
and  with  a  piece  of  wet  string,  it  is  clear  that  the  current  of 
living  nerve  is  out  of  the  question,  and  Dr.  Radcliffe  has  shown 
that  the  currents  manifested  by  the  galvanometer  at  the  two 
ends  of  a  nerve,  living  or  dead,  or  of  a  piece  of  moistened  string, 
through  an  intermediate  part  of  which  a  voltaic  current  is  passing, 
are  due  to,  and  proportionate  with,  the  resistance  to  this  current, 
in  consequence  of  which  the  electricity  spreads  from  each  pole 
outwards  in  the  nerve  or  string,  charging  it  with  free  electricity, 
the  presence  of  which  is  rendered  evident  by  the  electrometer. 
That  end  of  the  nerve,  then,  which  is  to  the  outer  side  of  the 
positive  pole  receives  a  charge  of  positive  electricity,  that  which 
is  beyond  the  negative  pole  receives  a  charge  of  negative  elec- 
tricity, and  in  this  way  arises  the  apparent  reinforcement  and 
diminution  of  the  proper  nerve- current.  As  to  the  impressibility 
of  the  nerve.  Dr.  Radcliffe  has  shown  by  conclusive  experiments 
with  two  frog's  legs  joined  together  by  the  isolated  nerves,  in 
which  an-electrotonus  is  set  up  in  one  leg  and  cath-electrotonus 
in  the  other  by  the  same  voltaic  current,  while  the  same  induced 
currents  simultaneously  test  the  nerve  impressibility  in  each, 
that,  instead  of  the  impressibility  being  suspended  in  an-electro- 
tonus and  exalted  in  cath-electrotonus,  it  is  suspended  in  both, 
but  in  a  greater  degree  by  an-electrotonus  than  by  cath-electro- 
tonus, while  it  lasts  much  longer  in  an-electrotonus. 

But  there  are  conditions  of  muscle  associated  with  electro- 
tonus which  have  to  be  considered.  In  cath-electrotonus  mus- 
cular contractions  are  greatly  increased  in  force,  and  this  has 
been  referred  to  increased  irritability.  If,  however,  muscular 
relaxation  is  the  result  of  pressure  on  the  sheath  by  the  mutual 
attractionof  two  opposite  charges  ofelectricity  disposed  on  its  inner 
and  outer  surfaces,  and  contraction  the  result  of  discharge  allowing 
the  natural  elasticity  to  come  into  play,  then  an  increased  charge, 
such  as  has  just  been  seen  to  accompany  the  condition  of  electro- 


316  Reviews.  [April, 

tonus,  ought  to  give  rise  to  increased  elongation,  and  this  increased 
elongation  to  a  more  energetic  recoil.  Now,  Dr.  liadcliffe  demon- 
strates that  electrotonus,  an-  and  cath-electrotonus  alike,  i.  e, 
whether  the  charge  is  positive  or  negative,  does  cause  increased 
elongation  of  the  muscular  fibres  as  an  antecedent  condition  to 
the  more  powerful  contraction.  It  is  to  be  remembered  that  Dr. 
KadclifFe  also  shows,  by  the  elastic  band  coated  with  tinfoil,  that 
the  electric  charge  is  capable  of  causing  elongation,  and  discharge 
contraction ;  a  fact  explicable  only  on  the  supposition  that  the 
attraction  between  the  two  opposite  kinds  of  electricity  com- 
presses the  band  transversely,  and  in  so  far  antagonises  its  longi- 
tudinal elastic  force. 

The  phenomena  of  electrotonus  in  muscle  having  thus  been 
shown  to  be  consistent  with  the  theory  of  muscular  action,  and 
the  phenomena  of  electrotonus  in  nerve  agreeing  with  those  of 
the  "  direct ''  and  "inverse"  current, — already  seen  to  be  in 
accordance  with  this  theory,  we  have  a  remarkable  mass  of 
cumulative  evidence  in  its  favour.  The  author,  therefore,  is 
justified,  after  examining  the  behaviour  of  sensory  and  motor 
nerve  under  the  action  of  different  forms  of  electricity  with 
similar  results,  in  saying  that  the  action  of  electricity  in  general, 
the  voltaic,  the  franklinic,  the  faradaic,  and  that  which  is 
natural  to  nerve  and  muscle,  would  seem  to  be  resolvable  into 
that  of  a  charge  and  discharge  of  free  electricity ;  each  form  of 
charge,  the  negative  as  well  as  the  positive,  though  not  to  the 
same  extent,  keeping  up  the  state  of  rest  and  impressibility,  the 
discharge  bringing  about  the  state  of  action. 

So  far  our  author  challenges  our  unqualified  admiration.  We 
have  not,  of  course,  had  the  opportunity  of  verifying  all  his  facts, 
but  we  have  no  hesitation  in  accepting  them.  They  hang  well 
together  ;  they  are  so  marshalled  as  to  constitute  one  connected 
and  cogent  argument,  and  the  theory  on  which  they  are  strung, 
and  which  seems  to  bring  them  into  a  simple  and  harmonious 
relation,  almost  commands  our  assent.  Our  hesitation  in  accept- 
ftig  it  arises  from  the  circumstance  that  it  ought  to  extend  over 
a  wider  area  of  phenomena  than  it  has  yet  been  shown  to  cover. 
There  are,  moreover,  difficulties  suggested  by  the  structure  of 
some  contractile  elements.  The  non-conducting  sheath  is  appa- 
rently absolutely  essential  to  the  Ley  den-jar  action  of  muscular 
fibre,  and  in  the  unstriped  variety  no  sheath  is  known  to  exist. 
Then  it  is  difficult  to  understand  how  the  delicate  sarcolemma 
of  the  striped  fibres,  which,  ecc  hypothesi,  is  that  constituent 
which  elongates  under  the  compression  induced  by  the  charge, 
and  produces  contraction  by  its  elastic  recoil,  can  really  exert 
the  power  manifested  by  muscle.  In  some  muscles  it  is  so  thin 
that  its  very  existence  is  doubtful,  as,  for  example,  in  the  heart. 


1872.] 


The  Dynamics  of  Nerve  and  Muscle.  317 


We  go  further,  indeed  ;  we  persist  on  various  grounds  in  our 
belief  that  the  substance  of  the  muscular  fibre,  and  not  tlie 
sarcolemma,  is  the  contractile  element.  The  behaviour  of  living 
fibre  under  the  microscope,  when  the  striae  can  be  seen  to  ap- 
proximate at  one  part  and  not  at  another,  on  one  side  of  the 
fibre,  indeed,  and  not  on  the  other — when  the  striped  sarcous 
material  can  sometimes  be  seen  to  contract  within  the  sheath 
and  break,  leaving  the  sheath  empty  and  collapsed — is  alone 
sufficient  to  demonstrate  this.  It  is  also  obvious  from  the  fact, 
that,  in  the  healtliy  well  nourished  muscle  of  a  vigorous  young 
man  or  animal,  the  microscopic  evidence  of  perfection  of  struc- 
tural condition  is  found  not  in  the  sarcolemma  but  in  the  striated 
contents;  moreover,  it  is  in  these  again  that  the  evidence  of 
degeneration  is  seen. 

We  cannot  help  thinking  that  a  better  imitation  of  the  con- 
ditions present  in  muscular  fibre,  for  the  purpose  of  illustrating 
on  a  large  scale  the  elongation  under  the  pressure  by  two 
mutually  attracting  charges,  might  have  been  found  than  that 
offered  by  the  flat  elastic  band  coated  on  the  two  surfiices  with 
tinfoil.  We  might  have  had,  perhaps,  an  elastic  tube  coated 
inside  and  out  with  metal,  and  enclosing  an  elastic  core,  and 
possibly  the  exercise  of  a  little  ingenuity  and  perseverance  in 
the  search  for  appropriate  material  for  the  sheath  and  core 
might  have  been  rewarded  by  a  much  increased  elongation  and 
contraction.  While  accepting  the  experiment  advanced  as 
demonstrating  change  in  length  on  charge  and  discharge,  we 
remember  that  this  was  extremely  small,  requiring,  even  with  a 
considerable  length  of  band,  a  multiplying  apparatus  and  long 
index  to  make  it  evident,  whereas  a  muscular  fibre  will  contract 
one  third  of  its  length.  We  do  not,  however,  insist  on  this  as 
a  serious  difficulty,  for  the  proportion  between  the  diameter  and 
length  of  muscular  fibre,  and  between  the  former  and  the  inten- 
sity of  the  charge  cannot  be  imitated,  and  may  have  an  important 
bearing  on  the  result. 

Other  objections  of  the  same  kind  might  be  urged,  but  we  will 
pass  to  another  point.  Marey  has  shown  that  the  response  of 
muscle  to  an  electrical  current  is  a  single  sccoiisse  or  jerk,  and 
that  a  sustained  contraction  resembling  its  physiological  action 
results  from  the  fusion,  so  to  speak,  of  a  rapid  succession  of 
jerks,  the  number  given  is  thirty  per  second.  Each  secousse 
would  imply  the  generation  and  discharge  of  free  electricity, 
that  is,  the  fibre  would  be  charged  and  discharged  thirty  times 
per  second.  This  is  not  easily  understood.  Coming  now  to 
nerve,  it  has  been  ascertained  by  Helmholtz,  Marey  and  others 
that  an  impression  is  transmitted  by  nerve  at  the  rate  of  100 
feet  per  second.  This  is  very  slow  for  anything  in  which  elec- 
98— xLix.  21 


318  Reviews.  [April, 

tiicity  is  concerned ;  and  if  discharge,  as  of  a  Leyden  jar,  is  the 
concomitant  of  nerve-action,  how  is  it  that  the  discharge  is  not 
simultaneous  from  end  to  end  of  the  nerve-tube  ? 

We  do  not  care  to  push  these  objections  too  far.  The  facts 
brought  forward  are  too  interesting  and  too  valuable  to  be 
allowed  to  pass  into  oblivion  with  a  shattered  theory.  Were  it 
open  to  still  graver  objections,  we  think  a  theory  which  explains 
so  much  must  have  a  basis  of  truth,  and,  if  superseded,  that  it 
will  be  by  some  larger  generalisation  into  which  it  will  probably 
fit,  and  towards  which  it  may  lead  the  way.  Most  physiologists 
now  look  upon  the  various  forms  of  energy  evolved  or  set  free 
in  living  creatures  as  the  liberation  of  force  stored  up  in  the 
food  consumed,  as  heat  is  liberated  by  combustion  of  coal,  and 
the  question  between  Dr.  Radcliife  and  them  is  not  now  whether 
muscular  contraction  is  a  manifestation  of  *  vital '  force  or  a 
phenomenon  capable  of  explanation  on.  the  principles  of  physical 
science,  but  of  the  steps  by  which  the  chemical  force  stored  up 
in  the  food  is  made  to  take  the  form  of  mechanical  motion.  In 
the  case  of  coal  we  have  the  clumsy  and  wasteful  process  of  the 
steam-engine ;  in  the  muscular  apparatus  of  animals  the  end  is 
attained  with  marvellous  economy,  perhaps  not  altogether  with- 
out what  seems  waste,  since  exertion  evokes  heat,  which  has  to 
be  got  rid  of  by  perspiration  ;  but  still  with  an  economy  which 
puts  to  shame  the  efforts  of  mechanicians.  How  is  this  effected  ? 
On  the  one  hand,  what  constituent  of  blood  or  of  tissue  under- 
goes oxidation  ?  What  are  the  successive  stages  in  this  oxida- 
tion, since  we  know  it  not  to  be  direct  ?  On  the  other  hand,  does 
the  chemical  energy  take  some  intermediate  form  of  force  in 
order  to  become  motion?  This  being  probable,  is  this  interme- 
diate force  heat,  as  in  the  case  of  the  steam-engine  ?  Or  have 
we  this  question  answered  by  Dr.  Radcliffe  in  the  researches 
just  detailed  ?     If  so,  then  science  owes  him  a  large  debt. 

Now  we  part  company  with  our  author.  In  combating  the 
vitalistic  notion  he  considers  it  important  to  show  that  muscular 
action  is  antagonised  by  arterial  blood,  and  he  adduces  in  evidence 
the  facts,  that  in  death  by  rapid  haemorrhage  or  sudden  strangl- 
ing there  is  convulsion,  and  further  seizes  upon  the  isolated  expe- 
riment that  strychnia  and  brucia,  which  induce  convulsions,  when 
mixed  with  blood  drawn  from  the  vessel,  retard  the  reactions 
between  it  and  air.  In  all  these  cases  convulsion  is  coincident 
with  deficiency  of  arterial  blood  in  the  vessel,  or  the  equivalent  of 
this,  inasmuch  as  the  blood  has  lost,  through  the  action  of  the 
poison,  its  power  of  carrying  oxygen;  and  it  is  concluded  therefore 
that  muscular  action  is  in  one  way  or  other  antagonised  by 
arterial  blood,  and  possibly  by  keeping  up  the  state  of  charge  in 
the  fibres.     Now,  the  fact  is^  that  in  the  cases  here  instanced 


1872.] 


The  Dynamics  of  Nerve  and  Muscle,  319 


the  muscles  are  simply  played  upon  by  the  nervous  system,  and 
of  themselves  have  nothing  to  do  with  the  convulsions.  If  the 
nerve  of  any  limb  be  divided  before  the  animal  is  bled  to  death 
or  strangled,  or  poisoned  by  strychnia,  the  muscles  of  that 
limb,  though  deprived  of  blood  or  supplied  by  poisoned  blood 
equally  with  the  rest  of  the  body,  take  no  part  in  the  convul- 
sions. The  occurrence  of  contraction  in  a  muscle  has  no  direct 
connection  whatever  with  the  amount  of  blood  circulating 
through  it.  This  maybe  much  or  it  may  be  little;  the  muscle 
will  not  act  till,  by  the  nerve  or  some  other  agencies  known  to 
have  this  power,  a  contraction  is  determined.  Moreover,  if 
muscular  action  is  antagonised  by  arterial  blood,  how  is  it  that 
during  muscular  exertion  the  circulation  and  aeration  of  the 
blood  are  so  greatly  increased  ?  Nothing  can  be  more  certain 
than  that  muscle  in  action  requires  and  receives  a  more  abun- 
dant supply  of  blood  and  oxygen,  from  which  the  energy 
developed  by  it  is  evolved.  If  Dr.  RadcliiFe^s  theory  necessitates 
a  denial  of  this,  then  assuredly  it  is  unsound  ;  but  we  cannot  see 
that  it  does ;  at  the  same  time  it  is  weakened  by  being  en- 
cumbered with  an  error  of  this  sort. 

An  error  of  a  similar  kind  runs  through  the  reasoning  which 
is  supposed  to  establish  that  muscular  action  is  associated  not 
with  the  presence  but  with  the  absence  of  nervous  influence.  It 
is  taken  for  granted,  that  the  amount  of  nervous  influence 
developed  in  the  great  nerve  centres  is  proportionate  to  the 
amount  of  blood  circulating  through  them  ;  and  apparently,  that 
this  influence  is  continuously  communicated  to  the  muscles  ; 
— both  of  which  positions  we  should  dispute  ;  this,  however,  by 
the  way.  Again,  the  occurrence  of  convulsions  in  death  by 
haemorrhage  or  strangling,  and  likewise  when  the  great  vessels 
of  the  head  are  compressed,  is  taken  as  demonstrating  that  the 
withdrawal  of  nervous  influence  is  the  cause  of  the  muscular  con- 
tractions. But  if  this  were  the  explanation,  it  would  make  no 
diflerence  whether  the  withdrawal  of  nervous  influence  were 
abrupt  or  gradual,  whereas  when  the  haemorrhage  is  gradual  or 
the  suflfocation  slow,  no  convulsion  takes  place  ;  the  suddenness, 
therefore,  of  the  change  in  the  circulation  counts  for  something, 
and  opens  the  door  to  another  interpretation.  Surely,  also,  the 
most  efficient  way  of  withdrawing  nerve  influence  is  to  divide 
the  nerve,  and  this  paralyses  instead  of  tetanising  the  muscle. 

Let  us  take  again  the  case  of  strychnine  poisoning,  lest  it 
be  supposed  that  we  only  seek  to  shift  the  question  from  the 
muscles  to  the  nervous  centres.  The  explanation  would  then  be, 
that  the  oxygenation  or  oxidation  (two  very  different  things)  being 
prevented  by  the  action  of  the  poison,  the  blood  carried  to  the 
nerve  centres  is  no  longer  competent  to  generate  nerve  influence, 


320  Reviews.  [April, 

for  lack  of  which  the  muscles  fall  into  convulsion.  Now,  this 
takes  no  note  of  two  important  facts — first,  that  in  poisoning  by- 
strychnine  the  cerebral  hemispheres,  which  are  the  first  to  be 
affected  by  want  of  oxygen,  do  not  at  all  suffer  in  their  function  ; 
and,  secondly,  that  other  substances,  and  notably  carbonic  oxide, 
interfere  with  the  oxygenation  of  the  blood  far  more  decidedly  than 
strychnine,  and  destroy  life  without  ever  inducing  convulsion. 

Our  mission  here  is  destruction,  not  construction,  and  we 
cannot  stop  to  discuss  this  vague  term,  nerve  influence,  or  try 
to  establish  a  conception  of  the  force  evoked  by  the  nervous 
centres  which  might  bring  it  into  possible  correlation  with  other 
forms  of  energy. 

When  the  question  is  not  the  simple  excitation  of  muscular 
contraction,  but  the  effects  on  the  duration  of  contractility,  on 
the  energy  of  contraction  and  on  the  susceptibility  to  electric 
shock  of  varying  intensity  in  muscles  separated  from  the  nerve 
centres,  the  considerations  advanced  are  far  more  weighty. 
There  is  Claude  Bernard's  experiment  of  the  lapin  a  sang  froid, 
in  which,  after  division  of  the  cervical  cord,  the  paralysed 
muscles  are  found  after  death  to  retain  their  contractility  almost 
as  long  as  if  the  animal  had  been  a  reptile.  Again,  the  leg  of 
a  frog  is  thrown  into  action  by  a  feebler  electric  shock  after  than 
before  division  of  the  spinal  cord,  and  by  a  still  more  feeble 
shock  if  the  lumbar  nerve  have  been  divided ;  and,  farther,  the 
force  of  the  contraction  is  greater  after  than  before  the  division 
of  the  cord.  Of  course,  the  conclusion  from  Dr.  Radcliffe's 
point  of  view  lies  on  the  surface — muscular  action  is  inversely 
related  to  nervous  influence,  and  we  will  not  now  dispute  it, 
though  different  interpretations  have  been  put  on  the  experi- 
ment. 

Shall  we  go  on  to  the  consideration  of  the  arguments  which 
Dr.  Radcliffe  draws  from  the  action  of  the  heart  and  vessels, 
from  the  respiratory  movement,  &c.  ?  If  we  do,  it  is  in  order 
that  the  theory  may  be  divested  of  difficulties  not  inherent  in  it, 
and  may  stand  upon  its  own  merits.  If  we  must  accept  with  it 
the  physiology  of  circulation  and  respiration  tacked  to  it  in  this 
book,  we  reject  the  whole ;  but  the  two  things  are  quite  distinct. 
The  rhythmic  action  of  the  heart  is  here  accounted  for  in  this 
way.  The  diastole  is  caused  by  the  injection  of  the  walls  of  the 
ventricles  with  arterial  blood  driven  by  the  recoil  of  the  aorta 
into  the  coronary  arteries,  the  blood  simultaneously  antagonising 
the  contraction  of  the  muscular  fibres  directly  and  indirectly  by 
generating  nerve  influence  in  the  ganglia,  which  has  the  same 
effect.  The  systole  is  due  to  the  change  of  the  blood  from 
arterial  to  venous,  when  it  no  longer  has  the  property  of  resisting 
contraction,  and  so  on.     How  can  this  rationale  be  accepted 


1872.] 


The  Dynamics  of  Nerve  and  Muscle.  321 


when  we  know  that  the  heart  may  go  on  contracting  for  some 
time  after  its  removal  from  the  body,  whether  exposed  to  air  or 
immersed  in  water;  that  when  it  is  cut  into  pieces  rhythmic 
movements  may  be  observed  in  the  fragments  from  the  base? 
The  physiology  of  respiration  is  even  less  comprehensible.  The 
inspiratory  movements  are  said  to  be  due  to  impressions  made 
upon  the  periphery  of  the  afferent  nerves  of  respiration  by  the 
oxygen  of  the  air,  the  expiratory  collapse  to  the  cessation  of 
the  impression  in  consequence  of  the  consumption  of  the  oxygen 
and  generation  of  carbonic  acid.  Now,  the  afferent  impression 
in  ordinary  respiration  is  known  to  start  from  the  air  passages, 
and  we  are  consequently,  at  the  end  of  respiration,  in  this  posi- 
tion. In  order  to  excite  inspiration  oxygen  is  wanted  for  the 
purpose  of  making  an  impression  on  the  afferent  nerves  of  the 
air  passages,  the  oxygen  of  the  contained  air  has  been  consumed, 
and  no  fresh  air  can  enter  except  by  inspiration ;  that  is  to  say, 
an  inspiration  must  take  place  in  order  to  produce  the  impres- 
sion necessary  to  excite  the  act  of  inspiration,  which  is  absurd, 
as  our  '  Euclid  '  used  to  say. 

Here  we  stop.  The  author  goes  on  to  summarise  his  conclu- 
sions, and  to  support  them  by  the  comparison  of  the  behaviour 
of  a  magnetised  bar  of  iron,  which  suddenly  elongates  without 
change  of  volume  when  charged  with  magnetism,  and  contracts 
when  the  current  by  which  this  is  effected  is  stopped.  He  deals 
also  with  various  objections  of  more  or  less  weight,  but  nothing 
which  appears  to  us  important  is  added.  We  do  not  propose  to 
follow  him  at  all  into  the  domain  of  Pathology.  His  views  as 
to  the  character  and  causation  of  epilepsy,  tremor,  tetanus,  and 
other  deviations  from  normal  muscular  action,  have  long  been 
before  the  profession,  and  have  been  frequently  discussed.  It 
is  not  too  much  to  say,  that  they  have  had  an  important  influ- 
ence in  the  production  of  the  change  of  opinion  respecting  these 
states  which  has  taken  place.  They  have  not  undergone  any 
such  radical  modification  as  the  theory  out  of  which  they  origi- 
nally sprung,  and  consequently  do  not  require  any  new  exami- 
nation. We  are  the  less  inclined  to  this  task  also,  since  it 
would  send  us  far  back  among  fundamental  questions  to  Avhich 
we  could  here  not  do  justice  when  they  were  raised,  and  would 
involve  long  discussions,  out  of  which  would  come  dispropor- 
tionately small  results. 

The  task  we  proposed  to  ourselves  was  to  endeavour  to  form  a 
correct  appreciation  of  Dr.  Radcliffe's  new  theory  of  muscular 
action.  We  find  that,  in  his  efforts  to  establish  it.  Dr.  lladcliffe, 
— unless  his  experiments,  and  not  his  arguments  merely,  can 
be  impugned,  has  at  any  rate  established  the  existence  of  a  new 
relation  between  electricity  and  muscular  action,  the  association 


322  Reviews.  [April, 

of  relaxation  with  charge,  and  of  contraction  with  discharge; 
he  has  thereby  reduced  to  beautiful  order  and  made  comprehen- 
sible the  confused  and  perplexing  phenonema  of  electrotonus 
and  of  the  direct  and  inverse  current.  This  is  a  service  to 
science  of  the  highest  value,  and  justifies  and  rewards  his  pro- 
longed devotion  to  the  question  of  muscular  and  nervous  action, 
and  if  we  cannot  think  that  he  has  established  his  view  of  the 
part  electricity  takes  in  the  process,  and  of  the  mode  in  which 
electricity  operates,  we  believe  he  has  laid  the  foundation  of  a 
true  theory  yet  to  be  evolved. 


III.-— Dr.  Porter  Smith  on  Chinese  Materia  Medica.i 

This  volume,  which  must  doubtless  have  taken  up  a  large 
amount  of  the  author's  time  and  attention,  is  arranged  alpha- 
betically in  the  fashion  of  our  old  dispensatories,  and  is  mainly 
based  on  the  native  books  of  the  Chinese  'Materia  Medica.' 

Such  an  arrangement  excludes  the  possibility  of  our  reviewing 
it  in  the  ordinary  sense  of  the  word ;  and  the  best  method  of 
giving  our  readers  an  idea  of  its  value  is  by  numerous  abstracts 
and  short  quotations  from  the  most  important  or  curious 
headings. 

Of  antelope  horn  we  are  told  that 

"  The  horn  of  a  kind  of  chamois,  usually  set  down  as  the  antelope 
gutturosa,  is  mainly  brought  from  Lung-ngan  fu  in  Sech'uen.  A 
country  called  0-tan-hwoh  is  said  to  have  a  sort  with  a  continuation  of 
the  dewlap  passing  along  the  under  surface  of  the  belly  to  the  tail. 
The  character  representing  this  animal  consisted  of  the  two 
characters  for  '  deer  '  and  '  spiritual '  combined.  It  is  said  to  hang 
itself  up  in  trees  by  its  horns.  It  is  described  as  a  sheep  with  coarse 
hair,  which  renders  its  skin  valuable  for  making  coverings  for  beds 
or  seats.  A  kind  of  '  wild  ass  '  or  shan-lu  is  described  in  connection 
with  it.  A  kind  of  unicorn  belonging  to  this  species  of  antelope  is 
said  to  be  met  with  on  a  mountain  in  Annam.  The  specimens  sold 
in  Hankow  are  about  five  inches  long,  of  a  dirty  white  translucent 
colour,  with  several  partial  rings  marking  the  base  of  the  horn,  which 
is  about  the  size  of  a  man's  thumb,  tapering  off  gradually  to  a  point, 
with  a  single  spiral  twist.  The  horn  is  given  in  coarse  powder,  or 
after  being  partially  calcined  as  a  remedy  in  convulsive  apopleptic, 
cerebral,  and  rheumatic  affections.  It  is  said  to  hasten  the  pains  of 
labour  when  given  in  wine.     Most  of  these  properties  are  mere 

'  Contributions  towards  the  Materia  Medica  and  Natural  History  of  China. 
For  the  Use  of  Medical  Missionaries  and  Native  Medical  Students.  By  Feedeeick 
Porter  Smith,  M.B.  Lond.,  Medical  Missionary  in  Central  China.  1871,  pp.  237. 
Shanghai  aiid  London. 


1872.]     Dr.  Porter  Smith  on  Chinese  Materia  Medica.    323 

conceits,  but  women  are  very  fond  of  taking  this  medicine  in  sundry 
diseases  of  the  pregnant  and  puerperal  states  "  (p.  18). 

Of  suhlimed  arsenic,  we  read  that  this  preparation  is  used  to 
cure  ague,  according  to  the  Pen  Ts'au,^  but  very  few  of  the 
practitioners  of  the  present  day  venture  to  prescribe  it.  Caustic, 
emetic,  anthelmintic,  and  alterative  properties  are  set  down  as 
the  effects  of  this  powerful  drug. 

"  The  water  of  the  Phaseolus  angidatus  is  said  to  be  antidotal  of 
this  poison.  Bottles  exposed  to  arsenical  fumes  are  said  to  preserve 
wine  kept  in  them  for  a  long  time.  Chinese  crackers  are  said  to  be 
much  louder  when  containing  a  portion  of  this  sublimate.  Asthma 
is  said  to  be  relieved  by  small  doses  of  this  drug,  but  it  is  distinctly 
forbidden  in  all  sorts  of  eruptions  and  sores.  It  is  recommended  in 
chronic  dysentery  along  with  massicot,  and  in  sundry  pains  and 
aches  of  a  neuralgic  nature." 

In  the  next  paragraph  on  white  arsenic  we  are  glad  to  find 
that  none  of  these  arsenical  preparations  are  sold  in  shops  with- 
out evidence  and  witness  to  the  propriety  of  the  sale.  The  punish- 
ment of  death  by  decapitation  is  inflicted  upon  both  the  seller 
and  the  buyer  if  fatal  effects  result.  If  not  fatal,  they  are  both 
strangled.  (The  alternative  is  a  pleasant  variety  !)  If  the  druggist 
ignorantly  or  carelessly  sells  the  poison,  he  receives  eighty  blows. 

The  following  history  of  Artemisia  moxa  is  curious.  This 
herb  is  hung  up  with  the  Acorus  calamus  over  the  doors  of  every 
Chinese  house  on  the  fifth  day  of  the  fifth  month.  Although 
its  principal  use  is  as  a  counter-irritant,  this  plant  is  in  general 
repute  as  a  charm,  or  remedy  in  internal  diseases.  The  downy 
leaves  are  collected,  dried  and  rolled  into  a  small  ball,  which  is 
ignited  upon  the  skin,  in  order  to  cauterize  the  part. 

"  The  heat  of  the  sun's  rays  collected  by  a  mirror  or  glass  is  said 
to  be  the  proper  way  of  igniting  the  moxa.  This  form  of  cautery, 
called  Ngdi-ho,  was  formerly  applied  indiscriminately  in  all  cases  of 
disease.  In  Hupeh,  at  least,  the  moxa  has  fallen  into  disuse,  as  it  is 
employed  by  the  buddhist  priests  in  initiating  their  neophytes.  The 
Teng-ho,  or  lamp  cautery,  and  the  bloody  cupping-vessel,  called 
Pa-ho-kwan,  have  replaced  the  moxa  to  a  very  great  extent.  The 
plant  itself  is  used  as  a  carminative,  stimulant,  stomachic,  astringent, 
alterative,  and  resolvent  remedy.  The  supply  comes  from  Chin-ting 
fu  in  Pehchihli,  and  a  reddish  variety  called  Tszngai,  comes  from 
Eung-yang  fu,  in  Nganhwui.     The  best,  called  Ki-ngdi,  comes  from 

^  The  Pen-ts'au-kang-muJi  is  a  "  synopsis  of  ancient  herbals,"  compiled  by  Li 
Shi-chtn,  a  district  magistrate,  born  in  the  Pz'ovince  of  Hupeh.  Its  preparation 
occupied  him  for  some  forty  years,  and  it  contains  no  less  than  11,896  formula}. 
The  substances  of  which  it  treats  are  arranged  in  sixty-two  great  classes,  under 
the  sixteen  orders  of  water,  fire,  earths,  minerals  and  metals,  herbs,  grain  and  pulse, 
vegetables,  fruits,  trees,  garments,  and  utensils,  insects,  scaly  animals,  mailed  and 
shelly  creatiires,  birds,  beasts,  and  man.  It  was  published  about  1597.  This  eucy- 
clopa3dic  work  is  more  often  referred  to  by  our  author  than  any  other  authority. 


824  Reviews.  [April, 

K-'i-chau,  in  Hwang-clmu  fu  (Ilupeb).  A  solid  substance  used  as  a 
febrifuge  is  mentioned  by  Dr.  Williams  in  his  '  Chinese  Commercial 
Guide,'  as  a  kind  of  camphor,  extracted  from  the  leaves  of  arteraisia. 
The  crystals  are  limpid  and  brittle,  and  present  a  brilliant  fracture. 
It  is  probably  identical  with  a  solid  volatile  stearoptene  called 
Ngdi-lah-hiang,  formerly  brought  as  a  tribute  from  some  foreign 
state.  It  is  said  to  be  disinfectant,  cooling,  astringent,  and  anthel- 
mintic "  (p.  25). 

Under  the  deceptive  title  of  asses^  glue,  or  O-Kiau,  we  meet 
with  a  drug  in  flat  rectangular  cakes,  two  inches  by  one  and 
one  third  of  an  inch  in  size,  and  three  or  four  lines  in  thick- 
ness. 

"  It  is  reddish  and  translucent,  with  all  the  properties  of  common 
glue.  The  cakes  are  wrapped  in  rouge-red  paper,  as  is  usual  with 
all  expensive  drugs.  The  name  asses'  glue  is  an  incorrect  and 
ridiculous  translation  of  the  Chinese  name ;  for  the  genuine  drug  is 
properly  the  extract  prepared  by  boiling  down  the  waters  of  a 
celebrated  well,  at  a  place  sixty  U  to  the  north-east  of  the  district 
city  of  Tang-kuh,  in  Kwan-chau  fu  (Shantung).  This  town  was 
anciently  called  0-yih  or  A-yih,  and  the  well  was  named  after  it.  The 
well,  as  large  over  as  a  wheel,  and  sixty  or  seventy  (Chinese) 
feet  deep,  contains  a  water  probably  like  that  of  Bareges,  in  Trance, 
which  has  a  gelatinous  principle  in  it,  conferring  peculiar  properties 
on  the  water.  As  hartshorn,  cowhide,  and  the  skin  of  a  black  ass 
are  said  to  be  often  used  to  make  this  valuable  article,  which  is  used 
by  artists  and  by  others  than  carpenters  to  join  articles  together, 
the  power  of  this  water  to  produce  such  a  substance  will  be  perhaps 
doubted.  .  .  .  Tonic,  astringent,  tussic,  emmenagogue,  arthritic,  seda- 
tive, and  diuretic  properties,  among  others,  are  attributed  to  this 
"  perfect  medicine,"  as  Li  Shi-chin  calls  it"  (p.  28). 

The  hat  is  a  very  common  animal  in  China,  "  being  a  frequent 
visitor  of  foreign  houses  in  quest  of  mosquitoes,  which  it  devours 
most  satisfactorily.  As  it  is  supposed  to  feed  upon  the  stalac- 
tites which  are  frequently  met  with  in  the  caves  which  it  is 
wont  to  hybernate  in,  its  medicinal  properties  are  rated  at  con- 
siderable value  by  the  Chinese.  From  its  asserted  longevity 
and  its  excellent  sight,  this  curious  creature  is  credited  by  the 
Chinese  with  the  power  of  conveying  these  desirable  qualities 
to  those  who  consume  the  disgusting  preparations  made  from  all 
parts  of  its  body.'^ 

But  unpleasant  as  a  bat  must  be,  hafs  dung,  which  is  sold  as 
a  dark  brown,  coarse  powder,  looking  something  like  teadust, 
and  consisting  of  debris  of  the  Mylabris  insect,  dirt,  bat's  dung, 
and  other  extraneous  substances,  must  be  still  more  decidedly 
objectionable. 

"  As  bats  fly  by  night,  the  Chinese  name  this  composition,  which 
according  to  the  Fen  Ts\m  was  formerly  much  better  made,  *  night- 


1872.]      Dr.  Porter  Smith  on  Chinese  Materia  Medica.    325 

bright  sand,'  and  appl}"-  it  to  the  eyes  as  a  powder  or  as  a  wash,  iu 
tinea  tarsi,  opacities  of  the  cornea,  &c.  They  profess  to  detect  the 
eyes  of  the  mosquitoes,  on  which  the  creature  feeds,  in  this  excre- 
ment, which  is  given  internally  in .  ophthalmic  affections,  otorrhoea, 
ague,  cough,  infantile  dyspepsia,  tabes,  offensive  perspirations,  &c." 
(p.  34). 

Under  the  heading  "  Bones  of  Tiger,"  we  find  a  notice  of 
several  curious  superstitions. 

"  This  animal  is  said  by  Chinese  writers  to  be  the  king  of  beasts 
and  to  have  very  intelligent  w^ays.  It  is  said  to  eat  its  victims 
according  to  the  calendar,  and  to  have  the  power  of  planning  out  the 
country  round  its  lair,  to  be  visited  according  to  a  fixed  system.  If 
it  leaps  up  three  times  at  its  prey,  and  fails,  it  withdraws.  Its  vic- 
tims become  devils  after  digestion,  but  the  flesh  of  the  dog  is  said  to 
intoxicate  this  cat-like  creature.  Bad  smells,  such  as  burnt  horn, 
are  said  to  scare  it  away,  and  the  hedge-hog,  or  tenrec,  is  said  to  be 
able  to  get  the  better  of  it.  It  is  believed  to  become  grey  at  the 
close  of  the  first  500  years  of  its  life.  An  animal,  spoken  of  as  the 
TsHu-rh,  is  said  to  be  much  larger  than  the  ordinary  tiger,  having  a 
white  body  with  black  stripes,  and  a  tail  as  long  as  the  body.  The 
tibiae  and  skull  bones  are  esteemed  the  best  for  making  the  tincture 
of  the  much  vaunted  drug,  which  is  much  used  in  Hankow  in  rheu- 
matic affections  of  the  joints,  diseases  of  the  bones,  ague,  and  general 
debility"  (p.  41). 

Carrot  seeds  are  recommended  in  chronic  diarrhoea ;  we  may 
add,  carrots  are  eaten  by  the  natives  with  wild  ducks. 

Turning  to  cassia  bark,  we  find  it  stated  that 

"The  compound  powder  of  cinnamon  is  an  excellent  remedy  in  the 
water  brash  of  Chinese  dyspeptic  patients,  and  with  a  small  quantity 
of  opium  it  is  one  of  the  best  things  that  can  be  given  to  an  opium- 
smoker  endeavouring  to  give  up  the  habit.  Some  action  is  ascribed 
in  Chinese  works  to  cinnamon  as  affecting  the  uterus,  a  property 
which  is  usefully  turned  to  account  in  the  treatment  of  menorrhagia, 
a  very  common  disease  in  China." 

The  writer  seems  not  to  be  aware  that  cinnamon  has  been 
successfully  employed  in  this  country  for  the  last  named 
affection. 

On  reading  the  article  on  the  "  Castor  Oil  Plant/^  we  find 
that  it 

*'  Is  grown  in  Hupeh  as  a  shelter  from  the  sun.  This  fact  lends 
considerable  probability  to  the  belief  that  the  gourd  of  Jonah  was 
this  plant,  which  attains  a  considerable  height,  and  is  self-sown  in 
tropical  climates.  It  has  been,  or  is  known,  in  all  parts  of  the 
world.  The  Saxons  were  acquainted  with  it,  and  in  their  translation 
of  the  '  Herbarium  of  Apuleius,'  a  favorite  book  with  them,  it  is 
said  that  this  'wort  smootheth  every  tempest.'  It  grows  to  the 
height  of  more  than  ten  feet,  and  forms  a  woody  stem,  which  never 
survives  the  winter  of  Central  China." 


326  Reviews.  [-^pril> 

The  cruslied  seeds  are  used  in  Chinese  medicine  as  an  out- 
ward application  in  a  large  number  of  diseases,  combined  with 
the  oil  of  the  seeds,  or  the  pulp  is  taken  internally  as  a  remedy, 
whose  effects  must  be  nearly  identical  with  those  of  the  oil. 

*'  The  pulp  is  rubbed  into  the  temples  in  headache,  into  the  palms 
of  the  hands  in  palsy,  and  is  introduced  into  the  meatus  of  the 
urethra  in  stricture.  The  pulp  is  rubbed  into  the  soles  of  par- 
turient women  to  hasten  the  birth  of  the  child,  or  the  expulsion  of 
the  placenta.  It  is  stuffed  into  deaf  ears,  rubbed  over  the  top  of 
the  head  in  cases  of  prolapsus  uteri,  and  is  applied  with  the  oil  to 
burns  and  scalds  "  (p.  55). 

Chloroform  is  introduced  into  the  author's  list  of  native 
remedies,  although  of  course  it  was  unknown  until  introduced 
at  the  mission  hospitals.     He  observes — 

"  That  it  has  a  most  excellent  effect  on  the  Chinese,  but  should 
always  be  given  with  much  caution  to  confirmed  opium  smokers,  and 
generally  with  more  care  during  the  very  hot  weather.  The  repeti- 
tion of  the  drug,  towards  the  close  of  the  operation,  when  conscious- 
ness has  been  already  restored,  is  a  dangerous  experiment  in  the 
author's  experience." 

The  term  Ma-yoh,  which  the  natives  have  given  to  chloro- 
form, appears  to  be  more  generally  applied  to  local  anaesthetics 
than  to  those  which  act  through  and  all  over  the  system.  The 
name  seems  to  have  been  taken  from  the  word  applied  to  the 
painless  eruptions  of  leprosy,  which  is  called  Ta-ma-fung. 

"  The  flowers  of  a  species  of  cannabis,  Ho-ona,  and  of  the  Datura, 
Man-tou-lo,  were  formerly  infused  in  wine,  and  drunk  as  a  stupefy- 
ing medicine  preparatory  to  acupuncture,  the  opening  of  abscesses, 
and  the  use  of  the  actual  cautery.  A  solanaceous  plant,  called 
Tah-puh-lu,  probably  identical  with  the  Atropa  mandragora  of  bota- 
nists, is  said  to  be  capable  of  causing  a  trance  of  three  days'  duration. 
Hwa-To,  a  celebrated  surgeon  of  the  Han  period,  the  Machaon  of 
Chinese  historical  romance,  used  this  latter  plant.  Aconite  root, 
the  tubers  of  Pinellia  tuberifera,  long  pepper,  the  root  of  Hetero- 
tropa  asaroides,  the  flowers  of  hyoscyamus,  azalea,  andromeda,  and 
rhododendron,  the  tubers  of  Ariscema  and  Arum  pentaphylUcm,  an 
unknown  gum  resin,  called  Mwan-Mang,  and  the  fat  extracted  from 
the  head  of  the  toad,  are  substances  which  are  reputed  to  have 
anaesthetic  properties,  generally  applied  locally.  These  substances, 
and  other  imaginary  or  superstitious  formulae,  are  said  to  be  em- 
ployed by  kidnappers  of  children,  who  manufacture  Yoh-p-ing  or 
'  medical  confectionary,'  containing  these  drugs.  On  this  account 
such  drugs,  called  Mi-yoh,  are  virtually  forbidden  to  be  sold  or  em- 
ployed. Bobbers  are  known  to  use  a  sort  of  pastille  containing  the 
Mwan-Jiiang  and  other  quieting  perfumes,  by  means  of  which  they 
certainly  seem  to  render  the  sleep  of  their  victims  very  profound  " 
(p.  61). 

The  Dragon  contributes  its  hlood,  hones,  spittle,  and  teeth  to 


1872.]     Dr.  Porter  Smith  on  Chinese  Materia  Medica.     S17 

the  Chinese  'Materia  Medica.'  Passing  over  the  first,  which  is 
a  common,  well-known  gum,  we  shall  give  our  author's  state- 
ments regarding  the  nature  and  the  properties  of  the  others. 
Under  the  name  of  dragons^  bones  we  read  that 
**  Irregular  pieces  of  fossil  ivory,  weighing  a  few  ounces,  are  sold, 
as  Hanbury  remarks,  in  stamped  packages.  They  have  been  ex- 
amined microscopically  by  the  latter  observer,  and  proved  to  be,  at 
least  in  some  cases,  fossil  ivory.  Fossil  bones  of  the  Stegodon 
orientalis,  of  Swinhoe,  are  brought  from  Ching-tu-fu  and  Ch'ung-king 
fu,  in  Sech'uen,  in  large  broken  masses,  showing  the  cancellous 
structure  of  the  large  fossil  bones  of  proboscidians.  Portions  of  lime- 
stone matrix,  bearing  the  impressions  of  these  bones,  are  sold  with 
these  genuine  fossils,  which  are  also  brought  from  I'-chau  fu,  in 
Shantung,  Tsangchau,  near  Tientsin,  and  from  Tai-yuen  fu,  in 
Shanse.  They  are  powdered,  levigated,  and  used  in  chorea,  sperma- 
torrhoea, ague,  fevers,  haemorrhages,  and  fluxes." 

The  following  is  the  description  of  dragorCs  spittle  or  lung- 
sin  : 

*'  A  costly,  odorous,  light  yellow,  gummy  substance,  found  floating 
on  the  sea,  or  procured  from  the  belly  of  some  large  fish  in  the 
Indian  Ocean,  is  described  in  such  a  particular  way,  under  this  name 
of  lung-sin,  as  to  leave  no  doubt  that  ambergris  is  meant.  This  is 
probably  the  origin  of  Dr.  Williams'  Lung-sin  hiang,  a  name  appHed 
to  a  counterfeit  ambergris,  made  by  mixing  together  Borneo  camphor 
and  musk.  The  dragon  is  said  to  cough  up  this  ambergris.  A 
similar  substance,  called  Xih-tiau-cJd,  brought  from  Canton  and 
Foocliow  in  former  days,  is  said  to  be  the  egg  of  the  dragon  or  a  kind 
of  sea-serpent,  named  Kih-tiau.  This  drug  is  of  a  greyish  or 
yellowish  colour,  according  to  Chinese  writers,  and  is  asserted  to 
have  marvellous  discutient,  vulnerary,  and  healing  properties." 

JDragoiTbS  teeth  or  Lung-chH  are 

"Possil  teeth  of  the  Stegodon  sinensis  (Owen)  that  have  been 
found  in  the  marly  beds  of  the  country  round  Shanghai  by  Lockhart, 
and  of  the  Stegodon  orientalis  (Owen),  by  Swinhoe,  near  Ch'ung- 
king  fu,  in  Sech'uen.  These,  with  the  horns  of  the  Chalicotherium 
sinense  (Swinhoe),  the  teeth  of  Hyla  sinensis,  from  Ch'ung-king  fu 
and  from  Ching-tu  fu,  in  Sech'uen,  and  molars  of  mastodons, 
elephants,  sheep,  stags,  teeth  of  the  hippotherium,  described  by 
Hanbury,  after  Waterhouse,  as  coming  from  Shensi  and  Shansi,  are 
sold  under  the  name  of  Lung-ch'i.  They  are  supposed  to  act  on  the 
liver,  and  to  be  of  great  service  as  cordial  or  sedative  remedies." 
The  dung  of  the  common  sparrow  is 

"  Mixed  with  pepper  corns,  powdered,  and  then  mixed  up  by  means 
of  spirits  of  wine.  This  mess  is  used  to  diminish  the  pains  of  open- 
ing abscesses,  the  thick  compound  being  first  applied  for  some  time 
to  the  skin.  It  is  also  applied  to  the  wounds  caused  by  arrow- 
heads or  shot,  to  diminish  the  pain  of  extracting  the  foreign  bodies" 
(p.  90). 


328  Reviews.  [April, 

The  excrements  of  other  birds,  as  the  magpie  and  the  white 
pigeon,  are  also  used  by  the  Chinese.  Of  the  dung  of  the 
former  we  read  that  it  is  cordial,  sedative,  anti-periodic,  astrin- 
gent, anthelmintic,  and  vulnerary,  with  almost  any  other 
quality  that  could  be  enumerated.  It  is  one  of  the  remedies  for 
leprosy,  being  applied  to  the  benumbed  parts  in  the  form  of  an 
ointment.  The  brain  of  the  magpie  is  eaten  to  increase  the 
thinking  power. 

Under  the  heading  "  Fowl,  Domestic,"  we  find  some  curious 
statements  ;  as,  for  example,  that  all  the  Chinese  names  for  this 
bird  refer  to  its  crowing,  which  they  say  is  regular  all  through 
the  day,  as  well  as  at  dawn.  The  Chinese  having  no  means  of 
reckoning  time,  pay  special  and  superstitious  regard  to  the 
crowing  of  cocks.  The  flesh  of  the  male  bird  is  said  to  be  in- 
jurious, especially  to  those  suffering  from  bad  eyes,  or  from 
growths  or  sores  of  any  kind.  This  objection  is  more  likely  to 
depend  on  the  fact  that  the  cock  is  used  in  oaths  and  sacrifices, 
and  is  not  to  be  slain  on  ordinary  occasions. 

"Black-boned  fowls  are  called  Yoh-Jci,  being  much  prized  for 
making  soup  for  those  suffering  from  lung  diseases  and  debility  after 
hgemorrhages.  Many  other  distinctions  are  made  between  the  colour 
and  sex  of  birds  as  to  their  suitability,  or  otherwise,  for  particular 
classes  of  sick  folk.  Cordial,  tonic,  and  many  other  fanciful  proper- 
ties are  attributed  by  the  Chinese  to  the  albumen  and  yolk  of  the 
egg,  which  they  compare  to  the  sky  and  soil  of  the  universe  respec- 
tively. The  white  of  the  egg  is  applied  like  collodion  to  burnt  sores, 
and  eruptions  on  the  head.  Egg  shells,  Ki-koh,  are  burnt  and 
pulverised,  to  be  given  in  dysuria,  and  for  use  topically  in  scald 
head"  (p.  48). 

The  article  on  "  Ginseng"  is,  as  might  be  expected,  curious, 
but  contains  less  information  than  we  should  have  expected  to 
find.  The  Manchurian  ginseng  is  the  best,  the  Manchus 
boasting  that  the  weeds  of  their  country  are  the  choice  drugs  of 
the  Chinese. 

"  The  pieces,  after  careful  trimming  with  a  bamboo-knife,  and 
drying  in  still  air,  are  made  to  assume  something  of  the  form  of  the 
human  body.  They  generally  do  resemble  a  miniature  human  hand, 
the  larger  pieces  being  the  size  of  a  man's  little  finger,  with  some 
two  to  four  finger-like  branching  rootlets.  They  are  yellowish,  semi- 
transparent,  firm,  brittle  to  some  extent,  and  of  a  sweet,  mucilagi- 
nous taste,  accompanied  with  a  slight  bitterness.  The  drug  is  usually- 
prepared  for  use  by  steaming  and  finishing  olF,  so  as  to  approximate 
its  appearance  to  the  normal  standard  of  clearness,  Eabulous 
stories  are  told  of  the  finding  of  special  depots  of  this  root,  which 
is  associated  with  guiding  voices  and  other  good  and  peaceful  omens. 
This  drug  is  prepared  as  an  extract,  or  as  a  decoction,  in  silver 
vessels  as  a  rule.     Its  effects  are  apparently  those  of  an  emetic. 


1872.]    Dr..  Porter  Smith  on  Chinese  Materia  Medica.      329 

tonic,  stimulant,  carminative,  and  demulcent  nature.  It  is  prescribed 
in  almost  every  description  of  disease  of  a  severe  character,  with 
few  exceptions,  but  with  many  reservations  as  to  the  stage  of  the 
disease  in  which  it  may  he  administered  with  the  greatest  benefit 
and  safety.  All  forms  of  debility,  spermatorrhoea,  the  asthenic  ha3- 
morrhages,  the  various  forms  of  severe  dyspepsia,  the  persistent 
vomiting  of  pregnant  women,  malarious  affections  of  a  chronic  cha- 
racter, the  typhoid  stage  of  fevers,  especially  of  an  epidemic  charac- 
ter, are  occasions  in  which  the  Chinese  use  this  drug.  Several  cases 
in  which  life  would  seem  to  have  been  at  least  prolonged  by  the 
taking  of  doses  of  this  drug,  so  as  to  allow  of  intelligent  disposition 
of  property,  indicate  that  some  positive  efficacy  of  a  sustaining  cha- 
racter does  really  exist  in  this  species  of  ivywort.  The  leaves  are 
sold  in  bundles  of  the  green,  fragrant,  excellently  preserved  foliage 
of  the  shrub.  They  are  said  to  be  emetic  and  expectorant  in  their 
effects"  (p.  104). 

Under  the  heading  "  Indigo"  we  read  that  indigo-dye  is 
almost  the  only  form  of  this  material  employed  medicinally. 

*' Swellings,  bruises,  stings,  strumous  glands,  and  tumours  in 
general,  are  treated  with  a  daub  of  this  remedy.  The  pages  of  the 
•  Pen  Ts'au  inform  us  that  fevers,  fluxes,  worms,  infantile  disorders 
of  all  kinds,  were  treated  by  means  of  some  form  or  other  of  this, 
perhaps,  rarer  remedy.  Li  Shi-chin  properly  remarks  that  the  lime 
used  in  its  manufacture  must  make  its  action  not  a  little  different 
from  that  of  so  much  indigo  juice.  It  is  curious  that  the  Chinese 
have  anticipated  us  in  the  treatment  of  convulsive  diseases  by  this 
agent,  the  action  of  which  in  such  cases  deserves  some  further  trial. 
The  domestic  use  of  the  blue-bag  in  England  as  a  remedy  for  the 
stings  of  bees  and  wasps  is  daily  carried  out  in  China.  Indigo 
extract  was  used  for  painting  the  eyebrows  in  olden  times,  as  henna 
was  employed  by  the  Arabians"  (p.  117). 

Lapis  hepaticus,  or  Fuh-lmg-kan,  is  supposed  by  the  author 
to  be  the  calcined  clay  which  forms  the  simple  fireplace  of  the 
poor  Chinese.  It  is  mixed  with  pig's  liver,  and  administered 
as  a  remedy  in  cross -births,  puerperal,  cutaneous,  and  many 
other  disorders,  and  is  probably  of  about  the  same  value  as  the 
majority  of  the  Chinese  drugs. 

The  so-called  Lotus  is  in  reality  the  beautiful  water-lily 
known  as  Nelumbium  speciosum,  and  has  scarcely  a  part  that 
has  not  a  special  name  and  use  amongst  the  Chinese. 

"  The  flower,  with  its  red-tipped,  pinkish-white  petals,  is  seldom 
gathered,  plants  being  placed  in  large  jars  for  ornamental  purposes. 
The  petals  of  a  flower,  with  the  horary  characters  of  the  person  traced 
upon  one  of  them,  were  formerly  swallowed  by  women  in  the  throes 
of  difficult  labour,  as  a  certain  relief.  The  carefully  dried,  beautifully 
yellow  fragrant  stamens  of  the  flower  are  brought  from  Honan  to 
Hankow ;  they  are  used  as  an  astringent  remedy,  and  as  a  cosmetic 
article ;  the  seeds  are  brought,  specially  as  a  medicine  and  as  an 


330  Reviews.  [April, 

article  of  dessert,  from  Fuh-kien,  Kwang-sin-fu,  in  Kiangai,  and 
from  Kwang-p-*ing  fu,  in  Pehchihli.  The  kernels  are  very  starchy, 
and  pleasant  when  boiled  in  soup  or  roasted ;  they  are  also  eaten 
raw ;  they  are  supposed  to  be  good  for  spermatorrhoea,  and  hajma- 
temesis.  As  sold  in  the  streets,  these  nuts  might  be  mistaken  for 
acorns.  The  leaves  are  prescribed  as  remedies  in  fevers,  fluxes,  and 
haemorrhages.  Even  to  the  leaf-stalks  are  assigned  some  therapeu- 
tical value  in  certain  movements  of  the  foetus  in  the  gravid  uterus, 
which  are  frequently  referred  to  in  the  '  Pen  Ts'au  as  something 
very  serious.  The  stalks  of  the  curious  receptacle  in  which  the 
carpels  are  embedded,  resembling  the  broad  nozzle  of  a  watering- 
pot,  are  a  popular  remedy  for  hsemoptysis,  a  frequent  symptom  with 
the  Chinese"  (p.  139). 

Under  the  heading  ^^  Mutton"  we  read  that  the  sheep  is  com- 
paratively rare  in  China,  and  hence  we  need  not  be  surprised 
to  learn  that  "  mutton-broth  is  advised  as  good  for  pulmonary 
diseases,  abdominal  obstructions,  debility,  and  for  parturient 
and  suckling  women." 

To  the  Mylahris  cMcorii,  a  coleopterous  insect  with  a  very 
wide  distribution  (known  as  the  Telini  fly  in  India),  the  most 
remarkable  properties  are  ascribed  : 

"  It  is  reputed  to  be  emetic,  diuretic,  and  antidotal.  It  is  taken 
internally  in  scrofula,  syphilis,  and  rectal  diseases,  and  is  given  to 
persons  for  purposes  of  abortion,  contrary  to  the  Tartar  code.  It  is 
the  grand  remedy  of  the  Chinese  faculty  for  hydrophobia,  a  disease 
by  no  means  common  in  China,  in  spite  of  the  street-plague  of  ill- 
conditioned  dogs  met  with  all  over  the  empire.  The  mad  dog  is 
supposed  to  have  impregnated  the  bitten  person,  and  the  little  dog, 
the  product  of  this  conception,  is  sought  for  in  the  urine,  rendered 
bloody  by  a  large  dose  of  the  powdered  mylahris,  digested  in  wine. 
Kecovery  is  thereupon  considered  certain"  (p.  154). 

Glancing  at  the  article  on  "Paper,"  we  find  that  the  ashes  are 
given  as  an  astringent,  and  the  paper  of  an  old  book  or  letter, 
after  cutting  out  the  printed  characters,  held  in  such  commend- 
able veneration  in  China,  is  a  remedy  for  barren  women  ! 

Torh  is  said  to  produce  phlegm,  and  is  considered  to  be  bad 
for  those  suffering  from  healing  wounds,  abscesses,  and  stru- 
mous, or  inflamed  joints.  Every  part  of  the  pig  is  assumed  to 
have  some  special  medicinal  property.  The  liver  and  lungs  are 
commonly  employed  to  make  soup  for  convalescents,  who 
almost  invariably  make  this  terrible  piece  of  extravagance  the 
climax  of  their  recovery.  The  blood  of  the  pig  is  carefully 
collected,  cooked,  and  hawked  about  the  streets  of  Hankow  at 
night,  as  a  favourite  supper  of  the  million.  Pig's  feet  make  a 
gelatinous  broth,  much  used  as  a  wash  for  irritable  carbuncular 
and  other  sores. 

Soy  being  a  fluid  popularly  regarded  as  mainly  composed  of 


1872.]  The  Medical  Jurisprudence  of  Insanity.  331 

black-beetles,  it  may  be  satisfactory  to  know  how  it  is  really 
prepared  : 

"  The  yellow  beans  of  the  Dolichos-soja  are  boiled  very  soft,  and 
mixed  with  any  cereal  flour  in  varying  proportions,  and  allowed  to 
ferment  and  become  mouldy.  Salt  and  tea  or  boiling  water  are 
then  added,  and  the  mixture  is  then  exposed  to  the  dew  and  sun  of 
the  open  air  for  three  weeks  or  a  month,  care  being  taken  to  avoid 
rain.  The  liquid  becomes  much  thicker,  darker,  and  more  uniform 
in  consistence,  and  after  constant  stirring  it  is  then  strained  and 
kept  for  use.  Bran  is  sometimes  used  in  making  it.  Large  quanti- 
ties are  both  sold  from  the  shops  and  made  at  home  by  the  Chinese. 
It  is  considered  to  provoke  the  appetite,  and  to  correct  any  injurious 
quality  of  food.  It  is  laxative,  cooling,  and  antidotal,  according  to 
Chinese  estimation.  It  is  sometimes  daubed  upon  burns,  scalds, 
eczematous  and  leprous  sores"  (p.  203.) 

The  quotations  and  abstracts  that  we  have  given  afford  suffi- 
cient evidence  that  Dr.  Porter  Smith  has  produced  a  very 
interesting  and  remarkable  volume,  which  deserves  a  place  in 
every  medical  library. 


IV.—  The  Medical  Jurisprudence  of  Insanity .^ 

The  difficulties  that  beset  the  subject  of  Insanity  in  its  relations 
to  law  are  very  numerous.  Law  itself  is  no  longer  unvarying ; 
the  absolute  dicta  of  a  Solon^  compelling  compliance,  would  now 
no  longer  be  accepted.  Law  "grows,"  as  our  author  puts  it. 
But,  unfortunately,  legal  form  still  carries  with  it  much  of  the 
old  pride  of  the  times  when  it  was  absolute.  The  necessity  of 
this  form  being  based  as  far  as  possible  upon  the  results  of 
scientific  research  is  indeed  acknowledged ;  but  there  is  a  ten- 
dency among  lawyers  to  revert  to  general  principles  which  are 
insufficiently  established,  and  to  deduce  from  them  conclusions 
for  particular  instances.  In  no  branch  of  law  has  this  tendency 
more  decidedly  displayed  itself  than  in  that  which  forms  the  sub- 
ject of  this  work.  Such  a  maxim  as  that  the  law  cannot  take  cog- 
nizance of  gradations  of  mental  disease, — one  lying  at  the  root 
of  many  of  the  mistakes  made  by  lawyers  in  dealing  with  the 
subject  of  Insanity, — is  unhesitatingly  affirmed.  Where  a  propo- 
sition is  so  unreasonable  that  no  reason  can  be  given  in  support 
of  it,  we  suppose  it  is  best  to  affirm  it  unhesitatingly. 

There  is  a  second  difficulty,  not  so  great  as  the  preceding  one, 
but  still  formidable,  viz.  that  medico-psychology  is  not  in  so 
forward  a  state  as  to  furnish  a  foundation  for  the  construction 

1  The  Medic  alJurisprudence  of  Insanity.  By  J.  H.  Balfoub  Bkownb,  Esq., 
of  the  Middle  Temple,  Barrister-at-Law.     London,  1871. 


33.2  Reviews.  [April, 

of  a  scientific  or  rational  code  of  legislation  for  the  insane.  In 
fact,  a  complete  science  of  Insanity  is  still  a  very  long  way  off, 
and  recent  advances,  though  great  in  comparison  to  former  pro- 
gress, are  very  small  when  measured  hy  the  length  of  road  still 
to  be  traversed.  But  this  difficulty  is  the  less  dangerous  of  the 
two;  for  when  we  compare  the  present  state  of  scientific  know- 
ledge with  tlie  excessive  haziness  in  which  the  followers  of  the 
law  seem  still  to  be,  we  have  no  unfit  companion  to  the  contrast 
between  the  perfect  science  of  the  future  and  the  imperfect  of 
the  present. 

In  the  third  place,  while  it  would  be  difficult  for  any  man  to 
write  a  work  on  the  '  Jurisprudence  of  Insanity,'  with  a  greater 
amount  of  ease  and  fluency  in  handling  legal  details  than 
Mr.  Browne  displays,  it  is  unmistakably  difficult  for  him  to 
understand  the  medical  aspects  of  cases.  If  it  be  true,  as  a 
modern  artist  has  said,  that  one  must  have  sympathy  with  a 
stone  in  order  to  draw  it,  much  more  is  it  true  that  the  physician 
must  have  sympathy  with  an  invalid's  case  in  order  to  under- 
stand and  treat  it.  Every  detail  must  be  patiently  acquired  and 
considered;  the  growth  and  constitution  of  the  person,  the 
whole  history  of  his  previous  health  and  disease,  must  be  present 
to  the  mind  of  him  who  would  influence  for  good  the  future 
course  of  the  patient.  And,  since  the  law  aspires  to  deal  with 
cases  of  lunacy  in  the  way  most  for  their  own  good  and  for  that  of 
the  community,  its  followers  ought  to  consider  the  work  of  the. 
physician  as  the  necessary  preliminary  to  their  own,  and  even 
condescend  sometimes  to  accept  his  leading.  Instead  of  this,  the 
practice  is  to  set  up  (especially  in  criminal  cases)  an  absolute  stan- 
dard of  responsibility  and  irresponsibility,  and  to  neglect  entirely 
the  fact  that  partial  responsibility  is  much  more  commonly  met 
with  in  asylum  wards  than  either  of  the  others.  The  physician's 
view  is  from  the  inductive  side ;  he  learns  all  he  can  about  his 
patient  before  prescribing  a  treatment.  The  lawyer's  is  from 
the  deductive  side ;  he  brings  forward  one  or  two  general  pro- 
positions, insufficiently  proved,  and  treats  the  lunatic  according 
to  that  which  seems  to  fit  him  best. 

Our  author  is  wise  in  not  often  treading  upon  the  field  which 
more  especially  belongs  to  the  medical  man.  When  he  does  so, 
want  of  regard  for  that  essential  quality  of  the  physician,  called 
tact,  is  apparent.  Thus,  under  the  heading  "  Examination  of 
the  supposed  Insane,"  we  come  on  the  following  : 

"  However,  let  us  suppose  those  obstacles  overcome  ;  the  medical 
man  is  in  the  presence  of  his  patient,  and  the  question  is,  how  should 
he  proceed  ? 

"  1.  He  ought  to  pay  considerable  attention  to  the  physiognomy 
of  the  individual  before  him." 


1872.]  The  Medical  Jurisprudence  of  Insanity .  333 

To  put  this  proceeding,  important  as  it  no  doubt  is,  first  in 
the  list,  is  of  questionable  propriety,  for  when  access  is  got  to 
the  patient,  it  would  be  extremely  injudicious  in  many  cases  to 
put  it  directly  into  practice.  In  fact,  it  is  often  true  that  the 
less  that  is  actually  done  towards  examination  in  the  first  five 
minutes  of  the  interview  the  better.  But  as  for  commencing 
with  a  scrutiny  of  the  physiognomy,  we  had  rather  Mr.  Browne 
than  ourselves  were  exposed  to  the  very  probable  consequences 
of  so  rash  an  act. 

We  repeat,  there  are  very  many  difficulties  in  performing 
a  task  such  as  the  present  writer  has  taken  on  himself,  and  it 
requires  a  ripe  knowledge  of  not  only  the  law  on  the  subject 
but  of  the  many  facts  also  which  scientific  observation  of  the 
insane  has  lately  accumulated  for  us,  and,  further,  of  the  spirit 
and  tendency  of  the  opinions  held  by  the  most  advanced  medical 
alienists  at  the  present  day,  to  enable  an  author  to  produce  a 
work  on  this  subject  which  shall  prove  thoroughly  satisfactory 
to  the  large  body  of  professional  men  interested. 

We  like  Mr.  Browne  best  in  his  expositions  of  the  law  of  the 
present  day,  and  in  his  lucid  histories  of  cases.  The  latter  are 
numerous,  and  serve  both  to  throw  light  upon  the  general  ten- 
dencies of  evidence,  and  to  illustrate  that  wonderful  uncertainty 
of  decision  which,  notwithstanding  the  bold  asseveration  of 
general  principles  by  many  ardent  a  priori  jurists,  still  reigns 
in  our  courts  of  law,  as  prominent  a  feature,  certainly,  as  the 
stupidity  in  medical  evidence,  of  which  these  gentlemen  make 
so  much. 

The  first  chapter  of  the  work  deals  with  "  Lunacy  and 
Limited  Responsibility."  We  may  say  of  it  what  holds  true  of 
other  parts  of  the  work,  that  without  perhaps  evolving  profound 
principles  on  the  subject,  it  gives  a  good  idea  of  what  is  the  pre- 
sent state  of  the  law.  The  artificial  lunatic  of  the  lawyer,  not  the 
madman  of  nature,  is,  however,  as  might  be  expected,  the  being 
dealt  with  throughout.  In  regard  to  criminal  cases  especially, 
the  illogical  alternative,  "  Either  a  man  must  have  all  his  mental 
powers  or  none  of  them,"  is  continually  appearing;  and  the 
solution  which  the  author  puts  forward  for  the  difficulties  that 
arise,  is  unreal.  Speaking  of  the  case  where  the  criminal  agent, 
from  want  of  understanding  or  from  mental  disease,  is  not  in  a 
position  to  choose  freely,  he  says — 

"  It  is  the  same  principle  that  induces  the  law  to  exempt  very 
young  children  from  the  criminal  respou«ibiHty  of  their  acts,  and  the 
same  principle  is  to  be  found  as  the  reason  for  the  non-infliction  of 
legal  penalties,  where  the  individual  is,  against  his  will,  compelled 
to  do  a  wrongful  act,  inasmuch  as  the  dread  of  distantly  future  penal- 
ties cannot  in  reason  be  expected  to  prevail  against  the  fear  of 
98— XLix.  22 


334  Reviews.  [April, 

present  suffering.  "Were  it  more  generally  understood — were  it 
more  thoroughly  appreciated — that  it  is  really  the  same  fundamental 
principle  which  induces  the  law  to  forego  its  penalties,  even  after 
proof  of  the  criminal  act  done  in  these  two  classes  of  cases,  less 
difficulty  would  undoubtedly  arise  in  practice,  as  to  what  amount 
and  what  kind  of  insanity  is  sufficient  to  establish  a  claim  to  immu- 
nity from  punishment.  Were  it  once  held  that  the  proof  of  that 
amount  of  insanity  would  relieve  from  the  consequences  of  a  crimi- 
nal act  which  deprives  the  individual,  either  by  amentia,  dementia, 
or  mania,  of  that  amount  of  free  will  or  choice — of  that  power  to 
balance  and  appreciate  motives  which  is  found  in  the  ordinary  ranks 
of  mankind — were  it  held  that  the  amount  of  insanity  which  deprives 
a  man  of  this,  as  the  amount  of  duress  which  deprives  a  sane  man  of 
of  the  same  power,  would  relieve  an  individual  of  criminal  respon- 
sibility, no  doubt  would,  it  seems,  in  any  case  arise." 

This  does  not,  we  fear,  go  quite  far  enough.  For  who  can 
always  say,  from  an  insane  man's  actions  to  what  extent  his 
insanity  is  compelling  him  to  them  ?  True,  in  some  cases,  as  in 
acute  mania,  any  one  can  answer  the  question,  and  it  is  just  in 
such  a  case  that  there  is  never  any  difficulty.  But  when  a 
chronic  maniac,  or  a  person  morally  insane,  is  before  the  court, 
who  can  any  more  declare  that  an  act  in  dispute  was  connected 
or  not  with  the  disease  of  the  mind,  than  he  can  assert  that  the 
attitudes  and  gesticulations  of  the  barrister,  as  he  arrives  at  the 
grand  concluding  stage  of  his  peroration,  are  conscious  or 
ideomotor  ?  "  The  power  to  balance  and  appreciate  motives  " 
is  one  which  is  possessed  by  sane  men,  from  the  philosopher  to 
the  criminal, in  the  most  various  degrees;  the  "higher  motives" 
themselves  vary  immensely  in  individual  cases,  in  degree  and  in 
character;  and  it  is  utterly  wrong  to  take  other  men's  ideas 
of  what  their  state  of  mind  would  have  been  under  the  cir- 
cumstances, as  a  criterion  by  which  to  judge  whether  insanity 
was  compelling  the  mind  of  the  accused  person.  When  will 
jurists  learn  that  mental  disease  means  decay,  not  of  one  part, 
but  of  the  whole;  that  the  individual  delusion  or  impulse  is 
only  like  the  first  branch  that  withers  on  a  rotting  tree,  that 
it  is  in  reality  the  symptom  of  a  weakness  pervading  the 
entire  organism  ? 

The  second  chapter  deals  with  the  causes  of  insanity — a  sub- 
ject which  it  is  hardly  in  the  power  of  any  one  at  the  present 
stage  to  grasp,  and  concerning  which  Mr.  Browne  contents  him- 
self chiefly  with  attacking  some  circumstances  that  are  commonly 
enough  and,  perhaps,  unjustly  set  up,  such  as  that  civilisa- 
tion is  one  of  these  causes.  The  next  chapter  is  headed 
"Unsoundness  of  Mind;"  it  contains  two  classifications  of  the 
forms  of  insanity — Ray's,  and  one  of  the  attempted  physical 
classifications  ;  the  former  is  adopted  by  the  author.     The  first 


1872.]  The  Medical  Jurisprudence  of  Insanity,  335 

paragraph  of  this  chapter  would  be  worth  quoting  had  we 
space ;  it  gives,  within  small  compass,  a  very  clear  and  useful 
account  of  the  commoner  attributes  of  insanity,  those  by  which 
people  in  general  might  define  the  latter. 

Amentia  is  divided,  in  this  work,  according  to  Ray's  plan, 
into  idiocy  and  imbecility.  The  legal  relations  of  the  latter 
form  a  very  important  item  in  such  a  book,  and  we  are  glad 
to  find  them  well  discussed  here.  The  reasonable  nature  of 
the  following  remarks  on  the  famous  Wyndham  case  is 
apparent : 

"  The  test  of  imbecility  is  undoubtedly  conduct,  and  that  conduct 
which  has  become  fixed  and  permanent,  namely,  disposition  ;  and  the 
objection  raised  by  a  writer  in  the  *  Solicitors'  Journal,'  that  unless 
the  system  of  lunacy  inquiry  be  materially  changed,  every  com- 
mission may  amplify  itself  into  a  biographical  inquisition,  has  evi- 
dently been  made  in  entire  ignorance  of  the  subject.  The  only  rea- 
sonable method  of  coming  to  a  right  conclusion  in  any  case  of 
imbecility  is  from  a  careful  consideration  of  all  the  facts  of  conduct 
during  a  long  series  of  years." 

We  do  not  think  Mr.  Browne  so  happy  in  his  dissertation 
on  the  criminal  responsibility  of  imbeciles.  It  is  rather  dis- 
appointing to  be  referred  to  the  "  questions  which  arise  in 
regard  to  general  and  partial  moral  mania,"  for  further  elucida- 
tion of  this  subject,  because  one  cannot  acknowledge  that  the 
principles  which  should  guide  the  treatment  of  two  so  different 
classes  of  lunatics  ought  to  be  identical.  Mr.  Browne  gives  two 
notorious  cases,  viz.  that  of  Cuthbert  Rodham  Carr  and  that  of 
"  the  Alton  murderer  ;"  and  although  the  conclusion  that  he 
comes  to,  viz.  that  both  of  these  men  should  have  been  considered 
responsible,  seems  just,  we  should  be  far  from  allowing  a  parity 
of  reasoning  in  the  case  of  a  moral  maniac.  The  brain  of  the 
imbecile  is  like  a  house  not  wholly  fitted  up,  that  of  the  moral 
maniac  is  a  house  shaken  to  its  foundations. 

We  pass  over  the  "  Pathology  and  Symptoms  of  Mania,"  the 
former  of  which,  with  its  (alas  !)  wide  scope  for  fancy,  meets 
with  fair  enough  treatment  here,  and  also  the  chapter  on  "  In- 
tellectual Mania."  That  on  "  Moral  Mania  "  possesses  no  little 
interest,  since  lawyers  have,  in  times  past,  comported  themselves, 
in  regard  to  this  subject,  in  various  extraordinary  ways. 

The  present  writer,  after  stating  the  current  sense  of  the 
words  "  moral  mania,"  remarks  upon  the  error  of  those  who 
assume  the  absence  of  a  "  moral  sense"  in  cases  falling  under 
this  head.  Since  there  is  no  proof  of  the  existence  of  an  inde- 
pendent moral  sense,  such  a  faculty  ought  not  to  be  assumed, 
either  as  present  or  absent,  to  explain  facts.  He  next  defines 
his  idea  of  the  sort  of  moral  sense  that  is  really  wanting  in 


336  Reviews.  [April, 

moral  maniacs,  viz.  the  capacity  for  realising  punishment  as  the 
direct  unpleasant  consequence  of  a  bad  act,  and  he  sums  up  as 
follows : 

"  It  will,  therefore,  he  understood  that  repeated  convictions  on 
account  of  the  same  crime  would  naturally  lead  to  a  suspicion  of  an 
amount  of  incapacity  which  would  justify  the  law  in  exempting  an 
individual  from  criminal  consequences ;  and  while  such  an  amount 
of  incapacity  is  proved  in  reference  to  acts  occurring  in  the  life  of 
the  individual,  other  than  those  which  have  come  under  the  cogni- 
zance of  courts  of  law,  the  presumption  is  strengthened ;  and,  further, 
if  in  conjunction  with  these  circumstances  it  is  found  upon  inquiry 
and  examination  that  there  is  an  inherited  tendency  to  insanity,  or 
malformation  of  the  skull — if  the  history  of  the  case  is  such  as  to 
lead  a  physician  to  suppose  that  it  is  not  impossible  that  the  mind 
may  be  diseased — in  such  a  case  it  seems  to  us  that  the  law  would 
do  well  to  admit  the  existence  of  moral  mania,  and  exempt  the  indi- 
vidual from  the  legal  consequences  of  criminal  acts." 

How  the  writer  can  reconcile  these  sentences  with  his  "opinion 
that  only  on  very  rare  occasions  should  moral  insanity  stand 
between  the  individual  and  the  consequences  of  his  criminal 
acts,"  and  his  assertion  that  laws  enact  punishments,  "  not 
because  Government  wishes  to  punish  crime  that  has  been 
committed,  but  because  the  invariable  connection  between  an 
act  and  a  serious  disadvantage  to  the  actor  is  likely  to  lead  to 
the  discontinuance  of  the  act,"  we  do  not  care  to  inquire,  for 
the  admissions  of  the  paragraph  just  quoted  are  liberal  ones  for 
a  lawyer  to  make,  and  we  are  well  content  with  them.  Nor 
does  Mr.  Browne  neglect  a  fact  of  science  which  goes  far  to 
explain  many  cases  of  moral  insanity,  viz.  that  motive  and  con- 
sequent action,  by  habit  (or,  what  Mr.  Browne  only  partly  ex- 
presses by  that  characteristic  feature  of  insanity,  weakness  of 
the  inhibitory  or  controlling  power  of  the  mind),  get  separated 
from  mind  and  imprinted  on  the  bodily  machinery,  so  that  when 
the  sensations  that  used  to  be  motive  are  experienced,  the  act 
goes  on  without  the  mind  being  stirred ; 

"  For  use  can  almost  change  the  stamp  of  nature," 

to  borrow  a  quotation  used  by  the  author. 

The  succeeding  chapter  on  partial  moral  mania  is  one  of  the 
longest  in  the  book,  and  treats  of  the  following  six  varieties  of 
this  disease : — Kleptomania,  Erotomania,  Oinomania,  Pyro- 
mania,  Suicidal  and  Homicidal  mania.  Two  exceptions  have 
struck  us  to  the  otherwise  satisfactory  consideration  of  these 
subjects.  The  first  of  these  is  the  author's  reference  of  moral 
mania  to  a  bending  aside  of  the  whole  disposition  into  one 
channel.     This  explanation  savours  too  much  of  theory,  not  to 


1872.] 


Medical  Jurisprudence  of  Insanity.  337 


say  of  fancy.  The  other  is  that  he  frequently  affirms  the  falla- 
cious proposition  which  is  such  a  favorite  in  his  profession,  that 
a  person  mentally  unsound  in  one  particular  can  he  perfectly 
sound  in  every  other  respect.  Those  who  are  best  acquainted 
with  the  course  of  cerebral  disease  know  and  have  frequently 
asserted  that  a  general  derangement  precedes  the  advent  of  the 
particular  lesion,  and  leaves  behind  it  a  general  weakness. 

Following  on  this  are  a  number  of  chapters  treating  of  the 
legal  relations  of  the  varieties  of  mental  disease.  It  is  satisfactory 
to  read  the  clear  expositions  of  existing  law  given  by  Mr.  Browne 
in  these  chapters ;  though  the  reasons  he  adduces  in  defence  of 
them  are  not  always  so  pleasing.  That  upon  the  legal  relations 
of  epilepsy  is  especially  interesting,  and  shows  both  that  the  sub- 
ject is  beginning  to  attract  the  attention  of  jurists,  and  that  they 
are  ignorant,  to  no  small  extent,  of  the  work  which  has  already 
been  done  by  medical  men  in  this  field.  We  ought  also  to  add 
that  Drunkenness,  Somnambulism,  and  Aphasia,  are  treated 
at  considerable  length,  and  that  the  views  advanced  on  these 
subjects  are  novel  and  interesting.  The  work  concludes  with  a 
consideration  of  prognosis  in  insanity,  and  with  directions  for 
examination  of  the  insane. 

Much  as  we  should  desire  to  be  able  to  say  that  a  complete 
treatise  on  the  important  and  difficult  subject  of  the  Medical 
Jurisprudence  of  Insanity  had  been  added  to  professional  litera- 
ture, it  seems,  we  confess,  impossible  that  such  should  be  pre- 
dicated of  any  work  until  a  full  and  clear  statement  of  the  views 
of  medical  and  scientific  men,  both  as  regards  the  legal  aspect 
of  mental  diseases,  and  as  regards  the  treatment  which,  in  their 
opinion,  lunatics  ought  to  receive  at  the  hands  of  the  law,  has 
been  made.  We  do  indeed  strongly  recommend  medical  men 
to  pay  attention  to  these  utterances  of  a  lawyer,  but  this  is  in 
the  hope  that  the  like  attention  will  in  the  future  be  recipro- 
cated on  the  part  of  the  lawyers.  Did  these  latter  study  a  little 
more  the  true  nature  of  mental  diseases,  less  scope  would  be 
found  for  the  expression  of  such  supreme  contempt  of  medical 
opinions  which  is  too  often  heard  in  courts  of  law.  In  short, 
results  would  in  all  points  be  vastly  more  satisfactory  were  more 
consideration  shown  on  both  sides ;  and  every  one  will  hail  the 
day  when  some  author  does  full  justice  to  the  opinions  and 
feelings  of  both  the  lawyer  and  the  physician.  Mr.  Browne  has 
not  been  altogether  successful  in  accomplishing  this ;  neverthe- 
less, allowance  being  made  for  the  unfortunate  professional  bias 
displayed  in  it,  this  work  may  be  pronounced  both  readable  and 
worthy  of  being  read. 


338  Reviews.  [April, 


V. — On  Protoplasm.^ 

No  one  can,  we  think,  mistake  the  tendency  of  modern 
biology ;  whenever  it  is  possible,  and  sometimes  when  it  is  hardly 
possible  as  yet,  rule  and  measure  are  called  in  to  give  exactness 
of  expression  to  our  knowledge  of  the  subject,  and  exact  data 
are  formulated  in  terms  of  mathematical  precision.  Improved 
chemical  processes  are  gradually  enabling  us  to  resolve  those 
waste  heaps  or  dust  bins  labelled  '^  extractive  matters "  into 
their  components ;  and  many  phenomena  which,  not  under- 
standing, we  used  to  term  vital,  have  been  found  after  all  to  be 
readily  intelligible  on  the  ordinary  principles  of  chemistry  or 
physics.  So  many  things  heretofore  supposed  to  depend  directly 
on  the  vital  principle  have  been  thus  resolved  that  some  have 
gone  so  far  as  to  call  in  question  the  existence  of  any  force 
different  from  the  physical  forces  we  see  at  work  around  us. 
Undoubtedly  the  discovery  of  the  correlation  of  these  forces,  the 
fact  that  one  is  transmutable  into  another  without  diminution 
and  without  increase,  has  had  a  most  important  bearing  on 
physiological  doctrines.  If  in  the  physical  world  we  see  motion 
transformed  into  heat,  this  into  light  and  chemical  action, 
chemical  force  into  electricity  and  magnetism,  and  so  on,  we  are 
tempted  to  make  another  step  in  advance.  In  vegetable  life  we 
know  that  light  and  heat  are  the  forces  whereby  carbon  is  fixed 
and  oxygen  set  free,  whereby  ammonia  is  converted  into  com- 
plex organic  compounds,  and  an  infinite  variety  of  other  changes 
is  effected.  In  animals  it  has  been  found  that  digestion  is  a 
chemical  process,  absorption  to  a  great  extent  a  physical  one ; 
respiration  is  partly  physical,  partly  chemical ;  not  a  muscular 
movement  can  be  performed  without  the  consumption  of  fuel  in 
some  shape  or  other ;  in  short,  in  all  these  so  called  vital  acts 
the  physical  forces  are  equally  manifest  as  if  there  were  no  com- 
plex organic  medium  through  which  to  exert  their  influence. 
The  question  therefore  arises.  Suppose  we  take  the  simplest 

1  1.  The  Fortnightly  Review  (February  1*^,  1869).  "  On  the  Physical  Basis  of 
Life.    By  Professor  Huxley.     London, 

2.  Protoplasm  or  Life,  Force  and  Matter.  By  Lionel  S.  Beale,  M.B.,  F.R.S., 
Fellow  of  the  Royal  CoUege  of  Physicians,  Physician  to  King's  College  Hospital. 
Second  Edition.     London. 

3.  As  regards  Protoplasm  in  relation  to  Professor  Huxley's  Fssay  on  the 
Physical  Basis  of  Life.  By  James  Hutchison  Stieling,  F.R.C.S.,  LL.D. 
Edin.     Edinburgh. 

4.  Fssat,s  on  Physiological  Subjects.  By  Gilbert  W.  Child,  M.A.,  F.L.S.,  &c.. 
Lecturer  on  Botany  at  St.  George's  Hospital.     London. 

5.  The  Cell  Doctrine,  its  History  and  Present  State,  for  the  Use  of  Students  in 
Medicine  and  Dentistry.  By  James  Tyson,  M.D.,  Lecturer  on  Microscopy  in  the 
University  of  Pennsylvania,  &c.     Philadelphia. 


1872.]  On  Protoplasm.  339 

organism  known^  and  consider  well  its  functions,  is  there  any- 
thing in  these  not  explicable  by  physical  force;  shall  we  be 
forced  to  call  in  some  mysterious  entity  of  which  we  know 
nothing,  to  explain  the  terms  of  its  being?  If  we  let  fall  a  drop 
of  white  of  e^g  yet  unboiled,  into  water,  this  drop  retaining  its 
individuality  and  mixing  not  with  the  water,  represents  the 
simplest  organised,  or  rather  we  might  say  unorganised,  being. 
Haeckel  calls  it  monera,  but  herein  consists  the  difference : 
this  monera  having  no  other  structure  than  a  drop  of  albumen, 
can  move  from  place  to  place  of  its  own  accord,  can  change  its 
shape  in  a  thousand  ways,  can  take  in  and  make  part  and  parcel 
of  itself  other  and  larger  portions  of  albuminous  matter,  and 
can  reproduce  itself  by  throwing  off  a  portion  of  its  own 
substance,  and  all  this  it  does  by  virtue  of  something  we  call 
life. 

But  it  has  been  roundly  asserted  that  this  property  is  in- 
herent in  the  kind  of  matter  with  which  we  are  now  dealing ; 
where  it  exists  life  exists,  and  where  it  does  not  exist  no  life  is, 
insomuch  that  it  has  been  called  the  physical  basis  of  life  ;  let 
us  call  \t  protoplasm. 

The  questions  in  dispute  seem  to  formulate  themselves  thus  : — 
Does  the  existence  of  protoplasm,  using  the  word  in  a  strict 
sense,  imply  life ;  may  life  and  matter  co-exist  whilst  the  latter 
assumes  no  distinctive  form  ;  can  life  begin  de  novo  and  without 
the  agency  of  pre-existing  life? 

But  to  the  preliminary  inquiry  of  what  is  protoplasm  ?  using 
the  word  in  the  strict  sense,  we  obtain  no  adequate  reply. 
We  are  told  that  all  forms  of  it  contain  carbon,  hydrogen, 
nitrogen,  and  oxygen  in  certain  proportions,  but  what  these  are 
we  know  not.  Protoplasm,  in  a  strict  sense,  is  not  known  chemi- 
cally. If  we  seek  for  an  example  of  protoplasm,  we  are  referred 
to  the  well-known  experiment  with  frog^s  blood.  A  drop  is  drawn 
from  a  blood-vessel  of  the  animal  and  deposited  on  a  piece  of 
thin  glass ;  this  is  placed  under  the  microscope,  and  kept  at  a  tem- 
perature of  about  100°  F.,  when  by-and-by  the  white  corpuscles 
will  be  seen  to  approach  the  edge  of  the  blood  drop,  exhibiting 
distinct  movements  of  the  kind  called  amoeboid.  Similar  bodies 
are  found  in  connective  tissues,  some  wandering,  some  fixed, 
but  apparently  otherwise  identical.  To  these  we  are  referred  as 
samples  of  protoplasm,  but  we  are  ignorant  as  ever  of  its  chemical 
composition ;  indeed,  this  would  seem  to  be  far  from  simple  even 
in  leucocytes ;  in  fact  the  type  of  protoplasmic  bodies  would 
appear  to  have  at  all  times  during  life  a  certain  proportion  of  fat 
intimately  combined  with  its  albuminous  matter,  the  separation 
of  these  two  constituents  being  the  first  certain  sign  of  the  death 
of  the  body.     Professor  Huxley  tells  us  that  all  the  forms  of  pro- 


340  Reviews.  [April, 

toplasm  yet  examined  behave  similarly  towards  several  reagents  ; 
if  this  be  true  of  protoplasm,  it  is  certainly  not  true  of  the  type 
of  such  bodies,  albumen  itself;  for  this  sometimes  will  coagulate 
with  acid,  and  sometimes  will  not ;  sometimes  too  it  will  coagu- 
late with  heat,  and  sometimes  it  will  not. 

Syntonin,  globulin,  and  peptone  are  all  varieties  of  albumen  ; 
of  all  may  different  characters  be  predicated,  but  of  none  can  it 
be  said  that  it  is  the  matter  of  life  or  protoplasm.  Nay,  if  we 
fall  back  on  what  we  are  told  is  the  type  of  protoplasmic  struc- 
ture, a  white  blood-corpuscle  or  an  amoeba,  we  find  in  its  body 
certain  portions  apparently  constituted  differently  from  the  rest, 
inasmuch  as  by  a  reagent  such  as  acetic  acid  we  can  demonstrate 
the  existence  of  particles  called  nuclei,  which  behave  differently 
from  the  rest  of  the  structure.  The  same  is  the  case  if  the  body  be 
killed  by  an  electric  shock,  without  any  chemical  reaction.  It 
is,  however,  perfectly  true  that  in  monera  there  is  no  nucleus, 
which  shows  that  this  is  not  quite  essential  to  the  performance  of 
all  the  acts  of  life,  but  it  is  also  quite  true  that  in  those  bodies 
possessing  a  nucleus,  changes  in  it  generally  precede  changes  in 
the  mass  of  the  being  itself.  If  possible,  this  nucleus  shows  a 
more  vigorous  vitality ;  is  it  protoplasm  ?  If  so,  it  reacts 
differently  from  the  rest  of  the  mass. 

If,  therefore,  we  mean  by  protoplasm  merely  the  simplest 
form  of  living  matter,  that  is,  if  we  make  vitality  the  test  of  its 
existence,  we  can  understand  the  meaning  of  the  word.  But  it  is 
plain  that  protoplasm  is  not  a  simple  substance  in  all  instances 
chemically  identical ;  in  this  sense  it  is  a  varying  admixture  of 
more  than  one  body  of  albuminoid  constitution,  reacting  differ- 
ently with  different  reagents.  Its  presence  is  not  the  test  of 
life,  but  life  of  its  presence.  Professor  Huxley  himself  hints  at 
these  differences  of  properties  when  he  speaks  of  the  difficult 
digestibility  of  lobster  protoplasms  as  compared  with  that  of 
sheep ;  in  other  words,  these  two  do  not  behave  exactly  in  the 
same  way  towards  the  reagent  we  call  gastric  juice. 

There  is,  however,  one  sense  in  which  we  may  make  use  of 
the  word  protoplasm  with  advantage ;  to  illustrate  this  we  must 
fall  back  on  matters  of  history.  When  Schleiden  had  shown 
that  the  plant  was  built  up  of  a  series  of  elements,  as  a  house  is 
of  bricks,  he  investigated  the  structure  of  these  elements,  and 
found  that  in  every  instance  they  seemed  to  possess  a  cellular 
wall,  slimy  contents^  and  a  nucleus,  besides  other  things,  as 
starch,  chlorophyll,  and  such  like.  Schwann  adapted  these 
principles  to  the  human  body,  and  applied  the  term  cell,  in- 
troduced by  Schleiden^  to  designate  these  ultimate  vegetable 
elements,  to  designate  also  those  of  the  human  frame.  Further- 
more, a  similar  constitution  was  predicated  of  them ;  that  they 


1872.]  On  Protoplasm.  341 

consisted  of  cell  walls,  slimy  contents,  and  nucleus ;  in  short, 
that  they  were  in  every  way  analogous  to  the  vegetable  cells. 
But  in  1835  Dujardin,  then  concerned  in  his  inquiries  into  the 
Khizopoda,  discovered  that  they  consisted  of  a  substance  irritable 
and  contractile,  having  nothing  of  a  cellular  character ;  it  was 
called  sarcode.  Hesearches  went  on,  and  new  discoveries  were 
made,  especially  that  the  slimy  substance  of  many  animal  cells 
was  also  contractile,  until  at  last  Max  Schultze  was  able  to  show 
that  the  contents  of  animal  cells  were  analogous  to  sarcode,  and 
that  the  cell  walls  were  of  comparatively  little  consequence 
compared  with  their  contents.  In  the  days  when  this  universal 
character  was  predicated  of  all  animal  structures,  blood  cor- 
puscles, red  and  white,  were  a  standing  difficulty  ;  by  no  means 
could  the  red  globules  be  reduced  to  the  highest  or  nucleated 
cell  type,  and  by  many  they  were  held  to  be  free  nuclei.  White 
corpuscles  were  more  easily  managed,  for  by  means  of  reagents 
something  like  a  cell  wall  and  multiple  nuclei  could  be  made 
out.  But  when  these  last  named  bodies  had  been  better  studied, 
and  their  curious  movements,  exactly  resembling  those  of  a 
protist,  became  known,  their  analogy  to  a  mass  of  sarcode  was 
recognised,  and  it  was  admitted  that  a  wall  was  no  longer  to  be 
held  as  an  essential  portion  of  an  animal  cell.  This  new 
advance  may  be  said  to  have  been  made  simultaneously  by  Max 
Schultze  and  Lionel  Beale.  These  two  observers,  however, 
looked  at  the  matter  from  different  points  of  view.  Schultze 
considered  chiefly  the  irritability  of  the  cell  contents,  to  which 
he  gave  the  name  of  protoplasm,  whilst  Beale,  looking  rather  at 
one  definite  chemical  reaction,  considered  all  material  readily 
tinged  by  carmine  solution  as  germinal  matter,  and  that  not  so 
affected  as  dead  or  formed  material.  The  selection  of  these 
terms  seems  to  have  been  peculiarly  unfortunate ;  they  have 
never  been  generally  accepted,  nor,  perhaps,  even  understood, 
and  their  use,  in  a  fashion  to  many  unintelligible,  has  done  much 
to  deprive  Beale  of  that  reputation  most  justly  his  due,  and  to 
cause  to  be  assigned  to  German  discovery  that  which  had  long 
before  been  done  among  ourselves.  At  all  events,  the  results 
of  Schnitzels  investigations  entailed  the  rejection  of  the  cell  wall 
as  an  essential  portion  of  the  animal  cell,  which  he  considered 
to  be  made  up  of  a  particle  of  protoplasm  and  a  central  nucleus, 
sometimes  having  the  outer  portion  of  the  protoplasm  condensed 
so  as  to  constitute  a  kind  of  membranous  wall,  or  even  modified 
into  a  substance  not  protoplasm,  and  constituting  a  true  wall. 
''  But,"  said  he,  '^  in  fact,  a  cell  with  a  membrane  chemically 
diff'erent  from  protoplasm  is  comparable  to  an  encysted  infusory." 
Nor  did  matters  halt  here.  Briicke  went  further,  and  denied  the 
necessity  of  a  nucleus  in  the  ideal  animal  cell ;  he  based  his 


312  Reviews.  [Ap^'Jl^ 

objections  mainly  on  the  cells  of  certain  cryptogams  in  which  no 
nucleus  was  known.  "And,"  he  argued,  '^  as  there  is  nothing 
known  either  of  the  constant  presence  of  the  nucleus  or  of  its 
functions  when  present,  why  should  we  include  it  in  our  con- 
ception of  what  is  essential  to  a  living  portion  of  animal  matter, 
commonly  called  an  animal  cell?" 

This  notion  as  to  the  non-essential  character  of  the  nucleus 
was  speedily  confirmed  by  the  discovery  in  the  Adriatic  of  an 
amoeba  {A.  porrecta),  by  Max  Schultze,  devoid  of  nucleus  ;  this 
again  was  followed  by  the  discovery  in  the  Mediterranean  of 
Protogenes  primordialis,  a  larger  form,  also  non-nuclear,  by 
Haeckel.  Other  kindred  organisms  were  found  by  Cienkowsky, 
and,  finally,  Haeckel  found  in  the  Canary  Islands  that  struc- 
tureless protist  he  has  so  well  described  in  his  monograph  as 
Monera.  This  irritable  and  contractile  substance  then,  the  sar- 
code  of  Dujardin,  the  protoplasm  of  Max  Schultze,  the  germinal 
matter  or  bioplasm  of  Beale,  so  constituted  as  to  be  able  under 
appropriate  circumstances  to  maintain  an  independent  existence, 
yet  corresponding  with  the  active  material  inside  true  cells, 
may  be  spoken  of  and  considered  histologically  as  protoplasm. 
Chemically,  it  agrees  with  a  whole  group  of  protein  or  albuminoid 
bodies.  If,  therefore,  we  use  the  word  protoplasm  chemically 
as  synonymous  with  protein  or  albuminoid  substance,  it  is 
nothing  new,  and  we  are  certain  that  it  is  not,  in  the  meantime, 
capable  of  a  more  exact  definition  by  chemistry. 

Of  all  chemical  substances,  perhaps  protagon  most  closely 
approximates  to  what  is  called  protoplasm  in  character,  but 
neither  of  that,  even  although  it  tends  to  assume  shapes  re- 
sembling cells,  can  it  be  said  that  it  is  protoplasm. 

But  though  incapable  of  this  close  and  exact  definition,  the 
term  is  nevertheless  a  very  useful  one.  It  expresses  the  idea 
which  it  is  so  desirable  to  bring  out,  that  between  animal  and 
vegetable  matter  there  is  no  great  gulf  fixed.  It  is  known  that 
certain  forms  of  life  are  at  one  time  similar  to  vegetable,  and 
at  another  period  of  life  history  more  like  unto  animal  organ- 
isms; it  is  well  then  that  there  should  be  a  common  title  for 
the  substance,  which  may  thus  be  impressed  with  either  an 
animal  or  a  vegetable  character,  but  which  in  essentials  remains 
the  same. 

There  is  yet  another  way  in  which  the  term  is  valuable.  It  is 
plain  the  term  ^  cell '  as  applied  to  a  body  possessing  the  charac- 
ters of  a  leucocyte,  whether  wandering  or  fixed,  is  a  misnomer, 
and  yet  a  very  considerable  number  of  what  are  now  frequently 
called  elements  are  constructed  on  this  type.  For  these  it  is 
desirable  that  the  term  cell  should  be  abandoned,  and  though 
the  substitution  of  protoplasmic  mass  for  cell  may  be  the  sub- 


1872.]  On  Protoplasm.  343 

stitution  of  a  long  term  for  a  short  one^  it  has  the  merit  of  con- 
veying no  false  impression. 

As  already  pointed  out^,  the  characters  of  such  a  protoplasmic 
mass  as  monera  or  a  white  blood-corpuscle  are  irritability^  con- 
tractility implying  the  power  of  changing  shape  and  station, 
nutrition  and  reproduction. 

But  apart  from  these  characters,  protoplasm  may  be  active, 
resting,  or  dead. 

By  irritability  we  merely  imply  the  possibility  of  the  powers 
of  a  protoplasmic  mass  being  called  into  play  by  some  agent 
external  to  itself,  and  of  these  the  simplest  and  most  efficient  is 
heat.  If  we  take  a  portion  of  the  leaf  of  an  Anacharis  alsin- 
astrum,  now  so  common,  or  of  a  Vallisneria,  surround  it  with  a 
drop  of  water,  and  cover  it  lightly  with  a  thin  piece  of  glass,  we 
may,  if  the  temperature  be  rather  low,  see  nothing  save  the 
cellulose  compartments  dividing  the  cells  one  from  another,  and 
the  cell  contents  containing  abundance  of  chlorophyll  granules ; 
but  if  we  use  a  lamp  for  our  illuminating  agent,  its  rays  of  heat 
are  reflected  on  to  the  leaf  as  well  as  its  light-giving  rays,  so  that 
presently  we  see  active  motion  of  the  cell  contents,  as  indicated 
by  motion  of  the  chlorophyll  granules,  set  up  in  every  direction. 
Here  is  the  stimulus  of  heat  setting  up  motion  in  the  previously 
resting  protoplasm. 

This  is  still  better  exemplified  by  the  behaviour  of  the  leu- 
cocytes contained  in  the  circulating  blood  of  a  triton  or  sala- 
mander. The  experiment  is  easily  made  by  any  one  who  can 
command  the  means  of  warming  the  stage  of  a  microscope,  and 
for  this  no  elaborate  apparatus  is  needed.  Care  must  also  be  taken 
that  the  drop  of  blood  does  not  dry,  so  it  must  be  placed  in  a  cell  and 
surrounded  by  vapour.  When  withdrawn  from  the  veins  of  the 
animal,  the  white  corpuscles  are  seen  as  rounded,  well  defined 
masses,  presenting  a  marked  contrast  to  the  elliptical  corpuscles 
of  the  red  kind.  This  is  the  resting  condition  when  no  particular 
stimulus  is  acting  upon  them.  For  as  the  observer  watches  these 
rounded  bodies  change  their  shape,  they  probably  become 
elongated  and  more  transparent ;  presently  their  edges  become 
jagged,  and  a  series  of  active  changes  of  shape  ensue.  These 
changes  become  more  active  up  to  a  temperature,  a  few  degrees 
above  a  hundred,  but  if  this  limit  be  transgressed  their  motion 
ceases, and  in  no  wise  can  it  be  made  to  begin  again;  the  leucocyte 
is  dead.  But  apparently  intermediate  between  the  conditions 
of  active  life  and  motion,  and  irretrievable  death  there  is  the 
condition  of  rest,  whether  of  repose  or  tension  is  not  quite  clear. 
At  all  events,  this  can  be  done ;  leucocytes  of  the  blood  can, 
by  electric  stimuli,  be  made  to  gather  together  into  a  clump, 
which  after  a  time,  if  the  stimulus  has  not  been  too  strong. 


344  Reviews.  [April, 

gradually  resumes  the  mobile  condition.  But  with  the  protoplasm 
of  a  cartilage-corpuscle  this  is  not  possible ;  contraction  of  the 
protoplasmic  mass  on  its  nucleus  may  be  easily  brought  about,  but 
no  further  change  results;  it  is  dead.  Nevertheless,  we  have  no 
reason  to  believe  that  the  electric  stimulus  has  in  any  way 
altered  the  chemical  properties  of  the  substance ;  it  will  imbibe 
carmine  as  readily  as  ever.  Yet  though  the  protoplasm  is  there, 
life  has  departed.  The  existence  of  protoplasm  cannot  be  said, 
therefore,  to  predicate  even  the  potential  presence  of  life. 

Nay,  more,  protoplasm  as  studied  in  the  living  body  presents 
different  degrees  of  vitality.  The  connective-tissue  corpuscles, 
of  which  one  has  heard  so  much,  seem  to  be  of  two  kinds,  some 
fixed  like  the  corneal  corpuscles,  which  give  out  processes  in 
various  directions,  some  like  the  cartilage-corpuscles,  resembling 
in  outline  a  resting  leucocyte,  but  not  possessing,  as  pointed 
out  above,  the  same  degree  of  inherent  vitality.  Others  again 
are  found  in  various  tissues,  emigrants  from  the  blood  vessels, 
though  now  in  a  condition  of  rest,  whilst  the  most  active  members 
of  the  class  seem  to  be  the  leucocytes  of  blood  and  lymph. 

These,  as  we  have  seen,  readily  respond  to  stimuli ;  they  also 
grow,  as  we  infer  from  their  presence,  in  very  various  sizes  in 
the  interior  of  the  vessels,  and  they  are  capable  of  reproduction  by 
fission,  in  all  probability  within  the  vessels  and  glands,  certainly 
outside  them,  when  they  have  wandered  into  the  surrounding 
tissues.  It  is  very  strange  that  doubts  as  to  the  truth  of  the 
phenomena  we  have  referred  to  should  still  exist  in  the  minds 
of  many  when  they  are  so  readily  capable  of  proof.  The 
changes  in  the  corneal  corpuscles  of  the  frog  after  irritation  as 
by  nitrate  of  silver,  are  easily  studied,  especially  by  the  method 
of  staining  with  chloride  of  gold,  now  in  vogue.  The  migration 
of  white  blood-corpuscles  may  now  be  studied  by  any  one  who 
can  command  a  tolerable  microscope,  and  can  get  hold  of  a 
frog.  By  all  these  phenomena  we  are  impressed  with  the  truth 
of  that  view  which  teaches  that  it  is  the  living  matter  of  the 
so-called  cell  which  is  of  importance  ;  its  outward  configuration 
or  its  envelope  matters  little.  It  is  absolutely  necessary  to  have 
a  name  for  this  irritable  and  contractile  substance,  and  we  know 
of  none  better  than  protoplasm ;  but  protoplasm  may  be  alive  or 
it  may  be  dead ;  in  the  latter  state  it  is  neither  irritable  nor 
contractile. 

It  is  clear,  therefore,  that  the  presence  of  life  implies  no 
specific  form,  neither  does  the  existence  of  protoplasm  imply 
the  presence  of  life  (its  pre-existence  is  another  question).  The 
final  question  arises,  May  life  begin  de  novo  without  the  agency 
of  pre-existing  life?  To  this,  after  due  consideration,  we  are 
bound  to  reply,  No,  not  as  far  as  our  knowledge  goes.     It  would 


1873.]  On  Protoplasm,  345 

be  beside  the  purpose  to  argue  the  question  whether  dead  pro- 
toplasm can  come  to  life  again  under  the  influence  of  the  simple 
forces  heat,  light,  &c.,  because  until  we  can  manufacture  pro- 
toplasm it  is  not  possible  to  say  that  we  do  really  begin  de  novo. 
And  yet  this  is  the  only  form  of  the  question  which  admits  of 
argument.  We  know  of  no  chemical  means  whereby  the  simple 
elements  already  alluded  to  oxygen,  hydrogen,  nitrogen,  and 
carbon,  with  sulphur  and  phosphorus,  can  be  combined  so 
as  to  resemble  living  matter,  or  the  matter  of  living  beings. 
And  the  idea  that  living  beings  can  be  formed  from  matter 
which  does  not  contain  all,  or  at  all  events  four  of  these 
elements,  may  be  surely  put  on  one  side,  so  that  any  admixture 
of  compounds  of  these  not  containing  all  of  them  cannot  by  any 
possibility  be  converted  into  a  living  being.  The  argument  as  to 
whether  dead  protoplasm  can  come  to  life  again  is  a  vain  one 
until  both  parties  can  agree  upon  a  distinct  boundary  line 
between  life  and  death,  and  on  an  unfailing  test  for  matter  in 
either  state ;  an  agreement  which  we  need  hardly  say  does  not 
exist  at  the  present  day. 

To  our  minds  reasoning  from  analogy  has  always  seemed  a 
powerful  weapon  if  used  aright,  and  in  the  present  inquiry  it 
cannot  be  denied  that  the  analogy  is  entirely  on  one  side.  If 
we  trace  the  history  of  the  simplest  protoplasmic  masses,  they 
begin  as  exceedingly  small  oftshoots  from  a  parent  like  them- 
selves. As  we  see  them  in  the  animal  body,  they  are  surrounded 
by  food,  and  rapidly  grow.  Yea,  leucocytes  as  they  exist  in 
living  animals  can  be  fed  on  special  substances.  In  the  frog 
white  corpuscles  often  devour  portions  of  red  ones.  If  aniline 
blue  is  introduced  into  a  lymph  sac  the  leucocytes  ingest  the 
blue  particles,  which  may  be  seen  in  their  interior  as  chlorophyll 
is  seen  in  the  protoplasm  of  a  vegetable  cell.  The  same  occurs 
if  they  are  fed  with  carmine,  and  so  these  corpuscles  may  be 
traced  throughout  the  body.  In  inflammation  such  marked 
bodies  are  seen  rapidly  dividing  and  rapidly  growing.  Even  in 
the  living  body  we  have  every  reason  to  believe  that  the  doctrine 
omnis  cellula  e  cellula  is  true  when  cellula  means  a  mass  of 
protoplasm.  Outside  the  body  the  rule  is  the  same;  when 
animals  are  unicellular,  their  history  is  like  that  of  a  leucocyte 
inside  an  animal.  The  more  plentiful  their  food,  the  greater  the 
heat  within  the  limits  already  pointed  out,  the  more  do  they 
multiply  and  increase,  and  if  any  one  reflects  on  the  rapidity 
with  which  an  abscess  forms  within  the  organism  he  can 
readily  understand  that  a  similar  rapidity  may  be  observed 
outside  it.  But  this,  again,  is  to  be  borne  in  mind  that  a  high 
temperature  is  not  absolute,  but  relative,  as  in  the  well  known 
instance  of  the  ova  of  certain  fishes  [ex.  gr.  the  trout),  which 


346  Reviews.  [April, 

proliferate  rapidly  at  a  temperature  which  would  kill  many 
forms  of  animal  life,  and  which  would  themselves  be  destroyed 
by  a  greater  heat.  Omne  vivum  e  vivo  is,  as  far  as  we  know, 
the  rule.  That  there  seem  to  be  exceptions  every  one  admits ; 
that  these  exceptions  are  real  and  not  apparent  only  is  another 
thing. 

In  dealing  with  the  history  of  protoplasmic  masses  we  found 
that  though  it  was  easy  to  tell  the  active  from  the  resting  form 
of  a  leucocyte,  it  was  by  no  means  easy  to  tell  the  resting  form 
from  the  dead  condition  save  by  the  separation  of  fat  and  gra- 
dually advancing  decay.  Experience  with  regard  to  infusories 
teaches  that  in  them  the  distinction  is,  if  possible,  harder,  and 
by  the  distribution  of  such  protoplasmic  masses  in  a  resting  state 
doubtless  many  of  the  instances  of  so-called  heterogeny  may 
be  explained.  With  experiments  like  those  of  Pasteur,  on 
the  one  hand,  and  those  of  Pouchet,  Bastian,  and  others, 
on  the  other,  a  hasty  judgment  would  be  the  acme  of 
rashness.  Nevertheless,  the  one  view  has  the  analogy  of  all 
animated  life  to  support  it,  the  other  merely  the  care  of  the  ex- 
perimenters or  their  reputation  for  care  ;  and  on  them,  too,  lies 
the  onus  probandi.  We  can  only  hope  that  in  due  time  their 
care  will  be  rewarded,  and  truth,  the  object  of  them  all,  attained. 

Finally,  the  active  and  the  resting  conditions  of  protoplasm 
are,  to  the  medical  world,  of  the  very  utmost  importance.  The 
two  conditions  explain  much  with  regard  to  the  spread  of  epi- 
demic and  contagious  disease,  without  calling  in  the  aid  of  any 
mysterious  bodies,  germs  or  otherwise.  They  encourage  the  use 
of  antiseptics  or  bodies  capable  of  unmistakably  killing  proto- 
plasmic particles,  be  they  what  they  may.  And  as  the  size  of  a 
particle  of  protoplasm  which  may  rest  for  a  time,  and  again, 
with  favourable  conditions  resume  activity  is  unknown,  but  is 
in  all  probability  infinitely  small,  they  suggest  the  utmost  care 
in  the  destruction  of  these. 


VI. — Holmes's  System  of  Surgery.^ 

The  success  of  a  great  work  like  that  before  us  must  be  con- 
sidered undoubted  when  a  second  edition  is  required  within  ten 
years  of  the  publication  of  the  first  volume  of  the  original  issue. 
Mr.  Holmes  is  an  indefatigable  writer  and  editor,  and  manages 

^  A  System  of  Surgery,  Theoretical  and  Practical,  in  Treatises  hy  various 
OAitTiors.  Edited  by  T.  Holmes,  M.A.  Cantab.,  Surgeon  and  Lecturer  on  Surgery 
at  St.  George's  Hospital.  Second  edition  in  five  volumes,  with  illustrations. 
London,  1869,  1870,  and  1871. 


1872.]  HoLMEs^s  System  of  Surgery.  317 

to  keep  liis  team  of  authors  in  hand  as  regards  punctuality,  in 
a  manner  which  must  make  the  publishers  and  subscribers  of 
other  compound  works  which  wearily  drag  their  slow  length 
along,  ready  to  gnash  their  teeth  in  despairing  envy.  We  could 
have  wished,  however,  that  Mr.  Holmes  had  exercised  a  little 
more  autocratic  power  over  some  of  his  authors  in  preparing  a 
second  edition,  so  as  to  have  led  to  a  more  uniform  perfectness 
of  work.  For,  high  as  is  the  standard  of  excellence  of  the  work 
as  a  whole,  some  of  the  essays  fall  very  short  of  perfection,  and, 
curiously,  those  which  in  the  first  edition  were  most  behind- 
hand, occupy  the  same  position  in  the  second,  their  authors 
being  apparently  incapable  of  effecting  any  improvement  in  their 
respective  productions.  Under  these  melancholy  circumstances 
it  must  become  a  question  whether  the  subjects  should  not, 
when  another  edition  is  called  for,  be  placed  in  other  hands. 

The  expansion  of  the  '  System'  into  five  volumes  allows  of  a 
somewhat  clearer  type,  and  the  introduction  of  a  considerable 
number  of  woodcuts.  The  first  volume  also  contains  some 
chromo-lithographs,  of  no  great  merit,  to  elucidate  the  subject 
of  syphilis;  and  a  series  of  beautiful  lithographic  plates  from 
drawings  by  Mr.  Henry  Arnott,  illustrating  the  microscopic 
structure  of  tumours,  which,  together  with  the  descriptive 
letter-press,  form  a  most  valuable  addition  to  the  essays  on 
"  Tumours^^  and  "  Cancer.^' 

We  propose  now  to  pass  the  several  essays  briefly  in  review, 
with  the  object  of  indicating,  so  far  as  may  be,  the  differences  in 
the  new  edition  as  compared  with  its  predecessor. 

Mr.  Simon^s  essay  on  "  Inflammation^^  is  practically  unal- 
tered, save  by  the  omission  of  the  description  of  the  process  of 
inflammation,  and  of  the  pathological  summary  of  the  first 
edition.  These  are  supplied,  together  with  the  most  recent  re- 
searches bearing  on  the  subject  of  inflammation,  by  the  article 
in  the  fifth  volume,  "  On  the  Process  of  Inflammation,^'  by  Dr. 
Burdon-Sanderson.  This  most  valuable  summary  of  modern 
research  gives  the  effects  of  injurious  irritation  of  the  tissues 
under  the  following  headings  :  (1)  disorder  of  the  circulation; 
(2)  transudation  of  the  constituents  of  the  blood ;  and  (3) 
altered  mode  of  growth  of  the  elements  of  the  inflamed  texture. 
Under  the  first  heading  Dr.  Sanderson  shows  that  the  eff'ect  of 
irritation  of  a  vascular  membrane  is  immediate  and  continuous 
dilatation  and  lengthening  of  the  vessels,  without  that  antece- 
dent stage  of  contraction  formerly  described.  The  rate  of  cir- 
culation of  the  blood  is  at  the  same  time  increased  temporarily, 
but  this  soon  subsides ;  and  by  the  time  the  arteries  are  fully 
dilated  the  circulation  is  much  slower  than  it  was  originally. 
The  results  of  investigations  on  the  vaso-motor  function  of  the 


348  Reviews.^  [April, 

cerebro-spinal  system  show  that  section  of  a  vascular  nerve  pro- 
duces congestion  of  all  the  tissues  to  which  it  is  distributed ; 
that  excitation  of  a  nerve  produces  constriction  of  the  vessels, 
and  consequent  anaemia  of  the  part  it  supplies ;  that  excitation 
of  a  sensory  nerve  produces  increased  activity  of  the  capillary 
circulation  in  the  part  in  which  the  nerve  originates ;  and  that 
all  arteries  manifest  alternating  states  of  contraction  and  dila- 
tation, independently  of  the  heart  and  lungs,  but  controlled  by 
the  nervous  supply.  In  the  second  part  the  exudation  of 
liquor  sanguinis  'and  the  migration  of  leucocytes  through  the 
capillary  walls  are  fully  described  and  investigated.  Justice  is 
done  to  the  researches  of  Williams,  Addison,  and  especially  of 
Waller,  who  so  long  ago  as  1846  placed  on  record  most  of  the 
facts  to  which  attention  has  been  recently  drawn  by  Cohnheim 
and  others.  Without  giving  all  the  details  of  the  experiments, 
it  will  be  sufficient  to  note  here  that  it  is  now  generally  con- 
ceded that  the  white  blood- corpuscles  find  their  way  through 
the  walls  of  the  capillaries,  and  are  identical  with  pus-cells, 
though  it  is  by  no  means  proved  that  the  cells  of  the  tissues 
do  not,  in  addition,  form  pus-cells  in  the  later  stages  of 
inflammation. 

Under  the  head  of  "  Stasis^^  it  is  shown  that  the  accumula- 
tion of  blood-corpuscles,  so  familiar  to  all  observers,  is  not  due 
to  alterations  in  the  blood  itself,  but  in  the  walls  of  the  vessels, 
or  in  the  surrounding  tissues  ;  and  it  has  further  been  shown 
that,  contrary  to  received  notions,  the  walls  of  capillaries  during 
inflammation  undergo  a  process  of  fatty  degeneration  tending, 
doubtless,  to  permit  the  passage  of  corpuscles  through  their 
walls. 

Dr.  Sanderson  next  considers  the  changes  which  take  place 
in  the  tissues  in  inflammation,  premising  that  he  believes  the 
multiplication  of  cells,  &c.,  to  be  due  solely  to  the  soaking  with 
liquor  sanguinis,  and  in  no  respect  dependent  upon  the  in- 
fluence attributed  by  some  pathologists  to  "  an  unknown  ner- 
vous centre,  supposed  to  preside  over  nutrition.''^  The  results 
of  inflammation  upon  non-vascular  structures,  such  as  cornea, 
cartilage,  and  tendon,  and  of  vascular  structures,  such  as  con- 
nective tissue  and  muscle,  are  then  given  in  detail,  together 
with  the  structural  changes  which  occur  in  the  epithelial  and 
glandular  tissues  in  inflammation.  In  part  3  the  influence 
exercised  by  the  form  and  mode  of  action  of  the  injurious  agent 
on  the  character  of  the  resulting  textural  changes  is  discussed, 
and  the  relation  between  inflammation  and  the  reparative  pro- 
cess is  described.  Suppuration  is  shown  to  depend  upon  the 
tendency  of  leucocytes  after  escaping  from  the  vessels  to  collect 
together  in  groups,  so  as  to  form  foci  of  suppuration ;  but  Dr. 


1872.]  HoLMEs^s  System  of  Surgery.  349 

Sanderson  confesses  himself  unable  to  explain  why  one  inflam- 
mation should  be  suppurative  and  another  not  so.  An  interest- 
ing and  ingenious  experiment  of  Strieker's^  on  the  cornese  of 
frogs_,  is  given  in  detail,  in  order  to  show  that  the  structural 
changes  occurring  in  inflammation  of  that  tissue  cannot  be  de- 
pendent on  any  influence  exercised  by  the  nervous  system,  or 
by  transmission  of  the  irritative  effect  from  one  structural 
element  to  another. 

We  have  thus  epitomised  the  leading  points  in  Dr.  Burdon- 
Sanderson^s  most  valuable  and  interesting  article,  and  we  pro- 
ceed to  give  his  conclusions  in  full,  since  they  cannot  fail  to  be 
of  service  to  all  engaged  in  pathological  research ;  they  are  as 
follows : 

"  1.  In  every  inflammation  which  attains  its  ftill  development  the 
changes  which  manifest  themselves  in  the  inflamed  part  are  of  three 
kinds,  distinguished  from  each  other  according  to  the  organs  which 
are  concerned  in  their  production.  They  are  either  (1)  effects  of 
disorder  of  the  vascular  nerves  and  centre,  (2)  effects  of  alteration 
of  the  properties  of  the  living  walls  of  the  capillaries,  or  (3)  effects 
of  the  stimulation  of  the  living  cells  by  transudation  of  liquor 
sanguinis. 

"2.  Of  these  three  orders  of  phenomena  the  second  only  can  be 
regarded  as  absolutely  essential  to  the  existence  of  inflammation, 
which  may,  therefore,  in  the  strictest  sense,  be  said  to  have  its  seat 
in  and  about  the  veins  and  capillaries,  it  being  there  that  the 
earliest  and  most  constant  effects  of  irritation  or  injury  manifest 
themselves. 

"  3.  The  nervous  and  vascular  effects  of  local  irritation  cannot  be 
directly  described  as  successive  stages  of  one  process,  for  the  deter- 
mination of  blood  to  the  seat  of  injury,  which  is  the  sole  result  and, 
if  I  may  so  speak,  purpose  of  the  vaso-motor  disturbance,  has  no  re- 
lation to  the  local  vascular  changes,  excepting  in  so  far  as  it  tends  to 
make  the  exudation  more  abundant.  Exudation  of  liquor  sanguinis, 
although  favoured  by  increased  arterial  afilux,  may  occur  without  it, 
and,  as  a  rule,  continues  after  the  afilux  has  ceased.  The  vascular 
and  textural  changes,  on  the  contrary,  may  be  regarded  as  successive 
stages  of  one  process,  for  they  are  connected  by  a  casual  relation — 
the  exudation  of  liquor  sanguinis,  in  which  the  former  ends,  being 
the  determining  cause  of  the  latter. 

"  4.  The  mode  in  which  an  injury  changes  the  living  substance  of 
the  vascular  walls  so  as  to  make  them  permeable  to  the  blood  is 
unknown,  the  only  clue  which  we  have  to  its  character  being  that 
afforded  by  the  structural  alterations  to  which  it  leads  in  certain 
organs,  and  particularly  by  those  which  are  observed  when  the 
process  of  reparation,  attended  with  the  formation  of  new  capillaries, 
is  commencing.  From  these  appearances  we  are  led  to  infer  that 
the  primary  change  consists  in  the  transition  of  the  material  from 
the  formed  to  the  plastic  condition ;  from  a  state  in  which  it  ia 

98— XLix.  23 


350  Reviews.  [April, 

resistant,  because  inactive,  to  one  in  whicli  it  is  more  living,  and, 
therefore,  more  liable. 

"  In  all  living  tissues  the  effect  of  inflammation  manifests  itself  in 
a  modification  of  the  action  and  properties  of  individual  cells.  In 
cells  which  form  part  of  permanent  structures  the  protoplasm  in- 
creases in  quantity,  and  becomes  more  or  less  contractile.  Subse- 
quently it  is  converted  entirely  or  partly  into  young  cells,  either  by 
cleavage  or  by  endogenous  germination." 

Keturning  to  the  essays  in  the  first  volume,,  we  come  to  that 
on  "  Abscess,"  by  Mr.  Holmes  Coote ;  and  as  that  gentleman 
apparently  favours  Virchow^s  views  as  to  the  development  of 
pus  from  the  connective  tissue,  and  only  casually  alludes  to  the 
transudation  of  blood-corpuscles,  it  is  but  fair  to  remind  our 
readers  that  the  article  was  in  type  some  two  years  before  Dr. 
Sanderson's  article,  to  which  we  have  just  been  referring.  The 
author  refers  very  briefly  to  the  proposals  to  limit  suppurative 
inflammation  by  ligature  of  the  main  artery,  as  practised  in 
America,  and  by  Mr.  Maunder  in  this  country,  or  by  digital 
compression,  as  suggested  by  Vanzetti  and  Nelaton — a  method 
which  appears  to  have  been  scarcely  tried  in  this  country.  No 
opinion  on  either  subject  is,  however,  expressed.  The  same 
thing  may  be  said  respecting  the  antiseptic  treatment  of  ab- 
scesses by  Lister,  which  is  shortly  described.  The  same  author's 
article  on  "  Gangrene''  includes  now  the  subject  of  phagedsena, 
which  is  regarded  as  "  an  insensible  transition  from  ulceration 
to  mortification."  Mr.  Coote  believes  phagedsena  to  depend  upon 
a  state  of  septicaemia,  and  that  it  is  not  contagious,  in  which, 
probably,  many  surgeons  will  not  agree  with  him.  The  articles 
by  Sir  James  Paget  on  "  Sinus"  and  on  "  Ulcers ;"  by  Mr.  De 
Morgan  on  "  Erysipelas,"  and  by  Mr.  Callender  on  "  Pyaemia," 
have  undergone  little  if  any  alteration  requiring  notice.  Mr. 
Croft's  article  on  "  Hectic  and  Traumatic  Fever,  and  on  the 
Treatment  of  Cases  after  Operation,"  is  properly  enough  brought 
out  of  the  appendix,  and  placed  after  that  on  pysemia,  and  is  fol- 
lowed by  Mr.  Poland  on  "  Tetanus,"  Dr.  Barclay  on  ''  Delirium 
Tremens,"  and  Mr.  Savory  on  "  Scrofula"  and  "  Hysteria." 
We  observe  that  Mr.  Croft  has  added  some  typical  thermo- 
graphic sheets  ;  that  Mr.  Poland  discusses  the  diagnosis  between 
tetanus  and  strychnia-poisoning,  particularly  in  relation  to 
Cook's  case,  and  gives  a  lithographic  plate,  showing  the  micro- 
scopic appearances  found  in  a  tetanic  spinal  cord;  and  that  Mr. 
Savory  summarises  the  experiments  on  inoculation  of  tubercle, 
and  finds  that  they  ^'  afford  no  support  to  the  doctrine  that 
tubercle  is  a  specific  disease." 

Mr.    Henry    Lee    has    entirely    rewritten    his    article    on 
"  Syphilis/'  w^hich  is  now  one  of  the  best  compendiums  of  in- 


I 


1872.]  Holmes's  System  of  Surgery,  351 

formation  on  this  important  subject  we  are  acquainted  with. 
He  broadly  draws  the  distinction  between  the  suppurating  non- 
infecting  sore  and  the  true  infecting  chancre,  of  which  he  de- 
scribes three  modifications^  and  remarks  that  two  of  these,  the 
peeling  off  of  the  cuticle,  and  the  formation  of  an  indurated 
tubercle,  are  often  not  recognised  as  sources  of  syphilitic  infec- 
tion. The  question  of  auto-inoculability  is  very  clearly  put,  and 
it  is  shown,  in  direct  opposition  to  the  teaching  of  a  few  years 
back,  that  the  infecting  sore  is  not  auto-inoculable,  while  the 
non-infecting  sore  usually  is  so.  Cauterization  or  excision  of  a 
true  chancre  are  found  by  Mr.  Lee  to  be  perfectly  useless,  and 
he  pins  his  faith  on  mercury  as  the  only  real  antidote  to  syphi- 
lis. The  effect  of  previous  disease  on  syphilitic  inoculation  is 
shown  by  Mr.  Lee  to  be  very  marked. 

We  are  glad  to  find  a  chapter  devoted  to  the  transmission  of 
secondary  syphilis,  since  many  members  of  the  profession  still 
doubt  its  possibility.  The  evidence  Mr.  Lee  quotes  from  his 
own  observations,  and  from  those  of  Dr.  Marston,  shows  con- 
clusively that  secondary  syphilis  can  be  transmitted  and  produce 
constitutional  infection.  Mr.  Lee  quotes  a  remarkable  case  of 
a  woman  who  nursed  a  syphilitic  child  with  one  breast  (which 
became  infected),  and  her  own  healthy  child  with  the  opposite 
breast.  The  mother  developed  a  secondary  eruption,  but  her 
child  remained  healthy,  and  he  regards  this  as  conclusive  that 
the  secretions  of  a  diseased  body  do  not  convey  infection.  This 
is  a  somewhat  dangerous  conclusion,  it  appears  to  us,  and  one 
which  we  cannot  regard  as  proven  when  we  find  well-authenti- 
cated cases  of  transmission  of  syphilis  to  a  hand  cut  against  the 
tooth  of  a  syphilitic  patient. 

In  the  treatment  of  syphilis,  in  its  primary  and  secondary 
forms,  Mr.  Lee  is,  as  we  have  said,  a  firm  upholder  of  mercury, 
and  he  relies  particularly  on  the  mercurial  bath  as  the  safest 
and  readiest  means  of  administering  the  drug.  He  also  recom- 
mends local  mercurial  fumigations  to  parts  affected  with  primary 
sores. 

Sir  James  Paget^s  article  on  "  Tumours^'  has  been  edited  by 
the  late  Mr.  Charles  Moore,  whose  article  on  "  Cancer"  follows. 
Mr.  Moore  has  written  an  introduction  to  the  entire  subject, 
in  which  he  supports  the  primary  local  character  of  cancers, 
and  shows  that  the  distinction  between  them  and  simple 
growths  is  less  and  less  marked  the  more  the  subject  is 
investigated.  He  has  added  to  Sir  J.  Paget's  article  short 
descriptions  of  the  tumours  described  by  Virchow  as  myxoma 
or  mucous  tumour,  psammoma  or  tumour  containing  sand, 
and  glioma,  the  fibro-cellular  tumour  found  in  connection 
with  the  retina.     Mr.  Moore's  article  on  ^'  Cancer"  contains 


353  Reviews.  [April, 

the  result  of  his  enlarged  experience,   but  does  not   require 
especial  notice. 

Following  appropriately  on  these  articles  are  twenty-four 
most  beautiful  microscopic  drawings  of  the  structure  of  tumours 
and  cancer  by  Mr.  Henry  Arnott.  A  short  but  clear  descrip- 
tion accompanies  each  drawing,  and  the  series  form  a  most 
valuable  addition  to  the  work,  and  will  be  of  great  service  to 
microscopists  as  standards  of  comparison. 

The  articles  on  "  Contusions"  and  "Wounds"  by  Sir  J.  Paget, 
on  "Animal  Poisons"  by  Mr.  Poland,  on  "  Wounds  of  Vessels" 
by  Mr.  Moore,  and  on  "  Collapse"  by  Mr.  Savory,  conclude  the 
first  volume. 

Local  injuries  are  brought  together  in  the  second  volume, 
and  comprise  the  essays  on  "  Burns  and  Scalds,"  by  Mr. 
Holmes ;  the  "  General  Pathology  of  Fractures,"  by  Mr. 
Hornidge ;  the  "  General  Pathology  of  Dislocations,"  by  Mr. 
Holmes ;  "  Gunshot  Wounds,"  by  Mr.  Longmore,  in  which 
the  qualities,  kinds,  and  forms  of  projectiles  receive  especial 
notice  on  the  present  occasion ;  and  "  Injuries  of  the  Head," 
by  Mr.  Prescott  Hewett,  in  which  depression  of  the  brain  fol- 
lowing contusion,  and  inflammation  after  contusion,  are  dis- 
cussed for  the  first  time. 

Mr.  Shaw's  essay  on  "Injuries  of  the  Back"  has  been 
considerably  expanded  by  a  lengthened  reference  to  sprains 
of  the  back — a  subject  of  increasing  interest  in  connection 
with  railway  injuries.  Mr.  Shaw's  experience  of  severe  sprains 
of  the  back  is,  that  they  do  well  if  there  are  no  symptoms  of 
paralysis  immediately  produced.  Paralysis  may  be  due  wholly 
to  extravasation  of  blood  within  the  theca  vertebralis ;  and  in 
these  cases  the  patient  often  slowly  recovers.  Inflammation  of 
the  joints  of  the  spine  may  result  from  sprain,  and  so  also 
suppuration  in  the  spinal  canal,  with  consequent  paralysis ;  of 
which  latter  aff*ection  two  interesting  cases  are  quoted  from 
Sir  Charles  Bell  and  Mr.  Simon.  Concussion  of  the  spinal 
cord  is  discussed  at  length  by  Mr.  Shaw,  who  does  not, 
however,  approve  of  the  term,  and  believes  that,  as  has 
been  shown  by  Mr.  Hewett  in  the  analogous  case  of  concus- 
sion of  the  brain,  there  are  frequently  actual  pathological 
changes  which  account  for  the  symptoms  put  down  to  mere 
concussion. 

The  progressive  paraplegia  due  to  chronic  degeneration  of  the 
cord  resulting  from  injury  of  the  spine  is  illustrated  by  refer- 
ence to  one  of  the  few  recorded  post-mortem  examinations,  which 
has  already  been  related  by  Mr.  Erichsen  and  by  Mr.  Le  Gros 
Clark.  Mr.  Shaw  draws  attention  to  the  disproportion  between 
the  slight  injury  sustained  and  the  magnitude  of  the  results,  and 


1872.]  Holmes's  System  of  Surgery.  353 

asks.  Was  the  shock  in  the  railway  accident  a  cause  or  merely 
a  coincidence  ? 

The  late  Mr.  Henry  Gray's  article  on  '^Injuries  of  the  Neck'' 
has  been  entrusted  to  Mr.  A.  Durham,  who  has  considerably 
added  to  and  improved  it.  The  portion  relating  to  foreign 
bodies  in  the  air-passages  and  tracheotomy  is  now  especially 
full  and  good,  and  is  illustrated  by  several  drawings  of  instru- 
ments. The  operation  of  tracheotomy  is  well  described,  and 
though  recommending  the  fixation  of  the  trachea  with  a  hook 
before  opening  it  in  most  cases,  Mr.  Durham  describes  also  and 
speaks  well  of  the  practice  of  fixing  the  trachea  with  the  finger 
and  thumb,  and  cutting  rapidly  upon  it  in  cases  of  urgency. 
Mr.  Marsh  and  Mr.  Holmes  are  quoted  to  show  that  the  calibre 
of  the  cricoid  cartilage  is  considerably  less  than  that  of  the 
trachea,  and  that  this  again  is  smaller  than  that  of  the  fully 
expanded  glottis;  and  it  is  concluded,  therefore,  that  moderate- 
sized  tracheotomy  tubes  are  sufficient  for  all  respiratory  pur- 
poses. With  the  view  of  readily  adapting  a  tube  to  the  depth 
of  the  neck,  and  also  of  obviating  ulceration  of  the  trachea  from 
pressure-,  Mr.  Durham  has  devised  an  ingenious  modification  of 
the  ordinary  tube,  the  only  drawback  to  which  is  its  price. 
The  question  of  gastrotomy  is  discussed  in  connection  with 
injuries  of  the  oesophagus,  and  two  tables  are  given,  one  of  nine 
cases,  in  which  the  stomach  was  opened  on  account  of  stricture 
of  the  oesophagus,  all  of  which  were  fatal,  the  latest  on  the  thir- 
teenth day ;  the  other  of  seven  cases  of  the  operation  for  removal 
of  foreign  bodies,  all  of  which  recovered  ! 

Mr.  Poland  has  added  to  his  article  on  ^^Injuries  of  the  Chest" 
a  description  of  the  dislocations  of  the  ribs,  and  elaborate  tables 
of  recorded  examples  of  these  injuries.  The  subject  of  wounds 
of  the  heart  has  also  received  more  attention  than  in  the  former 
edition,  and  a  table  of  452  cases  of  the  kind  is  appended.  Mr. 
Pollock's  article  on  "Injuries  of  the  Abdomen,"  and  Mr. 
Birkett's  on  "  Injuries  of  the  Pelvis,"  present  no  alteration  re- 
quiring remark.  Mr.  Flower's  essay  on  "  Injuries  of  the  Upper 
Extremity"  has  been  edited  by  Mr.  Hulke,  and  both  this  and 
the  essay  on  "Injuries  of  the  Lower  Extremity"  by  Mr.  Holt- 
house  are  much  improved  by  the  addition  of  woodcuts.  At  the 
same  time  we  must  protest  against  the  outlines  of  the  head  of 
the  femur,  shown  in  the  dislocations  figured  at  page  898,  since 
they  give  a  most  erroneous  idea  of  the  position  of  the  bone ;  and 
we  may  note  that  Mr.  Holthouse's  attention  does  not  appear  to 
have  been  called  to  Bigelow's  recent  work  on  the  hip,  and  the 
anatomy  of  its  dislocations,  in  time  for  him  to  modify  the  old 
received  methods  of  treating  these  injuries. 

The  third  volume  opens  with  Mr.  Dixon's  elaborate  treatise 


354  Reviews.  [April, 

on  ^'  Diseases  and  Injuries  of  the  Eye/'  which  extends  to  256 
pages,  and  is  divided  into  thirteen  chapters.  The  order  of  these 
varies  somewhat  from  that  of  the  former  edition,  the  first  two 
being  devoted  to  optical  defects  and  to  the  examination  of  the 
eye.  The  subjects  of  myopia,  hyper metropia,  astigmatism,  &c., 
are  well  explained,  and  the  theory  and  use  of  the  ophthalmoscope 
are  clearly  described  and  illustrated  by  lithographic  plates. 
The  diseases  of  the  several  structures  of  the  organ  are  then 
described,  with  the  treatment  of  each,  and  the  essay  forms 
altogether  one  of  the  most  readable  and  reliable  treatises  on  the 
subject  with  which  we  are  acquainted.  Mr.  James  Hinton  has 
made  a  few  additions  to  his  article  on  "Diseases  of  the  Ear,'' 
including  the  subjects  of  relaxation  of  the  membrana  tympani  : 
Politzer's  method  of  inflating  the  Eustachian  tube,  which  is  one 
of  the  few  modern  improvements  in  aural  surgery,  and  the 
diagnosis  of  afl'ections  of  the  tympanum  with  the  aid  of  the 
tuning-fork.  The  article  on  "Aneurism"  by  Mr.  Holmes  is 
one  of  the  most  important  in  the  work,  and  gives,  we  believe, 
one  of  the  best  reviews  of  the  whole  subject  to  be  found  in  the 
English  language.  The  author  has  evidently  taken  great  pains 
to  work  up  the  literature  of  the  subject,  and  has  added  much 
interesting  matter  to  the  former  edition.  The  subjects  of  acu- 
pressure and  temporary  ligature,  of  treatment  by  rapid  com- 
pression under  chloroform,  of  direct  pressure,  and  of  treatment 
by  wire  introduced  into  the  sac — a  plan  once  followed  by  the 
late  Mr.  Moore,  but  not  likely  to  be  undertaken  again — are  all 
fully  described.  The  subject  of  the  distal  ligature  by  Brasdor's 
or  Wardrop's  operation  has  received  particular  notice ;  and 
Mr.Fearn's  and  Mr.  Heath's  well-known  cases  of  double  ligature 
for  aneurism  of  the  root  of  the  neck  are  specially  referred  to.  A 
valuable  table  of  cases  of  distal  ligatures  is  appended,  and  an 
instructive  case  by  M.  Broca  of  innominate  aneurism  treated  by 
ligature  of  the  subclavian  is  published  for  the  first  time.  At 
the  end  of  the  essay  is  also  an  interesting  account  of  the  ligature 
of  the  first  part  of  the  left  subclavian  artery  by  Dr.  Kearney 
Rodgers,  of  New  York. 

Mr.  Tatum^s  essay  on  "  Afi'ections  of  the  Muscles"  has  been 
in  part  rewritten  by  Dr.  Lockhart  Clarke,  who  has  contributed 
a  valuable  addition  on  muscular  atrophy,  including  granular, 
fatty,  and  waxy  degeneration,  upon  which  the  author's  well- 
known  and  elaborate  researches  on  the  nervous  system  are 
shown  to  have  a  direct  bearing.  Dr.  Little's  article  on  "  Ortho- 
psedic  Surgery"  is  reproduced  with  but  slight  modifications,  but 
with  several  additional  woodcuts  illustrating  various  deformities. 
Mr.  Holmes'  essay  on  "Diseases  of  the  Bones,-"  with  which  the 
third  volume  concludes,  has  also  been  much  improved  by  the 


1872.]  Holmes's  System  of  Surgery.  355 

addition  of  numerous  woodcuts  from  specimens  in  the  museums 
of  the  College  of  Surgeons  and  St.  George's  Hospital.  We  note 
that  the  author  has  somewhat  modified  his  opinion  as  to  the 
existence  of  osteo-aneurism^  of  which  a  doubt  was  expressed  in 
the  former  edition.  Cases  recorded  by  Dr.  Mapother  and  Mr. 
Bickersteth  seem  to  prove  conclusively  the  existence  of 
pulsation  in  innocent  tumours  on  long  bones  displaying  no 
other  recognisable  structure  than  enlarged  blood-vessels. 

The  fourth  volume  opens  with  Mr.  Athol  Johnstone's  article 
on  "  Diseases  of  the  Joints/'  which,  like  the  preceding  essay, 
has  been  freely  illustrated  from  specimens  in  St.  George's 
Hospital  Museum.  It  is  one  of  the  drawbacks  of  the  arrange- 
ment of  a  work  of  this  kind  that  the  important  question  of 
excision  in  cases  of  diseased  joints  is  not  considered  in  con- 
nexion with  the  diseases  themselves,  but  by  a  different  author 
in  another  volume.  Mr.  Shaw's  essay  on  ^'  Diseases  of  the 
Spine"  has  no  material  alteration,  and  is  followed  by  a  valuable 
paper  on  "  Nerve  Lesions  and  their  more  Immediate  Effects," 
by  Dr.  Lockhart  Clarke.  He  believes  idiopathic  neuritis, 
though  less  common  than  traumatic,  to  be  more  common  than 
generally  supposed,  and  to  depend  upon  exposure  to  cold, 
excessive  bodily  exertion,  &c.  Several  cases  are  quoted  in  which 
the  large  nerves  of  the  body  were  found  red  and  swollen,  and 
had  produced  excessive  pain  during  life.  Neuroma  (for  which 
the  author  gives  no  cure  but  the  knife) ,  tubercle,  and  cancer  of 
nerves  are  considered,  and  then  the  effects  of  various  injuries. 
Perhaps  the  most  valuable  and  interesting  part  of  the  essay  is 
that  referring  to  the  nutritive  changes  resulting  from  injuries 
and  diseases  of  the  nerves.  These  effects  have  been  described 
by  various  authors;  but  the  most  complete  account  is  that  given 
by  Drs.  Mitchell,  Morehouse,  and  Keen,  of  the  United  States, 
who  had  abundant  opportunities  of  studying  the  effects  of 
division  of  nerves  by  gunshot  injuries,  after  the  American  civil 
war.  In  entire  division  of  a  main  nerve  there  is  of  course  palsy 
of  the  limb,  which  becomes  oedematous.  The  skin  thickens  and 
dries,  the  epithelium  hangs  in  patches,  and  the  nails  become 
curved.  In  partial  division  the  skin  is  red  or  mottled,  the  sur- 
face glossy  and  free  from  hair,  and  there  is  always  pain,  generally 
of  a  burning  character.  Dr.  Duchenne  has  shown  also  that 
complete  division  of  a  nerve  leads  to  slow  atrophy  of  the  muscles, 
but  that  partial  division  only  affects  the  muscles  whose  supply- 
fibres  are  severed,  but  the  atrophy  is  much  more  rapid.  Dr. 
Clarke  confirms  Dr.  Duchenne's  statement,  that  electro-muscu- 
lar contractility  is  not  necessary  for  the  exercise  of  voluntary 
contraction;  but  "whenever  this  contractility  is  lost,  or  even 
impaired,  the  prognosis  in  reference  to  the  return  of  voluntary 


856  Reviews,  [April, 

control  indicates  that  the  affected  muscles  will  suffer  in  their 
nutrition  and  become  atrophied."  It  must  be  always  borne  in 
mind,  that  "in  paralysis  resulting  from  cerebral  disease,  the 
electro-muscular  contractility  remains  unaffected,  and  therefore 
Faradisation  is  of  great  importance  in  the  differential  diagnosis 
of  paralysis  which  follows  injuries  of  nerves  or  affections  of  the 
spinal  cord/^  The  whole  essay  is  well  worthy  of  study,  and  is 
followed  by  Dr.  Brown- Sequard's  article  on  the  "  Remoter  Con- 
sequences of  Nerve-Lesions,^^  which  appeared  in  the  first  edi- 
tion ;  this  includes  the  diseases  of  the  nervous  centres  caused  by 
injury  to  or  disease  of  a  nerve,  and  includes  references  to 
epilepsy,  tetanus,  catalepsy,  chorea,  &c.,  and  is  especially 
valuable  for  its  numerous  references  to  published  accounts  of 
cases  bearing  on  the  question. 

An  article  of  six  pages  only  on  "  Locomotor  Ataxy ,'^  by 
Dr.  Lockhart  Clark,  is  introduced,  with  the  following  quasi- 
apology,  which,  however,  is  quite  unneeded  :  '^  Although  loco- 
motor ataxy  comes  more  frequently  under  the  care  of  the  phy- 
sician than  the  surgeon,  yet  in  the  early  part  of  its  course  the 
symptoms  are  so  equivocal,  and  so  liable  to  be  mistaken  for 
those  which  belong  to  certain  surgical  diseases,  that,  for  the 
sake  of  the  differential  diagnosis  alone,  a  short  description  of 
this  malady  should  have  a  place  in  every  system  of  surgery .^^ 

The  diseases  of  the  organs  of  digestion  and  respiration  are 
now  placed  consecutively,  an  order  which  was  not  possible 
before,  commencing  with  Mr.  Coote^s  article  on  "  Diseases  of 
the  Tongue."  The  late  Mr.  Alexander  lire's  article  on 
"  Diseases  of  the  Nose"  has  been  rewritten  by  Mr.  Durham, 
who  has  added  to  it  considerably,  and  has  especially  called 
attention  to  modern  methods  of  research  and  treatment. 
Among  these  may  be  especially  mentioned  the  treatment  of 
ozsena  by  washing  out  the  nostrils  with  a  continuous  stream 
passed  from  one  nostril  to  the  other  behind  the  septum.  This 
is  so  simple  that  a  patient  can  be  readily  taught  it,  and  no 
syringing  is  half  so  effective.  It  is  not  generally,  we  believe, 
known  how  completely  the  posterior  nares  are  under  the  control 
of  the  forefinger  of  the  surgeon,  both  for  examination  and 
treatment,  and  we  could  have  wished  that  more  attention  had 
been  directed  to  this  method,  which  is  only  mentioned  in- 
cidentally. 

Mr.  James  Salter's  valuable  essay  on  "  Surgical  Diseases 
connected  with  the  Teeth"  has  been  expanded  by  reference  to 
the  class  of  Odontomes  under  which  Broca  has  proposed  to 
classify  tumours  connected  with  the  teeth.  Under  this  head- 
ing Mr.  Salter  now  includes  (a)  enamel  nodules ;  (b)  exostosis  : 
(c)  hyper trophied  dilated  fangs ;   {d)  dentine  excrescence,  and 


1872.]  Holmes's  System  of  Surgery.  357 

(e)  warty  teeth,  and  these  are  illustrated  by  numerous  engravings. 
Mr.  Pollock's  original  article  on  Disease  of  the  Mouth  and 
Alimentary  Canal  has  been  subdivided  into  two,  the  first  essay 
treating  of  '^Diseases  of  the  Mouth,  Pharynx,  and  CEsophagus,'' 
and  the  other  of  "  Diseases  of  the  Intestines.''''  Between  these 
are  placed  Dr.  Barclay's  article  on  "  Diphtheria  and  Croup," 
and  Mr.  Durham's  article  on  "  Diseases  of  the  Larynx.'''  This 
last,  which  is  a  combination  of  the  author's  brief  article  on  the 
"Laryngoscope,"  and  of  the  late  Mr.  H.  Gray's  article  on 
"  Diseases  of  the  Larynx,"  in  the  first  edition,  has  been  con- 
siderably added  to  and  improved,  and  contains  a  very  good 
account  of  the  various  forms  of  laryngitis,  and  of  the  treat- 
ment of  growths  in  the  vocal  passages,  Mr.  Durham  speaks 
highly  of  the  practice  of  dividing  the  thyroid  cartilage  in  order 
to  clear  the  larynx  of  extensive  growths,  especially  if  of  an 
epitheliomatous  character. 

Mr.  Birkett's  elaborate  article  on  "  Hernia,"  Mr.  Henry 
Smith's  on  "Diseases  of  the  Rectum,"  Sir  Henry  Thomp- 
son's exhaustive  essay  on  "  Diseases  of  the  Urinary  Organs,'^ 
Mr.  Poland's  article  on  "  Urinary  Calculi  and  Lithotomy,"  and 
Mr.  Charles  Hawkins  on  "  Lithotrity,"  complete  the  fourth 
volume.  These  essays  appear  to  have  required  but  little  emen- 
dation at  their  respective  authors'  hands,  and  all  have  the  ad- 
vantage of  additional  illustrations. 

The  Diseases  of  the  Generative  System  are  grouped  together 
in  the  fifth  volume,  beginning  with  Mr.  Jonathan  Hutchinson's 
article  on  "  Surgical  Diseases  of  Women.'''  The  author  thus 
sums  up  his  matured  views  on  the  treatment  of  the  pedicle  in 
ovariotomy. 

"  On  the  whole,  I  think  that  the  operator  will  do  well  to  deter- 
mine to  use  the  clamp  in  all  cases  in  which  the  peduncle  is  long 
enough ;  in  cases  in  which  it  is  too  short  it  will  be  better  when 
practicable  to  employ  ligatures,  and  to  let  the  peduncle  sink  into  the 
wound  so  that  the  seat  of  ligature  is  level  with  the  peritoneum ; 
and  lastly,  in  cases  of  extreme  shortness  he  should  use  the  actual 
cautery.  In  spite  of  recorded  successes  I  cannot  but  feel  a  strong 
prejudice  against  cutting  ligatures  and  peduncles  off  short  and 
dropping  the  stump  into  the  abdomen.  This  incurs  the  risk  both  of 
haemorrhage  and  peritonitis." 

We  may  remark  in  passing  that  this  is  not  the  experience  of 
those  who  have  most  frequently  practised  the  method.  Dr. 
Humphrey's  valuable  article  on  "  Diseases  of  the  Male  Organs 
of  Generation"  is  reproduced  with  a  few  illustrations,  and  is 
followed  by  the  essay  on  "  Gonorrhoea,"  for  which  Mr.  H.  Lee 
is  now  alone  responsible.  Mr.  Birkett  appears  to  have  found 
little  alteration   required   in  his   essay  on   "  Diseases   of  the 


358  Reviews.  [A^ril, 

Breast/^  though  his  views  on  the  pathology  of  that  organ  have 
undergone  some  modification  since  the  publication  of  his  ori- 
ginal work  on  the  subject.  Mr.  Nayler  has  replaced  the  late 
Dr.  Hillier  as  Sir  William  Jenner's  colleague  in  the  article  on 
"  General  or  Constitutional  Affections  of  the  Skin/^  and  ex- 
presses an  opinion — 

"  That  the  microscopic  characters  hitherto  noted  of  the  various 
parasitic  fungi,  while  amply  sufficient  to  enable  the  one  plant  to  be 
distinguished  from  the  other,  are  not  sufficient  to  prove  their  essen- 
tial non-identity,  i.  e.  to  prove  that  they  are  not  different  stages  of 
development  of  the  same  fungus." 

Mr.  Thomas  Smith  describes  the  ^^  Local  or  Surgical  Affec- 
tions of  the  Skin/^  and  again  contributes  the  article  on  "  Minor 
Surgery,'^  which  is  followed  by  that  on  ^^  Plastic  Surgery/'  by 
Mr.  Holmes  Coote,  in  which  numerous  illustrations  are  intro- 
duced. Mr.  Lister  has  revised  his  articles  on  "Anaesthetics" 
and  "  Amputation. ■'■'  In  the  former  he  simply  upholds  the  views 
formerly  expressed  as  to  the  simplicity  required  in  the  adminis- 
tration, and  the  danger  resulting  from  the  falling  back  of  the 
tongue.  The  production  of  anaesthesia  by  sulphuric  ether, 
nitrous-oxide  gas,  and  cold  is  also  briefly  noticed.  In  the 
latter,  Mr.  Lister  devotes,  as  might  be  anticipated,  a  con- 
siderable space  to  the  antiseptic  treatment  of  wounds.  This  is 
not  the  place  to  express  any  opinion  on  the  method,  which  is 
still  suh  judice,  but  we  understand  that  since  the  article  was 
published  the  hitherto  all-important  carbolic  acid  has  been 
superseded  in  Edinburgh  itself  by  a  more  simple  and  less 
offensive  material.  Mr.  Holmes^ s  article  on  "  Excision  of 
Bones  and  Joints"  has  been  very  considerably  expanded  and 
improved.  The  author  has  had  a  very  considerable  experience 
upon  the  subject,  particularly  in  young  persons,  and  has  illus- 
trated his  paper  with  some  drawings  showing  the  amount  of 
movement  following  excision  of  the  larger  joints,  in  a  manner 
not  hitherto  attempted. 

The  Appendix  contains  as  before  the  articles  on  "  Surgical 
Diseases  of  Childhood,"  by  Messrs.  Holmes,  Brodhurst,  and 
Shaw ;  on  "  Apnoea,"  by  Dr.  Harley ;  on  "  Parasitic  and 
Venomous  Insects,"  by  Mr.  Busk ;  on  "  Surgical  Diagnosis 
and  Regional  Surgery,'^  by  Mr.  Holmes ;  on  "  Hospitals,^'  by 
Sir  Ranald  Martin,  and  on  "  Surgical  Instruments  and  Appa- 
ratus," by  Mr.  Holmes  Coote.  This  last  essay  is  illustrated 
from  the  catalogues  of  some  of  the  principal  metropolitan  in- 
strument-makers, but  does  not  give  a  very  satisfactory  account 
of  the  armamentarium  chirurgicum-. 

We  have  thus  endeavoured  to  sketch  the  alterations  in  the 
second  edition  of  the  '  System  of  Surgery,'  which,  take  it  for 


1872.]  Hospitals  and  their  Critics.  359 

all  in  all,  is  by  far  the  best  compendium  of  British  surgery- 
extant.  The  expansion  to  five  instead  of  four  volumes  has  the 
demerit  of  enhancing  the  price,  but  the  advantage  of  allowing 
more  scope  to  the  authors,  and  of  doing  away  with  a  quantity  of 
small  type.  The  addition  of  illustrations  (which  now  number 
472)  is  a  great  advantage  to  many  of  the  essays,  and  renders 
them  much  more  complete.  The  indefatigable  editor  is  to  be 
complimented  on  the  regularity  of  the  issue  of  his  volumes, 
and  we  only  wish  he  could  exercise  a  little  more  despotic  in- 
fluence over  some  of  his  staff  so  as  to  bring  all  of  them  up  to 
the  same  standard  of  excellence.  Most  of  the  articles  are 
good,  some  are  excellent,  and  a  very  few  inferior.  If  authors 
have  neither  power  nor  time  to  bring  their  contributions  fairly 
up  to  the  level  of  the  knowledge  of  the  day,  we  think  that  in 
justice  to  their  collaborateurs  they  ought  to  be  treated  as  defunct 
authors,  and  their  labours  entrusted  to  other  hands. 


VII. — Hospitals  and  their  Critics.^ 

That  the  world  increases  in  wisdom  with  its  increasing 
years  may  or  may  not  be  true ;  at  times  those  who  uphold  the 
sentiment  appear  to  have  reason  on  their  side,  but  at  others, 
alas,  its  opponents  may  claim  to  have  the  advantage.  If  re- 
formers succeed  in  carrying  their  point,  it  by  no  means  always 
follows  that  they  have  been  right,  but,  the  change  having  come, 
it  behoves  all  to  make  the  best  of  it;  and  hence  very  often 
a  change,  though  not  in  itself  the  cause,  becomes  the  oppor- 
tunity for  improvement.  When  the  artist  thankfully  acknow- 
ledged the  practised  eye  of  the  shoemaker  he  by  no  means 
justified  the  subsequent  criticism  of  the  man  of  the  last. 

Without  denying  the  benefit  that  has  already  taken  place 
through  agitation  on  the  subject  of  which  we  treat,  we  depre- 

1  Some  Propositions  on  Sospitalism.  By  the  late  Sir  J.  Y.  Simpson,  Bart. 
*  Lancet/  1870. 

2.  A  System  of  Surgery,  Theoretical  and  Practical,  in  Treatises  hy  various 
authors.  Edited  by  T.  Holmes,  M.A.  Cantab.,  Surgeon  and  Lecturer  at  St. 
George's  Hospital.     Second  edition,  in  five  volumes.     London,  1870«7l. 

3.  St.  Georges  Hospital  Reports.     Vol.  v. 

4.  Mortality  of  Childbed  and  Maternity  Hospitals.  By  J.  M.  DuNCAN,  A.M., 
M.D.,  &c.     Edinburgh,  1870. 

5.  IntrodMctory  Notes  on  Lying-in  Institutions,  Sfc.  By  Florence  Nightin- 
gale.    London,  1871. 

6.  The  Medical  Times  and  Gazette,  1871,  pp.  787,  and  The  British  Medical 
Journal,  1871,  pp.  736,  containing  a  notice  of  the  37th  Annual  Report  of  the 
Glasgow  Maternity  Hospital. 

7.  Report  of  the  Rotunda  Lying-in  Hospital.  Read  before  the  Obstetrical 
Society  of  Ireland,  January,  1872. 


360  Reviews.  [April, 

cate  many  of  the  changes  contemplated  by  those  who  have 
striven  for  sweeping  alterations,  assured,  partly  by  actual  ex- 
perience and  partly  by  reasoning,  that  injury,  not  benefit,  would 
arise  by  carrying  out  the  same. 

The  late  Sir  James  Simpson,  starts  in  the  paper  first  in 
our  list — which  we  believe  was  the  last  he  wrote  on  the 
subject — with  a  general  assertion  of  the  insalubrity  of  the 
older  hospitals  now  existing.  Mr.  Tait  very  fairly  says  that 
this  assertion  has  been  disputed  by  some  most  competent 
authorities,  and  whilst  he  is  prepared  to  admit  some  measure 
of  evil  and  need  of  change,  he  doubts  the  extent  to  be  as 
great  as  indicated  by  Sir  James  Simpson.  The  proposal  of 
this  distinguished  writer  to  revolutionise  the  old  hospitals  by 
making  the  staircases,  corridors,  &c.,  all  open,  is  evidently 
not  suited  to  the  British  climate.  The  same  objection  also 
applies  to  the  proposition  that  all  the  doors  and  entrances  of  the 
wards  opening  on  these  staircases  and  corridors  should  be  built 
up,  and  that  an  entrance  into  each  ward  should  be  made  from 
without.  The  plan  here  proposed  is,  indeed,  not  new,  having 
been  pretty  largely  tried  in  the  model  houses  in  London  for 
many  years  past,  and  been  found  objectionable  and  unpopu- 
lar. The  same  principle  that  induces  our  kinsmen  in  Canada 
and  the  inhabitants  of  Northern  Europe  to  fit  their  dwellings 
with  double  windows,  prompts  ns  to  secure  ventilation  in  winter 
free  from  the  frequent  dampness  and  coldness  of  the  outer  air; 
and  this  end  is  gained  by  the  modern  staircase,  which,  when  in 
itself  well  lighted  and  ventilated,  becomes  a  valuable  assistance 
in  ventilation  at  all  times,  especially  when  the  severity  of  the 
weather  allows  but  little  direct  ventilation  by  means  of  the 
windows.  When  an  outside  staircase  is  adopted  the  doors  and 
windows  of  a  ward  are  alone  available  for  the  purposes  of  ven- 
tilation, and  experience  has  repeatedly  shown  the  disadvantage 
thus  arising,  as  just  adverted  to,  by  prolonged  exposure  to  the 
inclemency  of  the  weather  incurred  by  those  using  them.  If  the 
system  of  outside  stairs  were  adopted,  pollution  of  the  air  of  the 
wards  would  nevertheless  follow,  as  exemplified  by  the  history 
of  the  so-called  model  lodging  houses;  for  practically  people 
will  exclude  cold  and  damp,  which  would  mean,  with  the 
arrangement  in  question,  exclusion  also  of  ventilation.  If  the 
atmosphere  of  the  wards,  staircases,  corridors  and  galleries  is 
allowed  to  become  polluted  it  is  the  fault  of  the  management  of 
the  institution ;  for,  unless  in  extraordinarily  exceptional  cases, 
such  default  cannot  be  laid  to  the  construction. 

At  the  same  time,  galleries  and  corridors  are  in  our  opinion 
objectionable,  and  the  system  of  construction  that  we  think 
should  always  be  pursued  is  that  of  pavilion  hospitals ;  by  these 


187.2.]  Hospitals  and  their  Critics.  361 

we  meau  buildings  of  two  or  three  stories,  with  a  central  stair- 
case of  ample  size  well  lighted  and  ventilated  by  large  windows, 
the  basement  story  to  be  rather  above  the  level  of  the  ground, 
or  if  necessary,  as  in  damp  localities,  elevated  to  some  height 
above  it ;  the  wards  to  extend  from  the  staircase  in  two  oppo- 
site directions,  with  ample  windows  placed  opposite  to  each 
other,  with  abundant  facilities  for  opening  from  above  as  well 
as  from  below  upwards ;  each  pavilion  or  building  to  contain 
not  more  than  from  80  to  100  or  120  patients,  and  so  placed 
as  to  be  completely  open  to  the  wind  and  to  the  sun's  power 
on  all  sides  (we  are  speaking  of  the  British  climate,  some 
modification  by  the  shelter  of  verandahs,  &c,,  might  be  ad- 
missible in  a  tropical  country) . 

The  late  Sir  J.  Simpson  spoke  of  corridors  and  galleries,  &c., 
as  if  normally  retaining  and  imprisoning  the  internal  befouled 
hospital  air.  We  do  not  know  any  establishment  that  does 
not  attempt  at  all  events  by  ventilation  and  cleanliness  to 
obviate  any  tendency  to  such  an  atmosphere.  Reformers  in 
other  days  have  tried  to  increase  the  utility  of  certain  hospitals 
by  adding  to  their  accommodation,  forgetful  of  the  original 
design  and  arrangements  of  the  buildings.  We  know  cases  of 
the  kind  where  material  impediments  have  so  been  thrown  in 
the  way  of  those  who  would  otherwise  have  had  comparatively 
little  difficulty  in  maintaining  a  salubrious  atmosphere  in  a 
well  designed  and  well  built  edifice.  The  old,  many-storied, 
palatial  Continental  hospitals,  which  are  regarded  with  so  much 
disfavour  by  some,  are  thus  spoken  of  by  Mr.  Ewart  in  his 
valuable  remarks  on  the  German  field  hospitals  in  the  late 
war  :  i  ^'  The  smallest  French  town  is  endowed  with  a  capacious 
hospital  or  Hotel-Dieu,  with  barracks,  and  with  large  com- 
munal schools.  The  first  was  a  real  boon,  whilst  the  latter 
contained  all  the  elements  which  were  strictly  necessary,  and 
could  easily  be  shaped  into  comfortable  ambulances." 

In  reference  to  the  employment  of  wooden  huts  and  canvas 
tents.  Professor  Gurlt  points  out  the  liability  of  canvas  and  wood, 
as  well  as  other  materials,  to  become  the  recipients  of  infection 
in  proportion  to  the  number  and  nature  of  the  cases  placed  in 
them,  and  the  length  of  time  they  are  in  use. 

Tents,  too,  are  not  exempt  from  defects,  and  serious  ones 
also ;  for,  besides  those  to  which  we  have  alluded  above,  may  be 
noted  the  very  imperfect  protection  they  offer  against  the 
changes  of  weather,  and,  apart  from  the  difficulty,  the  danger  of 
warming,  as  instanced  in  the  melancholy  accident  at  Wakefield, 
where  four  persons  were  burned  to  death  in  an  hospital  of  this 
frail  tent  structure. 

1  '  St.  George's  Hospital  Keports,'  vol.  v,  1870,  p.  366. 


362  Reviews,  [April, 

As  to  the  value  of  iron  as  the  material  for  hospital  construc- 
tion, so  much  insisted  on  by  Sir  J.  Simpson,  some  experience 
we  have  had  of  iron  ships  in  temperate  as  well  as  in  warmer 
latitudes,  did  not  so  favorably  impress  us  as  to  enable  us  to 
recommend  it  for  general  use  in  hospital  construction. 

The  hobby  which  some  recent  writers  have  so  well  ridden,  that 
a  cottage-hospital  must  necessarily  be  healthy,  borders  on  the 
absurd ;  for  cottages,  like  all  other  edifices,  have  their  defects, 
which  in  connection  with  structural  qualities  are,  there  is  little 
question,  greater  in  proportion  to  their  accommodation  than 
those  of  large  institutions,  and  are,  in  short,  so  obvious  and 
numerous  that  it  appears  quite  unnecessary  to  enlarge  upon 
them. 

We  would  not  have  it  thought  that  we  object  to  cottage- 
hospitals  when  required  for  a  small  community ;  on  the  con- 
trary, we  believe  them  especially  useful,  and  often  capable  of 
saving  life  which  might  be  endangered  by  a  journey  to  a 
more  distant  hospital.  What  we  object  to  is,  the  recom- 
mendation that  when  hospitals  are  required  to  accommodate  a 
hundred,  or  possibly  many  more  cases,  cottages  should  be  con- 
structed instead  of  larger  edifices.  Every  requisite,  combined 
with  economy  of  construction,  supervision  and  attendance,  and 
all  sanitary  requirements,  can  be  secured  by  pavilion  buildings, 
such  as  we  have  sketched,  whereas  if  the  cottage  system,  for 
any  considerable  number  of  patients,  should  be  carried  out  it 
would  be  at  the  sacrifice  of  many  advantages. 

In  1862  (Miss  Nightingale  writes)  the  Committee  of  the 
Nightingale  Fund,  with  a  view  to  extend  the  advantages  of 
their  training  institution,  entered  into  an  arrangement  with  the 
authorities  of  St.  John's  House,  under  which  wards  were  fitted 
up  in  the  new  part  of  King's  College  Hospital,  opening  out  of 
the  great  staircase,  and  shut  up  within  their  own  doors,  for  the 
reception  of  midwifery  cases.  The  wards  were  under  the  charge 
of  the  (then)  lady  superintendent.  Arrangements  were  made 
for  medical  attendance,  a  skilled  midwife  was  engaged,  a  certain 
number  of  pupil  nurses  were  admitted  for  training ;  and  hopes 
were  entertained  that  this  new  branch  of  our  training  school 
would  confer  a  great  benefit  on  the  poor,  especially  in  country 
districts,  where  trained  midwifery  nurses  are  needed. 

Every  precaution  had  apparently  been  taken  to  render  the 
midwifery  department  perfectly  safe ;  and  it  was  not  until  the 
school  had  been  upwards  of  five  years  in  existence  that  the 
attention  of  the  Nightingale  Committee  was  called  to  the  fact 
that  death  from  puerperal  diseases  had  taken  place  in  each  of 
the  preceding  years. 

During  the  period  of  nearly  six  years  that  the  wards  were  in 


]  872.]  Hospitals  and  their  Critics,  363 

use  the  records  show  that  780  women  had  been  delivered  in  the 
institution,  and  that  out  of  this  number  twenty-six  (exclusive 
of  a  poor  woman,  who,  delivered  in  a  cab,  had  died  in  the 
hospital  of  post-partum  haemorrhage)  had  died — a  mortality  of 
33'3  per  1000.  Of  the  fatal  cases  seventeen  were  due  to  puer- 
peral fever,  three  to  puerperal  peritonitis,  two  to  pysemia,  and 
one  to  metritis.  The  wards  were  closed  as  soon  as  possible. 
We  confess  we  are  not  surprised  at  the  fatality,  when  we  read 
at  page  41  that  the  smell  from  the  post-mortem  theatre  could 
be  distinctly  detected  in  the  wards,  and  find  other  objectionable 
points  in  connection  with  the  position  and  arrangement  of  the 
department. 

Miss  Nightingale  is  not  disposed  to  doubt  the  value  of  the 
returns  compiled  by  the  Registrar- General,  which  are  very 
favorable  to  delivery  at  the  patients''  homes.^  The  death-rate 
of  1  in  120,  in  the  hands  of  ''  educated  accoucheurs"  in  private 
practice,  should  in  Miss  Nightingale's  opinion  be  inquired  into. 
On  this  matter,  we  may  observe  that  neither^  are  the  cases 
delivered  in  hospitals  nor  yet  in  private  practice  among  the 
wealthier  classes  likely  to  be  the  most  natural  and  otherwise 
devoid  of  danger.  But  apart  from  this,  we  should  be  heartily 
rejoiced  to  feel  that  we  could  depend  on  the  statistical  returns 
commonly  published,  although  we  would  not  imply  want  of 
confidence  in  the  integrity  of  their  compilers.  But  statistics 
generally,  alas  !  are  largely  open  to  errors  both  in  collecting  and 
compiling.  Of  the  accuracy  of  the  information  given  to  regis- 
trars by  the  masses  of  our  people,  we  are  sceptical  of  in  no 
small  degree;  and  in  the  precision  of  the  certified  causes  of 
death  we  likewise  cannot  indulge  the  fullest  confidence.  An 
extended  experience,  in  short,  with  the  circumstances  attending 
the  collection  of  statistics  relative  to  the  causes  of  death  as  well 
as  many  other  matters  shakes  our  confidence  even  in  the  returns 
published  with  the  brand  of  authority  upon  them.  Isolated 
or  patchwork  returns  of  small  institutions,  as  well  as  those 
furnished  by  private  practitioners  who  trust  to  memory,  are 
very  untrustworthy. 

To  return,  however,  to  hospital  economies.  It  is  a  good  and 
laudable  service  to  draw  attention  to  the  miscarriage  and  the 
serious  results  which  have  in  so  many  instances  followed  want  of 
prudence  in  the  arrangements  of  hospitals,  and  especially  of 
maternities.  When  we  say  this  much  we  by  no  means  acquiesce 
in  the  reasoning  of  those  who  consider  the  miserable  tenements 


1  Perhaps  we  are  wrong  in  using  the  word  patient,  as  the  author  of  'Notes  on 
Lying-in  Institutions '  informs  her  readers  that  parturition  is  not  a  disease  at  all, 
but  custom  must  be  our  excuse. 


SGL  Keviews.  [April, 

of  the  masses  of  our  poor  people  as  the  only  safe  place  for 
lying-in  women.  Attention  has  been  directed  to  this  matter  in 
Glasgow,  where  the  lying-in  hospital  proved  truly  a  haven  of 
safety,  as  is  sufficiently  shown  by  the  thirty-seventh  annual 
report  of  the  hospital.  Of  313  women  delivered  in  that  hospital 
but  one  died  of  puerperal  fever;  whereas  of  698  who  were 
delivered  at  their  own  homes  that  disease  carried  off  five.  The 
report  adds  that  for  years  past  complete  segregation  of  cases 
of  puerperal  fever,  perfect  cleanliness,  thorough  ventilation, 
fumigation,  &c.,  have  been  diligently  practised  with  very  satis-* 
factory  results. 

The  report  of  the  Dublin  Lying-in  Hospital  for  the  year 
ending  30th  of  October,  1871,  shows  a  considerable  mortality; 
the  temporary  sojourn  of  the  cases  in  hospital  being  characterised 
by  the  same  disease  which  proved  destructive  to  the  population 
that  furnished  the  lying-in  women.  The  season  was  characterised 
by  an  unusual  prevalence  of  typhoid  fever,  of  scarlatina,  of 
smallpox  and  of  erysipelas,  whilst  bronchitic  pneumonia  and 
other  evidences  of  a  depressed  condition  of  the  vital  powers 
marked  the  period  in  the  Irish  metropolis  as  elsewhere. 

Eleven  hundred  and  sixty-one  cases  were  delivered  in  the  Ro- 
tunda in  the  year,  and  of  these  33  died.  Of  the  fatal  cases,  13  ac- 
knowledged that  they  were  unmarried.  Four  others  were  in 
mental  distress  ;  in  one  case  the  woman  had  been  deserted  by  her 
husband,  in  another  the  husband  was  in  America,  and  in  the 
other  two  the  husbands  were  separated  from  them.  In  all  such 
cases  it  has  been  found  that  the  mental  condition  predisposes 
most  seriously  to  fatal  diseaes.  The  depressing  influence  of  the 
season  was  forcibly  demonstrated  by  the  fact  that  the  fatal 
result  was  attributed  by  Dr.  Johnston  to  sloughing  of  the 
vagina  with  hectic  in  two  cases,  in  other  two  cases  to  sloughing 
with  peritonitis,  and  in  yet  two  other  cases  to  sloughing  with 
pyaemia.  One  of  the  cases  fatal  from  sloughing  with  peritonitis, 
was  that  of  an  unmarried  woman,  who,  although  but  twenty 
years  of  age,  had  daily  drunk  from  a  pint  to  a  quart  of  whiskey 
for  the  seven  months  preceding  her  confinement.  Our  space  and 
our  object  do  not  permit  us  going  into  details  of  each  fatal  case, 
nor  into  the  history  of  cases  that  recovered  from  accidents, 
operations,  or  illness;  for  such  our  readers  must  refer  to  the 
report  itself,  which  will  amply  repay  perusal.  That  the  hospital 
serves  as  a  refuge  for  the  friendless,  the  destitute,  and  the  de- 
sponding, is  abundantly  seen  in  the  details  of  the  report.  In 
not  a  few  cases  the  poor  women  had  suffered  the  greatest  priva- 
tions, some  were  but  partially  recovered  from  fever,  others  were 
actually  suffering  from  illness,  diarrhoea,  dysentery,  bronchitis, 
phthisis,   &c.,  and  others  again  from    the   results  of  previous 


1872. J  Hospitals  and  their  Critics.  365 

beatings.  To  tins  category  we  must  add  a  death  from  being 
run  over,  one  from  premature  delivery  induced  by  smallpox, 
one  from  anaemia  on  admission — placenta  prsevia — and  one  of 
sudden  death  forty-one  hours  after  use  of  forceps. 

To  compare  the  mortality  among  patients,  such  as  those  just 
detailed,  with  that  obtaining  among  most  of  the  higher  or  middle 
classes,  and  to  denounce  an  institution  of  such  manifest  public 
benefit,  because  of  the  necessarily  high  rate  of  fatality  attending 
the  cases  treated  in  it,  is  to  say  the  least  unjust.  Well  may  Dr. 
Guy  say  that  the  great  leading  cause  which  determines  the 
mortality  of  hospitals  is  the  selection  of  patients.  Others  have 
also  justly  remarked  that  a  low  d&ath-rate  too  often  denotes  but 
hospital  inefficiency.  We  will  give  Dr.  Johnston's  own  words 
in  reference  to  the  condition  of  cases  when  received  into  the 
hospital — 

"There  were  five  cases  of  what  I  may  call  malpraxis,  viz.  in 
two  instances  the  forceps  had  been  tried  several  times  ineffectually 
before  the  women  had  been  brought  into  hospital ;  two  were  under 
the  care  of  women  for  twenty-four  and  thirty-three  hours  respec- 
tively. In  the  fifth  case  we  were  not  able  to  ascertain  the  length  of 
time,  but  the  arm  was  protruding  through  the  vulva,  and  the  waters 
had  escaped  eight  hours  previously.  In  seven  cases  the  child  was 
born  for  some  hours  before  admission,  and,  therefore,  tlie  mothers 
were  exposed  to  all  the  dangers  of  haemorrhage,  inflammation,  &c. 
Forty-seven  were  in  very  delicate  health,  suffering  from  great  debility, 
either  from  severe  sickness  of  stomach  during  pregnancy,  recovering 
from  fever,  labouring  under  anasarca,  extreme  emaciation,  fretting 
with  great  anxiety  of  mind  from  seduction,  ill  treatment,  deserted 
by  or  death  of  husband,  &c.  ;  8  cases  of  exhaustion  from  accidental 
hajmorrhage,  1  from  unavoidable  haemorrhage,  36  from  bronchitis, 
2  from  pleuritis,  3  from  phthisis,  1  pneumonia,  2  from  laryngitis, 
1  tonsillitis,  admitted  from  another  hospital ;  3  inflamed  varicose 
veins,  1  erysipelas  of  the  head,  3  injuries  by  beating,  1  influenza, 
1  haemoptysis  with  peritonitis,  1  jaundice,  1  epilepsy,  3  condylomata, 
1  secondary  eruption,  3  purulent  vaginitis,  1  variola,  1  hysteric 
convulsions  with  haemorrhage  (three  months),  1  typhus." 

The  report  mentions  several  other  instances  of  illness  some 
of  which  were  fatal.  In  three  it  appears  death  was  sudden; 
they  are  thus  enumerated  : 

"  1  of  clot  in  the  left  ventricle,  1  of  rupture  of  a  varicocele  in  left 
spermatic  vein,  1  of  embolism." 

It  appears  cases  of  the  zymotic  class  did  not  spread  in  a 
single  instance  in  the  hospital. 

We  cannot  but  concede  to  the  master  of  the  Rotunda  the 
privilege  to  lay  before  the  public  the  unavoidable  liability  to  fatal 
results  in  an  institution  which  is  open  to  the  admission  of  "all 
seeking  admission,  even  the  most  abandoned,^'  who  "  may  freely 

98— xLix.  24 


366  Reviews.  [April, 

enter  without  any  previous  examination  or  inquiry  into  their  cir- 
cumstances, the  only  recommendation  being  that  they  stand  in 
need  of  assistance/'  &c.  We  must  bear  in  mind,  too,  that 
the  institution  founded  by  the  energy,  ability,  and  self-denial 
of  Bartholomew  Moss,  cannot  refuse  any  application  even 
though  coming  from  infected  houses  and  belonging  to  a  family 
suffering  with  contagious  diseases.  Thus  one  poor  woman  had 
it  appears  lost  four  of  her  children  by  scarlatina  before  her 
admission  to  the  Rotunda. 

Among  the  military  hospitals  a  mortality  of  10' 1  per  1000 
occurred  at  Aldershot.  At  Chatham  there  were  three  deaths 
in  342  deliveries,  and  at  Woolwich  eight  among  751  deliveries, 
and  live  of  these  from  puerperal  diseases.  It  would,  of  course, 
be  idle  to  compare  the  healthy  and  comparatively  well-to-do 
wives  of  soldiers  with  poor  and  outcast  women  of  a  city  popu- 
lation, such  as  those  admitted  into  the  Rotunda  hospital. 
Nevertheless,  this  course  has  been  pursued  by  some  who  have 
busied  themselves  writing  against  such  institutions. 

It  is  amusing  to  find  the  author  of  '  Notes  on  Nursing ' 
gravely  discussing  the  suitability  of  this  and  that  military  hos- 
pital for  lying-in  purposes,  and  of  the  admission  of  medical 
students  to  lying-in  hospital  practice,  at  the  same  time  that 
she  proposes  to  hand  over  the  whole  responsibility  of  midwifery 
to  practised  females,  who  are  to  be  medical  students  too,  and  if 
so  must  dissect,  as  so  many  of  the  fair  sex  now  insist  on  doing  : 
an  interpretation  of  women's  rights  we  are  by  no  means  inclined 
to  accept. 

We  should  be  rejoiced  if  the  rule  laid  down  by  Miss  Nightin- 
gale could  be  carried  out,  namely,  that  parturient  women  should 
be  perfectly  well  in  health.  Indeed,  as  we  have  before  remarked, 
this  lady  goes  further.  She  writes,  "  Since  lying-in  is  not  an 
illness,  and  lying-in  cases  are  not  sick  cases,  it  would  be  well, 
as  already  said,  to  get  rid  of  the  word  ^  hospital '  altogether,'^ 
&c. ;  and  further  on,  "  on  the  contrary,  a  death  in  childbed  is 
almost  a  subject  for  an  inquest."  But  really  this  is  too  much  ; 
we  must  leave  our  very  clever  authoress  with  Socrates'  Mother's 
Shade,  to  whom  she  has  dedicated  her  book. 

Individuals  with  every  mental  agency  of  a  depressing  nature 
at  work,  and  affected,  but  too  often,  with  diseases  of  various 
kinds  are  received  in  the  established  maternities  of  Vienna, 
Dublin,  and  other  cities,  and  if  we  look  for  further  explanation 
of  a  high  death  rate  in  such  establishments  it  may  be  found  in 
the  very  large  proportion  of  primiparse.  Thus,  at  the  great 
Dublin  hospital  there  were  403  such  out  of  the  1161  interne 
labour  cases  during  the  past  year.  Now,  Dr.  M.  Duncan  has 
clearly  shown  that  the  mortality  of  first  labours  is  about  twice 


1873.]  Hospitals  and  their  Critics.  367 

that  of  all  subsequent  labours  taken  together^  and  further  th  at 
the  mortality  from  puerperal  fever  following  first  labours  is  about 
twice  the  mortality  from  this  cause  following  all  subsequent 
labours  taken  together.  In  reference  to  this  point  the  works 
of  Collins,  Johnston  and  Sinclair,  Hardy  and  M^Clintock,  and 
the  registers  of  Edinburgh  and  Glasgow  have  been  had 
recourse  to  by  Dr.  Duncan,  and  we  may  give  full  credence  to 
his  conclusions. 

To  bring  forward  the  mortality  of  the  Dublin  Rotunda  Hos- 
pital during  the  fearful  period  of  the  famine-fever,  and  the  cholera 
years  1847 — 54 — (for  no  less  than  two  visitatious  of  cholera  as 
well  as  the  sad  period  of  the  Irish  famine  and  fever  were  included 
in  those  years) — is  manifestly  unfair,  yet  we  find  Le  Fort  cites 
those  years  as  specimens  of  the  mortality  of  the  Dublin  hos- 
pital, and  Miss  Nightingale  adopts  his  figures,  classing  them 
for  these  years  with  the  returns  for  certain  periods  in  some 
Continental  hospitals.  Looking  to  the  period  of  Dr.  Collinses 
mastership  of  the  Dublin  Hospital,  the  mortality  in  a  total  of 
16,414  women  delivered  in  seven  years,  be  it  observed,  was 
164,  or  in  the  proportion  of  1  in  100.  Again,  of  6634  women 
delivered,  as  recorded  by  Drs.  M^Clintock  and  Hardy,  65  died, 
or  1  in  102 ;  and  in  the  seven  years  recorded  by  Drs.  Sinclair 
and  Johnston,  13,748  were  delivered  and  163  died,  or  1  in  84. 

Prussia  conducts  her  records  probably  as  she  does  her  other 
public  aflPairs,  with  a  full  regard  to  realities,  yet  she  records  a 
mortality  of  1  in  108  deliveries  out  of  a  total  of  7,654,021. 

Dr.  Duncan  followed  up  Dr.  M'Clintock^s  inquiries  as  to  the 
deaths  omitted  in  the  registration  returns  of  deaths  of  childbed 
with  the  result, — among  the  married  women  alone,  of  showing 
the  deaths  to  be  153  instead  of  118  in  Edinburgh  and  Glasgow 
in  1855.  Now,  we  conceive  Miss  Nightingale,  and  those  who 
think  with  her,  can  take  their  choice  of  the  comparatively 
small  figures  in  relation  to  this  matter  in  the  case  of  the  joint 
numbers  in  Edinburgh  and  Glasgow  and  the  large  numbers 
seen  in  the  grand  total  of  Prussian  returns,  in  each  case  strangely 
at  variance  with  the  position  attempted  to  be  taken  by  those  of 
the  anti-maternity  school,  if  we  may  be  allowed  to  coin  the 
expression. 

The  question  of  so- called  hospitalism  has  very  much  hinged, 
in  all  past  discussions,  both  oral  and  written,  upon  the  experi- 
ence gained  in  those  hospitals  used  for  the  relief  of  lying-in 
women  and  therefore  we  have  in  the  present  paper  confined  our 
remarks  almost,  if  not  entirely,  to  those  establishments,  nor 
does  our  space  permit  us  now  to  enter  into  the  consideration  of 
institutions  intended  for  other  classes  of  cases. 

Dr.  Johnston  in  his  recent  address  answers  the  question^  as 


Reviews.  [April, 

to  the  practicability  of  maintaining  large  maternities  as  safe 
asylums,  in  the  affirmative,  and  he  shows  that,  as  we  have  before 
noticed,  individuals  were  received  not  only  from  the  midst  of 
their  families,  other  members  of  which  were  actually  suffer- 
ing from  typhus,  typhoid,  erysipelas,  scarlatina,  or  smallpox,  as 
the  case  may  have  been,  and  in  many  instances  the  parturient 
was  herself  suffering  from  one  or  other  such  disease,  yet  in  no  one 
instance  did  the  malady  extend  beyond  the  individual  so  affected. 

He  does  not  presume  to  maintain  that  hospitals  can  be  kept 
inviolate  from  epidemics  any  more  than  the  mansions  of  the 
rich  or  the  hovels  of  the  poor,  but  he  contends  that  it  is  within 
the  bounds  of  possibility  to  render  even  large  hospitals  as  safe 
as  private  dwellings,  and  certainly  more  so  than  the  hovels  of 
the  poor. 

What  have  been  the  means  pursued  in  the  Rotunda  for  the 
purpose?  The  report  enumerates  the  following;  namely, 
— perfect  purity  of  the  atmosphere,  secured  by  not  over- 
crowding patients  together,  by  allowing  ample  cubic  space  for 
each  individual,  with  thorough  ventilation ;  strict  cleanliness ; 
not  allowing  labour  to  run  on  too  long,  i.e.,  to  the  verge  of 
inflammation,  and  giving  a  generous  but  judicious  diet  from 
the  commencement  according  to  the  circumstances  of  the  case. 

To  complete  the  notice  of  the  report  of  a  large  maternity  it 
is  perhaps  right  to  give  an  idea  of  the  obstetric  features  of  the 
cases  treated  in  the  Dublin  Lying-in  Hospital,  or,  as  it  is  com- 
monly called,  the  "Rotunda/^  Of  the  1161  cases  403  were 
primiparse  and  758  pluriparse ;  of  the  foregoing  19  were  tedious, 
but  did  not  require  artificial  aid,  the  delay  being  in  the  first 
stage ;  24  were  abortions ;  56  were  preternatural  cases,  8  of  which 
presented  with  the  shoulder,  elbow,  or  hand;  4  were  breech  or 
lower  extremity  presentations;  64  were  forceps  cases.  In  2 
cases  the  crotchet  had  to  be  used,  and  in  4  the  cephalotribe ;  of 
these  there  was  distinct  evidence  that  the  child  was  dead  in  5, 
and  this  point  was  doubtful  in  one  instance.  In  39  cases  the 
labour  was  complicated,  viz.,  16  had  twins,  8  were  cases  of 
accidental  haemorrhage,  1  of  placenta  prsevia,  5  of  post-partum 
haemorrhage ;  in  9  cases  the  placenta  was  morbidly  adherent ; 
in  8  there  was  prolapse  of  the  funis,  in  1  rupture  of  the  uterus, 
in  2  convulsions,  and  in  1  epilepsy;  mania  occurred  in  12  in- 
stances.    In  55  chloroform  was  used. 

Of  the  diseases  remarked  there  were  25  cases  of  peritonitis, 
1  of  puerperal  fever,  1  of  metritis,  5  of  phlebitis,  4  of  pyaemia, 
4  of  sloughing  of  vagina  and  perinaeum,  1  of  gangrene  of  the 
uterus,  5  of  scarlatina,  1  of  variola,  3  of  erysipelas,  2  of  typhoid 
and  1  of  typhus  fever ;  and,  lastly,  36  of  bronchitis,  and  one  of 
pneumonia. 


1872.] 


Watson's  Practice  of  Physic,  369 


We  have  in  the  foregoing  remarks  and  quotations  devoted 
some  space  especially  to  enable  our  readers  the  better  to  com- 
prehend the  differences  obtaining  between  cases  that  seek  the 
aid  and  shelter  of  a  public  maternity  hospital,  and  the  average 
run  of  cases  met  with  in  healthy  rural  districts,  and  in  the 
well-found  and  well-circumstanced  military  hospitals ;  and,  in 
conclusion,  we  would  suggest  to  book  makers  and  critics  the 
necessity  of  comparing  like  with  like. 


VIII.— Watson's  Practice  of  Physic.^ 

Since  the  first  public  announcement  that  Sir  Thomas  Watson 
was  engaged  in  preparing  a  new  edition  of  his  lectures,  the 
question  has  often  been  asked,  and  more  than  once  we  have 
heard  it  discussed,  whether  he  did  well  to  undertake  a  task  so 
difficult  and  laborious  as  that  of  attempting  to  incorporate  into 
his  celebrated  work  the  available  results  of  medical  research 
during  the  fourteen  years  which  have  elapsed  since  the  publica- 
tion of  the  last  edition.  The  question  was  raised  by  those  who 
held  Sir  Thomas  Watson  in  the  highest  respect  and  esteem,  and 
who  naturally  feared  lest  his  reputation  as  an  exact,  trustworthy, 
and  eloquent  teacher  should  suffer  through  any  faulty  perform- 
ance of  the  difficult  task  which  he  had  undertaken.  The  work 
has  now  been  for  some  months  in  the  hands  of  the  profession ; 
it  has  been  examined  and  criticised  publicly  and  privately,  and 
the  result  is  a  general  concurrence  of  opinion  that  while,  as  in 
every  human  production,  it  is  not  difficult  to  point  to  faults  and 
omissions,  it  is  yet  easier  and  far  more  agreeable  to  indicate  in 
nearly  every  lecture  of  the  series  the  results  of  a  most  careful  and 
conscientious  revision,  and  these,  too,  expounded  by  a  pen  which 
has  evidently  lost  none  of  its  marvellous  skill.  The  traces  of 
retouching  by  the  hand  of  a  master  are  evident  at  the  very 
commencement  of  the  work.  The  first  part  of  the  well-known 
introductory  lecture,  with  its  eloquent  and  touching  peroration, 
has  been  rewritten.  In  this  newly  written  part  the  student  is 
earnestly  warned  not  to  lose  or  neglect  the  precious,  but  short 
and  fleeting  opportunity  which  is  afforded  him  by  his  hospital 
attendance.  Reference  is  then  made  to  the  study  of  anatomy 
and  physiology,  in  a  passage  which  we  cannot  resist  the  tempta- 
tion to  quote : 

"  Do  not  think  that  I  am  wandering  from  my  proper  subject  when 
I  bid  you  remember  how  profoundly  interesting,  how  almost  awful 
is  this  study  in  itself,  and  for  its  own  sake,  revealing,  as  it  surely 

I  Lectures  on  the  Principles  and  Practice  of  Physic.  By  Sir  Thomas  Watson, 
Bart.,  M.D.,  F.R.S.     Fifth  edition.     London,  1871. 


370  Reviews.  [April, 

does,  the  inimitable  workmanship  of  a  hand  that  is  divine.  Do  not 
lose  or  disregard  that  grand  and  astonishing  lesson.  Do  not  listen 
to  those  who  may  tell  you  not  to  look  for  the  evidence  of  purpose  in 
this  field  of  study ;  that  the  visible  mechanism  of  that  intricate,  but 
marvellously  perfect  and  harmonious  work,  the  animal  body — the 
numberless  examples  it  contains  of  means  suited  to  ends,  of  fitness 
for  a  use,  of  even  prospective  arrangements  to  meet  future  needs,  of 
direct  provisions  for  happiness  and  enjoyment — that  all  these  have 
no  force  at  all,  in  true  philosophy,  as  evidences  of  design.  For  my 
own  part  I  declare  that  I  can  no  more  avoid  perceiving,  with  my 
mental  vision,  the  evidential  marks  of  purpose  in  the  structure  of  the 
body  than  I  can  help  seeing  with  my  own  eyes  in  broad  daylight 
the  objects  that  stand  before  my  face.  There  are,  however,  minds, 
very  powerful  and  cultivated  minds,  too,  that  cannot  or  will  not,  or  at 
least  do  not,  recognise  or  acknowledge  these  teachings  of  anatomy, 
but  denounce  as  unscientific  and  unsound  all  reference  to  final 
causes  in  nature.  To  me,  believing  in  their  honesty,  this  is  intel- 
ligible only  on  the  hypothesis  suggested  by  an  eminent  living  philo- 
sopher and  anatomist,  that  the  minds  in  question  labour  under  some 
defect  analogous  to  that  which  renders  certain  eyes  imperfect  and 
untrustworthy,  and  which  has  received  the  name  of  colour-blindness." 

We  believe  that  we  shall  best  succeed  in  our  endeavour  to 
give  a  fair  and  accurate  statement  of  the  extent  and  thorough- 
ness of  the  revision  to  which  these  lectures  have  been  subjected 
by  referring  first  to  some  of  the  leading  scientific  questions 
which  are  discussed,  and  subsequently  to  the  important  subject 
of  the  treatment  of  disease. 

Very  early  in  the  first  volume  we  discover  that  Sir  Thomas 
Watson  keeps  himself  au  courant  with  the  progress  of  phy- 
siology. He  distinctly  recognises  the  fact  that  the  function 
of  the  minute  muscular  arteries  is  to  regulate  the  blood- 
supply  in  accordance  with  the  requirements  of  the  various 
tissues  and  organs  ;  and  he  applies  this  modern  but  now  gene- 
rally accepted  physiological  doctrine  in  explanation  of  a  variety 
of  pathological  phenomena  in  a  manner  which  we  will  now 
endeavour  briefly  to  explain.  It  has  long  been  known  that,  in 
cases  of  death  from  apnoea,  the  circulation  through  the  lungs  is 
in  some  way  impeded  and  finally  arrested.  It  has  been  very 
generally  assumed  that  the  blood  is  brought  to  a  stand  by  some 
influence  exerted  upon  it  by  the  pulmonary  capillaries ;  but  Sir 
Thomas  Watson  clearly  shows  that,  in  cases  of  acute  apnoea,  the 
capillaries  are  empty  of  blood,  that  therefore  the  blood  must 
have  been  arrested  before  it  arrived  at  the  capillaries,  and  the 
only  conceivable  cause  of  this  arrest  is  the  contraction  of  the 
muscular  walls  of  the  minute  arteries  under  the  influence  of  the 
vaso-motor  nerves. 

"  It  was  reserved,"  he  says,  "for  Dr.  George  Johnson  to  sug- 


1872.]  Watson's  Practice  of  Physic.  371 

gest,  that  when  the  conversion  of  venous  into  arterial  blood  in 
the  pulmonary  capillaries  is  suspended,  the  stream  of  dark  blood 
is  arrested  by  what  he  happily  calls  the  stop-cock  action  of  the 
ultimate  pulmonary  arteries/'  If  now  we  turn  to  the  lecture  on 
acute  laryngitis,  we  find  the  same  physiological  principle  applied 
in  a  very  interesting  way  to  explain  the  state  of  lung  and  of 
pulmonary  artery  gradually  induced  by  obstruction  in  the  larynx, 
a  state  which  renders  intelligible  the  occasional  inadequacy  of 
tracheotomy  to  save  life.  The  explanation  is,  that  the  ob- 
struction in  the  larynx  limits  the  supply  of  air  to  the  lungs ; 
the  blood  in  the  pulmonary  capillaries  is  imperfectly  aerated,  and 
some  partially  aerated  blood  passes  on  into  the  systemic  arteries. 
At  the  same  time  the  minute  pulmonary  arteries  by  their  con- 
traction lessen  the  supply  of  blood  to  the  pulmonary  capillaries 
in  proportion  to  the  limited  access  of  air.  The  blood  accumu- 
lates therefore  in  the  trunk  and  larger  branches  of  the  pulmo- 
nary artery,  in  the  right  cavities  of  the  heart  and  in  the 
systemic  veins.  The  distension  of  the  superficial  veins  renders 
the  lips  and  the  skin  more  or  less  livid ;  while  the  retrograde 
engorgement  of  the  bronchial  veins  and  capillaries,  which  belong 
to  the  systemic  venous  system,  results  in  a  serous  effusion  into 
the  bronchial  tubes.  This  serous  exudation  gravitates  towards 
the  bases  of  the  lungs,  filling  the  air-cells  and  smaller  bronchi, 
and  thus  still  further  impeding  respiration.  Meanwhile  the 
slowly  moving,  partially  stagnating  blood  in  the  pulmonary- 
artery  becomes  more  and  more  viscid,  and  at  length  partially 
coagulates.  Hence,  on  post-mortem  examination,  fibrinous 
coagula,  which  had  evidently  been  in  process  of  formation  for 
several  hours  before  death,  are  often  found  in  the  pulmonary 
artery.  Secondary  causes  of  apnoea  are  thus  established,  which 
do  not  cease  when  the  primary  cause  is  removed  by  the  ope- 
ration of  tracheotomy.  Obviously,  then,  the  practical  lesson  is, 
in  suitable  cases,  to  resort  to  that  operation  before  this  unfavor- 
able state  of  lung  and  of  pulmonary  artery  has  been  induced  by 
long-continued  partial  apnoea. 

The  next  disease  upon  whose  pathology  the  recognition  of  the 
true  function  of  the  minute  muscular  arteries  has  shed  a  new 
light  is  epilepsy.  Sir  Thomas  refers  to  the  opinion  which 
formerly  prevailed,  that  an  overfull  condition  of  the  cerebral 
vessels  is  the  proximate  cause  of  that  terrible  malady;  and  he 
points  out  that  the  phenomena  of  the  disease  are  inconsistent  with 
this  theory.  He  then  goes  on  to  state  that  the  very  opposite 
condition  of  the  cerebral  circulation,  extreme  emptiness  of  the 
blood-vessels  of  the  brain,  is  now  generally  believed  to  deter- 
mine the  fit.  Clearly,  as  he  says,  the  cause  of  the  fit  must  be 
some  condition  which  may  be  both  sudden  and  transitory ;  and 


372  Reviews.  [April, 

such  a  condition  an  abrupt  and  brief  privation  of  arterial  blood 
would  furnish.  Reference  is  then  made  to  the  experiments  of 
Kussmaul  and  Tenner,  who  in  numberless  instances  threw  rab- 
bits into  epileptiform  convulsions  by  ligaturing  their  carotids 
and  subclavians,  and  thus  suddenly  arresting  the  circulation 
through  the  brain.  Again,  it  is  shown  that  convulsions  fre- 
quently result  from  a  profuse  and  rapid  haemorrhage.  If,  then, 
as  appears  probable  from  a  consideration  of  these  facts,  sudden 
anaemia  of  the  brain  be  the  immediate  cause  of  an  epileptic 
paroxysm,  a  rapid  and  energetic  contraction  of  the  minute 
cerebral  arteries  affords  a  sufficient  explanation  of  the  abrupt 
arrest  of  the  circulation  through  the  brain;  and  this  theory  of  the 
proximate  pathology  of  epilepsy  is  now  generally  accepted. 

Then,  turning  to  a  very  different  but  a  scarcely  less  terrible 
disease,  the  impeded  circulation  through  the  lungs,  now 
believed  to  be  the  essential  cause  of  the  collapse  stage  of  cholera, 
is,  for  reasons  which  we  shall  presently  state  at  some  length, 
ascribed  to  the  contraction  of  the  identical  minute  pulmonary 
arteries,  which,  as  we  have  seen,  are  the  immediate  cause  of  the 
arrested  circulation  in  cases  of  death  from  apnoea. 

The  arterial  contraction  which  is  now  admitted  to  form  so 
important  an  element  in  the  pathology  of  the  diseases  hitherto 
referred  to  is  of  a  more  or  less  transient  character — sudden  and 
paroxysmal  in  the  cerebral  vessels  of  an  epileptic  patient,  more 
persistent  in  the  pulmonary  vessels  during  apnoea  and  cholera 
collapse.  There  is,  however,  one  class  of  cases  in  which  this 
arterial  contraction  is  so  vigorous  and  so  continuous  as  to 
result  in  hypertrophy  of  the  muscular  walls  of  the  arteries 
concerned. 

Sir  Thomas  Watson,  in  his  lecture  on  Bright's  disease,  refers 
to  the  fact  which  was  first  made  known  by  Dr.  Bright,  that  in  a 
large  proportion  of  cases  of  chronic  Bright^s  disease,  the  left 
ventricle  of  the  heart  is  found  hypertrophied,  even  when  there  is 
no  disease  of  the  valves  or  of  the  large  arteries  to  explain  the 
hypertrophy.     Sir  Thomas  goes  on  to  say, 

"Dr.  Bright  suggested  that  the  altered  qualities  of  the  blood 
might  so  affect  the  minute  and  capillary  circulation  as  to  render 
greater  action  necessary  to  force  the  blood  through  the  distant  sub- 
divisions of  the  vascular  system.  But  to  Dr.  Johnson  must  be 
given  the  merii  of  having  discovered  the  true  and  full  cause  of  this 
hypertrophy  of  the  left  ventricle,  in  the  fact  that  the  muscular  walls 
of  the  small  arteries,  not  only  in  the  kidneys,  but  also  in  most  or  all 
of  the  tissues  of  the  body,  in  these  cases  of  chronic  Bright's  disease 
are  greatly  hypertrophied.  The  fact  itself  is  demonstrable,  and 
beyond  question.  This  excessive  growth  of  muscular  tissue  implies 
long  continued  over-action ;  and  since  the  tonic  contraction  of  the 


1872.]  Watson's  Practice  of  Physic.  373 

small  arteries  is  known  to  oppose  the  passage  of  blood,  the  hyper- 
trophy of  the  left  ventricle  is  presumably  due  to  the  excessive 
resistance  offered  to  the  circulation,  by  the  excessive  contraction  of 
the  minute  arteries,  this  excessive  contraction  being  the  consequeiice 
of  the  irritant  action  oF  the  deteriorated  blood." 

Once  more,  iu  the  lecture  on  apoplexy,  Sir  Thomas  Watson 
applies  this  doctrine  in  explanation  of  some  cases  of  cerebral 
hsemorrhage  occurring,  as  it  often  does,  in  association  with 
chronic  Bright's  disease  : 

"  The  arterial  stop-cocks  resist  the  passage  of  the  unpurified 
blood  into  the  capillaries.  The  strong  left  ventricle  strives  to  force 
on  the  blood.  The  resulting  distension  of  the  systemic  arteries  is 
indicated  by  the  full  and  hard  radial  pulse,  and  by  the  existence  of 
increased  arterial  tension  afforded  by  the  sphygmograph.  There  is 
thus  excessive  pressure  on  the  whole  of  the  arterial  pipes  between 
the  stop-cocks  and  the  forcing-pumps;  and  in  the  struggle  between 
the  two  contending  forces  a  minute  artery  in  the  brain  may  be 
broken,  and  so  cerebral  haemorrhage  may  occur." 

With  reference  to  hypertrophy  of  the  muscular  walls  of 
the  minute  arteries  —  a  tissue  change  which  may  be  taken 
as  a  true  index  of  self-registered  continuous  over  action  of 
the  arterial  stop-cocks — we  venture  to  suggest  that  if  this 
interesting  discovery,  instead  of  being  of  home  production, 
had  been  imported  from  the  Continent,  it  would  have  been 
more  heartily  welcomed  and  more  loudly  heralded  than  it 
has  hitherto  been.  It  has  always  appeared  to  us  that 
amongst  the  most  striking  characteristics  of  Sir  Thomas 
Watson  have  been  his  aptitude  to  learn  and  to  unlearn,  his 
readiness  in  availing  himself  of  the  results  of  recent  research, 
and  his  generous  appreciation  of  other  men^s  labours.  It 
appears  to  us  that  he  has  done  good  service  to  the  cause  of 
rational  and  scientific  medicine  by  so  interweaving  into  the 
texture  of  his  discourses  these  modern  discoveries  and  doc- 
trines relating  to  the  circulation,  as  to  show  in  the  clearest 
and  most  convincing  manner  not  only  their  high  scientific 
interest,  but  also  that  the  light  which  they  throw  upon  some 
very  intricate  morbid  phenomena  affords  material  and  valu- 
able aid  in  the  treatment  of  disease. 

Plugging  of  the  vessels  by  embolism  and  by  thrombosis  is 
referred  to  and  discussed  in  connection  with  the  various 
phenomena  to  which  it  gives  rise.  Thus,  in  the  interesting 
lecture  on  the  dififerent  modes  of  dying,  allusion  is  made  to 
the  not  uncommon  case  of  a  clot  of  fibrine  either  brought 
from  a  distant  vein,  or  formed  within  the  right  chambers  of 
the  heart,  getting  into  the  current  of  blood,  and  plugging 
the  pulmonary  artery.     If  the  obstruction  be  complete  death 


374  Reviews.  [April, 

may  be  instantaneous  ;  if  the  vessel  be  not  perfectly  sealed, 
extreme  dyspnoea,  with  pallor  and  faintness,  comes  on  at 
once,  and  the  patient  dies  within  a  period  ranging  from  a 
few  minutes  to  several  hours.  Then  attention  is  directed  to 
the  fact  that  an  impediment  to  the  supply  of  blood  to  the 
lungs  through  the  pulmonary  artery  causes  dyspnoea  as 
urgently  as  an  impediment  to  the  supply  of  air  to  the  lungs 
through  the  air-passages;  and  it  is  shown  that  physiologically 
this  is  explicable  by  the  want,  common  in  both  cases,  of 
aerated  blood  by  the  system,  expressing  itself  in  the  chemical 
cry  from  the  famishing  tissues  for  the  indispensable  oxygen. 
What  is  peculiar  to  this  mode  of  dying  is  that  the  circulation 
is  stopped,  yet  not  by  asthenia,  and  the  function  of  respiration 
is  suspended,  yet  not  by  apnoea.  Death  does  really  in  this  case 
begin  in  the  lungs,  and  the  mode  of  dying  may  with  literal 
accuracy  be  called  death  by  pulmonary  asphyxiay  or  pulseless- 
ness in  the  pulmonary  artery. 

Embolism  and  thrombosis  are  further  discussed  in  the  lectures 
on  apoplexy,  and  are  there  shown  to  be  a  not  infrequent 
cause  of  hemiplegia  and  white  softening.  Again,  in  the 
lecture  on  chorea,  which  has  been  in  great  part  rewritten, 
reference  is  made  to  the  frequent  association  of  chorea  with 
endocarditis,  and  the  views  of  Dr.  Kirkes,  Dr.  Hughlings 
Jackson,  Dr.  Tuckwell,  and  others,  are  discussed.  It  is  pointed 
out  that  the  one-sided  character  of  the  disease  has  an  im- 
portant bearing  on  its  pathology,  for  it  shows  at  least  this, 
that  the  same  region  of  the  brain  is  concerned,  directly  or  in- 
directly, in  that  disease,  in  hemiplegia,  and  in  epileptic  hemi- 
spasm ;  the  region,  namely,  which  includes  the  corpus  striatum, 
the  optic  thalamus,  and  the  structures  adjacent.  Occasionally 
hemichorea  runs  into  hemiplegia,  and  conversely  hemiplegia 
is  occasionally  accompanied  by  choreiform  movements,  and  it 
even  improves  sometimes  into  chorea,  paralysis  being  succeeded 
by  a  return  of  motor  power,  but  of  an  incomplete  and  disor- 
derly character.  Again,  the  same  muscles  are  affected  in  he- 
mispasm as  in  hemichorea,  and  if,  as  has  been  appositely  said, 
chorea  be  "  next  door  to  palsy,"  it  is  as  near  a  neighbour  to 
epilepsy  also,  and  not  unfrequently  traceable  to  similar  ex- 
citing causes. 

Sir  Thomas  Watson  accepts  the  conclusion  that  chorea 
"is  often,  not  always,  the  ultimate  result  of  the  injection  of 
molecular  particles  of  fibrine  into  some  of  the  minutest  ar- 
teries or  capillaries  of  the  nervous  tissue/'  and  he  alludes 
to  the  probability  that  the  chorea  which  results  from  fright, 
or  other  emotional  disturbance,  may  be  due  to  a  temporary 
interruption  of  the  circulation  through  a  limited  portion  of 


1872.]  Watson's  Practice  of  Physic,  375 

the  brain^  caused  by  spasm  of  the  minute  cerebral  arteries; 
so  that  "  molecular  embolism  and  spasm  of  the  minute 
arteries  would  have,  common  to  them  both,  the  effect  of 
depriving  a  portion  of  the  brain  mass  of  its  due  supply  of 
nutritive  blood." 

Much  care  and  labour  have  evidently  been  bestowed  upon 
the  revision  of  the  lectures  on  diseases  of  the  nervous  system. 
Amongst  the  subjects  which  have  attracted  especial  attention 
since  the  publication  of  the  last  edition  of  these  lectures  one 
of  the  most  interesting  and  intricate  is  that  of  aphasia ;  and 
we  would  refer  to  Sir  Thomas  Watson's  treatment  of  this 
subject  as  an  admirable  example  of  methodical  and  lucid 
statement.  The  facts  are  set  forth  in  orderly  array,  the 
clinical  history  of  the  affection  is  given  with  remarkable  com- 
pleteness, and  the  various  speculations  to  which  it  has  given 
rise  receive  due  consideration,  reference  being  made  to  the 
observations  of  Drs.  Bateman,  Bastian,  Broadbent,  Hugh- 
lings  Jackson,  Maudsley,  Moxon,  Ogle,  Sanders,  Wilks,  &c. 
Two  diseases  are  here  introduced  for  the  first  time  :  these  are 
locomotor  ataxy  and  progressive  muscular  atrophy.  We  can 
understand  that  some  readers  would  have  been  better  pleased  to 
find  a  longer  and  more  elaborate  history  of  these  formidable 
maladies,  but  the  narrative  as  we  have  it  is  a  model  of  clear 
and  condensed  statement. 

In  the  discussion  of  the  subject  of  Croup  we  find  much 
that  is  new  and  interesting.  It  is  shown  that  in  this  country 
the  term  has  been  applied  to  three  distinct  forms  of  disease  :  thus 
we  have,  1,  Spasmodic  Croup,  or  laryngismus  stridulus,a  purely 
nervous  affection,  unattended  by  structural  change  of  any  kind 
in  the  larynx;  2,  Inflammatory  Croup,  or  infantile  laryngitis, 
a  catarrhal  affection  of  the  larynx,  not  contagious,  and  not 
resulting  in  the  exudation  of  false  membrane  within  the 
larynx;  3,  Diphtheritic  Croup,  or  membranous  laryngitis,  the 
exudation  of  false  membrane  within  the  larynx  being  a  result 
of  the  specific  general  and  contagious  disorder  diphtheria. 

It  has  long  been  the  custom  with  French  writers  to  limit 
the  term  croup  to  this  last  class  of  cases,  namely,  those  in 
which  a  diphtheritic  exudation  extends  into  the  larynx ; 
with  them  croup  forms  a  part  of  the  history  of  diphtheria. 
The  name  is  of  little  importance  so  long  as  we  have  a  definite 
notion  of  what  it  is  intended  to  designate,  but  Sir  Thomas 
Watson  shows  that  ever  since  the  publication  of  Dr.  Home's 
pamphlet  on  ^^  Croup,"  in  1765,  English  writers  on  this 
subject  have  confounded  under  this  one  name  two  totally 
distinct  diseases.  In  describing  croup  they  give  the  history, 
the  symptoms,  and  the  treatment  of  catarrhal  laryngitis,  but 


376  Reviews.  [April, 

with  this  they  combine  the  morbid  anatomy  of  diphtheria. 
After  a  careful  consideration  of  the  subject  our  author 
arrives  at  the  conclusion  that  croup  accompanied  by  false 
membranes  in  the  larynx  is  always  diphtheritic,  whether  in  the 
child  or  in  the  adult,  and  that  simple  laryngitis  or  inflamma- 
tory croup  is  never  associated  with  the  exudation  of  false 
membrane.  We  are  grateful  to  Sir  Thomas  Watson  for 
having  placed  this  important  matter  in  so  clear  a  light. 
Etymologically  we  believe  that  the  word  croup  signifies  a 
noise  in  the  throat  such  as  is  made  by  crows  or  frogs;  the 
term  might,  therefore,  with  equal  propriety  be  applied  to  all 
the  three  forms  of  disease^  the  spasmodic,  the  inflammatory, 
and  the  diphtheritic.  It  might,  perhaps,  be  better  to  use  it 
as  a  generic  term,  with  a  prefix  designating  the  specific  form 
of  croup  referred  to.  It  is  obviously  of  vital  importance  that 
two  diseases  so  distinct  in  their  pathological  history  as  diph- 
theria and  catarrhal  laryngitis  should  not  be  confounded 
under  one  name.  One  result  of  this  confusion  in  past  times 
has  been  that  in  numberless  instances  children  suff'ering 
from  inflammatory  croup  have  been  injuriously  medicated 
by  mercury,  with  a  view  to  prevent  a  dreaded  exudation  of 
lymph  within  the  larynx;  yet  an  exact  knowledge  of  the 
nature  of  the  disease  would  have  shown  that  no  such  exuda- 
tion ever  occurs  as  a  result  of  catarrhal  laryngitis ;  while,  on 
the  other  hand,  if  the  case  were  one  of  laryngeal  diphtheria 
mercury  is  powerless  to  prevent  the  exudation.  The  obvious 
inference  is  that  mercury,  except  occasionally  as  a  purgative, 
is  not  an  appropriate  remedy  for  any  form  of  croup. 

In  discussing  the  subject  of  tubercle  and  phthisis  the  results 
of  all  modern  researches  and  speculations  are  passed  in  review. 
Reference  is  made  to  the  experiments  of  Villemin,  of  Simon, 
Sanderson,  and  Wilson  Fox  ;  and  accepting  Dr.  Andrew  Clark's 
definition  of  phthisis  pulmonalis  as  "  comprehending  all  pro- 
gressive consolidations  and  circumscribed  suppurative  degene- 
rations of  the  lung,''  the  disease  is  shown  to  be  one  of  many 
forms  and  aspects.  The  chief  of  these  are  discriminated  and 
described. 

The  lecture  which  in  the  present  edition  has  undergone  the 
greatest  amount  of  change — a  change  so  great  as  to  constitute 
a  complete  reversal  of  its  author's  former  doctrines — is  that  on 
cholera.  We  observe  that  some  critics  have  expressed  regret 
that  Sir  Thomas  Watson  should  have  unreservedly  accepted 
Dr.  George  Johnson's  views  as  to  the  nature  and  treatment  of 
cholera,  yet  they  make  no  attempt  to  point  out  wherein  consists 
the  error  of  the  teaching  which  they  profess  to  dislike. 

No  one  who  reads  Sir  Thomas  Watson's  rewritten  account  of 


1872.]  Watson's  Practice  of  Physic.  S77 

the  pathology  and  treatment  of  cholera  can  fail  to  see  that  he 
has  thoroughly  reconsidered  and  studied  the  whole  subject,  and 
that  the  arguments  which  he  adduces  in  opposition  to  the  older 
doctrines  and  in  favour  of  the  new  are  such  as  it  would  be  very 
difficult  to  refute  or  to  gainsay.  He  shows  that  the  theory  of 
the  collapse  of  cholera  being  a  result  of  the  drain  of  liquid 
through  the  alimentary  canal  is  inconsistent  with  the  fact,  that 
in  the  worst  cases  there  is  rather  an  inverse  than  a  direct 
relation  between  collapse  and  discharges ;  that  the  symptoms  of 
collapse  are  not  such  as  exhausting  discharges  would  give  rise 
to ;  that  they  are  not  beneficially  influenced  by  the  remedies — 
alcoholic  stimulants,  for  instance — which  have  a  telling  effect  in 
cases  of  mere  exhaustion;  that  the  state  of  collapse  passes  off 
while  the  discharges  continue,  and  that  recovery  from  collapse 
is  often  so  rapid  as  to  be  inconsistent  with  the  theory  of 
exhaustion  by  profuse  discharges.  Then,  on  the  other  hand,  it 
is  shown  that  all  the  facts  of  the  disease  are  consistent  with  the 
theory  that  the  essential  cause  of  choleraic  collapse  is  au 
impeded  flow  of  blood  through  the  lungs,  and  consequently 
through  the  whole  system ;  the  immediate  cause  of  this  impedi- 
ment being  the  contraction  of  the  minute  pulmonary  arteries 
upon  the  poisoned  blood. 

The  morbid  anatomy  of  the  disease  is  in  entire  harmony 
with  this  theory.  The  left  side  of  the  heart  being  empty  or 
nearly  so,  while  the  right  cavities,  the  large  systemic  veins,  and 
the  pulmonary  artery  to  its  minutest  ramifications  are  distended 
with  black  blood.  The  extreme  anaemia  of  the  pulmonary  ca- 
pillaries is  explained  by  the  fact  that  the  stop- cock  action  of 
the  minute  arteries  has  arrested  the  blood  before  it  could  reach 
the  capillaries.  This  abrupt  stoppage  of  the  blood  explains  on 
the  one  hand  the  emptiness  of  the  systemic  arteries,  and  on 
the  other  the  fulness  of  the  systemic  veins  and  the  consequent 
lividity  of  the  surface.  The  scantiness  of  the  oxygen-bearing 
blood-stream  in  the  arteries  explains  the  lowering  of  the  tem- 
perature, and  the  suppression  of  those  secretions,  bile  and  urine 
in  particular,  which  are  products  of  oxidation ;  while  it  is  inter- 
esting to  observe  that  when  a  nursing  mother  is  passing  through 
the  stage  of  collapse,  the  mammary  secretion  continues  appa- 
rently unchecked,  and  the  breasts  become  painfully  distended. 
The  most  reasonable  explanation  of  this  being  the  fact  that  the 
milk  constituents,  curd,  sugar,  oil,  and  water,  may  be  obtained 
from  unoxidised  blood. 

The  discharges  from  the  stomach  and  bowels  are  looked  upon 
as  the  means  by  which  the  morbid  poison  and  its  products  are 
eliminated.  It  is  a  notorious  fact,  and  confirmatory  of  this 
view,  that  recovery  from  collapse  is  always  associated  with  a 


378  Reviews.  [April, 

continuance  of  the  discharges,  while,  on  the  other  hand,  an 
abrupt  and  complete  arrest  of  the  discharges  during  the  state 
of  collapse  is  a  sign  of  fatal  import.  Surely,  then,  there  is 
reason  to  believe  that  these  discharges  are  an  essential  part  of 
that  process  by  which  a  natural  cure  is  effected.  If  this  be  so, 
then,  as  Sir  Thomas  Watson  says  : 

"  It  must  be  wrong  to  dam  the  choleraic  poison  and  its  products 
within  the  body.  Even  when  those  products  have  in  one  sense  been 
separated  from  the  system,  they  may  produce  highly  noxious  effects 
if  they  remain  shut  up  in  the  stomach  or  bowels,  there  to  ferment 
and  decompose.  Admitting,  as  we  must,  that  a  minute  quantity  of 
the  morbid  excretions  swallowed  with  water  may  suffice  to  produce 
the  disease,  a  large  quantity  retained  through  weakness  of  the  ex- 
pulsive powers  or  otherwise  can  scarcely  be  harmless.  Eather  may 
we  expect  that  its  expulsion  will  tend  to  liberate  the  patient  from 
danger  and  discomfort." 

Heference  is  made  to  the  success  of  the  evacuant  or  cleans- 
ing treatment  in  all  stages  of  the  disease,  as  shown  by  the 
results  of  a  large  number  of  cases  treated  in  the  Liverpool 
parish  infirmary,  and  recorded  by  Drs.  M'^Cloy  and  Robertson, 
in  the  50th  volume  of  the  'Medico-Chirurgical  Transactions.' 
In  our  endeavour  to  present  a  brief  sketch  of  this  most  im- 
portant lecture,  we  have  done  but  scant  justice  to  the  subject ; 
we  trust,  however,  that  we  have  said  enough  to  show  that  no 
practitioner  of  medicine  can  with  safety  or  credit  to  himself 
remain  in  ignorance  of  the  arguments  here  set  forth.  We 
venture  also  to  suggest  that,  unless  the  statements  can  be  shown 
to  be  erroneous  or  the  reasoning  inconclusive,  the  inevitable 
practical  conclusion  will  have  to  be  accepted ;  as  we  believe  it 
has  been  by  a  large  and  rapidly  increasing  number  of  the  pro- 
fession, and  we  may  add,  too,  of  the  intelligent  and  reading 
portion  of  the  public. 

In  the  lecture  on  mechanical  occlusion  of  the  intestinal  tube 
Sir  Thomas  Watson  refers  to  and  accepts  as  probably  true  the 
late  Dr.  Brinton^s  theory  of  faecal  vomiting. 

Dr.  Brinton  maintained  that  there  is  no  such  thing  as  a  re- 
versed peristaltic  action  of  the  intestine.  He  believed  the 
reflux  of  the  contents  of  the  gut  to  be  caused  by  the  direct  and 
forward  propulsive  action  of  the  impeded  bowel;  part  of  the 
force  being  expended  against  the  sides  of  the  bowel,  which  yield 
and  become  stretched,  part  in  producing  a  backward  current 
along  the  axis  of  the  bowel.  We  confess  that  we  find  a  difficulty 
in  accepting  this  theory.  Sir  Thomas  admits  two  facts  in 
contravention  of  the  absoluteness  of  the  rule,  namely,  the 
regurgitation  of  food  from  the  cardiac  end  of  the  stomach  into 
the  mouth,  and  of  bile  from  the  duodenum  into  the  stomach. 


1872.]  Watson's  Practice  of  Physic.  379 

A  reversed  action  of  the  oesophagus  and  of  the  duodenum  being 
proved,  there  is  an  a  priori  probability  that  the  same  reversal 
of  the  peristaltic  movement  may  occur  in  other  parts  of  the 
canal ;  and  we  see  no  other  way  of  accounting  for  the  fact  that 
whereas  in  cases  of  obstruction  at  the  lower  part  of  the  ileum 
the  distended  and  dilated  portion  of  bowel  extends  only  to  a 
distance  of  a  few  yards  above  the  seat  of  obstruction,  a  portion 
of  the  contents  of  the  distended  bowel  finds  its  way  backwards 
to  the  stomach  and  is  vomited.  Now,  it  seems  clear  that  when 
the  regurgitating  contents  of  the  obstructed  bowel  have  passed 
upwards  to  the  portion  of  the  small  intestine  which  is  not  filled 
and  distended  by  liquid,  the  only  way  in  which  it  can  reach 
the  stomach  is  by  a  reversed  peristaltic  action  of  the  bowel.  In 
short.  Dr.  Brinton's  theory  requires  that  the  distension  and 
dilatation  of  the  bowel  should  be  continued  up  to  the  pyloric 
end  of  the  stomach.  In  fact,  however,  when  faecal  vomiting 
has  occurred,  it  has  often  been  found  after  death  that  many 
yards  of  empty  and  collapsed  intestine  have  intervened  between 
the  stomach  above  and  the  obstructed  and  dilated  bowel  below. 
We  therefore  retain  our  belief  that  a  reversed  peristalsis  in  the 
bowel  is  an  essential  part  of  the  process  of  faecal  vomiting ; 
and  further,  it  is  highly  probable  that  in  some  instances  ob- 
struction of  the  bowel  is  due  to  a  disorderly  peristaltic  action, 
from  which  it  may  result  that  instead  of  that  regular  wave-like 
movement  of  the  bowel  by  which  the  contents  are  continually 
driven  in  an  onward  direction,  one  portion  of  bowel,  by  a  dis- 
orderly reversed  action,  antagonises  another.  The  effect  of  such 
a  conflict  of  forces  would  be  a  painful  and  perilous  obstruction, 
and  the  remedies  for  it  are  warm  baths,  fomentations,  and 
anodynes.  These  are  some  of  the  cases  in  which  drastic  purga- 
tives may  fatally  prolong  constipation,  while  narcotics  are  the 
most  eflective  laxatives  and  aperients. 

In  the  77th  lecture  the  theory  of  contagious  fevers  is  dis- 
cussed at  some  length,  and  with  the  author^s  characteristic 
caution  and  sagacity.  Reference  is  there  made  to  the  humoral 
pathology  of  Hippocrates  and  his  followers,  and  Sir  Thomas 
remarks  that — 

"  It  is  most  curious  to  see  that  these  very  doctrines  which  had 
sunk  into  universal  discredit  and  contempt,  are  now  again  assuming 
their  places  as  scientific  truths — a  wonderful  example  of  the  sagacity 
of  the  older  physicians,  of  the  despised  wisdom  of  our  forefathers." 

Reference  is  made  to  Liebig's  theory  of  fermentation,  as 
illustrating  analogically  the  possible  influence  of  a  fever  poison 
upon  some  of  the  blood  constituents.  Attention  is  also  directed 
to  Mr.  Simon^s  hypothesis  that  some  material  pre-existing  in 
the  bloody  but  not  forming  an  essential  or  vital  part  of  it,  com- 


380  Reviews.  [April, 

bines  somehow  with  the  cxeiting  virus  from  without  to  cause 
the  febrile  commotion^  and  in  consequence  of  the  exhaustion 
of  that  material,  the  subsequent  immunity  of  the  individual 
from  the  same  disorder.  We  are  then  reminded  that  Sir  James 
Paget  looks  at  this  curious  subject  in  a  somewhat  different 
light.  The  maintenance  of  morbid  structures  is,  he  says,  so 
familiar  a  fact  that  not  only  its  wonder  but  its  significance 
seems  to  be  too  much  overlooked.  What  we  see  in  scars  and 
thickening  of  parts  appears  to  be  only  an  example  of  a  very  large 
class  of  cases  ;  for  this  exactness  by  which  the  formative  process 
in  a  part  maintains  the  change  once  produced  by  disease^  offers 
a  reasonable  explanation  of  the  fact  that  certain  diseases  usually 
occur  only  once  in  the  same  body.  The  poison  of  smallpox  or 
of  scarlet  fever  being,  for  example,  once  inserted,  soon  by  mul- 
tiplication or  otherwise  affects  the  whole  of  the  blood;  alters 
its  whole  composition ;  the  disease  in  a  definite  form  and  order 
pursues  its  course^  and,  finally,  the  blood  recovers  to  all  appear- 
ance its  former  state.  Yet  it  is  not  as  it  was,  for  now  the  same 
material,  the  same  variolous  poison  will  not  produce  the  same 
effect  upon  it,  and  the  alteration  thus  made  on  the  blood  or 
the  tissues  is  made  once  for  all ;  for  commonly  through  all 
after  life  the  formative  process  assimilates  and  never  deviates 
from  the  altered  type,  but  reproduces  materials  exactly  like 
those  altered  by  the  disease ;  the  new  ones,  therefore,  like  the 
old,  are  incapable  of  alteration  by  the  same  poison^  and  the 
individual  is  safe  from  the  danger  of  infection. 

The  occasional  recurrence  of  the  disease  is,  on  this  hypo- 
thesis, an  example  of  the  operation  of  that  law  that,  after  a 
part  has  been  changed  by  disease,  it  tends  naturally  to  regain  a 
perfect  state ;  most  often  the  complete  return  is  not  effected, 
but  sometimes  it  is,  and  the  part  at  length  becomes  what  it 
would  have  been  if  disease  had  never  changed  it. 

In  further  illustration  of  the  same  subject.  Sir  Thomas 
Watson  says  that,  to  his  own  mind,  the  whole  train  of  events 
has  always  seemed  analogous  rather  to  a  cycle  in  the  progression 
of  vegetable  life. 

""We  have  the  visible  and  tangible  seed,  the  manifest  sowing,  the 
hidden  germination  ;  then,  the  outgrowth  and  efflorescence,  the 
ripening,  the  mature  seed-time,  the  reproduction  manifold  of  the 
original  specific  germ — every  stage  in  the  process  of  development 
occupying  a  definite  period  of  time.  Lastly,  for  here  the  analogy, 
though  weaker,  does  not  wholly  fail,  we  have  the  total  or  the  partial, 
the  final  or  the  temporary  exhaustion  of  the  soil,  even  by  a  single 
crop  for  that  particular  substance.  Sometimes  (to  continue  the  meta- 
phor) the  soil  slowly  regains  the  power  to  grow  the  same  disorder ; 
we  see  this  ia  the  waning  protective  influence  of  distant  bygone 
vaccination." 


1872.]  Watson's  Practice  of  Physic.  381 

The  same  view  is  suggested  in  the  writings  of  Dr.  William 
Budd;,  and  Professor  Tyndall  wrote  to  Sir  Thomas  Watson  in 
the  following  terms : 

"  A  tree  or  a  grain  crop  requires  for  its  existence  an  infinitesimal 
amount  of  mineral  matter,  without  which,  however  rich  the  soil,  it 
cannot  grow.  It  is  perfectly  conceivable  that  a  soil  may  contain  this 
matter  in  such  minute  quantity  that  a  single  crop  may  exhaust  it, 
and  this  without  prejudice  to  the  capacity  of  the  soil  as  regards 
other  crops.  JSTow,  may  there  not,  prior  to  the  sowing  of  the  virus, 
be  something  analogous  in  the  human  system,  which  a  single  crop  of 
pustules  entirely  removes  ?  Some  such  change  is  certainly  wrought, 
and  1  would  rather  express  it  in  terms  of  matter  than  in  terms  of 
force.  If  after  one  attack  of  smallpox  the  system  ever  becomes 
receptive  of  a  second,  this  would  be  equivalent  to  the  restoration  of 
the  requisite  mineral  matter  to  the  soil." 

Sir  Thomas  Watson  discusses  at  considerable  length  the 
exciting  causes  of  fevers.  Upon  this  subject  he  says,  there  has 
been  and  there  still  is  a  confusing  and  pernicious  contrariety  of 
opinion  amongst  medical  men^  and  he  remarks  that — 

"  The  two  great  questions  about  which  we  have  to  make  up  our 
minds  are  these — 1.  Are  the  three  diseases,  typhus  fever,  typhoid 
fever,  and  relapsing  fever,  contagious  diseases ;  communicable,  I 
mean,  from  one  who  has  the  disease  to  one  who  has  it  not  ?  2.  If 
contagious  do  they  ever  arise  except  from  contagion  ?  My  own  con- 
viction respecting  every  one  of  the  three  is,  that  the  first  of  these 
questions  must  be  answered  in  the  affirmative,  and  the  second  in  the 
negative." 

In  the  advocacy  of  the  doctrine  of  the  essentially  specific 
exciting  cause  of  all  these  fevers^  he  sides  with  Dr.  William 
Budd  against  Dr.  Murchison,  who,  while  admitting  the  conta- 
gious nature  of  typhus,  typhoid,  and  relapsing  fevers,  maintains 
that  the  first  may,  in  exceptional  cases,  be  generated  spon- 
taneously by  filth  and  over-crowding,  the  second  by  fcBcal  fer- 
mentation, and  the  third  by  destitution.  Upon  this  disputed 
question,  after  setting  forth  many  facts  and  arguments  in  support 
of  his  own  view.  Sir  Thomas  Watson  says  : 

"  Mind,  I  neither  deny  nor  doubt  that  filth,  foul  air,  and  the 
gaseous  products  of  animal  and  vegetable  decomposition,  are  things 
hurtful  to  health  ;  or  that  they  are  capable,  especially  when  abun- 
dant and  concentrated,  of  causing  serious  disease  and  even  death ; 
what  I  do  doubt  and  deny  is,  that  of  themselves  they  ever  produce 
a  contagious  fever.  I  agree  with  Dr.  Guy — whose  interesting  report 
upon  the  health  of  nightmen,  scavengers,  and  dustmen,  is  well  worth 
your  perusal  in  connection  with  this  subject — I  agree  with  him  in 
believing  that  filth  is  rather  the  nurse  than  the  parent  of  fever,  but 
I  am  not  persuaded  of  the  correctness  of  his  final  conclusion,  that 
*  in  extreme  cases  fever  may  be  bred  of  filth.'     In  old  countries  the 

98— xLix  25 


382  Reviews,  [April, 

seminium  of  each  of  these  diseases  is,  doubtless,  always  dormant 
somewhere,  as  that  of  smallpox  must  be,  ready  to  rouse  into  wide- 
spread mischief  upon  the  first  return  of  the  mysterious  influences 
which  awaken  or  renew  its  epidemic  power." 

This  question  of  the  possible  spontaneous  origin  of  some 
cases  of  contagious  fevers  merges  into  that  of  the  spon- 
taneous generation  of  some  of  the  lower  forms  of  organic 
life.  Upon  this  wide  and  difficult  subject  we  have  neither 
space  nor  inclination  now  to  enter. 

We  have  hitherto  referred  only  incidentally  to  the  treat- 
ment of  disease ;  in  what  remains  of  our  space  we  shall  limit 
our  remarks  chiefly  to  this  important  subject.  Those  who 
are  familiar  with  the  former  editions  of  these  lectures  will 
remember  that,  although  in  each  successive  edition  the 
author  had  endeavoured,  with  more  or  less  complete  success, 
to  keep  pace  with  the  progress  of  pathology,  he  had  made 
but  little  change  in  his  therapeutics.  The  directions  given 
for  the  treatment  of  disease  in  the  fourth  edition,  issued 
fourteen  years  ago,  did  not  difi*er  materially  from  those  which 
appeared  in  the  original  edition.  In  the  present  edition,  how- 
ever, there  are  manifest  signs  that  the  subject  of  treatment 
has  been  most  carefully  revised,  and  we  do  not  hesitate  to 
express  our  conviction  that,  as  a  safe  therapeutical  guide  for 
the  student  and  young  practitioner,  these  lectures  are  unrivalled 
either  in  our  own  or  in  any  other  language. 

Foremost  amongst  the  methods  of  treatment  respecting 
which  there  has  been,  and  still  is,  a  conflict  of  opinion,  stands 
that  of  bloodletting.  Sir  Thomas  Watson,  in  his  thirteenth 
lecture,  discusses  this  important  subject,  examines  and  weighs 
the  arguments  on  either  side,  and  delivers  his  calm  judgment 
with  an  authority  which  can  scarcely  fail  to  convince  an  un- 
prejudiced reader.  It  is  notorious  that  for  some  years  past, 
while  there  has  been  a  wide-spread  disposition  to  push  the 
administration  of  stimulants  to  a  mischievous  excess,  there 
has  been  an  unreasonable  shrinking  from  the  practice  of 
bloodletting  in  any  form.  It  may  be  that  this  excessive 
dread  of  abstracting  blood  is  in  part  to  be  explained  by  a 
natural  though  not  wise  reaction  from  the  undiscriminating 
employment  of  depletory  measures  by  a  past  generation.  One 
melancholy  consequence  of  blind  submission  to  authority,  or 
of  the  senseless  influence  of  what  is  called  fashion,  is  the 
almost  total  want  of  experience  about  bloodletting  among  the 
current  generation  of  medical  men.  Now,  there  is  abundant 
evidence  that  this  great  dread  of  extracting  blood  is  a  mere 
bugbear ;  men  and  women  bear  often  large  losses  of  blood 
with  impunity,  from  wounds  on  the  battle-field,  in  hundreds 


1872.]  Watson's  Practice  of  Physic.  383 

of  accidents,  in  floodings  from  the  uterus,  and  this  not  only 
during  health,  but  also  when  the  strength  has  been  already 
reduced  by  disease.     Sir  Thomas  Watson  maintains  that — 

"  The  reasoning  of  the  out-and-out  decriers  of  bleeding  is  faulty 
and  fallacious.  '  Disease  signifies  always,'  they  say,  'a  subtraction 
from  the  general  welfare  and  vital  powers  of  the  body.'  Grranted. 
'  Tour  aim  as  physicians  is  to  obviate  this  lowering.*  This  also,  as 
physicians,  we  may  to  a  certain  extent  admit.  '  But  the  abstraction 
of  blood  must  increase  and  promote  it.'  To  this  we  demur.  The 
relief  of  pain — in  itself  a  great  subduer  of  vitality — the  removal  of 
a  local  and  lowering  morbid  process,  the  restraining  of  the  circula- 
tion throughout  the  frame  of  blood  altered  and  made  poisonous  by 
passing  through  the  area  of  the  part  inflamed,  the  setting  free  or 
restoring  the  oppressed  and  hampered  functions  of  a  great  blood- 
purifying  organ,  such  as  the  lung  or  the  kidney,  these  are  very 
conceivable  ways  in  which  the  removal  of  blood  may  operate  in 
preventing  instead  of  furthering  the  depression  of  vital  energy. 
But,  after  all,  the  great  argument  for  the  abstraction  of  blood  in 
inflammation  is  its  conspicuous  and  undeniable  success  in  innumer- 
able cases  ;  though  the  force  of  the  argument  may  not  be  so  apparent 
to  those  who  have  scarcely  ever,  if  ever,  seen  the  remedy  put  fairly 
to  the  test." 

He  then  proceeds  to  show  that  in  many  cases  of  inflam- 
mation, as  of  the  pleura,  the  pericardium,  or  the  kidney, 
local  bleeding  by  leeches  or  by  cupping  is  a  powerful,  a  safe, 
and  therefore  a  proper  and  eligible  remedy,  and  that  its 
beneficial  operation  consists  in  diminishing  by  direct  with- 
drawal, or  by  diversion,  the  quantity  of  blood  distributed  to 
the  part  or  organ  inflamed.  It  is  shown  that  in  order  to 
obtain  relief  by  local  bleeding  it  is  not  necessary  that  there 
should  be  a  direct  capillary  communication  between  the 
inflamed  part  and  the  place  where  the  bleeding  is  efi'ectedj 
on  the  contrary,  all  that  is  required  is  that  there  shall  be  a 
close  arterial  link  of  connection.  The  stream  of  blood 
passing  through  a  branch  or  branches  which  enter  and  feed 
the  suff'ering  part  will  be  lessened  in  proportion  to  the 
amount  which  is  withdrawn  from  the  contiguous  branches  of 
the  same  artery.  Thus,  suppose  the  case  to  be  one  of  peri- 
carditis. The  internal  mammary  artery  supplies  the  peri- 
cardium and  the  integuments  over  the  heart.  By  the  appli- 
cation of  leeches  over  the  heart,  we  abstract  blood  from  the 
integumentary  branches  of  the  artery,  and  in  the  same  pro- 
portion we  divert  blood  from  the  deeper  pericardial  branches. 
And  this  operation  of  local  bleeding  is  illustrated  by  the 
faint  and  feeble  burning  of  a  gas  chandelier  when  the  gas  is 
largely  diverted  and  the  pressure  lessened  by  a  neighbouring 
street  illumination. 


384  Reviews,  [April, 

With  reference  to  venesection,  Sir  Thomas  admits  that  ia 
past  times,  when  employed  for  the  relief  of  local  inflamma- 
tion, great  mistakes  have  been  made,  and  a  potent  remedy- 
has  been  misdirected.  It  is  not  denied  that  by  abating  the 
force  of  the  heart's  contraction,  and  by  diminishing  the  amount 
of  circulating  blood,  the  local  mischief  may  sometimes  be 
lessened,  but  it  is  maintained  that  this  relief  is  purchased  at 
the  cost  of  a  needless  expenditure  of  blood,  and  a  consequent 
weakening  of  the  reparative  powers  of  the  body.  The  mitiga- 
tion of  local  inflammation  is  the  proper  object  of  topical  bleed- 
ing, and  this,  in  Sir  Thomas  Watson's  present  judgment,  ought 
*'  almost  never  to  be  attempted  by  venesection/'  Almost  never, 
he  says,  because  there  is  at  least  one  exception  to  this  general 
rule.  There  are  conditions  in  pneumonia — the  very  disease 
that  has  been  the  battle-field  for  the  recent  contentions  about 
bloodletting — there  are  in  that  special  disease  conditions  which 
warrant  and  require  venesection,  not,  indeed,  as  a  form  of 
general  bleeding,  but  as  a  derivative  topical  bleeding  of  the  very 
part  inflamed.  It  is  peculiar  to  the  lungs  that  all  the  blood  of 
the  body  has  to  pass  through  them,  and  under  their  inflamma- 
tion the  portions  of  those  organs  that  remain  permeable  by 
blood  may  be  totally  unable  to  transmit  the  requisite  quantity; 
so  that  death  may  be  the  imminent  consequence  of  that  inade- 
quacy. In  this  stress  venesection  may  sometimes  suffice  when 
all  other  means  would  fail  to  avert  the  fatal  issue.  To  tap  a 
large  vein,  to  draw  off"  a  portion  of  the  circulating  blood  on  its 
way  back  to  the  lungs,  must  tend  indirectly  to  diminish  the 
pulmonary  engorgement,  to  divert  blood  from  the  imperilled 
organ.  The  condition  here  referred  to  as  incidental  to  some 
cases  of  pneumonia  is  but  one  of  several  morbid  states,  for 
which  prompt  and  free  venesection  is  the  appropriate  and  the 
only  adequate  remedy.  In  some  cases  relief  by  venesection  has 
been  shown  in  the  emergence  from  deep  coma,  the  subsidence 
of  urgent  dyspnoea,  the  departure  of  unspeakable  pain  and 
anguish  while  the  blood  is  flowing.  Sir  Thomas  remarks 
that— 

"All  these  morbid  states  are  now  recognised  as  belonging  to 
one  category.  The  striking  relief  is  always  due  to  liberation  from 
the  efiects  of  a  mechanical  obstacle  or  block  in  the  circulation.  Dr. 
Hughes  Bennett,  a  strenuous  denouncer  of  bloodletting  except  in 
these  emergencies,  Dr.  Markham  and  Dr.  George  Johnson,  who 
advocate  its  limited  and  rational  use,  all  agree  in  this.  As  the  source 
of  the  danger  and  difficulty  Dr.  Bennett  assigns  *  over-distension  of 
the  right  side  of  the  heart,  and  perhaps  venous  congestion  and 
engorgement  of  the  lungs.*  Dr.  Markham,  '  some  mechanical 
obstruction  to  the  play  of  the  thoracic  organs,  and  a  consequently 
distended,  oppressed,  and  a  partially  paralysed  heart.'    Dr.  John- 


1872.]  Watson^s  Practice  of  Physic.  385 

son,  *  over-distension    of  the  venous  system  including  under  that 
term  all  the  vessels  that  contain  black  blood.'  " 

Then  it  is  pointed  out  that  this  accident  of  disease — for  such 
it  is — may  or  may  not  be  associated  with  inflammation^  and  it 
is  to  the  accident,  and  not  to  the  mere  inflammation,  when  that 
is  present,  that  the  remedy  is  addressed  and  adapted.  Dr. 
John  Reid  long  ago  showed  by  experiments  how  a  distended 
and  therefore  motionless  right  ventricle  may  be  set  going  again 
by  opening  the  jugular  vein  of  a  dying  animal,  and  suff'ering 
the  blood  to  flow  back  again,  as  it  will  do,  from  the  gorged 
right  cavities  of  the  heart.  An  instructive  example  of  relief 
from  opening  the  jugular  in  the  human  subject  is  cited,  and 
then  in  brief  terms  it  is  stated  that — 

"  The  condition  which  cries  out  for  and  obtains  relief  so  signal 
from  phlebotomy  may  be  described  as  that  of  great  and  often  sudden 
engorgement  of  the  vessels  that  carry  black  blood — of  the  systemic 
veins,  of  the  pulmonary  artery,  and  especially  of  the  right  chambers 
of  the  heart.  In  this  embarrassed  condition  of  the  circulation, 
with  so  unequal  a  distribution  of  blood  in  the  two  different  systems 
of  vessels,  it  is  the  veins  that  require  emptying,  not  the  arteries.  As 
the  tension  of  the  stretched  and  almost  paralysed  right  ventricle  is 
lessened,  the  hollow  muscle  again  becomes  capable  of  contracting 
upon  and  propelling  its  contents,  the  clogged  lung  is  set  free,  the 
functions  of  the  oppressed  brain  are  eased  and  retrieved,  and  the 
balanced  play  of  the  heart  and  lungs  is  restored." 

We  have  devoted  so  large  a  portion  of  our  allotted  space  to 
the  setting  forth  of  Sir  Thomas  Watson's  philosophical  views 
on  the  operation  and  use  of  bloodletting,  for  the  reason  that 
in  our  judgment  they  cannot  be  too  widely  known.  Surely 
there  is  ground  to  hope  that  in  future  this  powerful  means  of 
controlling  disease  will  be  employed  with  scientific  discrimina- 
tion, and  not,  as  in  past  times,  either  recklessly  abused  or 
timidly  shunned  as  caprice  or  fashion  may  dictate. 

With  regard  to  the  employment  of  mercury,  we  find  that  it 
is  no  longer  recommended  as  having  antiphlogistic  powers  in 
ordinary  cases  of  inflammation.  It  is  still,  with  reason,  looked 
upon  as  specially  curative,  either  alone  or  combined  with  iodide 
of  potassium,  in  certain  forms  of  syphilitic  inflammation,  and 
in  combination  with  other  drugs  as  a  purgative  and  a  diuretic 
in  some  cases  of  inflammation  and  of  dropsy.  Referring  to  the 
treatment  of  pericarditis.  Sir  Thomas  says  : 

"  The  hope  which  I  once  cherished  that  the  inflammation  could 
be  controlled  by  the  constitutional  influence  of  mercury  has  faded 
away.  Pericarditis  has  been  known  not  seldom  to  spring  up  while 
the  patient  was  still  under  mercurial  salivation.  I  am  obliged, 
therefore,  to  recant  the  advice  which  I  was  formerly  in  the  habit  of 


386  Reviews,  [April, 

giving  in  respect  of  mercury  as  a  remedy  for  pericardial  inflamma- 
tion. I  recommend  you  to  abstain  from  giving  it  with  the  view  of 
obtaining  its  peculiar  eff'ects  upon  the  gums  and  the  general  system, 
but  I  should  never  scruple  to  prescribe  it  with  other  aims,  and 
especially  for  its  tendency  to  quicken  and  promote  the  action  of 
some  diuretic  remedies." 

In  the  recommendation  of  paracentesis  thoracis  for  the 
removal  of  a  pleuritic  eflFusion  Sir  Thomas  exercises,  as  we 
think,  a  wise  and  discriminating  caution.  He  advises  the 
operation  when  the  effusion  is  so  copious  as  to  threaten 
suffocation.  Again,  when  the  patient,  without  suffering 
much  dyspnoea  while  he  lies  quiet,  is  yet  evidently  losing 
ground,  while  other  means  fail  to  get  rid  of  the  effusion,  and, 
lastly,  when  the  effused  liquid,  no  matter  how  we  ascertain  the 
fact,  is  known  to  be  purulent.  He,  however,  deprecates  the 
early  employment  of  the  trochar  in  ordinary  cases  of  pleuritic 
effusion. 

Referring  to  the  observations  of  Dr.  Hughes  and  Dr.  Hamilton 
Roe,  who  had  expressly  treated  of  this  subject  before  Dr. 
Bowditch^s  researches  were  made  known,  he  says : 

"  To  those  gentlemen  the  profession  is  much  indebted  for  having 
shown  with  what  facility,  and  with  how  little  risk  and  pain,  the  ope- 
ration may  be  performed.  They  have  not  convinced  me  of  its  fre- 
quent necessity." 

For  this  display  of  caution  we  find  that  he  has  been  blamed 
by  one  critic,  who  also  says  that  Sir  Thomas  fails  to  recognise 
the  fact  "that  it  is  now  perfectly  easy  to  tap  with  (practi- 
cally) no  admission  of  air.^'  This  statement,  which  curiously 
enough,  has  been  repeated  (shall  we  say  copied  ?)  by  another 
critic,  affords  a  good  illustration  of  the  fact  that  even  a  reviewer 
may  fall  into  error,  as  will  be  seen  from  the  following  extract 
(vol.  ii,  p.  145) : 

'*  Should  you  desire  to  take  away,  as  some  advise,  so  much  of  the 
liquid,  and  no  more,  as  the  expansion  of  the  lung  and  the  elastic 
resiliency  of  the  thoracic  parietes  suffice  to  press  out,  without  ad- 
mitting air,  that  object  may  be  insured  by  adopting  a  simple  con- 
trivance of  Professor  Shuh's,  of  Vienna,  which  was  shown  to  me  by 
Mr.  Spencer  Wells.  But  a  method  which  I  have  seen  employed  by 
the  late  Mr.  Stanley  seems  to  me  more  simple  and  equally  certain. 
He  used  a  trochar  furnished  with  a  stop-cock.  To  the  trochar  thus 
shut  he  adapted  a  long  flexible  tube,  the  open  extremity  of  which 
was  immersed  in  a  vessel  containing  water." 

It  would  be  well  if  some  modern  critics  would  set  themselves 
the  task  of  imitating  that  which  one  of  them  professes  to  admire 
in  these  lectures,  namely — 

"  That  high-minded  modesty  to  which  exaggeration  of  all  kinds 
appears  a  fault  to  be  shunned  as  scrupulously  as  falsehood  itself." 


1872.]  \Yatsons  Practice  of  Physic.  387 

Now,  with  reference  to  the  indications  for  the  operation  of 
paracentesis,  there  has  of  late  been  an  attempt  to  show  that 
tapping  the  chest  is  useful,  and  therefore  desirable,  in  a  large 
proportion  of  cases  of  simple  acute  pleurisy.  We  are  quite  con- 
vinced that  this  attempt  will  be  unsuccessful,  as  in  our  opinion 
it  deserves  to  be,  and  we  will  briefly  state  our  reasons  for  this 
belief.  In  the  first  place,  whatever  doctors  may  say  upon  the 
subject,  patients  and  their  friends  will  always  look  upon  the 
operation  as  somewhat  formidable,  and  they  will  not  submit  to 
it  unless  fairly  convinced  of  its  necessity.  Then,  allowing,  as 
we  do,  that  with  due  precautions  the  liquid  may  be  withdrawn 
without  the  risk  of  admitting  air  into  the  cavity  of  the  pleura, 
we  would  ask  what  is  the  necessity  for  this  proceeding  when,  as 
every  physician  of  experience  knows,  in  the  great  majority  of 
cases  serous  effusion  into  the  pleura  is  quickly  and  completely 
absorbed  without  surgical  aid,  and  with  little  or  no  medical 
treatment?  The  absorption  of  the  liquid  is  much  impeded  and 
may  be  entirely  prevented  when  the  pleura  is  covered  by  a  thick 
unorganized  layer  of  fibrine,  which  thus  intervenes  between  the 
eflPused  liquid  and  the  vessels  by  which  it  should  be  absorbed. 
This  exudation  of  fibrine  takes  place  during  the  first  intensity 
of  the  inflammation,  and  it  may  most  surely  and  effectually  be 
prevented  by  the  prompt  application  of  leeches,  followed  by  lin- 
seed poultices,  as  recommended  by  Sir  Thomas  Watson.  Now, 
it  is  not  a  little  remarkable  that  one  of  the  most  strenuous  of 
recent  advocates  for  early  tapping  in  cases  of  pleuritic  effusion 
discourages  the  employment  of  leeches,  and  advises  that  the 
pain  of  pleurisy  should  be  subdued  by  the  hypodermic  use  of 
morphia.  We  highly  approve  of  morphia  in  aid  of  and  after 
topical  bleeding,  but  to  trust  to  morphia  alone  in  the  early  stage 
of  an  acute  and  severe  attack  of  pleurisy  is,  in  our  judgment, 
needlessly  to  incur  the  risk  of  so  copious  an  effusion  of  lymph 
and  serum  as  may  render  necessary  at  a  later  stage  the  opera- 
tion of  tapping.  Acute  pleurisy,  painful  as  it  is,  is  not  a  merely 
neurotic  disease,  and  cannot  be  successfully  combated  by  anodynes 
alone. 

Before  concluding  our  pleasant  task,  we  feel  bound  to  refer 
to  a  suggestion  made  by  one  reviewer  and  echoed  by  another, 
that,  notwithstanding  the  labour  which  has  been  bestowed  upon 
successive  editions, 

"  It  might  have  been  well  simply  to  have  reprinted  the  original 
lectures,  without  any  attempt  to  adapt  them  to  the  changed  state  of 
medical  science." 

If  the  labour  of  revision  had  been  undertaken  by  some  inferior 
workman,  there  would  have  been  some  reason  to  fear  the  result 
of  unskilful  attempts  to  patch  an  old  garment  with  new  cloth. 


388  Reviews.  [April, 

Happily,  ho\Tever,  the  gifted  author  survives/ and,  while  in  the 
full  possession  of  his  high  faculties,  he  has,  with  great  labour, 
subjected  his  lectures  to  a  more  thorough  revision  than  was 
possible  during  the  earlier  and  busier  period  of  his  life.  The 
result  is  a  work  by  one  master-mind,  uniform  and  perfect  in 
style,  from  the  opening  sentences  of  the  introductory  lecture  to 
the  graceful  and  generous  epilogue  at  the  end — a  work  evincing 
in  a  degree  rarely  equalled  calm  judicial  wisdom,  a  truly  reverent 
spirit,  and  an  ardent  love  of  truth. 


IX. — Contagious  Diseases  Acts.^ 

It  is  not  our  intention  here  to  discuss  the  more  immediate  and 
obvious  elements  which  connect  the  medical  profession  with  the 
legislation  involved  in  these  Acts,  present  or  future.  There 
must  be  very  few  indeed  of  our  readers  who  are  not  satisfied 
that  their  operation  has  within  a  limited  sphere  materially 
diminished  the  extension  and  virulence  of  syphilis,  and  who  on 
sanitary  grounds  would  hesitate  to  bid  them  God-speed.  Neither 
will  we  linger  long  over  the  commercial  aspect  of  the  question 
set  before  the  Privy  Council  by  their  medical  adviser,  who 
argues  that  we  have  no  right  to  spend  the  money  collected  from 
chaste  taxpayers  in  preserving  the  health  of  the  unchaste.  A 
true  political  economy  teaches  that  every  sick  person  in  every 
sickness  is  a  loss  to  the  whole  community,  for  his  removal  from 
the  class  of  healthy  workers  deprives  the  (country  either  of  his 
labour  or  of  money  which  would  otherwise  be  distributed  finally 
in  paying  labour.  It  is  therefore  financially  just  to  use  the  con- 
solidated fund  for  the  necessary  expenses  of  these  Acts. 

But  it  is  to  their  politico-moral  aspect  that  we  think  attention 
should  now  especially  be  directed ;  and  medical  men  are  not  to  ex- 
cuse themselves  from  attending  to  this  part  of  the  matter  on  the 
plea  of  the  physical  needs  of  the  population  being  their  peculiar 
department.  For  medical  men,  as  medical  men  and  not  merely 
as  citizens,  from  their  intimate  relations  to  all  classes  at  once, 
have  opportunities  for  forming  unbiassed  opinions  on  such-like 
social  questions,  which  surpass  even  those  enjoyed  by  clergymen, 
policemen,  and  philanthropists  specially  devoted  to  the  subject. 
And  we  will  say  at  once  that  we  consider  the  mental  effect  of 
the  legislation  now  suh  judice  of  infinite  more  importance  than 
any  physical  result,  and  that  we  should  hold  it  quite  unjustifiable 

'  Meport  of  the  Royal  Commission  upon  the  Administration  and  Operation  of 
the  Contagious  Diseases  Acts."  Vol.  ii.  Minutes  of  Evidence,  8fc.  London,  1871.. 
Folio,  pp  846.  ^ 


1872.] 


Contagious  Diseases  Acts,  389 


to  compass  a  sanitary  benefit,  however  great,  at  the  expense  of  a 
moral  evil  or  degradation. 

We  will  take  seriatim  all  the  objections  raised  by  the  opponents 
on  moral  grounds  to  the  Acts ;  omitting,  however,  those  which 
appear  frivolous  and  the  result  of  mere  factious  advocacy.  And 
of  these  serious  objections  we  will  endeavour  to  estimate  the 
value  and  point  out  their  true  bearings  on  the  matter  in  hand. 

First,  then,  it  is  urged  that  by  diminishing  the  risk  run  by 
fornicators  you  remove  a  natural  deterrent  from  vice.  This  ap- 
plies to  both  sexes,  but  with  greatest  force  to  men ;  for  to  the 
other  sex  the  deterring  influence  of  risking  possible  disease  is  as 
nothing  compared  with  the  certainty  of  placing  themselves  in 
the  ranks  of  an  outcast,  pariah  caste,  and  probably  has  never 
frightened  a  woman  from  the  brink  of  prostitution.  But  to  men 
there  is  indubitably  some  safeguard  in  fear.  We  have  heard  a 
middle-aged  surgeon  of  police  remark,  "  Thank  God,  I  had 
syphilis  before  I  was  twenty.  It  made  me  think — that's  what  it 
did  ;  and  I  have  never  had  illicit  connection  since.  I  should  have 
been  too  frightened."  This  objection  is,  therefore,  a  very  serious 
matter,  and  we  should  protest  loudly  against  any  legislation  which 
ignores  it.  But  that  has  not  been  the  case  in  the  administration 
of  the  Contagious  Diseases  Acts.  When  it  was  found  that  the 
printed  notices  to  attend  on  a  future  day,  which  were  given  to 
women  subjected  to  periodical  examination,  were  shown  as  certi- 
ficates of  health,  their  issue  was  immediately  discontinued  ;  and 
every  effort  is  used  to  make  the  needful  attendance  as  private  as 
possible,  so  that  it  may  be  not  known  who  are  and  who  are  not 
diseased.  Still  it  must  be  allowed  that  a  good  deal  depends  on 
the  discretion  and  good  faith  of  the  police  by  which  the  Acts 
are  carried  out,  and  that  the  constant  supervision  of  right- 
minded  and  observant  persons  will  be  required.  When  the 
intending  fornicator  has  only  the  prostitute's  word  for  the  fact 
of  her  having  been  passed  as  healthy,  we  do  not  see  that  he  has 
any  protection  in  the  individual  instance.  She  would  be  just  as 
likely  to  tell  a  lie  in  a  protected  district  as  in  an  unprotected. 
But  the  chief  care  should  be  taken  not  to  administer  the  law  in 
any  way  that  could  be  made  a  recognition  of  brothels  or  brothel 
keepers.  Not  even  special  visitations  of  the  houses  should  be 
made,  for  it  may  be  inferred  that  a  visit  without  penal  results  is 
in  fact  a  bill  of  health.  The  great  mistake  made  by  continental 
governments  in  their  control  of  prostitution  is  the  direct  or 
indirect  licensing  of  brothels. 

It  may  be  remarked  that  the  risk  of  the  minor  punishment  of 
vice,  gonorrhoea,  is  not  appreciably  lessened  by  the  administration 
of  these  Acts,  as  appears  from  the  statistics  brought  forward  by 
several  witnesses.     By  washing  the  mucous  membrane  shortly 


390  Reviews.  [April, 

before  inspection,  a  woman  may  easily  escape  the  detection  of 
this  disease ;  and  she  suffers  so  little  pain  from  it  that  she  does 
not  care  to  be  cured,  but  lets  the  secretion  get  well  in  the  course 
of  nature.  To  the  male  urethra  the  consequences  are  much 
more  serious,  but  still  they  do  not  involve  innocent  persons,  nor 
sap  the  vital  development  of  future  generations.  So  that  we 
may  congratulate  ourselves  that  we  have  left  a  substantial  de- 
terrent to  the  male  debauchee,  threatening  a  punishment,  milder 
indeed,  but  much  more  difficult  to  escape  than  syphilis,  which 
at  the  same  time  confines  itself  as  much  as  any  punishment  can 
do  to  the  guilty.  It  would  be  well  if  it  were  more  clearly  ex- 
pressed in  a  preamble  to  future  Acts  extending  to  the  civil 
population,  that  they  are  designed  to  protect  the  innocent, 
women  and  children  especially,  and  coming  generations,  from 
the  consequences  of  others'  vice — in  fact,  that  "  contagious 
diseases"  means  *^  syphilis."  Legislation  about  gonorrhoea 
would  be  strongly  to  be  deprecated. 

Another  objection  is,  that  to  recognise  the  existence  of  prosti- 
tution, without  aiming  at  punishment,  is  really  to  sanction  it, 
and  for  special  legislation  to  do  that  will  corrupt  the  moral 
sense  of  the  nation.  In  a  country  like  England  the  spirit  of  the 
law  is  peculiarly  important — more  important  even  than  her 
songs,  in  spite  of  the  popular  apothegm  to  the  contrary — 
and  we  are  not  likely  long  to  retain  a  higher  standard  of 
ethics  than  what  a  great  statesman  calls  suggestively  "our 
psedagogue."^  It  is  not  indeed  a  religion  or  fount  of 
morality  itself,  but  it  guides  thither  our  blundering  steps. 
This  is  a  very  grave  matter  indeed,  for  it  is  incapable  of  being 
judged  of  by  practical  experience  ;  the  mischief,  if  done,  could 
only  be  estimated  after  many  years'  working,  and  then  would 
stand  in  the  way  of  its  own  cure.  For  a  nation  whose  ethical 
feelings  were  corrupted  would  become  continuously  less  and  less 
likely  to  amend  the  evil.  And,  no  doubt,  scrupulous  care  will 
be  requisite,  in  watching  the  working  of  the  details  of  this 
legislation,  to  secure  the  non-recognition  of  harlotry  as  a  legiti- 
mate occupation.  There  must  be  no  opposition  between  legality 
and  morality.  But  such  care  we  feel  sure  will  be  exercised;  we  see 
evidence  of  it  cropping  out  in  every  portion  of  the  Acts,  and  of 
a  strong  desire  to  enhance  this  principle.  All  who  love  England 
and  long  to  see  her  humblest  sons  and  daughters  as  pure  and 
brave  as  their  own,  have  shed  bitter  tears  of  disappointment  at 
the  historical  failure  of  every  attempt  to  deal  penally  with 
fornication.  The  stronger  the  panacea  the  more  harm  it  does, 
by  reason  of  the  difficulty  of  limiting  what  constitutes  crime. 

1  6  vofioQ  Traidayiaybg  ^fxCiv  ykyovev. — Galatians  iii,  24k 


1872.]  Contagious  Diseases  Acts,  391 

Now  in  these  acts  it  seems  to  us  a  judicious  step  is  for  the  first 
time  made  towards  employing  the  strong  arm  of  authority 
in  curbing  vice.  Instead  of  being  protected  and  trusted  as 
all  other  occupations  are,  harlotry  as  a  trade  is  punished 
by  subjection  to  suspicion  and  repugnant  questioning.  There 
is  a  difficulty,  doubtless,  in  classifying  and  defining  the  de- 
grees of  iniquity  exhibited  in  its  pursuit;  but  a  syphilized 
woman  who  habitually  hires  out  her  person  for  money  may  be 
justly  selected  as  a  typical  specimen  for  punishment.  And 
punished  she  is,  by  a  loss  of  liberty  till  she  gets  well ;  that 
is,  for  a  time  closely  proportioned  to  the  period  during  which  she 
has  been  going  about  with  the  disease  neglected  upon  her.  And 
the  trade  is  further  pointed  at  as  criminal  by  its  pursuers  being 
made  subject  to  punishment  with  less  ceremony  than  the  rest  of 
the  population.  In  other  cases  of  summary  convictions  the  limit 
of  the  magistrate's  power  is  six  months  imprisonment ;  and  in 
the  great  majority  of  cases,  with  one  or  two  exceptions  under 
the  Metropolitan  Police  Act,  three  months'  is  the  outside  which 
a  magistrate  can  give  on  summary  conviction.  But  under  these 
Acts  a  woman  may  be  detained  for  nine  months  upon  one  certi- 
ficate made  by  a  doctor  on  his  sole  opinion.  The  very  fact  of 
being  a  prostitute  puts  her  in  the  position  of  an  imprisoned 
felon,  subjects  her  to  severe  discipline,  and  deprives  her  of  the 
safeguards  provided  by  our  criminal  law  and  the  checks  which 
necessarily  attend  a  public  hearing.  This  is  very  clearly  pointed 
out  by  Mr.  W.  Shaen,  Solicitor  to  the  Association  for  the  Pro- 
tection of  Women  (Answer  19,582).  Mr.  Stuart  Mill  also  argues 
that  the  Acts  intentionally  take  away  the  security  of  personal 
liberty  from  a  particular  class  (Answer  19,994).  These  witnesses 
indeed  consider  the  fact  a  ground  of  objection,  but  we  are 
disposed  to  take  an  opposite  view,  and  to  agree  with  the  Rev. 
C.  Ellison,  who  would  deal  with  prostitutes  "  as  with  any  other 
criminal  '^  (Answer  20,280),  sending  those  who  are  diseased  to 
a  hospital  to  be  cured  while  they  are  undergoing  a  punishment. 
What  indeed  are  loose  women  but  criminals,  and  enemies  in 
open  rebellion  against  the  welfare  of  the  State  ?  Their  live- 
lihood is  seduction,  and  almost  every  man  who  has  left  the 
paths  of  virtue  has  done  so  in  consequence  of  the  provocative 
exhibitions  of  these  creatures.  To  have  a  son  seduced  by  any 
person  except  an  habitual  harlot  is  an  almost  unknown  ex- 
perience. If  the  tempting  to  vice,  sporadically  and  for  pleasure, 
is  a  crime  in  a  man  ;  and  if  it  is  possible,  as  some  think,  to 
make  it  penal;  then  surely  the  regular  trade  of  temptation 
may  justly  deprive  its  followers,  when  brought  under  the 
operation  of  law,  of  some  of  those  rights  of  citizenship  which 
the  rest  of  their  countrymen  enjoy.     These  considerations  will 


392  Reviews.  [April, 

answer,  we  think,  Mr.  Mill's  demurrer  to  special  legislation  for 
prostitutes  as  a  class. 

Strong  objections  are  made  by  several  witnesses  to  the  perio- 
dical examination  of  the  person,  essential  to  the  administration 
of  any  police  control  of  syphilis.  Professor  Newman  seems  to 
aim  at  condensing  all  these  objections  when  he  designates  it  as 
"  indecent,  depraving,  barbarous,"  "  an  instrumental  rape," 
"  an  intrinsic  wickedness."  The  language  is  somewhat  vague, 
but  seems  to  mean  that  it  is,  in  the  first  place,  painful  and 
repugnant  to  the  individual;  and,  secondly,  lowering  to  the 
moral  feelings.  These  are  two  quite  different  characteristics, 
and,  to  a  certain  extent,  inconsistent.  For  the  disagreeable 
nature  of  the  operation,  the  more  acutely  it  is  felt,  the  more 
will  it  inspire  disgust  at  the  mode  of  life  which  necessitates  it. 
Welcome  pain,  welcome  shame,  welcome  any  temporary  evil, 
that  makes  sin  hateful.  We  do  not  doubt  that  the  introduction 
of  a  speculum  into  an  ulcerated  mucous  surface  is  painful,  and 
we  hope  that  women  do  "  loathe  "  (as  the  witnesses  say)  the 
letting  the  light  of  day  into  their  vicious  nastiness.  We  are 
glad  to  hear  that  some  come  to  the  examining  surgeon  in  tears, 
and  fall  hysterical  during  the  process,  and  we  are  not  careful 
to  enquire  into  the  balance  of  evidence  as  to  whether  the 
women  do  or  do  not  object  on  these  grounds  to  submit  to 
inspection — though  a  cynic  might  make  himself  merry  on 
the  conflict  of  the  positive  statements  reported  by  the  wit- 
nesses to  be  made  regarding  other  persons'  private  sensations 
by  a  class  who  are  scarce  to  be  trusted  in  speaking  of 
their  own.  But  we  are  deeply  interested  by  the  opposite 
opinions  expressed  as  to  whether  the  effect  may  be  demoralizing, 
degrading,  hardening,  and  destructive  of  decency,^  because  such 
a  result  would  render  the  machinery  of  the  Act  unjustifiable. 
We  believe  the  fact  to  be,  that  those  who  have  a  taste  for  in- 
decency use  the  occasion  for  enhancing  it,  and  that  those 
already  hardened  after  a  short  time  make  a  boast  of  their 
shame.  It  is  impossible  however  to  imagine  that  even  their 
real  moral  nature  can  be  lowered  by  an  exposure  which  is  not 
(like  their  habitual  exposure)  for  the  purpose  of  satisfying  lust, 
but  for  a  philanthropic  object.  But  to  a  different  and  more 
hopeful  class  the  periodical  contact  with  a  person  of  superior 
intelligence  to  their  own,  ex  officio  kind  and  considerate,  cannot 
but  be  advantageous.  They  become  more  decent  in  their 
behaviour,  more  self-respectful  and  cleanly  in  their  persons,  and, 
in  many  instances,  are  restored  to  virtuous  society  through  the 

^  See  Index  to  Report.  Examinations — demoralizing,  2  answers ;  degrading, 
6  answers ;  hardening,  10  answers ;  not  demoralizing,  1  answer ;  not  degrading, 
8  answers;  not  hardening,  10  answers;  promote  external  decency,  3  answers. 


1872.]  Contagious  Diseases  Acts,  393 

agency  of  those  whom  they  are  introduced  to  by  the  periodical 
examination.  While  it  is  doubtful  if  any  are  made  worse,  it 
is  certain  that  many  are  made  better.  The  introduction  to  a 
new  description  of  fellow-creature  cannot  fail  to  be  humanizing. 
What  can  a  common  strumpet's  notion  of  a  man  be  ?  A  vulgar 
animal,  so  stupid  as  to  be  easily  seduced  by  the  most  glaring 
imposture,  and  to  be  amused  by  the  stalest  indecencies,  paying 
money  to  be  flattered  by  a  show  of  love  which  barely  veils 
disgust  and  hatred.  And  what  is  her  experience  of  a  woman  ? 
Such  as  she  is  herself.  It  must  be  a  new  revelation  to  her  to 
be  spoken  to  with  Christian  courtesy  and  charity. 

We  saw  lately  a  proposition  made  in  the  Sequel  to  Dr. 
Chambers's  Harveian  Oration,  that  the  ladies  who  have  lately 
been  fighting  against  so  many  difficulties  in  order  to  secure  a 
medical  education,  would  find  an  open  path  of  employment  in 
conducting  these  examinations.  Their  undertaking  the  duty 
would  remove  all  pretext  of  indelicacy  or  outrage,  while  the 
shame  of  what  is  shameful  would  remain  the  same.  It  is  true 
that  the  task  is  a  disagreeable  one ;  but  if  one  of  the  opposite 
sex  stands  forward  and  says  "  Homo  sum,"  she  must  add 
**  humani  nihil  a  me  alienum  puto ;"  the  doing  of  disagreeable 
work  is  a  test  of  earnestness  in  the  pursuit  of  a  profession. 

There  is  alarm  expressed,  even  by  advocates  of  the  legislation, 
lest  it  should  effect  "  an  increase  of  clandestine  prostitution." 
Some  state  that  clandestine  prostitution  has  increased,  others  that 
it  has  diminished.  The  discrepancy  in  the  statements  of  fact 
seems  to  us  to  be  partly  due  to  the  phrase  being  a  vague  one ; 
but  mainly,  and  most  importantly,  to  the  witnesses'  information 
respecting  increase  and  decrease  being  derived  from  different 
sources.  Those  who  speak  to  the  increase  cite  the  opinion  of  men 
who  have  contracted  disease,  and  who  attribute  their  misfortune 
to  women  that  they  believe  not  to  be  on  the  register,  such  as 
shop  girls  and  the  like ;  while  those  who  speak  to  the  decrease, 
and  who  are  the  more  numerous,  give  as  their  authority  observa- 
tions made  by  the  police  and  others  on  the  women  themselves. 
Now  it  seems  extremely  probable  that  women  who  formerly  would 
have  lived  solely  by  prostitution  have  been  driven  by  the  opera- 
tion of  the  Acts  some  to  be  really,  and  some  to  pretend  to  be, 
engaged  in  industrial  occupations,  and  these  would  be  very 
likely  to  be  diseased  and  to  conceal  it  also.  We  are  sorry  for 
their  customers'  sufferings,  but  still  it  is  evident  that  the  cause 
of  morality  has  prospered ;  for  the  women  have  made  the  first 
step  towards  reform  by  assuming  or  pretending  industry.  If 
they  can  once  get  permanent  employment  they  can  always, 
when  they  like,  re-enter  the  paths  of  respectability. 

The  decrease  reported  in  the  ranks  of  the  unrecognized  is 


394  Reviews,  fApril, 

traceable  to  the  attention  of  tlie  witnesses  who  speak  of  it 
being  drawn  to  those  young  persons  living  at  home  with  their 
friends  who  eke  out  their  gains,  or  obtain  funds  for  extra- 
vagance, by  occasional  prostitution.  It  appears  that  many  of 
these  are  frightened  at  the  exposure  threatened  by  the  new  law, 
and  give  up  their  malpractices.  If  that  effect  continues  it 
would  alone  justify  the  morality  of  the  Acts. 

It  is  urged  by  some  that  it  is  an  injustice  to  apply  a  law 
to  one  sex  which  we  do  not  apply  to  another,  and  that  dissolute 
men  ought  also  to  be  under  supervision.  This  is  a  flaw  doubt- 
less in  the  legislation,  but  it  is  a  flaw  of  omission,  not  of  com- 
mission, and  we  shall  be  bound  to  aim  at  some  means  by  which 
men  who  actively  spread  the  infection  of  syphilis  can  be 
detected  and  punished.  At  present  the  only  case  that  may  be 
brought  under  the  operation  of  law  is  that  of  a  husband  who 
infects  his  wife,  which  offence  makes  him  guilty  of  legal  cruelty, 
and  liable  to  be  divorced.  Yet  because  human  contrivances 
are  confessedly  imperfect,  that  is  not  a  reason  for  refusing  to 
adopt  them.  The  difficulty  in  the  present  instance  is  that  there 
is  no  class  of  men  answering  to  prostitutes,  no  male  trade  whose 
W'hole  business  is  seduction,  so  that  we  do  not  see  what  equi- 
valent rule  of  inspection  can  be  adopted.  However,  this  is  not  a 
time  for  the  periodical  inspection  of  soldiers  to  be  discontinued. 

But  we  must  unhesitatingly  condemn  attempts  at  a  retaliatory 
vrarfare  of  one  sex  upon  the  other.  We  are  informed  by  a 
witness  before  the  Commission  (Answer  13,030),  that  an  asso- 
ciation has  been  formed  of  persons  who  engage,  first,  never  to 
refuse  to  aid  a  fallen  woman,  and,  secondly,  never  even  to  receive 
within  their  doors  a  fallen  man.  This  spirit  of  union  is  directly 
the  converse  of  that  of  Christianity  and  patriotism,  where  "  there 
is  neither  male  nor  female,"  and  is  a  relapse  into  the  antagonism 
between  the  sexes  of  barbarous  times.  We  have  not,  however, 
seen  the  statement  contradicted. 

When  these  Acts  were  first  tried  in  certain  districts  we  were 
afraid  that  serious  inconvenience  would  arise  to  virtuous,  but 
imprudent,  women  in  their  administration.  We  have  been 
agreeably  surprised  by  the  few  cases  in  which  this  has  been  even 
alleged,  and  the  still  fewer,  we  think  we  might  say  none,  in 
which  the  allegation  has  been  justified.  All  who  have  been 
connected  with  hospitals  or  the  police  know  how  ready  unedu- 
cated persons  are  to  fancy  every  man's  hand  against  them,  and 
really  without  malice  to  tell  groundless  tales  of  ill  usage ;  and 
it  therefore  speaks  forcibly  in  favour  of  the  administrators  of 
the  laws,  and  of  their  conciliatory  demeanour,  that  the  mouths 
of  those  in  risk  of  injury  have  been  shut.  Even  the  "  Men  of 
Kent,"  who  threatened  the  Home   Secretary  with  a  revival  of 


1872.]  Practical  Lithotomy  and  Lithotrity.  395 

"  the  spirit  of  Wat  Tyler,"  have  not  found  a  plausible  case  for 
wielding  such  an  illogical  argument.  But  the  danger  of 
respectable  persons  being  annoyed  must  not  be  forgotten  never- 
theless. It  is  a  very  real  one,  though  it  has  hitherto  been 
practically  escaped,  and  we  look  with  gratification  on  the  energy 
of  those  ladies  and  others  who  have  been  agitating  the  matter 
in  opposition.  The  same  earnest  activity  will  probably,  in  the 
event  of  this  legislation  being  extended,  watch  jealously  over 
the  conduct  of  its  administrators ;  and  all  cases  of  abuse  will 
be  rigidly  investigated,  and  the  machinery  of  the  Acts  improved 
by  experience. 

It  is  important  that  both  sides  in  this  controversy  should  be 
thoroughly  agreed  upon  the  end  aimed  at  by  the  Acts.  As  we 
understand  them,  the  end  is  not  the  suppression  of  vice,  not  the 
suppression  of  disease,  not  even  of  all  contagious  disease,  but 
the  diminution  of  syphilis  only.  The  curing  of  gonorrhoea  is  a 
side  blow,  needful  in  order  to  include  all  cases  where  the  true 
existence  of  syphilis  might  be  hidden.  It  cannot  be  expected, 
and  we  have  given  some  reasons  why  it  should  not  be  altogether 
desirable,  that  gonorrhoea  should  be  much  checked.  The  object 
of  these  pages  has  been  to  show  that  in  the  proposed  means  of 
diminishing  syphilis  we  need  not  fear  that  any  germs  of  injury 
to  public  morality  are  latent. 


X.— Sir  H.  Thompson  on  Practical  Lithotomy  and  Lithotrity.^ 

Part  11. — Lithotrity. 

By  the  term  lithotrity  the  author  denotes  all  those  processes 
by  which  the  stone  is  broken  up,  crushed  and  powdered  in  the 
bladder,  and  by  which  the  debris  are  removed  through  the 
natural  canal  of  the  urethra  without  the  use  of  the  knife. 
Thirty-five  years  ago  the  operation  had  barely  made  good  its 
claim  to  be  admitted  into  the  list  of  recognised  surgical  opera- 
tions. Fifty  years  ago  it  was  only  a  theory.  The  author  con- 
siders that,  as  performed  at  the  present  day,  it  is  a  safer  and 
better  operation  than  it  was  even  ten  years  ago,  and  that  it  is 
founded  on  principles  and  regulated  by  laws  deduced  from  a 
large  experience,  and  is  no  longer  a  mere  experiment. 

After  a  short  reference  to  the  introduction  of  the  drilling 
process  by  Gruithuisen,  the  Bavarian,  in  1813,  and  to  its  modi- 
fication by  Elderton,  the  Scottish  surgeon,  in  1819,  the  author 

^  Practical  Lithotomy  and  Lithotrity.  By  Sir  H.  Thompson,  Surgeon  Ex- 
traordinary to  H.M.  the  King  of  the  Belgians;  Professor  of  Clinical  Surgery  and 
Surgeon  to  University  College  Hospital.     {Continued  from  our  last  Number.) 


396  Reviews.  [April, 

mentions  the  instruments  of  Civiale  devised  in  1817,  and  the 
contributions  of  Leroy  d'Etoilles  and  of  Amussat.^  The  first 
successful  operation  of  Civiale  was  performed  in  1824,  before  a 
Committee  of  the  French  Academy.  Improvements  in  the 
lithotrite  have  been  made  by  Weiss,  Heurteloup,  L'Estrange, 
Costello,  and  Charriere ;  but  the  experience  of  Civiale  himself 
the  author  regards  as  exceeding  that  of  any  other  operator.  The 
author's  "  own  experience,  however,  now  very  large,"  has  led 
him  to  modify  the  character  and  action  of  the  lithotrite,  and  the 
method,  to  a  certain  extent,  has  necessarily  somewhat  changed 
with  it,  and  he  considers  it,  as  at  present  practised  by  him,  to  be 
more  rapid  and  a  safer  method  than  any  previous  one. 

On  turning  to  page  169  we  find  that  the  author's  contri- 
bution towards  the  perfected  instrument  is  that  of  a  cylin- 
drical fluted  handle,  associated  with  Weiss's  excellent  and  simple 
method  of  changing  the  sliding  into  the  screw  action,  by  shift- 
ing a  button  along  a  groove  in  the  handle.  There  can  be  no 
doubt  that  this  cylindrical  handle,  as  applied  by  Sir  Henry  both 
to  the  lithotrite  and  the  sound,  is  a  very  great  improvement 
upon  the  awkward  and  ponderous  arrangement  which  is  found 
even  in  Charriere's  improved  lithotrite,  and  upon  the  flat  spoon- 
handled  figure  which  forms  the  termination  of  the  sounds  in 
common  use. 

The  remarks  at  page  151,  as  to  the  treatment  preliminary  to 
the  operation  of  lithotrity,  concerning  the  importance  of  attend- 
ing in  metropolitan  patients  to  the  general  deterioration  of 
health  before  operation,  and  also  of  allowing  a  time  for  rest  and 
acclimatization  to  patients  from  the  country,  show  evidences  of 
much  thought  and  experience.  To  overcome  the  feverishness 
and  excitement  of  a  country  patient,  resulting  from  altered  habits 
and  anxiety,  he  considers  that  from  three  or  four  days  in  some 
cases  to  even  a  fortnight  in  others  should  be  allowed.  Still  more 
important  is  it  to  subdue  by  rest  in  bed,  regulated  diet,  ano- 
dynes, local  bathing,  &c.,  the  condition  of  irritability  of  the 
bladder  and  kidneys,  and  the  chronic  cystitis,  which  exists  more 
or  less  in  all  cases  of  calculus  of  some  standing.  A  favorite 
remedy  of  the  author  is  the  decoction  of  the  rhizome  of  the 
Triticum  repens,  a  pint  daily  in  divided  doses.  From  the 
language  of  the  author  we  infer  that  he  believes  in  the  local 
action  upon  the  bladder  and  other  urinary  organs  of  the  demul- 
cent virtues  of  this  decoction  and  of  similar  preparations,  in 
addition  to  and  distinct  from  their  good  effect  as  mere  diluents 
increasing  the  quantity  and  diminishing  the  acidity  of  the  urine 

^  The  author  in  these  references  omits  mention  of  the  use  of  Haygarth's 
sliding  instrument,  with  a  screw  added,  by  the  late  Mr.  Hodgson  at  the  Birmingham 
Hospital  in  1825,  and  also  the  invention  of  the  oval  slit  in  the  female  blade  by 
Mr.  Oldham. 


1872.]  Practical  Lithotomy  and  Lithotrity.  397 

which  flows  through  the  bladder.  In  this  we  fancy  he  differs 
from  some  of  the  best  therapeutic  writers  of  the  present  day. 
He  recommends  a  pint  of  the  decoction  to  be  taken  daily  in 
divided  doses. 

He  also  recommends  the  preliminary  employment  of  bougies, 
at  first  soft  and  elastic,  and  then  those  of  a  metallic  composition, 
previously  to  the  use  of  the  sound.  To  most  patients  who  do 
not  suffer  from  the  additional  evil  of  a  strictured  urethra,  the 
passage  of  a  warm,  well-oiled,  moderate-sized  metallic  instru- 
ment gives  rise  to  less  irritation  than  any  of  the  elastic  bougies. 
And  we  venture  to  think  that  most  surgeons  having  to  deal  with 
a  healthy  urethra  would  be  apt  to  prefer  the  use  of  the  sound 
possessing  these  qualities,  in  addition  to  its  power  of  imparting 
information  as  to  the  size  and  character  of  the  stone,  to  a  pre- 
vious faddling  with  bougies.  It  is,  of  course,  understood  that  an 
irritable  urethra,  addicted  to  spasm  and  to  the  production  of  a 
subsequent  febrile  attack,  or  the  presence  of  a  stricture  or  other 
impediment,  will  demand  previous  appropriate  instrumental 
treatment  of  the  kind  indicated  by  the  author,  who,  it  is  fair 
to  say,  afterwards  states  that  this  elaborate  preparation  by  in- 
struments is  really  necessary  in  only  exceptional  cases. 

Chapter  VIII  concludes  with  an  enumeration  of  the  condi- 
tions most  favorable  for  the  successful  application  of  lithotrity, 
viz. — 

1.  A  fajrly  capacious  and  not  very  tender  urethra. 

2.  A  bladder  capable  of  containing  three  or  four  ounces  of 
urine,  not  very  irritable,  yet  possessing  a  moderate  degree  of 
tonicity ;  that  is,  capable  of  expelling  its  contents. 

3.  Fair  general  health. 

Chapter  IX  treats  of  the  instruments  employed  in  lithotrity. 
It  prudently  premises  that  the  object  in  lithotrity  is  not  merely 
the  breaking  up  of  the  stone  into  fragments,  but  also,  as  an 
ultimate  end,  the  reduction  of  the  stone  to  powder  and  small 
debris,  which  can  be  easily  voided  by  the  patient.  To  this  the 
author  applies,  as  in  his  opinion  the  most  expressive,  the  term 
"  granulation."  To  this  word  occurs  at  once  the  objection  that 
it  is  already  appropriated  to  a  very  different  surgical  meaning. 

Lithotrites  are  divided  by  the  author  into  two  classes,  according 
to  the  disposition  of  the  blades.  The  first  class  includes  those 
adapted  by  the  formation  of  the  blades  to  seizure  and  fracture  of 
the  stone.  They  have  a  fenestrated  female  blade  and  a  male  blade 
provided  with  sharp-wedged  teeth  of  a  larger  or  smaller  size,  the 
larger  adapted  to  the  stronger  instruments  for  dealing  with  large 
and  hard  calculi.  The  inclination  of  the  blades  to  the  shaft  Sir 
Henry  considers  should  not  be  more  than  li^O°,  as  the  instrument 
thereby  loses  power,  though  easier  to  pass  through  the  urethra. 

98— xLix,  26 


398  Heviews.  [April, 

The  second  class  includes  those  in  which  the  blades  are  some- 
what shorter,  and  arranged  so  as  to  crush  fragments  to  powder 
rather  than  to  break  them  up  into  pieces.  They  have  plain 
blades,  not  fenestrated,  the  female  blade  wider  than  the  male, 
which  it  receives  between  its  raised  edges.  One  of  these,  figured 
at  page  163,  has  the  male  blade  so  much  narrower  than  the 
female  as  to  break  up  more  easily  the  larger  fragments,  while 
the  male  blade  of  the  other  is  wider,  so  as  to  crush  more  com- 
pletely the  small  fragments  into  powder.  The  inner  surface  of 
the  female  blade  is  smooth,  with  a  small  hole  at  the  bend,  to 
permit  the  escape  of  fluid.  That  of -the  male  blade  is  rough- 
ened, to  catch  a  firmer  hold  upon  the  fragment,  and  to  grind  it 
more  completely  to  powder.  The  author  states  that  the  pre- 
vailing fault  of  both  the  London  and  Paris  instruments  is  to 
have  the  female  blade  too  deeply  recessed  near  the  head,  thereby 
retaining  the  debris  and  interfering  with  the  perfect  action 
of  the  instrument.  These  instruments  act,  when  necessary,  as 
efficiently  in  removing  debris  as  the  older  fashioned  scoop. 

The  mechanism  of  the  handle  may  be  the  same  in  both  kinds 
of  lithotrite,  the  distinctive  efficiency  of  each  being  placed 
essentially  in  the  blades.  The  most  improved  mechanism  is  a 
simple  application  of  the  wheel  and  screw,  admitting  of  gradual, 
even,  and  continuous  pressure ;  and  so  adapted,  in  Charriere's, 
Coxeter's,  and  Weiss's  latest  improvements,  as  to  permit  of  the 
male  blade  being  opened  and  shut  by  the  hand  alona  to  search 
for  and  seize  the  stone.  This,  by  a  thumb-catch  action,  can  be 
changed  into  the  screw  power  at  the  option  of  the  operator,  to 
crush  the  stone  when  caught  by  the  blades. 

This  mechanism,  enclosed  in  the  fluted  cylindrical  handle  of 
the  author,  completes  an  instrument  which,  as  made  by  Weiss, 
Coxeter,  and  Matthews,  leaves  little  to  be  desired  in  the  way 
of  lightness  and  power  combined.  The  author  gives  also  a  descrip- 
tion and  woodcut  of  the  rack-and-pinion  lithotrite  devised  by  Sir 
W.  Fergusson,  and  made  by  Matthews,  and  states  fairly  enough 
the  advantages  which  it  possesses  in  enabling  the  operator  to 
apply  a  jerking  force  to  the  stone  which  will  act  like  percussion 
and  will  sometimes  break  a  hard  stone  when  the  direct  screw 
power  fails,  and  is  also  somewhat  more  susceptible  of  the  direct 
action  of  the  intelligence  of  the  operator  than  the  screw  power. 
We  have  lately  had  occasion  to  verify  this  in  an  operation  upon 
a  very  hard  stone,  breaking  with  a  flint-like  fracture.  We  have 
found  in  addition  that  the  rack-and-pinion  power,  acting  in  Fer- 
gusson's  instrument  parallel  to  the  axis  of  the  shaft,  had  the 
advantage  of  not  twisting  round  the  blades,  as  the  severe  appli- 
cation of  the  screw  does,  necessitating,  where  great  force  is  re- 
quired, the  fixing  of  a  movable  cross-bar   to   the   cylindrical 


1872.]  Practical  Lithotomy  and  Lithoirity,  399 

handle  to  enable  the  operator  to  resist  this  rotating  tendency, 
which  might,  when  a  large  fragment  is  seized  by  the  blades, 
damage  somewhat  the  coats  of  the  bladder. 

Sir  Henry  speaks,  with  a  complacency  pardonable  enough, 
of  his  power  to  detect  with  one  of  his  improved  instruments  a 
piece  of  stone  of  the  size  of  a  split  pea. 

The  diminution  of  the  thickness  of  the  shaft  by  Sir  William 
Fergusson,  so  as  to  permit  the  freer  play  of  the  instrument  in 
the  urethra,  is  commended  by  the  author  and  applied  to  all  his 
own  lithotrites.  He  considers  that  the  best  and  strongest  in- 
struments, cut  from  the  solid  steel,  to  be  those  produced  by 
English  makers.  For  merely  reducing  fragments,  however,  he 
thinks  a  forged  shaft  is  sufficient. 

In  Chapter  X  the  author  applies  the  term  "  sitting"  as  the 
equivalent  of  the  French  seance,  and  the  term  "operation" 
as  embracing  the  same  total  of  sittings  required  to  remove  the 
stone  altogether. 

Of  the  positions  of  the  patient  during  the  sitting,  two  modes 
are  given,  viz.  the  ordinary  and  extraordinary.  In  the  first,  he 
reclines  upon  his  back  on  a  couch  somewhat  higher,  for  the 
operator's  greatest  convenience,  than  the  common  sofa  (viz.  at 
least  thirty  inches).  If  an  ordinary  bed  is  used,  a  hard  mattress 
should  be  laid  upon  it,  and  then  a  firm  pillow  two  to  three 
inches  thick,  to  prevent  the  patient's  pelvis  sinking  below  the 
plane  of  the  shoulders,  the  knees  being  a  little  separated  and 
bento  ver  a  couple  of  small  pillows.  When  the  patient  is  so  placed 
the  stone  will  lie  a  little  behind  the  neck  of  the  bladder.  In 
the  exceptional  position  the  pelvis  is  raised  from  five  to  six 
inches  above  the  level  of  the  shoulders,  with  the  thighs  slightly 
raised  and  the  abdomen  inclined  from  the  pelvis.  The  stone 
here  lies  near  the  posterior  wall  of  the  bladder.  This  position 
is  required  when  the  prostate  is  large,  the  patient  stout,  and  in 
searching  for  the  last  fragments. 

The  figures  given  of  these  positions  are  very  large,  and  the 
directions  of  the  lithotrite  very  clear  to  the  comprehension. 

The  area  of  operation  in  the  bladder  is  thus  brought  to  the 
centre  of  the  viscus,  and  the  part  of  the  cavity  immediately 
below  it,  away  from  the  sensitive  and  easily  damaged  neck  of 
the  bladder,  and  the  lithotrite  can  be  reversed  with  comfortable 
facility. 

Upon  the  condition  of  the  bladder  at  the  time  of  the  opera- 
tion. Sir  Henry  says  (p.  178)  that  he  has  for  several  years  dis- 
continued the  practice  of  previous  injection  of  the  viscus,  or 
even  of  requiring  the  patient  to  hold  his  water  for  an  hour  before 
the  operation,  which  the  nervous  anxiety  of  the  patient  usually 
renders  impossible.     For  young  operators  the  presence  of  three 


400  Reviews.  [April, 

or  four  ounces  of  fluid  he  considers  desirable,  but  lie  himself,  as 
frequently  as  not,  operates  in  the  empty  bladder.  By  avoiding 
the  preliminary  injection  of  water  he  thus  shortens  the  sitting 
and  the  manipulation  more  than  one  half. 

He  urges  justly  that  most  frequently  the  only  method  of 
subduing  irritation  is  to  crush  the  fragments  more  completely. 

A  flabby  unexcitable  condition  of  the  bladder  is  as  objection- 
able as  an  abnormal  irritability,  because  the  stone  may  be,  if 
small,  hidden  in  loose  folds,  and  the  bladder  rendered  irregular 
in  shape  by  the  pressure  of  the  neighbouring  tissues,  as  in  the 
dead  subject,  instead  of  presenting  an  evenly  contracted  ovoid 
shape. 

In  introducing  the  lithotrite  the  angular  bend  requires  more 
management  than  the  even  curve  of  the  catheter,  and  the  end 
of  the  instrument,  if  not  properly  managed,  is  brought  into 
awkward  entanglement  with  the  urethra  at  the  pubic  arch. 

It  must  be  directed  more  evenly  than  the  catheter,  and  for  a 
longer  period  backward  before  the  handle  is  depressed,  the 
latter  action  being  performed  rather  by  the  weight  of  the  instru- 
ment alone.  A  slight  rotary  motion  may  be  advantageously  im- 
pressed upon  it  as  it  enters  the  prostatic  portion,  with  a  gentle 
pressure  upon  the  pubis  to  push  down  and  relax  the  suspensory 
ligament  of  the  pelvis.  The  author,  like  most  other  litho- 
tritists,  prefers,  while  doing  this,  to  stand  on  the  right  side  of  the 
patient,  so  as  not  to  have  occasion  to  change  position  after- 
wards. 

In  his  instructions  for  finding  and  seizing  the  stone  the 
author  premises  that  the  operator  should  accustom  himself  to 
the  familiar  use  of  the  lithotrite,  so  that  he  may,  when  operating 
upon  the  living  subject  manage  the  instrument  instinctively. 

Unmistakable  woodcuts  render  the  meaning  of  the  directions 
so  plain  that  it  is  impossible  to  be  in  doubt. 

Sir  Henry  advocates  the  method  of  catching  the  stone  em- 
ployed by  Civiale,  viz.  bringing  the  blades  of  the  lithotrite  to 
the  stone  wherever  it  may  be,  in  preference  to  that  ascribed  to 
Heurteloup  and  practised  by  Sir  Benjamin  Brodie,  the  principle 
of  which  is  to  place  the  closed  blades  of  the  instrument  in  a 
central  and  safe  position,  and  then,  by  depressing  slightly  with 
them  the  base  of  the  bladder,  to  open  them  and  by  a  slight 
lateral  concussion  with  one  hand  upon  the  other  grasping  the 
handle,  to  cause  the  stone  to  drop  between  them.  He  finds 
usually  that  the  blades  need  not  be  inclined  laterally  more  than 
30°  with  the  vertical  line  of  the  body. 

The  author  first  determines,  if  possible,  the  position  of  the 
stone,  and  then,  inclining  the  blades  slightly  to  the  opposite  side, 
carries  the  female  blade  backwards,  carefully  sliding  open  the 


1872.] 


Practical  Lithotomy  and  Lithotrity.  401 


male  blade,  and  then,  inclining  the  opened  blades  towards  the 
stone,  almost  certainly  seizes  it  with  the  sides  rather  than  the 
end  of  the  blades. 

If  the  stone  is  not  found  by  this  means,  he  searches  the 
whole  of  the  cavity  by  a  series  of  five  movements,  which  he 
designates  thus — the  vertical,  the  right  and  left  incline,  right 
and  left  horizontal,  and  right  and  left  reversed  incline  respec- 
tively, the  two  latter  being  especially  adapted  to  search  behind 
the  prostate.  He  considers  it  essential  to  good  practice  to  main- 
tain the  axis  of  the  shaft  as  far  as  possible  always  in  the  samo 
direction,  moving  only  the  blades  laterally.  In  cases  in  which 
the  stone  is  small,  movable,  or  unusually  placed,  this  maxim, 
taken  literally,  must  surely  admit  of  many  exceptions,  unless  it 
is  meant  to  hold  good  only  when  the  stone  is  already  in  the 
grasp  of  the  blades,  a  meaning  which  the  context  alone  renders 
clear  in  the  allusion  to  an  intentional  alteration  of  the  direction 
of  the  shaft.  When  thus  explained  it  means  simply,  we  take 
it,  a  steady  instead  of  an  undulating  grasp  upon  the  handle, 
and  a  regard  for  the  urethral  turning  axis  at  the  triangular  liga- 
ment upon  which  the  shaft  of  the  lithotrite  plays  lengthwise. 

To  the  rule  which  has  been  laid  down  that  a  large  stone  is 
usually  found  near  the  neck  of  the  bladder,  and  a  small  one  at 
the  back  of  the  trigone.  Sir  Henry  scarcely  assents,  to  the  latter 
part  especially,  and  moreover  considers  that  to  seize  a  large 
stone  near  the  neck  requires  much  care,  that  the  female  blade 
should  be  pushed  backwards  alone,  while  the  male  maintains  its 
position  at  the  neck  of  the  bladder,  to  insure  against  the  stone 
being  drawn  with  it  when  opened  towards  and  against  the 
sensitive  neck  of  the  viscus  behind  the  pubis. 

As  to  the  manner  of  crushing  the  stone  when  seized,  the 
author  inculcates  the  simple  rule  of  keeping  the  lithotrite  in 
the  centre  of  the  bladder,  with  the  certainty  of  the  fragments 
being  found  again  at  the  base  of  the  cavity  immediately  under 
the  instrument,  and  may  thus  be  picked  up  again  and  again 
with  very  little  movement  of  the  blades. 

We  feel  compelled  to  speak  with  less  approval  of  his  recom- 
mendation that  the  lithotrite  should  not,  "  at  all  events," 
remain  in  the  bladder  more  than  one  or  two  minutes.  Such  a 
limitation  of  the  time  seems  to  us  to  savour  strongly  of  the  vice 
against  which,  in  his  section  on  lithotomy.  Sir  Henry  inveighs, 
as  we  took  occasion  to  notice  in  our  last,  and  concerning  which 
he  indorses  Dr.  Keith's  application  of  the  maxim  "  Festina 
lente." 

It  is  surely  not  the  length  of  time,  within  reasonable  limits, 
during  which  instruments  are  in  contact  with  the  bladder  that 
influences  the  success  of  the  operation,  but  the  gentleness  and 


402  Reviews,  [April, 

care  with  which  the  instruments  are  used  while  there,  and  this 
gentleness  and  care  is,  in  the  hands  of  the  younfy  operators 
who  will  constitute  the  majority  of  the  readers  of  the  book, 
much  more  likely  to  be  associated  with  deliberation  than  with 
haste.  The  manual  dexterity  which  experience  has  produced 
in  Sir  Henry's  own  hands  may  have  combined  gentleness  and 
care  with  speed  of  manipulation  and  conclusion,  but  such  a 
happy  combination  can  scarcely  be  taught  in  a  book  which, 
liberally  professing  to  lead  others  to  a  like  facile  result,  should 
all  the  less  be  used  to  proclaim  a  fact  already  sufficiently  well 
known.  It  is  the  more  surprising  that  this  expression  should 
have  escaped  from  the  author's  pen  at  page  197,  when,  at  page 
191,  a  very  short  time  before,  he  states — ^'  As  a  rule,  all  these 
movements  are  to  be  executed  without  hurry,  rapid  movement, 
or  any  other  which  partakes  of  the  nature  of  a  jerk  or  concus- 
sion, and  without  causing  more  than  a  very  slight  degree  of 
pain  to  the  patient." 

The  judicious  recommendation  which  immediately  follows, 
that  after  the  first  sitting  the  patient  should  lie  on  his  back  for 
twenty-four  hours,  even  while  passing  water,  to  prevent  the 
large  angular  fragments  from  being  driven  forcibly  against  the 
neck  of  the  bladder,  suggests  the  idea  that  it  is  better  to  crush 
or  "  granulate  "  such  fragments,  when  made,  at  once,  and  as 
completely  as  possible,  even  at  the  expense  of  a  little  minute 
more  of  time. 

An  energetic  injunction  that  on  no  account  should  the  blad- 
der be  washed  out  or  injected  at  the  first  sitting,  because  it  is 
desirable  to  avoid  unnecessary  irritation,  and  because,  the  first 
object  being  to  make  fragments,  no  great  amount  of  detritus 
capable  of  removal  would  probably  be  found,  is,  of  course,  a  most 
prudent  one  under  the  conditions  supposed. 

No  less  judicious  is  the  position  that  calculous  matter  in  a 
granulated  condition  will  come  away  more  easily  than  you  can 
remove  it,  and  that  fragments  too  large  to  pass  the  urethra  will 
remain  behind,  do  what  you  will.  It  is  the  further  statement, 
that  fragments  small  enough  to  pass  with  some  difficulty  should 
be  left  to  take  their  chance,  which  admits  of  much  difference  of 
opinion. 

Sir  Henry's  position  is,  that  under  the  vesical  irritation 
induced  by  ineffective  instrumentation  for  their  removal,  they 
are  in  danger  of  beng  driven  into  the  neck  of  the  bladder  and 
urethra  before  their  sharp  edges  are  smoothed  off  by  a  day  or 
two's  sojourn  in  the  viscus,  when  they  will  find  their  own  way 
safely  enough.  We  cannot  but  suspect  that,  in  spite  of  the 
author's  weighty  and  concluding  warning  against  a  meddle- 
some disposition,  over-haste,  and  undue  anxiety  to  show  the 


1872.]  Practical  Lithotomy  and  Lithotrity.  403 

results  of  our  work^  it  is  in  this  direction  that  all  future  im- 
provements in  lithotrity  will  be  made,  and  that  a  shortening  of 
the  whole  time  occupied  by  treatment,  and  especially  of  the 
number  of  sittings,  will  be  accepted  as  a  boon  by  the  future 
sufferers  from  this  painful  malady.  We  entirely  agree  with 
the  opinion  which  the  author  shares  with  Sir  Benjamin  Brodie 
and  Mr.  Charles  Hawkins,  both  of  whom  he  quotes  in  a  foot- 
note to  page  201,  that  the  removal  of  large  portions  of  stone 
with  the  scoop,  at  the  risk  of  laceration  of  the  urethra,  and 
subsequent  impaction  of  fragments  therein,  with  consecutive 
abscess  and  urinary  infiltration,  is  a  bad  practice,  and  one  to 
be  avoided,  the  example  of  surgeons  of  note  in  the  profession 
notwithstanding.  It  is  much  better  and  safer  to  crush  such 
fragments  into  smaller  pieces  while  they  are  within  the  grasp 
of  the  lithotrite. 

The  author  says  justly  that  the  detection  and  removal  of  the 
last  fragments  frequently  demand  more  skill  and  operative 
power  than  any  other  part  of  the  proceeding  (page  S03),  and 
he  uses  for  this  purposes  a  lithotrite  with  short,  wide,  plain 
blades  and  well-rounded  ends,  for  searching  and  catching  them. 
It  is  an  instrument  very  well  suited  for  the  purpose,  and  recom- 
mends itself  in  the  woodcut  more  powerfully  and  agreeably 
than  in  the  example  given  by  Sir  Henry  of  its  wonderful  pro- 
perties, shown  in  his  own  hands,  in  producing  a  click  upon  a 
fragment  so  small  as  to  come  easily  with  the  instrument  through 
the  urethra,  to  the  astonishment  of  the  admiring  bystander,  and 
we  must  say  to  the  controvention  of  his  own  rule  just  quoted. 

He  claims,  fairly,  credit  for  the  handiness  of  the  cylindrical 
handle  of  the  lithotrite,  which  is  really  a  great  improvement 
both  to  this  instrument  and  the  sound.  A  case  is  given  in  proof 
of  the  value  under  certain  circumstances  of  a  lithotrite  provided 
with  a  hollow  male  blade  to  permit  of  a  flow  of  urine  along  it, 
which  had  the  effect  of  bringing  a  very  small  stone  with  the 
current  thereby  induced  into  the  jaws  of  the  lithotrite;  it  was 
then  crushed  by  drawing  forwards  the  female  blade.  This  little 
bit  he  had  previously  failed  to  catch  in  two  sittings.  He  mentions, 
without  particular  encomium,  Civiale's  favourite  "  trilabe,"  for 
seizing  and  removing  stones  from  the  bladder  or  urethra.  He 
is  not  impressed  in  favour  of  the  practice  of  copious  wash- 
ings of  the  bladder  to  remove  the  last  debris,  from  the  use  of 
which  he  has  obtained  very  meagre  results.  He  makes  an 
exception,  however,  in  favour  of  Mr.  Clover's  evacuating 
apparatus.  As  to  the  use  of  syringes,  double-current  catheters, 
and  current  propellers,  devised  by  French  mechanical  genius, 
he  regards  them  as  useless  and  even  positively  mischievous, 
in  necessitating  prolonged  contact  of  instruments  with  the  coats 


404  Reviews.  [April, 

of  the  bladder.     Among  these  he  includes  by  name  Mercier's 
double  catheter  ''  coudee,"  as  well  as  Maisonneuve's  Lithexere. 

A  good  description  of  Clover's  evacuating  catheters  and 
bottle  to  receive  fragments  is  given  at  pp.  21S — 215.  In  the 
use  of  these  he  advises  great  gentleness,  and  his  estimate  of 
their  advantages  he  qualifies  by  the  remark  that  "  their  em- 
ployment is  quite  as  irritating  to  the  bladder  as  a  sitting  vy^ith 
the  lithrotrite/'  so  that  he  prefers  to  do  even  without  them  if 
possible. 

In  the  section  dealing  with  the  after-treatment  (p.  216)  Sir 
Henry  states  that  impaction  of  fragments  in  the  urethra  is  of 
rare  occurrence,  but  gives  a  drawing  of  a  very  handy  pair  of 
urethral  forceps  made  for  him  bylWeiss. 

For  the  removal  of  stones  and  foreign  bodies  from  the  urethra 
the  author  recommends  the  forceps  just  alluded  to,  assisted, 
perhaps,  by  a  cuvette  rather  than  any  of  the  urethral  litho- 
trites  or  complicated  instruments  which  have  been  brought 
out  in  France.  At  page  219  he  turns  aside  from  the  subject 
of  his  book  to  take  a  passing  glance  at  the  instruments  for 
removing  hair-pins,  pieces  of  catheter,  and  other  foreign  bodies, 
from  the  bladder,  a  subject  so  closely  connected  with  the  direct 
object  of  the  work  as  scarcely  to  be  considered  a  digression. 
In  one  case  Sir  Henry  removed  a  flexible  hair-pin  from  a  male 
bladder  by  means  of  an  or  dinary  lithotiite.  In  another  patient, 
a  female,  he  used  one  of  the  French  instruments  unsuccessfully, 
from  want  of  sufficient  power  to  bend  the  pin,  but  succeeded 
afterwards  Avith  a  stronger  instrument  made  by  Weiss. 

For  the  febrile  symptoms  which  occasionally  occur  after  a 
sitting.  Sir  Henry  recommends  preventive  treatment  by  warm 
drinks,  warm  clothing,  and  hot-water  bottles  to  the  feet,  and, 
above  all,  ease,  gentleness,  and  rapidity  in  the  operation.  For 
subsequent  pains  in  the  loins  and  sickness,  he  knows  of  no 
better  application  than  hot  linseed-meal  poultices,  sprinkled 
with  mustard,  applied  to  the  back.  Hip  baths,  demulcent 
drinks,  diaphoretic  regimen,  and  mild  nutriment,  with  his 
favorite  decoction  of  Tritricum  repens.  For  cystitis  and  mucous 
urine  he  recommends  washing  out  the  bladder,  and  the  appli- 
cation of  the  scoop  lithotrite,  to  break  down  the  large  frag- 
ments which  keep  up  the  irritation,  as  soon  as  possible.  In 
orchitis,  which  occasionally  occurs,  fomentation  and  rest,  but  no 
lowering  measures,  are  advisable.  Haemorrhage  from  the  bladder 
and  urethra  is  exceptional.  The  author  lost  one  patient  from 
severe  bleeding  from  the  bladder  after  a  sitting  of  short  dura- 
tion, the  haemorrhage  continuing  for  a  week  until  death  ensued. 
An  autopsy  showed  intense  congestion  of  the  whole  vesical 
mucous  membrane,  but  no  abrasion  or  injury  whatever.     The 


1873.]  Practical  Lithotomy  and  Lithotrity,  405 

patient  had  been  subjected  to  free  loss  of  blood  by  the  urine 
previously  to  the  operation.  Would  not  this  seem  to  have 
contra-indicated  lithotrity,  and  to  indicate  lithotomy  as  a  pre- 
ferable operation  in  such  a  case  ? 

In  another  case  the  disposition  to  bleed  after  the  first  sitting 
or  two  caused  some  anxiety,  but  the  case  terminated  well.  The 
treatment  followed  was  ice  in  the  rectum  and  washings  of  the 
bladder,  carefully  conducted,  with  ice-cold  water,  elevated  posi- 
tion to  the  pelvis,  and  strict  rest  and  recumbency. 

In  elderly  subjects  retention  of  urine  after  a  sitting  is  very 
common,  resulting,  not  from  the  impaction  of  fragments,  but 
partly  to  defective  power  of  the  bladder,  partly  to  swelling 
of  the  prostate  and  urethra.  In  these  cases  the  condition  of 
the  bladder  as  to  distension  should  be  carefully  explored,  and 
the  catheter  used  daily  twice  or  even  more  times. 

Sir  Henry  does  not  consider  it  necessary  for  the  patients  to  be 
strictly  confined  to  the  house  if  in  good  health  and  with  a  small 
stone.  Air  and  even  gentle  exercise  may  be  taken  in  the  in- 
tervals of  the  sittings.  We  know  of  one  case,  at  least,  in 
which  exposure  to  the  open  air  in  very  cold  weather  led  to  an 
attack  of  renal  infiammation  under  such  circumstances. 

With  respect  to  the  question  of  the  administration  of  chloro- 
form, the  author  says  (p.  S28) — 

"The  pain  arising  from  lithotrity  properly  performed  is  really 
not  much,  It  is  uneasiness  rather  than  pain,  and  as  a  sitting  is 
rarely  longer  than  one  or  two  minutes,  the  demand  on  the  patient's 
fortitude  is  not  very  considerable." 

And  in  nervous  or  susceptible  patients,  labouring  under  those 
irritable  conditions  of  the  parts  to  which  calculous  patients  are 
subject  more  on  some  days  than  on  others,  of  the  cause  of  which 
we  have  little  knowledge,  and  over  it  but  little  or  no  control, 
he  thinks  that  operative  procedure  should  be  always  postponed 
when  the  mere  passage  of  an  instrument  causes  the  patient 
much  pain  and  uneasiness.  This  indication,  or  hypersensibility, 
is,  of  course,  wanting  when  chloroform  is  taken  and  the  voice 
of  nature  stifled.  This  benefit  is  the  only  one  which  Sir  Henry 
considers  to  be  attached  to  the  withholding  of  anaesthesia  on 
the  side  of  the  patient.  His  remark  is,  indeed,  true,  that  on 
the  part  of  the  surgeon,  operating  without  chloroform  produces  an 
unconscious  habit  of  care,  gentleness,  watchfulness,  and  delicate 
manipulation,  which  is  of  great  value.  But  we  will  venture  to 
remind  Sir  Henry  that  all  these  may  be  arrived  at  by  the  ap- 
preciative mind  and  obedient  hand  equally  without  the  expense 
of  suffering  to  the  patient.  We  must  do  him  the  justice  to  say, 
however,  that  he  does  not  think  the  sensibility  of  the  patient's 
bladder,  as  written  on  his  face  should  be  necessary  to  tell  the 


406  Reviews,  [April, 

operator  when  lie  has  seized  the  coats  of  the  bladder  instead  of 
the  stone !  If  it  were,  we  unhesitatingly  agree  with  him  that 
the  patient's  chances  of  recovery  from  such  a  complaint  and 
such  an  operator  are  slender  indeed ! 

Lithotrity  in  children. — From  the  narrowness  of  the  urethra 
in  patients  under  puberty,  and  from  the  pyriform  shape  and 
greater  irritability  of  the  bladder  necessitating  very  small  in- 
struments and  longer  time  in  finding  and  crushing  the  stone, 
because  of  the  uncertainty  of  its  position^  Sir  Henry  comes  to 
the  conclusion  that  they  are  not  such  favorable  subjects  for  the 
crushing  operation  as  adults  are.  Impaction  of  fragments  in 
the  urethra  and  distressing  irritability,  spasm,  and  retention  of 
urine,  are  apt  to  result. 

During  the  operation  chloroform  is  absolutely  necessary. 
Guersant  states  that  out  of  twenty-one  cases  of  lithotrity  at  the 
Children's  Hospital  in  Paris,  there  were  six  deaths,  two  from 
the  operation  and  four  from  intercurrent  disease.  Three  others 
were  subsequently  submitted  to  lithotomy,  and  all  of  these  died. 
This  is  a  fearful  rate  of  mortality,  and,  as  Sir  Henry  remarks, 
English  lithotomy  yields  very  much  better  results  than  this. 
The  author  seems  to  conclude  that  with  a  very  small  stone,  such 
as  could  be  crushed  at  one,  two,  or  three  sittings,  lithotrity 
is  a  good  operation  for  children,  but  with  the  larger  calculi 
lithotomy  is  a  safer  operation.  He  recommends  a  very  small 
lithotrite,  of  which  he  gives  an  illustration,  with  the  handle 
adapted  bymeans  of  a  cross-bar  for  crushing  by  manual  force  only. 
Small  lithotrites  are  now  made  by  Weiss,  Matthews,  and  others, 
so  powerful  and  strong  that  more  will  probably  be  done  in  this 
direction  in  England  than  has  hitherto  been  the  case. 

The  practical  maxims  with  which  Chapter  XI  concludes 
express  in  brief  the  opinions  given  by  the  author  upon  the 
whole  subject  of  lithotrity  under  ordinary  conditions.  All  or 
most  of  these  have  already  been  passed  in  review,  but  we  take 
again  occasion  to  express  our  dissent  from  the  injunction  here 
again  recapitulated,  "  that  no  sitting  should  exceed  five  minutes 
in  duration,  except  under  very  peculiar  circumstances,"  and  that 
'^  the  large  majority  of  sittings  should  occupy  only  two  or  three 
minutes.'^  Such  an  arbitrary  limitation  of  time  can  only  con- 
tribute to  a  hurried  and  careless  style  in  young  operators,  in 
which  the  element  of  quickness  will  be  unduly  and  injuriously 
cultivated  at  the  expense  of  other  advantages  of  somewhat 
more  value.  We  think  the  author  unduly  exaggerates  the 
effect  of  mere  contact  of  proper  instruments  with  the  coats  of 
the  bladder  when  in  a  fairly  healthy  condition. 

In  Chapter  XII  are  considered  cases  of  calculus  complicated 
with  serious  organic  disease.     Sir  Henry  states  that  he  has  not 


1873.]  Practical  Lithotomy  and  Lithotrity.  407 

found  that  organic  stricture  of  the  urethra  constitutes  an  inse- 
parable obstacle  to  lithotrity,  and  gives  in  the  appendix  of  cases 
three  notable  instances,  viz.  91,  110,  and  194,  of  the  successful 
application  of  the  lithotrite  under  these  circumstances.  His 
method  is  first  to  overcome  the  stricture  by  "  continuous  dila- 
tation," by  tying  an  elastic-gum  catheter,  large  enough  to  pass 
the  stricture  with  tolerable  ease,  and  in  two  days  replacing  by 
a  larger  size,  until  No.  10  or  11  is  reached.  He  then  gives 
chloroform,  and  uses  a  rather  small  flat-bladed  lithotrite, 
removing  with  great  care  the  debris  made.  As  the  cases 
referred  to  in  the  appendix  are  very  meagre  in  detail,  we  are  at 
a  loss  to  understand  exactly  how  Sir  Henry  accomplishes  this 
desirable  result,  and  are  left  to  the  inference  that  it  was  done 
with  the  scoop  lithotrite  only.  If  so  the  stones  must  have  been  of 
very  small  size,  and  since  one  of  these  fortunate  patients  was  also 
the  subject  of  diabetes  (Case  110)  we  presume  that  none  of  the 
five  sittings  recorded  were  prolonged  beyond  the  three  to  five 
minutes  fixed  by  the  operator,  for  fear  of  the  effect  of  the  con- 
tinued contact  of  instruments  with  the  bladder.  Sir  Henry 
has  no  doubt  that  lithotrity  may  be  made  successful  in  stricture 
cases,  except  in  case  of  large  hard  stones.  Does  he  not  think 
that  in  such  instances  some  more  certain  and  reliable  means 
of  removing  the  debris  than  the  forceps-like  action  of  the  litho- 
trite scoop  would  render  his  anticipations  more  probable  ? 

Still  more,  if  possible,  are  such  means  to  be  desired  in  cases 
of  enlarged  prostate,  in  which  the  fragments  are  not  expelled 
by  the  natural  contractions  of  the  bladder. 

Sir  Henry  states  that  he  has  met  with  less  difficulty  than 
might  have  been  anticipated  in  such  cases  by  the  use  of 
the  scoop  lithotrite  and  Clover's  apparatus.  His  good  skill 
and,  shall  we  add,  good  fortune  (quite  as  useful  an  attribute 
of  the  surgeon  as  the  other),  have  had  under  these  difficulties 
as  good  an  outcome  as  in  most  of  the  perplexities  of  lithotrity. 

In  confirmed  atony  and  paralysis  of  the  bladder  there  is 
frequently  found  the  complication  of  a  calculus,  chiefly  of  a 
phosphatic  character.  In  such  cases  the  author  considers  that, 
on  account  of  the  habituation  of  the  organs  to  the  use  and 
contact  of  catheters,  we  have  a  far  less  formidable  complication 
than  in  enlarged  prostate.  His  treatment  by  the  use  of  the 
lithotrite  and  the  evacuating  apparatus  of  Clover  is  mentioned 
only  by  a  very  brief  allusion. 

Sacculation  of  the  bladder  the  author  considers  to  be  one  of 
the  most  serious  and  unpromising  complications  the  surgeon 
can  meet  with,  both  in  lithotomy  and  lithotrity.  He  considers 
that  he  has  overcome  the  difficulty  of  diagnosis  in  these  cases 
by  causing  the  patient,  after  apparently  complete  evacuation  of 


408  Reviews,  [April, 

the  bladder  by  means  of  a  catheter,  to  lie  on  each  side  alter- 
nately for  two  or  three  minutes  and  then  to  rise  to  the  erect 
posture  ;  then,  if  some  ounces  more  are  withdrawn,  "  there  can 
be  no  doubt  as  to  the  existence  of  some  sac  in  the  bladder  "  (p. 
241).  Although  Sir  Henry  has  tried  this  experiment  re- 
peatedly, and  has  founded  upon  it  a  diagnosis  of  sacculation 
which  has  been  ultimately  confirmed  by  examination  after 
death,  a  shrewd  doubt  is  irresistible  as  to  the  possibility  of 
distinguishing  by  this  means  a  true  sacculus,  especially  if  small 
enough  to  retain  a  stone,  from  irregularities  of  the  cavity  of  the 
bladder  arising  from  nodulated  tumours  of  the  prostate  and 
other  growths.  Something  of  this  has  apparently  dictated  the 
author'^  exclamation,  "  Unhappily,  the  diagnosis  of  sacculation 
is  not  by  any  means  always  possible." 

In  these  cases,  again,  the  desirability  of  removing  manually 
the  debris  after  crushing  is  presented  to  the  author's  mind, 
although  his  means  of  doing  so  are  so  limited  as  to  lead  him  to 
the  opinion  that  lithotomy  is,  cceteris  paribus,  somewhat  less 
hazardous  in  such  cases  than  lithotrity.  In  one  case  of  malig- 
nant tumour  of  the  bladder  the  author  crushed  a  coexistent 
calculus  with  extreme  gentleness  and  care,  with  the  effect  of 
much  mitigating  the  sufferings  of  the  unfortunate  patient 
during  the  remaining  months  of  his  existence. 

He  has  had  several  times  to  perform  lithotrity  for  patients 
suffering  from  advanced  renal  disease.  He  found  them  more 
liable  to  severe  constitutional  disturbance  and  fever  after  a 
sitting,  and  hence  advises  the  sittings  to  be  short  and  at  longer 
intervals.  All  rapid  changes  of  temperature  should  be  provided 
against. 

In  cases  of  multiple  calculi  he  considers  the  advantages  of 
lithotrity  to  be  more  promising  than  a  single  large  one,  weight 
for  weight.  The  presence  of  two  or  three  stones,  each  of  con- 
siderable size,  however,  augments  the  risk.  The  author  recom- 
mends that  one  should  be  attacked  at  a  time  and  perfectly 
crushed  before  meddling  with  the  others. 

Chapter  XIII  deals  with  the  results  of  lithotrity.  In  dis- 
cussing this  subject  the  author  premises  some  remarks  upon 
the  difficulty  of  comparing  the  results  with  those  of  lithotomy 
on  account  of  the  selection  of  the  more  favorable  and  smaller 
cases  for  the  former  operation,  and  the  unavoidable  discrepan- 
cies in  the  rule  of  selection  with  different  surgeons,  some  limit- 
ing the  application  of  the  lithotrite  to  stones  of  three  drachms' 
weight,  and  others  extending  its  use  to  those  of  five  or  six 
drachms  or  more.  The  latter  will,  of  course,  have  results  more 
unfavorable  than  the  former. 

The  estimate  made  by  Sir  Benjamin  Brodie  in  his  paper  in 


1872.] 


Practical  Lithotomy  and  Lithotrity.  409 


the  '  Medico-Chirurgical  I'rans.actions '  he  looks  upon  as  a 
valuable  record  of  his  own  experience,  but  no  more,  and  so  also 
with  the  annual  reports  of  Civiale.  The  latter  surgeon  he 
considers  to  have  been  so  biassed  in  favour  of  the  method  he 
has  practised  so  long  and  so  successfully,  and  towards  which 
he  contributed  so  much,  that  he  barely  admitted  that  lithotrity 
could  occasion  death  at  all.  This  bias  influences  all  his 
writings  upon  the  subject,  so  much  as  to  lead  to  his  attributing 
all  the  deaths  to  some  other  cause  than  the  operation.  Upon 
this  the  author  remarks  that  "  Lithotrity  does  not  less  surely 
destroy  life  in  certain  cases,  although  no  palpable  lesion  may  be 
produced,  than  lithotomy  does  when  the  necessary  wound  proves 
fatal "  (p.  248). 

At  the  meeting  of  the  British  Medical  Association,  in  Dub- 
lin, in  1867,  Sir  Henry  presented  an  analysis  of  100  cases  of 
operation,  in  Avhich  84  cases  of  lithotrity  were  compared  with 
16  of  lithotomy.  Since  that  time  he  states  that  he  has  operated 
upon  120  cases  more  by  lithotrity,  making  a  total  of  204  cases, 
all  performed  by  the  method  and  instruments  in  present  use. 
All  the  cases  were  in  adults,  the  youngest  22  years  old ;  most 
of  advanced  age,  the  oldest  84  years;  eighteen  of  them  are 
recorded  twice  occurring  in  the  same  individual.  In  the  few 
cases  in  which  a  third  operation  was  necessary  to  remove 
calculous  matter  continually  forming,  none  has  been  recorded 
more  than  twice.  To  this  there  occurs  one  remarkable  excep- 
tion (given  in  a  footnote),  in  which  two  years  after  a  second 
operation  for  a  single  stone,  in  a  gentleman  upwards  of  seventy 
years  old,  he  found  numerous  small  stones,  which  he  removed 
by  a  third  operation,  in  six  sittings,  the  debris  collectively 
weighing  upwards  of  an  ounce. 

In  Brodie's  paper  one  individual  reckons  for  eight  cases  in 
the  course  of  as  many  years.  Sir  Henry's  204  cases  thus  repre- 
sent 185  individuals,  who  include  (as  he  specifies  with  ex- 
cusable though  evident  complacency)  patients  from  every 
quarter  of  the  world,  "  which  seek  the  aid  of  a  well-known 
operator."  As  a  rule,  crushing  was  confined  to  calculi  below 
one  ounce  in  weight,  i.e.  about  the  size  of  a  large  date. 

In  considering  the  question  of  the  number  of  recoveries  per 
cent.  Sir  Henry  requests  attention  to  the  three  following  state- 
ments (p.  252)  :  1st.  That  he  has  never  found  it  necessary  or 
desirable  to  complete  by  the  use  of  the  knife  a  case  of  stone 
in  which  he  has  commenced  the  operation  by  crushing,  as  has 
been  frequently  done  in  Paris,  and  thus  the  death,  if  occurring, 
has  not  been  placed  to  the  account  of  lithotrity,  but  to  that 
of  the  sister  operation. 

In  a  footnote  to  the  same  page,  however,  he  qualifies  this 


410  tteviews.  [April, 

statement  by  giving  tlie  particulars  of  two  cases,  one  in  which 
he  removed  the  phosphatic  crust  from  an  oxalate  of  lime  stone, 
but  finding,  we  suppose,  that  it  was  too  hard  a  nut  to  crack,  he 
afterwards  performed  lithotomy. 

The  other  case  is,  we  presume,  that  of  a  gentleman  well 
know  in  the  profession,  for  whom  Sir  Henry  crushed  several 
small  uric  acid  calculi,  at  six  sittings,  in  October,  1868  ?  (sic). 
Afterwards  he  had  severe  cystitis,  orchitis,  and  abscesses  in  the 
scrotum  and  abdominal  walls,  and  on  the  20th  April,  1870,  an 
examination  under  chloroform  having  been  decided  upon  in  the 
presence  of  Sir  W.  Fergusson  and  Messrs.  Pollock,  Marshall, 
and  Hutchinson,  two  small  uric  acid  calculi  were  removed  by 
lithotomy  by  Sir  Henry.  Half  a  pint  of  matter  escaped  from 
the  incision.  Sir  Henry  states  that  the  stones  were  not  frag- 
ments, but  entire  calculi,  and  his  case  is  that  these  were  formed 
afresh  in  the^^e  months  between  the  operation  of  crushing  in 
the  months  of  October  and  November  and  the  month  of  April. 
We  presume  that  some  error  has  crept,  therefore,  into  the  text, 
either  in  the  date  1868  (?  1869)  or  1870.  The  case,  of  course, 
is  open  to  the  surmise  that  these  stones  w^ere  present  in  the 
bladder  at  the  time  of  the  operation  of  crushing. 

2ndly.  Sir  Henry  states  that  he  has  not  left  incomplete  or 
unfinished  a  single  case  upon  which  he  has  begun  a  crushing 
operation,  and  that  the  practice  of  doing  so,  not  unusual  in 
Paris,  as  also  the  custom  of  refusing  operative  interference  in  a 
certain  proportion  of  unfavorable  stone  cases,  is  almost  unknown 
to  English  surgeons.  It  is  much  to  the  credit  of  the  latter, 
indeed,  that  such  a  statement  can  be  made. 

3rdly.  Sir  Henry  has  never  refused  to  operate  in  any  case  of 
stone,  either  by  lithotrity  or  lithotomy,  and  in  some  he  has 
crushed  at  the  patient's  request  when  lithotomy  would  have 
been  a  preferable  operation,  although  absolutely  refused  by  the 
patient.  He  states  that  in  two  or  three  fatal  cases  given  in  his 
table,  lithotomy  would  have  been,  as  he  advised,  the  preferable 
proceeding. 

By  a  saving  clause  he  asserts,  however,  that,  "  as  a  rule,  the 
surgeon  must  decline  to  perform  any  operation  but  that  which 
appears  to  him  the  better  of  two  courses  open,  but  in  rare  ex- 
ceptions he  cannot  refuse  to  be  influenced  by  circumstances, 
and  adopt  the  less  promising  when  by  its  means  some  hope  of 
saving  life  exists  "  (p.  253). 

The  summary  of  his  204  cases,  averaging  61  years  of  age,  he 
gives  as  follows  (p.  254) : — 13  cases  ended  in  death,  and  the 
rate  of  recovery  was  therefore  93i  per  cent.  The  first  84  cases 
included  4  deaths,  or  at  the  rate  of  95  per  cent,  of  recoveries. 
The  last  hundred  were  rather  less  promising,  though  he  remarks 


1872.]  Practical  Lithotomy  and  Lithotrity.  411 

justly  that  two  or  three  bad  cases  tell  heavily  against  a  small 
percentage  rate  of  mortality  in  the  total. 

The  most  common  cause  of  death  in  the  fatal  cases  was  in- 
flammation of  both  kidneys.  A  certain  amount  of  cystitis  is  usually 
met  with  in  cases  where  several  sittings  are  necessary.  Rigors 
more  or  less  severe  indicate  that  the  kidneys  have  been  invaded. 
Fever  continues,  and  in  the  fatal  cases  slowly  increasing,  ex- 
haustion and  death  occurs  in  from  seven  to  twenty-one  days. 
Traces  of  inflammatory  action  and  deposits  of  pus  in  the  kidneys 
and  course  of  the  ureters  are  the  post-mortem  signs.  The  author 
is  satisfied  that  in  some  or  all  of  these  cases  chronic  pyelitis  or 
nephritis  has  pre-existed,  set  up  by  the  stone  before  operation, 
and  he  states  that  we  have  no  certain  means  at  present  of  de- 
tecting such  a  condition.  There  may  be  no  albumen  or  any 
significant  deposits  or  renal  casts  in  the  urine.  The  mucus, 
pus,  and  blood,  which  may  be  present  in  any  cases,  are  usually 
derived  from  the  bladder,  and  it  is  impossible  to  determine 
whether  their  source  may  not  be  partially  from  the  kidney. 
We  are  not  so  certain  that  the  microscopic  pathologists  of  the 
urine  will  unreservedly  accept  Sir  Henry's  conclusion  upon  this 
matter,  viz.  that  "  in  fact,  neither  physical  signs  nor  subjective 
symptoms  are  by  any  means  frequently  present,  yet  advanced 
pyelitis  and  even  sometimes  chronic  nephritis  may  exist"  (p.  255). 

Acute  cystitis  is  more  liable  to  be  fatal  when  the  bladder  is 
previously  diseased  and  sacculated,  when  frequent  and  continued 
catheterism  to  relieve  the  atonied  viscus  may  induce  slow 
cystitis  or  pyelitis.  In  three  cases  only  the  scourge  of  surgery, 
pyc87nia,  was  the  cause  of  death. 

The  author  thinks  that  though  it  is  not  possible  to  draw  so 
hard  and  fast  a  line  as  that  drawn  by  Sir  B.  Brodie  between 
the  cases  in  which  a  fatal  result  occurred  from  the  operation 
itself,  and  those  in  which  it  is  to  be  attributed  to  the  coexistence 
of  some  other  disease  roused  into  activity  by  the  shock  of  the 
operation,  but  tending  to  prove  ultimately  fatal  even  if  let  alone, 
yet  that  this  basis  affords  a  useful  and  fair  classification.  He 
would  place  among  the  latter  the  cases  of  advanced  organic 
diseases  of  the  bladder  or  kidneys,  such  as  marked  sacculation 
of  the  former  viscus  and  pyelitis  or  other  organic  change  in  the 
latter  organs,  and  he  considers  that  they  would  prove  equally 
fatal  after  either  lithotomy  or  lithotrity.  These  conditions 
existed  in  five  out  of  his  thirteen  fatal  cases.  In  the  eight  other 
fatal  cases  the  death  may  be  attributed  to  the  operation.  Some 
showed  mere  exhaustion,  others  acute  cystitis,  and  the  three 
cases  of  pysemia.  Tims,  Sir  Henry  claims  as  a  fair  view  of  the 
subject  a  mortality  of  only  four  per  cent,  due  to  the  operation 
(p.  257).     He  does  not  state  in  the  record  of  any  of  his  pygemic 


412  Reviews,  [April, 

cases  whether  any  injury  or  abrasion  of  the  surface  tissue  had 
been  caused  by  the  operation.  This  omission,  although,  perhaps, 
in  one  of  the  cases  (Case  193,  p.  321)  unavoidable  from  the 
patient's  absence  from  town,  is  yet  unfortunate  as  giving  us  no 
clue  to  the  occurrence  of  a  malady  which  is  so  often  traumatic 
in  its  origin. 

It  is  always  pleasanter  for  both  author  and  reviewer  to  dilate 
upon  the  details  of  successful  than  of  unsuccessful  cases,  and  we 
turn  with  more  satisfaction  to  read  that  "  by  far  the  greater 
number  (of  Sir  Henry's  patients)  are  living  still,  free  from  all 
symptoms  and  enjoying  fair  health."  Three  were  masters  of 
hounds  and  over  seventy  years  of  age  when  operated  on,  all  of 
whom  returned  to  their  duties,  and  two  had  enjoyed  many  a  hard 
day's  riding  since. 

In  the  practice  of  lithotrity  the  author  is  forcibly  reminded, 
in  contemplating  the  result  of  most  of  his  cases,  of  Deschamp's 
classical  axiom,  "  causa  sublata  effectus  tollitur."  But,  in  a 
few,  chronic  inflammation  continues  to  affect  the  bladder,  and 
these,  he  thinks,  occur  more  in  middle  life  than  even  in  advanced 
age.  He  considers  that  this  result  ought  not  to  be  produced  by 
the  operation  if  gently  and  properly  conducted,  and  he  again 
alludes  in  terms  of  reprehension  to  the  practice  of  dragging  large 
angular  fragments  through  the  urethra. 

Among  the  204  cases  there  are  eighteen  in  which  the  stone  has 
reappeared  after  a  year  or  more's  absence,  necessitating  another 
operation.  Sir  Henry  explains  that  this  may  occur  in  two  ways. 
1st.  By  a  fresh  descent  from  the  kidney.  This  seems  to  have 
occurred  in  seven  cases.  2nd.  More  common  than  the  last,  so  as 
to  constitute  an  opprobrium  in  lithotrity,  viz.  the  formation  of 
phosphatic  incrustation  through  persistent  chronic  cystitis.  This 
occurred  in  eleven  cases,  with  the  addition,  perhaps,  of  three 
others,  lost  sight  of  afterwards  by  the  author.  One  of  the 
causes  of  this  persistence,  viz.  irritation  caused  by  instrumental 
manipulation,  is  looked  upon  by  the  author  as  yet  capable  of 
diminution  by  improved  instruments,  methods  of  operating,  and 
skill  in  the  operator.  A  good  deal  may  be  done  by  daily  injec- 
tions of  the  bladder  with  tepid  water,  and  thorough  washing  out 
of  mucus,  pus,  and  sand.  Sacculation  of  the  bladder  encysting 
a  stone  accounts  for  some  few  of  these  obstinate  cases.  Sir 
Henry  has  diagnosed  it  in  three  or  four  living  cases,  one  of 
which  was  afterwards  identified  by  examination  (whatever  that 
soothing  eupheuism  may  signify  we  are  left  to  infer,  and  venture 
to  do  so  in  the  usual  way,  viz.  that  it  means  necropsis)  by 
himself  and  Mr.  Cadge,  of  Norwich. 

At  this  point  of  his  labours  (p.  262),  Sir  Henry  comes  to  the 
important  practical  conclusion,  not  ofifered  as  his  own  or  any 


1872.]  Practical  Lithotomy  and  Lithotrity.  413 

other  persons'  opinion,  but  as  the  hard  logic  of  facts,  that  litho- 
trity is  an  eminently  successful  operation,  and  that  in  a  number 
of  cases,  by  no  means  limited,  success  may  be  regarded  as  a 
certainty,  absolutely  and  with  as  little  fear  of  contingencies  as 
the  minor  operations  of  surgery,  such  as  the  opening  of  a  small 
abscess  or  the  passing  of  a  catheter.  We  have  a  sentence 
placed  before  us  conspicuously  in  italics: — '^  For  I  have  never 
lost  a  single  patient  in  the  whole  course  of  my  experience  after 
crushi?ig  a  stone  which  was  no  larger  than  a  small  nuV  (p.  263). 
*'  And  this  is  a  size  at  which,  with  very  very  few  exceptions 
indeed,  every  stone  should  be  discovered."  But  again,  "  The 
rate  of  mortality  will  correspond  with  augmentation  in  the  size 
of  the  stone,  and  with  the  amount  of  existing  disease  and  age 
on  the  part  of  the  patient." 

Perhaps  as  much  could  really  be  said  of  nearly  every  opera- 
tion within  the  scope  of  surgery.  All  diseases  and  injuries 
vary  in  the  severity  of  their  consequences  with  their  extent, 
the  coexistence  of  other  diseased,  conditions,  and  in  relation  to 
the  age  of  the  patient.  And  what  can  be  said  of  all  or  nearly 
all  may  undoubtedly  be  said  by  Sir  Henry  in  support  of  the 
operation  to  which  he  has  devoted  his  special  attention,  with- 
out fear  of  contradiction  by  surgeons  perhaps  less  experienced 
than  himself  in  this  particular  operation. 

Of  the  204  cases  of  lithotrity,  135  were  instances  of  uric,  47 
of  phosphatic,  16  mixed,  4  of  oxalate  of  lime,  1  of  phosphate  of 
lime,  and  1  of  a  rather  large  cystic  oxide  calculus. 

The  last  chapter  of  the  author's  work  deals  with,  perhaps, 
the  most  difficult  part  of  the  whole  subject,  viz.  on  the  choice 
of  proceedings  best  adapted  to  different  cases. 

So  long  as  lithotomy  was  the  only  remedy  for  the  removal  of 
stone  from  the  bladder,  little  choice  was  afforded  except  that 
between  the  lateral,  median,  or  high  operation.  But  when  the 
safer  operation  of  crushing  became  matured  and  improved.  Sir 
Henry  believes  that  a  "  diagnosis  of  the  size ^  form ^  and  chemical 
character  of  the  stone  was  absolutely  necessary ^^  so  that  "  the 
case  and  the  method  should  be  judiciously  adapted  to  each 
other"  (p.  m^\ 

He  considers  that  at  first  "  the  new  method,  although  a  great 
advance  in  surgery  at  this  time,  actually  increased  the  fatality 
from  stone  operations,  and  was  a  positive  calamity  for  many  stone 
patients  at  that  era."  We  have  at  this  point  the  somewhat 
strong  statement,  the  words  "  I  have  abundant  evidence  of 
the  increased  mortality  which  was  occasioned  by  it  during  the 
period  in  which  its  application  was  mainly  experimental." 
"  The  cause  was,  partly,  that  experience  was  at  first  necessarily 
wanting  by  which  to  form  rules  for  the  operator's  guidance,  and 

98— XLix.  27 


414  Reviews.  [April, 

partly  that  the  importance  of  diagnosing  the  characters  of  the 
stone  had  not  been  perceived."  Cases  better  adapted  for  litho- 
tomy were  subjected  to  the  crushing  operation  and  terminated 
fatally.  The  author  still  further  ventures  to  say  with  deliberate 
conviction,  "  that  the  importance  of  such  a  diagnosis  is  not 
sufficiently  perceived  at  the  present  day  and,  consequently,  only 
a  portion  of  the  advantages  placed  within  our  reach  by  modern 
methods  has  yet  been  attained"  (p.  269).  Again,  unless  this 
is  done  (^.  e.  the  physical  and  chemical  diagnosis)  "  with  toler- 
able accuracy  it  will  be  better  to  return  to  the  use  of  a  single 
method,  say  the  lateral  operation,  than  to  risk  the  application  by 
guess  of  a  method  inapplicable  to  the  case."  This  statement 
Sir  Henry  repeats  a  little  further  on,  and  in  proof  of  the  pro- 
found nature  of  his  conviction,  in  a  distinct  paragraph  and  in 
italics.  The  means  by  which  he  at  this  place  proposes  to 
ensure  this  accurate  degree  of  information  is  a  measuring  sound 
of  his  own  invention,  hollow  and  provided  with  an  eye  at  the 
bend,  so  as  to  let  off  or  inject  water  into  the  bladder  as  may  be 
required,  and  mounted  on  the  cylindrical  fluted  handle  of  which 
we  have  in  the  foregoing  pages  spoken  with  approval.  The 
shaft  is  graduated,  and  has  a  movable  marker  to  indicate  the 
distance  between  the  touch  of  the  point  on  the  stone  behind 
and  that  in  front. 

Sir  Henry  determines  the  points  of  a  classification  based 
upon  (1)  size — small,  medium,  or  large;  and  (2)  texture — 
soft  or  hard,  and  of  the  hard  stones  whether  friable  or  com- 
pact. His  definition  of  a  medium  sized  stone  is,  that  the 
mean  of  two  of  its  diameters  is  one  inch.  Soft  stones  are 
phosphatic,  and  hard  stones  oxalate  of  lime,  uric  acid,  or 
urate  of  soda,  sometimes  mixed  with  phosphates.  Oxalate  of 
lime  and  uric  calculi  are  very  compact,  require  much  force  to 
break  them,  and  fracture  into  hard,  sharp,  sometimes  jagged 
splinters.  Urate  of  soda  and  cystine  are  also  hard,  but  more 
friable.  Mixed  calculi  break  easily,  because  of  the  unequal 
power  of  resistance  of  its  several  layers.  Phosphate  of  lime  is 
hard,  and  breaks  up  into  angular  rhomboidal  masses. 

In  a  paragraph  further  on  Sir  Henry  prefers  to  estimate  the 
size  of  the  stone  with  the  lithotrite ;  its  hardness  or  softness 
by  the  click  or  ring ;  its  friability  by  ascertaining  the  persistent 
deposit  in  the  urine  for  some  days  or  weeks.  From  the  last 
symptoms  he  says,  "one  may  almost  certainly  judge  of  the 
chemical  nature,  and  hence  of  the  physical  structure,  of  the 
existing  calculus ;"  and  he  gives  the  prudent  truism  as  a 
reminder,  "  that  phosphates  are  frequently  present  from  irrita- 
tion produced  by  acid  calculi."  We  must  here  submit,  with 
all  deference^  that  the  author  has  not  aiForded  in  these  pages  a 


1873. J  Practical  Lithotomy  and  Lithotrity.  415 

sufficiently  explicit  method  or  description  by  which  another  may 
judge  with  the  same  quasi-certainty  that  Sir  Henry's  illative 
power  apparently  gives  him  upon  the  point  immediately  before 
us ;  and,  moreover,  that  we  should  hesitate  to  pronounce  with 
any  such  a  degree  of  certitude  upon  the  author's  premises, 
with  the  single  exception  of  the  following  : — "  But  in  very  many 
cases  small  calculi  have  been  passed  before,  and  their  compo- 
sition is  known."  The  presumption  which  directly  follows  this, 
*^  that  which  is  in  the  bladder  will  mostly  be  identical  in  kind," 
expresses  exactly  the  degree  of  certainty,  viz.  from  the  proba- 
bility of  sequence,  to  which  a  cautious  man  would  like  to  venture 
in  many  of  these  cases. 

The  single  or  multiple  character  of  calculi.  Sir  Henry  pre- 
fers to  determine  also  with  the  lithotrite  rather  than  the  sound, 
which  is  deceptive.  He  seizes  one  stone  firmly  with  the  in- 
strument and  strikes  upon  the  other  with  it. 

After  having  carefully  studied  the  herein-contained  results  of 
the  author's  reflection  and  experience,  we  can  scarcely  say  that  the 
merits  of  this  simple  classification  are  so  striking,  original,  or 
beneficial,  as  to  render  it  probable  that  the  lithotritists  who  have 
preceded  Sir  Henry  Thompson,  ("  fortes  vixerunt  ante  Aga- 
memnon,") should  not  have  been  able  to  shake  their  ideas 
into  a  right  form  without  its  aid,  to  arrive  at  those  safe 
conclusions  which  are  necessary  to  make  lithotrity  a  gain  upon 
the  older  operation,  and  to  guard  against  that  increased  mor- 
tality of  which  the  author  complains,  as  well  as  against  any 
underrating  of  the  importance  of  diagnosis. 

The  remaining  series  of  necessary  data  are  age,  absence  or 
presence  of  local  disease,  and  susceptibility  to  constitutional 
disturbance. 

From  the  table  which  the  author  gives  in  the  book,  it  appears 
that  one  third  of  the  total  number  of  cases  occurs  under  six 
and  a  half  or  seven  years  of  age.  One  half  tlie  entire  number 
of  cases  occur  before  the  thirteenth  year.  These  he  considers, 
with  a  few  exceptions,  to  be  best  adapted  for  lithotomy. 

The  author  considers,  however,  that  in  proportion  to  the 
number  of  the  existing  population  at  that  age,  calculus  is  most 
common  between  fifty  and  seventy,  next  between  two  and  six 
years,  least  frequent  between  twenty-six  and  thirty-six. 

The  author  has  operated  by  crushing  in  two  patients  affected 
with  Bright's  disease.  One  of  them  died  within  one  year 
afterwards;  and,  as  he  remarks,  encouraged  by  this  result,  he 
operated  upon  the  other,  probably  a  more  advanced  case,  but 
death  rapidly  followed.  This  was  anything  but  encouraging, 
and,  accordingly.  Sir  Henry's  conclusion  is  the  not  unreason- 
able one  that,  ''  When  the  disease  is  in  an  advanced  stage. 


416  Reviews.  [April, 

no  condition  is  more  unpromising  for  the  success  of  any  opera- 
tive procedure." 

Another  class  of  renal  cases  are  the  results  of  continued  irri- 
tation of  calculus  in  the  bladder,  of  stricture  of  the  urethra,  such 
as  chronic  nephritis,  pyelitis,  sacculation  and  cystic  formations. 
Of  these,  says  Sir  Henry,  "  We  can  by  no  means  be  certain 
from  any  signs  or  symptoms  that  the  changes  exist  in  any  given 
case,  and  it  is  certain  that  they  prejudice  exceedingly  the 
results  of  an  operation^^  (p.  279). 

Cases  of  constitutional  irritability  uncomplicated  by  organic 
disease  are  more  hopeful  ;  preparatory  treatment  and  careful 
manipulation  may  bring  the  system  into  such  a  tolerating  con- 
dition as  to  prevent  the  necessity  of  dealing  with  the  stone  by 
the  one  operation  of  lithotomy  instead  of  several  by  crushing. 

In  case  of  children  with  small  stones,  capable  of  being  pul- 
verized by  a  single  application  of  the  lithotrite.  Sir  Henry 
considers  crushing  to  be,  at  all  events,  admissible. 

He  considers  that  in  choosing  between  lithotomy  and  litho- 
trity  in  adults  it  is  necessary  to  draw  a  broad  distinction  between 
healthy  and  diseased  subjects.  In  the  former,  with  tolerant 
bladder,  medium  sized  stone  (and  not  above  that  size,  viz.  one 
inch  diameter,  in  cases  of  oxalate  of  lime  stone),  whether  hard, 
compact,  friable,  or  soft,  lithotrity  should  be  preferred.  In 
stricture  cases  with  a  small  stone  he  thinks  median  lithotrity 
(which,  for  the  most  part,  he  thinks  an  unnecessary  operation) 
may  be  preferred ;  with  a  large  stone,  lateral  lithotomy  should 
be  selected ;  but  if  the  stone  be  friable,  even  a  large  stone  in 
stricture  cases  is  best  dealt  with  by  crushing. 

In  patients  diseased,  but  not  markedly  so  as  to  the  urinary 
organs,  yet  feeble  and  failing  in  strength,  he  prefers  lithotrity. 
Where  well-marked  disease  of  the  urinary  organs  exists,  as  in 
stricture,  usually  lithotomy  is  chosen,  but  Sir  Henry  has  been 
able,  as  we  have  before  seen,  by  previous  dilatation  to  treat 
the  stone  successfully  by  crushing. 

In  enlarged  prostate  with  tolerant  bladder,  and  stones  under 
medium  size  lithotrity  is  successful.  But  with  an  irritable 
bladder  and  large  hard  stones  lateral  lithotomy  seems  preferable 
to  either  lithotrity  or  median  lithotomy. 

Atony  of  the  bladder,  formerly  held  to  contra-indicate 
lithotrity,  is  now  considered  much  more  favorable  for  it.  Litho- 
trity is  admissible  even  in  marked  disease  with  sacculi  of  the 
bladder,  cystitis,  with  constitutional  disturbance  and  tumours 
of  all  kinds.  Though  it  is  hazardous,  it  is  not  more  so  than 
lithotomy  in  such  cases. 

For  cases  of  very  large  sized  stones  the  author  thinks  that 
the  lateral  operation  is,  upon  the  whole,  the  best. 


1872.J  Practical  Lithotomy  and  Lithotrity,  417 

Sir  Henry  closes  the  last  chapter  with  a  glance  at  the  ques- 
tion which  must  frequently  be  met  with  in  practice,  viz.  should 
we  ever  refuse  to  operate  for  stone,  and  if  so,  under  what 
circumstances  ? 

In  hospital  practice  in  this  country  very  few  cases  are  rejected 
as  unfit  for  operation.  In  private  there  are  more  instances,  in 
consequence  of  the  greater  means  of  alleviating  the  pain  in 
well-to-do  patients. 

In  France  a  large  proportion  of  cases  are  rejected,  and  it 
appears  to  the  author  that  lithotomy  is  more  dreaded  there  than 
in  this  country,  both  by  patient  and  operator,  while  the  French 
surgeons  seem  unwilling  to  hazard  the  application  of  lithotrity 
in  very  unpromising  cases.  In  the  practice  of  M.  Civiale,  in 
1862,  eleven  cases  out  of  a  total  of  sixty-nine  were  rejected  as 
impossible  cases  for  either  operation. 

Sir  Henry  thinks,  however,  that  the  percentage  of  recoveries 
in  England  after  lithotomy,  with  large  stones  and  in  broken- 
down  constitutions,  viz.  two  out^of  three  and  a  half,  justifies  us 
in  offering  that  chance,  but  he  would  make  an  exception  against 
advanced  renal  disease. 

The  author  concludes  by  adverting  to  the  importance  of  ap- 
plying lithotrity  at  as  early  a  period  in  the  growth  of  stones  as 
possible,  to  detect  them  early,  and  operate  on  them  while  small, 
"  rather  than  to  extend  the  process  to  large  stones^^  and  he 
believes  that  undue  attempts  to  extend  the  application  of  litho- 
trity to  very  large  stones  will  end  in  disaster.  The  surgeon  is 
compelled,  however,  to  take  his  patients  as  he  finds  them,  and 
must  apply  his  art  to  the  case  presented,  without  laying  much 
stress  upon  the  way  in  which  it  came  about.  Yet  the  fact  ad- 
verted to  in  the  last  two  pages  is  curious,  that  the  later  records 
of  stone  cases  show  a  decreasing  average  size  in  successive  years. 
Sir  Henry  ventures  to  foretell  from  this  phenomenon  (while 
disclaiming  pretension  to  the  gift  of  prophecy)  that  lithotrity 
will  come  to  be  still  more  frequently  applied,  as  the  stones  are 
detected  earlier,  and  as  it  becomes  year  by  year  more  perfect  in 
detail.  In  the  Appendix  to  the  volume  are  given  notes  of  the 
204  cases  of  lithotrity.  They  are  very  brief,  not  to  say  meagre, 
and  give  little  more  than  the  bare  evidence  that  lithotrity  is 
Sir  Henry's  strongest  point,  and  that  in  this  respect  he  is,  if 
not  a  prophet,  verily  a  past  master  in  the  masonry  of  stones. 


418  Reviews.  [April, 


XI.— The  Pathology  of  Diabetes.^ 

It  is  a  profitable  custom  to  take  stock  at  intervals  of  tbe  state 
of  our  knowledge  on  certain  subjects,  to  review  our  progress, 
and  to  mark  out  the  line  for  future  advance.  In  no  branch  of 
human  inquiry  is  this  kind  of  survey  more  useful  than  in 
medicine,  and  in  no  part  of  medicine  than  in  the  case  of  such 
diseases  as  diabetes,  of  which  our  knowledge  is  daily  growing 
with  the  advance  of  physiological  experiment.  When  the 
subject  of  this  article  was  last  considered  in  these  pages  the  ex- 
periments of  Pavy  had  been  confirmed  by  McDonnell,  Schiff, 
Meissner,  Jager,  and  Eulenberg.  Bernard^s  theory  of  the 
sugar-producing  function  of  the  liver  was  regarded  as  a  view 
based  altogether  upon  the  fallacy  of  post-mortem  change,  and 
the  glycogenic  function  was  relegated  to  the  category  of  many 
other  forgotten  speculations  relative  to  hepatic  function. 

Now,  once  again  the  whole  subject  demands  attentive  con- 
sideration, on  account  of  the  new  facts  which  have  been  accu- 
mulated during  the  last  three  years.  To  show  how  far  recent 
observations  tend  to  establish  or  refute  the  conclusions  which 
not  long  since  appeared  so  certain  will  be  the  object  of  this 
article. 

The  works  before  us  naturally  divide  themselves  into  two 
classes,  the  experimental  and  the  clinical ;  some  being  simply 
a  record  of  physiological  experiment,  whilst  others  are  wholly 
occupied  with  the  clinical  aspects  of  saccharine  assimilation.  In 
accordance  with  this  division  we  shall  consider  the  new  matter 
to  be  found  in  them. 

The  experiments  on  which  Pavy  based  his  opinion,  that  the 
sugar  found  in  the  liver  after  death  was  the  result  of  post- 
mortem change,  were,  indeed,  controverted  by  Dr.  G.  Harley  in 

1  1.  On  the  Origin  of  Diabetes,  with  some  new  Experiments  regarding  the  Gly- 
cogenic Function  of  the  Liver.  By  W.  T.  LuSK,  M.D.,  Professor  of  Physiology, 
L.  I.  Medical  College.     New  York,  1870. 

2.  Sugar  Formation  in  the  Liver.  By  J.  C.  Dalton,  M.D.,  Professor  of  Phy- 
siology in  the  College  of  Physicians  and  Surgeons,  New  York.  Reprinted  from 
the  '  Transactions  of  the  New  York  Academy  of  Medicine,'  June,  1871. 

3.  Sulla  Poliuria  e  il  Diahete,  Studi  e  Considerazioni.  Del  Prof.  Pibteo 
BuREESi.  Estratte  dal  volume  secondo,  f ascicolo  primo,  della  *  Rivista  Scientilica 
de  Fisiocritici  de  Siena.'     1870. 

4.  Diahete  Sucre.  Jaccoud.  *  Nouveau  Dictionnaire  de  Medecine  et  de 
Chirurgie  Pratiques,'  tome  onzieme.     Paris,  1869. 

5.  Remarks  on  Diabetes,  especially  with  reference  to  Treatment.  By  WiLLlAM 
RiCHAEDSON,  M.A.,  M.D.,  &c.     London,  1871. 

6.  The  Skim  Milk  Treatment  of  Diabetes  and  Brighfs  Disease,  with  Clinical 
Observations  on  the  Symptoms  and  Pathology  of  these  Affections.  By  Aethub 
Scott  Donkin,  M.D.,  &c.  &c.    London,  1871. 


i8r2.] 


Pathology  of  Diabetes,  419 


1860.  The  strong  confirmatory  evidence  of  the  accuracy  of 
Pavy's  results,  which  came  from  so  many  independent  observ- 
ers, might  have  been  considered  sufficient  to  settle  the  question. 
There  w^as,  however,  left  behind  some  slight  room  for  doubt  in 
the  fact  that  in  all  these  experiments  the  portions  of  liver 
removed  ever  so  rapidly  showed  a  certain  trace  of  sugar,  minute 
as  compared  with  the  quantity  developed  a  few  minutes  after 
death,  it  is  true,  but  still  sufficiently  distinct  to  induce  some 
sceptics  to  reinvestigate  the  question. 

In  1868  Professor  Flint,  jun.,  published  in  the  '  New  York 
Medical  Journal'  an  account  of  some  experiments  on  dogs. 
Portions  of  liver  were  cut  out  during  life,  sliced  into  boiling 
water,  and  an  extract  made,which,  when  tested  by  Trommer's  and 
Fehling's  tests,  was  found  to  give  no  decided  trace  of  sugar. 
"When  the  operation  occupied  only  ten  seconds  no  trace  what- 
ever of  sugar  was  detected.  Dr.  Flint's  next  step  was  to  obtain 
the  blood  of  the  hepatic  veins,  which  was  done  by  ligature  of 
the  inferior  vena  cava,  this  operation  occupying  less  than  a 
minute.  In  the  blood  so  obtained  there  was  well-marked  evi- 
dence of  sugar.  From  these  experiments  he  came  to  the  con- 
clusion "  that  during  life  the  liver  contains  only  glycogenic 
matter,  and  no  sugar,  because  the  great  mass  of  blood  which 
constantly  passes  through  that  organ  washes  out  the  sugar  as 
fast  as  it  is  formed ;  but  after  death,  or  when  the  circulation  is 
interfered  with,  the  transformation  of  glycogenic  matter  into 
sugar  goes  on.  The  sugar  is  not  removed  under  these  condi- 
tions, and  can  then  be  detected  in  the  liver."  Pavy  replied, 
"  That  so  quickly  is  sugar  formed  in  the  liver  after  death  that 
the  result  was  to  have  been  expected,  considering  the  expendi- 
ture of  time  involved  in  applying  the  ligatures."  To  test  the 
value  of  this  objection  another  American  physiologist  came  for- 
ward. Professor  Lusk  made  his  experiments  on  dogs,  and  first 
confirmed  the  results  of  his  predecessors  as  to  the  absence  of 
sugar  in  the  liver  when  rapidly  removed  and  treated  by  methods 
calculated  to  arrest  post-mortem  change.  His  next  step  was 
to  obtain  blood  from  the  hepatic  veins,  by  lifting  up  the  liver 
and  opening  them  as  they  emerge.  The  blood  thus  obtained 
was  always  strongly  saccharine,  but  the  time  occupied  in  the 
operation  left  room  for  objection.  He  next  endeavoured  to  ob- 
tain the  blood  of  the  right  side  of  the  heart,  according  to 
Pavy's  method,  viz.  rapidly  opening  the  chest,  and  placing  a 
ligature  round  the  base  of  the  heart.  The  amount  of  blood  pro- 
cured in  this  way  from  a  dog  of  ordinary  size  was,  however,  too 
small  to  give  definite  results.  There  remained  only  Bernard's 
plan  of  passing  a  catheter  down  the  jugular  vein  into  the  right 
auricle.      Dr.  Lusk  performed  this  operation,  over   and   over 


420  Reviews.  [April, 

again,  with  great  care,  observing  all  the  precautions  indicated 
by  his  predecessors.  lie  drew  only  one  ounce  of  blood  in  each 
experiment;  this  was  treated  with  alcohol,  and  when  tested 
was  found  to  contain  only  a  small  quantity  of  sugar,  varying 
from  a  quarter  to  half  a  grain.  The  blood  of  the  jugular  vein 
was  next  tested,  and  in  each  case  a  feeble  reaction  with 
Fehling's  test  was  observed.  So  far  every  step  confirmed 
Pavy's  researches ;  traces  of  sugar  were  proved  to  exist  in  dif- 
ferent parts  of  the  venous  system.  The  only  question  that  re- 
mained was,  were  the  quantities  of  sugar  in  the  blood  of  the 
right  heart  and  the  jugular  vein  at  all  equal  ?  To  determine 
this  question  Lusk  tested  the  comparative  powers  of  the  extracts 
of  the  two  bloods,  in  discharging  the  colour  of  a  given  quantity 
of  Fehling's  solution,  and  found  that  the  result  was  very  much 
in  favour  of  the  blood  drawn  from  the  right  heart.  In  order  to 
show  the  constancy  of  his  results,  he  repeated  his  experiments 
in  four  additional  instances ;  twice  in  dogs  fasting  and  twice 
during  full  digestion.  The  quantity  of  sugar  appeared  to  be  two 
to  four  times  greater  in  the  blood  of  the  right  auricle  than  in 
that  drawn  from  the  jugular  vein.  Three  times  the  blood  was 
drawn  from  the  jugular  vein  after  it  had  been  drawn  from  the 
heart,  in  order  to  meet  any  objection  as  to  the  disturbing  effects 
of  the  operation ;  Pavy  having  affirmed  ''  that  should  sugar  ap- 
pear in  the  right  ventricular  blood,  it  will  also  be  found  to  a  cor- 
responding extent  in  that  of  the  carotid  artery  and  jugular  vein." 
From  these  experiments  Lusk  concludes  that,  while  Pavy  is 
right  as  to  the  post-mortem  nature  of  the  abundant  sugar-pro- 
duction in  the  liver  discovered  by  Bernard,  we  are  author- 
ised in  believing — (1)  that  the  blood  of  carnivorous  animals  fed 
on  nitrogenous  food  contains  appreciable  quantities  of  glucose  ; 
(2)  that  the  blood  of  the  right  side  of  the  heart  contains  from  a 
quarter  to  half  a  grain  per  ounce,  a  quantity  two  to  four  times 
greater  than  that  found  in  blood  of  the  jugular  vein;  and  (3) 
that  this  argues  a  by  no  means  insignificant  amount  of  sugar  in 
the  hepatic  blood  before  dilution  by  the  blood  of  vense  cavse,  and 
that  we  are  thus  forced  to  admit  the  sugar-formation  in  the 
liver,  though  we  fail  to  detect  the  presence  of  sugar  in  the  liver- 
tissue. 

While  these  results  were  being  arrived  at.  Professor  Dalton, 
the  distinguished  Professor  of  Physiology  in  New  York,  was 
engaged  in  a  somewhat  similar  inquiry.  His  first  experiments 
having  convinced  him  of  the  necessity  of  determining  the  exact 
limits  of  sensibility  of  the  various  tests  for  sugar  and  the  best 
mode  of  employing  them.  Dr.  Dalton  made  a  very  careful  pre- 
liminary investigation  on  these  points.  After  carefully  computing 
the  limit  of  the  practical  operation  of  Fehling's  test,  which  he 


1872.J  Pathology  of  Diabetes.  421 

found  to  be  the  most  delicate,  and  capable  of  detecting  even 
1-lOOOth  grain  of  sugar  dissolved  in  one  cubic  centimetre  of 
water,  he  proceeded  to  test  the  extract  made  from  portions  of 
liver  removed  from  living  dogs  fed  on  animal  food.  He  used  a 
special  form  of  machine  for  comminuting  the  liver-tissue,  so  that 
the  contact  of  alcohol  or  boiling  water  should  at  once  affect  its 
entire  mass.  In  all  his  experiments,  twenty  in  number,  he  was 
aided  by  three  assistants,  and  the  average  time  occupied,  from 
the  separation  of  the  liver  to  its  immersion  in  alcohol  or  boiling 
water,  was  six  and  a  quarter  seconds ;  the  longest  time  was 
thirteen  seconds,  the  shortest  three  seconds.  The  extract 
always  contained  sugar,  and  in  the  ten  instances  in  which  it  was 
determined  this  sugar  varied  from  8-lOths  to  4  parts  per  1000. 
Dr.  Dalton  further  proved  that  the  sugar  could  not  be  due  to 
the  presence  of  arterial  blood  in  the  liver  when  removed,  by  ex- 
cising and  testing  the  spleen  in  three  cases  after  the  removal  of 
portions  of  the  liver.  In  no  instance  was  any  sugar  detected  in 
the  splenic  tissue,  and  even  w^hen  the  extract  was  concentrated 
to  one  tenth  its  volume,  the  reaction  obtained  was  altogether 
too  feeble  for  quantitative  determination.  These  experiments, 
which  are  models  of  careful  scientific  research,  justify.  Dr.  Dalton 
thinks,  the  following  conclusions  : 

"  1.  Sugar  exists  in  the  liver  at  the  earliest  period  at  which  it  is 
possible  to  examine  the  organ  after  its  separation  from  the  body  of 
the  living  animal. 

"  2.  The  average  quantity  of  sugar  existing  in  the  liver  at  this 
time  is  at  least  2^  parts  per  1000. 

"  3.  The  liver  sugar  thus  found  does  not  belong  to  the  arterial 
blood  with  which  the  organ  is  supplied,  but  is  a  normal  ingredient 
of  the  hepatic  tissue." 

These  results,  and  the  results  previously  quoted,  demand  a 
careful  reconsideration  of  the  position  hitherto  accepted.  It 
certainly  seems  from  them  that  we  can  no  longer  avoid  the 
acceptance  of  Bernard's  theory  of  sugar  formation  in  the  liver. 
There  may  be  some  source  of  fallacy,  and  the  extremely  varied 
results  which  able  observers,  experimenting  on  this  subject, 
have  obtained,  make  us  fully  alive  to  such  a  possibility.  As 
far  as  we  can  judge,  however,  the  experiments  are  worthy  of 
acceptance,  and  once  accepted  they  restore  Bernard's  theory. 
Pavy's  experiments  in  fact  only  pointed  out  that  the  abundant 
presence  of  sugar  in  the  liver  after  death  was  not  a  condition 
of  life  ;  whether  it  was  an  increase  of  matter  already  existing  in 
small  quantity  or  a  substance  entirely  of  post-mortem  production 
was  not  shown.  The  amyloid  matter  or  glycogen  admitted 
to  be  present  in  the  liver  had  at  the  end  of  Pavy's  researches 
no  apparent  destination.     The  results  were  destructive  rather 


422  Reviews.  [April, 

than  constructive  in  their  character.  Hence  they  have  always 
failed  to  satisfy  some  students  anxious  to  probe  the  mystery 
more  deeply,  and  have  probably  suggested  more  experimental 
investigation  than  most  other  observations  that  we  possess. 
From  time  to  time  the  pendulum  of  medical  opinion  has  oscil- 
lated between  Pavy  and  Bernard,  but  altogether  has  mainly  in- 
clined towards  the  former.  These  results  of  American  investiga- 
tion once  more  change  the  direction.  There  can  be  now  little 
room  for  doubting  that  the  liver  does  form  a  small  but  appre- 
ciable amount  of  sugar,  and  passes  it  constantly  into  the  blood 
in  animals  fed  on  purely  albuminous  diet.  The  hypothesis 
originally  propounded  by  Bernard,  and  advocated  by  Dr.  Flint, 
appears,  after  all,  to  be  nearest  to  the  truth. 

The  destination  of  this  sugar  in  the  economy  is  the  next 
problem  to  be  solved.  On  this  point  we  have  no  data  before  us. 
There  are  many  facts  which  would  point  to  its  combustion  in 
the  lungs  and  tissues  generally,  but  the  direct  evidence  is  still 
"wanting.  Speculations  on  such  questions  can  lead  to  little  good, 
and,  as  they  frequently  prove  productive  of  much  ill,  we  prefer 
to  leave  this  part  of  our  subject  with  the  bare  statement  of  the 
actual  position  in  which  recent  experiments  place  us. 

Experiments  on  the  artificial  production  of  glycosuria  have 
always  formed  a  most  interesting  part  of  the  history  of  our 
knowledge  of  diabetes.  Bernard  originally  pointed  out  that 
any  hyper-activity  of  the  liver  circulation  was  associated  with 
an  increase  in  the  amount  of  sugar  formed.  From  a  series  of 
experiments  he  concluded  that  the  vessels  of  the  liver  were 
influenced  by  impressions  made  on  the  pulmonary  terminations 
of  the  vagi,  by  them  conducted  to  the  medulla,  and  thence 
reflected  to  the  liver  along  the  splanchnic  nerves.  The  line 
by  which  the  impressions  were  conducted  from  the  medulla  to 
the  splanchnics  was,  however,  not  quite  clear,  and  the  awkward 
fact  remained  that  after  irritation  of  the  roots  of  the  vagi  had 
produced  glycosuria  section  of  the  splanchnics  did  not  remove 
it.  Several  observers  have  added  to  our  knowledge  by  operating 
on  the  cervical  and  dorsal  ganglia  of  the  sympathetic.  Pavy 
produced  glycosuria  by  section  of  the  superior  cervical  ganglion, 
Eckhart  by  section  of  the  last  cervical  or  any  dorsal  ganglion, 
while  section  of  the  splanchnic  nerves  did  not  produce  it. 
The  explanation  ofl'ered  by  this  last  observer  was  that  exposure 
of  the  cut  surfaces  of  the  ganglia  to  the  air  caused  irritation, 
and  not  paralysis.  Cyon  {vide  '  British  Med.  Journal,'  Dec. 
23,  1871)  has  shown  that  this  explanation  is  insufficient,  and 
by  successive  steps  has  traced  the  line  of  conveyance  of  the 
nerve  influence  which  governs  the  liver  circulation  to  the  fila- 
ments which  pass  from  the  cord  along  the  vertebral  artery  to 


1872.] 


Pathology  of  Diabetes.  423 


the  last  cervical  ganglion.  Pavy,  it  should  be  stated,  had  pre- 
viously found  that  the  section  of  these  nerves  produced  glyco- 
suria. These  nerves  in  their  downward  course  from  the  last 
cervical  to  the  first  thoracic  ganglion  enclose  the  subclavian 
artery,  forming  the  annulus  of  Vieussens ;  in  this  ring  the 
nerves  of  the  hepatic  artery  are  contained,  and  their  division 
causes  the  vessel  to  dilate,  and  at  the  same  time  produces 
glycosuria.  Section  of  the  splanchnics  had  no  effect  on  this 
condition  of  the  urine,  unless  performed  before  the  division  of 
the  annulus  of  Vieussens.  Cyon's  explanation  is  this.  Sec- 
tion of  the  splanchnics  or  gangliated  cord  causes  dilatation  of 
the  vessels  of  the  intestines,  and  allows  the  blood  to  accumulate 
in  them  to  such  an  extent  that  when  the  hepatic  vessels  are 
paralysed  by  an  after  operation  the  liver  circulation  cannot  be 
increased.  On  the  other  hand,  when  the  liver  circulation  is 
increased  first,  the  relaxation  of  the  intestinal  vessels  does  not 
materially  divert  the  current.  These  experiments  render  Ber- 
nard's hypothesis  that  glycosuria  and  possibly  diabetes  depend 
on  increased  circulation  in  the  liver  highly  probable ;  at  the 
same  time  they  strike  a  serious  blow  at  Pavy's  and  Schiff'^s 
hypothesis  of  a  ferment  in  the  blood  being  the  cause  of  this 
conversion  of  the  glycogen.  Schiff  has  shown  that  this  ferment 
does  not  exist  in  the  blood  normally,  but  is  produced  by  any 
disturbance  of  the  circulation,  such  as  that  produced  by  section 
of  the  nerves  mentioned.  If  this  were  true  the  section  of  the 
splanchnics  ought  to  favour  instead  of  prevent  the  development 
of  glycosuria,  by  allowing  the  ferment  to  make  its  appearance 
in  the  blood  circulating  in  the  intestines  and  on  its  way  to  the 
portal  vein.     We  have  seen  that  the  contrary  is  the  fact. 

Turning  now  to  the  clinical  aspect  of  our  subject,  we  find  a 
noteworthy  tendency  on  the  part  of  the  authors  under  notice  to 
accept  the  glycogenic  theory  in  some  form.  Dr.  W.  Richardson, 
who  is  evidently  a  disciple  of  Bouchardat,  accepts  the  theory  in 
part,  and  regards  diabetes  as  a  result  of  a  too  rapid  transformation 
of  starch  in  the  stomach  and  intestines,  or  of  over-production  of 
sugar  by  the  liver.  In  the  first  class  of  cases  the  rapid  change 
of  starch  into  sugar  causes  the  liver  to  receive  more  sugar  than 
it  can  fix  as  glycogen,  and  the  surplus  consequently  passes  on 
into  the  general  circulation  to  be  eliminated  by  the  kidneys. 
This  form  of  the  disease,  which  would  depend  really  on  an 
insufficient  action  of  the  liver,  can  only  occur  when  the  sugar 
is  entirely  derived  from  starchy  food.  In  addition  to  the 
assumption  on  which  it  rests,  it  demands  also  the  occurrence  of 
a  too  rapid  absorption  of  the  sugar,  and  entirely  overlooks  the 
fact  that  much  sugar  disappears  in  the  intestinal  canal  by  con- 
version into  lactic  acid. 


424  Reviews,  [April, 

Donkin  refers  diabetes  to  the  liver,  and  somewhat  naively 
remarks,  "  It  has  often  occurred  to  me  that  diabetes  may  pos- 
sibly depend  on  perverted  functional  action  of  the  liver-cells, 
whereby  they  morbidly  secrete  diabetic  sugar  instead  of  gly- 
cogen, their  normal  secretion."  In  the  original  this  profound 
reflection  is  printed  in  italics. 

Jaccoud,  however,  is  unwilling  to  accept  the  hepatic  theory. 
The  results  of  Pavy's  experiments  have  influenced  him  against 
it,  although  he  admits  that  it  more  nearly  solves  the  difficulty 
than  any  other.  After  summing  up  all  the  evidence  against 
Bernard's  views,  the  French  clinician  proceeds  to  expound  his 
own  notion  of  the  disease.  Diabetes  he  holds  to  be  the  develop- 
ment of  a  new  operation  in  the  body.  Believing  in  a  ferment 
as  the  active  agent  in  changing  the  glycogen  into  sugar  after 
death,  he  agrees  with  Schiff"  that  this  ferment  does  not  exist  in 
health,  but  can  always  be  produced  by  disturbance  of  the  circu- 
lation. The  sugar  production  which  this  ferment  excites  is 
altogether  a  pathological  phenomenon,  foreign  to  the  healthy 
economy,  and  not,  as  others  hold,  simply  an  exaggeration  of  a 
healthy  function.  Schiff"  limits  this  sugar  production  to  the 
liver,  Jaccoud  does  not.  He  believes  that  every  tissue  (and 
they  are  many)  containing  glycogen,  or  zoamyline  as  he  calls  it 
after  Rouget,  is  robbed  of  this  substance  by  the  ferment,  and 
thus  the  formation  of  sugar  becomes  a  process  of  the  whole  body, 
and  not  of  a  single  gland.  Diabetes  is  a  disorder  of  nutrition, 
a  dystrophia.  The  saccharine  state  of  the  urine,  which  results 
either  from  excessive  absorption  of  sugar  in  the  intestine  or 
from  defective  transformation  of  sugar  into  glycogen,  he  calls 
glycosuria.  True  diabetes  is,  on  the  other  hand,  the  expression 
of  the  formation  of  sugar  at  the  expense  of  the  tissues  containing 
glycogen,  and  is  a  constant  de-nutrition  of  these  tissues.  Such 
are  the  conclusions  arrived  at  in  this  excellent  essay. 

The  experiments  we  have  referred  to  in  the  early  part  of  this 
article  must,  in  our  opinion,  bring  about  a  modification  of 
Jaccoud's  position,  which  rests  mainly  on  the  experiments  of 
Pavy.  The  weak  point  of  the  whole  fabric  appears  to  us  to 
consist  in  the  wild  assumption  of  the  existence  of  a  ferment.  To 
drag  in  this  imaginary  substance  as  a  kind  of  deus  ex  machind 
to  solve  all  the  difficulties  which  remain  is  unworthy  of  science. 
"While  physiologists  and  physicians  lack  the  courage  to  state 
barely  their  results,  and  yield  to  a  weak  anxiety  to  make  every 
theory  teres  atque  rotundus,  such  speculations  will  continue  to 
work  evil.  The  time  has  fully  come  when  we  must  face  the 
unknown  without  such  idols. 

There  is  another  theory  of  diabetes  on  which  Jaccoud  touches 
slightly,  and  which  has  shown  evident  signs  of  vitality  of  late, 


1872.]  Pathology  of  Diabetes.  425 

we  mean  the  respiratory  theory.  If  the  sugar  formation  in 
the  liver  is  accepted,  the  destination  of  this  sugar  becomes  the 
next  question,  and  the  appearance  of  sugar  in  the  urine  may 
depend  on  either  increased  formation  or  defective  consumption. 
The  hypothesis  that  the  sugar  is  burnt  off  in  the  lungs  has 
always  been  a  favorite  idea  with  many,  and  some  recent 
researches  of  Pettenkofer  and  Voit  tend  to  strengthen  it.  These 
observers  have  shown  that  a  diabetic,  while  consuming  more 
food  than  a  healthy  man,  not  only  absorbs  considerably  less 
oxygen,  but  gives  off  much  less  carbonic  acid.  With  more  com- 
bustible matter  there  is  less  combustion.  They  refer  the  disease 
to  a  faulty  relation  between  the  amount  of  sugar  formed  and 
the  quantity  of  oxygen  absorbed.  Huppert,  who  has  also 
worked  in  the  same  direction,  agrees  with  them  in  attributing 
this  defect  to  a  peculiarity  of  the  blood-corpuscles  in  diabetes, 
which  have  lost  their  power  of  fixing  oxygen.  Hence  the 
defective  oxidation  which  constitutes  the  disease.  These  views 
have  a  strong  speculative  flavour,  but  nevertheless  there  has 
been  of  late  a  steady  increase  in  the  number  of  facts  which 
point  to  a  state  of  suboxidation  in  diabetes.  The  low  body 
temperature  in  diabetics  strongly  suggests  such  a  state.  This 
is  more  marked  in  the  later  stages  of  the  malady,  and  may 
be  used,  as  Jaccoud  has  remarked  and  we  can  confirm,  to 
indicate  the  more  advanced  period  of  the  malady.  This  low 
temperature,  associated,  as  it  is,  with  rapid  tissue  wasting,  is  a 
phenomenon  worthy  of  the  most  attentive  study.  That  it  is 
not  directly  due  to  the  non-combustion  of  the  sugar  may  be 
inferred  from  the  fact  that  the  amount  of  sugar  excreted  bears 
no  constant  relation  to  the  body  heat. 

Cantani,  who  has  recently  proposed  the  use  of  lactic  acid 
in  diabetes,  holds  that  diabetic  sugar,  or  paraglucose  as  he 
terms  it,  is  a  non-combustible  element,  with  which  oxygen 
cannot  combine,  and  that  consequently  all  combustion  is 
effected  at  the  expense  of  the  albuminates  and  fats.  The 
oxygen  finds  no  material  wherewith  to  combine  in  the  lungs, 
hence  the  low  temperature.  Cantani  says  that  respiration  in 
diabetics  is  very  infrequent,  and  cites  this  in  favour  of  his  view. 
We  have  not  observed  this  infrequency,  and  when  we  have 
tested  the  temperature  of  the  expired  air  in  diabetics  we  have 
not  discovered  any  difference  between  it  and  that  expired  in 
health.  With  defective  oxidation  in  the  lungs  it  is  probable 
that  a  difference  would  show  itself.  Cantani  proposes  lactic 
acid  as  a  remedy  to  supply  a  combustible  element  and  save  the 
albuminates  and  fats.  The  results  of  this  treatment  have  yet 
to  be  fully  tried  ;  the  proposer  speaks  of  no  slight  success, 
which,  if  confirmed,  will  strongly  support  the  respiratory  theory. 


426  Reviews.  [April, 

The  suboxidation  is  most  probably  not  confined  to  the  lungs, 
but  is  distributed  to  all  the  tissues,  and  if  Huppert's  hypothesis 
of  the  defective  fixing  powers  of  the  blood-corpuscles  prove  true, 
we  have  a  ready  explanation  of  this  state,  and  of  the  ill  success 
which  has  hitherto  attended  the  inhalation  of  oxygen.  Whether 
the  sugar  formed  by  the  liver  is  burnt  off  in  the  lungs,  or  in 
the  tissues  generally,  is  at  present  open  to  doubt ;  it  is,  how- 
ever, highly  probable,  as  Bernard  himself  thinks,  that  much 
glycogen  remains  unconverted  into  sugar,  but  is  carried  away  in 
some  combination  in  the  blood.  The  destination  of  this  we  do 
not  know ;  it  is  probably  stored  up  in  many  tissues,  hence  the 
general  distribution  of  glycogen  in  the  body,  and  it  may  be 
converted  into  force  by  oxidation,  and  thus  give  rise  to  the 
appearance  of  lactic  acid.  The  two  theories,  the  hepatic  and 
the  respiratory,  are  so  closely  connected  with  our  present  know- 
ledge of  the  phenomena  of  diabetes  that  in  our  opinion  it  is 
only  by  a  comprehensive  application  of  both  that  we  can  gain 
any  clear  notion  of  the  disease.  To  regard  it  as  a  deviation 
from  a  normal  process  is,  at  all  events,  more  philosophical  than 
to  adopt  with  Jaccoud  the  hypothesis  of  a  ferment,  and  to 
describe  the  disease  as  the  development  of  a  vfhoWy  new  process 
in  the  economy.  Some  theory  is  almost  essential  to  give 
interest  and  method  to  the  work  of  the  clinical  observer. 
Theories  are  only  bad  when  they  cease  to  be  the  servants  of 
facts  and  become  their  masters.  Kept  in  their  proper  places 
they  encourage  good  work,  and  the  two  theories  mentioned 
above  seem  at  present  to  indicate  the  most  fruitful  direction  for 
the  clinical  study  of  saccharine  diabetes. 

In  the  books  before  us  there  is  a  good  deal  of  diversity  of 
opinion  as  to  treatment.  Dr.  Richardson,  who  has  himself 
suffered  from  diabetes  in  its  milder  form  for  many  years, 
has  entered  on  this  part  of  the  subject  with  much  earnestness. 
His  remarks  on  treatment  will  repay  perusal.  He  very  pro- 
perly insists  on  the  gradual  instead  of  the  sudden  substitution 
of  restricted  for  general  diet,  and  points  out  how  often  a  sudden 
change  is  productive  of  ill  effects.  In  his  own  case,  likewise, 
he  shows  that,  in  the  milder  form  of  the  malady,  the  best 
results  will  occasionally  follow  the  relaxation  of  the  strict  rules 
of  diet.  Both  he  and  Jaccoud  strongly  urge  the  importance  of 
following  Bouchardat's  advice,  and  making  daily  exercise  in 
the  open  air  part  of  the  treatment.  To  this  Richardson  mainly 
attributes  his  own  recovery,  and  he  quotes  other  cases  in  sup- 
port of  its  value.  The  exercise  should  be  regular  and  always 
stop  short  of  fatigue.  With  reference  to  the  use  of  alcohol 
there  is  a  variety  of  opinion.  The  French  author  recommends 
Burton  bitter  ale,  Donkin  considers  alcohol  inadmissible,  while 


1872.] 


Pathology  of  Diabetes.  427 


Richardson  believes  small  quantities  of  brandy,  or  sherry,  or 
claret,  useful  in  some  forms  of  the  disease,  and  considers  their 
effects  constitute  a  good  diagnostic  test  of  the  state  of  the  liver 
function.  When  the  liver  function  is  over-active,  alcohol,  he 
thinks,  increases  the  sugar;  when  the  disease  depends  on  a 
want  of  power  in  the  gland  to  convert  amylaceous  compounds 
into  glycogen,  then  he  looks  upon  it  as  useful.  Warm  baths 
are  strongly  advised,  and  on  their  use,  no  doubt,  much  of 
the  success  obtained  at  Continental  spas  depends.  The  waters 
of  Vichy  and  Carlsbad  are  recommended,  and  their  alkaline 
characters  referred  to  as  the  probable  explanation  of  their  good 
effects.  It  is  remarkable  that  alkalies  administered  medicinally 
have  so  little  control  over  the  disorder.  Over  and  over  again 
their  use  has  been  tried,  and  in  our  experience  little  or  no 
diminution  in  the  sugar  excreted  has  followed.  We  cannot 
help  thinking,  therefore,  that  the  regimen  and  general  treat- 
ment pursued  at  such  places  as  Vichy  have  more  to  do  with 
the  results  than  the  reaction  of  the  waters.  The  patients  get 
good  in  some  way,  and  there  is  no  reason  to  apply  Pliny's 
sarcasm,  Medici  qui  diverticiilis  aquarum  (Bgrotos  falluntj  to 
those  who  send  diabetics  to  these  spas. 

With  reference  to  drugs,  opium,  to  our  surprise,  meets  no 
great  support.  Richardson  says,  "  I  tried  it  on  myself  in  large 
doses,  as  I  have  tried  almost  every  medicine  that  has  been 
recommended  with  any  authority,  but  found  mischief  from  it. 
The  urine  was  reduced  from  76  to  32  ounces  ;  the  specific 
gravity  was  1054  instead  of  1036  ;  on  boiling  with  Liq.  Potassae 
the  urine  became  very  dark ;  I  felt  so  ill  and  heartless  that  I 
had  not  the  resolution  to  make  out  the  quantity  of  sugar  it 
contained."  This  evidence  is  in  striking  contrast  to  much  that 
has  been  published  as  to  the  good  effects  of  the  drug.  In  some 
cases  it  does  much  good,  as  we  can  testify,  but  in  others  it  acts 
as  described  above,  and  while  diminishing  the  amount  of  water 
afifects  the  sugar  much  less.  In  some  advanced  cases  its  good 
effects  are  often  due,  in  our  opinion,  more  to  its  power  of 
checking  excessive  elimination  of  urea  than  to  lessening  the 
sugar.  Pavy's  success  in  its  administration  has  been  confirmed 
recently  by  independent  observation  on  the  Continent.  In 
Jaccoud's  experience  the  two  drugs  which  are  most  valuable 
are  strychnia  and  arsenic.  The  former  he  thinks  keeps  up  the 
activity  of  the  digestive  process,  diminishes  the  polyuria,  and 
lessens  the  sugar.  In  two  cases  he  has  seen  the  sugar  disappear 
under  its  use.  Arsenic  has  succeeded  in  some  cases  where 
strychnia  has  failed.  Dr.  Donkin's  book  is  written  to  advocate 
a  special  treatment,  and  therefore  contains  little  on  the  general 
therapeutics  of  the  disease.    By  the  employment  of  skim  milk  he 


428  Reviews.  [April, 

argues  that "  we  can  administer  to  a  diabetic  both  an  albuminous 
and  saccharine  proximate  principle  of  food.  The  lactin  appears 
to  undergo  conversion  in  the  presence  of  the  casein  into  lactic 
acid,  and  thus  skim  milk  becomes  a  food  containing  a  quality  of 
albumen  in  the  highest  degree  capable  of  assimilation,  with  the 
addition  of  a  saccharine  principle,  which  is  also  assimilated." 
There  is  no  doubt  that  Dr.  Donkin  has  done  good  service  by  his 
advocacy  of  this  treatment  and  by  the  careful  rules  he  has  laid 
down  for  its  application,  but  we  could  wish  that  his  proofs  of  its 
-success  were  more  satisfactory.  He  gives  seven  cases  in  his 
book,  which  are  none  of  them  as  carefully  recorded  as  such 
cases  should  be.  In  no  single  instance  is  there  a  regular  quan- 
titative analysis  of  the  sugar  given,  but  the  quantity  of  water 
passed,  its  specific  gravity,  and  an  occasional  appeal  to  Liq. 
Potassse  or  Trommer's  test  are  alone  relied  on.  Now,  we  hold 
that  no  case  of  diabetes  is  recorded  scientifically  in  which 
there  is  not  a  daily,  or  at  least  a  bi-weekly  quantitative  analysis 
of  the  urine.  As  a  preliminary  to  any  treatment,  indeed,  the 
quantity  of  sugar  excreted  under  mixed  and  restricted  diet 
should  be  determined.  We  are  sorry  that  none  of  these  in- 
quiries were  made  in  the  seven  cases  recorded.  That  the  skim 
milk  treatment  is  valuable,  and  possibly  more  valuable  than 
restricted  diet  in  the  early  stage  of  the  malady,  the  first  two 
recorded  cases  indicate.  Dr.  Donkin  has  also  shown  that  skim 
milk  is  preferable  to  new  milk.  How  far  this  may  depend  on 
the  conversion  of  the  lactin  more  readily  into  lactic  acid  is  a  very 
interesting  question.  In  this  there  is  probably  a  common  point 
between  Cantani's  method  and  the  skim  milk  treatment.  The 
Italian  gives  his  patients  nothing  but  animal  food  and  lactic 
acid  (150  to  250  grains  a  day),  and  his  practice  appears  to  be 
eminently  successful. 

Dr.  Balfour  has  recently  tried  this  plan  with  a  success  equal 
at  least  to  the  skim  milk  treatment.  His  cases  are,  however, 
incomplete,  and  a  much  more  minute  study  of  the  effects  of 
the  acid  on  the  composition  of  the  urine  must  be  forthcoming 
before  the  true  position  of  the  remedy  can  be  ascertained. 
We  trust  that  ere  long  such  data  may  be  laid  before  the 
profession,  and  that  the  vaunted  effects  of  lactic  acid  and 
skim  milk  may  be  established  on  a  satisfactory  basis. 


1872.]      Use  of  the  Ophthalmoscope  in  Nervous  Diseases.     429 


XII. — Dr.  AUbutt  on  the  Use  of  the  Ophthalmoscope  in  Diseases 
of  the  Nervous  System. ^ 

The  ophthalmoscope  has  for  some  years  been  making  a  place 
for  itself  in  medicine  as  distinguished  from  surgery.  As  long  as 
anything  has  been  known  of  diseases  of  the  brain  it  has  also 
been  known  that  troubles  and  loss  of  vision  were  among  their 
consequences,  and  soon  after  the  discovery  of  the  connection 
between  albuminuria  and  renal  disease  amaurosis  was  noticed 
as  an  occasional  attendant  symptom ;  but  physicians  were  slow 
to  see  that  not  only  might  the  mode  in  which  sight  came  to  be 
lost  be  ascertained  by  means  of  the  ophthalmoscope,  but  that 
the  process  by  wliich  it  was  lost  might  afford  important  revela- 
tions respecting  the  original  disease  to  which  the  loss  was  due. 
Naturally  the  first  steps  in  the  use  of  the  ophthalmoscope  in  the 
diagnosis  of  diseases  of  the  nervous  system,  and  in  the  investi- 
gation of  the  effect  of  certain  constitutional  conditions  on  the 
structures  of  the  eye,  were  made  by  ophthalmic  surgeons,  by 
Sichel,  Grafe,  Liebreich  and  others  in  France  and  Germany, 
and  a  little  later  by  Hutchinson,  Hulke,  Carter  and  others  in 
this  country.  After  a  time,  however,  the  ophthalmoscope  was 
taken  up  by  physicians,  Germany  and  France  having  preceded 
us  again  here ;  but,  at  length,  an  English  work  has  appeared 
which  will  go  far  to  place  us  on  a  level  with  our  Continental 
brethren,  and  will  certainly  give  an  impetus  to  the  employment 
of  this  instrument  here.  Papers  have  been  written  from  time  to 
time  by  Dr.  Hughlings  Jackson  and  by  Dr.  Allbutt,  which  have 
already  compelled  attention  to  the  subject,  and  it  is  to  the 
latter  of  these  physicians  that  we  owe  the  book  we  now  welcome. 
It  has  merits,  too,  in  addition  to  its  being  the  first  work  in  a 
new  and  interesting  department  of  medicine.  It  is  one  of  those 
books  into  which  the  author  throws  himself  body  and  soul, 
giving  token  of  what  he  is  and  of  all  he  has  in  him. 

This  infusion  of  character  is  something  quite  independent  of 
the  intrinsic  value  of  the  work  as  a  contribution  to  science,  or 
of  its  subject-matter,  and  constitutes  a  charm  which  might 
redeem  from  dulness  a  book  which  had  no  other  merit,  and 
which  lends  attractions  to  the  most  profound  research,  or  the 
most  lucid  exposition  of  principle.  Too  frequently,  and  especi- 
ally in  medical  writing,  the  only  apparent  relationship  between 
an  author  and  his  book  is  the  asserted  paternity ;  as  far  as  any 
likeness  or  resemblance  is  concerned,  it  might  just  as  well  be  the 
offspring  of  X,  Y,  or  Z  ;  all  the  likeness  is  on  the  maternal  side, 

^  On  the  Use  of  the  Ophthalmoscope  in  Diseases  of  the  Nervous  System  and  of 
the  Kidneys.     By  T»  CLiiTOED  Allbutt,  M.D. 

98 — XLix.  28 


430  Reviews,  [April, 

as  we  may  call  the  circumstances — the  special  opportunities  or 
necessities — which  brought  it  forth.  The  very  contrary  is  the 
case  here  ;  the  embodiment  of  the  author's  personality  is  a 
feature  which  is  prominent  throughout.  The  preface,  the  in- 
troductory chapter,  and  last,  not  least,  the  dedicatory  letter  to 
Dr.  Hughlings  Jackson,  so  honorable  to  both,  would  alone  make 
the  book  noteworthy.  Such  generous  appreciation,  on  the  author's 
part,  of  merit  in  one  who  might  be  said  to  divide  with  him  his 
chosen  field  of  work,  and  so  frank  an  acknowledgment  of  obli- 
gation, are  not  common.  We  are  equally  struck  with  the 
enthusiasm  and  honesty  of  purpose  in  the  search  for  truth  which 
are  everywhere  displayed ;  accompanied,  perhaps,  with  too  great 
an  impatience  of  the  errors  in  method  and  of  fact  which  have 
come  down  to  us  from  our  forefathers,  but  associated  also  with  a 
philosophical  breadth  of  view  which  not  only  immediately  widens 
the  horizon  of  the  careful  reader,  but  prepares  him  to  attach 
additional  importance  to  results  obtained  under  such  inspiration. 
We  must  add  that  the  elegance  and  felicity  of  expression  found 
throughout  this  book  are  rare  in  medical  literature,  and  indicate 
a  degree  of  culture  not  attained  by  the  average  man  of  any 
profession.  We  think,  perhaps,  that  literary  instincts  or 
an  exuberant  fancy  have  sometimes  been  allowed  too 
liberal  exercise ;  for  example,  in  the  opening  of  the  chapter  on 
the  normal  optic  nerve  and  retina  we  have  a  series  of  metaphors, 
more  or  less  appropriate,  in  illustration  of  deviations  from  health, 
which  reminds  us  of  Sancho  Panza's  strings  of  proverbs,  and  we 
confess  to  having  experienced  some  irritation  when  we  came  to 
the  final  address  to  the  'kind  reader.'  It  was  not  for  the 
courteous  and  courtly  old  patron  of  former  days  that  this  book 
was  written,  and  it  is  something  like  affectation  to  apostrophise 
him.  Surely  Dr.  Allbutt  has  sufficient  faith  in  himself  and  in 
his  generation  to  feel  assured  that  there  are  earnest  workers  who 
can  appreciate  honest  work,  men  who  know  the  ring  of  true 
metal,  and  before  whom  he  is  ready  to  throw  down  his  talent. 
Readers  he  will  have  who  may  not,  perhaps,  think  of  doffing 
their  hats  as  they  express  a  difference  of  opinion,  but  who  are 
keenly  interested  in  any  new  application  of  scientific  method  to 
medical  investigation,  and  are  ready  to  become  followers  also, 
when  they  see  a  path  opened  to  a  new  region  of  knowledge; 
these  are  his  constituents,  and  to  them  we  hope  he  will  appeal 
in  future  editions  and  in  the  new  work  foreshadowed  in  this. 

Coming  now  to  our  subject,  the  first  question  which  arises  is : — 
What  is  the  use  and  place  of  the  ophthalmoscope  in  medical 
investigation  ?  It  is  something  different  and  something  higher 
than  that  of  the  laryngoscope  or  endoscope,  which  simply  reveal 
local  conditions  and  facilitate  local  applications.     It  is  this  and 


1872.]      Use  of  the  Ophthalmoscope  in  Nervous  Diseases.     431 

more  already  in  the  hands  of  the  ophthalmic  surgeon,  who  hy 
its  aid  sees  his  way  clearly  to  a  definite  and  exact  dia^^nosis 
amono^  the  complicated  conditions  present  in  the  eye.  We  are 
also  disposed  to  give  it  a  higher  place  than  the  sphygmograph, 
one  reason  being  that  it  will  come  into  more  general  use.  For 
the  sphygmograph  is  a  costly  instrument,  its  application  demands 
the  expenditure  of  much  time,  not  only  in  the  acquirement  of 
skill  in  its  use,  but  in  making  individual  observations;  the 
results  or  tracings  obtained,  moreover,  differ  greatly  in  value  in 
different  hands  ;  so  much  depending  on  the  exact  adjustment  of 
pressure  and  on  individual  aptitude  in  the  use  of  the  instru- 
ment. After  all,  too — and  we  are  not  among  those  who  depre- 
ciate the  sphygmograph,  it  reveals  little  at  the  bedside  which 
the  educated  finger  cannot  detect,  so  that  Dr.  Sanderson 
actually  found  a  nomenclature  for  its  indications  ready  made  by 
the  older  physicians.  Now,  the  ophthalmoscope  tells  us  some- 
thing new,  something  we  could  not  otherwise  get  at,  and  that 
which  assists  not  only  in  the  solution  of  physiological  and  pa- 
thological problems,  but  is  of  immediate  value  in  diagnosis  and 
prognosis ;  while  lastly  as  an  instrument  it  is  inexpensive,  and 
is  prompt  in  its  revelations.  It  cannot,  on  the  other  hand,  be  com- 
pared with  the  thermometer,  either  in  the  range  or  in  the  value 
of  its  indications;  nor  can  it  compete  with  the  stethoscope,  or 
rather  with  the  complete  physical  examination  of  which  ausculta- 
tion forms  a  part.  The  information  it  affords  is  neither  so  exten- 
sive, nor  so  direct,  nor  so  complete.  It  is  restricted  chiefly  to  the 
state  of  the  intra-cranial  circulation,  of  which  the  vascular  system 
of  the  optic  nerve  and  retina  is  a  sort  of  offshoot ;  and  even  on  this 
point  it  is  not  infallible,  for  when  positive  facts  are  obtained,  their 
interpretation  is  not  always  easy,  and  the  absence  of  change  in 
the  retina  and  disc  is  not  unequivocal  evidence  of  a  normal  con- 
dition of  the  cerebral  circulation.  Experience  will,  however, 
render  inference  more  certain,  and  is  almost  daily  filling  up 
gaps  in  the  knowledge  afforded  by  this  method  of  investigation, 
while  the  negative  evidence  is  gradually  being  explained,  and 
thus  made  to  yield  information  of  a  positive  kind. 

Already  the  light  thrown  upon  cerebral  diseases  by  the  oph- 
thalmoscope is  astonishing.  While  it  was  unknown  that  changes 
in  the  retina  and  optic  nerve,  secondary  to,  or  in  continuity  with 
changes  in  the  membranes  or  substance  of  the  brain,  or  con- 
sequent upon  variations  in  the  intra-cranial  blood  pressure, 
were  a  common  cause  of  the  loss  of  vision  often  met  with  in 
cerebral  disease,  the  utmost  confusion  necessarily  prevailed  in  the 
diagnosis  of  the  conditions  to  which  this  loss  was  due.  At  one 
time  a  tumour  was  found  in  a  situation  where  it  might  possibly 
exercise  pressure  on  the  optic  tract  or  ganglia;    at  another. 


433  Reviews.  [April, 

by  no  ingenuity  could  such  pressure  be  predicated,  and  some 
vague  transcendental  reason  had  to  be  invented,  or  the  sympa- 
thetic nervous  system  was  invoked.  The  result  was  a  dis- 
heartening uncertainty.  Now  the  optic  neuritis  or  ischsemia,  or 
the  direct  or  consecutive  atrophy,  is  watched  from  hour  to  hour; 
and  if  the  exact  situation  of  the  intra-cranial  disease  is  not  thereby 
indicated,  at  any  rate  false  conclusions  as  to  this  point  are 
avoided;  and  frequently  the  nature  of  the  morbid  change,  which 
is  of  more  importance  than  its  seat,  is  revealed.  More  than 
half  of  Dr.  Allbutt's  work  is  devoted  to  the  consideration  of  the 
ophthalmic  signs  of  diseases  of  the  nervous  system,  but  the  eye 
also  affords  evidence  of  certain  constitutional  conditions, 
curiously  justifying  Sir  Thomas  Watson's  classical  illustration 
of  morbid  processes  by  reference  to  what  is  seen  of  them  in  this 
organ.  Among  them  the  most  interesting  and  important  is  the 
condition  dependent  on,  or  at  least  associated  with,  renal 
disease.  But  there  are  other  affections,  such  as  leukaemia, 
diabetes,  lead  poisoning,  &c.,  which  give  rise  to  optic  changes. 
Dr.  Allbutt,  however,  looks  not  merely  to  the  direct  and  imme- 
diate advantages  of  increased  accuracy  of  diagnosis,  and  more 
extensive  knowledge  of  morbid  processes  to  be  obtained  by  the 
use  of  the  ophthalmoscope ;  but  takes  a  comprehensive  and 
almost  enthusiastic  view  of  the  improvement,  both  in  the 
method  and  in  the  spirit  of  research, — more  especially  of  research 
into  diseased  conditions  of  the  nervous  system  which  must  re- 
sult. The  ophthalmoscope  has  for  him  this  great  charm,  "  that 
its  use  must  favour  a  spirit  of  industrious  and  accurate  observa- 
tion, and  must  favour  also  that  wholesome  disposition  of  the 
mind  which  tolerates  any  facts,  however  far  away  they  may 
seem  to  be  from  traditional  doctrines  or  dignified  theories." 
There  can  be  no  doubt  that  a  new  instrument  of  precision,  by 
opening  a  new  avenue  to  knowledge,  does  stimulate  research 
and  improve  method.  Possibly,  however,  Dr.  Allbutt  attributes 
too  much  to  the  instrument  and  too  little  to  the  pre-existing  mental 
attitude,  and  applies  too  directly  and  immediately  the  philosophy 
which  makes  intellectual  improvement  consist  in  adjustment  of 
the  mind  to  new  opportunities  of  acquiring  knowledge. 

A  prominent  characteristic  of  the  w^ork  before  us  is,  that 
the  author  is  not  content  simply  to  ascertain  and  state  the 
relation  between  certain  cerebral  or.  constitutional  diseases,  and 
certain  appearances  in  the  fundus  of  the  eye ;  but  endeavours  in 
all  cases  to  trace  the  mode  of  causation  of  the  symptoms  he 
describes.  In  this,  however,  he  is  not  singular ;  the  sort  of 
necessity  (most  felt,  apparently,  by  minds  least  capable  of  giving 
or  of  estimating  it  when  given)  for  a  reason  for  everything  .is 
universally  recognised  and  very  freely  met  by  plausible  guesses 


1872.]      Use  of  the  Ophthalmoscope  in  Nervous  Diseases,     433 

or  vague  speculations ;  it  is  in  the  fact  that  these  find  no  place 
in  his  pages,  and  that  anatomical  data  constitute  the  sole  ground 
of  the  explanations  given,  that  he  is  honorably  distinguished. 
But  we  are  reminded  here,  again,  that  there  is  anatomy  and 
anatomy,  and  that  by  some  an  elaborate  description  of  the  dis- 
tribution of  the  sympathetic  nerve  is  considered  proof  of  the 
uterine  origin  of  hysteria,  and  explanation  of  all  the  varied  sen- 
sations and  symptoms  described  under  this  term.  This  is  not 
what  Dr.  Allbutt  would  mean  by  anatomical  data.  The  posi- 
tion he  takes  up  is  that  the  implication  of  the  optic  nerve  in 
cerebral  diseases  is  to  be  accounted  for,  not  by  any  transcendental 
considerations,  but  by  its  rich  vascularity,  its  large  share  of 
connective  tissue,  and  its  extensive  relations  with  the  parts  at 
the  base  of  the  encephalon.  We  naturally  find  in  the  chapter 
on  the  aspect,  structure,  and  connections  of  the  normal  optic 
nerve  and  retina  the  basis  for  this  conclusion.  There  are 
several  points  in  the  structure  and  relations  of  the  optic  nerve 
which  call  for  attention  from  their  bearing  on  the  pathology  of 
the  nerve  and  retina.  Perhaps  the  most  important  of  these  is 
the  comparative  independence  one  of  the  other,  in  their  vascular 
supply,  of  the  nerve  and  retina.  The  central  artery  and  vein  of 
the  retina  lie,  it  is  true,  among  the  fibres  of  the  nerve,  but  they 
distribute  no  branches  to  it.  The  vessels  of  the  nerve  are 
derived  mainly  from  the  pia  mater,  and  they  ramify  between 
the  nerve-tubules,  and  supply  them  with  blood  up  to  the  disc, 
the  vascularity  of  which  forms  part  of  the  system,  though  there 
is  here  in  the  disc  itself  a  network  of  vessels  connecting  to- 
gether the  arteries  of  the  nerve,  the  central  artery  of  the  retina, 
the  ciliary  arteries,  and  the  capillary  coat  of  the  choroid.  The 
disc  is  thus  more  directly  connected  with  the  vascular  system 
of  the  cerebrum  than  the  retina,  which  is  supplied  by  the 
ophthalmic  artery,  and  may  consequently  be  expected  to  afford 
a  better  index  of  the  condition  of  the  cerebral  circulation. 
Another  important  feature  in  the  structure  of  the  optic  nerve 
is  the  amount  of  connective  tissue  in  which  its  fibres  are  im- 
bedded, though  we  fail  to  see  in  this  anything  more  than  a  dif- 
ference in  degree,  and  do  not  understand  how  it  constitutes  the 
marked  peculiarity  it  is  made  to  appear  by  Dr.  Allbutt.  The 
unyielding  margin  of  the  aperture  in  the  sclerotic,  by  which  the 
nerve  enters  the  eye,  again  appears  to  play  an  important  part 
in  the  production  of  some  of  the  morbid  appearances  presented  by 
the  disc,  as  will  be  seen  later.  A  kind  of  lymph  space  is  described 
as  existing  between  an  outer  and  inner  sheath  of  the  nerve,  but 
it  has  not  as  yet  been  shown  to  have  any  pathological  interest. 

The  plan  of  Dr.  Allbutt's  work  is,  after  giving  directions  for 
the  examination  of  the  eye,  and  describing  the  normal  appear- 


434  Reviews,  [April, 

ances,  along  with  the  anomalies  sometimes  presented  by  the  disc 
and  retina  in  health,  to  consider  the  variations  from  health 
observed,  together  with  their  causes,  and  subsequently  to  treat 
seriatim  the  ophthalmic  signs  of  intra-cranial,  spinal,  renal 
disease,  &c.  It  is  in  the  description  and  in  the  examination  as 
to  the  causation  of  the  departures  from  the  normal  condition  of 
the  disc  and  retina  that  the  practical  interest  of  the  book  begins. 
The  healthy  appearances  are  taken  as  the  standard  of  reference, 
and  hyperaemia,  anaemia,  oedema  of  the  disc,  ischsemia,  neuro- 
retinitis,  chronic  optic  neuritis,  retinitis,  peri-neuritis,  consecu- 
tive atrophy,  and  primary  atrophy,  are  successively  described. 

A  primary  and  fundamental  point  to  be  determined  for 
the  due  estimation  of  the  ophthalmic  signs  of  intra-cranial 
disease  is,  whether  the  distinction  between  the  *  choked  disc' 
('  stauungs  papilla'  of  German  writers), — the  ischaemia  of 
the  disc  of  Dr.  AUbutt,  and  optic  neuritis  proper,  is  real  and 
valid,  and,  again,  whether  these  two  conditions,  if  actually  dis- 
tinct, can  be  distinguished  by  means  of  the  ophthalmoscope. 
As  to  the  first  question,  there  can  be  doubt  whatever.  There 
is  a  congested,  swollen,  almost  strangulated,  condition  of  the 
disc,  which  is  not  primarily  neuritis,  and  which  arises  from  ob- 
structed venous  return,  and  there  is  a  neuritis  which  descends 
by  continuity  of  structures  along  the  nerve  from  the  meninges 
of  the  base  of  the  brain.  The  distinction  was  apparently  first 
pointed  out  by  Grafe  ;  it  is  now  generally  recognised  by  oph- 
thalmic surgeons,  and  careful  microscopic  examinations  have 
established  it  beyond  the  reach  of  question.  A  drawing  of  the 
interior  of  an  eye  after  death  by  Dr.  Fitzgerald,  from  a  case 
under  the  care  of  Mr.  Swanzy,  accompanying  the  description  of 
the  frontispiece,  which  is  a  coloured  plate  of  the  ophthalmoscopic 
appearances  presented  by  the  same  eye  during  life,  furnishes 
an  effective  and  impressive  demonstration  of  the  fact;  the  co- 
loured plate  shows  in  an  extreme  degree  the  changes  in  the 
disc  usually  attributed  to  inflammation,  and  in  the  drawing  it 
is  seen  projecting  into  the  back  of  the  eye  like  a  small  nipple, 
while  beneath  is  the  simple  statement  that  there  was  no  neu- 
ritis extending  up  the  optic  nerve.  Are  the  two  conditions, 
then,  distinguishable  one  from  the  other,  so  that  the  different 
pathological  changes  can  be  made  use  of  in  diagnosis?  We 
think  this  question  also  must  be  answered  afiirmatively.  The 
reply  of  our  author  is  unhesitating,  but  it  must  not  be  supposed 
that  the  task  is  an  easy  one.  Ophthalmic  surgeons  of  un- 
doubted skill,  and  perfectly  intimate  with  the  use  of  the  ophthal- 
moscope, hesitate  to  give  an  unqualified  adhesion  to  Dr.  Allbutt's 
statement  of  the  diagnostic  differences  between  ischaemia  and 
neuritis  ;  and  unless  it  is  quite  recently,  it  has  been  obvious  that 


1872.]      Use  of  the  Ophthalmoscope  in  Nervous  Diseases.     435 

Dr.  Hughlings  Jackson  has  not  been  clear  upon  the  point.  It 
is  well  known  that  Dr.  Jackson  has  long  been  engaged  in  the  in- 
vestigation of  the  ophthalmic  signs  of  cerebral  disease  ;  he  has  un- 
equalled opportunities  ;  his  enthusiasm,  assiduity,  patience,  and 
skill,  are  not  to  be  surpassed  by  any  one.  And  if  he  does  not 
recognise  the  different  appearance  of  the  choked  disc  and  in- 
flamed nerve,  the  difference  cannot  be  very  marked.  Possibly 
his  conscientious  care  in  making  sure  of  every  step  as  he 
proceeds,  his  extreme  regard  for  observation  and  extreme  caution 
in  inference — qualities  which  are  simply  invaluable — have  here, 
as  in  other  instances,  allowed  others  to  get  the  start  of  him. 

The  importance  of  the  differential  diagnosis  between  isch- 
semia  and  neuritis  will  be  seen,  when  the  causes  to  which  they 
are  respectively  due  are  considered ;  the  differential  characters,  as 
given  by  Dr.  AUbutt,  are  the  following  : — While  in  both  condi- 
tions there  is  swelling  and  projection  of  the  disc,  it  is  more 
considerable  and  more  abrupt  in  ischaemia,  and  presents  a 
steep  elevation  on  one  side,  which  is  peculiar.  The  colour  of 
the  part  is  different ;  in  ischsemia  there  is  a  circumscribed  intense 
redness  or  brownish-grey,  in  neuritis  a  reddish-lilac  or  grey 
tint,  which  diffuses  itself  more  widely  over  the  surrounding 
retina,  and  is  more  uniform  and  opaque,  while  there  is  exuda- 
tion by  which  even  the  large  retinal  veins  are  often  concealed 
dipping  in  and  out  of  it.  In  both  ischeemia  and  neuritis  the 
retinal  arteries  become  thin  and  indistinct,  and  the  veins  en- 
larged and  tortuous,  but  in  ischaemia  there  are  many  more 
minute  branches  to  be  seen  in  the  disc,  which  becomes  ex- 
tremely vascular,  and  presents  a  '  mossy'  appearance,  while  in 
neuritis  the  term '  woolly'  is  considered  to  convey  a  better  idea. 
Minute  haemorrhages  are  common  in  both,  and  the  outline  of 
the  disc  is  lost  in  both.  These  are  differences  which  ought  to  be 
appreciable  by  any  moderately  competent  observer  when  present 
in  a  well-marked  degree  ;  but  very  frequently  the  same  intra- 
cranial condition  gives  rise  simultaneously  to  obstruction  to  the 
return  of  venous  blood  and  to  true  primary  inflammation  of  the 
nerve.  One  point  must  be  mentioned  which  has  struck  all 
observers  with  surprise,  that  is  the  remarkably  slight  interference 
with  vision  in  even  extreme  ischsemia  of  the  disc. 

We  have  still  to  enumerate  the  causes  of  papillary  ischaemia 
and  of  true  neuritis,  and  to  show  why  this  vascular  offshoot 
from  the  cerebrum  exhibits  a  degree  of  congestion  not  seen  in 
the  meninges  themselves.  The  causes  of  ischaemia  of  the  disc 
are  all  such  as  more  or  less  directly  distend  the  ophthalmic 
veins,  of  which  (1)  meningitis,  (2)  hydrocephalus,  and  (3) 
tumours,  are  the  chief.  Softening,  acute  or  chronic,  haemor- 
rhage, sclerosis,  arterial  degeneration,  do  not  give  rise  to  this 


436  Reviews,  [April, 

condition.  The  explanation  of  the  exaggerated  congestion  of 
the  disc  produced  by  intra-cranial  pressure  is  very  interesting. 
The  sclerotic  aperture  or  ring  embraces  the  nerve  at  its  entry 
quite  closely.  When,  therefore,  from  obstruction  to  the  return 
of  blood  by  the  ophthalmic  vein,  whether  this  be  due  to  coagu- 
lation or  stasis  in  the  cavernous  sinus,  or  to  local  pressure  on 
the  sinus  and  the  entering  veins  by  fluid  in  the  third  ventricle, 
or  to  a  general  increase  of  pressure  within  the  cranium,  the 
minute  veins  and  capillaries  in  the  nerve  and  disc  tend  to  enlarge, 
but  the  resulting  swelling  is  prevented  at  this  particular  point, 
and  the  ring  forms  an  actual  constriction.  A  sort  of  strangu- 
lation is  thus  produced,  and  the  swelling  and  congestion  of  the 
disc  are  the  result  and  evidence  of  this.  As  Grafe  expresses 
it,  the  sclerotic  ring  "  plays  the  part  of  a  multiplier"  placed 
upon  a  vascular  offshoot  of  the  brain.  We  are  tempted,  how- 
ever, notwithstanding  the  beauty  of  the  explanation,  to  ask  if 
it  is  really  necessary.  To  deviate  for  a  moment  into  the  figu- 
rative language  which  Dr.  Allbutt  holds  in  such  detestation,  are 
we  to  suppose  that  nature  neglected  to  provide  for  the  contin- 
gency of  intra-cranial  pressure,  and  made  the  sclerotic  ring  too 
small,  or  was  the  utility  of  the  condition  as  a  sign  of  intra- 
cranial disease  foreseen  ?  Seriously,  it  seems  to  us  that  the 
ocular  extremity  of  the  optic  nerve,  being  the  only  offshoot  of 
the  vascular  system  of  the  brain,  which  is  not  within  the  rigid 
walls  of  the  cranic-spinal  cavity,  might,  on  mechanical  prin- 
ciples, be  expected  to  exhibit  extreme  congestion  on  the  occur- 
rence of  intra-cranial  pressure  without  the  intervention  of  this 
strangulating  ring,  just  as  an  india-rubber  ball  in  communica- 
tion with  a  cistern  will  be  gradually  distended  to  bursting  as 
the  water  rises,  or  as  hernia  cerebri  protrudes  and  bleeds.  A 
tumour  or  fluid  in  the  ventricles  squeezes  the  blood  out  of  the 
the  meninges,  and  flattens  the  convolutions  against  the  roof  of 
the  cranium  ;  there  being  no  counter  pressure  in  the  eye  to 
compare  with  that  of  the  cranial  walls,  the  blood  will  be  driven 
into  the  vessel  of  the  disc.  Whether  the  congestion  which  is 
obviously  inevitable  could  reach  the  degree  presented  in  ischsemia 
papillaris  without  the  strangulating  action  of  the  [sclerotic  ring, 
we  do  not  pretend  to  decide.  Grafe  has  discussed  the  ques- 
tion, and  regards  the  strangulation  as  necessary,  but  he  appears 
to  have  taken  into  consideration  only  the  passive  obstruction, 
such  as  would  be  caused  by  blocking  of  the  cavernous  sinus,  or 
obstruction  to  return  of  blood  by  the  ophthalmic  vein,  and 
not  the  active  hydrostatic  or,  rather,  haemostatic  pressure,  of 
which  we  have  been  speaking. 

The  encephalic  causes  of  neuro-retinitis  are  meningitis  and 
encephalitis,  the  former  being  the  more  frequent  of  the  twoj 


1872.]      Use  of  the  Ophthalmoscope  in  Nervous  Diseases.      437 

and  it  is  when  the  meningeal  inflammation  has  the  favorahle 
conditions  of  contiguity,  duration,  and  activity,  as  in  syphilitic 
meningitis  about  the  base  of  the  brain,  that  it  is  most  likely  to 
involve  the  nerve  and  its  ocular  extremity,  the  disc.  If  it  is 
remote  from  the  optic  tracts  and  nerves,  or  if  brief  in  duration, 
though  contiguous,  this  symptom  does  not  usually  appear. 

We  postpone  certain  remarks  which  occur  to  us  till  we  come 
to  consider  the  application  of  ischaemia  and  neuritis  as  signs  of 
cerebral  disease,    but  we  are  tempted  to  try   a  fall   with  the 
author  on  the  general  question   of  inflammation,  into  which  he 
enters  with  a  certain  vehemence  obviously  arising  out  of  strong 
convictions   on  the   subject.     We  think  there   are   few  of  his 
readers  who  do  not  recognise  with  him  the  distinction  between 
congestion  and  inflammation,  and  we  do  not  propose  to  bring  in 
'nature'   again,   the  personage  of  the  '  female  gender'    (would 
not  either  sex  or  feminine  have  been  more  appropriate  ?)  for 
whom   he  has  such   a  contempt.     We  question  the  adequacy 
and  the  accuracy  of  his  idea  of  inflammation,  which  he  defines 
as  "  lesion  with  reaction  or  resistance."     We  want  a  definition  of 
lesion,  and  Ave  want  an  explanation  of  reaction.     If,  as  the 
context  implies,  lesion  is  taken  to  mean  rupture  of  continuity, 
then  we  say  that  in  erysipelas  and  similar  inflammations  in  which 
the  disturbance   of  the  relation  between  blood  and  tissue  is  on 
the  side  of  the  blood,  inflammation  is  antecedent  to  lesion ;  so 
also  in  herpes  zoster,  where  the  disturbance  comes  through  nerves. 
Reaction  or  resistance,  again,  unless  resolved  into  its  factors, 
unless  the  different  steps  of  the  process  are  stated,  is  just  as 
much  a  figurative  term  as  the  old  '  effort  of  nature,'  borrowed,  it 
is  true,  from  physical  or  mechanical  science,  instead  of  being  a 
metaphysical  abstraction,  but  none  the  less  likely  to  become 
an  obstructive  idolon.     For  ourselves,  inflammation  is  a  condi- 
tion which  is  produced  whenever  the  normal  relations  between 
blood  and  tissue  are  deranged  beyond  a  certain  varying  and  un- 
defined limit,   whether  the  derangement  start    in    an    altered 
condition  of  the  blood,  or  in   damage  to  the  structure,  or  be 
initiated  by  deviation  from  the  normal  nerve-influence  (let  this 
last  expression  be  allowed   us  in  the  absence  of   opportunity 
better  to  define  it).     The  immediate  result  we  believe  to  be  in- 
creased local  oxidation,  with  consequent  increased  evolution  of 
energy  in  some  form  or  other.  The  tendency  we  may  suppose  would 
be  to  the  production  of  the  least  specialised  form  of  energy,  heat ; 
but  whether  this  be  the  case  or  not  a  part  of  the  excess  of  force 
is  appropriated  by  the  organic  structures,  and  expended  in  the 
increased  activity  of  the  tissue  changes ;  any  local  heat  would 
represent  unappropriated  energy.     The  increase  of  the  cohesive 
affinity  between   the  blood-corpuscles  and  the  capillary  wall. 


438  Reviews.  [April, 

leading  to  their  extrusion,  as  shown  by  Cohnheim  and  explained 
by  Norris  of  Birmingham,  is  probably  the  primary  effect  of  this 
force  ;  the  phenomena  of  congestion  and  the  proliferation  of  the 
tissue  elements,  secondary  results.  We  cannot,  of  course,  here 
justify  the  position  taken  up,  we  indicate  it  only  to  illustrate 
the  inadequacy  of  the  definition  of  inflammation  given  by  the 
author.  On  another  question  of  general  pathology  or  morbid 
physiology  we  are  thoroughly  in  accord  with  him,  that  is,  on 
the  current  exaggeration  of  the  influence  of  the  sympathetic 
nervous  system,  fancies  about  which,  as  he  says,  are  very  fashion- 
able ;  its  mysterious  agency  is  perpetually  called  upon  to  explain 
all  sorts  of  phenomena,  and  the  less  the  writer  and  the  reader 
know  about  the  sympathetic  nervous  system  the  more  satisfactory, 
of  course,  is  the  explanation. 

In  the  sections  on  hypersemia  and  anaemia  of  the  disc  and 
retina,  or  oedema  of  the  disc,  these  conditions  are  carefully  de- 
scribed, and  many  valuable  hints  are  given,  more  particularly 
with  respect  to  the  diagnosis  of  early  stages  of  hypereemia,  in 
which  the  appearance  of  radiating  vessels  in  the  disc  is  to  be 
looked  for,  and  any  difference  of  vascularity  in  the  two  eyes  is 
to  be  noted  as  important.  Directions  are  given  by  which  ansemia 
may  be  distinguished  from  atrophy,  and  the  causes  of  hypersemia, 
ansemia,  and  cedema,  are  discussed.  Chronic  optic  neuritis  is  a 
term  introduced  by  Dr.  Allbutt  to  indicate  a  condition  scarcely 
less  interesting  than  the  more  common  acute  neuritis.  It  con- 
stitutes an  early  stage  of  what  has  been  called  ^  simple  optic 
atrophy,'  and  is  chiefly  associated  with  sclerosis  of  the  nerve 
centres.  Hutchinson  has  described  it  as  initiating  the  process 
which  ends  in  the  white  atrophy  of  tobacco  amaurosis.  The 
disc  is  first  too  red  and  the  choroid  too  full  of  blood,  but  there 
are  no  ecchymoses  or  efi'usions  of  lymph ;  the  redness  gradually 
fades,  and  eventually  the  discs  become  too  white  and  the 
arteries  almost  disappear. 

Consecutive  atrophy,  again,  is  particularly  interesting.  Dr. 
Huffhlings  Jackson  has  been  led  to  make  a  distinction  between 
atrophy  in  which  the  margin  of  the  disc  is  ragged  and  the  out- 
line blurred,  and  atrophy  in  which  the  surface  is  brilliant  and 
the  edge  sharp  and  even.  The  former  he  traces  to  antecedent 
neuritis,  the  latter  he  considers  to  be  primary  *  simple  or  pro- 
gressive atrophy.'  It  is  true  that  the  atrophy  with  an  uneven 
outline  is  a  result  of  neuritis,  but  according  to  Dr.  AUbutt's 
observations  the  shining  smooth-edged  condition  is  the  final 
stage  of  all  atrophies,  whether  these  are  primary  or  are  conse- 
quent upon  the  chronic  optic  neuritis  to  which  reference  has 
just  been  made,  or  the  results  of  acute  neuritis  or  iscbaeraia. 
The  intermediate  stage  he  calls  transition  atrophy ,  a  term  which 


1872.]     Use  of  the  Ophthalmoscope  in  Nervous  Diseases.     439 

will  be  found  very  convenient.  We  cannot  follow  the  author 
into  the  nice  distinctions  by  which  primary  atrophy  is  charac- 
terised and  differentiated  from  anaemia  on  the  one  hand  and 
consecutive  atrophy  on  the  other.  They  are  evidently  the 
result  of  careful  observation,  and  will  repay  careful  study  by  all 
who  are  seeking  to  make  use  of  the  ophthalmoscope  in  medicine. 

One  or  two  points  brought  out  prominently  are  deserving  of 
something  more  than  the  casual  mention  made  of  them  in 
passing.  Of  these,  the  first  is  the  amazing  degree  of  change 
often  observed  in  the  discs  when  central  vision  is  so  little  affected 
that  sight  appears  to  be  quite  good  to  the  patient  and  when 
tested  by  ordinary  methods.  As  the  author  says,  "  To  base 
any  inferences  as  to  states  of  the  optic  discs  upon  degrees  of 
vision  is  simply  a  waste  of  time."  It  is  one  of  the  surprises 
awaiting  those  who  take  up  the  ophthalmoscope  as  an  instru- 
ment of  clinical  research  to  find  extreme  ischsemia,  or  even  a 
considerable  degree  of  true  neuritis  or  appearances  character- 
istic of  advanced  atrophy,  without  any  acknowledged  affection 
of  sight,  and  without  any  pain  or  photophobia.  Another  point 
is  the  advantage  sometimes  to  be  derived  from  mapping  out  the 
field  of  vision,  a  procedure  which  may  betray  an  unsuspected 
failure  of  sight,  and  which  distinguishes  the  general  feebleness 
of  the  retina  in  anaemia  from  the  local  deficiency  of  functional 
power  in  atrophy.  Again,  the  necessity  of  cultivating  the 
direct  method  of  examination  as  well  as  the  indirect  becomes 
more  and  more  evident  as  the  numerous  instances  in  which  it 
furnishes  information  not  yielded  by  the  indirect  examination 
are  successively  adduced. 

From  the  account  of  the  variations  from  health  of  the  optic 
nerve  and  retina  we  pass  to  the  consideration  of  the  oph- 
thalmoscopic evidences  of  the  intra-cranial  disorders  which 
form  the  subject  of  the  longest  and  most  important  chapter  in 
the  work.  They  are  taken  in  the  following  order,  suggested 
simply  by  convenience — epilepsy,  chorea,  mania,  dementia, 
meningitis,  concussion  and  fracture,  hydrocephalus^  tumours  and 
chronic  periostitis,  atheroma,  softening  and  haemorrhage,  cere- 
britis,  abscess  and  sclerosis,  and  general  paralysis ;  illustrative 
cases  to  the  number  of  123  from  the  practice  of  the  author 
and  other  observers,  and  statistical  tables,  forming  an  appendix. 

In  epilepsy,  properly  speaking,  we  have  none  of  the  violent 
changes  in  the  optic  disc,  such  as  ischaemia,  or  neuritis,  or 
atrophy.  The  result  of  careful  and  repeated  examination  of 
the  fundus  of  the  eye  in  epileptics  is  an  opinion  that  during 
the  intervals  there  is  a  higher  degree  of  vascularity  in  the  discs 
and  retina,  the  discs  being  more  red  than  normal  and  the 
vessels  larger.     During  or  immediately  after  the  fits  the  disc 


440  Reviews,  [April, 

has  been  found  entirely  anaemic  in  a  majority  of  the  few  obser- 
vations that  have  been  made.  Dr.  Hughlings  Jackson  and  Mr. 
Carter  are  among  those  who,  with  Dr.  Allbutt,  have  had  the 
rare  opportunity,  and  have  succeeded  in  the  difficult  task  of 
examining  the  fundus  of  the  eye  during  an  epileptic  attack. 
Out  of  six  cases  of  which  the  author  has  notes,  anaemia  of  the 
disc  was  present  in  three,  in  three  others  considerable  hypersemia, 
but  in  these  latter  the  fits  were  succeeding  each  other  in  rapid  suc- 
cession, the  patients  not  regaining  consciousness  in  the  interval. 
On  the  whole,  therefore,  the  ophthalmoscopic  evidence  tends  to 
confirm  the  view  that  the  common  epileptic  seizure  is  due  to 
spasm  of  the  cerebral  vessels  ;  but  we  agree  with  the  author  that 
epilepsy  has  more  than  one  cause,  and  may  be  associated  with 
diverse  conditions  of  the  blood  supply  to  the  brain. 

Chorea  is  not  attended  with  any  affection  of  the  retina  or 
disc.  In  mania  symptomatic  changes  in  the  eye  are  found  in  a 
large  proportion  of  cases,  and  there  appears  to  be  for  a  period 
after  the  paroxysm  a  pink  suffusion  of  the  fundus  oculi ;  a 
single  observation  during  a  paroxysm  showed  the  disc  to  be 
ansemic.  Dementia,  as  the  author  observes,  includes  worn-out 
lunatics  of  all  sorts,  and  nothing  is  to  be  gained  by  associating 
changes  in  the  eye  with  this  condition  as  such. 

It  will  give  some  idea  of  the  labour  bestowed  on  investiga- 
tions, the  results  of  which  are  given  in  a  few  pages  or  almost 
in  a  few  lines,  when  we  state  that  in  the  appendix  are  tabulated 
43  cases  of  epilepsy  with  insanity,  51  cases  of  mania,  38  of 
dementia,  17  of  monomania  and  melancholia,  and  12  of  idiocy. 
These  tables  have  already  been  printed  in  the  '  Medico-Chirur- 
gical  Transactions.' 

We  come  now  to  meningitis,  in  which  the  labours  of  the 
author  and  of  Dr.  Hughlings  Jackson  have  rendered  the  ophthal- 
moscope a  most  valuable  and  important  aid  to  diagnosis.  It  is 
here  that  the  most  important  addition  to  our  knowledge  has 
been  made,  and  if  Dr.  Allbutt  has  not  been  the  only  pioneer 
who  has  pushed  on  into  untried  ground  at  this  point,  he  is  the 
first,  so  far  as  we  know,  who  has  systematised  the  results  and 
secured  the  newly  acquired  possessions ;  whatever  else  he  may 
have  done  or  may  yet  achieve,  this  is  one  advance  with  which 
his  name  must  always  be  honorably  associated.  Meningitis 
has  various  origins,  and  is  called,  therefore,  by  various  names. 
By  far  the  most  important  is  tubercular  meningitis,  common 
enough  at  all  ages,  but  especially  frequent  in  children ;  from 
its  usual  seat  and  characters  it  has  been  called  granular  basilar- 
meningitis.  As  the  author  says,  the  general  opinion  in  the 
profession  is  that  this  disease  is  invariably  fatal,  an  opinion 
qualified,  perhaps,  in  the  case  of  most  men  of  considerable  ex- 


]872.]      Use  of  the  Ophthalmoscope  in  Nervous  Diseases.     441 

perience  by  a  recollection  of  one  or  two  exceptional  recoveries. 
The  rule  is  that  patients  who  present  well-marked  symptoms  of 
tubercular  meningitis  die,  and  when  recovery  occurs  it  is 
usually  concluded  that  the  diagnosis  was  erroneous,  the  old- 
rooted  conviction  that  tubercular  disease  in  any  important 
organ  is  inevitably  fatal  overruling  every  other  conclusion. 
Now,  the  position  Dr.  AUbutt  takes  is  this :  some  at  least  of 
these  recoveries,  with  or  without  damage  to  the  brain,  from 
symptoms  characteristic  of  tubercular  meningitis,  are  really 
what  they  seem  to  be  ;  there  has  been  tubercular  meningitis, 
and  the  patient  has  got  well.  Still  more  commonly  a  child  will 
have  occasional  '  purposeless  '  vomiting,  evening  feverishness 
and  restless  nights,  with  movements  or  even  convulsions  during 
sleep,  will  suffer  at  times  from  pain  in  the  head,  become  irri- 
table and  unable  to  fix  his  attention,  and  will  eventually  regain 
health  with  or  without  some  impairment  of  the  mental  facul- 
ties. Here  again  there  has  been,  or  may  have  been,  tubercular 
meningitis  and  recovery.  The  grounds  for  this  conclusion  are 
as  follows :  in  cases  of  tubercular  meningitis,  verified  by  post- 
mortem examination,  the  changes  in  the  eye  have  been  watched 
during  life,  and  ischsemia  of  the  disc,  or  neuritis,  or  both,  have 
been  observed ; — the  ischaemia  caused  by  obstruction  to  the 
venous  return,  or  by  general  intra-cranial  pressure ; — the  neuritis 
due  to  extension  along  the  nerve  of  the  inflammatory  process 
going  on  in  the  pia  mater  enveloping  it.  In  cases  presenting 
almost  the  same  train  of  symptoms,  but  which  have  not  ter- 
minated fatally,  the  optic  ischaemia  or  neuritis  has  been  equally 
observed,  and  it  can  scarcely  have  any  other  than  the  same 
cause.  But  not  only  in  acute,  but  also  in  those  milder  cases 
which  medical  men  have  not  ventured  to  attribute  to  tubercular 
meningitis,  optic  changes  of  the  same  kind  have  been  watched 
in  a  considerable  number  of  instances,  and  one  case  is  related 
by  Dr.  Allbutt  in  which,  after  recovery  from  a  first  attack,  the 
patient  died  in  a  second,  and  evidences  were  found  of  an  old 
and  of  a  recent  meningitis.  We  should  have  been  glad  to  have 
had  more  definite  expectations  held  out  to  us  that,  in  the 
tubercular  meningitis  of  adults,  the  ophthalmoscope  would  afford 
a  much-needed  aid  in  diagnosis.  There  are  no  cases  more 
perplexing  than  these ;  the  antecedent  history  which  is  so  sug- 
gestive in  the  child  is  often  wanting  later  in  life,  and  there  is 
the  utmost  diversity  in  the  mode  of  attack  and  in  the  march  of 
the  disease.  In  a  certain  number  of  cases,  however,  optic 
changes  do  not  occur  in  the  course  of  fatal  meningitis. 
Bouchut  states  that  he  found  them  in  all  but  two  of  fifty- 
nine  cases,  but  Dr.  Allbutt  met  with  them  in  only  twenty-nine 
out  of  thirty-eight ;  the  absence  of  any  affection  of  the  disc  is 


442  Reviews,  [April, 

not,  therefore,  conclusive  against  the  existence  of  meningitis, 
and  when  the  inflammation  is  on  the  upper  aspect  of  the  hemi- 
spheres, away  from  the  optic  tracts  and  nerves,  it  is  not  to  be 
expected,  according  to  the  author's  explanation  of  the  connec- 
tion between  the  two,  that  they  will  be  so  liable  to  become 
involved.  After  recovery  from  tubercular  meningitis  either  the 
mental  powers  or  vision,  or  both,  may  be  impaired,  and  a 
remarkable  fact  comes  out  in  Dr.  Allbutt's  inquiries,  namely, 
that  idiocy  and  blindness  are  among  the  results  which  some- 
times follow,  as  well  as  the  stupidity  and  change  of  disposition 
coming  over  precocious  children.  Dr.  Crichton  Browne  has 
not  only  no  hesitation  in  classing  tubercular  meningitis  among 
the  causes  of  idiocy,  but  he  traces  insanity  to  this  source  also. 
This  causation  has  only  to  be  stated  to  be  at  once  recognised, 
and  examples  occur  to  our  mind  both  of  idiocy,  blindness,  and, 
we  may  add,  deafness,  following  tubercular  meningitis ;  in  two 
cases  of  deafness  so  caused,  at  the  age  of  about  six,  the  child, 
after  having  learnt  to  speak,  became  as  completely  mute  as  if 
the  deafness  had  been  congenital. 

Meningitis  occurring  in  fevers,  erysipelas,  pyaemia,  &c.,  has 
not  yet  been  so  thoroughly  worked  out,  but  there  can  be  no 
doubt  that  the  ophthalmoscope  will  frequently  be  of  service 
in  determining  whether  violent  delirium  in  a  given  case  is  due 
to  meningitis  or  simply  to  the  effect  on  the  brain  of  the  altered 
blood.  Syphilitic  meningitis,  on  the  contrary,  which  is  common, 
and  from  its  chronic  course  offers  a  favorable  opportunity  of 
watching  the  optic  changes,  has  been  very  fully  observed.  It 
is  here  that  the  true  neuritis  descendens  is  most  commonly  met 
with  and  best  seen ;  it  is  here,  too,  that  treatment  meets  with 
the  greatest  success. 

In  concussion  of  the  brain  and  fracture  of  the  skull  we 
cannot  expect  to  have  any  constant  or  valuable  opthalmo- 
scopic  indications ;  the  most  interesting  point  is  the  fact  that 
blows  on  the  head  and  elsewhere  often  seem  to  determine  the 
occurrence  of  local  syphilitic  mischief,  an  observation  which 
entirely  accords  with  our  own  experience.  We  must  not  pass 
from  the  subject  without  saying  how  greatly  we  admire  Dr. 
Allbutt's  self-denial  in  dismissing  railway  accidents  as  mere 
pitfalls  for  the  inquirer.  What  traps  for  large  fees  would  a 
few  pompous  words  on  the  use  of  the  ophthalmoscope  in  these 
important  and  perplexing  cases  have  been ! 

With  respect  to  intra-cranial  tumours,  in  which  a  vast  amount 
of  work  has  been  done  by  other  observers,  and  which  have, 
of  course,  been  the  object  of  most  careful  and  patient  obser- 
vation by  Dr.  Allbutt,  we  find  him  honestly  but  regretfully 
confessing  that    he  is  unable  to  indicate  with    anything  like 


1872.]      Use  of  the  Ophthalmoscope  in  Nervous  Diseases.     443 

finality  the  actual  value  of  the  presence  or  absence  of  optic 
changes  in  the  diagnosis  or  exclusion  of  encephalic  tumour,  or 
to  state  with  anything  like  certainty  what  are  the  intermediate 
processes  which  connect  these  changes  in  the  head  with  in- 
flammatory or  congestive  changes  in  the  disc.  The  ophthal- 
moscope is,  nevertheless,  of  great  value  in  the  diagnosis  of 
tumours,  and  all  the  more  valuable  because  the  two  physicians 
who  have  taken  the  lead  in  introducing  it  into  medical  prac- 
tice in  this  country,  the  author  and  Dr.  Hughlings  Jackson, 
have  displayed  true  scientific  caution,  and  have  not  rushed 
along  the  broad  path  of  hasty  generalisation. 

No  fact  is  more  certainly  established  than  that  intra-cranial 
tumours  commonly  give  rise  to  changes  in  the  optic  disc.  The 
mode  in  which  these  changes  are  brought  about  is  a  subject  of 
hot  controversy.  We  have  above  seen  that  Dr.  Allbutt  recog- 
nises two  conditions  of  the  disc,  congestive  and  inflammatory, 
consequent  upon  cerebral  disease,  leaving  out  of  consideration, 
for  the  moment  primary  atrophy.  The  congestive  or  strangu- 
lated state  of  the  disc  is  the  more  common  result  of  tumour, 
but  true  neuritis  also  occurs.  The  question  is,  are  these  con- 
ditions induced  by  obstructed  venous  return  on  the  one  hand, 
and  by  extension  by  continuity  of  the  inflammation  along  the 
nerve  on  the  other,  or  are  they  not  both  due  to  general  ^  vas- 
cular storms,'  in  which  the  sympathetic  nervous  system  is  the 
agent  ?  The  latter  view  has  the  delightful  vagueness  and  in- 
tangibility so  attractive  to  some  minds,  but  so  hateful  to  such 
as  seek  to  see  clearly  and  know  exactly.  Benedikt  is  the 
champion  of  it  selected  for  attack  by  our  author,  who  is  mis- 
taken, as  we  think,  in  saying  that  it  is  adopted  by  Dr.  Hugh- 
lings  Jackson,  whose  attitude  has  seemed  to  us  to  be  rather  one 
of  dissatisfaction  with  other  explanations  than  of  adhesion  to 
the  sympathetic  hypothesis  as  an  adequate  solution  of  the 
problem. 

We  are  not  concerned  to  discuss  here  the  agency  of  the  sym- 
pathetic system  in  the  production  of  the  ophthalmic  changes  ; 
it  is  admissible  only  on  the  supposition  that  hyperaemia  is  iden- 
tical with  inflammation,  which  is  not  the  fact,  and  to  admit  it 
would  only  shift  the  difficulty  to  other  ground  without  in  any- 
wise diminishing  it.  What  we  have  to  do  is  seriously  to  inquire 
whether  these  changes  can  be  explained  by  the  intervention  of 
ischaemia  or  neuritis,  the  result  of  pressure,  direct  or  indirect, 
or  of  extension  of  inflammation  by  continuity  of  structure  ;  or 
if,  as  must  be  acknowledged,  this  explanation  is  not  always 
tenable,  whether  it  is  valid  in  so  many  cases  that  we  are  justi- 
fied in  exercising  a  degree  of  scientific  faith  in  it  when  it  is  not 
obvious  to  the  understanding.     We  are  indebted  to  Benedikt 


444  Reviews.  I  April, 

for  putting  the  difficulties  clearly  and  forcibly,  if  not  quite 
fairly,  and  they  resolve  themselves  into  the  following  points : — 
1.  That  in  intra-cranial  tumour,  associated  with  changes  in  the 
optic  disc,  the  tumour  may  be  incompetent  by  its  size  or  situa- 
tion to  give  rise  to  general  or  local  pressure  or  to  venous  ob- 
struction, or  to  communicate  inflammation  to  the  optic  tract  or 
nerves.  2.  That,  the  tumour  constantly  increasing  in  size,  the 
changes  in  the  disc  may  advance  and  recede  in  turns,  with 
exacerbations  and  remissions  in  the  headache  and  other  general 
symptoms  attributable  to  '  vascular  storms.'  3.  That  tumours 
may  attain  a  large  size  without  giving  rise  to  ophthalmic 
changes.  To  these  it  is  replied — 1.  That  the  intra-cranial 
pressure  giving  rise  to  ischsemia  of  the  disc  may  be  not  merely 
such  as  might  be  due  to  the  bulk  or  seat  of  a  tumour,  but  to 
the  general  vascular  pressure  of  inflammation  set  up  by  the 
tumour,  or  to  dropsy  of  the  ventricles  caused  by  it.  2.  That 
the  exacerbations  and  remissions  are  traceable  to  attacks  of 
local  or  general  inflammation,  excited  by  a  growing  tumour, 
which  subside.  3.  That  a  slowly  growing  tumour  may  cut  off 
the  blood  supply  of  neighbouring  parts,  which  then  fall  into 
softening,  or  may  cause  Wallerian  atrophy  by  separating  parts 
from  their  functionally  associated  centre  and  thus  make  room 
for  itself,  and  never  cause  increased  pressure.  Taking  these 
explanations,  and  remembering  that  red  softening,  arterial 
degeneration,  &c.,  are  not  attended  with  ophthalmic  signs,  we 
are  disposed  to  exercise  the  required  faith,  even  in  cases  such 
as  those  instanced  by  Benedikt,  and  in  cases  like  one  which 
came  under  our  own  observation,  in  which  the  only  morbid 
appearances  were  three  small  dead  and  withered  entozoa  on 
the  surface  of  the  convolution  above  the  posterior  end  of  the 
fissure  of  Sylvius  of  the  right  hemisphere,  the  patient  having 
suffered  from  unilateral  convulsions,  loss  of  sight  with  atrophy 
of  the  disc,  and  loss  of  smell. 

Dr.  Allbutt  does  not  content  himself  with  stating  the  degree 
of  liability  to  optic  changes  attending  tumours  in  diff'erent  situ- 
ations, but  gives  fully  and  carefully  the  symptoms  to  which 
tumours  in  various  parts  of  the  encephalon  and  of  the  cranial 
fossae  give  rise.  We  cannot  follow  him  in  this — the  general 
conclusion  with  respect  to  the  use  of  the  ophthalmoscope  in  the 
diagnosis  of  intra-cranial  tumours  is  that,  while  changes  in  the 
disc  are  often  valuable  evidence  of  the  presence  of  tumours,  and 
sometimes  especially  valuable  from  their  early  appearance  when 
other  symptoms  are  indefinite,  they  afford  no  indication  of  the 
nature  of  the  tumour  and  very  little  information  as  to  its  seat 
and  size. 

Recent  cerebral  haemorrhage  is  attended  with  no  important 


1872.  J      Use  of  the  Ophthalmoscope  in  Nervous  Diseases.      445 

ophthalmic  signs,  but  old  clots  sometimes  give  rise  to  neuritis 
and  atrophy.  The  retinal  changes  caused  by  albuminuria,  and 
the  liability  to  cerebral  hsemorrhage  in  renal  disease,  make  an 
examination  of  the  eye  important,  even  in  recent  apoplexy. 
Embolism  and  red  softening  are  not  attended  with  significant 
changes  in  the  eye  ;  cerebritis,  abscess,  and  sclerosis,  on  the 
other  hand,  very  commonly  set  up,  the  two  former  neuritis,  the 
last  primary  atrophy.  General  paralysis,  which  is  due  to  dif- 
fuse sclerosis,  is  almost  always  accompanied  by  optic  atrophy, 
as  was  shown  by  Dr.  Allbuttin  a  paper  read  before  the  Medical 
and  Chirurgical  Society.  In  "Locomotor  Ataxy ,^'  another  dis- 
ease due  to  sclerosis,  it  is  about  equally  constant,  and  it  is 
common  in  connection  with  paralysis  agitans. 

In  locomotor  ataxy  which  is  due  to  sclerosis  of  the  posterior 
columns  of  the  cord,  and  in  other  diseases  dependent  on  this 
kind  of  change  in  different  parts  of  the  nervous  system,  the  optic 
atrophy  is  probably  not  consequent  upon  the  disease  in  the  cord, 
but  is  due  to  sclerosis  of  the  tract  or  nerve,  arising  out  of  some 
general  condition  which  is  the  common  cause  of  the  morbid 
changes  in  both  cord  and  eye.  But  in  spinal  diseases  arising 
from  injury,  which  run  a  long  course,  changes  in  the  optic  disc 
are  common,  and  these  are  hyperaemic  and  not  primarily 
atrophic ;  they  are,  moreover,  directly  consequent  upon  the 
affection  of  the  cord.  The  temptation  to  invoke  the  sympathetic 
system  is  here  particularly  strong,  but  the  well-known  indica- 
tions of  injury  to  this  nerve  are  commonly  absent  when  the 
disc  is  affected  consecutively  to  spinal  injury,  and  may  be 
present  without  any  change  in  the  disc  when  the  sympathetic 
is  diseased  or  destroyed.  The  explanation  Dr.  Allbutt  offers  is 
that  an  ascending  meningitis  creeps  upward  from  the  cord  to 
the  base  of  the  brain,  and  gives  rise  to  hyperaemia  or  ischsemia  of 
the  optic  discs  in  the  same  way  as  cerebral  meningitis. 

Next  in  importance,  and  almost  equal  in  interest,  to  the  optic 
changes  accompanying  diseases  of  the  nervous  system,  are  those 
associated  with  diseases  of  the  kidneys.  The  vitreous  body, 
the  retina,  and  the  choroid  are  all  affected  ;  but  the  most  con- 
spicuous change  is  the  retinitis,  which  has  a  course  and  results 
so  characteristic  that  it  is  at  once  recognised  as  albuminuric. 
The  first  stage  is  one  of  diffuse  infiltration,  the  retina  round  the 
disc  becomes  swollen  and  purplish-red,  the  disc  becomes 
suffused  with  a  dark  red  colour,  and  its  margin  is  no  longer 
defined ;  the  arteries  are  small,  the  veins  large  and  tortuous, 
and  an  exudation  spreads  over  the  disc  and  surrounding  retina. 
If  the  inflammation  goes  on,  haemorrhages  occur  in  the  retina, 
and  certain  white  patches  appear  surrounding  the  disc  and 
extending  outwards  upon  the  retina  along  the  course  of  the 

98— xiix.  29 


446  Reviews.  [April, 

vessels,  wliich  are  probably  patches  of  coagulated  exudation, 
while  other  smaller  stellate  white  spots^^  due  to  degeneration  of 
Miiller's  rods,  surround  the  yellow  spot.  Nothing  can  be  more 
striking  than  this  assemblage  of  white  patches  and  hsemorrhages 
in  various  stages  of  retrogressive  change  around  a  disc  which  is 
itself  no  longer  to  be  distinguished,  except  by  the  convergence 
of  the  vessels,  together  with  the  independent  constellation  of 
white  dots  about  the  yellow  spot.  The  vision  is  usually  seriously 
affected,  but  recovery  may  take  place  and  nothing  remain  of  all 
these  appearances ;  a  retinal  anaemia  and  yellow  patches  in  the 
choroid  alone  persisting.  Many  interesting  questions  arise  with 
respect  to  this  retinitis,  which  are  fully  and  ably  discussed  by 
Dr.  Allbutt.  Is  it  peculiar  to  any  form  of  renal  disease  ?  To 
this  he  answers,  '^  No."  It  is  most  commonly  associated  with  the 
contracted  granular  kidney,  but  has  been  met  with  in  amy- 
loid and  other  forms  of  large  smooth  kidney,  and  in  the 
epithelial  nephritis  following  scarlatina.  We  have  ourselves 
recently  seen  the  first  stage  of  this  retinitis  well  marked  in  a 
case  of  epithelial  nephritis  following  exposure  to  cold,  and  of  no 
long  duration.  Has  it  any  relation  with  the  cardiac  hypertrophy 
also  associated  with  renal  disease  ?  Here,  again,  we  concur 
with  the  reply  of  our  author — the  two  conditions  certainly  do 
not  stand  in  any  constant  relation.  In  the  most  marked  example 
of  albuminuric  retinal  change  which  has  come  under  our  obser- 
vation there  was  no  hypertrophy  of  the  heart.  In  one  of  the 
most  striking  cases  of  cardiac  hypertrophy  and  high  vascular 
pressure  due  to  renal  disease  no  retinitis  or  evidence  of  past 
retinitis  existed.  Is  there,  then,  any  necessary  relation  between 
the  retinitis  and  nephritis  at  all  ?  Most  assuredly,  and  yet  no 
satisfactory  mode  of  causation  of  the  one  by  the  other  can  be 
made  out ;  the  most  likely  guess,  as  Dr.  Allbutt  puts  it,  being, 
however,  that  ursemic  blood  sets  up  the  irritative  changes  in  the 
retina.  The  temporary  loss  of  sight  from  uraemia  is,  however, 
not  attended  with  optic  changes. 

Leucaemia,  diabetes,  oxaluria,  chronic  poisoning  by  alcohol, 
tobacco,  and  lead,  have  been  found  to  cause  changes  of  various 
kinds  in  the  retina  and  discs.  Cases  of  this  kind  are,  however, 
comparatively  rare,  and  the  more  frequent  and  important,  such 
as  tobacco  amaurosis  and  amaurosis  from  lead  poisoning,  are 
more  likely  to  come  under  the  notice  of  the  ophthalmic  surgeon 
than  of  the  physician.  The  physician  should  be  aware  of  their 
occasional  occurrence,  and  they  should  not  be  lost  sight  of  in 
the  study  of  tissue  changes  associated  with  any  constitutional 
condition  or  due  to  any  particular  poison.  It  should  be  stated 
that  Dr.  Allbutt   accepts  with  considerable  reserve,  if  at  all. 


1872.]      Use  of  the  Ophthalmoscope  in  Nervous  Diseases,     447 

HutcMnson  and  Wordsworth's  conclusions  as  to  the  causation  of 
white  atrophy  by  tobacco. 

The  final  chapter  is  an  essay  on  embolism  of  the  Sylvian 
artery,  in  which  the  changes  following  embolism  of  the  central 
artery  of  the  retina  are  made  use  of  to  explain  the  consequences 
of  the  graver  lesion.  Into  this  we  do  not  now  enter,  but  con- 
clude by  expressing  our  sincere  admiration  of  Dr.  Allbutt's 
book.  He  has  not  only  taught  us  the  great  use  which  the  oph- 
thalmoscope may  have  in  medicine,  and  cleared  up  many  of  the 
difficulties  which  threw  uncertainty  upon  its  indications  ;  he  has, 
while  considering  the  optic  changes  resulting  from  cerebral  and 
constitutional  diseases,  furnished  a  vast  amount  of  information 
respecting  these  diseases  themselves,  and  he  has,  by  the  whole 
spirit  and  method  of  his  work,  given  an  impetus  to  the  truly 
scientific  pursuit  of  medicine. 


448  [April, 


3Bi6liosrai)i)uaI  ^etorlr. 


Bastian  on  Lowest  Organisms.^ — Dr.  Bastian  is  certainly  an  adroit 
controversialist,  as  well  as  an  innovator.  We  remember,  last  year, 
a  violent  polemical  discussion  which  was  carried  on  between  him 
and  Professor  Huxley.  In  the  inception  of  the  dispute  the  facts 
were  all  on  the  side  of  the  Jermyn  Street  professor ;  but,  owing  to 
the  skill  of  his  antagonist  and  the  peculiar  style  of  argument  into 
which  Professor  Huxley  was  often  led,  Dr.  Bastian  carried  his  lance 
fairly  broken  out  of  the  arena. 

The  experiments  of  Pasteur  and  Pouchet  have  so  long  occupied 
the  attention  that  it  is  unnecessary  to  quote  them  here.  Dr.  Bastian 
professes  to  have  repeated  with  success  the  experiments  of  Pouchet, 
and  to  have  entirely  demolished  the  counter-experiments  of  Pasteur, 
Tyndall,  and  Huxley.  We  must  glance  at  Dr.  Bastian's  experiments 
before  we  enter  upon  the  consideration  of  his  arguments.  He  gives 
us  sixty-five  experimental  instances,  in  which  he  alleges  that  he  has 
proved  what  he  terms  the  theory  of  Archebiosis.  Of  those,  the 
following,  perhaps,  best  illustrate  his  method  of  proceeding  : 

"  Pluid  (in  vacuo)  in  a  flask,  the  neck  of  which  was  hermetically 
sealed  by  means  of  a  blow-pipe  flame  during  ebulHtion. 

"  No.  XIII. — Urine  in  forty-four  hours  showed  a  very  slight 
amount  of  sediment.  During  the  next  two  days  the  sediment  very 
slightly  increased,  but  was  still  small  in  amount.  At  the  expiration 
of  fifteen  days,  no  further  increase  in  the  turbidity  having  taken 
place,  the  fluid  was  examined.  The  vacuum  was  still  partially  pre- 
served, as  evidenced  by  the  rapid  inbending  of  a  portion  of  the  neck 
of  the  flash  after  it  had  been  carefully  made  red  hot.  When  opened, 
the  odour  of  the  fluid  was  stale,  but  not  foetid,  and  its  reaction  was 
still  faintly  acid.  On  microscopical  examination  bacteria  and  torulae 
were  found  in  tolerable  abundance. 

"  No.  XXIV. — Pluid  in  a  bent-neck  flask,  having  eight  acute  flexures. 
Urine,  in  forty-eight  hours,  showed  no  change.  After  twelve  days 
there  was  still  no  general  turbidity,  though  there  was  a  slight  floc- 
culent  deposit  of  an  uncertain  nature.  Two  days  afterwards  the 
flask  was  broken,  when  the  odour  of  the  fluid  was  still  found  to 

^  The  Modes  of  Origin  of  Lowest  Organisms,  including  a  Discussion  of  the  Ex- 
periments of  M.  Pasteur,  and  a  Reply  to  some  Statements  hy  Professors 
Suxley  and  Tyndall.  By  H.  Chablton  Bastian,  M.A.,  M.D.,  F.R.S.  London 
and  New  York.     1871. 


1B72.]  Bastian  on  Lowest  Organisms.  449 

resemble  that  of  fresli  urine,  and  its  reaction  was  acid.  The  flocculi 
were  made  up  of  granular  aggregations,  in  the  midst  of  which  were  a 
few  bodies  closely  resembling  torulae,  though  they  were  somewhat 
doubtful  in  nature ;  neither  bacteria  nor  vibriones  could  be  found. 
The  flask,  having  a  short  open  neck,  was  then  replaced  in  the  warm 
bath.  In  sixteen  hours  the  whole  fluid  had  become  turbid,  it  was 
also  slightly  foetid,  and  on  microscopical  examination  it  was  found 
to  be  swarming  with  bacteria,  vibriones,  and  leptothrix." 

Against  his  conclusions  may  be  cited  the  testimony  of  such  an 
experienced  observer  as  Dr.  Sanderson^  on  whose  researches  on 
microzymes  we  commented  in  a  past  number.  In  a  recent  memoir 
in  the  '  Quarterly  Journal  of  Microscopical  Science'  Dr.  Sanderson 
gives  a  series  of  experiments  which  appear  to  contradict  those  of 
Dr.  Bastian  in  nearly  every  essential  respect.  Dr.  Sanderson  shows, 
firstly,  that  neither  bacteria  nor  fungi  ever  develope  in  solutions 
raised  to  the  boiling-point,  and  placed  in  carefully  cleansed  and 
boiled  vessels,  which  are  subsequently  closed  ;  secondly,  that  if  such 
solutions  in  such  flasks  be  exposed  to  atmospheric  air,  no  bacteria 
ever  develope,  but  yeast-cells,  and  ultimately  blue  mould,  do  develope 
(whence  it  is  inferred  that  the  germs  of  fungi,  but  not  of  bacteria, 
are  carried  in  the  air) ;  thirdly,  that  if  unboiled  water  be  used,  or 
glass  or  other  surface  not  duly  cleansed  be  brought  in  contact  with 
the  above-mentioned  solutions,  bacteria  always  develope  in  great 
quantity  (whence  it  is  inferred  that  water  and  surfaces  which  have 
been  or  are  more  or  less  damp  are  the  means  of  dissemination  of 
bacteria).  It  is  impossible  to  reconcile  these  statements  with  those 
of  Dr.  Bastian,  and  when  two  such  skilful  observers  arrive  at  such 
diametrically  opposite  results,  we,  at  least,  must  be  pardoned  for 
deferring  our  judgment. 

Such,  however,  are  the  facts. 

"  Yarius  Sucronensis  ait ;  OEmilius  Scaurus  negat,  utri  creditis 
quirites?" 

The  arguments  and  conclusions  of  Dr.  Bastian  rest  upon  an 
entirely  distinct  basis  from  his  facts.  He  sums  up,  we  think,  the 
whole  case  in  the  following  words  : 

**  If  fluids  in  vacuo  (in  hermetically  sealed  flasks)  which  were 
clear  at  first,  have  gradually  become  turbid,  and  if  on  microscopical 
examination  this  turbidity  is  found  to  be  almost  wholly  due  to  the 
presence  of  bacteria  or  other  organisms,  then  it  would  be  sheer 
trifling  gravely  to  discuss  whether  the  organisms  were  living  or  dead, 
on  the  strength  of  the  mere  activity  or  languor  of  the  movements 
which  they  maybe  seen  to  display.  Can  dead  organizations  multiply 
in  a  closed  flask  to  such  an  extent  as  to  make  an  originally  clear 
fluid  become  quite  turbid  in  the  course  of  two  or  three  days  ? 

"  In  these  experiments  with  heated  fluids  in  closed  flasks  nothing 
is  easier  than  to  obtain  negative  results.  The  same  kinds  of  infusion 
which,  if  care  has  been  taken  to  obtain  them  strong  eiiQugh,  will  iu 


450  Bibliographical  Record.  [April, 

a  few  days  teem  with  living  organisms,  often  show  no  trace  of 
living  things  after  much  longer  periods  ;  when  the  solutions  are  weak, 
again,  those  cases  where  only  a  few  organisms  exist  in  a  solution 
which  has  been  made  the  subject  of  experimentation,  nothing  is 
easier  than,  by  a  perfunctory  examination  of  the  fluid,  to  fail  finding 
any  of  these  sparsely  distributed  living  organisms.  Experiments, 
the  results  of  which  are  positive,  may,  therefore,  in  the  absence  of 
sufficient  care,  be  cited  as  negative ;  and  experiments  which  would 
otherwise  have  been  crowned  with  unmistakably  positive  results  may 
be  rendered  wholly  barren  by  the  employment  of  infusions  which 
have  been  carelessly  made." 

The  nomenclature  adopted  by  Dr.  Bastian  is  very  peculiar.  The 
hideously  ugly  word  "  archebiosis^'  is  coined  to  express  an  idea, 
which,  when  it  is  examined,  is  closely  allied  to  that  of  heterogenesis. 
Dr.  Bastian  would  probably  not  admit  this  fact. 

The  possible  modes  of  origin  of  bacteria  and  torulse  may  therefore 
be  tabulated  as  follows : 

^  -,    ^r  .       ( a.  Direct. 

Modes  of  origin  of  f  ^'  Homogenesis.    ^^^  j^^.^^^^^ 

bacteria  and  to-  <    2.  Heterogenesis. 
^^^^  L  3.  Archebiosis. 

We  confess  that  we  fail  to  see  the  logical  distinction  between 
these  methods  of  origin.  If  the  presence  of  organic  matter  is  once 
admitted  as  a  factor,  it  matters  very  little  whether  the  organic 
matter  in  its  individualised  state  is  living  or  dead.  Whether  "par- 
ticles of  living  matter^^  or  "  certain  fluids  containing  organic 
matter^^  are  the  ambient  medium  in  which  organized  beings  are 
produced,  is  a  mere  question  of  words  on  which  a  wordy  war  might 
continue  for  years.  The  allegation  by  Dr.  Sanderson  that  in  solu- 
tions which  have  been  raised  to  the  boiling-point,  and  placed  in 
carefully  cleansed  vessels,  bacteria  and  fungi  are  not  developed,  is 
entirely  destructive  of  Dr.  Bastian^s  forty-fourth  experiment.  If 
neither  bacteria  nor  fungi  develope  under  the  conditions  which  Dr. 
Bastian  asserts  to  be  favorable  to  their  birth  and  existence,  the 
whole  controvery  is  reduced  to  a  dispute  between  Drs.  Bastian  and 
Sanderson  on  mere  facts.  Still,  it  must  be  remembered  that  Dr. 
Sanderson^s  conclusions  are  merely  negative.  It  is  in  the  nature  of 
things  that  they  should  so  be,  but  Dr.  Bastian's  conclusions  are 
nevertheless  overturned  unless  some  observer  of  equal  scientific 
weight  with  Dr.  Sanderson  arises,  who,  with  the  same  apparatus  as 
Dr.  Bastian  employed,  will  produce  results  identical  with  those  of 
the  ingenious  University  College  professor.  This  is  really  the  only 
satisfactory  solution  of  the  difficulty,  and  until  it  is  carried  into 
execution  we  hope  that  Dr.  Bastian  will  postpone  the  publication  of 
his  great  work  on  the  physical  doctrine  of  life.  It  is  true  that,  because 
his  testimony  is  at  variance  with  that  of  other  observers,  it  need  not 


1872.]  Nosology  of  Zanzibar,  451 

necessarily  be  wrong.  There  have  been  many  instances,  even  in 
anatomy  and  physiology,  of  the  opinion  of  one  solitary  observer 
being  opposed  to  the  unanimous  voice  of  his  contemporaries,  the 
one  man  having  been  afterwards  triumphantly  proved  to  have  been 
correct.  Yet  it  is  difficult  for  dispassionate  observers  when,  as  in  a 
jury,  investigating  questions  of  absolute  fact,  not  to  lean  towards 
the  feeling  of  the  majority  of  witnesses.  If  the  presence  of 
bacteria  is  merely  due  to  the  existence  of  water  or  damp  substances — 
if  the  water  is  carefully  boiled,  and  other  precautions  familiar  to  the 
readers  of  M.  Pasteur's  work  are  taken — and  if,  when  these  precau- 
tions are  rigorously  and  formally  carried  out,  no  bacteria  whatever 
arise,  the  verdict  of  "not  proven^'  must  be  certainly  returned 
against  Dr.  Bastian's  conclusions. 

Then  follows  the  inquiry,  what  amount  of  antecedent  probability 
exists  in  their  favour  ?  Were  it  not  that  we  are  investigating  a 
strictly  scientific  subject,  on  which  the  mere  facts  have  to  be 
examined  and  taken  at  their  value,  we  would  be  inclined  to  think 
that  the  probabilities  in  favour  of  the  origin  of  living  beings,  as 
Professor  Owen  has  pointed  out,  by  a  sort  of  heterogenesis,  has  much 
to  be  said  in  its  favour.  We  regard  the  alleged  refutation  of  the 
probability  of  heterogenesis,  made  by  Professor  Huxley  at  the  Liver- 
pool meeting,  as  entirely  unsatisfactory,  based,  as  it  was,  upon  not  a 
single  cited  original  experiment. 

The  advocates  of  spontaneous  generation  have  a  right  to  demand 
a  demonstration  of  the  im])ossibility  of  their  statements,  instead  of  a 
mere  allegation  of  their  improbability.  Dr.  Bastian  has  certainly 
carried  out  a  long  series  of  experiments,  and  propounded  certain 
distinct  hypotheses,  and  the  character  both  of  his  experiments  and  of 
his  views  is  such  as  to  call  for  a  serious  re-examination  and  dis- 
cussion. 

Nosology  of  Zanzibar."" — The  recent  work  of  the  distinguished 
African  traveller  Captain  Burton  contains  so  many  important  facts 
which  may  be  of  value  to  the  traveller  on  the  coasts  of  Eastern 
Africa,  that  we  have  no  hesitation  in  calling  our  readers'  attention 
to  the  medical  facts  which  we  find  recorded  therein.  The  climate  of 
Zanzibar,  better  than  that  of  the  hot  damp  eastern  coast,  has  never- 
theless many  unfavorable  points,  which  seem  to  preclude  its  ever 
proving  to  be  a  convenient  station  off  which  Her  Majesty's  ships 
could  long  cruise.  Though  on  the  island  many  of  the  white  resi- 
dents have  escaped  severe  fever,  the  disastrous  fate  of  Captain  Owen's 
surveyors,  the  loss  of  life  on  board  our  cruisers,  and  the  many 
deaths  amongst  the  Mombas  missionaries,  even  though,  finding  the 
seaboard  dangerous,  they  built  houses  on  the  mountain  slopes,  prove 

1  Zanzibar ;  its  City,  Island,  and  Coast.  By  Captain  B.  F.  BuETON.  8vo. 
London.     1872. 


452  Bibliographical  Record.  [April, 

that  malaria  is  as  active  in  Eastern  as  in  Western  Africa.  The  late 
consul  (Hamerton)  once  visited  the  Pangani  river  in  the  month  of 
August ;  of  his  nineteen  men,  three  died,  and  all  but  one  suffered 
extremely.  It  has  been  asserted,  on  good  authority,  that  the  pro- 
phylactic use  of  quinine,  which  was  such  a  success  in  Western 
Africa,  does  not  prove  equally  valuable  on  the  Eastern  coast.  Con- 
trary to  the  rule  of  Madagascar,  the  lowlands  upon  which  the  fresh 
sea-breeze  plays  are  the  only  place  where  the  white  stranger  can  hve 
and  thrive  ;  the  interior,  covered  as  it  is  with  rank  vegetation,  being 
fatal  to  Europeans.  It  is  Captain  Burton's  opinion  that  no  Euro- 
pean, unless  thoroughly  free  from  organic  disease,  should  venture  to 
remain  longer  than  three  or  four  years  at  Zanzibar ;  the  same  has 
been  observed  at  Bagdad  and  in  the  Euphrates  valley  generally. 
The  stranger  is  compelled  to  take  troublesome  precautions.  "  lie 
may  bathe  in  cold  water,  sweet  or  salt,  but  he  must  eschew  the 
refreshment  of  the  morning  walk ;  during  the  rains,  when  noxious 
mists  overhang  the  land,  the  unpleasant  afternoon  is  the  only  safe 
time  for  exercise.'^  Elannel  must,  of  course,  be  worn,  and  extra 
warm  clothing  is  considered  necessary  as  long  as  mugginess  of 
"  msika-weather^'  lasts.  The  half-hour  following  sunset,  when  the 
dews  fall,  is  held  dangerous,  especially  in  hot  weather.  Captain 
Burton,  acting  on  a  practical  experience  of  the  necessities  of  the 
human  frame  in  the  tropics,  probably  contravenes  many  of  the 
canons  of  English  medicine  when  he  says  that  he  should  prescribe 
for  the  stranger — 

"  Contrary  to  the  usual  plan,  an  abnormal  amount  of  stimulants, 
port  and  porter,  not  claret  nor  Rhine  wine.  It  is  evident  that,  where 
appetite  is  wanting,  and  where  nourishing  food  is  not  to  be  obtained, 
the  patient  must  imbibe  as  much  nutriment  as  he  safely  can.  In 
these  lands  a  drunkard  outlives  a  water  drinker,  despite  Theodoret, 
vinum  hibere  non  est  malum  sed  intem/peranter  libere  perniciosum 
estr 

It  is  evident  that  the  gallant  captain  was  not  aware,  when  he  thus 
unconsciously  corroborates  the  late  Dr.  Todd,  of  the  declaration 
against  alcohol  which  so  many  British  medical  men  have  signed. 
The  common  practice  is,  after  fever,  to  use  purgatives  in  large  doses, 
for  which  Captain  Burton  proposes  to  substitute  tonics  and  bitters. 
How  far  the  stomach  of  a  convalescent  fever- stricken  patient  in  the 
tropics  is  able  to  endure  these  *' bitters,"  we  are  doubtful.  Our 
own  experience  has  told  us,  that  the  hideous  "  cocktail  ^'  which  the 
Central  American  imbibes  after  fever  rapidly  induces  concomitant 
dysentery.  Captain  Burton  proceeds  to  say,  "  In  all  debilitating 
countries,  when  the  blood  is  thin,  laxatives  must  be  mild,  otherwise 
they  cause,  instead  of  curing,  fever ;  in  fact,  double  tonics  and  half 
purgatives  should  be  the  rule.'''     Crede  experto. 

The  nosology  of  Zanzibar  is  remarkable  for  the  prevalence  of 


1872.]  Nosology  of  Zanzibar.  453 

urinary  and  genital  diseases.  These  have  been  rouglily  estimated 
to  affect  75  per  cent,  of  the  population.  Sarcocele  and  hydrocele 
attack  all  classes ;  elephantiasis  affects  20  per  cent.  Arabs  and 
Hindoos,  Moslems  and  Africans,  however  dissimilar  their  habits  and 
diet,  all  suffer  alike.  The  malady  has  never  attacked  a  pure  white, 
European  or  American.  It  is  a  strange  coincidence  that  Captain 
Burton,  during  his  vast  experience  in  the  Brazil,  never  saw  a  Euro- 
pean stranger  subject  to  the  leprosy  or  to  the  goitre,  so  prevalent  in 
the  great  provinces  of  Sao  Paulo  and  Minas  Geraes.  The  Banyans 
have  the  idea  that  a  journey  home  to  Bombay  retards  the  progress 
of  the  incipient  disease ;  it  recurs,  however,  on  return  to  Zanzibar. 
No  cure  is  locally  known  for  elephantiasis.  Phagedsenic  sores  are 
most  common  amongst  the  poor  and  the  slaves,  who  live  on  manioc 
fruit  and  salt  shark  often  putrid.  Scabies,  framboesia,  and  psoriasis, 
as  in  Central  America,  commonly  result  from  personal  uncleanliness, 
unwholesome  food,  and  insufficient  shelter  and  clothing. 

Persians  and  Northern  Asiatics  are  more  liable  to  attacks  of  fever 
than  Europeans,  and,  as  in  Egypt,  rude  health  is  rare.  The  mahg- 
nant  typhus  is  rare  at  Zanzibar;  it  raged,  however,  amongst  the 
crew  of  a  Erench  ship,  wrecked  on  the  northern  end  of  the  island, 
where  the  men  were  long  exposed  to  privation  and  fatigue.  Inter- 
mittent ague  fevers  are  as  common  as  a  cold  in  England.  They  are 
mild  and  easily  treated  with  emetics  in  the  preliminary  stages. 
Captain  Burton  advises  evacuants,  cooling  lotions  applied  to  the 
head,  and  sulphate  of  quinine  (4  to  12  grains  every  three  or  four 
hours) .  He  alleges  that  calomel  and  tartar  emetic  must  be  avoided, 
on  account  of  their  depressing  effects.  It  must  not  be  forgotten 
that  there  is  no  ipecacuanha  in  Zanzibar.  Liquor  arsenicalis  and 
the  patent  medicine  Tinctura  Warhurgii  (which  is  said  to  have 
failed  in  yellow  fever)  have  cured  malignant,  inveterate,  and  chronic 
cases.  It  is,  perhaps,  impossible  for  the  tropical  voyager  to  overrate 
the  effect  of  this  excellent  preparation,  which  in  dysentery  has  pro- 
duced the  most  beneficial  results. 

The  Zanzibar  remittent  fever  is  of  much  more  danger  than  the 
intermittent,  and  Captain  Burton  gives  a  minute  description  of  it. 

"  When  an  unfavorable  phase  sets  in,  all  the  evils  are  aggravated. 
Great  anxiety,  restlessness,  and  delirium  wear  out  the  patient ;  the 
mind  wanders,  the  body  loses  all  power,  the  ejecta  become  offensive, 
the  pulse  is  almost  imperceptible,  the  skin  changes  its  dry  heat  for  a 
clammy  cold,  the  respiration  grows  loaded,  the  evacuations  pass 
involuntarily,  and,  after  perhaps  a  short  apparent  improvement,  stupor, 
insensibility,  and  sinking  usher  in  death.  On  the  other  hand,  if  the 
fever  intends  yielding  to  treatment,  it  presents,  after  the  seventh 
day,  marked  signs  of  abatement ;  the  tongue  is  clearer,  pain  leaves 
the  head  and  eyes,  the  face  is  no  longer  flushed,  nausea  ceases  after 
profuse  emises  of  bile,  and  a  faint  appetite  returns." 


454  Bibliographical  Becord.  [April, 

Excessive  action  of  the  liver  is  the  consequent  of  the  mildest 
attacks  of  the  Zanzihar  remittent,  accompanied  by  debility  and  often 
by  boils,  which  follow  each  other  in  rapid  succession. 

Diarrhoea  and  dysentery  are  mostly  sporadic ;  the  former,  however, 
has  at  times  attacked  simultaneously  every  European  on  the  island. 
Dysentery  is  especially  fatal  during  the  damp  and  rainy  weather.  It 
was  often  imprudently  treated  with  mere  astringents,  and  without 
due  regard  to  the  periods  of  remission  and  to  the  exhausted  condi- 
tion which  invariably  accompanies  it.     Captain  Burton  asserts — 

"  As  in  remittents  the  patient  was  weakened  and  his  stomach  was 
deranged  w^ith  'slops,'  when  essence  of  meat  was  required,  the  anti- 
diarrhoea  or  anti-cholera  pill  of  opium,  chalk  and  catechu,  has  been 
fatal  wherever  English  medicine  has  extended.  Witness  the  Crimean 
campaign,  where  the  bolus  killed  many  more  than  did  the  bullet." 

Catarrh  and  bronchitis  are  common  in  Eebruary.  Pneumonia, 
asthma,  and  consumption  are  frequently  amongst  the  higher  classes, 
especially  the  Arab  women,  debilitated  by  over-seclusion.  Hsemor- 
rhoids  are  very  common  both  on  the  island  and  on  the  coast ;  the 
people  suffer  as  much  as  the  Turks  in  Egypt,  without  wearing  the 
enormous  bag  trousers  which  have  been  so  severely  blamed.  The 
smallpox  (a  gift  of  inner  Africa  to  the  world)  is  fatal,  as  at  Goa  or 
Madagascar.  It  disfigures  half  the  population,  and  is  especially 
dangerous  to  full-blooded  Africans.  All  classes  of  the  ignorant 
natives  were  equally  prejudiced  against  vaccination. 

Until  1859  cholera  was  unknown,  even  by  name.  In  1835,  it  is 
true,  there  was  an  epidemic  whose  principal  symptoms  were  giddi- 
ness, vomiting,  and  purging,  the  peculiar  anxious  look,  collapse,  and 
death.  After  1859  cholera  of  the  most  fatal  type  broke  out,  and 
decimated  the  population  of  Zanzibar. 

The  medical  profession  is  not  represented,  and  is  entirely  un- 
known. 

"  Amongst  Arabs,  and  indeed  Moslems  generally,  every  educated 
man  has  a  smattering  of  the  healing  art.  H.  H — ,  the  late  Sayyid, 
was  a  *  hakim '  of  great  celebrity.  A  physician  is  valuable  on  the 
island  ;  throughout  the  African  interior  he  is  valueless  in  a  pecuniary 
sense,  as  every  patient  expects  to  be  kept  and  fed." 

Upon  the  whole,  there  can  be  little  doubt,  from  the  experienced 
and  accurate  account  of  Captain  Burton,  that  Zanzibar  is  one  of  the 
best  places  either  for  the  professional  or  layman  to  "  live  out  of "  in 
the  old  world. 

St.  Andrew's  Graduates'  Transactions.!— The  wide  but  somewhat 
loose  bond  of  graduation  at  the  same  University  (and  this,  too, 
for  the  most  part,  without  residence  there),  and   the   feeling   of 

^  St.  Andrew's  Medical  Graduates'  Association  Transactions,  1869.  Edited 
by  Leonard  W.  Sedgwick,  M.D.    London,  vols,  iii  and  iv.    1870  and  1871. 


1872.]  St.  Andrew's  Graduates'  Transactions.  455 

fellowship  derivable  therefrom,  lias  given  rise  to  the  St.  Andrew's 
Medical  Graduates^  Association.  Moreover,  the  goodly  company  of 
graduates,  not  content  with  the  ordinary  amenities  of  such  associa- 
tions centering  in  meetings  for  mutual  gratulations  and  festive 
doings,  has  sought  to  render  itself  a  scientific  body  for  the  extension 
of  medical  knowledge.  The  present  volumes,  the  third  and  fourth 
published,  exhibit  the  results  of  the  association's  work  in  that  direc- 
tion, besides  presenting  the  reports  of  meetings  of  the  association, 
memoranda  of  the  results  of  deliberations  of  the  members,  and  lists 
of  office-bearers  and  associates.  Of  the  value  of  the  papers  generally 
printed  in  these  volumes  no  doubt  can  be  entertained;  but  the 
question  arises,  is  such  a  special  medium  for  publishing  the  lucu- 
brations of  St.  Andrew's  graduates  needed  ?  We  have  many  '  Hos- 
pital Reports,'  so  called,  published,  filled  with  similar  matter,  and 
there  are  several  societies  which  receive  and  insertj  in]  their 
^  Transactions '  articles  of  the  same  stamp ;  and  there  are  not  a  few 
medical  periodicals  in  currency,  in  one  or  other  of  which  some,  at 
least,  of  these  papers  would  have  found  a  convenient  and  wider 
channel  of  communication.  The  members  of  the  association  expend 
from  above  one  half  to  two  thirds  of  their  income  derived  from  sub- 
scriptions in  producing  their  annual  volume  of  '  Transactions,'  and, 
at  the  close  of  each  of  the  two  years,  ended  with  a  deficit  of  £20  and 
upwards.  Hence,  the  volume  represents  well-nigh  the  guinea  sub- 
scribed by  each  member,  and,  at  the  same  time,  is  an  imperfect 
vehicle  for  communicating  the  scientific  labours  of  its  contributors ; 
for  a  glance  at  its  receipts  from  its  sale  to  non-members  reveals  the 
fact  that  exceedingly  few  copies  find  their  way  to  the  hands  of 
others  outside  the  association. 

Indeed,  it  may  be  inferred,  from  the  republication  of  several  of 
the  essays  found  in  these  present  volumes,  that  their  writers  have 
courted  a  larger  circulation  of  their  views  than  they  could  find  in 
their  pages. 

This  fact  of  the  republication  of  some  of  the  essays  in  a  separate 
form,  and  the  general  inabihty  of  reviewing  together  a  collection  of 
essays  on  divers  topics,  makes  it  incumbent  on  us  to  do  little  more 
than  notify  the  contents  of  these  volumes  to  our  readers. 

The  first  communication  in  vol.  iii  is  the  ^^Anniversary  Address," 
by  the  President,  Dr.  B.  W.  Richardson,  which,  like  other  produc- 
tions from  the  same  indefatigable  worker  and  independent  thinker, 
adds  something  to  our  apprehension  of  the  subject  treated,  which,  in 
in  this  instance,  was  "  The  Science  of  Cure."  This  address  is 
followed  by  a  long  essay,  by  Dr.  C.  Black,  on  the  "  Clinical  Exami- 
nation of  the  Urine  in  relation  to  Disease,"  of  which  we  have  spoken 
elsewhere  when  dealing  with  it  as  a  separate  publication.  Professor 
PoUi  contributes  two  short  papers  of  observations  ^'  On  Haschish ;" 
Dr.  W.  Cholmeley   some  ^^  Notes   on  the  Therapeutic  Yalue  of 


456  BibliograpJdcal  Record.  [April, 

Chloride  of  Ammonia  ;'*  Dr.  W.  Procter,  a  few  ''  Remarks  on  The- 
rapeutics ;"  Dr.  S.  Lawrence  discusses  "  Aphasia  and  its  Seat ;"' 
Dr.  AV.  H.  Day,  the  features,  varieties,  and  treatment  of  "  Gastric 
Neuralgia ;''  and  Dr.  W.  Norris  narrates  some  cases  of  melanosis. 
An  important  paper  entitled  '^A  Study  of  Convulsions'^  follows, 
written  by  Dr.  J.  Hughlings  Jackson,  a  competent  writer  and 
skilled  observer  in  such  matters.  Dr.  D.  Lloyd  Roberts  collects 
and  enforces  the  "  Points  to  be  observed  in  Ovariotomy  /'  Dr. 
Tilbury  Fox  examines  very  carefully  the  doctrines  afloat  respecting 
the  relations  of  pediculi  and  skin  affections,  particularly  porrigo ; 
and  the  President  reappears,  to  close  the  volume,  with  a  learned 
paper  "On  Intermittent  Pulse  and  Palpitation,^'  which  has  since 
been  reprinted  in  a  volume  of  essays  entitled,  ^  Discourses  on  Prac- 
tical Physic.''^ 

After  the  1869  meeting  two  memoranda  were  placed  before  the 
members — one,  relative  to  a  proposed  Royal  Commission  to  inquire 
into  the  state  of  the  law  and  the  legal  dicta  concerning  the  criminal 
responsibility  of  the  insane  ;  the  other,  concerning  the  advantages  of 
the  registration  of  disease,  and  the  instrumentality  required  to  secure 
them.  The  former  memorandum  called  forth,  at  the  meeting  in 
1870,  a  resolution  which  did  nothing  more  than  refer  back  the 
question  to  the  council  of  the  association,  whilst  the  latter  seems 
not  again  to  have  attracted  the  attention  of  the  members. 

The  fourth  volume  equals  the  previous  one  in  its  contents,  for, 
besides  the  President's  address,  with  the  title  ''  Por  the  Future  of 
Physic/'  there  are  eleven  essays  or  communications,  some  of  which 
have  assumed  an  independent  existence  in  the  pamphlet  form.  To 
cite  their  titles,  they  are — "On  the  Eff'ects  of  recent  Sanitary 
Legislation  on  the  Health  of  the  Metropolis,  and  on  our  Present 
Urgent  Sanitary  Needs,"  by  Dr.  J.  Whitmore ;  "  On  the  Diagnosis 
and  Treatment  of  Aortic  Aneurism,"  by  Dr.  George  W.  Balfour; 
"  On  Syphihs,"  by  Dr.  Drysdale ;  "  On  Atmospheric  Dust :  is  its 
total  Interception  absolutely  necessary  for  the  preservation  of 
Health  ?"  by  Dr.  P.  E.  Jencken ;  "  Clinical  Notes,"  by  Dr.  Mackin- 
der ;  "  On  Diphtheria  and  the  Diseases  allied  to  it,  or  which  may 
be  mistaken  for  it,"  by  Dr.  R.  H.  Semple ;  "Therapeutic  Memo- 
randa," by  Dr.  W.  B.  Woodman ;  "  Brain  Exhaustion,"  by  Dr. 
F.  Needham ;  "  On  the  Extrusion  of  the  Morphological  Elements 
of  the  Blood,"  by  Professor  Norris,  M.D. ;  "  On  Apoplexy,  and  the 
Value  of  the  Abstraction  of  Blood,"  by  Dr.  T.  Ballard ;  and, 
lastly,  "  Notes  on  the  late  Prussian  Siege  of  Paris,"  by  Dr.  C.  A. 
Gordon,  C.B. 

Of  these  several  papers  the  most  considerable  as  to  length,  and 
the  one  which  strikes  us  as  the  most  important  in  its  matter,  is  the 
essay  of  Dr.  Balfour,  on  "  Aortic  Aneurism,"  containing,  as  it  does, 
the  collected  histories  of  twenty-nine  cases  of  the  lesion  illustrating 


1872.] 


Action  and  Use  of  Digitalis.  45 1 


the  diagnosis,  course,  and  treatment.  But  although  we  single  out 
this  paper  for  especial  remark,  we  are,  nevertheless,  able  to  report 
that  it  is  in  very  good  company,  and  that  in  both  volumes  now 
before  us  are  to  be  found  contributions  to  the  science  and  practice 
of  medicine  which  must  be  highly  appreciated  by  the  profession  as 
upward  steps  in  the  advancement  of  the  medical  art. 

Digitalis ;  its  Mode  of  Action  and  its  Use.^ — In  this  essay  Dr. 
Eothergill  brings  together  a  great  number  of  facts,  experiments, 
clinical  observations,  and  reasonings  on  the  subject  of  digitaUs  and 
its  action  on  the  heart  and  circulating  system  generally.  He  begins 
by  showing  its  action  on  the  lower  forms  of  organized  beings,  and 
proves  that  it  exercises  a  toxical  influence  even  upon  plants,  some  of 
which  wither  and  die  when  treated  by  an  infusion  of  the  drug. 
The  invertebrated  animals  are  not  much  affected  by  it,  but  its  effect 
on  fishes  and  birds  is  well  marked,  for  it  kills  them,  and  after  death 
the  heart  is  found  to  be  firmly  contracted.  Special  reference  is 
made  to  the  action  of  digitahs  on  frogs,  for  these  animals  have  been 
subjected  to  a  great  variety  of  experiments,  on  account  of  their  great 
susceptibility  to  medicines.  Dr.  Fothergill  has  himself  made  many 
experiments  with  digitalis  on  these  creatures,  and  he  finds,  as  other 
preceding  physiologists  have  done,  that  the  uniform  effect  is  con- 
traction of  the  heart  under  its  use;  and  it  is  shown  that  this  effect 
may  be  produced,  not  only  by  the  administration  of  the  drug  by  the 
ordinary  methods,  but  also  by  its  direct  appHcation  to  the  organs 
of  circulation,  the  heart  being  caused  to  contract  by  having  its  apex 
dipped  in  a  solution  containing  digitalis,  and  even  the  capillaries 
exhibiting  contractile  movements  when  infusion  of  digitalis  is  applied 
to  a  frog's  foot.  This  contractile  influence  of  the  drug  on  the  heart 
and  the  vascular  system, — which  influence  is  inferred,  on  good 
grounds,  to  be  exerted  through  the  medium  of  the  vaso-motor  or 
sympathetic  nerves,  is  the  text  from  which  Dr.  Fothergill  unfolds 
his  views  as  to  the  therapeutical  action  of  digitalis.  The  opinions 
formerly  entertained  as  to  its  sedative  operation  are  shown  to  be 
erroneous,  or,  rather,  the  sedative  effect  is  proved  to  be  primarily 
due  to  a  contractile  action.  Palpitation  of  the  heart  having  been 
formerly  regarded  as  being  an  instance  of  overacting,  the  remedial 
agency  of  digitahs,  was  supposed  to  be  derived  from  sedative  powers ; 
but  palpitation  is  really  an  evidence  of  deficiency  of  the  heart's 
power,  and  digitalis  acts  remedially  because  it  is  a  tonic.  Hyper- 
trophy of  the  heart  is  often  accompanied  by  palpitation,  but  Dr. 
Fothergill  argues  that  in  this  case  the  hypertrophy,  which  is  a  com- 

1  Digitalis;  its  Mode  of  Action  and  its  Use.  An  Inquiry  illustrating  the 
JEffect  of  Remedial  Agents  over  Diseased  Conditions  of  the  Heart.  The  Hastings 
Prize  Essay  of  the  British  Medical  Association  tor  1870.  By  J.Milner  Fothee- 
GiLL,  M.D.    London.     1871. 


4S8  Bibliographical  Record.  [April, 

pensatory  condition  to  counteract  valvular  obstruction  or  insuffici- 
ency, is  inadequate  to  its  object,  and  digitalis  acts  remedially  by 
assisting  it  in  that  object  and  restoring  the  normal  conditions.  The 
limits  of  the  present  notice  will  not  permit  us  to  follow  Dr.  Pother- 
gill  through  his  chain  of  reasoning,  intended  to  show  the  influence, 
remedial,  injurious,  or  doubtful,  of  digitalis  on  the  various  diseased 
conditions  of  the  heart ;  although,  as  we  have  just  indicated,  the 
starting-point  is  to  be  found  in  the  power  of  the  herb  to  induce 
contraction  of  the  muscular  fibres  of  the  heart  and  vascular  system. 
Thus,  in  palpitation  from  weakness,  digitalis  induces  contractions, 
and  thereby  strengthens  and  regulates  the  organ,  in  hypertrophy 
the  drug  aids  the  enlarged  organ  in  doing  its  additional 
work  ;  in  dilatation  it  induces  contraction,  and  thereby  counteracts 
further  dilatation  from  engorgement  of  blood ;  in  valvular  disease 
the  drug  acts  differently  according  to  the  valve  affected,  and  according 
as  the  condition  is  one  of  stenosis  or  of  insufficiency.  Eor  instance, 
in  aortic  obstruction  digitalis  is  serviceable  because  it  assists  in 
increasing  the  driving  action  of  the  heart,  but  in  aortic  regurgita- 
tion its  administration  is  hazardous  from  the  risk  of  its  bringing  the 
ventricle  to  a  state  of  contraction  which  may  never  be  relaxed. 
These  views  are,  of  course,  open  to  controversy,  but,  on  the  whole, 
we  may  state  that  Dr.  Tothergiirs  essay  is  a  valuable  contribution 
to  therapeutical  science,  and  well  deserves  a  thoughtful  perusal,  both 
on  account  of  the  experimental  and  clinical  evidence  which  it  adduces 
and  of  the  valuable  suggestions  which  it  offers  for  the  treatment  of  a 
very  numerous  class  of  diseases. 

State  of  our  Knowledge  respecting  the  Action  of  Mercury  on  the 
Liver.' — Dr.  Eraser,  in  this  useful  little  pamphlet,  gives  a  sketch  of 
the  history  of  mercury  as  a  therapeutical  agent,  from  its  earliest 
introduction  as  a  medicine  down  to  the  present  day,  and  he  examines 
in  consecutive  order  the  difficult  theories  which  have  been  suggested 
as  to  its  mode  of  operation.  He  arranges  the  various  doctrines  which 
have  been  held  as  to  the  action  of  mercury  under  four  heads.  1st. 
That  the  drug  simply  increases  the  flow  of  bile  into  the  intestines ; 
2nd,  that  it  causes  an  increased  formation  of  bile  by  an  indirect 
action  on  the  liver;  3rd,  that  it  causes  an  increhsed  fbi'maUofi  of 
bile  by  a  direct  and  primary  action  on  the  liver;  and  under  a  5th 
head  he  adduces  the  doctrine  held  by  some  modern  physicians,  that 
mercury  has  no  cholagogue  action  whatever.  After  quoting  a  great 
number  of  authorities  in  proof  of  the  physiological  and  therapeutical 
action  of  mercury  upon  the  biliary  secretion,  and  showing  that  under 
its   use   the   amount  of  bile  secreted   is   certainly  increased.  Dr. 

1  Sketch  of  the  Present  State  of  our  Knowledge  respecting  the  Action  of  Mer- 
cury on  the  Liver.  By  Thomas  R.  Feasee,  M.D.,  F.R.S.E.,  F.E.C.P.E»,  Lecturer 
on  Materia  Medica,  Therapeutics,  &c.     Edinburgh,  1871. 


1872.]  Dr.  Atthill  on  Diseases  of  Women.  459 

Eraser  examines  more  particularly  the  fourth  doctrine  laid  down^ 
namely,  that  mercury  acts  directly  and  primarily  on  the  liver,  and 
thus  causes  an  increased  formation  of  bile.  He  thinks  it  quite 
legitimate  to  suppose  that  mercury  increases  the  formation  of  bile  by 
a  direct  and  primary  effect  on  the  liver-cells,  and  that  this  view  may 
be  maintained  as  a  possible  or  probable  explanation  of  several  of  the 
observed  facts,  and  he  entertains  the  opinion  that  mercury  un- 
doubtedly possesses  a  cholagogue  action. 

This  doctrine  is  founded  on  the  facts  that  certain  characters  of 
the  alvine  dejections  imply  an  absence  or  diminution  of  bile ;  that 
in  such  conditions  mercury  will  restore  the  natural  constituents  of 
the  discharges ;  and  that  the  characteristic  appearance  caused  in  the 
alvine  dejections  by  the  use  of  mercury  are  due  to  the  presence  of 
bile-constituents.  Dr.  Eraser  then  sets  forth  the  objections  that 
may  be  raised  to  these  propositions,  but  he  shows  how  they  may  all 
be  answered.  Lastly,  he  considers  the  fifth  doctrine  laid  down, 
namely,  that  mercury  has  no  cholagogue  action  whatever,  a  doctrine, 
as  is  well  known,  which  has  been  founded  chiefly  on  some  experi- 
mental researches  made  by  the  "Edinburgh  Committee  on  the 
Action  of  Mercury  on  the  Liver,"  and  conducted  by  Dr.  Hughes 
Bennett.  To  these  researches,  and  to  the  doctrine  founded  upon 
them,  Dr.  Eraser,  while  giving  the  greatest  credit  to  the  labours  of 
the  investigators,  offers  various  objections,  the  chief  of  which  are 
that  the  division  of  the  bile-duct  (which  was  an  essential  feature  in 
the  Edinburgh  experiments),  and  the  consequent  derangement  of 
the  whole  digestive  process,  introduced  entirely  new  elements  into 
the  inquiry,  and  that  the  inflammation  and  suppuration  caused  by 
the  experiments  themselves,  the  probable  derangement  of  the  nervous 
supply  of  the  digestive  organs,  and  other  disturbing  influences 
militate  against  the  reception  of  the  conclusions  which  the  experi- 
ments are  designed  to  support. 

Dr.  Eraser^s  opinion  is,  that  the  doctrine  advanced  by  the  Edin- 
burgh Committee  is  not  supported  by  sufficient  evidence,  and  this 
opinion  will  probably  be  indorsed  by  the  profession  generally,  the 
more  especially  as  it  is  in  opposition  to  daily  experience  and  a 
multitude  of  recorded  facts,  showing  the  power  of  mercury,  both  in 
health  and  disease  in  the  human  subject,  in  increasing  the  biliary 
secretion. 

Dr.  Atthill  on  Diseases  of  Women.i— Dr.  Atthill  tells  us  in  his 
preface  that  he  publishes  these  lectures  at  the  request  of  some 
members  of  his  class,  and  also  because  the  candidates  for  degrees  at 
the  Queen's  University  and  the  College  of  Physicians  (Ireland)  display 
great  ignorance  of  the  diseases  peculiar  to  women,  ^^  pleading  that 

1  Clinical  Lectures  on  Diseases  peculiar  to  Women.  By  Lombe  Atthill, 
M.D.,  Univ.  Dub.     Pp.  208.     Dublin,  1871. 


460  Bibliographical  Record.  [April, 

they  have  not  leisure  to  read  up  the  subject  in  the  voluminous 
[?  West,  Hewitt]  works  which  exist  on  uterine  disease."  We  trust 
the  teachers  in  the  medical  schools  in  Ireland  will  accept  the 
challenge  thus  given  by  the  examiner  for  the  said  degrees. 

The  present  book  is  addressed  to  the  student,  but  others  may 
here  and  there  glean  a  useful  hint. 

The  first  chapter  is  taken  up  with  a  description  of  the  mode  of 
examining  patients,  supposed  to  be  suffering  from  uterine  disease — 
by  the  touch,  the  speculum,  and  the  sound.  There  is  nothing  in 
the  text  requiring  remark,  but  w^e  may  call  the  attention  of  other 
wTiters,  who  employ  diagrams  and  drawings  to  illustrate  their 
teaching,  to  the  common  error  committed  in  representing  the  bladder 
and  rectum  distended  to  their  utmost  as  the  ordinary  condition  of 
the  parts.  This  error  is  repeated  in  the  present  book,  in  a  vertical 
section  of  the  pelvis  introduced  to  show  how  the  sound  should  be 
passed,  and  besides  this  the  vagina,  instead  of  being  shown  flattened, 
is  also  represented  as  distended  enough  to  take  a  couple  of  fingers 
and  the  sound.  The  first  step  before  making  an  examination  of  the 
uterus  to  see  that  the  bladder  and  rectum  are  empty  is  consequently 
ignored. 

Dr.  Atthill  divides  leucorrhoea  into  vaginal,  cervical,  and  uterine. 
He  finds  tobacco  injections  of  great  service  in  allaying  pruritus 
accompanying  chronic  vaginitis ;  he  makes  the  injection  by  infusing 
two  drachms  of  the  unmanufactured  leaf  in  a  pint  of  boiling 
water,  and  declares  that  "  he  has  never  seen  the  least  unpleasant 
results  follow  its  use,  while  the  relief  it  aff'orded  has  often  been 
marked. ■'^  His  remarks  on  menstruation  and  its  irregularities 
appear  to  us  judicious  and  practical,  but  we  are  much  surprised  to 
read  at  page  38  what  he  has  written  about  a  galvanic  intra-uterine 
stem.  After  detailing  a  case  of  amenorrhcea  in  which  the  catamenia 
reappeared  subsequent  to,  and  apparently  consequent  on,  the  appli- 
cation of  the  poles  of  a  galvanic  battery,  one  to  the  sacrum  and  the 
other  to  the  vulva,  Dr.  Atthill  says,  "  There  is  another  mode  of 
stimulating  the  uterus,  w^iich  I  think  I  prefer  to  electricity  as 
ordinarily  applied — I  allude  to  the  galvanic  stem  pessary.  This  little 
instrument  is  made  of  copper,  the  upper  half  of  the  stem  being 
coated  with  zinc/'  The  stem  is  to  be  worn  for  some  time  with 
occasional  removals.  Dr.  Atthill  plainly  refers  the  stimulation  of 
the  uterus  to  the  galvanic  action  set  up  by  his  compound  metal 
stem  immersed  in  alkaline  mucus,  and  yet  we  think  that,  if  he  were 
to  try  and  measure  the  quantity  and  tension  of  the  electricity  that 
such  a  battery  in  such  a  position  would  yield  to  the  galvanometer, 
he  would  get  but  a  negative  result.  We  are  strongly  reminded  of 
the  galvanic  rings  that  some  years  ago  were  bought  by  credulous  old 
ladies  to  be  worn  against  rheumatic  pains.  The  presence  of  a 
foreign  body  in  the  cervical  canal,  and  especially  in  contact  with  the 


1872.]  Dk.  Atthill  07i  Diseases  of  TVomen,  461 

OS  internum,  which  we  know  to  be  sensitive, — shown  by  the 
sickness  and  other  sensations  caused  on  the  passage  of  a  sound 
through  it,  sufficiently  accounts  for  the  advantages  which  often 
undoubtedly  result  from  this  treatment  without  looking  for  any 
hypothetical  voltaic  action  which  is  simply  non-existent.  The  glass 
stem  with  vulcanite  button  of  Dr.  Meadows  is  cleaner  than  metal. 

Dysmenorrhoea_,  which  Marion  Sims  and  others  refer  to  a  supposed 
mechanical  obstruction,  consisting  in  the  narrowing  of  the  cervical 
canal  by  the  tumefaction  of  its  coat,  Dr.  Atthill  argues  is  not  merely 
mechanical  but  due  to  endometritis,  and  that  it  is  this  diseased 
condition  of  the  mucous  membrane  which  occasions  the  dysmenorrhoea. 
He  concludes  this  to  be  the  case  because  he  found  he  could  repro- 
duce the  pain  felt  at  "the  period"  whenever  he  passed  a  sound  into 
the  cavity  of  the  uterus,  although  it  met  with  no  obstruction  at  the 
OS  internum.  Dr.  AtthilFs  remedy  is  to  dilate  the  cervix  and  mop 
out  the  uterus  with  strong  nitric  acid. 

Division  of  the  cervix  in  the  case  of  "the  pinhole  os^'  he  thinks 
very  feasible  for  dysmenorrhoea,  but  that  "  it  is  not  warranted  as 
a  proposed  cure  of  sterility^  because  the  narrow  os  and  contracted 
cervical  canal  are  not  the  cause  of  the  sterility,  but  merely  an  index 
of  some  congenital  condition  or  defect  in  the  uterus  itself  which 
hinders  conception.'''' 

In  referring  to  the  constitutional  causes  predisposing  to  menor- 
rhagia,  Dr.  Atthill  quotes  the  case  of  a  woman,  for  some  time  under 
his  observation,  who  suffered  from  profuse  and  dangerous  menor- 
rhagia  apparently  dependent  on  mitral  obstruction  in  the  heart. 
The  local  causes  of  the  malady  he  enumerates  are  (1)  subinvolution 
of  the  uterus ;  (2)  granular  ulceration  of  the  os  and  cervix  uteri ; 
(3)  inflammation  and  congestion  of  the  membrane  lining  the  cavity 
of  the  uterus,  and  a  granular  condition  of  that  membrane ;  (4)  reten- 
tion within  the  uterus  of  a  portion  of  placenta  or  of  the  fcetal 
membranes  ;  (5)  polypus  of  the  uterus;  (6)  fibrous  tumours  of  the 
uterus;  (7)  inversion  of  the  uterus;  (8)  ovarian  excitement  or 
congestion  ;  (9)  epithelioma.  In  the  treatment  of  menorrhagia  due 
to  subinvolution.  Dr.  Atthill  finds  "  nothing  so  simple  and  so  safe 
as  the  introduction  of  a  piece  of  solid  nitrate  of  silver,  weighing  ten 
grains,  into  the  cavity  of  the  uterus  and  leaving  it  there.  It  checks 
the  menorrhagia  and  stimulates  the  uterus  to  take  on  the  suspended 
disintegrating  process."  The  secretions  of  the  uterus  probably 
form  inert  albuminates  and  chlorides  of  silver,  and  thus  stay  its 
destructive  powers. 

To  dilate  the  cervix,  Dr.  Atthill  prefers  sea  tangle  tents  to  sponge, 
and  speaks  of  putting  as  many  as  seven  pieces  side  by  side  into  the 
cervix.  His  method  is  to  introduce  first  a  piece  long  enough  to 
pass  the  os  internum,  and  then  pass  by  the  side  of  this  guide  as 
many  short  pieces  as  he  can  introduce.     He  prefers  to  place  the 

98— XLix,  30 


462  Bibliographical  Record.  [Aprils 

patient  in  ''Marion  Sims' ''  position,  and  to  use  a  duckbill  speculum 
and  tenaculum. 

If  on  examination  the  mucous  membrane  of  the  uterus  is  found 
rough,  Dr.  Atthill  a])plies  strong  nitric  acid  freely  by  means  of  a 
strip  of  lint  on  a  holder ;  the  cervix  having  first  been  dilated,  "  at  the 
end  of  five  or  six  weeks  I  introduce  the  speculum,  and  examine  the 
OS.  The  slough  caused  by  the  nitric  acid  has  generally  by  this 
time  separated,  and  you  have  a  healthy  granulating  surface  exposed 
to  view.  I  brush  this  over  with  a  ten-grain  solution  of  nitrate  of 
silver  at  intervals  of  a  day  or  two,  and  in  a  fortnight,  as  a  rule,  it  is 
perfectly  healed.''  It  is  not  clear  whether  Dr.  Atthill  applies  the 
nitrate  of  silver  to  the  mucous  membrane  of  the  uterus  or  only  to 
the  cervix,  for  he  says  "you  have  a  healthy  granulating  surface 
exposed  to  vieWy"  while  the  treatment  is  intended  for  the  uterine 
cavity.  In  retained  placenta  after  abortion,  Dr.  Atthill  gives  ergot 
combined  with  strychnia,  and  recommends  such  a  combination  to  be 
used  in  labour  cases  requiring  ergot.  He  finds  good  results  from 
gallic  acid  in  ten-grain  doses,  but  thinks  acetate  of  lead  very  irritable 
in  metrorrhagia.  When  treating  of  fibrous  polypi.  Dr.  Athill  brings 
under  notice  a  modification  of  the  ecraseur.  As  all  operators  know 
the  difiiculty  in  getting  the  wire  (the  chain  is  now  seldom  used,  as  it 
breaks  more  readily)  round  the  base  of  the  tumour  when  high  up  in 
the  uterus  is  sometimes  very  great.  Dr.  Atthill  has  had  an  ecraseur 
made  with  the  end  so  modified  as  to  allow  of  the  passage  through 
it  of  the  tubes  of  Gooch's  canula.  The  wire  being  adjusted  by 
means  of  these  canula,  they  are  passed  through  the  eyes  of  the 
ecraseur  till  it  reaches  the  base  of  the  tumour,  when  they  are  with- 
drawn and  the  wire  fastened  in  the  ordinary  way.  Weiss  is  the 
maker. 

Gastrotomy  for  the  removal  of  the  sub -peritoneal  fibrous  tumour 
of  the  uterus.  Dr.  Atthill  utterly  repudiates.  He  considers  these 
tumours  "  to  be  entirely  beyond  the  reach  of  treatment,  and  yet  it 
may  reasonably  be  questioned  whether  in  the  case  he  quotes,  as 
illustrative  of  the  disease,  operation  would  not  have  been  justifiable. 
''  The  patient,  set.  35,  had  detected  a  small  tumour  in  the  iliac 
region ;  this  in  two  years'*  time  had  increased  till  she  had  attained 
the  size  of  a  woman  when  near  the  full  term  of  pregnancy.  The 
diagnosis  of  uterine  cystic  disease  was  made,  and  all  idea  of  surgical 
interference  was  given  up.  This  patient  subsequently  died  of  an 
attack  of  acute  peritonitis.  The  post-mortem  disclosed  an  enormous 
tumour  which  consisted  mainly  of  an  immense  cyst ;  it  sprang  from 
the  anterior  and  upper  surface  of  the  uterus,  being  connected  with  it 
by  a  short  thick  pedicle.'' 

Dr.  Atthill  most  judiciously  urges  the  necessity  of  dilating  the 
cervix  previous  to  injecting  either  Tinct.  lodini  or  Tinct.  Terri 
Perchlor.  for  the  purpose  of  restraining  haemorrhage ;  almost  all,  if 


1872.]  Dr.  Atthill  on  Diseases  of  Women,  465 

not  all  the  cases^  in  which  tliis  treatment  has  been  followed  by 
peritonitis  have  been  when  the  dilation  of  the  cervix  has  not  been 
performed ;  for  even  a  few  drops  of  glycerine  have  induced  uterine 
colic.  Abstraction  of  blood  from  the  cervix  is  often  required  when 
there  is  congestion  of  the  part.  Dr.  Atthill  prefers  puncturing  the 
organ  to  leeching  it.  "The  depth  to  which  I  make  the  point  of  the 
knife  penetrate  varies  from  one  eighth  to  a  quarter  of  an  inch  or  even 
more  according  as  the  cervix  be  soft  and  vascular  or  firm  and 
indurated.  I  punctured  it  in  two  or  three  places,,  using  a  ^long 
straight-backed  Prench  bistoury,  which  terminates  in  a  very  sharp 
point."  We  think,  how^ever,  it  is  the  general  experience  that,  if  it 
be  required  to  take  blood  from  a  hard  fibrous  feeling  cervix,  leeches 
are  the  only  effectual  mode.  If  the  os  is  plugged  with  a  piece  of  cotton 
w^ool,  and  four  or  six  leeches  be  passed  down  to  it,  the  speculum 
being  carefully  kept  in  situj  a  better  result  will  be  obtained  than  by 
stabbing  the  gristly  mass. 

Inflammation  of  the  cervix  is  minutely  treated  in  the  eleventh 
lecture.  Dr.  Atthill  divides  the  acute  form  into  two  stages — the 
congestive,  manifested  by  great  vascularity  of  the  mucous  membrane, 
covering  the  vaginal  portion  of  the  organ,  which  becomes  of  a 
bright  pink  colour,  and  by  engorgement  and  tumefaction  of  the 
substance  of  the  cervix,  which,  however,  feels  soft  and  elastic  to  the 
touch.  In  the  second  stage  the  mucous  membrane  is  denuded  and 
its  epithelial  covering  presents  the  appearance  of  an  irregular 
abraded  surface  of  a  deep  red  hue,  which  pours  out  a  profuse 
mucopurulent  discharge,  and  is  studded  with  papillae.  This  latter 
form  Dr.  Atthill  terms  ulceration,  following  Dr.  Bennett^s  definition, 
"  A  solution  of  continuity  from  which  is  secreted  pus  or  a  puri- 
form  sanious  or  other  matter.''^  At  the  same  time  he  believes 
actual  loss  of  substance,  to  which  state  Dr.  Tane  and  others  restrict 
the  word  ulceration,  is  very  rare.  The  treatment  advocated  by 
Dr.  Atthill  is  to  puncture  the  cervix  if  abstraction  of  blood  be 
desirable,  as  is  almost  always  the  case ;  or  if  it  be  desirable  to  stop 
haemorrhage,  he  paints  with  a  saturated  solution  of  the  perchloride 
of  iron  in  glycerine.  When  the  canal  is  involved  he  dilates  it  and 
applies  strong  nitric  acid,  and  subsequently  puts  up  a  plug  of  cotton 
wool  saturated  in  glycerine,  in  which  ten  grains  of  tannic  have 
been  dissolved.  In  place  of  the  nitric  acid  he  has  also  apphed  a 
styptic  colloid  made  by  dissolving  ten  grains  of  benzoic  acid  and 
fifteen  grains  of  tannic  acid  in  four  drachms  of  collodion,  and 
adding  twenty-five  grains  of  carbolic  acid  if  uterine  disease  is 
present.     "  This  application  has  proved  very  successful." 

Endometritis  is  characterised  by  paroxysmal  pain,  dysmenorrhoea, 
and  is  frequently  accompanied  with  pain  of  an  unusually  severe  character 
felt  along  the  edge  of  the  false  ribs ;  the  sound  passed  internally  causes 
.severe  pain  on  touching  the  fundus;    menorrhagia  is  a  frequent 


464  i^ibliofjraphical  Record.  [April, 

sequel  when  the  inflammation  has  become  chronic,  while  the  bladder 
and  rectum  are  often  severely  affected. 

We  have  now  brought  forward  the  principal  points  of  interest, 
and  must  refer  those  who  wish  to  know  Dr.  Atthill's  opinions  on 
ovarian  disease,  displacement  of  the  uterus,  cancer,  and  epithelium 
to  the  book  itself,  which,  with  the  exceptions  we  have  taken  to  it 
above,  will  be  found  to  be  a  very  useful  and  judiciously  written 
work. 

Murray,  cure  of  Aneurism.' — This  brochure  gives  a  full  account 
of  the  well-known  case  in  which  Dr.  Murray,  of  Newcastle,  cured  an 
aneurism  of  the  abdominal  aorta  by  the  '^  rapid  pressure  treatment." 
As  the  patient  was  exhibited  at  the  Eoyal  Medical  and  Chirurgical 
Society  in  1864,  and  as  a  description  of  his  case  appeared  in  the 
'  Transactions^  for  that  year,  our  readers  are  probably  familiar  with 
its  chief  features.  In  the  essay  before  us  the  history  of  the  patient  is 
completed  to  the  time  of  his  death  in  1870.  The  narrative  throws 
a  most  interesting  light  upon  the  treatment  of  aneurism  by  means  of 
rapid  pressure,  as  practised  by  the  author.  All  the  information  that 
can  be  given  with  regard  to  the  experience  of  surgeons  upon  its  use 
is  here  collected,  and  other  cases,  more  or  less  like  his  own,  in  which 
the  treatment  he  recommends  has  been  followed,  and  with  no  small 
success,  are  referred  to  by  Dr.  Murray.  Indeed,  we  are  encouraged 
to  hope  that  the  rapid  pressure  may  enable  us  hereafter  to  deal  suc- 
cessfully with  a  class  of  cases  which  have  hitherto  been  regarded  as 
incurable,  and  to  expedite  the  treatment  of  other  aneurisms  for  which 
long-continued  pressure  has  been  applied.  "Are  we  to  have  cure 
by  the  coagulation  of  blood  in  Jive  Jiours  by  completely  arresting  the 
current  through  the  aneurism,  or  cure  by  lamination  of  fibrine  in 
twenty -five  days  by  frequently  and  imperfectly  arresting  the  circu- 
lations ?^'  This  is  the  question,  as  it  is  very  pointedly  stated  by  Dr. 
Murray ;  and  he  has  no  hesitation  in  replying,  that  the  former  is  the 
most  desirable  course. 

Dr.  Murray's  brilliant  achievement  has  been  fully  appreciated  by 
the  profession ;  but  perhaps  it  has  hardly  been  noticed  how  wide  a 
bearing  it  is  likely  to  liave,  and  how  many  cases  may  be  treated  on 
the  same  principle.  All  surgeons  who  are  called  upon  to  undertake 
the  charge  of  cases  of  aneurism  should  make  themselves  acquainted 
with  this  little  monograph,  for  it  is  scarcely  too  much  to  say  that  the 
treatment  which  it  explains  adds  another  notable  step  to  those  which 
have  already  been  taken  in  the  cure  of  this  serious  affection,  and  that 
it  is  as  great  an  advance  upon  slow  and  gradual  compression  as  the 
latter  was  upon  the  use  of  the  hgature. 

1  The  Rapid  Cure  of  Aneurism  hy  Pressure ;  illustrated  hy  the  Case  of  Mark 
Wilson,  toho  tvas  Cured  of  Aneurism  of  the  Abdominal  Aorta  in  the  year  1864. 
By  William  Mtjeeay,  M.D.,  &c.,  Lecturer  ou  Physiology  in  the  University  of 
Durham,  &c.     London,  1871.     Pp.  43. 


1872.  J  Adams's  Operation  for  Bony  Anchylosis.  465 

Adams's  Operation  for  Bony  Anchylosis.^ — In  this  pamphlet 
Mr.  William  Adams  has  brought  together^  in  a  collected  form,  a 
variety  of  materials  relating  to  his  new  operation  for  the  cure  of  bony 
anchylosis  of  the  hip-joint  with  malposition  of  the  limb.  These 
materials  have  for  the  most  part  already  appeared  elsewhere,  and 
are  now  merely  reprinted ;  consequently,  they  need  not  be  noticed  at 
any  length.  ]3ut  the  subject  is  one  of  so  much  interest  to  the  pro- 
fession, that  we  should  be  sorry  to  pass  it  over  in  silence. 

The  operation  of  subcutaneous  division  of  the  neck  of  the  thigh- 
bone has  attracted  so  much  attention,  and  has  been  so  generally 
recognised  as  one  of  the  most  remarkable  advances  that  operative 
surgery  has  recently  made,  that  Mr.  W.  Adams  has  acted  wisely  in 
putting  all  the  information  that  he  is  able  to  give  respecting  it  in  a 
concise  shape.  Many  surgeons,  who  may  have  under  their  care  cases 
of  anchylosed  and  distorted  hip-joints,  will  be  glad  to  learn  from  this 
pamphlet  to  what  classes  of  cases  the  operation  is  suitable,  and  what 
are  the  steps  in  its  performance. 

Mr.  W.  Adams  gives  first  a  shght  sketch  of  osteotomy  so  far  as 
it  has  been  practised  for  the  relief  of  anchylosis  of  the  hip-joint,  and 
he  takes  the  opportunity  of  pointing  out  wherein  his  own  operation 
differs  from  every  other  previously  adopted.  He  next  goes  on  to 
explain  fully  the  operation  which  he  performed  in  the  end  of  1869, 
and  w^iich  was  the  first  of  the  kind  in  the  annals  of  surgery.  It  was 
speedily  accepted  and  practised  by  other  surgeons,  and  the  author  is 
now  able  to  give  us  brief  notes  of  six  other  cases  in  which  his 
operation  has  been  carried  out.  Only  one  of  these  cases  terminated 
unfavorably ;  and  the  nature  of  this  fatal  one  was  such  as  to  throw 
much  light  on  the  subject,  and  to  indicate  clearly  the  class  of  cases  to 
which  the  operation  is  most  applicable. 

The  pamphlet  concludes  with  a  reprint  of  the  public  correspond- 
ence which  passed  between  Mr.  Adams  and  Mr.  Brodhurst  with 
respect  to  priority  in  adopting  this  operation.  There  can  be  no 
doubt,  we  think,  that  the  former  has  thoroughly  established  his 
position,  and  we  can  only  regret  that  there  should  have  been  grounds 
for  such  a  correspondence  in  the  first  instance,  and  that  it  should  now 
be  thought  necessary  to  reprint  it. 

Dr.  PuUar's  translation  of  Neumann's  Skin-Diseases.^ — Having 

reviewed  the  first  German  edition  of  this  work  at  some  length,  we 
need  not  repeat  the  high  estimate  there  given  of  Dr.  Neumann's  per- 

1  A  New  Operation  for  £ont/ Anchylosis  of  the  Hip -Joint ;  with  Malposition 
of  the  Limb  hy  Subcutaneous  Division  of  the  NecJc  of  the  Thigh-bone.  By 
William  Adams,  F.R.C.S.,  Surgeon  to  the  Royal  Orthopaedic  and  Great  Northern 
Hospitals,  &e.     London,  1871.     Pp.  68. 

'^  Text-hook  of  Skin  Diseases.  By  Dr.  IsiDOE  Neumann.  (Translated  from  the 
second  German  edition  by  special  permission  of  the  author  by  Alfred  Bullae^ 
M.D.     1871.     Pp.  327. 


466  Bibliographical  Record.  [Aprils 

formance.  The  second  edition,  published  in  July,  1870,  which 
forms  the  text  of  the  translation  before  us,  corrects  some  of  the 
numerous  misprints  of  the  former  one,  and  adds  fresh  information  on 
a  few  points.  The  number  of  engravings  of  microscopic  appearances 
is  also  increased,  and  some  of  the  earHer  ones  are  corrected,  e.g.j 
that  of  the  hair-bulb  and  sheath  (fig.  8) .  But  the  most  important 
additions  are  those  in  the  section  on  senile  changes  of  the  skin  and 
in  that  on  parasitic  diseases.  The  effects  of  age  upon  the  skin  are — 
atrophy  of  the  papilla,  especially  marked  on  the  face,  so  as  to  render 
the  surface  of  the  cutis  perfectly  level  in  advanced  cases,  atrophy  of  the 
hair-follicles  and  the  muscular  fibres  connected  with  them,  with  their 
loss  of  elasticity  as  well  as  of  contractiUty,  dilatation  of  the  sebaceous 
glands,  pigmentary  degeneration  and  thinning  of  the  rete  mucosum, 
and  accumulation  of  masses  of  horny  cuticle.  The  atrophy  of  the 
subcutaneous  fatty  tissue  and  the  loss  of  elasticity  in  the  cutis  pro- 
duce the  lines  and  furrows  characteristic  of  the  aged  skin,  and  addi- 
tional depressions  are  formed  by  open  orifices  of  the  shrivelled  hair 
follicles,  into  which  the  dilated  sebaceous  glands  open. 

The  chapter  on  parasitic  fungi  is  well  illustrated.  Dr.  Neumann 
does  not  undertake  to  decide  the  botanical  relations  of  the  plants 
which  produce  the  various  diseases.  It  excludes  from  this  group  the 
so-called  Tinea  decalvans,  which  appears  in  the  chapter  on  atrophy  of 
the  hair,  under  the  title  Alopecia  areata.  Whatever  may  be  the 
result  of  the  long-continued  controversy  as  to  the  parasitic  origin  of 
this  disease,  the  woodcuts  and  further  details  given  in  this  edition 
can  leave  no  doubt  that  the  affection  described  by  Hebra  as  eczema 
marginatum  owes  its  pecuhar  features  to  the  presence  of  a  fungus. 
Dr.  Neumann  finds  that  by  cultivating  the  mycelium  for  a  week  or 
more  penicillium  is  produced. 

As  the  most  compact  and  accurate  handbook  of  the  first  school  of 
cutaneous  medicine  now  existing,  and  as  the  only  complete  account 
yet  published  of  the  great  advances  recently  made  in  the  morbid 
anatomy  of  the  skin,  this  work  well  deserved  translation,  and  Dr. 
Pullar  has  on  the  whole  performed  his  task  with  care.  There  are, 
however,  numerous  misprints,  especially  of  names,  e,  g.,  Caillants  for 
Caillault,  Grubi,  and  some  of  the  prescriptions  are  a  curious  jumble 
of  Latin,  German,  and  English.  Blunders  such  as  17X17  for  x^?^*? 
have  survived  both  German  editions,  and  now  reappear  in  the 
translation. 

The  first  volume  of  Hebra^s  great  work  is  referred  to  (p.  7) 
without  any  hint  that  the  second  has  now  appeared  for  several  years, 
and  has  been  translated  and  published  by  the  Sydenham  Society. 
The  admirable  microscopic  drawings  which  form  perhaps  the  most 
valuable  part  of  the  German  work  are  reproduced  in  the  translation, 
and  lose  very  little  of  their  sharpness  of  outline  and  clearness  of 
detail.    The  printing  of  the  letter-press  is,  however,  inferior,  and  the 


1872.]  Gant's  Science  and  Practice  of  Surgery.  467 

book  has  a  curious  resemblance  to  the  excellent  translations  published 
in  America.  On  the  whole  we  can  conscientiously  recommend  Dr. 
Pullar's  translation  to  every  medical  man  who  cannot  read  German. 
It  is  the  most  complete  and  accurate  book  on  cutaneous  diseases 
published. 

Gant's  Science  and  Practice  of  Surgery.^— In  the  opening  para- 
graph of  his  Preface^  Mr.  Gant  writes : — ''  It  is  now  many  years 
since  a  new  systematic  work,  representing  the  science  and  practice  of 
surgery,  has  appeared  in  this  country."  On  reading  this  statement 
we  rubbed  our  eyes  to  be  assured  it  was  no  delusion  we  were  under, 
for,  without  straining  the  memory,  some  not  inconsiderable  works 
on  surgery  offered  themselves  to  our  recollection,  and  we  should  have 
ventured  the  opinion  that  Mr.  Gant  must  have  heard  of  them,  did 
not  his  remarks  intimate  the  contrary.  Por  example,  we  may  allude 
to  the  treatises  bearing  the  names  of  Pergusson,  Erichsen,  Holmes^ 
and  Spcnce.  But,  letting  this  marvellous  assertion  pass,  we  hope 
it  may  be  many  more  years  before  another  volume  like  the  one  under 
notice  makes^  its  appearance,  so  little  credit  does  it  to  the  writer  as 
a  contributor  to  surgical  science  and  practice. 

So  far  as  it  represents  modern  practice,  it  does  so  by  giving  a 
rechauffe  of  other  men's  opinions.  The  very  name  and  external 
appearance  of  the  book  at  once  suggest  one  of  our  best-known  and 
most  valuable  works  on  surgery,  and  a  careful  comparison  serves  to 
show  how  closely  Mr.  Gant  has  fashioned  his  treatise  on  the  model 
of  Mr.  Erichsen's  '  Science  and  Art  of  Surgery.'  But  it  is  not 
only  the  distinguished  surgeon  of  University  College  who  has  reason 
to  complain  of  our  author's  plagiarism.  He  has  made  an  equally 
free  use  of  Mr.  Holmes's  ^  System  of  Surgery ;'  and,  indeed,  there 
is  scarcely  a  writer  of  any  reputation  who  has  not  been  laid  under 
heavy  contribution  by  Mr.  Gant,  It  is  not  only  that  their  opinions 
are  alluded  to,  and  quoted  for  the  purpose  of  discussing  them — a 
proceeding  that  could,  indeed,  not  be  avoided  in  any  treatise  on  the 
same  subject,  but  whole  passages  have  been  transcribed.  In  fact,  a 
great  part  of  the  book  is  composed  of  extracts  from  the  writings  of 
living  authors.  It  is  not  difficult  to  supply  examples  of  this  method 
of  book-making.  Almost  any  chapter,  if  closely  examined,  may  be 
traced  to  some  well-known  book  or  essay,  and  paragraphs  have  been 
transferred  to  Mr.  Gant's  pages,  verhatim  et  literatim,  but  with  very 
scanty  acknowledgment.  Thus,  the  chapters  upon  Cleft  palate  and 
Lithotomy  are  taken  from  Sir  W.  Pergusson's  '  System  of  Practical 
Surgery.'  In  a  similar  way  the  chapters  upon  Hernia  and  Aneurism 
are  derived  from  Mr.  Erichsen  ;  while  Mr.  P.  Hewitt's  article  upon 

"•  The  Science  and  Practice  of  Surgery.  Illustrated  by  470  wood  engravings. 
By  Frederick  James  Gant,  F.R.C.S,,  Surgeon  to  the  Royal  Free  Hospital; 
formerly  Surgeon  to  Her  Majesty's  Military  Hospitals,  Crimea  and  Scutari. 
London,  1871.     Pp.  1265. 


468  Bibliographical  Record.  [April, 

"  Injuries  of  the  Head/^  in  '  Holmes's  System/  appears  to  have 
supplied  the  material  for  Mr.  Gaut's  remarks  on  the  same  subject. 
Examples  of  this  kind  might  be  multiplied  to  almost  any  number  ; 
indeed,  the  frankness  with  which  our  author  points  out  the  sources 
whence  he  has  drawn  his  information  would  be  almost  amusing  if  he 
were  not  guilty  of  a  very  serious  literary  fault. 

There  are,  however,  some  subjects  upon  which  Mr.  Gant  flatters 
himself  that  he  has  some  original  material  to  lay  before  us.  One  of 
these  is  the  arrest  of  hsemorrhage.  But  here  his  observations  are 
by  no  means  on  a  level  with  the  knowledge  of  the  day.  He  seems 
to  be  ignorant  of  the  minute  changes  which  take  place  when  a  vessel 
is  ligatured,  and  of  the  researches  upon  this  point  both  by  English 
and  Continental  writers.  Indeed,  though  our  author  speaks  much 
of  "  Pathological  Surgery,"  and  of  what  he  has  done  to  enforce  it, 
his  own  acquaintance  with  pathology  appears  very  limited.  Eor 
instance,  at  p.  259,  speaking  of  the  ligature  and  its  effect  in  normal 
cases,  we  are  told — "  The  included  portion  of  external  cellular  coat 
and  sheath,  having  undergone  continued  compression,  sloughs,  and 
is  detached  with  the  thread,  in  a  period  varying  from  twenty-four 
hours  or  so  to  about  three  or  four  weeks,  chiefly  according  to  the 
size  of  the  artery.''^  Now,  as  a  matter  of  fact,  no  sloughing  occurs. 
The  compressed  portion  is  absorbed  by  the  action  of  the  lymphatics 
and  veins.  When,  unhappily,  sloughing,  or  even  ulceration,  does 
take  place,  it  involves  the  patient  in  all  the  risks  of  secondary 
hsemorrhage. 

There  is  another  subject  upon  which  Mr.  Gant  has  given  his  own 
experience,  and  here  with  better  effect.  The  chapers  upon  "  Exci- 
sional  Surgery'^  are  the  best  in  the  book.  They  are  the  expansion 
of  the  author's  Lettsomian  Lectures,  which  were  favorably  received 
at  the  time  of  their  delivery ;  and  Mr.  Gant  would  have  consulted 
his  own  dignity  and  reputation  if  he  had  been  contented  with  writing  a 
monograph  upon  a  subject  of  which  he  is  confessedly  master,  instead 
of  publishing  a  patchwork  treatise  upon  general  surgery. 

But  it  is  not  merely  opinions  that  he  has  derived  from  others,  but 
also  illustrations.  Everywhere  throughout  his  pages  we  are  met 
by  old  familiar  woodcuts,  some  of  which  are  quite  obsolete,  and  repre- 
sent methods  of  treatment  which  have  now  passed  out  of  use. 

It  will  be  seen,  therefore,  that  there  is  but  a  very  small  portion  of 
this  ponderous  volume  which  we  can  recommend  to  our  readers. 
Eor  the  rest,  they  will  do  better  to  consult  the  original  treatises  from 
which  our  author  has  borrowed  his  materials  so  extensively. 

Gulia  on  Diptheria.^ — We  have  on  our  table  a  volume  written  in 
choice  Italian  by  Dr.  Gavino  Gulia  on  the  subject  of  diphtheria,  under 
the  title  of  '  Clinical  Notes  on  Diphtheria.'     The  writer  hails  from 

^  Xfofixie  Cl'miche  szdla  Difteria,     Per  Gayino  Gulia. 


1872.]  Camp  Life  as  Seen  by  a  Civilian.  469 

Malta,  one  of  our  most  cherished  possessions,  and  might  almost  call 
himself  a  fellow  countryman.  As  in  his  Preface  he  appeals  "  to 
the  kind  reader/'  and  states  that  his  work  is  a  "  raccolta"  (collec- 
tion) of  various  writings  on  diphtheria  printed  from  time  to  time  in 
the  '  Corriere  Mercantile/  which  is  not  a  medical  paper ;  and  as  he 
adds,  that,  without  "presumptuous  vanity/'  he  has  published  it 
for  the  benefit  of  young  medical  men,  old  practitioners  may  be 
excused  for  noting  that  it  is  simply  a  compilation.  In  short,  it  is  a 
made-up  book  with  pages  of  quotations  from  well-known  writers  on 
the  subject,  and  includes  a  chapter  which  drags  its  length  along 
from  page  186  to  page  206,  in  which  almost  the  only  allusion  to  the 
disease  the  author  is  supposed  to  be  writing  about  is  in  page  204, 
where  an  extract  is  copied  from  Bricheteau. 

Dr.  Gulia's  industry  and  perseverance  as  a  practitioner  are  well 
known  in  the  "  Fior  del  mondo," — the  name  which  his  fellow-citizens 
delight  to  give  to  their  beloved  island;  but  we  fail  to  find  in  the 
treatise  he  has  now  published  any  original  observation,  or,  indeed, 
any  marks  of  its  professed  character  as  a  result  of  clinical  observa- 
tion. Indeed,  the  latter  defect  is  not  much  to  be  wondered  at,  since 
his  opportunities  for  careful  clinical  inquiries,  properly  so  called,  are, 
as  we  can  speak  from  personal  knowledge  of  the  island,  necessarily 
limited  by  the  comparatively  small  population  coming  under  his 
professional  supervision  in  the  absence  of  a  hospital  appointment 
to  furnish  him  with  cases. 

It  is,  however,  but  fair  to  remember  that  a  rechaiiffe  of  this  sort, 
though  of  little  value  to  practitioners  in  Great  Britain,  may  prove 
instructive  and  useful  to  those  in  Malta,  and  be  well  appreciated  by 
them. 

Camp  Life  as  seen  by  a  Civilian.^— This  book  is  sadly  out  of 
time.  The  camp  life  it  has  to  tell  of  is  that  of  the  British  army  in 
the  Crimea,  and  considering  the  many  volumes  of  descriptions  con- 
tained in  books  and  papers  of  all  matters,  great  and  small,  con- 
nected with  the  belhgerents,  with  the  seat  of  operations ;  giving  a 
"true,  full,  and  particular"  account  of  what  was  said  and  done,  or 
intended  to  be  done,  by  all  classes  in  the  ranks  of  the  British  forces, 
and  bristhng  with  impressions  of  every  hue  of  peoples  and  places 
having  the  charm  of  novelty;  considering  (we  repeat)  a  veritable 
plethora  of  descriptions,  of  which  a  large  proportion  have  in  the 
course  of  seventeen  years  lapsed  into  oblivion,  it  required  much 
hardihood  to  challenge  the  attention  of  the  public  to  yet  another 
personal  narrative  of  bygone  events.  In  short,  we  hold  Dr. 
Buchanan  to  be  a  very  bold  man,  and  one  who,  though  not  a 
soldier,  would  Uke  to  fight  his  battles  over  again.     We  fear,  how. 

'  Cam'p  Life  as  seen  by  a  Civilian;  a  Personal  Narrative.  By  Geoege 
Buchanan,  A.M.,  M.D.     Glasgow,  1871.     Pp.  298, 


470  Bibliographical  Record.  [April, 

ever,  he  will  lack  the  encouragement  of  a  large  and  attentive 
audience,  the  part  of  the  narrator  of  personal  experience  in  the 
Crimean  campaign  having  been  played  out. 

We  should  have  attributed  the  appearance  of  the  book  wholly  to 
those  fosterers  of  unnecessary  literature,  the  kind  and  appreciative 
friends  whose  mission  is  to  make  work  for  printers  and  publishers 
at  the  cost  of  the  aspiring  litterateur ;  but  the  author  tells  us  that 
another  incentive  to  his  putting  his  memoranda  into  ])rint  was,  that 
his  friends  had,  by  their  eager  perusal,  nearly  thumbed  his  MS.  into 
shreds,  and  so  jeopardised  its  longer  existence. 

The  result  in  the  matter  of  typography  is  everything  that  could 
be  desired;  and  although  our  wonderment  at  the  appearance  in 
1S71  of  a  narrative  of  ofttold  events  that  happened  seventeen 
years  ago  remains,  we  are  bound  to  say  that  Dr.  Buchanan's 
jottings  of  his  observations,  sayings,  and  doings,  have  much  vivacity, 
and  bear  the  marks  of  truthfulness  and  of  an  observant  mind. 

They  are  by  no  means  of  a  medical  character,  although  he  served 
for  a  short  time  as  a  civil  surgeon  in  the  army,  was  attached  to  an 
hospital,  and  had  medical  charge  of  troops. 

The  contents  are  in  the  form  of  a  diary,  written  whilst  the  events 
described  transpired,  and  now  printed  almost  verbatim  from  the 
original  memoranda.  Notes  of  his  own  doings,  of  his  illness  in 
Turkey,  of  his  impressions  of  towns,  scenery,  and  people,  and  of 
camp  gossip,  constitute  the  substance  matter  of  the  book.  The 
production  of  the  volume  will  at  least  give  its  author  that  degree  of 
satisfaction  which  every  ordinary  mortal  experiences  on  finding 
himself  in  print,  and  we  hope  his  partial  friends  will  now  demonstrate 
their  appreciation  of  his  narrative  by  largely  possessing  themselves  of 
copies  of  it  in  its  present  very  eligible  form. 


1872.]  471 


©riffmal  Communuations?^ 


I. — Observations  on  the  Use  of  Mercury  in  general,  and  in  certain 
diseases  of  the  Brain  in  particular.  By  E.  Copeman,  M.D., 
F.RC.P. 

It  must  not  be  expected  that  in  the  (3ompass  of  a  paper  of  this 
description,  I  shall  be  able  to  enter  fully  into  a  subject  of  so  much 
importance  as  the  one  I  have  chosen ;  but  as  the  minds  of  medical 
men  are  by  no  means  settled  with  regard  to  the  employment  of 
mercury  in  disease,  or  its  influence  upon  the  system,  it  may  be  well 
to  say  a  few  words  in  explanation  of  one's  own  experience  of  nearly 
forty  years  as  to  the  benefits  to  be  derived  from  mercurial  treatment. 
At  the  outset  of  my  professional  career  mercury  was  used  to  a  very 
considerable  extent  and  in  almost  every  form  of  disease,  and  I  have 
lived  long  enough  to  find  it  almost  discarded  from  the  prescriptions 
of  the  medical  practitioner.  Now  my  firm  belief  is,  that  both  these 
extremes  are  wrong,  and  that  mercury  is  a  very  powerful  agent  in 
our  hands  either  for  good  or  harm,  according  as  it  is  used  with  judg- 
ment and  ability,  or  recklessly  and  without  discrimination. 

I  believe  it  is  pretty  well  determined  that  mercury  is  not  suitable 
for  the  treatment  of  acute  serous  inflammations  in  their  early  stage. 
Inflammation  has  now,  as  in  Hunter's  day,  natural  terminations , 
viz.  effusion,  adhesion,  suppuration  and  mortification,  the  latter  in 
more  senses  than  one.  Now  I  do  not  think  that  mercury  is  adapted 
to  the  prevention  of  any  of  them ;  but  that  it  may  prove  a  hin- 
drance to  some  of  the  natural  processes,  especially  that  of  adhesion, 
which  nature  sets  up  for  the  cure  of  inflammation ;  and  when  the 
terminations  by  effusion  and  adhesion  have  taken  place  in  organs 
not  endangered  thereby,  it  will  be  best  to  leave  the  further  restoration 
of  the  affected  parts  to  the  efforts  of  nature,  in  healthy  consti- 
tutions. But  when  the  attack  of  inflammation  results  in  the  effusion 
of  fluid  (serum)  or  lymph  in  organs  of  vital  importance  which  cannot 
be  damaged  even  for  a  time  without  a  certain  amount  of  danger  to 
life,  then  I  believe  mercury  to  be  a  very  powerful  agent  in  eftecting 
the  speedy  removal  of  such  depositions,  and  assisting  nature  in 
restoring  the  healthy  action  of  the  part  affected.  Mercury  will  not 
prevent  the  deposition  of  lymph  in  an  inflamed  lung,  but  it  will 
greatly  aid  in  the  removal  of  it  during  convalescence  from  the  acute 


472  Original  Communications.  [April, 

attack.  It  may  not  prevent  the  formation  of  false  membrane  in 
croup,  but  it  will  assist  materially  in  removing  it  when  formed.  It 
will  not  cure  the  acute  stage  of  phrenitis^  but  it  will  tend  greatly  to 
assist  nature  in  the  removal  of  inflammatory  products.  It  will  not 
prevent  iritis,  but  it  will  clear  away  the  lymph  deposited  by  the  in- 
flammation, and  restore  the  organ  to  a  healthy  condition.  I  do  not 
advocate  the  use  of  mercury  to  any  extent  in  acute  inflammations, 
but  I  have  firm  faith  in  its  power  to  remove  the  lymph  and  cause  the 
absorption  of  the  fluid  consequent  upon  either  acute  or  chronic 
inflammations  in  previously  healthy  organs.  Take  for  example  a 
case  of  pneumonia  in  a  healthy  constitution,  in  which  we  find  there 
is  always  a  tendency  to  the  speedy  termination  of  the  inflammation 
in  the  deposit  of  lymph,  which  soon  consolidates  the  portion  of  the 
lung  affected.  Now  the  effect  of  giving  mercury  freely  in  the  acute 
stage  of  this  disease  would  probably  be  to  interfere  with  its  natural 
termination  by  rendering  the  eff'asion  less  plastic,  more  like  that 
deposited  in  strumous  inflammation ;  and  the  stage  of  consolidation 
would  be  prolonged  and  imperfectly  terminated ;  but  when  this  stage 
has  been  accomplished,  the  addition  of  mercury  to  whatever  other 
treatment  may  be  adopted  will,  I  am  quite  sure,  tend  very  much  more 
to  the  speedy  aad  entire  removal  of  the  deposited  lymph  than  if,  as  a 
medicine,  it  be  thrown  aside  or  rejected.  The  great  value  which 
mercury  possesses  in  the  treatment  of  inflammations  appears  to  be 
its  power  of  aiding  the  absorption  of  inflammatory  products,  so  as 
to  restore  the  diseased  organ  to  a  healthy  condition.  I  now  propose 
to  offer  a  few  cases  illustrative  of  cerebral  disease,  in  w^hich  mercury 
has  also  appeared  to  have  been  of  material  service  in  clearing  up  the 
functions  of  an  affected  brain. 

Case  1. — A  retired  tradesman,  of  full  habit  and  previously  in 
good  health,  about  sixty  years  of  age,  was  attacked  suddenly  in  1859 
with  apoplexy,  having  stertorous  breathing  and  general  insensibility. 
He  could  not  be  roused,  and  could  neither  speak  nor  swallow.  But 
in  a  few  days,  without  any  other  treatment  than  counter-irritation  and 
purgative  injections,  he  partially  recovered  his  senses,  and  was  found 
to  be  paralysed  on  the  right  side.  His  tongue,  which  he  was  now 
just  able  to  protrude,  was  thickly  coated  with  yellowish  white  fur  ; 
his  vision  was  indistinct,  and  although  he  appeared  to  understand  to 
a  certain  extent,  he  could  not  answer  questions  in  an  inteUigible 
manner,  neither  could  he  swallow  without  difliculty.  Ten  grains  of 
calomel  were  put  upon  his  tongue,  and  some  of  it  was  washed  down 
with  a  little  water;  a  blister  was  applied  to  the  nape  of  the  neck, 
and  purgative  injections  continued.  His  bowels  were  several  times 
well  relieved  and  the  stertor  abated,  but  for  several  days  he  lay  in  a 
semi-conscious  state,  and  made  but  little  progress  towards  recovery. 
It  was  now  determined  in  consultation  to  try  the  full  effect  of  mer- 


1872.]  Dr.  Copeman  on  the  Use  of  Mercury.  473 

curial  action,  and  2-grain  doses  of  calomel  were  given  at  repeated 
intervals.  It  was  not,  however,  pushed  to  full  salivation ;  but  during 
its  exhibition  he  gradually  became  more  sensible,  could  swallow 
better,  and  seemed  to  be  slowly  regaining  the  power  of  moving  the 
paralysed  limbs.  He  was  supported  by  beef  tea,  milk,  and  wine 
and  water.  His  pulse  had  never  varied  much  from  the  natural 
standard,  his  bowels  were  every  now  and  then  largely  relieved 
though  not  purged;  his  tongue  cleaned,  his  speech  gradually 
improved,  and  there  seemed  a  good  prospect  of  recovery. 

The  mercurial  treatment  was  continued  in  a  modified  form  (Bi- 
chloride) for  several  weeks,  whilst  his  strength  was  supported  with 
improved  diet ;  and  in  four  months  after  his  attack  his  health  was  so 
much  restored  that  he  was  able  to  walk  about  a  little,  and  com- 
plained only  of  a  shght  degree  of  weakness  in  the  right  limbs.  He 
continued  to  improve,  could  soon  walk  without  help,  and  I  fre- 
quently meet  him  in  the  street,  looking  perfectly  well,  and  showing 
no  sign  of  his  former  illness  (which  has  never  been  succeeded  by  a 
second  attack)  except  slight  hesitation  in  his  speech.  He  has 
remained  well  up  to  this  present  month  of  September,  1865,  rather 
more  than  six  years  from  the  attack. 

(Since  this  report  I  have  heard  of  his  death  rather  suddenly  by  an 
attack,  I  believe,  of  diarrhoea.) 

Case  2. — J.  C — ,  a  cabinet  maker,  of  sallow  appearance  and  weak 
health,  about  forty-five  years  of  age,  had  been  subject  to  headaches 
and  sharp  diarrhoea  every  now  and  then  for  two  or  three  years,  and 
for  the  last  few  weeks  his  bowels  have  been  so  disordered  as  to  mate- 
rially reduce  his  strength.  His  pain  in  the  head  was  more  frequent, 
alternating  with  the  diarrhoea,  and  there  was  a  suspicion  that  slowly 
progressive  cerebral  disease  might  be  the  '^fons  et  origo  mali.'' 
On  the  13th  of  March,  1856,  I  was  called  in  consultation  in  conse- 
quence of  increased  cerebral  disturbance,  and  found  him  confused  in 
intellect  and  partially  paralysed  on  the  left  side,  pulse  feeble,  tongue 
red  and  dry,  and  bowels  not  now  acting.  He  could  be  roused,  but 
answered  questions  imperfectly,  and  his  countenance  was  expressive 
of  pain.  We  ordered  him  an  aperient  and  nourishing  diet,  but  my 
colleague  was  afraid  of  acting  much  on  the  bowels,  as  he  had  several 
times  experienced  great  difficulty  in  controlling  the  diarrhoea.  He 
did  not  improve,  but  daily  became  more  obtuse,  and,  after  a  short 
time,  completely  comatose,  with  stertor  and  entire  loss  of  conscious- 
ness, indeed  quite  apoplectic,  and  we  thought  it  was  almost  the 
closing  scene  of  long  standing  cerebral  disease.  In  this  dilemma  we 
agreed,  as  a  dernier  ressort,  to  have  recourse  to  mercury ;  and  although 
we  could  scarcely  make  him  swallow,  we  did  manage  to  get  some 
Hyd.  c.  cret.  down,  thinking  this  the  best  form  to  give  it  in  with  his 
irritable  bowels.  He  soon  began  to  improve  a  little,  and  as  he  became 


474  Original  Communications,  [April, 

more  able  to  swallow,  we  gave  liitn  5  grs.  of  the  powder  every  four 
hours,  with  beef  tea,  and  wine  and  water.  It  is  needless  to  report 
the  changes  from  day  to  day ;  suffice  it  to  say  that  in  the  course  of 
a  few  weeks,  to  our  utter  astonishment,  his  mental  faculties  gradu- 
ally reappeared,  his  paralysis  gradually  disappeared,  and  in  course 
of  time  his  health  was  so  much  restored  that  lie  was  able  to  resume 
his  occupation,  and  was  much  less  subject  to  diarrhoea  than  before 
his  attack.  He  remained  w^ell  until  the  year  1859,  in  the  early  part 
of  which  he  became  dropsical,  but  from  this  he  also  recovered.  Just 
before  Christmas  of  the  same  year,  when  seemingly  quite  well^  he 
caught  a  severe  cold  and  died  in  six  days  with  epileptic  fits. 

Case  3. — On  the  9th  of  August,  1856, 1  was  summoned  a  few  miles 
into  the  country  to  visit  in  consultation  Mr.  H — ,  a  wine  merchant 
of  about  thirty  years  of  age,  married,  and  who  had  travelled  a  good 
deal  abroad.  He  had  been  too  fond  of  the  commodities  in  which  he 
dealt,  and  was  spare  and  feeble  in  constitution.  I  found  him  just 
recovering  from  a  severe  epileptic  fit,  with  frequent  pulse,  stra- 
bismus, semi-consciousness,  and  every  sign  of  exhaustion.  It  was 
difficult  to  assign  a  cause,  unless  it  were  the  habitual  use  of  stimu- 
lants in  greater  degree  than  was  prudent  or  safe ;  but  from  his  pre- 
vious history,  disease  of  the  brain  was  suspected.  He  was  treated 
by  mercurial  purgatives,  ammonia,  and  blister  to  the  nape  of  the 
neck.  The  attack  passed  ofi",  but  left  his  nervous  system  a  good 
deal  disturbed;  he  had  confusion  of  thought  and  partial  loss  of 
memory,  and,  for  these  symptoms,  he  was  treated  with  drachm  doses 
of  the  Liq.  Hyd.  Bichlor.,  and  a  seton  in  the  back  of  the  neck.  The 
result  was  satisfactory,  and  after  a  short  time  he  seemed  to  have 
quite  recovered. 

I  heard  no  more  of  him  till  December  of  the  .same  year, 
when,  on  the  22nd  of  that  month,  I  was  summoned  in  conse- 
quence of  an  attack  of  sudden  loss  of  consciousness  preceded  by  an 
unusual  degree  of  mental  depression  and  forget  fulness.  He  had 
feeble  pulse  and  pale  countenance,  respiration  loud,  and  it  w^as  with 
great  difiiculty  that  he  could  be  roused  at  all.  The  apoplectic 
symptoms,  however,  soon  abated,  and  after  a  few  hours  he  was  able 
to  answer  questions.  He  became  very  sick  and  vomited  freely ;  we 
gave  him  a  turpentine  enema,  which  acted  on  the  bowels.  The  rcvst 
of  the  treatment  consisted  in  giving  him  a  colocynth  and  henbane 
pill  every  night,  and,  owing  to  his  depressed  condition,  a  dose  of 
quinine  three  times  a  day.  But  he  did  not  improve  much,  his 
intellect  remained  dull,  his  muscular  power  became  more  and  more 
feeble  and  imperfect,  his  stomach  was  at  times  so  irritable  that 
nothing  would  keep  down,  and  he  became  emaciated ;  indeed,  he 
appeared  to  be  labouring  under  gradual  softening  of  the  brain,  and 
his  case  seemed  almost  hopeless.     He  remained  much  the  same  for 


1872.]  Dr.  Copeman  on  the  Use  of  Mercury.  475 

two  or  three  weeks,  and  then  became  insensible ;  he  seemed  to  hav  e 
general  paralysis^  could  neither  speak  nor  move  his  limbs,  breathed 
with  a  degree  of  stertor,  and  lay  in  bed  quite  in  a  passive  state.  We 
thought  it  the  concluding  scene  of  his  life;  but  as  he  could  still  be 
made  to  swallow,  we  determined  as  a  last  resource  to  try  the  effect  of 
mercury,  and  gave  him  2  grs.  of  calomel  every  four  hours,  putting 
it  on  his  tongue  and  washing  it  down  with  wine  and  water.  For  two 
days  he  continued  much  the  same,  and  we  seemed  to  have  gained 
nothing  but  time ;  but  on  the  third  day  he  was  a  little  more  con- 
scious, which  encouraged  us  to  persevere  till  we  produced  the 
constitutional  effects  of  mercury.  It  would  be  tedious  to  give  the 
daily  reports  of  the  progress  he  made ;  suffice  it  to  say,  that  by 
keeping  up  slight  mercurial  action  for  a  month,  he  gradually  got  out 
of  his  very  critical  state,  and  eventually  recovered  without  any 
remaining  paralysis  or  mental  incapacity.  He  was  able  after  a  time 
to  resume  his  business ;  his  illness  had  taught  him  the  necessity  for 
temperance,  and  to  the  present  time  (1865)  he  has  remained  in 
fair  health,  and  conducts  his  business  as  usual.  I  have  heard 
nothing  about  him  since,  and  for  all  I  know  he  is  even  now  alive 
and  well.^ 

Case  4^. — Mr.  M — ,  a  collector  of  rates,  and  much  engaged  in  parish 
accounts,  upwards  of  sixty  years  of  age  and  inclnicd  to  obesity,  was 
seized  with  a  fit  of  apoplexy  in  April,  1858,  and  lost  all  conscious- 
ness and  power  of  motion.  I  saw  him  on  the  23rd,  the  day  after  the 
attack,  and  feared  from  the  deep  coma,  stertorous  breathing,  cold- 
ness of  extremities,  and  contracted  pulse,  that  there  might  be  fatal 
extravasation  of  blood  within  the  cranium.  We  applied  a  blister  to 
the  nape,  and  after  rousing  him  as  much  as  we  could,  put  some 
calomel  on  his  tongue,  and  made  him  swallow  some  water  after  it, 
although  apparently  by  reflex  action  only.  Mustard  had  been 
applied  to  the  legs,  and  a  turpentine  enema  administered.  He  had 
for  some  time  been  in  low  spirits  about  his  affairs,  and  the  keeping 
of  his  accounts  had  lately  been  very  fatiguing  to  him,  producing 
headache  and  confusion  of  thought  to  such  a  degree  that  he  was 
obliged  to  give  it  up.  I  saw  him  again  a  few  days  after  and  found 
him  somewhat  rallied.  He  could  articulate  slightly,  swallow  beef 
tea,  &c.,  and  his  limbs  were  not  paralysed.  We  agreed  to  give  him 
as  nourishing  a  diet  as  his  stomach  would  bear,  and  to  put  him  under 
a  course  of  mercurial  treatment  in  the  form  of  dram  doses  of  Liq. 
Hydr.  Bichlor.  three  times  a  day,  with  aperients  when  required. 
The  result  of  this   treatment  was,   that   he  gradually   recovered, 

1  Since  this  was  written  I  have  made  furtlier  inquiries  about  this  patient,  and 
find  he  is  now  (1871)  living  with  his  family  in  Italy  in  good  health  and  without 
having  had  any  return  of  his  disease. 


4/6  Original  Communications,  [April, 

although  his  constitution  was  evidently  impaired  by  the  shock  he 
had  undergone. 

As  I  observed  before,  I  have  no  doubt  as  to  the  power  of  mercury 
to  assist  nature  materially  in  the  absorption  of  wflammatory  pro- 
ducts ;  and  the  cases  I  have  related,  as  well  as  others  with  which  1 
am  acquainted,  seem  to  prove  also  its  value  as  a  medicine  in  clearing 
up  many  diseases  of  the  nervous  system  more  or  less  involved  in 
obscurity,  but  which  we  have  reason  to  believe,  as  far  as  morbid 
anatomy  has  instructed  us^  are  dependent  on  some  kind  of  effusion 
causing  pressure  and  diseased  action  in  the  part,  which  must  be 
absorbed  before  recovery  can  be  accomplished.  Such  effusions  or 
deposits,  whether  inflammatory  or  otherwise,  may  often  be  removed 
by  the  action  of  mercury,  and  I  should  never  feel  satisfied  to  let 
patients  die  of  obscure  cerebral  symptoms  without  giving  them  the 
chance  of  recovery  which  mercurial  treatment  might  afford. 


1872.]  On  Cancer  of  the  Tonsil  Glands.  4^77 


II.— On  Cancer  of  the  Tonsil  Glands.    By  Alfred  Poland. 

Preliminary  Remarks. — Cancer  seldom  attacks  tlie  tonsils,  and 
this  is  remarkable,  considering  the  amount  of  friction  and  the 
contact  of  all  kinds  of  substances,  as  well  as  the  influence  of 
atmospheric  changes,  besides  an  intimate  association  with  the  lymph- 
atic system. 

It  is  true  that,  like  all  other  glandular  bodies,  they  are  liable  to 
the  varied  forms  of  inflammation,  to  ulceration,  to  sloughing,  and  to 
diphtheritic  deposits ;  but  all  these  affections  are  within  the  scope  of 
remedial  treatment. 

It  must  also  be  borne  in  mind,  and  I  will  casually  allude  to  the 
circumstance,  that  there  seems  to  be  some  pathological  relation  of 
the  tonsils  with  the  lymphatic  glands,  and  more  especially  with  those 
in  the  cervical  region.  Enlarged  cervical  glands  are  often  attended 
with,  or  followed  by,  enlargement  of  the  tonsils,  and  vice  versa j  and, 
again,  there  is  one  gland  found  especially  comprised  in  disease  of 
the  tonsils,  viz.  the  one  near  the  angle  of  the  lower  jaw;  this  often 
becomes  enlarged,  and  gives  rise  to  the  popular  expression  of  the 
"  kernels  having  come  down.'^  Indeed,  the  tonsils,  when  increased 
in  size,  are  not  far  off  from  the  angle  of  the  jaw,  and  this  fact  has 
been  made  use  of  to  advantage  in  the  operation  of  removal  of  the 
tonsil  by  external  incision  below  the  jaw  in  the  neck,  and  to  this  I 
shall  refer  presently. 

The  association  of  enlarged  tonsils  with  cervical  glandular 
swellings  is  a  well-recognised  practical  fact,  and  is  a  matter  of  much 
importance  when  the  question  of  removal  of  enlarged  tonsils  by 
operation  is  entertained.  Many  and  many  a  tonsil  has  been  un* 
necessarily  removed  where  it  could  have  been  dissipated  by  attention 
to  the  general  health,  and  the  administration  of  tonics,  &c. 

Again,  the  tonsils  are  sometimes  the  seat  of  new  growthsy  some  of 
which  have  recently  received  the  name  of  lymphosarcoma^  as  con- 
sisting of  a  new  formation,  resembling  the  lymphatic  gland-tissue ; 
others,  in  which  the  fibrous  elements  are  more  prolific,  are  called 
fibro-jolastic  tumours  ;  and,  lastly,  others  in  which  cancer  degenera- 
tion has  attacked  the  gland.  It  is  to  this  latter  class  of  affection 
that  I  have  devoted  the  following  pages. 

Cancer  of  the  tonsils  is  a  disease  inevitably  fatal  in  its  results. 
This  rare  affection  has  more  especially  arrested  attention  since  the 
publication  of  two  recent  and  remarkable  cases.  The  one  is  a 
case  of  encephaloid  disease  of  the  tonsil,  removed  by  external  in- 
cision by  Dr.  Cheever  ('  City  of  Boston  Medical  and  Surgical 
Journal,'  1871,  vol.  i,  p.  390).     The  other  is  a  case  of  cancer  of 

98— XLix.  31 


478  Original  Communications.  [April, 

the  left  tonsil,  the  lymphatic  glands,  and  the  spleen,  by  Dr.  Moxon 
('Trans.  Path.  Soc.,'  London,  1870,  vol.  xx,  p.  369). 

These  two  cases  may  be  taken  as  fair  examples  of  the  two  forms 
in  whicli  cancer  may  attack  the  tonsils.  The  first  case  is  one  of 
purely  primary  cancer  of  the  encephaloid  or  most  common  variety ; 
whilst  the  second,  on  the  other  hand,  may  be  regarded  as  an  entirely 
secondary  formation,  developed  in  the  gland  probably  from  trans- 
mission through  the  medium  of  the  lymphatic  system,  and  not,  as  is 
usually  the  case,  propagated  by  contiguity  and  extension  of  the 
disease  from  the  neighbouring  involved  organs  and  tissues. 

On  referring  to  the  medical  literature  of  this  and  other  countries 
concerning  this  disease,  I  felt  much  disappointed  by  the  meagre 
details  and  scarcity  of  information  on  the  subject.  The  only  article 
is  one  occurring  in  the  second  volume  of  the  '  Dictionnaire  de 
Medecine,'  1865,  p.  150,  by  M.  L.  A.  de  Saint  Germain, 
"  Amygdales — lesions  organiques — degenerescences  cancereuses  et 
fibro-plastiques.^' 

Although  it  may  be,  perhaps,  considered  somewhat  arbitrary,  I 
have  arranged  the  subject  according  to  the  text  of  the  two  cases 
cited,  viz.  the  primary  and  the  secondary  forms  of  the  cancer  of  the 
tonsils. 

A.  Primary  Cancer  of  the  Tonsil. 

a.  On  the  frequency  of  the  disease, — There  is  much  difficulty  in 
arriving  at  any  definite  conclusion  on  this  point,  for  in  the  majority 
of  cases  of  deaths  from  cancer  the  tonsil  is  scarcely  ever  alluded  to, 
little  or  no  attention  being  paid  to  it  in  post-mortem  examinations. 
Still,  from  what  sHght  information  can  be  gathered,  these  glands  do 
not  appear  to  be  a  favourite  soil  for  the  deposition  of  cancerous 
germs. 

Lebert  ('Maladies  Cancereuses,'  Paris,  1851)  quotes  the  statistics 
of  cancer,  collected  by  M.  Tauchou  from  the  '  Death  Eegister '  of 
Paris  and  two  adjacent  arrondissements  between  the  years  1830  and 
1840,  both  years  inclusive.  Of  9118  deaths  from  cancer,  only 
3  cases  are  mentioned  as  occurring  in  the  tonsils. 

Dr.  Sibley's  statistics  of  cancer  ('  Med.-Chir.  Trans.,'  vol.  xlii,  p. 
Ill)  comprise  520  cases  in  which  the  seat  of  primary  cancer  was 
noticed,  occurring  in  the  wards  of  the  Middlesex  Hospital  during 
1853,  '54,  '55,  and  '56  ;  but  he  has  not  made  special  mention  of  the 
tonsil,  but  has  classed  it  together  under  one  heading,  viz..  Tonsil, 
Palate,  and  Parotid,  6  cases,  of  which  5  were  males  and  1  female. 
And  again,  in  the  analysis  of  173  post-mortems  he  gives  4  cases  of 
Cancer  of  the  Throat  and  Palate,  of  which  3  were  females  and  1 
male. 

Mr.  Baker's  statistics  ('  Med.-Chir.  Trans.,'  vol.  xlv,  p.  389)  are 
a  little  more  precise  as  regards  the  tonsils.     The  collection  comprises 


1872.]  On  Cancer  of  the  Tonsil  Glands.  479 

500  cases  taken  from  notes  of  cases  furnished  by  Sir  James  Paget, 
occurring  in  hospital  and  private  patients  between  the  years  1843  and 
1861,  the  patients  being  in  proportion  of  two  fifths  hospital  to  three 
fifths  private.  Of  this  number  there  are  only  two  examples  of  primary 
cancer  in  the  tonsil,  the  one  in  a  male,  and  the  other  a  female. 
The  one  was  scirrhous  and  the  other  medullary ;  the  age  of  one  was 
between  twenty  and  thirty,  the  other  between  forty  and  fifty. 

The  average  duration  of  life  in  cases  of  cancer  attacking  the 
gums,  palate,  and  tonsils,  and  w^here  the  primary  disease  is  not 
removed,  Mr.  Baker  gives  as  12'4  months. 

d.  On  the  varietiesj  symptoms,  and  cJiaracters  of  jprimary  cancer  of 
the  tonsil, — Like  as  in  other  structures,  cancer  may  attack  the 
tonsils  under  two  forms,  viz.  the  scirrhous  and  the  encephaloid,  and 
these  are  often  sufficiently  well-marked  and  distinct  as  to  warrant  me 
in  assuming  a  distinction,  both  as  regards  their  clinical  and  ana- 
tomical characters.  The  encephaloid  variety  appears  to  be  the  most 
frequent,  and  is  the  most  rapid  in  its  progress,  and  is,  moreover, 
generally  attended  with  encephaloid  disease  of  the  lymphatic  glands 
in  the  neighbourhood ;  it  kills  by  its  prolific  grow^th,  blocking  up 
the  openings  of  the  larynx  and  pharynx;  the  disease  seems  to 
involve  early  the  pillars  of  the  fauces,  the  pharynx,  and  neighbouring 
tissues ;  it  projects  into  the  mouth,  gradually  encroaching  upon  the 
isthmus,  and  rendering  deglutition  painful  and  difficult;  it  soon 
impedes  respiration,  rendering  the  patient's  condition  peculiarly 
distressing;  there  is  hunger,  without  the  ability  to  swallow  food; 
there  is  impending  suffocation,  with  eager  gaspings  for  breath ;  and 
speedy  death  but  too  surely  carries  off  its  victim.  The  essential 
characters  are  rapidity  of  growth  and  rapidity  of  death. 

The  scirrhous  variety,  on  the  other  hand,  is  by  no  means  so 
common;  it  is  of  but  slow  growth,  and  generally  attended  wdth 
ulceration,  there  being  a  deep  excavated  ulcer  with  hardened  base 
and  edges,  of  the  true  carcinomatous  type,  but  which  must  not  be 
mistaken  for  the  syphilitic  ulcer  of  the  tonsil.  It  is  generally 
attended  with  intense  pain,  and  with  difficulty  of  swallowing ;  the 
ulcer  gives  exit  to  an  offensive  ichorous  discharge.  This  form  kills 
slowly,  rather  by  starvation,  cancerous  cachexia,  and  exhaustion, 
than  by  suffocation.  It  generally  does  not  immediately  attack  the 
cervical  glands  like  the  encephaloid  variety,  by  rapidly  enlarging 
growths  of  brain-like  matter,  but  remains  rather  as  stony  hard 
nodules,  little  disposed  to  active  extension. 

Still,  in  some  instances  these  distinctive  characters  may  not 
always  be  present;  nevertheless,  the  above  description  may  with 
safety  be  taken  as  a  fair  standard  of  the  two  conditions. 

I  will  now  briefly  detail  examples  of  these  forms  : 

1st.  Cases  of  primary  encephaloid  cancer  of  the  tonsil. "^'Dy. 
Cheever's  case  is  a  well-marked  example  of  the  early  condition,  but 


480  Original  Communications.  [April, 

is  somewhat  modified  in  character,  owing  to  there  having  been  a 
previous  partial  excision  of  the  gland,  which  led  to  the  existence  of 
an  ulcerated  surface. 

G.  M — ,  a  well-formed,  robust  sailor,  set.  34,  without  any  heredi- 
tary predisposition  to  disease,  and  in  the  enjoyment  of  perfect  health 
previous  to  his  present  disability,  presented  himself  at  the  hospital 
with  the  following  history  : — Six  months  before,  without  any  known 
cause,  his  left  tonsil  became  enlarged  and  painful.  It  was  treated 
by  his  physician  as  a  case  of  tonsillitis,  and  in  due  time  a  portion  of 
it  was  excised  from  within.  No  rehef  followed,  but  instead,  the 
tonsil  continued  to  increase  m  size,  and  the  region  of  the  section 
became  an  obstinate  ulceration.  His  articulation  and  deglutition 
were  impaired  to  a  considerable  degree,  and  dyspnoea  was  quite 
marked,  especially  at  night. 

On  admission  the  affected  tonsil  appeared  much  enlarged;  the 
mass  protruded  into  the  fauces,  and  at  its  apex  presented  an 
indolent  ulcerated  surface,  an  inch  and  a  half  in  diameter,  with 
raised  and  everted  edges.  Externally  corresponding  with  the  in- 
ternal growth,  and  moving  with  it  as  if  it  were  a  part,  was  a  nodule 
lying  in  the  left  submaxillary  triangle  of  the  size  of  an  English 
walnut.  Manipulation  of  this  mass  gave  pain.  The  condition  of 
the  man  was  otherwise  excellent;  there  was  neither  the  history  nor 
any  appearance  of  syphilis. 

He  was  able  to  take  only  liquid  diet.  The  discharge  from  the 
ulcer  being  offensive,  he  was  ordered  a  gargle  of  the  Liq.  Sodse 
Chlorinatse. 

During  an  interval  of  three  weeks  the  tumour  doubled  its  size, 
internally  and  externally.  The  consequent  symptoms  became  much 
more  grave,  and  called  for  some  operative  interference.  The  situation 
and  large  size  of  the  tumour,  as  well  as  its  projection  outside  the 
throat,  contra-indicated  any  operation  from  inside  the  mouth,  and  it 
was  therefore  decided  to  attempt  removing  it  from  the  outside  by 
external  incision,  which  was  accordingly  performed. 

Examination  of  the  tumour  after  removal. — It  was  of  a  soft  and 
friable  nature,  slightly  lobulated,  and  of  a  greyish-red  colour.  On 
section  it  yielded  an  abundance  of  juice  of  a  milky  colour,  and  of 
considerable  consistency.  Under  the  microscope  both  the  tonsil  and 
the  enlarged  lymphatic  gland  appeared  the  same ;  they  were  com- 
posed of  cells  of  moderate  and  uniform  size  and  ovoid  form,  con- 
taining nuclei,  and  many  also  nucleoli.  There  was  no  fibrous 
tissue  between  them,  but  a  great  number  of  small  dark  granules, 
appearing  to  be  freed  nucleoli.  On  the  addition  of  acetic  acid,  the 
nuclei  became  more  distinct,  and  cells  were  visible,  containing  three 
or  four  of  them. 

One  of  the  earliest  cases  on  record  is  quoted  by  Lohstein  (^  Traite 
d'Anat.  Path.,^  Paris,  1829,  vol.  i,  p.  430),  as  occurring  in  the 


1872.]  On  Cancer  of  the  Tonsil  Glands,  481 

hospital  under  M.  Cailliot.  A  man  eet.  63  had  been  the  subject  of 
partial  paralysis  from  nervous  apoplexy,  and  was  recovering,  when 
he  experienced  a  difficulty  in  breathing.  On  examining  the  throat 
the  right  tonsil  was  much  enlarged ;  by  means  of  the  finger  a  small 
portion,  about  the  size  of  a  very  large  nut,  was  detached,  and  which 
had  all  the  appearances  and  consistence  of  encephaloid  disease. 
Some  months  afterwards  the  whole  of  the  isthmus  of  the  fauces 
became  blocked  up  by  the  enlargement  of  both  tonsils,  producing 
difficulty  of  breathing  and  threatening  sulTocation.  He  continued  a 
miserable  existence  for  two  months,  and  then  died  quietly  without 
pain. 

On  examination  both  tonsils  were  found  in  a  state  of  encephaloid 
degeneration ;  the  lymphatic  glands  on  both  sides  of  the  neck  had 
undergone  the  same  alteration.  Small  encephaloid  tumours  were 
found  at  the  base  of  the  epiglottis  and  on  the  arytenoid  cartilage. 

Velpeau  ('  Traite  de  Med.  Operat.,^  tom.  iii,  p.  568)  has  met 
with  five  examples  of  cancer  of  the  tonsil,  and  all  belonging  to  the 
encephaloid  variety.  He  merely  states  that  their  situation  and 
relation  with  the  large  vessels  of  the  neck  have  hitherto  intimidated 
surgeons,  and  preventing  them  from  meddling  with  them ;  he,  how- 
ever, once  practised  extirpation  in  1836,  but  did  not  find  the  opera- 
tion difficult.  He  gives  no  further  account  of  these  cases,  otherwise 
than  the  one  in  which  he  operated  upon ;  it  was  that  of  a  peasant 
a3t.  68,  who  came  into  the  hospital  to  be  relieved  of  a  swelHng  of 
the  left  tonsil,  which  had  first  shown  itself  about  two  years  pre- 
viously; the  tumour  was  now  bleeding,  ulcerated  on  the  surface, 
and  blocking  up  completely  the  pharynx ;  it  was  penetrating  into 
the  nostrils,  pushing  the  soft  palate  forwards,  and  was  threatening 
sufi'ocation.  He  determined  to  give  the  man  a  chance  for  life,  and 
removed  it  from  within  the  mouth.  The  patient  died  on  the 
eighteenth  day  after  the  operation  from  purulent  infection,  diarrhoea, 
and  prostration.  On  examination  the  whole  of  the  cancerous  mass 
was  found  to  have  been  completely  removed  by  the  operation,  and 
there  was  no  appreciable  disease  in  any  of  the  viscera. 

Vidal  mentions  that  he  had  seen  one  case  that  occurred  in  the 
Chirurgie  de  la  Charite  in  1838,  having  been  under  the  care  of  M. 
Yelpeau,  and  it  is  probably  one  of  the  cases  cited  by  Yelpeau. 

Roux  is  quoted  by  M.  Pano  ('  Bull,  de  la  Soc.  d'Anat.,'  1846, 
tom.  xxi,  p.  109)  as  having  removed  a  tumour  of  the  tonsil  from  a 
female  set.  40,  who  appeared  otherwise  healthy.  He  had  also  to 
extirpate  by  external  incision  a  tumour  behind  the  angle  of  the  jaw. 
Under  the  microscope  both  these  structures  had  all  the  characters  of 
encephaloid  disease. 

Lehert  (op.  cit.,  p.  422)  observed  this  form  of  cancer  in  a  very 
aged  female,  who  succumbed  in  the  space  of  a  few  months ;  the 
glands  of  the  neck  were  much  enlarged,  and  were  the  se^t  of  can- 


482  Original  Communications.  [April, 

cerous  deposition.  At  the  autopsy  there  was  no  localisation  of  cancer 
in  the  other  organs. 

Erichsen  (^Science  and  Art  of  Surgery/  1869^  vol.  ii,  p.  370) 
had  a  case  of  encephaloid  disease  of  the  tonsil  under  his  care,  when 
he  obtained  some  temporary  advantage  by  removing  portions  of  the 
soft,  projecting,  and  very  vascular  tumour  by  means  of  the 
ecraseur. 

My  colleague,  Mr.  Bryant,  has  furaished  me  with  two  cases, 
occurring  among  his  out-patients  at  Guy's  Hospital. 

Henry  S — ,  set.  62,  leather-dresser,  had  soft  cancer  of  the  left 
tonsil  of  six  months'  standing ;  it  was  accompanied  with  enlarged 
cervical  glands  of  three  weeks'  duration.  He  had  pain  in  the  left 
ear,  and  for  two  months  some  difficulty  in  swallowing.  He  con- 
tinued his  visits  for  three  months,  when  he  ceased  his  attendance, 
and  was  evidently  sinking.  His  mother  had  cancer  of  the  lip,  which 
was  removed  at  the  age  of  forty-six,  and  she  was  still  living,  at  the 
age  of  eighty-eight,  quite  well. 

James  S — ,  set.  65,  had  soft  cancer  of  the  right  tonsil ^  involving 
the  pillars  of  the  fauces;  it  was  in  a  state  of  ulceration.  There 
were  also  enlarged  cervical  glands  ;  it  was  of  six  weeks'  standing. 
,As  nothing  could  be  done,  he  ceased  his  attendance. 

2nd.  Cases  of  scirrhous  disease  of  the  tonsil.  —  As  I  have 
before  observed,  the  scirrhous  variety  is  a  very  rare  form  of  the 
disease,  and  it  is  doubtful  whether  some  of  the  cases  considered  and 
recorded  as  such,  were  not  instances  of  chronic  hypertrophy  and 
adenoid  conditions.  Again,  several  cases  are  recorded  as  cancer, 
without  reference  to  their  variety  being  generally  classed  under  the 
head  of  scirrhus  and  epithelioma. 

Dr.  J.  C.  Warren,  in  his  work  on  tumours  (p.  356),  was  the 
first  to  bring  under  special  notice  this  form  of  disease ;  but  he 
asserts  "  that  scirrhous  affections  of  the  tonsils  are  not  very  rare," 
and  he  only  adverts  to  two  unsatisfactory  cases  as  examples.  He 
says  "  that,  like  those  of  the  palate,  they  are  slow  of  growth,  not 
painful,  and  not  much  disposed  to  assume  the  cancerous  ulceration ; 
the  disease  is  difficult  to  eradicate,  as  it  runs  into  the  substance  of 
the  pharynx." 

One  of  his  cases  he  describes  pretty  fully,  and  the  case  is  again 
published  by  his  son,  J.  Masson  Warren,  in  his  '  Surgical  Observa- 
tions,' 1869,  p.  124,  and  hence  the  case  has  in  some  instances  been 
quoted  as  two  separate  examples.  The  son's  account  is  the  follow- 
ing : 

The  patient  was  a  Mrs.  A — ,  set.  65,  who  observed  in  January, 
1835,  a  swelling  on  the  left  tonsil,  which  gradually  increased  in 
size,  became  more  firm  in  consistence,  and  finally  extended  to  the 
soft  palate  and  attached  itself  to  the  lower  jaw,  so  as  materially  to 
impede  its  motions.     She  was  not  much  emaciated  or  reduced  in 


1872.]  On  Cancer  of  the  Tonsil  Glands,  483 

strength ;  the  countenance  was  pale  and  digestion  good.  On  ex- 
amination, on  the  left  side  of  the  throat  and  occupying  all  the  back 
part  of  the  fauces,  was  a  firm,  indurated  tumour,  extending  back- 
wards and  upwards  into  the  posterior  nares,  and  forwards  to  the 
lower  jaw,  to  which  it  was  firmly  attached.  The  tonsil  on  that  side 
and  soft  palate  were  all  implicated ;  there  was  no  doubt  about  the 
cancerous  nature  of  the  disease.  J.  C.  Warren,  the  father,  states 
that  she  was  only  sixty  years  of  age,  that  she  had  been  labouring 
under  the  disease  for  some  years,  and  that  the  respirations  were 
impeded  and  deglutition  difficult ;  and  that  she  had  the  appearance 
of  a  person  sinking  under  the  pressure  of  disease;  that  he  was  urged 
to  perform  the  operation  of  removal  immediately,  in  consequence  of 
the  distressing  state  she  was  in.  The  tumour  was  removed  through 
the  mouth,  and  she  recovered,  after  some  exfoliation  of  bone  had 
taken  place.  She  died  eight  months  after  the  operation  from  an 
independent  disease,  viz.  peritonitis,  and  on  examination  there  was 
remarkable  displacement  of  the  viscera,  but  no  disease  of  any  organ 
is  recorded.  The  tumour  was  found  to  be  of  a  firm,  cartilaginous 
nature,  almost  of  a  bony  hardness,  somewhat  ulcerated  in  its  centre. 

This  case  was,  no  doubt,  one  of  enchondroma  of  the  jaw,  and  not 
one  of  scirrhus  of  the  tonsil. 

Warren's  second  case  is  a  mere  casual  allusion  to  a  case  of 
scirrhus  of  the  tonsil,  in  which  he  cast  a  loop  of  wire  round  the 
growth,  so  as  to  strangulate  it ;  but  this  produced  at  the  end  of  five 
days  symptoms  of  tetanus,  so  that  he  was  glad  to  remove  the  wire, 
but  the  tumour  afterwards  sloughed  away. 

Erichsen,  in  his  work  '  On  Surgery,'  1869,  vol.  ii,  p.  370,  stated 
that  he  has  seen  instances  both  of  scirrhus  and  of  epithelioma  in 
this  organ  as  a  primary  affection,  but  his  description  of  the  disease 
tends  more  to  the  encephaloid  variety.  He  has  lately  published  in 
the  ^Medical  Times  and  Gazette '  for  June  24th,  1871,  p.  714,  an 
interesting  case,  which  may  be  regarded  as  a  fair  example  of  the 
scirrhous  kind. 

Ehza  B — ,  a  married  woman,  set.  50,  admitted  on  May  1st,  1871, 
with  a  tumour  of  the  tonsil,  apparently  cancerous.  She  stated  that 
she  had  always  enjoyed  good  health,  and  that  her  parents  had  both 
lived  to  a  great  age ;  her  five  children  also  were  perfectly  healthy. 
Last  October  she  caught  cold,  and  with  it  sore  throat,  and  when  this 
had  continued  for  a  month  she  noticed  a  swelling  in  the  throat, 
which  had  steadily  increased,  with  much  pain  and  soreness.  She 
noticed  at  the  same  time  that  the  neck  glands  became  swollen,  but 
these  after  a  time  subsided  somewhat,  although  still  much  enlarged. 
Her  appetite  now  began  to  fail,  and  she  lost  flesh  rapidly. 

On  admission  there  was  found  a  large  tumour  occupying  the 
position  of  the  left  tonsil.  This  growth  reached  down  out  of  sight, 
below  the  root  of  the  tongue,  and  on  a  digital  examination  its 


484  Original  Communications.  [April, 

lower  extremity  was  found  to  be  about  on  a  level  with  the  epiglottis. 
It  was  nodulated  on  the  surface,  and  the  mucous  membrane  covering 
it  was  slightly  redder  than  natural.  The  soft  palate  was  not  im- 
plicated by  the  growth ;  it  was  not  tender  on  pressure,  nor  was 
there  any  ulceration  on  the  surface ;  it  was  of  firm  consistence,  and 
covered  with  thick  white  mucus.  The  glands  beneath  the  jaw  on 
the  left  side  were  clearly  visible,  forming  rounded  prominences  as 
large  as  a  filbert.  They  were  perfectly  free  from  adhesions,  were 
hard,  and  not  at  all  tender. 

It  was  not  deemed  prudent  to  attempt  any  operation  for  the  relief 
of  the  disease  in  so  advanced  a  stage. 

Br.  Burnett  J  of  Biggleswade,  is  reported  by  Dr.  Tanner  (^  Practice 
of  Medicine,'  vol.  ii,  p.  II)  to  have  had  the  care  of  a  woman  set. 
68,  whose  pharynx  was  much  obstructed  by  a  firm  medullary  cancer 
of  the  left  tonsil,  and  where  the  disease  was  completely  excised,  but 
with  only  temporary  relief.  On  a  private  communication  with  Dr. 
Burnett  for  further  information,  he  writes  to  say  that  but  few  notes 
were  taken  at  the  time;  the  woman  was  of  advanced  life,  set.  65  or 
66,  and  had  always  been  exceedingly  regular  in  her  habits.  The 
disease  was  one  of  scirrhus,  and  not  encephaloid,  but  it  had  pro- 
ceeded to  ulceration  and  sloughing ;  the  mass  was  about  the  size  of 
a  small  pigeon^s  ^^^^  and  was  removed  by  ligature  and  excision ;  no 
haemorrhage  occurred.  She  had  but  slight  difficulty  in  swallowing 
and  respiration ;  there  was  very  great  emaciation.  She  stated  that 
the  disease  had  existed  quite  two  years.  She  was  operated  on  late 
in  Pebruary,  and  died  early  in  May ;  there  was  no  return  of  the 
disease,  but  she  had  enlargement  of  the  cervical  glands,  and  she  died 
from  general  exhaustion.  No  post-mortem  was  made,  as  it  was 
objected  to  on  the  part  of  the  friends. 

One  of  the  most  remarkable  cases  of  scirrhus  of  the  tonsil 
occurred  among  the  out-patients  at  Guy's  Hospital  in  January, 
1863,  under  the  care  of  Mr.  Bryant,  to  whom  I  am  indebted  for  the 
following  notes : 

WiUiam  S — ,  set.  17,  a  chimney-sweep,  who  had  never  had 
syphilis ;  he  applied  to  the  hospital,  suffering  from  a  tumour  of  the 
right  tonsil,  of  six  months'  standing,  and  which  was  now  in  a  state 
of  ulceration.  On  examination  it  was  found  to  be  of  a  truly  car- 
cinomatous nature ;  it  was  of  stony  hardness,  and  the  ulceration 
assumed  the  aspect  and  characters  of  cancer.  The  disease  steadily 
progressed  during  the  four  months  of  his  attendance  at  the  hospital ; 
he  became  extremely  emaciated,  and  was  evidently  sinking  fast  when 
last  seen. 

Mr.  Bryant  had  another  case  in  the  year  1869.  David  B — ,  set. 
49,  who  was  admitted  as  an  out-patient,  suffering  from  scirrhous 
cancer  of  the  left  tonsil,  and  having  a  deep  excavated  ulcer  of  the 
same;  there  was,  moreover,  a  glandular  swelling  to  be  observed 


I 


1872.J  On  Cancer  of  the  Tonsil  Glands.  485 

externally.  The  disease  had  been  in  progress  for  two  years  j  and 
he  attended  the  hospital  for  only  two  months,  the  disease  having 
gradually  spread,  and  his  health  was  failing  fast ;  in  fact,  he  was 
sinking. 

It  is  to  be  regretted  that  these  cases  were  lost  sight  of,  and  no 
opportunity  afforded  of  studying  the  pathological  changes. 

M.  Houel  ('Bull,  de  la  Soc.  de  Chir.  de  Paris,'  1869,  vol.  ix,  p. 
162),  who  had  had  large  opportunities  of  studying  pathological 
anatomy,  observed  only  one  case  of  cancer  perfectly  limited  to  the 
tonsil.  It  occurred  in  a  medical  man,  and  was  removed  by  M. 
Nelaton.     There  is,  unfortunately,  no  record  of  the  case. 

M.  JDesormeaux  (loc.  cit.)  has  seen  a  case  where  the  left  tonsil 
presented  an  ulceration,  which  was  regarded  by  M.  Eicord  as 
syphiHtic,  but  which  subsequently  was  ascertained  to  be  of  a  can- 
cerous nature,  and  was  confined  to  the  tonsil. 

M.  Bemarquay  ('Bull,  de  la  Soc.  de  Chir.  de  Paris,'  1863, 
series  ii,  vol.  iii,  p.  163)  relates  a  case  in  which  the  disease  had 
extended  to  the  pillars  of  the  fauces  and  to  the  base  of  the  tongue, 
and  which  he  removed  by  the  ecraseur.     He  says — 

"  I  was  called  to  a  strong  robust  man,  set.  51,  who  had  an  ulcerated 
tumour  occupying  the  right  tonsil,  the  anterior  and  posterior  pillars 
of  the  velum,  and  also  the  tongue  at  corresponding  side.  The 
disease  appeared  five  months  previous  to  admission ;  he  had  under- 
gone several  treatments,  and  chiefly  iodide  of  potassium. 

''  The  right  tonsil  was  occupied  by  a  cancerous  tumour  ulcerated 
on  its  surface.  The  disease  was  not  confined  to  the  tonsil,  but  in- 
volved the  mucous  membrane  of  the  pillars,  and  part  of  the  velum  ; 
below,  it  extended  to  the  border  of  the  base  of  the  tongue,  the 
tumour  did  not  project  considerably  into  the  throat;  its  circum- 
ference was  very  irregular,  and  was  continuous  under  the  line  of 
demarcation  with  the  mucous  membrane  of  the  neighbouring  parts, 
from  which  it  was  distinguished,  however,  by  the  hypertrophy  of  the 
glandular  follicles  and  deeper  colouration;  the  centre  of  its  surface 
was  rough,  and  the  ulcer  gave  exit  to  a  small  quantity  of  ichor 
mixed  with  pus.  There  was  slight  induration  on  manipulation,  and 
the  tonsil  glided  over  the  deep  parts;  there  was  no  lymphatic 
enlargement.  Deglutition  was  embarrassed,  and  he  was  losing 
strength." 

3.  Cases  of  cancer  of  the  tonsil,  in  which  the  character  of  the 
growth  is  not  specified. — M.  Chassaignac  ('  Bull,  de  la  Soc.  de  Chir.,' 
op.  cit.)  stated  that  he  had  met  with  several  cancers  of  the  tonsil, 
and  in  one  case  he  removed  it  with  the  ecraseur. 

M.  Maissoneuve  (op.  cit.)  had  also  observed  several  cases  of 
cancer  of  the  tonsil,  which  would  have  required  section  of  the  jaw- 
bone for  their  removal.     He  had  not  done  so,  but  had  effected  a 


486  Original  Communications.  [April, 

sloughing  away  of  the  mass  by  means  of  '^  cauterisation  en  fleches  " 
in  one  case. 

4.  Cases  of  doiiUful  character  (lymphoma  and  lympho-sar- 
coma.) — Dr.  Meissnery  in  his  report  on  cancer  ^^  Schmidt^s  Jahr- 
buch./  1870,  Bd.  146,  p.  314),  quotes  a  case  of  primary  lympho- 
sarcoma of  the  tonsil  as  an  instance  of  cancer.  It  is  recorded  by 
Dr.  G.  Milani,  and  occurred  in  a  young  woman  set.  17,  and  was 
first  observed  in  January,  1869,  as  a  red  swollen  condition  of  the 
left  tonsil ;  in  June  of  that  year  it  was  of  the  size  of  a  gooseys  e^g, 
and  produced  difficulty  of  breathing  and  swallowing ;  it  then  rapidly 
increased  to  an  enormous  size,  pressing  down  the  epiglottis ;  the 
cervical  glands  became  affected  with  the  same  disease,  as  also  the 
left  lobe  of  the  thyroid  gland.  The  disease  was  considered  to  be 
primary  lympho-sarcoma  of  the  tonsil,  spreading  to  the  lymphatic 
glands  of  the  neck. 

Virchow,  under  the  article  on  "  Lymphoma,"  says — 

^^  The  worst  cases  are  those  where  the  tumours  quickly  grow  to 
large  medullar^/  tumours  (not  unfrequently  under  the  form  of  fascicu- 
lated medullary  fungi),  and  where  the  neighbouring  tissue  is  also 
changed  to  lymphoma.  Patients  with  such  tumours  rarely  escape ; 
anaemia  comes  on,  the  nutrition  is  impaired,  and  hypertrophy  of  the 
spleen  may  appear,  and  the  patient  die  of  excessive  anaemia  and 
marasmus.  These  mahgnant  lymphomata,  which  Liicke  calls 
lympho-sarcomata,  cannot  be  anatomically  distinguished  from  the 
benignant  forms.  But  they  may  be  recognised  from  the  fact  that 
they  proliferate  rapidly,  and  especially  that  they  unite  with  the  parts 
immediately  around.  It  seems  to  me  they  are  certain  to  recur,  and 
are  the  most  dangerous  of  tumours.''^ 

Mr.  Lawrence,  in  his  ^Lectures  on  Surgery,'  published  in  1863, 
p.  611,  gives  a  most  interesting  case  of  doubtful  malignant  disease 
of  the  tonsil.  He  removed  a  portion  of  the  tonsil,  and  it  was 
pronounced  to  be  simple  hypertrophy  of  the  gland;  this  was 
succeeded  by  a  return  of  the  disease,  and  extirpation  of  the  whole  of 
the  tonsil  performed.  Soon  afterwards  he  was  again  admitted  into 
the  hospital  with  a  mahgnant  affection  of  the  cervical  glands.  The 
case  is  thus  described  : 

A  man  about  forty-five,  who  had  always  enjoyed  good  health,  his 
occupation  through  life  having  been  agricultural,  came  into  St. 
Bartholomew^'s  Hospital  under  my  care  for  an  enlargement  of  the 
right  tonsil,  presenting  the  usual  character  of  hypertrophy,  and 
obviously  requiring  excision;  the  only  complaint  was  of  some 
difficulty  in  swallowing.  The  enlargement  was  rather  beyond  the 
bulk  that  could  be  passed  into  the  opening  of  the  guillotine.  I 
therefore  cut  off  as  much  as  protruded ;  the  part  removed  was 
simply  hypertrophied  tonsil.  He  returned  to  the  country,  but  came 
again  to  the  hospital  in  the  month  of  October  with  a  swelling  as 


1872.]  On  Cancer  of  the  Tonsil  Glands.  487 

large  as  an  egg,  proceeding  from  the  former  site,  and  seeming  to  fill 
up  the  pharynx,  so  as  to  produce  a  formidable  impediment  to 
swallowing.  This  I  removed  with  the  ecraseur,  getting  the  loop  of 
the  chain  over  the  lower  end  of  the  swelling,  which  was  at  some 
distance  below  the  tongue,  drawing  up  the  ends,  so  as  to  include 
the  root  of  the  mass,  and  then  fixing  them  to  the  movable  branches 
of  the  instrument,  the  action  of  which  caused  so  much  choking 
feeling  and  involuntary  efforts  of  the  surrounding  parts,  that  it  was 
necessary  to  hasten  the  process,  which  was  accomplished  almost 
without  loss  of  blood.  The  part  removed  appeared  as  an  entire 
tonsil,  simply  enlarged  by  hypertrophy,  with  slight  surrounding 
covering  of  cellular  tissue  in  a  perfectly  natural  state.  The  section 
presented  a  substance  of  very  light  brown  tint,  similar  to  that  of 
the  natural  gland,  and  in  a  lobular  arrangement.  Mr.  Savory 
reported  that  a  most  careful  microscopical  examination  detected 
nothing  but  gland  elements. 

This  patient  once  more  came  to  the  hospital  in  July,  with  a 
swelHng,  apparently  glandular,  larger  than  my  fist,  under  the  right 
sterno-mastoid,  of  firm  but  not  scirrhous  hardness,  and  covering 
closely  all  the  important  structures  at  the  side  of  the  neck,  up  to 
the  angle  of  the  jaw.  It  was  not  painful,  and  had  not  been  so 
during  its  increase,  which  had  been  rather  rapid. 

My  colleague  and  myself  regarded  this  swelling,  which  had 
attained  its  great  bulk  within  a  few  months  after  the  removal  of  the 
primary  disease,  as  a  malignant  affection,  deciding  at  once  and 
unanimously  that  it  was  not  a  fit  case  for  operation.  If  it  could 
have  been  considered  as  an  innocent  growth,  I  should  not  have 
hesitated  to  remove  it. 

Considered  as  a  secondary  fatal  tumour,  consequent  upon  a 
primary  disease  to  which  no  suspicion  of  malignancy  could  be 
attached,  it  is  of  no  slight  practical  importance. 

On  the  diagnosis  of  cancer  of  the  tonsil. — In  the  early  stage  of 
both  forms  of  the  disease  there  is  no  distinguishing  mark  to  guide 
us  as  to  the  nature  of  the  disease.  Enlargement  of  the  tonsil  is  the 
only  sign,  and  this  does  not  arrest  the  attention  of  the  patient,  nor 
excite  any  suspicion  in  the  mind  of  the  surgeon  in  consequence  of 
the  very  frequent  occurrence  of  subacute  and  chronic  inflammation 
of  the  glands  in  a  very  great  majority  of  persons.  Hypertrophy  of 
the  tonsils  seldom  alarms  or  produces  any  inconvenience  unless  both 
tonsils  are  afPected  and  thus  block  up  the  isthmus  of  the  fauces ; 
and  seldom  are  any  operative  measures  requisite,  excepting  under 
these  conditions  or  when  respiration  is  interfered  with.  As  the 
disease  advances,  the  peculiar  nature  of  the  fatal  disease  begins  to 
develop  itself,  and  assumes  either  a  rapid  or  slow  course;  when 
rapid,  it  steadily  encroaches  upon  the  fauces  and  pharynx,  involves  the 
lymphatic  gland  at  the  angle  of  the  jaw,  and  afterwards  the  cervical 


488  Original  Communications.  [April, 

glands,  and  soon  destroys  the  patient  j  this  form  of  the  disease  is 
not  liable  to  be  mistaken  for  any  other  affection.  Encephaloid 
cancer,  wherever  it  may  be,  is  unfortunately  seldom  to  be  mistaken. 

The  scirrhous  variety,  on  the  contrary,  may  often  fail  to  be  recog- 
nised ;  but  its  slow  progress  and  its  becoming  ulcerated  and  excavated 
on  its  surfaces  (an  attempt  of  nature  to  enucleate  the  disease)  renders 
it  less  liable  to  be  confounded  with  chronic  hypertrophy  and  syphilitic 
ulceration ;  however,  both  these  diseases  have  passed  for  cancer,  and 
on  the  other  hand  cancer  has  been  presumed  when  subsequent  results 
have  disproved  the  supposition.  Excessive  hardness,  implication  of 
the  lymphatic  glands,  peculiar  ulceration,  foetid  discharges,  increasing 
growth  and  peculiar  cachexia  seem  to  be  its  characteristics. 

M.  de  Saint  Germain  thus  adverts  to  its  diagnosis  :  If  at  the 
outset  the  cancer  appears  with  the  aspect  of  a  benign  hypertrophy,  or 
if  on  the  other  hand  the  jagged  appearance  of  the  tonsil,  the 
ulceration  of  the  orifices  of  the  lacunae,  in  a  simple  hypertrophy  may 
lead  one  to  think  of  a  cancerous  degeneration,  there  arrives  a  period 
when  the  presence  of  stony  hardness,  of  sanious  offensive  ulcerations, 
of  signs  of  cancerous  cachexy,  and  the  progress  of  the  malady, 
will  allow  its  nature  to  be  appreciated. 

The  syphilitic  changes  of  the  tonsil  most  often  confounded  with 
cancer  are  the  "gummous^^  tumours  at  different  periods  of  their 
development,  and  especially  at  the  time  of  their  ulceration.  Indeed 
it  is  an  error  with  difficulty  to  be  avoided  in  the  absence  of  know- 
ledge of  the  antecedents  of  the  patient,  or  at  least  of  the  absence  of 
proof  of  a  specific  treatment. 

Another  kind  of  syphilitic  lesion  may,  moreover,  be  a  source  of 
error.  It  is  the  hypertrophy  and  vegetations  of  ^'plaques  muquensis'^ 
of  the  tonsils. 

M.  St.  Germain  quotes  the  case  mentioned  by  Tournier,  where  a 
syphilitic  tumour  of  the  tonsil  simulated  cancer,  and  was  cured  by 
the  internal  exhibition  of  the  proto-iodide  of  mercury.  The  isthmus 
of  the  fauces  in  his  case  was  completely  blocked  up — its  right  half 
by  a  large  tumour,  seemingly  developed  from  the  tonsil  and  pillars 
of  the  fauces  on  that  side — the  surface  thereof  was  shining,  greyish 
at  some  points,  rugose,  granular  and  ulcerating ;  its  consistence  was 
firm  and  there  was  redness  and  tumefaction  of  the  parts  around. 
It  was  at  first  considered  to  be  epitheliomatous,  but  on  careful  exami- 
nation into  the  history  of  the  case,  evidences  of  syphilis  were  found. 

Blandin  (^Bull.  de  la  Soc.  de  Chir.  de  Paris,^  1862,  p.  467) 
removed  a  tumour  from  the  tonsil  which  was  regarded  as  cancer, 
and  a  recovery  resulted.  The  disease  shortly  afterwards  returned, 
and  the  patient  then  came  under  the  care  of  M.  Maissoneuve,  who 
placed  him  under  iodide  of  potassium,  and  an  effectual  cure 
resulted.  The  case  proved  to  be  a  syphilitic  tumour  of  the  tonsil, 
and  not  cancer. 


1872.]  On  Cancer  of  the  Tonsil  Glands.  489 

Dr.  J.  C.  Warren's  case  may  also  be  considered  as  one  of  enclion- 
droma,  mistaken  for  scirrhus ;  the  history  and  chnical  details  of  the 
casCj  the  evidence  of  the  tumour  itself  after  removal,  and  the  absence 
of  any  cancerous  cachexia,  fully  justify  such  a  decision. 

Roux  diagnosed  a  cancer  of  the  tonsil,  and  was  about  to  remove 
it  when  the  patient  died.  On  examination  there  was  found  besides 
some  small  isolated  tumours  on  the  epiglottis,  and  another  at  the  orifice 
of  the  Eustachian  tube.  On  microscopic  examination  the  tumours 
of  the  tonsil  and  throat  were  found  to  be  of  fibro-plastic  nature. 

Lr.  Cheever  thus  sums  up  the  diagnosis  of  his  case  : — In  my 
case  there  seemed  to  be  no  doubt  as  to  its  being  cancer.  The 
growth  of  the  tumour  as  distinguished  from  the  ulceration  and  waste 
of  syphilis  was  one  marked  point.  The  tumour  of  the  tonsil 
doubled  in  three  weeks.  The  gross  and  microscopic  appearances 
were  submitted  to  several  observers,  who  were  of  opinion  as  to  its 
being  cancer.  The  enlargement  of  the  lymphatic  gland  and  the 
identity  of  its  structure  under  the  microscope  with  that  of  the 
tonsil,  were  other  strong  points  indicating  cancer.  The  whole 
aspect  of  the  man  was  singularly  free  from  syphilitic  taint. 

On  the  treatment  of  cancer  of  the  tonsil. — We  cannot  but  admire 
the  bold  and  novel  operation  of  Dr.  Cheever  in  extirpating  an 
encephaloid  tonsil  and  an  enlarged  gland  at  the  angle  of  the  jaw  by 
an  external  incision  in  the  neck ; — the  ease  with  which  he  carried 
out  his  plan,  the  little  haemorrhage,  the  enucleation  of  the  tonsil  by 
means  of  the  finger,  and  the  success  attending  the  case  almost 
persuades  one  to  recommend  the  operation  in  other  similar  cases. 
Before  alluding  to  his  operation  let  us  consider  the  usual  and  general 
treatment  hitherto  adopted.  In  the  early  stage  of  the  disease, 
when  its  nature  cannot  satisfactorily  be  agreed  upon,  the  case 
must  be  treated  as  one  of  chronic  or  subacute  inflammation  of  the 
tonsil,  by  such  means  as  are  recommended  for  such  affections.  But 
above  all  a  careful  scrutiny  of  the  history  of  the  case  must  be  insti- 
tuted respecting  the  probabilities  of  a  syphilitic  taint,  and  the  treat- 
ment directed  accordingly ;  and  even  should  there  be  no  evidence  of 
syphilis,  still  I  should  be  disposed  to  give  the  benefit  of  a  doubt 
by  treating  it  with  the  specific  remedies  for  that  disease,  taking  care 
not  to  lower  the  patient  too  much  in  the  event  of  its  being  considered 
necessary  to  remove  the  disease  by  ablation. 

When  the  disease  has  so  far  advanced  as  to  have  developed  its 
terrible  character,  active  measures  must  be  taken  before  the  lym- 
phatic system  becomes  too  far  contaminated. 

a.  Caustics  and  eschar otics  have  been  recommended  and  employed, 
but  these  generally  aggravate  the  pain,  and  cannot  be  borne  for  any 
length  of  time,  and  indeed  often  aggravate  the  disease. 

if.  Maissoneuve  (^Bull.  de  la  Soc.  de  Chir.  de  Paris,'  1859,  torn. 
9,  p.  162)  suggested  '^cauterisation  en  fleches'^  to  be  applied  to 


490  Original  Communications.  [Aprils 

cancer  of  tlie  tonsil,  and  he  presented  to  the  society  a  mass  of  tonsil 
(which  had  the  appearance  of  a  ball  of  mastic)  removed  successfully 
by  him.  He  plunges  these  "fleches"  of  caustic  paste  into  the 
gland,  and  at  the  end  of  a  few  days  the  tumour  is  destroyed. 
Should  the  patient  swallow  the  mass  it  will  not  poison.  The 
members  of  the  society  entertained  some  doubts  about  the  nature  of 
the  disease,  and  were  not  disposed  to  recommend  his  treatment  for 
cancer  of  the  tonsil. 

b.  Removal  by  the  amygdalotome  or  guillotin  is  generally  quite 
out  of  the  question  in  consequence  of  the  size  of  the  tumour. 

c.  Removal  by  the  wire  ligature. — This  was  performed  by  Dr.  J.  C. 
Warren  in  one  of  his  cases;  he  cast  a  loop  of  wire  around  the 
diseased  tonsil,  and  twisted  it  until  the  tumour  was  strangulated ; 
its  effects  were  distressing  and  alarming ;  the  patient  suffered . 
atrociously  from  difficulty  of  swallowing,  salivation  and  dyspnoea; 
at  the  end  of  five  days  symptoms  of  tetanus  appeared,  and  then  he 
was  glad  to  remove  the  ligature  without  delay.  However,  the 
tumour  was  destroyed  and  sloughed  away.  He  considers  the  ligature 
objectionable. 

d.  Removal  by  the  ecraseur  may  be  undertaken  when  the  tumour 
has  not  attained  any  large  size,  and  when  the  loop  of  the  instrument 
can  readily  embrace  the  whole  base  of  the  tumour ;  but  danger  is 
attached  to  this  operation  at  all  times,  as  the  loop  may  include  some 
of  the  important  vital  structures  in  the  neighbourhood,  viz.  the 
internal  carotid,  jugular  vein,  and  pneumogastric  nerve.  To  obviate 
this,  Demarquay  had  recourse  to  Blandin's  procedure  of  a  tempo- 
rary incision  in  the  neck  so  as  to  lay  bare  the  structures  he  wished 
to  avoid,  and  having  them  held  aside  by  an  assistant,  then  introduc- 
ing the  finger  and  conducting  the  loop  of  the  ecraseur  over  the  tumour 
from  within  the  mouth ;  he  thus  so  far  kept  all  the  important 
vessels  and  nerves  from  the  grasp  of  the  loop.  His  description  of 
the  operation  is  as  follows  : — The  case  was  one  of  ulcerating  cancer 
of  the  tonsil,  palate,  and  advancing  on  the  base  of  the  tongue ; 
there  was  no  glandular  enlargement,  and  iodide  of  potassium  had 
failed. 

Having  carefully  ascertained  the  extent  of  the  disease,  I  thought 
I  could  remove  the  whole  with  the  linear  ecraseur ;  but  in  order  to 
avoid  comprising  within  the  loop  of  the  ecraseur  any  important 
structure,  I  made  an  incision  four  finger's  breadth  along  the  course 
of  the  internal  border  of  the  sterno-mastoid.  I  reached  easily  the 
vessels  and  nerves  in  contact  with  the  tonsils,  and  separated  them ; 
having  done  this  I  proceeded  slowly  to  remove  the  tumour  with  the 
chain  of  the  ecraseur;  and  having  first  made  an  oblique  incision 
through  the  velum  palati  to  the  right  of  the  uvula,  and  then 
carefully  using  Chassaignac's  instrument,  I  seized  the  tonsil  with 
hook  forceps  and  drew  it  forwards  to  the  side  of  the  mouth,  and 


1872.]  On  Cancer  of  the  Tonsil  Glands.  491 

threw  the  chain  around  the  mass  comprising  the  tonsil,  pillars,  and 
a  large  piece  of  the  right  portion  of  the  velum.  During  the 
proceeding  with  the  ecraseur,  I  took  care  that  it  did  not  pass  beyond 
the  prescribed  limits.  There  was  no  hsemorrhage.  I  removed  after- 
wards with  the  curved  scissors  a  portion  of  the  tongue  in  relation 
with  the  tonsil,  as  also  some  hypertrophied  glands.  I  closed  the 
preliminary  incision,  which  united  in  a  few  days.  The  conditions 
inside  the  mouth  proceeded  satisfactorily,  although  he' had  spitting 
of  blood  for  forty-eight  hours,  which  ceased  under  the  use  of  ice. 
The  operation  entirely  succeeded  ;  his  health  was  restored,  and  he 
became  stout.     However,  a  return  may  take  place. 

By  thus  making  a  preliminary  incision  he  not  only  secured  the 
carotid  from  injury,  but  was  enabled  to  ascertain  that  the  cancer 
had  not  extended  along  the  pharyux.  (^Bull.  de  la  Soc.  et  de  Chir. 
de  Paris,' 1862,  p.  467.) 

e.  Removal  hy  incision  from  within  the  moi^th. — /.  C.  Warren 
describes  it  as  a  bloody  and  dangerous  operation,  requiring  also  to  be 
aided  by  the  actual  and  potential  cautery.  In  his  case,  the  jaws  being 
fixed  apart  by  an  assistant,  the  tumour  was  seized  with  a  pointed 
hooked  forceps,  and  then  with  a  round-edged  knife  the  whole  mass 
was  removed  by  two  strokes  of  the  instrument ;  an  enormous  gush 
of  blood  followed.  Passing  the  finger  in,  another  mass  was  felt  in 
the  pharynx,  below  the  situation  of  the  former  one,  which  was  seized 
and  cut  out  by  a  curved  probe-pointed  bistoury.  When  the  hsemor- 
rhage had  a  little  subsided,  a  red-hot  iron  was  passed  on  a  con- 
ductor to  the  diseased  spot  twice;  no  further  hsemorrhage  occurred. 
The  woman  recovered.  However,  subsequent  to  the  operation  several 
applications  of  caustic  potash  were  required,  and  exfoliation  of  a 
small  piece  of  bone  followed. 

Velpeau  performed  the  operation  upon  a  man  a3t.  68,  where  the 
mass  filled  up  the  pharynx,  and  suffocation  was  imminent. 

Velpeau  first  cut  down  upon  the  carotid,  and  placed  a  controlling 
ligature  under  it,  to  be  tied  if  the  occasion  should  require  it ;  he 
then  hooked  the  tumour  deeply,  drawing  it  forwards  towards  the 
middle  of  the  mouth,  and  with  a  short  knife,  curved  on  the  flat,  he 
divided  the  left  side  of  the  soft  palate,  whereby  he  was  enabled  to 
uproot  the  entire  mass  from  below  upwards,  and  from  within  out- 
wards. Seeing  that  there  was  no  hsemorrhage,  he  next  removed  the 
enlarged  lymphatic  gland  that  was  situated  at  the  lower  part  of  the 
parotid  gland,  pressing  against  the  pharynx,  by  an  external  incision. 
The  hgature  having  proved  unnecessary,  was  removed  the  next  day. 

All  went  on  well  for  the  first  week,  when  the  patient  was  attacked 
with  symptoms  of  purulent  infection,  diarrhoea,  and  prostration  on 
the  tenth  day,  and  death  on  the  eighteenth  day  after  the  operation. 
CMed.  Operat.,' t.  iii,  p.  568.) 


492  Original  Communications.  \K\}v\\, 

f.  Operation  for  removal  of  the  tonsil  hy  external  incision^  as 
performed  by  Dr.  Cheever,  and  thus  described  by  him : 

Etherization  was  slow  and  difficult  on  account  of  the  obstruction 
to  respiration  by  the  tumour  in  the  fauces.  As  soon  as  it  was 
accomplished  an  incision  was  made,  extending  from  just  within  the 
angle  of  the  jaw  downward,  over  the  most  prominent  part  of  the 
tumour,  a  distance  of  three  and  a  half  inches,  and  in  a  direction 
parallel  with  the  sterno-mastoid  muscle ;  this  incision  was  met  by 
another,  one  inch  and  a  half  long,  extending  along  the  lower  border 
of  the  jaws.  The  parts  were  dissected  away  on  either  side  until  the 
diseased  growth  was  reached.  On  enucleation  this  was  found  to  be 
an  enlarged  and  diseased  lymphatic  gland,  of  the  size  of  an  English 
walnut.  It  had  no  distinct  connection  with  the  tonsil  within, 
but  the  disease  was  encephaloid  in  character.  It  lay  outside  all 
important  structures,  and  was  entirely  removed  without  difficulty. 
The  dissection  was  now  extended  until  the  tonsil  was  reached.  In 
its  course  the  digastric,  stylo-hyoid,  and  the  stylo-glossus  muscles 
were  divided,  the  stylo-pharyngeus  being  left  intact,  on  account  of 
its  proximity  to  the  glosso-pharyngeal  nerve.  The  fibres  of  the 
superior  constrictor  of  the  pharynx  were  picked  apart  with  a 
director,  and  the  pharynx  thus  opened  between  them.  The  finger  of 
the  operator  was  now  enabled  to  sweep  entirely  around  the  diseased 
tonsil,  the  pillars  of  the  soft  palate  being  left  intact ;  the  mass  was 
removed,  and  presented  all  the  appearance  of  encephaloid  disease, 
its  size  being  of  a  pullet's  ^g'g.  The  haemorrhage  during  the  opera- 
tion was  free,  but  not  excessive ;  the  largest  vessel  divided  being 
the  facial  artery,  which  was  cut  close  to  the  carotid.  Twelve  liga- 
tures were  applied. 

A  few  of  the  smaller  branches  of  the  facial  nerve  were  divided, 
and  paralysis  of  the  lower  lip  on  the  same  side  was  the  consequence. 
It  was  also  observed  that  on  account  of  the  section  of  the  stylo- 
glossus muscle  the  tongue,  when  protruded,  took  a  direction  towards 
the  opposite  side.  A  single  suture  closed  the  horizontal  incision; 
the  wound  otherwise  was  left  freely  open,  air  passing  through  it  with 
each  expiration.  Recovery  from  ether  was  speedy,  and  there  was  no 
marked  depression  from  the  operation. 

Not  a  single  complication  occurred  to  hinder  the  progress  of 
recovery.  Suppuration  of  a  satisfactory  character  commenced  on 
the  second  day.  During  the  first  week  after  the  operation  the 
patient  took  liquid  nourishment,  administered  by  means  of  the 
stomach-pump.  Erom  the  outset  there  was  no  pain,  and  respi- 
ration was  easy.  The  granulating  process  was  rapid,  and  at  the 
end  of  eight  days  no  fluid  passed  through  the  wound  in  degluti- 
tion. 

After  eleven  days  a  small  patch  was  observed  at  the  lower  part  of 
the  posterior  pillar  of  the  palate,  which  had  the  appearance  of  the 


1872.J  On  Cancer'  of  the  Tonsil  Glands.  493 

original  malignant  growth ;  it  was  freely  cauterized  with  nitric  acid, 
and  there  was  no  subsequent  reappearance. 

After  seventeen  days  solid  food  was  swallowed  without  difficulty. 
In  thirty-one  days  the  wound  had  entirely  closed.  The  pharynx 
was  entirely  clear,  and  except  that  the  pillars  of  the  palate  on  the 
side  affected  were  somewhat  separated,  it  appeared  in  perfectly 
normal  condition.  The  tongue  was  protruded  in  a  straight  line, 
and  no  paralysis  of  the  lip  remained.  From  the  operation  until 
recovery  there  w^as  no  constitutional  disturbance  requiring  special 
notice. 

Dr.  Cheever,  in  his  remarks,  adds  : 

"  The  facility  with  which  the  tonsil  can  be  enucleated  with  the 
finger  is  surprising.  The  following  anatomical  peculiarity,  however, 
explains  the  reason  pretty  well.'''' 

Chassaignac  thus  describes  this  point : 

"  It  is  enclosed  in  a  semi-fibrous  capsule ;  when  one  has  enu- 
cleated a  well- developed  tonsil,  and  examined  with  attention  its 
external  and  internal  surface,  it  is  found  that  the  external  or  adherent 
surface  is  covered  with  a  fibrous  semi-capsule,  well  circumscribed 
and  independent  of  the  neighbouring  aponeurosis,  and  resting  on  the 
cellular  tissue.''^ 

Dr.  Hueter  (' Jahresbericht  der  Gesammten  Medicin,'  1869,  Bd. 
ii,  p.  435),  in  his  review  of  Cheever^s  case,  says  : 

^^Dr.  Cheever's  assertion  that  as  yet  no  one  had  extirpated  the 
tonsil  from  without  is  not  correct.  He  has  seen  the  operation 
performed  by  Laugenbeck  in  1865,  and  a  second  case  he  himself 
performed  in  1865.  In  both  cases  the  lower  jaw  was  sawn  through 
at  the  second  molar  tooth,  and  the  jaw  temporarily  displaced 
upwards  so  as  to  lay  bare  the  tonsil.  Both  cases  were  instances  of 
large  sarcoma  of  the  tonsils.  Langenbeck^s  patient  recovered; 
Hueter's  case  was  operated  on  in  the  sixth  month  of  pregnancy,  and 
died  in  three  -weeks  from  pneumonia.  Both  cases  have  as  yet  not 
been  published. 

B.  Secondaey  Cancer  of  the  Tonsils. 

It  is  a  general  impression  that  cancer  of  the  tonsils  is  a  secondary 
disease,  but  the  foregoing  facts  give  ample  evidence  of  its  occurrence 
as  a  primary  aflTection  of  the  gland;  still,  the  subject  of  secondary 
deposition  is  one  requiring  much  further  investigation  in  order  to 
form  any  definite  conclusions.  The  most  frequent  mode  of  its 
occurrence  is  undoubtedly  by  the  extension  of  the  cancer  from  the 
neighbouring  tissues,  more  especially  from  the  base  of  the  tongue 
and  pharynx ;  but  it  may  likewise  be  independently  deposited  during 
the  progress  of  the  disease  elsewhere  in  other  organs  and  tissues. 
It  is  remarkable  that  in  the  numbers  of  post-mortem  examinations 
made  of  cancer  patients,  the  tonsil  is  scarcely  ever  mentioned ;  it  is 

98— XLix.  32 


494  Original  Communications,  [April, 

more  than  probable  that  the  tonsil  has  never  undergone  scrutiny. 
Prom  what  lew  records  exist  this  secondary  affection  seems  always  to 
have  been  associated  with  cancerous  disease  of  the  lymphatic  system, 
and  in  two  of  the  four  instances  cited,  combined  with  similar  disease 
in  the  spleen.  Secondary  cancer  of  the  tonsils  seldom  permits  of 
any  surgical  interference,  with  the  exception  of  the  operation  of 
tracheotomy  for  impending  suffocation.  It  is  a  lesion  of  purely 
pathological  interest,  and  1  shall,  therefore,  merely  give  an  account 
of  such  cases  as  are  considered  to  be  examples  of  the  disease. 

Case  \,—Lobstein  (^Traite  d'Anat.  Path.,'  vol.  i,  p.  429,  1829) 
states  that  '•''in  1821  a  man  set.  75,  tall,  and  enfeebled  by  disease  for 
several  months,  and  had  suffered  from  dysphagia,  so  that  he  could 
not  swallow  the  least  thing,  had  at  the  upper  and  anterior  part  of 
the  thigh  a  tumour  as  large  as  a  foetal  head ;  it  was  indolent,  and 
without  any  alteration  in  the  integument  over  it.  This  man  died  a 
few  days  after  his  admission  from  suffocation.  On  examination  the 
tumour  in  the  thigh  was  lobulated,  hke  the  convolutions  of  the 
brain,  resting  upon  the  femoral  vessels  and  nerves ;  it  weighed  2 
lbs.,  and  had  the  appearance  and  consistence  of  cerebriform  fungus. 
The  inguinal  and  lumbar  glands  on  the  same  side,  and  all  the  glands 
in  front  of  the  vertebral  column,  were  similarly  degenerated,  extend- 
ing from  the  coccyx  to  the  first  vertebra  of  the  neck.  What  was 
most  remarkable,  the  amygdalae  were  very  much  enlarged,  and  con- 
verted into  the  same  cerebriform  substance. 

Case  II. — Br.  Car  swell  has  recorded  an  interesting  case  of 
cerebriform  cancer  of  the  tonsils,  lymphatic  glands,  and  spleen,  and 
the  drawings  illustrating  this  case  are  preserved  in  the  Museum 
of  University  College. 

The  case  is  casually  alluded  to  in  ^  Walshe  on  Cancer  /  but  the 
general  outline  and  description  is  to  be  found  in  Dr.  Hodgkin's 
paper  "  On  some  Morbid  Appearances  of  the  Absorbent  Glands  and 
Spleen,"  in  the  seventeenth  volume  of  ^Med.  Chir.  Trans.,'  p.  90, 
1832. 

The  patient,  who  w^as  between  thirty  and  forty  years  of  age,  stout 
made  and  not  lean,  had  been  affected  with  swelling  of  the  glands 
under  the  jaws,  along  both  sides  of  the  neck;  in  the  axillae  and 
groins,  for  between  three  and  four  months,  and  from  which  he  had 
suffered  but  little  inconvenience,  to  which  he  had  paid  but  little 
attention,  and  had  employed  no  remedies.  It  was  only  a  short  time 
before  he  applied  to  be  taken  into  the  hospital,  that  he  felt  a 
difhculty  in  swallowing,  which  rapidly  increased,  and  for  the  last  two 
or  three  days  was  such  as  to  prevent  him  from  taking  any  kind  of 
food  whatever.  He  was  admitted  into  St.  Louis'  Hospital  at  Paris 
in  the  month  of  April,  under  the  care  of  Dr.  Lugol.  As  his 
appetite  had  never  been  affected  by  the  disease,  he  was  now  in  a 
great  state  of  suffering,  not  only  from  want  of  food   and   from 


1872.]  On  Cancer  of  the  Tonsil  Glands.  495 

debility,  but  from  the  idea  he  was  rendered  incapable  of  satisfying 
the  cravings  of  hunger,  together  with  the  prospect  of  inevitable 
death.     He  lived  rather  more  than  two  days. 

Inspection  of  the  hody. — On  each  side  of  the  neck  were  large 
groups  of  glands,  extending  from  the  angle  of  the  jaw  down  to  the 
clavicle,  where  they  were  joined  to  another  group,  coming  up  from 
the  axillae,  and  passing  under  the  clavicle.  The  submaxillary  and 
sublingual  glands  were  greatly  enlarged,  and  united  with  the  other 
lymphatic  glands,  formed  an  almost  continuous  chain,  stretching 
along  the  border  of  the  jaw,  and  uniting  under  the  chin.  These 
glands  were  of  various  sizes ;  some  of  them  were  not  larger  than  a 
pea,  while  others  were  as  large  as  a  hen's  egg ;  they  were  round, 
oval,  or  of  an  irregular  form,  particularly  where  they  were  united  by 
a  common  capsule.  A  great  many  of  them  presented  the  colour 
which  distinguishes  them  in  the  healthy  state;  others  were  of  a 
yellowish  tinge,  with  more  or  less  redness  and  vascularity,  whilst  a 
few  were  of  a  deep  red  colour,  and  highly  vascular.  The  greater 
number  of  them  when  pressed  between  the  fingers  felt  pretty  firm 
and  somewhat  elastic ;  those  that  were  red  and  vascular  were  softer. 
All  of  them  were  enclosed  in  a  thin  but  firm  capsule,  which  con- 
tained a  substance  of  the  colour  and  consistence  of  brain,  and  in 
which  were  distributed  a  considerable  number  of  blood-vessels,  and 
on  the  softest  the  vascularity  was  such  as  to  give  to  the  cerebriform 
matter  an  appearance  resembling  a  mixture  of  equal  parts  of  brain 
and  blood.  A  similar  state  of  the  glands  was  observed  in  both 
groins.  The  greater  number  of  them  were  as  large  as  pigeons'  eggs, 
and  could  be  followed  passing  upwards  under  Poupart's  ligament, 
surrounding  the  great  blood-vessels,  and  terminating  in  the  diseased 
lymphatic  and  mesenteric  glands.  The  diseased  appearance  observed 
in  the  glands  of  the  groin  are  represented  in  Nos.  4 — 6,  fig.  1 ; 
those  of  the  neck  and  axillse  No.  4  a. 

In  Nos.  4 — 6  is  seen  the  appearance  of  the  substance  of  which 
the  glands  were  formed;  in  one  of  them  the  vascularity  of  this 
substance  is  shown  to  be  very  great,  whilst  in  the  others  the  vessels 
are  few  in  number,  long,  and  slender.  The  quantity  of  cerebriform 
matter  is  also  seen  to  differ  considerably  in  each.  Besides,  in  the 
lower  figure  the  lobulated  structure  which  it  presents  is  pretty  well 
marked. 

In  fig.  Ill  two  of  the  glands  are  represented  after  having  been 
injected.  In  the  upper  one  a  large  vein  is  seen  coming  out  from  it, 
and  arising  from  a  great  number  of  minute  vessels,  which  apparently 
are  situated  near  the  surface  of  the  gland.  In  the  lower  one  the 
corresponding  artery  is  shown,  dividing  and  subdividing  into  an 
immense  number  of  extremely  fine  branches,  which  are  distributed 
throughout  the  substance  of  the  gland. 

No.  4  c,  fig.  I,  represents  an  enormous  tumour  formed  by  the 


496  Original  Communications.  [April, 

lymphatic  glands  situated  near  the  liver,  duodenum,  pancreas,  and 
great  blood-vessels  of  those  parts.  It  was  as  large  as  an  adult's 
head,  projecting  forwards  on  a  level  with  the  convex  surface  of  the 
liver,  and  carried  before  it  the  duodenum,  pancreas,  and  gall  ducts, 
which  pushed  over  its  anterior  surface. 

Pig.  II  represents  a  section  of  this  tumour,  which  is  seen  to  be 
formed  of  a  great  number  of  glands,  some  of  which  are  as  large  as  a 
small  orange.  Like  those  of  the  neck  and  axillae,  they  were  com- 
posed of  cerebriform  matter,  possessing  a  greater  or  less  degree  of 
vascularity.  In  the  centre  of  the  tumour  considerable  haemorrhage 
had  taken  place;  the  centre  of  the  hsemorrhagic  effusion  was 
occupied  by  coagulated  blood,  and  the  circumference  by  layers  of 
fibrine.  The  vena  cava  and  aorta  passed  through  the  tumour,  and 
the  former  was  nearly  perforated  by  one  of  the  diseased  glands. 

No.  4  c  represents  the  same  pathological  conditions  in  the  glands 
situated  in  the  posterior  fauces.  The  glands  situated  around  the 
root  of  the  tongue  were  so  much  enlarged  as  to  shut  up  completely, 
by  their  projecting  backwards  and  forwards,  the  posterior  nares  and 
superior  aperture  of  the  oesophagus.  I  could  not  ascertain  the 
precise  state  of  the  epiglottis,  but  it  must,  to  a  certain  extent  at 
least,  have  been  free,  as  it  did  not  appear  that  inspiration  had  been 
much  impeded.  T/ie  amygclalcBj  formed  entirely  of  cerebriform 
matter,  presented  a  pale  yellow  colour,  tinged  here  and  there  with 
red  specks,  produced  apparently  from  the  rupture  of  minute  blood- 
vessels. They  have  also  lost  that  characteristic  appearance  from 
which  they  derive  their  name,  having  become  almost  perfectly 
smooth  from  the  accumulation  of  the  cerebriform  matter  and  the 
distension  of  their  envelope. 

The  spleen  was  the  only  organ  apart  from  the  lymphatic  glands 
which  in  this  remarkable  case  presented  a  similar,  or  indeed  any,  dis- 
ease. The  external  surface  of  this  organ  is  shown  in  No.  4,  a,  Fig. 
I.  Besides  great  increase  of  its  bulk,  it  presents  externally  a  great 
number  of  irregular  elevations  surrounded  by  redness  and  vascula- 
rity. "When  divided  longitudinally  (Fig.  II),  it  appeared  to  be 
formed  entirely  of  cerebriform  matter  and  fine  blood-vessels,  hardly 
any  trace  of  its  natural  structure  being  observable.  It  presented  a 
lobulated  structure,  the  lobules  varying  from  the  size  of  a  small  pea 
to  that  of  a  large  gooseberry,  these  being  again  divided  and  subdi- 
vided into  smaller  ones ;  the  boundaries  of  the  lobules  and  the 
intersections  of  the  latter  were  the  parts  in  which  vascularity  was 
greatest ;  it  did,  indeed,  appear  as  if  the  lobulated  structure  had  been 
the  result  of  a  vascular  network,  so  disposed  as  to  enclose  and 
separate,  more  or  less  completely,  portions  of  different  sizes  of  the 
cerebriform  matter.  It  depended,  however,  in  all  likehhood,  on  the 
structure  of  the  spleen,  in  the  cells  of  which,  or  in  the  blood  which 
they  contain,  the  cerebriform  matter  was  deposited  or  formed,  while 


1872.]  On  Cancer  of  the  Tonsil  Glands.  497 

tlie  blood-vessels  wliicli  surrounded  the  lobules,  and  ramified  in 
their  interstices,  arose  from  those  which  belong  to  the  splenic  cells. 

The  body  having  been  removed  by  inadvertence  before  I  had  time 
to  examine  the  chest,  I  did  not  ascertain  the  state  of  the  bronchial 
glands ;  but  I  was  informed  by  one  of  the  house  physicians  that  they 
were  not  diseased. 

Lr.  Ilodgkin,  in  his  criticisms  on  this  case,  writes  thus  : — 
"Although  the  doctor  has  employed  the  term  cerebriform  matter, 
which  conveys  a  ready  idea  of  the  texture  of  the  diseased  glands,  he 
will  excuse  my  differing  from  him  so  far  as  to  regard  the  affection  in 
this  case  as  distinct  from  cerebriform  cancer.'" 

Case  III. — Sydney  Jones  (^  Trans.  Path.  Soc.,'  London,  1856,  vol. 
viii,  p.  369)  exhibited  at  the  society  a  tumour  weighiug  between  6  lbs. 
and  7  lbs.,  formed  by  encephaloid  disease  of  the  cervical  glands,  and 
taken  from  a  man  set.  40.  who  had  been  admitted  into  St.  Thomas's 
Hospital,  in  July,  1856,  with  extensive  disease  of  the  cervical  glands 
on  either  side ;  the  disease  had  commenced  about  five  months  pre- 
viously as  a  small  oval  tumour  opposite  the  left  cornu  of  the 
OS  hyoides.  It  took  a  rapid  growth,  impeded  respiration  and  deglu- 
tition, and  caused  sloughing  of  the  skin  and  ulceration,  from  which 
recurrent  haemorrhages  took  place,  and  death  ensued  in  the  month 
of  November,  from  ansemia  rather  than  asphyxia. 

The  disease  was  found  to  have  extended  to  and  involved  the  tonsils, 
which  were  much  enlarged,  being  about  two  inches  in  length  to 
three  quarters  of  an  inch  thick ;  they  were  composed  of  soft  brain- 
like matter.  The  axillary  glands  and  the  mesenteric  were  soft  and 
brain-like.  There  were  some  fibroid  growths  in  each  kidney,  and 
considered  to  be  cancerous  masses  of  the  scirrhous  variety.  The 
viscera  were  healthy,  but  no  mention  made  of  the  spleen. 

Case  IV. — Br.  Moxon's  case  of  cancer  of  the  left  tonsil,  the  lym- 
phatic glands,  and  the  sj^leen  ('  Trans.  Path.  Soc.  -.'  Lond.,  1870,  vol. 
XX,  p.  369) .  The  specimens  were  removed  from  the  body  of  a  man,  set. 
61, who  was  in  Onyx's  Hospital  for  tumours  in  the  neck.  These  were  en- 
larged glands,  and  of  eight  or  nine  months'  duration.  An  operation 
was  undertaken  for  their  removal,  as  the  man  was  well  nourished  and 
had  good  health  and  no  sign  of  disease  of  other  organs  was  present. 
The  operation,  however,  revealed  the  nature  of  the  case.  The  lymphatic 
glands  could  not  be  separated  from  the  great  vessels,  and  those  that 
were  removed  were  found  to  be  in  a  state  of  encephaloid  disease. 
OEdema  of  the  glottis  came  on  shortly  after  the  operation,  and  the 
man  died  within  twenty-four  hours  from  its  performance.  On 
inspecting  his  body,  which  was  that  of  a  large  and  fat  man,  it  was 
found  that  very  extensive  disease  existed.  The  cervical  glands,  some 
of  which  had  been  removed,  were  of  large  size,  generally  about  six 
or  eight  times  their  natural  dimension.  The  mediastinal  and  bron- 
chial glands  were  large,  especially  the  former;  and  here  a  most 


498  Original  Communications.  [April, 

important  condition  was  observed,  for  the  disease  of  the  glands  had 
infected  the  neighbouring  parts,  so  that  both  the  tissue  of  the  medi- 
astinum and  the  neighbouring  part  of  the  lung  were  included  in  the 
disease :  the  lung  was  affected  to  the  depth  of  an  inch.  This  was 
the  only  instance  of  infection  by  contiguity  that  was  present  in  the 
body.  The  visceral  glands  and  the  lumbar  and  iliac  glands  were  in 
the  same  state  of  enlargement,  but  the  axillary  and  inguinal  glands 
were  free.  The  spleen  showed  a  very  remarkable  change ;  it  was 
large,  weighing  24  oz. ;  its  surface  showed  small  whitish,  granular 
growths  in  the  capsule.  A  section  of  it  revealed  the  same  growths, 
extending  throughout  it  in  enormous  numbers,  these  growths  varying 
in  size  from  a  scarcely  visible  minuteness  to  the  size  of  a  vetch  seed. 
They  were  angular  in  form  and  continuous  with  the  tissue  around, 
not  appearing  to  exercise  pressure  upon  it.  The  appearance  of  the 
section  exactly  resembled  that  figured  by  Virchow,  under  the  name 
of  lympho-sarcoma  of  the  spleen.  The  left  tonsil  was  swollen  to  five 
or  six  times  its  natural  size,  and  one  section  showed  the  same  soft 
brain-like  substance,  which  composed  the  enlarged  glands  and  the 
formation  in  the  spleen. 

Some  of  the  compound  follicular  glands  at  the  root  of  the  tongue 
were  in  a  like  state. 

Mr.  Durham  also  examinedand  prepared  sections  of  the  tonsils  and 
glands  of  the  tongue^  and  it  was  found  that  in  microscopic  character 
the  growth  in  these  parts  strictly  correspond  with  that  in  the  spleen 
and  glands. 

On  microscopic  examination  the  new  tissue  was  found  to  consist 
of  two  elements,  viz.,  first,  cells  rather  larger  than  lymph-cells,  and 
having  their  interior  nearly  filled  by  a  great  nucleus,  within  which 
were  many  nucleoli;  and  second,  a  network  of  fine  fibres,  the  meshes 
of  which  were  of  pretty  uniform  size,  and  thus  such  as  would  con- 
tain one  to  two  dozen  of  the  cells.  The  cells  were  in  such  enormous 
profusion  that  the  network  could  not  be  seen  until  the  section  was 
shaken  in  water.  A  good  shaking  in  water  washed  out  most  of  the 
cells  from  the  meshwork,  but  a  few  remained  entangled,  and  then  it 
was  seen  that  a  small  number  of  stellate  corpuscles,  with  smaller 
nuclei,  were  present  in  the  network.  The  cell- wall  of  the  cells  was 
exceedingly  perishable  on  addition  of  water,  so  that  in  a  water  speci- 
men the  cells  soon  looked  like  large  free  nuclei.  This  simple  struc- 
ture was  common  to  the  growth  in  the  spleen,  the  glands,  and  the 
tonsils.  There  was  no  excess  of  white  corpuscles  in  the  blood  ;  the 
lungs,  liver,  kidneys,  and  other  organs  were  quite  healthy, 

Br.  Moxon  gives  some  very  interesting  comments  upon  this  case, 
which  I  should  have  liked  to  have  detailed  in  full,  but  space  will 
only  permit  me  to  take  one  or  two  short  extracts. 

He  says,  '^  We  have  here  a  disease  of  allied  organs.  The  tonsils, 
lymph-glands  and  spleen  only  are  affected,  and  these,  as  modern 


1872.]  On  Cancer  of  the  Tonsil  Glands.  499 

physiology  teaches,  are  organs  that  resemble  each  other  in  essential 
character.  The  disease  of  these  organs  is  the  same  in  all,  consisting 
of  a  new  formation,  which  resembles  the  lymphatic  gland  tissue,  but 
that  the  elements  are  larger/' 

^'  The  tissues  diseased  are  not  identical,  though  they  are  function- 
ally and  structurally  allied/'' 

"  Taking  the  facts  as  they  stand  on  their  own  merits,  and  seeing 
the  tumours  soft  and  brain-like,  so  as  to  deserve  the  name  encepha- 
loid,  and  that  some  of  them  spread  by  contiguity  to  the  tissues 
around,  so  proving  themselves  malignant,  I  have  called  them  encepha- 
loid  cancer.  The  word  cancer  I  use  in  a  strictly  clinical  significa- 
tion, as  meaning  an  infecting  growth,  and  not  in  any  pathological 
sense ;  indeed,  I  believe  the  word  cancer  is  not  pathological,  and 
should  cease  out  of  existence  in  pathological  discourse.  Bat 
although  it  is  clinically  encephaloid  cancer  of  the  glands,  yet  the  rela- 
tion of  the  case  in  point  of  strict  pathological  classification  is  highly 
interesting." 


500  Original  Communications.  [April, 


III.— On  Hereditary  Transmission  of  Structural  Peculiarities. 
By. John  A.  Ogle,  M.D.,  P.E.C.P.^  Physician  to  and  Lecturer 
at  St.  George^s  Hospital. 

The  general  subject  of  hereditariness  of  disease  and  malformation 
has  received  much  attention  of  late,  and  has  especially  been  handled 
in  a  series  of  papers  in  this  Ueview  by  Mr.  Sedgwick,  who  has 
particularly  dwelt  upon  the  hereditary  transmission  of  disease, 
deformity  and  peculiarity  as  limited  by  sex  and  by  the  law  of 
Atavism.^ 

The  case  which  I  shall  immediately  describe  does  not  illustrate 
either  of  these  limitations,  but  is  sufficiently  interesting  to  be 
recorded  as  a  good  example  of  transmission  of  a  deformity  by  no 
means  commonly  met  with ;  that  is,  of  hereditary  deficiency  of  the 
distal  elements  of  the  fingers  and  toes. 

Those  who  have  studied  Mr.  Sedgwick's  paper  will  remember  with 
what  fulness  he  exemplified  his  subjects,  quoting  cases  of  affections 
and  peculiarities  of  the  skin,  the  eyes,^  ears,  teeth,  hair,  the 
organs  of  circulation  and  respiration,  as  also  of  the  limbs  and  bones ; 
but  illustrations  from  the  latter  were  less  numerous  and  important 
than  those  from  other  organs,  especially  the  outer  integument. 

On  referring  to  illustrations  of  hereditary  transmission  of  defor- 
mities and  malformations,  and  especially  to  deficiency  in  parts  of  the 
fingers  and  toes,  I  find  that  Mr.  Sedgwick  quotes^  a  remarkable  case 
of  hereditary  absence  of  two  distal  phalanges  said  to  have  existed  for 
ten  generations ;  also  a  second  case,  in  which  for  three  genera- 
tions all  the  toes  and  fingers  had  but  two  phalanges  each ;  and  a 
third  case,  in  which  for  three  generations  the  hand  had  only  three 
fingers,  and  the  foot  but  four  toes. 

Darwin  again  (among  Englishmen),  in  his  work  ^  On  Animals  and 
Plants  under  Domestication,'  who  illustrates  not  only  the  transmis- 
sion of  mental  habits,  of  gait,  gesture,  but  also  of  predisposition  to 
insanity  and  disease  of  various  kinds,'^  alludes  also  (vol.  ii,  p.  73) 

^  See  April  and  October,  1861  and  January  and  July,  1863.  Inquiries  on  these 
subjects  are  shown  to  bo  most  important  in  connection  with  marriage  and  with 
the  insurance  of  life. 

2  Dr.  Armitage,  who  has  paid  great  attention  to  the  condition  of  the  blind,  in- 
forms me  that  the  Indigent  Blind  Visiting  Society  are  collecting  statistics  among 
the  blind  as  to  hereditary  transmission  of  blindness.  They  only  commenced  about 
two  years  and  a  half  ago,  and  have  not  yet  tabulated  the  results.  Congenital  and 
puerile  cataracts,  atrophy  of  retina,  and  glaucoma,  seem  to  be  the  common 
hereditary  causes  of  loss  of  sight.  The  Blind  Institution  of  New  York  has  col- 
lected statistics,  but  has  only  published  a  table  showing  the  connection  of  blind- 
ness with  consanguinity.     Mr.  Wait  is  the  superintendent. 

3  Mr.  Sedgwick  cites  many  interesting  cases  from  Petit,  St.  Hilaire,  Lucas, 
Morel,  Webster,  &c.,  in  illustration  of  the  various  subjects  which  he  treats. 

^  Including  especially  inherited  affections  of  the  eye,  as  ptosis,  myopia,  hyper- 
mctropia,  cataract,  amaurosis,  malformations,  Daltonism,  squinting. 


1872.]  Hereditary  Transmission  of  Structural  Peculiarities.  501 

to  deficiency  in  the  phalanges  having  been  inherited  by  females 
alone  for  ten  generations,  evidently  the  case  above  quoted  by  Mr. 
Sedgwick. 

Prosper  Lucas  also,  in  his  treatise  '  De  I'Heredite  Naturelle/  ^ 
gives  instances  of  inherited  malformation  of  the  hands,  fingers,  &c. 

Allied  to  the  above  is  the  following  remarkable  case,  which  some 
time  ago  I  met  with  at  St.  George^s  Hospital,  of  deficiency  of  the 
phalanges  of  the  fingers  and  toes.  The  patient  was  a  young  woman 
set.  28,  who  w\is  under  my  colleague  Dr.  FuUer^s  care  for  hysteria  of  six 
years'  standing,  and  who  was  constantly  emitting  a  peculiar  sound  like 
a  "  grunt,"  which  came  on  and  interrupted  speech,  or  occurred  equally 
at  other  times,  and  was  attended  by  a  jerk  of  the  head  and  neck. 
In  this  person  the  following  congenital  defects  existed : — The  first 
and  second  fingers  of  both  hands  had  only  two  phalanges,  the  final 
one  of  the  second  finger  of  the  left  hand  being  scarcely  detectible, 
and  being  shorter  than  its  fellow  on  the  right  hand,  which  was  also 
very  small.  The  third  and  fourth  fingers  of  both  hands  had  only 
one  phalanx,  and  none  of  the  fingers  were  provided  with  nails.     At 

Subjoined  are  some  interesting  cases  of  congenital  and  hereditary  affections  of  the 
eye  which  have  been  lately  recorded,  and  which  may  be  considered  along-  with  those 
brought  together  by  Sedgwick  and  Darwin,  &c.  Thus,  an  interesting  case  of 
malformation  and  cataractous  state  of  the  lenses  of  tlie  eye  occurring  in  four 
members  of  the  same  family,  viz.  one  brother  and  three  sisters,  out  of  twelve 
children  (two  boys  and  ten  girls),  is  related  by  Mr.  Hulme,  at  p.  618  of  the 
*  Lancet'  for  December  6th,  1862.  Mr.  Hulme,  at  the  time  of  description,  con- 
sidered the  state  to  have  been  congenital,  and  looked  forward  to  the  time  when 
the  cataractous  state  would  be  complete.  He  has  lately  informed  me  that  the  two 
girls  are  now  married,  and  that  he  has  operated  on  the  boy  as  to  both  eyes.  Mr. 
Hulme  alludes  to  a  somewhat  similar  case,  published  by  Mr.  Dixon,  in  the  first 
vol.  of  the  *  Ophthalmic  Hospital  Reports,'  p.  54.  In  this  case  I  find  the  mother 
and  three  sons  were  all  affected  by  abnormal  position  of  the  crystalline  lens,  the 
eyes  of  the  father  and  three  younger  children  being  healthy.  In  the  same  vol.  of  the 
'Ophthalmic  Hospital  Reports,'  p.  101,  I  find  a  description  of  six  cases  of  cataract 
in  one  family,  viz.  a  mother  aud  five  children,  by  Mr.  Streatfeild,  who  observes, 
however,  that  it  did  not  appear  that  any  of  the  paternal  or  maternal  relations  had 
been  similarly  affected.  The  grandmother  had  observed  the  deficiency  of  vision 
and  defect  of  eyes  of  the  mother  when  she  was  a  year  and  a  half  old,  and  noticed 
the  same  in  the  grandchildren  at  various  ages  latee  ix  life,  according  to  the 
SENIORITY  OE  THE  FIVE  CHILDREN.  Also  in  the  same  volume,  p.  260,  is  given  by 
Mr.  Streatfeild  a  description  of  seven  cases  of  convergent  strabismus  in  one 
family,  viz.  six  children  of  one  mother,  and  two  cousins,  all  being  boys  but  one. 
Again,  at  p.  153,  are  described  by  the  same  author  two  instances  of  rare  and  here- 
ditary coloboma  of  the  iris,  in  one  case  seven  members,  chiefly  males,  of  the 
mother's  family,  being  affected;  in  the  other  case  a  brother  and  sister,  two 
cousins,  and  a  grandfather.  At  p.  366  of  vol.  v  of  the  '  Reports'  is  quoted  a  case 
of  congenital  irideremia  in  a  woman,  of  whose  two  children  one  was  in  the  same 
state.  Mr.  Hussey,  of  Oxford,  has  lately  mentioned  to  me  a  case  in  which  a  man, 
£et.  40,  had  soft  cataract,  whose  mother  had  had  cataract,  and  whose  daughter,  at 
about  fifteen,  had  soft  cataract  in  both  eyes.  In  Mr.  Chance's  work  on  *  Bodily 
Deformities,'  part  i,,1862,  p.  71,  is  related  a  case,  recorded  by  Dr.  Staveley  King, 
of  a  woman  with  the  sclerotic  perfectly  blue,  whose  mother  and  grandfather  had 
the  same  kind  of  eyes.  Professor  Humphry,  of  Cambridge,  has  informed  me  of 
an  entire  family  affected  by  ptosis,  whose  father  had  the  same  peculiarity. 

1  Tomes  i  and  ii,  1847. 


502  Original  Communications.  [April, 

the  tip  of  the  first  finger  on  both  hands  existed,  however,  a  smar 
depression,  and  at  the  tip  of  the  third  one  was  a  slight  amount  of 
thickening  of  the  integument  where  the  nail  ought  to  be.  The  toes 
of  both  feet  were  exactly  in  the  same  condition,  i.  e.  the  second  and 
third  toe  had  only  two  phalanges,  the  fourth  and  fifth  only  one 
phalanx;  all  the  toes,  with  the  exception  of  two  (unlike  the  fingers), 
had  nails.  The  thumbs  were  all  right,  also  the  great  toes,  and  were 
free  from  any  defect. 

When  further  examining  the  fingers,  I  found  that  the  young 
woman  was  apparently  at  very  little  disadvantage  by  reason  of  this 
pecuharity,  as  she  could  sew,  work  crochet,  and  pick  up  anything 
readily  with  the  fingers ;  she  could  also  play  dexterously  on  the 
pianoforte.  The  hitegument  of  the  tips  of  the  fingers  evidently 
enjoyed  a  high  degree  of  common  sensibilit}^,  although  it  was  of 
unusual  thickness  and  hardness,  and  possessed  its  full  share  of 
tactile  discrimination,  as  indicated  by  the  aphemetric  compass.^ 
No  other  malformation  or  defect  of  the  body  existed. 

On  examining  into  the  family  history,  I  ascertained  that  this  kind 
of  malformation  was  not  restricted  to  the  young  woman  alone.  Her 
father  had  had  ten  children;  and  two  sons  and  one  daughter,  in 
addition  to  herself,  have  the  defect.  In  the  case  of  the  sister,  all 
the  fingers  of  both  hands  were  defective,  each  wanting  one  phalanx. 
In  that  of  one  brother,  who  was  alive  and  married,  and  who  had  the 
same  defects  of  the  fingers,  the  defect  existed  in  his  two  sons  also. 
In  that  of  another  brother,  also  married,  and  with  children,  now 
living  in  Australia,  the  same  defect  exists  in  some  of  his  sons. 
The  third  brother  who  had  the  defect  never  married. 

In  the  case  of  an  aunt  (the  father's  sister)  there  was  the  same 
defect,  as  also  in  four  of  her  sons,  a  fifth  son  being  exempt.  An 
uncle  (a  brother  of  the  father)  who  was  himself  perfect,  had  married 
for  his  second  wife  a  kind  of  cousin  of  the  name  of  C — ,  and  out 
of  their  six  children  four  had  fingers  and  toes  in  a  similar  defective 
condition.  The  children  by  the  first  wife  were  perfect.  Among 
these  various  relatives  it  was  also  said  that  all  those  who  have  their 
toes  so  deformed  have  their  two  middle  toes  adherent,  presenting 
a  webbed  condition ;  in  some  cases  also  the  fingers  are  in  like 
manner  webbed.  It  appears  also  that  in  some  instances  the  webbed 
and  united  toes  have  been  separated,  but  in  the  case  of  a  brother  the 
union  of  the  bones  was  pronounced  by  a  surgeon  to  be  so  complete 
that  separation  could  not  be  attempted.  There  are  generally  two 
toes  webbed  together  on  one  or  both  feet,  and  in  some  cases  it  is 
the  same  with  the  fingers  on  one  of  the  hands.  It  is  so  in  one 
hand  of  a  brother  and  also  of  his  little  girl.  In  all  cases  the  thumbs 
are  perfect,  having  nails,  but  in  some  individuals  they  are  remarkably 
broad  and  flat,  and  will  not  bend  at  the  joint ;  in  others  the  thumbs 

'  An  interval  of  one  tenth  of  an  inch  between  the  points  being  discriminated. 


1872.]  Hereditary  Transmission  of  Structural  Peculiarities,  503 

are  ''partially  turned  round,"  to  use  tlie  woman^s  expression. 
It  was  stated  that  there  was  a  great  and  often  striking  resemblance 
in  features,  which  are  generally  considered  to  be  oi  a  Jewish  type, 
between  all  who  have  the  defect. 

Enquiring  still  further  as  to  the  family  history,  I  found  that  the 
young  woman  understood  that  the  above-mentioned  defect  was 
known  to  have  existed  for  two  or  three  generations,  and  to  have 
existed  upon  and  to  have  been  inherited  from  the  father^s  mother's 
side,  whose  name  was  C — .  Their  grandmother  had  the  defect  in 
hands  and  feet,  and  herself  had  nine  children,  of  whom  two  sons  and 
a. daughter  had  the  malformation.  (These  have  been  alluded  to.) 
The  mother  remembers  that,  when  she  was  twenty-one  years  of  age, 
she  knew  a  lady,  set.  70,  in  Lincolnshire,  who  had  the  defect 
in  her  fingers.  Her  maiden  name  had  been  C — .  She  married, 
but  had  no  children.  She  had  also  been  given  to  understand  that 
many  individuals  in  and  about  Manchester,  but  of  different  surnames, 
had  a  similar  peculiarity,  and  that  or  near  Lincoln,  at  the  present 
time,  resided  a  family  of  the  name  of  C — ,  the  members  of  which 
were  said  to  have  it  also,  and  who  were  therefore  looked  upon  by  her 
friends  in  London  as  being  relatives.  One  was  a  captain  in  the 
army,  who  is  now  dead ;  he  had  the  defect,  but  never  married.  On 
learning  this  I  communicated  with  Dr.  Palmer,  resident  physician 
at  the  Lincoln  Asylum,  and  asked  him  to  be  so  good  as  to 
make  some  inquiries  for  me  on  the  matter.  He  replied  that  he 
had  found  that  a  family  of  the  name  of  C — ,  living  in  Lincoln 
and  its  neighbourhood,  have  deformity  of  the  fingers ;  that  adju- 
tant C — ,  of  the  militia  (now  dead),  had  "short  fingers;"'''  that 
his  brother,  parish  clerk  of  one  of  the  churches  (also  dead),  had 
short  fingers ;  that  two  daughters  of  the  latter,  and  also  several  of 
their  cousins  (all  living),  have  short  fingers;  and  that  a  second  or 
third  cousin  of  these  women,  who  has  a  similar  deformity,  had  been 
recently  confined,  and  that  the  child  has  some  of  its  fingers  webbed. 
Dr.  Palmer  understood  that  there  were  several  other  instances, 
occurring  in  the  same  family,  of  the  same  kind  of  defect. 

The  young  woman  whose  case  I  have  related  also  informed  me 
that  a  family  was  known  to  be  living  in  Manchester  whose  fingers 
were  deformed,  and  who  were  supposed  in  consequence  to  be  distant 
relations.  Mr.  Windsor,  surgeon  of  that  city,  has  been  able  to 
trace  for  me,  at  any  rate,  one  family  with  the  defect.  He  visited 
one  of  its  members,  a  cutler,  set.  73,  who  "appeared  to  want  the 
last  two  phalanges  of  most  of  the  fingers  (so-called  spontaneous 
amputation),  and  learnt  from  him,  though  not  inclined  to  be  very 
communicative,  "  that  there  were  at  least  nine  relations  of  his  in 
whom  the  hands  were  defective." 

The  above  case  is  highly  interesting  in  reference  to  the  subject  of 
hereditary  deficiencies  in  or  suppression  of  the  phalanges,  and  may 


504  Orif/mal  Communications.  [April, 

be  considered  in  connection  with  the  instructive  communication,  to 
which  I  will  specially  draw  attention,  by  Dr.  Struthers,  professor 
of  anatomy  at  Aberdeen,  published  in  the  'Edin.  New  Philosophical 
Journal''  for  July,  1863,  on  variation  in  the  number  of  fingers 
and  toes  and  in  the  number  of  phalanges  in  man.  In  that  paper, 
after  reference  to  cases  of  increase  and  diminution  in  the  number 
of  entire  digits,  with  and  without  hereditary  origin  (distant  or 
otherwise),  the  author  adduces  cases  of  variation  in  number,  both 
increase  and  diminution  of  phalanges,  noticing  one  which  is 
remarkable  in  relation  to  the  case  which  I  have  quoted,  described 
by  Dr.  0.  H.  Bell,  of  St.  Andrew's,  in  which  all  the  fingers  and  toes 
wanted  a  phalanx  in  several  members  of  a  family ;  also  a  case  in 
which  four  fingers  of  one  hand  possessed  but  one  phalanx  each,  the 
thumb  having  two  phalanges  ;  also  a  case  in  which  the  fingers  were 
so  formed  as  to  give  the  hand  a  resemblance  to  a  foot,  and  also  a 
case  of  five  rudimentary  digits  on  the  hand.  None  of  the  cases 
were,  however,  hereditary.  In  the  instance  of  the  person  in  whom 
a  phalanx  on  each  finger  and  toe  was  wanting  (the  same  defect 
which  exists  in  the  case  I  have  just  related  at  large)  a  brother  and 
a  sister  were  similarly  afi'ected.  It  did  not  appear  that  any  other 
collateral  relative  or  ancestor  had  the  defect  in  question.  The 
patient  could  "  easily  seize  and  retain  minute  articles,  as  a  needle  or 
pin,  between  the  thumb  and  index  finger,  and  could  write  with 
comparative  ease.'"'  Dr.  Struthers,  contrasting  hereditary  cases  of 
variation  affecting  the  hand  alone  with  those  of  the  foot,  observes 
that  a  far  higher  proportion  exists  in  which  the  hand  is  afi'ected  than 
the  foot ;  this  fact  coincides  with  the  zoological  one,  that  in  those 
mammalia  in  which  digits  differ  in  number  on  two  feet,  the  greater 
number  is  on  the  fore  foot.  He  notices  a  curious  fact  in  one  case 
in  which  an  increase  of  digits  existed  (this  variety  being  transmitted 
through  at  least  four  generations),  and  that  is,  that  the  variety,  so 
far  from  being  weakened,  had  gathered  force  in  each  new  generation, 
"although  it  had  not  the  advantage  of  the  greater  development 
attending  utility  to  enable  it  to  increase  its  hold  on  the  organism.^' 
The  defect  made  its  way  to  an  additional  limb  in  each  successive 
generation. 

Dr.  Struthers  also  noticed  that  the  defect  or  variation  as  to  digits 
extended  in  some  cases  in  depth  as  well  as  symmetrically  and 
serially,  beginning  at  one  phalanx  and  extending  at  length  to  the 
metacarpal  or  metatarsal  region.  He  alludes  to  two  cases,  of  which 
he  had  heard,  in  whiclt  the  thumb  alone  was  wanting,  in  one  of  the 
cases  on  both  hands.  As  before  said,  Dr.  Struthers  only  adduces 
one  new  case  resembling  the  one  I  have  recorded,  in  wanting  a 
phalanx  of  each  finger  and  toe,  but  he  quotes  the  case  of  hereditary 
transmission  of  deficient  phalanx  by  A.  Robert,  mentioned  by 
Mr.  Sedgwick,  to  which  I  have  already  alluded  above,  and  also  the 


1872.]  Hereditary  Transmission  of  Structural  Peculiarities.  505 

case  related  by  Dr.  Kellie,  of  Leitli,  in  the  '  Edin.  Medical  and 
Surgical  Journal'  for  1868_,  alluded  to  by  Mr.  Sedgwick,  as  before 
described. 

Professor  Struthers  refers  to  and  quotes  several  of  the  more 
interesting  cases  of  hereditary  transmission  of  increase  in  the  number 
of  digits  placed  on  record.^  This  variation  in  the  number  of  digits 
or  phalanges  is  much  more  common  than  the  diminution,  and  is 
pictured  by  Struthers  in  the  paper  alluded  to,  and  by  Annandale  in 
his  book  on  the  '  Malformation,  Diseases,  and  Injuries  of  Pingers 
and  Toes.'' 2 

Lately  a  case  was  described  in  the  'Brit.  Med.  Journ.,'  for 
April  22,  1871,  p.  433,  in  which  two  supplemental  fingers  were 
removed  by  Dr.  Churchill,  jun.,  of  Dublin. 

Hereditary  transmission  of  this  polydactylism,  as  well  as  of  web- 
bing of  the  fingers  and  toes,  is  alluded  to  by  Sedgwick,  and  several 
cases  are  cited  by  him.  Por  some  others  which  he  does  not  quote, 
or  which  have  been  published  in  England  since  his  papers,  see  the 
following  places,  viz.  '  Med.  Times  and  Gazette,'  1861,  March  23, 
p.  312  ;  also  1862,  Aug.  23,  p.  212 ;  also  1863,  June  20,  p.  656 ; 
also  1863,  Nov.  14,  p.  520;  also  1865,  Dec.  2,  p.  606. 

Darwin  also  alludes  to  it  in  his  work  before  cited,  vol.  ii,  pp.  12 
and  13.  He  remarks,  that  the  number  of  five  digits  is  not  exceeded 
by  any  mammal,  bird  or  existing  reptile.^ 

^  He  quotes  the  Old  Testament  case  of  the  son  of  the  giant  in  Gath,  who  had  six 
fingers  on  each  hand,  and  six  toes  on  each  foot ;  and  also  the  two  cases  mentioned 
hy  Pliny  (Book  xi,  ch.  43),  among  the  Komans,  with  six  fingers  on  eacli  hand ; 
and  also  the  case  of  Anne  Boleyn,  with  six  fingers  on  each  hand. 

Snch  superfluities  are  not  always  possessed  with  impunity,  as  I  find  that  Dr.  M. 
Clarke  observes('  Trans,  of  Ethnolog.  Soc.,'  new  series)  that  among  the  Africans  of 
Sierra  Leone  a  child,  in  one  instance,  born  with  supernumerary  fingers  was  burnt 
alive,  soon  after  birth,  on  that  account,  and  in  another  instance  the  children  were 
destroyed  by  twisting  the  neck,  and  then  buried  in  a  dung-heap.  Burton,  in  his 
"  Notes  on  Waltz's  Anthropology"  (Vol.  i  of  '  Memoirs  of  the  Anthropological  Soc.,' 
1863-4,  p.  235),  mentions  that  the  Shaykhs  of  the  Great  Fazli  Tribe  have  invariably 
six  fingers  on  their  hands.  He  also  observes  that  in  Persia,  if  a  Sayzid  child,  a 
descendant  of  the  Prophet,  be  born  without  the  upper  eyelids  being  pink,  it  is 
not  believed  to  be  legitimate. 

'  No  doubt,  the  commonest  instance  of  hereditary  transmission  of  variety,  as 
regards  the  fingers,  is  in  the  crookedness  of  the  little  fingers.  Dr.  Dobell  de- 
scribes, in  the  'Trans,  of  the  Med.-Chir.  Soc.,'  vol.  xlvi,  p.  25,  a  case  in  which, 
along  with  thickening  of  all  the  joints  of  the  fingers,  crookedness  of  the  little  and 
ring  fingers  was  transmitted  hereditarily  for  five  generations.  Mr.  Annandale, 
in  his  '  Edinburgh  Lectures  on  the  Malformations,  &c.,  of  the  Fingers  and  Toes,' 
refers,  among  other  points,  to  congenital  deficiencies,  both  of  entire  digits  and  of 
their  segments,  the  phalanges.  He  observes  that  diminution  in  number  of  the 
digits  is  usually  associated  with  deficiency  in  number  and  development  of  the 
phalanges,  and  alludes  to  the  description  of  cases  by  Simpson  and  Montgomery, 
in  which  portions  of  the  digits  have  been  spontaneously  amputated  in  ufero.  He 
relates  several  cases  of  such  deficiencies,  which  are  represented  in  a  plate.  In 
none  of  these  do  I  find  that  any  hereditary  history  of  the  malformations  existed. 

^  Darwin,  op.  cit.,  ii,  p.  13,  alludes  to  the  re-growth  of  supernumerary  fingers 
after  amputation.  At  p.  IG  he  speaks  of  the  latent  tendency  to  the  formation  of 
an  additional  digit  as  existing  in  all  mammals,  including  man. 


506  Orifjinal  Communications.  [April, 

I  would  here  refer  to  a  paper  lately  published  by  Dr.  Weiizel 
Gruber,  of  St.  Petersburg,  which  contaiaa  the  most  complete 
analysis  existing  of  all  the  cases  of  polydactylism,  including  two 
additional  cases  (with  illustrations)  of  his  own.  This  communica- 
tion^ gives  nearly  a  hundred  references  to  cases  of  which  a  great 
many  were  instances  of  hereditary  transmission  of  the  malfor- 
mation.^ 

Polydactylism  is  exhibited  in  that  well  known  variety  of  our 
English  fowl  called  the  Dorking  (which  has  five  toes),  also  in  a 
variety  of  the  dog  described  as  having  a  supernumerary  toe  on  the 
hind  foot,  by  Cuvier  (^Disc.  Prehm.  Ossem.  Fossiles/  ed.  iv,tom.  1, 
p.  205),  and  quoted  by  Palmer  in  his  edition  of  Hunter^s  works, 
vol.  iv,  p.  329. 

Casting  about  for  other  recent  instances  of  hereditary  transmission 
of  deficiencies  in  the  fingers  or  phalanges,  I  obtained  the  follow- 
ing highly  interesting  one  from  my  friend  Professor  EoUeston.  It 
is  that  of  a  woman  living  at  Oxford,  who  has  the  following 
variation  of  fingers  on  both  hands.  The  forefingers  are  the  shortest, 
the  second  fingers  are  the  next  shortest,  the  ring  fingers  are  the 
longest  of  all,  and  tlie  little  fingers  the  next  longest.  This  pecu- 
liarity of  structure  already  extends  to  four  generations,  being 
found  in  the  woman  herself,  her  father,  her  father^s  mother,  and  her 
own  little  boy. 

As  regards  observations  on  hereditary  malformations  of  fingers,  I 
may  mention  a  case  of  hereditary  deformity  (webbed  fingers),^ 
in  four  successive  generations,  published  by  Mr.  H.  Barker,  of 
Ulverstone,  in  the  '^  Medical  Mirror^  for  December,  1864,  p.  758. 
In  this  singular  case,  a  woman,  J.  K — ,  both  thumbs  are  deformed ; 
as  respects  one  thumb,  there  are  two  distinct  bones  in  the  metacarpus, 
and  the  first  phalanx  is  all  right,  but  there  are  three  distinct  phalanges 
in  the  ungual  end  of  the  thumb ;  the  other  thumb  presents  only  one 

•  See  '  Bulletin  de  FAcademie  Imperiale  des  Sciences/  vol.  xv,  1870,  pp.  460 — 
483.  Zusainmenstelliing  veroffentlicher  Falle  von  Polydactylie,  mit  6  Fingern  an 
der  Hand  und  6  Zehen  an  dsm  Fusse ;  und  Beschreibung  zweier  neuen  Falle  von 
Duplicitat  des  Daumens. 

^  The  subject,  not  only  of  supernumerary  fingerg,  but  of  supernumerary  hands, 
is  exemplified  by  a  case,  recorded  in  vol.  xlvi  of  the  '  Transactions  of  the  Med.- 
Chir.  Soc.,'  1863,  p.  29,  of  a  woman  with  three  hands,  illustrated  by  analogous 
malformations  in  the  lower  animals,  and  communicated  by  Mr.  Jardine  Murray,  of 
Brighton.  The  case  does  not  seem  to  have  been  hereditary.  Mr.  Murray  ex- 
hibited drawings  of  preparations  of  double  feet  in  the  pig,  from  the  museum,  and 
of  a  similar  malformation  in  birds,  lent  by  Mr.  Cobbold.  In  passing  I  would  here 
refer  to  a  communication  by  Dr.  Struthers,  in  vol.  iii  of  the  '  Journal  of  Anatomy 
and  Physiology,'  of  a  case  of  additional  bone  in  the  human  carpus,  which  occurred 
in  both  wrists  at  the  same  place ;  he  alludes  to  the  few  cases  in  which  an  additional 
bone  has  been  found  in  the  human  carpus. 

3  Mr.  Murray,  in  the  description  of  the  case  of  the  woman  just  mentioned 
with  three  hands,  speaks  of  the  webbing  of  fingers  as  due  to  ^absence  of  fission, 
or  properly  to  an  arrest  of  development ;  for  in  the  embryo  the  rudiments  of 
hands  and  feet  do  not  at  first  pi'esent  any  division  of  the  fingers  and  toes. 


1872.]  Hereditary  Transmission  of  Structural  Peculiarities.  507 

metacarpal  bone,  but  lias  two  phalanges  at  its  ungual  cud ;  also  a 
separate  supplemental  metacarpus.  This  person  was  the  only  one 
of  five  children  who  had  the  defect.  It  appears  that  her  grand- 
mother, during  pregnancy,  was  bitten  and  seriously  injured  by  a  dog, 
and  had  her  hands  much  lacerated.  Her  child  (the  father  of  J.  K — ) 
presented  at  birth  the  same  appearances  observed  in  J.  K — .  J. 
K —  has  had  five  children,  viz.  one  son  and  four  daughters ;  the 
son  and  youngest  daughter  had  the  deformity,  the  three  intermediate 
daughters  being  free  from  the  deformity.  Her  son  married,  and 
had  six  children,  and  one  only  out  of  the  six  escaped  malformation. 
The  youngest  daughter  also  married,  and  had  two  boys,  and  of  those 
one  had  the  deformity.     To  this  case  I  allude  later  on  (see  p.  517). 

Mr.  Brodhurst,  who  informs  me  that  hereditary  contraction  of  the 
toes,  and  especially  the  second  toe,  is  often  hereditary,  has  only 
once  met  with  it  in  the  fingers.  For  club-foot,  which  is  often 
hereditary,  he  has  operated  on  three  generations  of  one  family.^ 

I  find  an  interesting  case  of  hereditary  webbing  of  the  fingers, 
related  by  Dr.  Harker,  of  Lancaster,  in  the  'Lancet'  for  1865, 
September  30th.  The  individual  was  an  active  and  intelligent  boy, 
all  of  whose  fingers  were  webbed  and  united  together  completely  to 
their  tips,  the  little  fingers  having  an  extra  nail. 

The  thumb  of  the  right  hand  possessed  three  sets  of  phalanges, 
that  of  the  left  hand  had  two  sets  webbed  together,  the  right  tliurab 
being  furnished  with  three  nails,  the  left  one  with  two.  Tlie  little 
toe  of  the  right  foot  was  webbed  to  the  next  toe.  It  appeared  that 
the  child's  father  and  grandfather  had  similar  hands.  Some  (not 
all)  of  its  brothers  and  sisters  have  similar  hands. 

In  Mr.  Chancers  work  '  On  the  Nature,  Causes,  Varieties,  and 
Treatment  of  Bodily  Deformities,'^  a  case  is  cited  of  Dr. 
Pollock's,  of  Hatton  Garden,  in  which  five  out  of  eight  children 
(brothers  and  sisters)  have  an  absence  of  a  movable  articulation 
between  the  second  and  the  end  phalanges  of  the  forefinger,  which 
thus  has  two  instead  of  three  joints.  In  two  of  the  children  this 
exists  in  both  hands,  and  in  the  three  others  in  one  hand.  The 
deformity  has  existed  in  the  family  for  four  generations,  and  it  is 
understood  that  it  also  existed  in  a  fifth  generation. 

In  considering  the  above  cases  of  hereditary  transmission  of 
DEFECTS  in  man,  one  is  naturally  tempted  to  inquire  whether  they 
can  in  any  degree  be  referred  to  "  reversion  "  or  retrogression  to 
any  ancestral  type.     My  friend  Mr.  Mower  thinks  this  can  have 

1  Mr.  Brabazan,  describing  a  case  of  malformatioti  in  the  'Dublin  Hospital 
Gazette'  for  1854  (vol.  i,  p.  375),  observes  that  congenital  malformation  of  the 
upper  limb,  as  contrasted  with  the  lower  limb,  are  rare.  He  remarks  that  con- 
genital malformation  of  the  Iiaiid  follows  the  law  of  other  congenital  malforma- 
tions, representing  the  natural  condition  of  the  limb  in  lower  animals,  the  i)cr- 
sistence  of  the  interdigital  membrane  producing  an  accurate  resemblance  to  the 
limb  of  the  Cheiroptera. 

'  Part  i,  1862,  p.  79.     Part  ii  was,  I  believe,  never  published. 


508  Original  Communications.  [April) 

nothing  to  do  with  defect  either  in  numbers  of  digits  or  of  phalanges, 
for  the  lowest  known  types  of  mammals  have  the  same  number  as  in 
man.  He  observes  : — "  The  most  imaginative  evolutionist  has 
never  attempted  to  trace  his  descent  through  any  of  the  paucidigi- 
tate  types^  unless  it  be  some  in  which  the  pollex  or  hallux  alone  are 
rudimentary  or  suppressed."  Mr.  Flower  had  not  met  with  any 
cases  of  hereditary  transmission  of  defective  phalanges.  Neither 
had  Mr.  W.  K.  Parker,  the  w^ell-known  author  of  most  valuable 
researches  in  natural  history  and  comparative  anatomy,  who  observed 
to  me  that  he  did  not  know  of  any  of  the  quadrumana  that  have 
other  than  certain  toes  and  fingers  abortively  developed.  He 
remarks,  '^In  the  Potto  (Peredicticus)  the  thumb  has  the  usual 
phalanges/  and  the  index  is  a  single-jointed  stump.  The  third 
finger  is  short,  but  has  possibly  the  usual  number  of  phalanges.^' 
Mr.  Parker  observes  that  many  odd  things  of  this  sort  occur  in  that 
order,  but  no  regular  absence  of  all  the  terminal  digits.  He  further 
remarks  that  "the  number  of  phalanges  has  become  restricted  in 
man,  and  if  we  went  down  amongst  oviparous  prototypes  we  should 
find  more  and  not  fewer  joints.  As  a  rule,  the  modification  of  the 
human  hand  is  by  excess,  and  that  is  very  doubtfully  to  be  referred 
to  reversion.""  ^ 

I  would  here  allude  to  the  elaborate  and  interesting  researches  of 
Professor  Humphry,  of  Cambridge,  "  On  the  Myology  of  the  Limbs 
of  the  Man,  the  Ai,  the  Two-toed  Anteater,  and  the  Pangolin," 
published  in  the  fourth  volume  of  the  '  Journal  of  Anatomy  and 
Physiology.''  In  this  communication  consideration  is  given  to  the 
carpus,  tarsus,  and  digits  of  these  animals,  and  also  observations  on 
the  order  and  manner  of  suppression  of  digits. 

On  the  whole,  the  above  recorded  cases  of  hereditary  defect  of 
fingers  or  parts  of  fingers  must  be  looked  upon  as  instances  of  arrest 
of  development  {i.  e.  of  abortion),  ^'anomalous  arrest  of  an  early 
character,^'  the  persistence  of  an  embryonic  condition,  to  use  Mr. 
Darwin's  phrase,  or  the  result  of  some  perverted  formative  power  in 
the  sperm-cell  itself,  the  tendency  to  which  has  been  transmitted 
from  ancestors,  just  as  other  minute  peculiarities  or  qualities, 
psychical  or  physical,  may  be  handed  down.     We  are  well  aware  of 

1  See  Mivart's  '  Genesis  of  Species,'  p.  105. 

^  Mr,  Harker,  of  Lancaster,  who  informs  me  that  he  has  had  under  his  notice 
some  interesting  cases  of  accessory  toes  in  children,  observes  that  he  has  noticed 
"  that  between  the  fore  and  middle  rays  of  the  palmar  or  pedal  membranes  there 
is  occasionally  a  certain  amount  of  union.  These  rays  acting  in  unison,  as  they 
do  by  their  anatomical  relations,  seem,  on  that  account,  to  be  occasionally  united 
at  the  base  of  the  first  phalanges,  and  this  not  merely  by  webbing,  but  by  the 
whole  fleshy  structure;  this  is  especially  the  case  in  the  index  and  middle  toe." 
Again,  he  remarks,  "that  palmar  and  pedal  degeneration  shows  itself  as  frequently 
in  the  tendency  to  increase  in  the  number  of  the  rays  as  in  the  retrogressive  ten- 
dency in  the  way  of  deficiency  of  phalanges  of  the  less  important  rays.  The  sub- 
ject of  their  malformation  is,  no  doubt,  one  of  very  great  importance,  not  merely 
as  to  degeneration,  but  also  as  to  human  type  and  character." 


1^72.]  Hereditary  Transmission  of  Structural  Peculiarities,  509 

numberless  such  instances  among  domestic  animals,  and  it  is  well 
known  that  qualities  which  have  only  accidentally  arisen  may  be 
transmitted.  Thus  we  get  what  is  called  "  breeding  "  or  variety  of 
"race/'  and  even  new  races.  Take,  for  example,  the  race  of 
"  Otter  sheep/'  which,  with  peculiarly  long  bodies  and  short  legs, 
have  originated  in  Massachusetts.^  Again,  we  have  a  race  of  Hun- 
garian cattle  with  ?mcloven  hoofs. ^ 

It  is  not  unlikely  that  mutilation  was  originally  the  source  of 
many  inherited  defects.  In  support  of  this  supposition  I  will  quote 
instances  of  the  hereditary  transmission  of  the  results  of  mutilation, 
as  well  among  animals  as  man. 

Thus  Waitz'^  quotes  the  observations  of  Williamson,  who  saw  dogs 
in  Carolina  which  have  been  deficient  in  tails  for  three  or  four 
generations,  in  consequence  of  one  of  their  ancestors  having  acciden- 
tally lost  it.  A  cow,  three  years  ago,  which  had  lost  by  suppuration 
her  left  horn,  produced  three  calves  which,  instead  of  the  left  horn, 
presented  only  a  small  protuberance  on  the  skin.  Darwin  (op.  cit.,  p. 
12)  alludes  to  this  case  and  to  hereditary  absence  of  a  horn  in  the 
stag.  Dogs  and  horses  whose  tails  or  ears  are  chpped,  as  the  draught 
dogs  in  Kamtschatka,  often  transmit  these  deficiencies,  according  to 
Blumenbach,  to  their  off'spring.  A  bull  without  horns,  in  Paraguay,^ 
produced  only  calves  without  horns,  and  a  buck  goat  with  cartilagin- 
ous prominent  nasal  organs,  transmitted  its  peculiarities  to  its  offspring. 

Darwin,  quoting  Sedgwick,  speaks  (op.  cit.,  vol.  ii,  p.  23)  of  a 
soldier  who  lost  an  eye  by  ophthalmia,  and  whose  two  sons  were  micro- 
cephahc  on  the  same  side ;  and  Sedgwick  alludes  (op.  cit.,  p.  484) 
to  small-eyed  boys,  the  sons  of  a  father  who  lost  an  eye  by  ophthal- 
mia. Darwin  (op.  cit.,  p.  23)  alludes  to  cases  recorded  of  cats,  dogs, 
and  horses  which  have  had  their  tails,  legs,  &c.,  injured  or  ampu- 
tated, and  whose  offspring  had  the  same  parts  deformed,  and  alludes 
to  a  long  list  of  inherited  injuries  which  Prosper  Lucas  mentions,  and 
which  Mr.  Sedgwick  has  availed  himself  of.  He  refers  to  the 
inheritance  of  exostoses  on  the  legs  (spavin,  ringbones,  splints)  of 
horses,  and  quotes  a  case  from  Blumenbach,  in  which  the  sons  of  a 
man  with  fingers  amputated  had  the  same  fingers  crooked  ;^  also  to 
the  now  celebrated  guinea-pigs  of  Dr.  Brown- Sequard,  which,  when 
rendered  epileptic  by  injuries,  had  offspring  suffering  from  the  same 
affection.^     My  friend  Dr.  Brown-Sequard  informs  me  that  division 

'  See  '  Waitz's  Introduction  to  Anthropology,'  published  by  the  Anthropological 
Society,  1863,  p.  82. 

-  At  the  end  of  this  communication  I  subjoin  some  observations  by  Dr.  Short* 
house  on  the  ditFereuce  betwixt  "breeds"  and  "races." 

^  Loc.  cit.,  p.  83.  [Sedgwick. 

'1  The  hornless  oxen  of  Paraguay   mentioned   by  Azara   are   quoted  by   Mr. 

6  To  this  also  Mr.  Sedgwick  alludes. 

'■'  Corroborated  by  Dr.  Westphal.  See  '  Berliner  Klinischen  Wochenschrift',  1871, 
No.  38. 

98— XLix.  33 


510  Original  Communications.  [April, 

of  the  sciatic  nerve  causes  epilepsy,  and  oftentimes  guinea  pigs  will 
eat  their  own  toes  which  are  deprived  of  sensation.  Their  young 
ones  will  become  epileptic  and  have  defective  toes,  and  also  their 
grandchildren.  At  page  12  of  vol.  i,  op.  cit.,  Darwin  mentions  the 
case  of  a  bitch  with  a  leg  deformed,  having  several  puppies  with  similar 
defect.  At  page  173  of  the  'Brit.  Med.  Journ.'  for  Feb.  10,  1872, 
under  the  title  of  "Transmission  of  Induced  Changes,'"  is  the  record  of 
the  shepherd's  dog  always  having  his  tail  cut  off  to  render  him  exempt 
from  taxes  under  the  old  excise  laws,  and  it  is  stated  that,  in  pro- 
cess of  time,  many  mothers  produced  htters  or  parts  of  a  litter 
wholly  without  tails. 

Waitz  mentions  the  fact,^  that  among  the  Chaonia-Berbers  in  the 
Auras  mountains,  the  absence  of  the  lobule  of  the  ear,  which  also 
occurs  among  the  Cajots,  in  Spain,  has  doubtless  become  general 
from  accidentally  arisen  peculiarity.  He  also  cites  from  authors  the 
following  cases,  viz.  the  children  of  an  officer  whose  little  finger  had 
been  cut  across  and  became  crooked,  possessing  an  analogous  defect; 
and  the  case  of  an  officer,  wounded  in  battle,  transmitting  to  his  chil- 
dren a  scar  on  the  forehead. 

It  might  have  been  expected  that  the  results  of  circumcision,  as 
among  the  Jews,  might  have  become  hereditary.  I  am,  however, 
informed  that  this  is  not  known  to  occur.^ 

It  has  been  thought  by  some  high  authorities  that,  among 
people  who  give  an  artificial  form  to  the  skull,  succeeding  genera- 
tions exhibit  a  similar  shape.^ 

1  Loc.  cit.,  p.  86,  quoted  from  Guyeii,  in  *  L'Institut/  and  '  Nouv.  Ann.  des 
Voyages.' 

^  I  may  mention  the  fact  of  phymosis  very  frequently  existing  in  several  members 
of  one  family.  Thus,  I  am  personally  acquainted  with  a  family  in  which  operations  for 
its  relief  had  been  performed  on  one  brother,  and  on  his  son ;  on  the  son  of  a  second 
"brother;  on  the  son  of  a  third  brother;  on  the  two  sons  of  a  sister;  and  on  one 
Bon  of  another  sister.  Mr.  Prescott  Hewett  has  lately  told  me  of  one  family  in 
which  he  frequently  had  to  operate  for  this  malformation  (phymosis),  which  ex- 
isted in  the  father  and  several  of  his  sons  and  their  children,  as  also  in  several 
sons  of  some  of  the  married  sister's;  but  the  defect  Avas  worse  in  the  sons  of  the 
brothers  than  of  the  daughters.  Mr.  Hewett  had  also  to  operate  for  sebaceous 
tumours  of  the  scalp,  which  had  existed  in  three  generations,  but  which  always 
affected  the  females,  and  never  the  males. 

2  As  regards  the  transmission  of  family  peculiarities  of  various  kinds,  Waitz  ob- 
serves as  follows  (op.  cit.,p.  84)  :— "  Themost  frequently  quoted  instances  of  this  kind 
are  the  thick  lips  of  the  house  of  Hapsburgh  since  its  alliance  with  the  Jagellones ; 
the  tall  life-guards  of  Frederick  I  of  Prussia,  who  produced  a  large-sized  progeny. 
Colour  and  quality  of  the  skin  are  also  transmitted,  and  so  are  temperament,  acute- 
ness,  idiocy,  or  deficiencies  in  the  organs  of  sense.  Instances  of  hereditary  blindness 
and  deafness,  and  of  alternating  dumbness,  so  that  every  second  or  third  child  was 
deaf,  are  given  by  Lucas.  Harris  (see '  Highlands  of  Ethiopia,'  second  edition,  vol.  i, 
p.  286)  communicates  a  case  of  hereditary  blindness  in  one  eye  and  of  a  double 
thumb  on  the  right  hand.  The  so-called  Porcupine-men  of  the  family  Lambert, 
with  their  excrescences  on  the  hands  and  feet,  have  often  been  quoted.  Thomson 
(see  '  Ed.  Med.  Journ.,'  1858,  p.  501)  has  endeavoured  to  prove  that  the  peculi- 
arities of  the  skin  are  transmitted  in  the  male  line,  which  he  supports  by  many 
illustrative  cases.    In  Burmah,   remarkably  hirsute  men  have  been  met  with, 


1872.]  Hereditary  Transmission  of  Structural  Peculiarities,  511 

Very  recently  we  have  had  described  an  interesting  case  of 
transmission  of  acquired  structural  defect  as  occurring  in  the  human 
subject.  I  allude  to  a  case  communicated  by  Mr.  Addenbroke  to 
the  '  Brit.  Med.  Journ./  of  congenital  facial  paralysis  (on  the  left 
side)  in  two  children  (cousins),  whose  mothers,  during  pregnancy, 
had  nursed  their  mother  in  an  attack  of  hemiplegia,  which  came  on 
suddenly  whilst  they  were  lifting  her,  and  which  was  attended  by 
facial  paralysis,  which  specially  attracted  their  attention. 

Sedgwick  quotes  the  case,  observed  by  Stahl,  and  quoted  by 
Steinan  in  his  essay  on  hereditary  disease,  of  a  soldier  who  lost  in 
war  one  of  his  eyes ;  on  his  return  home  he  married,  and  his  wife 
bore  him  a  son,  one  of  whose  eyes  was  quite  dried  up,  so  that  he 
was  monocular  like  his  father. 

Although  Darwin  quotes  cases  of  inherited  transmission  of  results 
of  mutilation,  &c.,  it  is  right  to  say  that  he  speaks  (p.  12)  of  the 
doubtful  subject  of  inherited  mutilation;^  and  at  page  135  of  his 
work  on  the  '  Origin  of  Species,'  when  speaking  of  deficiency  or 
absence  of  anterior  tarsi  or  feet  of  certain  beetles,  observes,  "  there 
is  not  sufficient  evidence  to  induce  us  to  believe  that  mutilations  are 
ever  inherited.'' 

Is  it  unlikely  that  the  races  of  one- eared  and  earless  rabbits  (the 
latter  are  mentioned  by  Darwin"^),  tailless  cats  and  dogs  and  mon- 
keys, which  are  famihar  to  us,  have  had  their  beginnings  in 
mutilations  ? 

Dr.  Shorthouse,^  who  for  twenty-five  years  has  paid  special 
attention  to  the  physiology  of  breeding,  or  "  the  laws  which  regulate 
the  function  of  reproduction,"  and  who  has  records  of  many 
thousands  of  experiments  on  the  subjects,  informs  me  that 
though  he  has  known  many  hundred  cases  in  which  physical  defects 

to  whom  the  peculiarity  was  transmitted  through  three  generations  (see 
*  Ausland,'  1858,  p.  461).  There  are  also  instances  recorded  of  six-fingered,  six- 
toed,  and  of  web-footed  individuals,  who  transmitted  these  peculiarities  to  their 
offspring.  The  frequent  tendency  of  succeeding  generations  to  reproduce  devia- 
tions presents  itself  also  in  the  hereditary  transmissions  of  a  number  of  diseases, 
such  as  goitre,  cretinism,  and  mental  affections."  As  a  curious  and,  I  would  add, 
questionable  instance  of  the  transmission  of  acquired  psychical  qualities,  Waitz 
states  (see  op.  cit.,  p.  83)  that  dogs  who  return  to  a  wild  state  no  longer  bark, 
and  that  "  cats  are  said  not  to  mew  in  America."  Hunter  (see  vol.  iv,  p.  329, 
of  Palmer's  edition  of  his  works)  observes  that  "the  dogs  in  the  South  Sea 
Islands  learn  *  to  bark'  by  imitation."  Pouchet,  in  his  work  on  the  '  Plurality  of 
the  Human  Race,'  1864,  p.  34,  alludes  to  the  fact  of  dogs  not  barking  in  certain 
countries,  or  on  returning  to  the  savage  state,  and  quotes  from  Roulin  observations 
as  to  the  wild  cats  losing  troublesome  me  wings. 

^  Sir  T.  Watson,  in  the  last  edition  of  his  *  Lectures  on  the  Practice  of  Medi- 

icine,'  makes  allusion  to  Darwin's  observations  on  the  transmission  of  acquired 

'  deformities. 

2  Op.  cit.,  vol.  i,  pp.  12  and  108. 

3  Author  of  an  essay  on  the  '  Physiology  of  Breeding ;'  and  of  *  Pedigree  Tables 
[of  many  of  the  most  remarkable  Thoroughbred  Horses  of  the  present  and  past 
[days.' 


512  Original  Communications.  [April, 

and  deformity  have  been  transmitted,  he  has  not  known  a  single 
instance  in  the  lower  animals  of  mutilation  being  transmitted.  This 
he  accounts  for  by  the  fact  that  when  any  animal  is  born  minus  a 
limb  or  other  important  member,  it  is  generally  destroyed  or  sold  to 
the  showman,  and  is  never  used  for  breeding. 

He  says  he  has  seen  hundreds  of  cases  of  malformations  of  every 
kind,  and  thousands  of  such  cases  as  club-foot  being  transmitted. 
"  When  the  malformation  is  of  a  serious  nature,  the  animal  is  not 
used  for  breeding  purposes;  when  it  appears  in  a  more  modified 
form,  so  that  the  animal  may  be  useful  for  such  purpose,  and  the 
animal  is  bred  from  the  malformation,  defect  is  almost  certain  to  be 
transmitted.  The  late  Marquis  of  Westminster  had  a  famous  mare 
called  Glenzner,  which  liad  very  defective  fore  feet,  scarcely  any 
hoof  or  horny  crust  at  all,  and  was  always  lame  unless  she  wore 
'bar'  shoes  with  high  heels.  Most  of  the  foals  inherited  the 
same  defect.  One  of  her  daughters,  named  Melance,  the  property 
of  the  late  Earl  of  Derby,  w^as  famous  as  a  racer  in  spite  of  her 
defective  feet.  She  was  put  to  the  stud  at  the  end  of  her  third 
year,  and  all  her  foals  have  had  the  same  defects  in  the  feet.  There 
is  now  at  the  stud  a  horse  called  Knight  of  Kars.  He  was  not  of 
much  account  himself  on  the  turf,  because  he  had  a  club  foot ;  but 
when  put  to  the  stud  he  w^as  patronised  very  extensively,  because  he 
was  half-brother  to  Stockwell,,  who  was  considered  the  best  stallion 
in  the  world,  and  his  covering  fee  was  200  guineas.  The  Knight  of 
Kars  covered  mares  at  15  or  10  guineas,  and  therefore  breeders 
patronised  him  because  they  argued  that  they  should  have  the  same 
blood  as  Stock welFs  at  a  much  lower  figure.  The  horse  begat 
from  thirty  to  forty  foals  a  year  for  many  years,  and  nearly  all  these 
foals  had  a  club-foot,  and  would  not  stand  training  for  racing 
purposes.  Consequently  the  Knight  of  Kars  is  now  at  a  discount. 
The  sire  of  this  horse,  Nutwith,  and  his  grandsire.  Tomboy,  both 
had  deformed  feet.     I  could  multiply  such  cases  by  hundreds. 

"  There  are  other  characteristics,  though  hardly  to  be  classed  with 
deformities,  which  are  peculiar  to  certain  family  lines,  e.  g.  nine- 
tenths  of  the  descendants  of  a  famous  horse  called  Birdcatcher  have 
a  tendency  to  curbs  on  the  hocks  (a  kind  of  exostosis).  The 
descendants  of  another  famous  horse  called  Melbourne  are  nearly  all 
of  them  afflicted  with  roaring.^' 

Dr.  Shorthouse  proceeds  to  furnish  me  with  a  few  cases  of 
hereditary  mutilation  and  deformity  in  the  human  subject  which 
have  fallen  within  his  own  practice.     They  are  as  follows  : 

"  A  poor  w^oman  formerly  living  at  Carshalton  had  mutilated  hands 
— mutilated  in  utero  ;  the  little  finger  and  the  fingers  next  it  were 
entirely  missing,  and  a  sort  of  little  nipple  grew  at  the  end  of  the 
metacarpal  bone.  That  woman  had  a  husband  whose  urethra  opened 
underneath  the  penis  and  behind  the  glans.     The  couple  had  six 


1872.]  Hereditary  Transmission  of  Structural  Peculiarities.  513 

children,  four  boys  and  two  girls.  Both  the  girls  inherited  the 
mother's  mutilated  hands,  and  all  the  boys  had  the  pecuHar  state  of 
urethra  I  have  described. 

''  I  have  known  several  instances  in  which  a  parent  has  had  an 
extra  finger,  or  toe,  or  breast,  and  has  transmitted  that  super- 
abundant organ  or  appendage  to  one  or  two  offspring ;  but  I  know 
a  case  in  which  a  man  who  had  six  toes  on  each  foot — inherited 
from  his  father — transmitted  the  same  superabundance  to  all  his 
legitimate  children,  and  to  a  few  illegitimate  ones.  Most  of  these 
children  I  brought  into  the  world  myself.  I  once  attended  a 
woman  in  childbirth  with  her  first  child,  and  I  found  that  she  had 
three  mammary  glands  and  three  nipples.  I  ascertained  that  the 
mother  had  the  same  peculiarity.  The  child  to  which  she  gave 
birth  was  a  boy,  and  he  had  only  two  rudimentary  nipples ; '  her 
next  child,  however,  was  a  female,  and  that  had  three  breasts  like 
the  mother.  In  this  case  sex  would  seem  to  have  influenced  the 
transmission  of  the  peculiarity."^ 

^  In  reference  to  cases  of  "  snpernnmerary  nipples,"  and  also  to  eases  of  super- 
numerary fingers  above  alluded  to,  I  would  here  quote  some  observations  which 
I  received  some  time  ago  (and  which  are  interesting  in  connection  with  the 
question  of  reversion)  from  Mr.  Sedgwick,  and  which  arose  out  of  a  consideration 
of  the  use  which  Mr.  Darwin  made  of  such  cases.     He  remarks  as  follows : — 

"If  you  have  not  yet  seen  Darwin's  'Descent  of  Man,'  it  may  interest  you  to 
know  that  he  has,  in  this  lately  published  work,  considei-ably  modified  his  earlier 
statements,  especially  on  the  subject  of  *  reversion ;'  and  that  the  objections  urged 
against  his  theory  in  the  'review'  of  his  work  on  variation  under  domestication 
have  been  strengthened  by  later  observations,  and  have  been  accepted  by  Darwin 
himself.  In  this  review  ('Medico-Chir.  Rev./  July,  1868,  pp.  155-6)  the  subject 
of  supernumerary  digits  was  discussed,  and  objections  were  urged  against  Darwin's 
reasons  for  regarding  such  digits  as  evidence  of  our  being  descended  from  a  fish. 
At  pp.  125-6,  vol.  i,  of  his  present  work,  all  his  former  and  elaborate  reasoning  on 
this  subject  is  given  up,  and  he  now  sees  '  that  it  is  extremely  doubtful  whether 
supernumerary  digits  can  thus  be  accounted  for.'  The  credit  of  having  wrung 
such  an  admission  from  Darwin  is  due  to  Prof.  Gegenbaur,  whose  paper  on  the 
subject  has  settled  the  question  on  that  point. 

"  Another  and,  if  possible,  a  still  more  fatal  admission  is  referable  to  the  occur- 
rence of  supernumerary  mammas.  In  the  cases  I  had  published  they  occurred  in 
the  inguinal  region,  or  on  the  abdominal  surface  of  the  body;  and  Darwin  was 
led  to  refer  such  peculiarities  to  reversion,  because  in  the  lower  animals  which 
have  multiple  mamma),  such  as  the  cow,  they  are  so  placed.  But  in  1869  Prof. 
Preyer  published  evidence  to  show  that  such  supernumerary  mammas  in  the 
human  subject  were  not  limited  to  the  abdominal  surface  of  the  body,  but  had 
been  observed  also  to  occur  on  the  hack ;  and  again  the  evidence  from  reversion 
has  collapsed,  and  Darwin,  with  praiseworthy  candour,  now  writes  '  the  force  of 
my  argument  is  greatly  weakened  or  perhaps  quite  destroyed'  (ibid.,  p.  125,  note). 

"  You  will  readily  see  why  in  the  review  referred  to  so  much  importance  was 
ascribed  to  'reversion,'  for  without  the  support  of  this  principle  in  hereditary 
transmission  cartloads  of  writings  to  show  that  organized  forms  are  liable  to 
*  variation '  become  valueless.  For  reversion  is,  strictly  speaking,  the  backbone 
of  the  argument,  and  without  it  the  whole  theory  of  the  origin  of  species,  and  of 
man's  descent  through  monkeys,  lemurs,  marsupials,  &c.,  from  some  now  lost 
sight  of  ascidian  progenitor,  becomes  not  merely  limp,  but  altogether  without  form 
and  void. 

"  So  great,  indeed,  has  been  the  necessity  for  modifying  the  theory  of  '  natural 


514  Original  Communications,  [April, 

In  considering  the  probability  of  mutilations  and  injuries  having 
been  the  original  cause  of  many  transmitted  or  hereditary  defects,  it 
may  be  allowable  to  entertain  the  question,  whether  they  could  have 
had  their  rise  hi  malformations  consequent  upon  fright  of  the  mother 
during  pregnancy.  How  far  mental  emotion  of  a  mother  can  affect 
the  foetus  in  utero^  is  of  course  a  very  old  and  very  much  debated 
question.  But  we  have  some  good  authority  for  supposing  that  such 
influence  may  exist  and  be  operative.  Darwin,  at  page  61  of  vol.  ii 
of  his  work,  observes,  that  it  is  probable  that  hardly  a  change  of  any 
kind  affects  either  parent  without  some  mark  being  left  on  the 
germ.^     I  do  not  propose  to  introduce  instances  from  well-known 

selection*  as  the  efficient  cause  of  the  origin  of  species,  that  the  greater  part  of 
the  present  work  has  heen  occupied  by  the  consideration  of  '  sexual  selection,'  in 
which  the  same  ground,  differently  planted,  is  again  gone  over,  with  an  equally 
unsatisfactory  result.  For  in  this  theory  of  the  origin  of  species  there  are  two 
great  harriers  which  block  the  way — reversion  and  hybridism.  As  regards 
hybridism,  the  union  of  distinct  species  leads  to  sterility ;  and  as  regards  rever- 
sion, even  from  the  domesticated  to  the  wild  state,  the  change  is  not  true  in  its 
completeness,  for  it  appears  to  be  impossible  (from  various  causes)  for  either 
animals  or  plants  which  have  undergone  much  change  to  live  over  again,  either 
as  regards  themselves  or  their  descendants,  in  a  backward  course,  the  life  that  is 
passed.  Hence  it  may  be  urged  now  as  strongly  as  in  the  review  of  1868  (p.  166), 
with  respect  to  the  150  distinct  breeds  of  pigeons  descended  from  the  wild  rock 
pigeon,  '  that  there  is,  at  present,  no  sufficient  evidence  to  warrant  the  supposition 
that  time  will  confirm  their  promotion,  so  as  to  entitle  them  hereafter  to  the  rank 
of  true  species,'  " 

1  Regarding  amputation  of  limbs  in  the  uterus,  see  observations  of  Sir  J. 
Simpson,  in  the  '  Dublin  Medical  Gazette,'  vol.  x,  p.  220 ;  also  article  "  Foetus,"  in 
the  '  Cyclopedia  of  Anat.  and  Phys.,'  vol  ii,  p.  324,  where  it  is  alluded  to  as  a 
result  of  gangrenous  inflammation. 

The  interesting  observations  of  Harvey  on  transmitted  peculiarities,&c.,  I  have 
never  seen  quoted.  In  his  *  Anatomical  Exercises  on  the  Generation  of  Animals* 
[see  *  Sydenham  Society's  Translation,'  p.  429]  he  observes,  "And  this,  too,  is  a  re- 
markable fact,  that  virtues  and  vices,  marks  and  moles,  and  even  particular  dispo- 
sitions to  disease,  are  transmitted  by  parents  to  their  offspring,  and  that  while 
some  inherit  in  this  way,  all  do  not.  Among  our  poultry  some  are  courageous 
and  pugnaciously  inclined,  and  will  sooner  die  than  yield  or  flee  from  an  adver- 
sary ;  their  descendants,  once  or  twice  removed,  however,  unless  they  have  come 
of  equally  well-bred  parents,  gradually  lose  this  quality,  according  to  the  adage, 
'The  brave  are  begotten  by  the  brave.'"  In  various  other  species  of  animals, 
and  particularly  in  the  human  family,  a  certain  stability  of  race  is  observed ;  nu- 
merous qualities,  in  fact,  both  of  mind  and  body  are  derived  by  hereditary 
descent."  Again,  in  his  tract  '  On  Conception,'  p.  582,  he  says  :  "  By  this  same 
law  the  son  is  born  like  his  parents,  and  virtues  which  ennoble,  and  vices  which 
degrade  a  race,  are  sometimes  passed  on  to  descendants  through  a  long  series  of 
years.  Even  diseases  propagate  their  kind,  as  lepra,  gout,  syphilis,  and  others. 
But  why  do  I  speak  of  diseases,  when  the  moles,  warts,  and  cicatrices  of  the  pro- 
genitor are  sometimes  repeated  in  the  descendants  after  many  generations?" 
[Here  he  alludes  to  the  description  given  by  Aristotle  in  his  *  Hist.  Animal.,' 
lib.  vii,  cap.  6,  and  his  *  De  Gen.  Animal.,'  lib.  i,  cap.  17.] 

"Every  fourth  birth,"  says  Pliny  [lib.  vii,  cap.  11],  "the  mark  of  the  origin 
of  the  Dacian  Family  is  repeated  on  the  arm.  Why  may  not  thoughts,  opinions, 
and  manners  now  pi'evalent,  many  years  hence  return  again,  after  an  intermediate 
period  of  neglect  ?"  Again,  in  his  work  on  *  Generation'  [op.  cit.,  see  p.  408],  he 
quotes  the  saying  of  Seneca  [from  his  '  Nat.  Quast.,'  lib.  iii,  cap.  29],  "  In  the 
semen  is  comprised  the  entire  cause  of  the  future  man;  and  the  unborn  babe 


1872.]  Hereditary  Transmission  of  Structural  Peculiarities.  515 

sources  supporting  this  view,  as  the  reader  will  be  familiar  with 
them.  Mr.  Sedgwicki  quotes  the  case  related  by  Mr.  Wright  (in 
the  'Lancet^  of  1830-31,  vol.  ii,  p.  464),  of  a  woman  frightened  by  a 
ferret  when  pregnant,  and  the  child,  when  born,  had  eyes  precisely 
like  that  animal ;  every  child  born  afterwards  had  the  same  kind 
of  eyes,  and  they  all  became  blind  or  nearly  so  about  the  age  of 
puberty.  Also  the  case,^  related  by  Dr.  Tosbroke  (see  '  Lancet/ 
1830,  vol.  i,  p.  740),  of  a  lady  who  fell  out  of  a  window,  in  a 
state  of  pregnancy,  and  instantly  became  deaf  in  one  ear.  The 
child  produced  by  this  pregnancy  was  born  deaf  in  the  corresponding 
ear.  Later  on,  Mr.  Sedgwick  alludes  to  the  acquirement  of  disease 
through  the  influence  of  maternal  emotion,  and  refers  to  cases  showing 
this  influence  which  have  been  under  his  own  notice. 

I  have  lately  heard  of  the  following  cases,  bearing  on  this 
subject : 

Dr.  Thurnam,  of  the  Wiltshire  County  Asylum,  informs  me  of  the 
case  of  a  woman,  whom  he  met  in  Borrodale,  in  Cumberland,  who 
had  the  left  hand  imperfectly  developed.  The  carpal  bones  were 
normal,  but  there  was  no  trace  of  metacarpal  bones  or  phalanges. 
The  thumb  alone  was  represented  by  a  projection  of  the  skin  half  an 
inch  in  length,  and  supporting  a  tiny  nail.  The  stump  of  the  hand 
had  four  rudimentary  nails  planted  on  the  dorsal  surface,  but  these 
nails  were  in  no  relation  to  bones.  No  other  member  of  the  family 
was  known  to  have  been  similarly  afPected,  but  the  mother  asserted 
that  previous  to  her  birth,  her  mother,  going  to  look  at  the  body  of  her 
dead  son  in  the  dusk,  fancied  he  rose  up  and  tried  to  bite  her  hand. 
To  this  occurrence,  during  her  pregnancy,  the  mother  attributed  the 
malformation  of  the  hand  of  her  child. 

Mr.  Gill,  of  Woburn  Place,  met  with  the  following  case  : 

A  woman,  set.  40,  was  about  six  months'  pregnant  with  her 
eleventh  child,  and  was  feeling  quite  well  when  she  went  to  church 
one  Sunday  morning,  and  there  saw  a  girl  in  front  of  her,  whose 
left  hand  looked  like  a  "  hook.""  From  her  description  it  would 
appear  as  if  the  index  finger  only  remained,  and  that  the  second, 
third,  and  little  fingers  were  lost  at  their  metacarpal  articulation, 
owing  to  burn  or  scald.  The  lady  was  much  frightened,  and  very 
nearly  fainted.  She  felt  no  movement  of  the  child  (she  had  quick- 
ened two  months).  She  was  seen  by  her  medical  man  the  next 
MORNING,  to  whom  shc  related  what  had  occurred,  and  stated  to 
him  her  firm  belief  "  that  her  baby  would  have  something  the  matter 
with  its  left  hand,  remarking,  at  the  same  time,  that  'you  doctors 
don't  believe  this  sort  of  thing ;  but  I  do,  and  we  shall  see.'  "     She 

has  written  within  it  the  law  of  a  beard  and  a  hoary  head,  for  the  whole  body 
and  head  of  future  years  are  already  traced  in  delicate  and  obscure  outlines  in  its 
constitution." 

1  '  Brit,  and  For.  Med.-Chir.  Rev./  April,  1861,  p.  485. 

2  '  Brit,  and  For.  Med.-Chir.  Rev.,'  July,  1861,  p.  202. 


516  Original  Communications.  [April, 

went  to  the  full  time^  and  a  boy  was  born.  Directly  it  was  born 
the  mother  said,  "  No2v  look  at  baby's  left  hand,  and  see  who  is 
right,  you  or  I."  We  found  the  left  hand  with  the  thumb  and 
INDEX  finger  all  right ;  the  remaining  lingers  were  ^'  hooked"  down, 
and  could  not  be  perfectly  straightened,  even  with  force,  and  unless 
pulled  out  were  firmly  fixed  against  the  palm  of  the  hand.  Other- 
wise the  child  was  quite  right,  though  not  a  strong  child. 

Mr.  Davis,  of  Harrow,  relates  the  following  in  the  '  Lancet  -.'  ^ 

A  healthy  woman,  of  twenty-five  years  of  age,  whilst  pregnant 
with  her  second  child,  about  the  sixth  week,  was  walking  one  day 
in  the  street,  when  she  met  a  child  without  arms.  She  was  "  horri- 
fied at  the  sight "  at  the  time,  but  forgot  the  circumstance  until  she 
was  confined,  when  her  infant  was  found  to  be  quite  healthy,  but  to 
have  no  arms.  On  the  left  side  the  glenoid  cavity  and  acromion 
process  of  the  scapula  may  be  plainly  felt,  but  there  was  no  trace  of 
a  humerus.  The  right  side  is  similar  to  the  left,  except  that  a  fleshy 
protuberance  was  attached  to  it,  surmounted  by  a  well-formed  finger. 
This  case  was  quoted  by  Mr.  Chance,  in  his  work  above  quoted 
(see  p.  507)  on  'Bodily  Deformities,'  and  at  the  time  led  to  a 
correspondence  in  the  '  Lancet'  as  to  whether  maternal  impressions 
had  any  influence  on  the  foetus  or  not.  I  myself  have  good  authority 
for  two  cases  in  the  human  subject  of  malformation  of  the  upper 
extremities  resulting  from  fright  in  the  mother. 

The  following  case  is  related  in  volume  ix  of  the  '  Linnaean 
Society's  Transactions '  (p.  323)  by  Mr.  G.  Milne.  A  young 
female  cat,  pregnant  for  the  second  time,  and  at  the  middle  period 
of  gestation  had  its  tail  heavily  trodden  upon  and  injured.  She 
screamed  most  frightfully,  and  ran  out  of  the  room,  and  from  the 
nature  of  the  noise  which  she  emitted  it  was  evident  that  a  con- 
siderable amount  of  terror  mingled  with  the  sense  of  injury. 
Eventually  she  gave  birth  to  five  kittens,  "  one  of  which,  exactly 
resembling  herself,  was  apparently  perfect ;  but  the  other  four  had 
the  tail  most  remarkably  distorted.  About  one  third  of  the  length, 
reckoning  from  the  base,  there  was  a  nochos,  equal  in  size  to  a  very 
large  pea,  or  about  twice  as  thick  as  the  tail  itself,  the  remaining 
portion  being  turned  on  one  side  at  an  angle  nearly  approaching  a 
right  angle,  and,  what  may  deserve  notice,  all  of  them  turned  the 
same  way,  towards  the  left  side."  All  the  kittens  were  at  once 
destroyed,  excepting  the  apparently  perfect  one.  As  this  afterwards 
became  ill  it  was  also  killed,  but  it  was  found  that  ''  this  also  had 
the  tail  distorted  and  turned  aside  at  a  considerable  angle,  although 
free  from  the  knot  which  distinguished  the  other  four." 

I  have  already  (see  pp.  506-7)  quoted  a  case  of  hereditary  deformity 
of  the  hand,  which  appeared  to  have  its  origin  in  an  injury  to  a 
woman  during  pregnancy. 

1  See  October,  1850,  p.  466, 


1872.]  Her editanj  Transmission  of  Structural  Peculiarities.  517 

I  may  here  observe  that  Geoffrey  St.  Hilaire,  Serres,  Bi'eschet_, 
Soemmering,  Meckel,  were  all  in  favour  of  maternal  impressions 
being  communicated  to  the  foetus,  as  mentioned  by  Mr.  Davis  in 
connection  with  the  observations  which  I  have  related  (see  p.  51G). 
I  find  also  that  Burdach  was  inclined  to  believe  in  this  influence  of 
the  mother  on  the  foetus ;  and  that  Morgagni,  Boerrhaave  and  Yan- 
Swieten  (see  article  "Foetus,"  by  Montgomery,  in  the  ^  Cyclop.  Anat. 
and  Phy.,'  above  quoted)  did  not  deny  it. 

The  above  illustrations  of  transmission  of  deformities  are  all 
taken  from  mammals.  My  friend  Dr.  Giinther,  of  the  British 
Museum,  speaking  of  deformities  of  fish,  observes  that  in  certain 
locahties  defect  of  the  intermaxillaries  is  common  with  the  river 
trout ;  and  as  these  cases  are  limited  to  certain  places,  it  may  be  as- 
sumed that  this  is  hereditary.  He  informs  me  that  a  paper  had  been 
read  at  the  British  Association  in  Edinburgh  on  a  locality  where 
most  of  the  trout  are  without  caudal  fin. 

Among  plants  hereditary  transmission  of  defects  is  known  to  be 
not  uncommon.  Darwin  alludes  to  the  subject  in  his  work  on 
'  Variation  of  Animals,  Plants,^  see  vol.  i,  pp.  324  and  365,  and 
also  vol.  ii,  pp.  18,  70,  and  166.  Dr.  Maxwell  Masters  informs  me 
that  the  inheritance  of  abnormal  or  unusual  characters  is  a  very 
common  phenomenon  in  plants  under  cultivation.  ''Most  of  the 
so-called  '  florist^ s  flowers,''  such  as  pelargoniums,  dahlias,  asters, 
roses,  auriculas,  are  abnormal,  and  are,  as  well  as  double  flo\^ers 
in  general,  reproduced  from  seed.''''  The  same  holds  good  with 
many  "  cultivated  vegetables,  cabbages,  broccoli,^^  &c.  &c. 

In  Dr.  Masters^  '  Vegetable  Teratology^  (Ray  Society)  are  obser- 
vations connected  with  the  subject,  see  p.  15,  as  regards  inheritance 
of  fasciation,  also  pp.  226,  235,  305,  and  396.  See  also  last  para- 
graph on  p.  490,  and  the  appendix  regarding  double  flowers.  Dr. 
Masters  remarks  that  the  inheritance  of  abnormal  pecuharities  is  not 
confined  to  cultivated  plants,  but  is  seen  also  in  wild  plants,  though 
to  a  less  degree. 

I  now  add  observations  of  Dr.  Shorthouse  (to  which  at  page  509, 
foot-note,  I  have  alluded),  and  which  he  has  placed  at  my  disposal. 

He  remarks  : — ^'  I  divide  the  lower  orders  of  animals  into  two 
'divisions,''  'races^  and  'breeds/  the  '  races^  being  those  which 
naturally  herd  together,  breed  together ;  and  the  '  breeds^  those 
animals  which  have  been  produced  or  manufactured  by  the  sedulous 
care  of  man.''^ 

"  As  illustrations  of  '  races^  we  may  take  deer.  The  red  deer 
herd  together,  and  never  associate  or  seek  sexual  congress  with 
fallow  deer,  but  keep  aloof.  In  the  park  opposite  my  own  house 
there  is  a  herd  of  red  deer,  used  for  stag  hunting  with  the  Surrey 
hounds,  and  a  herd  of  fallow  deer  indigenous  to  the  park ;  these  two 


518  Original  Communications.  [April, 

herds  keep  aloof  and  never  even  in  rutting  season  come  in  contact. 
Amongst  cattle^  the  Devons,  Herefords,  Mderneys,  &c.,  are  the 
pure  'races/  and  the  renowned  Shorthorns  the  mongrels  or  manu- 
factured animals.  Amongst  sheep  the  Southdowns  are  a  pure  '  race/ 
but  the  renowned  Leicesters  are  the  manufactured  articles.  All  the 
•  horses  we  have  in  this  country  are  mongrels,  all  manufactured. 
We  have  not  a  pure  race  like  the  Arab.  Some,  of  course,  are 
called  '  thorough-bred/  and  some  half  bred  or  cocktails,  but  that  is 
because  the  repeated  thoroughbreds  or  their  ancestors  found  their  way 
into  the  stud  book  some  years  ago,  and  the  owners  of  the '  cock-tails' 
did  not  take  the  trouble  to  obtain  admission  into  such  a  pantheon. 

"  But  what  I  am  driving  at  in  my  distinction  between  races  and 
breeds  is  to  show  that  in  the  pure  races  there  is  no  degeneracy  and 
but  very  seldom  any  deformity  or  monstrosity  ;  they  hold  their  own 
in  a  state  of  purity  and  perfection  without  the  interference  of 
man.  The  'breeds/  on  the  other  hand,  if  left  to  themselves  after 
being  'manufactured/  resolve  themselves  into  their  elements,  and 
traces  of  all  the  mongrels  and  other  animals  of  which  they  were 
concocted  show  themselves  in  a  few  generations.  The  Shorthorns, 
for  example,  were  made  up  of  Devons,  Herefords,  Alderneys ; 
and  if  you  breed  from  Shorthorns  now-a-days,  i.  e,  from  the 
best  Shorthorn  bull  with  the  best  Shorthorn  cow,  you  must 
not  be  certain  what  the  offspring  will  be.  It  may  be  a  Devon, 
Hereford,  or  some  nondescript  animal,  the  like  of  which  was  never 
seen  before.'!  Breeders  of  Shorthorns  know  well  enough  that  at  every 
generation  they  must  either  infuse  new  blood  or  dip  again  into  one 
of  the  original  fountain  stocks  to  prevent  their  breeds  from  degene- 
rating. The  intelligence  and  care  of  man  are  necessary  to  keep 
them  from  decay  or  from  monstrosity,  or  from  resolving  themselves 
into  their  elements.  This  is  not  the  case  with  the  pure  races; 
wherever  they  may  be  located,  whether  on  the  banks  of  the  Exe,  or 
in  the  meadows  of  the  Trent,  or  on  the  plains  of  upland  counties, 
they  always  remain  steadfast  to  themselves  and  produce  reduplications 
of  papa  and  mamma,  and  it  is  but  seldom  indeed  that  a  deformed, 
mutilated,  or  diseased  youngster  is  produced.  The  human  '  race/ 
'  breed'  I  call  it,  as  we  know  it  in  England,  is,  of  course,  only 
mongrel,  a  compound  of  all  sorts  of  races  and  tribes,  and,  therefore, 
deformities,  malformations^  degeneracy,  idiocy ^  mutilation,  &c.  &c., 
are  not  very  uncommon.'' 

Dr.  Shorthouse  has  also  kindly  given  me  the  following  memoranda, 
which  are  highly  interesting  in  connection  with  the  subject  of  breeding 
and  transmission  of  peculiarities.  He  says  he  first  received  the  hint 
on  the  subject  from  Mr.  South. 

He  observes  that  men  with  cleft  palates  do  not  beget  children ; 
they  copulate  in  all  ways  like  other  men,  but  do  not  procreate. 
It  is  a  fact  for  which  there  is  no  explanation.     He  remarks,  "  We 


]873.]  Hereditary  Transmission  of  Btrtctural  Peculiarities.  519 

are  all  acquainted  with  the  relationship  which  the  tonsils  and  glands 
at  the  posterior  part  of  the  palate  have  with  the  organs  of  genera- 
tion ;  also  of  the  fact  that  the  excision  of  the  tonsil  causes  the  ab- 
sorption of  the  testes.  Parotitis  also  is  very  frequently  the  cause  of 
the  wasting  of  the  left  testis.  Of  this  circumstance  I  have  seen  at 
least  thirty  cases.  It  is  probably  because  the  tonsils  and  other  glands 
at  the  posterior  part  of  the  mouth  are  either  defective  or  interfered 
with.  The  non-fecundity  does  not  extend  to  the  weaker  sex,  as 
women  with  cleft  palate  breed  as  well  as  their  more  developed  sisters. 
It  is  also  a  fact  that  cleft  palate  is  about  seven  times  as  frequent  in 
females  as  in  men."  He  goes  on  to  say  next,  "the  young  lions  (or 
lion  cubs)  which  are  whelped  at  the  London  Zoological  Society^s 
Garden  are  all  of  them  born  with  cleft  palate,  and  all  of  them 
DIE.  I  do  not  mean  those  which  are  the  issue  of  one  particular  lion 
or  lioness,  but  of  all  the  pairs  of  lions  and  lionesses  at  the  gardens. 
It  seems  a  sort  of  indigenous  deformity.  But,  as  a  matter  of  fact, 
the  managers  cannot  rear  any  young  lions ;  they  all  of  them  die  and 
all  of  them  have  cleft  palates.^  Now,  in  travelling  menageries 
and  also  at  the  Dublin  Zoological  Gardens,  the  lions  and 
lionesses  rear  up  cubs  to  maturity,  and  none,  or,  at  any  rate, 
very  few,  if  any,  have  cleft  palates.  But,  at  any  rate,  they  live  and 
are  reared,  whilst  those  born  at  the  London  Zoological  Gardens  all 
die  in  infancy."  Is  this  difference,  I  would  ask,  solely  attributable 
to  climate  ? 

In  a  further  communication.  Dr.  Shorthouse  observes,  "  There  are 
many  other  branches  of  the  extensive  subject  of  breeding  in  which 
I  have  amassed  a  number  of  statistics,  such  as  the  nature  of  sterility, 
the  propagation  of  twins.  These  two  circumstances,  .though  at  first 
sight  they  may  appear  very  wide,  are  closely  akin  to  each  other,  and 
I  have  a  mass  of  evidence  in  support  of  such  a  conclusion  which  is 
overwhelming.  The  tendency  to  abort  is  also  nearly  allied  to  the 
tendency  to  produce  or  beget  twins,  or  to  impotency  in  the  male 
and  steriHty  in  the  female. 

"  If  I  am  convinced  of  any  one  thing  more  than  another  relating 
to  the  function  of  reproduction,  it  is  that  impotency,  sterility,  the 
procreation  of  twins,  and  the  tendency  to  abort,  are  but  phases  of 
the  same  condition.  They  may  seem  paradoxical,  but  it  is  a  fact 
which  I  have  verified  in  many  hundreds  of  cases.  The  mere  procrea- 
tion of  twins  is  no  proof  of  extraordmary  virility;  on  the  con- 
trary, it  is  coexistent  with  a  condition  Kke  that  of  impotency.  I 
have  noticed  the  fact  hundreds  of  times  amongst  horses,  bulls,  pigs, 
and  sheep,  and  in  not  a  few  cases  in  the  human  family.     One  of  the 

1  This  statement  is,  I  find,  not  strictly  accurate.  My  friend,  Mr.  Sclater,  the 
Secretary  of  the  London  Zoological  Society,  informs  me  that  though  in  several 
instances  the  lions  born  in  the  Gardens  have  had  cleft  palates,  it  is  not  always  so. 
He  is  unable  to  give  any  explanation  of  the  fact. 


520  Original  Communications.  [April^ 

famous  families  of  thorough-bred  horses  is  known  as  the  Pantaloon 
line,  because  about  thirty  years  ago  a  horse  of  that  name  was  famous 
on  the  turf.  It  is  a  singular  fact  that  the  majority  of  his  daughters 
have  a  tendency  to  barrenness,  but  if  they  do  happen  to  get  a  foal 
they  are  very  likely  to  produce  twins  or  to  slip  twins  before  they 
have  gone  the  full  period.  They  are  either  sterile  or  super- 
naturally  fruitful.  The  sons,  too,  of  Pantaloon  were  all  but 
impotent.  One  of  them  (Windhound)  covered  thirteen  mares  one 
year  at  the  Eawcliffe  stud ;  eleven  of  these  were  barren,  and  one 
of  the  other  two  produced  twins.  Hobbie  Noble,  another  son  of 
Pantaloon,  a  brother  of  Windhound,  was  almost  impotent  in  his  early 
life  and  quite  so  during  his  latter  years ;  all  the  mares  put  to  him 
proving  barren.  He  could  cover  the  mares  but  was  incapable  of 
fertilising  the  ovum,  but  when  he  did  fertilise  the  ovum  he  generally 
fertilised  two  ova.  The  Dupe,  another  son,  had  a  similar  propensity. 
Subjoined  are  a  few  names  of  mares  of  this  family  with  the  results 
of  their  stud  life.i  The  idiosyncrasy  seems  to  be  transmitted  for 
several  generations. 

"  The  Melbourne  line  is  also  another  family  prone  to  impotency 
and  sterility. 

"  In  the  human  family  I  have  seen  hundreds  of  times  that  when 
abortion  with  early  months  of  pregnancy  takes  place,  it  is  almost 
invariably  with  twins.  In  my  earlier  life  I  had  a  very  extensive 
midwifery  practice,  and  in  cases  of  abortion  whenever  I  took  the 
pains  to  search  I  almost  invariably  found  two  or  more  foetuses  in  the 
discharges  and  clots.''^ 

In  some  "  Notes  on  Breeding^'  by  the  same  writer  in  the  '  Sport- 
ing Gazette^  for  March  ^Ist  and  28th,  1863,  the  readers^  in  addition 

1  No.  1.  Barren  in  1858,  1859,  1862,  1863,  1864,  1866,  and  1867. 

2.  Ditto      1856,  1858,  1860,  1861,  1864,  and  1865. 

3.  Ditto      1856,  1858,  1860,  1864,  and  1866;    slipped  foals  in    1862 

and  1868. 
1858,  1859,  1860,  1862,  and  1864. 
1857  and  1860;  twins  in  1858. 
1867;   twins  in  1861. 

1858,  1860,  1864,  and  1867 ;  twins  in  1867. 
1858,  1860,  and  1864;  twins  in  1861. 
1858,  1863,  and  1864;  slipped  foals  in  1859  and  1865. 
Pantaloon  Mares,  i.  e.  daughters  of  the  Horse  Pantaloon. 
Caricature. — 1856,  twins ;    1852,  barren ;    1854,  barren  ;    1855,  barren ;    1861, 
barren ;  1863,  twins ;   1866,  slipped  foals  ;    1867,  barren ;  1868,  barren,  and  then 
she  was  destroyed. 

Legerdemain. — 1849,  slipped  a  foal ;  1856,  slipped  twins ;  1860,  slipped  twins ; 
1862,  slipped  twins;  1852,  barren;  1859,  barren;  1864,  barren;  1866,  barren. 

Lady  JbA».— 1855,  barren ;    1856,  barren  ;   1858,  barren ;  1859,  barren  ;  1863, 
barren. 

Miserrima.—l'i^Q,  slipped  foal ;    1859,  slipped  foal ;    1863,  slipped  foal ;    1860, 
had  twins  (dead) ;  1862,  had  twins ;  1855,  barren ;   1858,  barren ;  1867,  barren. 
Crystal. — 1858,  barren;  1860,  barren;  1865,  barren;  1866,  slipped  twins. 
Slander.— IQhl,  barren;    1854,  barren;    1864,  barren;    1865,  barren;  1866, 
barren  j  1857,  slipped  twins. 


4. 

Ditto 

5. 

Ditto 

6. 

Ditto 

7. 

Ditto 

8. 

Ditto 

9. 

Ditto 

1872.]  Hereditary  Transiuission  of  Structural  Peculiarities.  521 

to  observations  on  the  effects  of  impregnation  on  the  female  with 
reference  to  future  offspring/  will  find  interesting  remarks  on  the 
qualities  contributed  by  each  parent  to  their  offspring.  It  is  deter- 
mined that  the  male  parent  chiefly  and  within  certain  limitations  and 
restrictions  contributes  the  external  characters,  the  general  appear- 
ance, in  fact,  the  outward  structures  and  locomotive  powers  {e.(/. 
brain,  nerves,  organs  of  sense,  skin,  bones,  and  muscles),  while  from 
the  female  are  derived  the  internal  structure  and  the  general  size  and 
quality,  tlie  vital  organs,  heart,  lungs,  glands,  digestive  organs,  and 
the  tone  and  character  of  defective  nutrition,  &c.  Further  allusion 
is  also  made  to  the  distinction  between  "races^^  and  "  breeds,''''  and 
to  the  self  or  uniform  cattle  of  pure  colour  in  contradistinction  to 
the  patches  and  glaring  colours  of  cross-breeds,  a  fact  recognised  by 
the  ancients  and  supported  by  quotations  from  Homer  and  Virgil. 

As  connected  with  hereditary  proclivities  I  may  -mention  the 
fact  that  susceptibility  to  the  effect  of  certain  remedies  as  mercury 
and  opium  has  been  known  to  be  hereditary,  as  mentioned  by  Mr. 
J.  Brown  in  his  remarks  on  hereditary  transmission  of  disease  (see 
'Cyclop,  of  Pract.  Med.')  A  curious  statement  is  made  by  Mr. 
AVallace  in  his  work,  '  Contributions  to  the  Theory  of  Natural 
Selection,'  to  the  effect  that  white  pigs  and  sheep  are  not  affected 
by  certain  plants  in  the  same  way  that  dark  ones  are. 

P.S. — In  reference  to  the  subject  of  Polydactilism,  alluded  to  at 
a  former  page,  I  would  quote  the  case  very  recently  described  by 
Dr.  Arthur  Mitchell,  in  his  third  Morisonian  Lecture,  given  at 
Edinburgh  (see  '  Lancet,'  March  16, 1872,  p.  383).  It  was  that  of 
a  man  whose  father  and  brother  and  sister  had  six  fingers  on  each 
hand,  whilst  he  himself  had  the  natural  number.  He  married, 
and  his  first  child  was  six -fingered. 

^  Count  Strzelecki  is  quoted  to  show  that  if  fruitful  intercoui'se  take  place  between 
an  European  male  and  an  aboriginal  female  of  New  South  Wales  or  Van  Diemen's 
Land,  that  the  female  is  for  ever  baiTen  to  a  male  of  her  own  race,  and  only  ca- 
pable of  procreating  with  white  men.  Strzelecki,  at  page  347  of  his  *  Physical 
Description  of  New  South  Wales  and  Van  Diemen's  Land'  (London,  1845), 
referring  to  the  above  fact,  observes  : — "  Hundreds  of  instances  of  this  extra- 
ordinary fact  recurring  invariably  imder  the  same  circumstances  amongst  the 
Hurons,  Scminolas,  Red  Indians,  Gakirs,  Mendoze  Indians,  Araucos,  South  Sea 
Islanders,  and  natives  of  New  South  Wales  and  Van  Diemen's  Land,  and  all 
tending  to  prove  that  the  sterility  of  the  female  which  is  relative  only  to  one  and 
not  to  the  other  male  is  not  accidental  but  follows  laws  as  cogent,  though  as  mys- 
terious, as  the  rest  of  those  connected  with  generation."  This  law  does  not  extend 
to  the  Negro  race.  Section  vii  of  the  Count's  work,  on  the  aborigines  of  New 
South  Wales,  &c.,  their  language,  customs,  characteristics,  &c.,  is  full  of  interest, 
and  will  well  repay  the  reader.  Although  some  of  the  facts  there  recorded  are  start- 
ling. Dr.  Shorthouse  tells  me  that  the' late  Mr.  Goodsir  assured  him  they  were  strictly 
true,  and  had  been  corroborated  by  several  travellers  and  acute  observers  since  the 
Count  published  his  work. 

The  reader  will  find  observations  on  the  influence  of  a  first  impregnation  ex- 
tending to  the  products  of  subsequent  ones  in  the  article  on  "  Generation" 
in  the  '  Cyclopedia  of  Anatomy  and  Physiology,'  vol.  ii,  p.  468.  The  influence 
is  traced  not  only  in  the  cases  of  the  marc  and  the  ass,  the  mare  and  the  quagga, 
but,  according  to  Burdach,  the  sow  and  the  bitch,  as  well  as  man. 


1872. J  522 


(Bbtonitlt  of  ileiriral  ^cienu, 


EEPORT   ON   PHYSIOLOGY. 
By  Henet  Powee,  F.E.C.S.,  M.B.  Lond., 

Senior  Oplithalmic  Surgeon  to,  and  Lecttirer  ou  Ophthalmic  Diseases  at,  St.  Bartholomew's  Hospital 


Absoeption — Blood-Cieculation. 

1.  H.  AusPiTZ.  On  the  Absorption  of  InsoluUe  Suhstances  in  Mam- 
mals. ('Wiener  Medizinische  Jahrblicher/  N.  F.,  1871,  Baud 
iii. 

2.  Dr.  GrENEESiCH.  Ou  the  Absorption  of  Lymph  by  Tendons  and 
FascicG  of  the  Muscles.  ('  Ludwig's  Arbeiten  aus  der  Physio- 
logischen  Anstalt  zu  Leipzig,')  Fiinfte  Jahrgang,  1870. 

3.  W.  Manassein,  On  the  Variation  in  Size  of  the  Bed  Corpuscles 
of  the  Blood  as  a  result  of  the  action  of  various  Reagents. 
('  Centralblatt  fiir  die  Med.  Wiss.,'  No.  44,  1871.) 

4.  Dr.  D.  GrATZTJCK.     On  the  Influence  of  Loss  of  Blood  on  the  Cir- 

culation and  on  the  Temperature  of  the  Body.      ('  Centralblatt 
fiir  die  Mediziniscbe  Wissenschaften,'  No.  53,  1871.) 

5.  Jakob  Woem  Mullee.  On  the  Tension  of  the  Oxygen  in  the 
Blood Bishs.       ('Ludwig's  Arbeiten,  &c,'  5te  Jahrgang,  1870.) 

6.  Adolf.  Gaeisch.     Besearches  on  the  Inorganic  Constituents  of 

the   Blood.      '  Strieker's    Medizin.    Jahrbiicher,'   Heft   iv.,    Jahr- 
gang, 1871.) 

Fe.  Jolly.  Besearches  on  the  Pressure  of  the  Brain  and  the 
Movement  of  the  Blood  in  the  Skull.  (Pp.  65,  '  Habilitatious 
Schrift,'  Wurzburg,  1871.) 

G.  Althaun.     Essays  on  the  Bhysiology  and  Bathology  of  the 
Circulation.    Pp.  247.     Dorpat,  1871. 
P.  Pagenstechee.     Experiments  on  the  Brain  Pressure.    Pp.  62. 
Heidelberg,  1871. 

H.  C.  SoEBT.  On  Some  Improvements  in  the  Spectrum  Method 
of  Detecting  Blood.  ('  Monthly  Microscopic  Journal,'  1871,  vol. 
vi,  p.  9.     An  important  paper  for  toxicologists.) 

J.  C.  EiCHAEDSoif .  On  the  Cellidar  Structure  of  the  Bed  Blood- 
corpuscle.  (  '  Monthly  Microscopic  Journal,'  1871,  vol.  vi,  p.  17. 
Beverts  to  the  old  cell  theory.) 
Thomas  L.  Ealph.  Experiments  with  the  Microscope  on  the 
Chemical  Effects  of  Chloral  Hydrate,  Chloroform^  Brussic  Acidy 
and  other  Agents,  on  the  Blood.  ('  Monthly  Microscopic  Journal,' 
,      vol.  vi.,  p.  75,  1871.) 


1872.] 


Report  on  Physiology.  523 


BoTD  Moss.     Rematozoa  in  the  Blood  of  Ceylon  Beer.     (*  Monthly 
Microscopic  Journal,'  vol.  vi,  p.  181.') 

1.  Auspitz,  after  reviewing  the  various  researches  that  have  been 
made  in  regard  to  the  absorption  of  insoluble  substances,  gives  the 
results  of  his  own  observations  on  rabbits.  The  substance  he  employed 
and  recommends  is  starch  meal  suspended  in  water  or  oil,  which  is 
well  adapted  for  the  purpose  from  its  low  specific  gravity,  the  well- 
marked  form  of  its  particles,  their  reaction  with  iodine,  and  their 
aspect  under  polarized  light.  He  found  that  when  injected  into  the 
veins,  following  the  current  of  the  blood,  the  particles  reached  the 
lungs,  where  the  greatest  portion  was  arrested,  without  occasioning 
any  obstruction  to  the  blood  or  inflammation,  whilst  a  small  quantity, 
chiefly  consisting  of  the  smaller  granules,  entered  the  systemic  circula- 
tion, and  was  distributed  to,  and  discoverable  in,  the  liver,  spleen, 
kidneys  and  vessels  generally.  The  grains,  whether  suspended  in  oil 
or  in  water,  but  especially  in  the  former,  were  readily  absorbed,  both 
from  the  peritoneal  cavity  and  from  the  connective  tissue  when 
injected  subcutaneously.  The  granules  thus  absorbed  considerably 
surpassed  in  size  both  the  red  and  the  white  corpuscles.  Some  were 
found  in  the  thoracic  duct,  showing  that  the  lymphatic  system  took 
part  in  the  process  of  their  absorption.  Lastly,  a  salve  containing 
starch-granules  was  rubbed  into  the  shaved  skin  of  rabbits  shortly 
before  or  after  its  separation  from  the  living  animal,  and  this  was  then 
examined  from  within  in  successive  layers,  special  precautions  being 
taken  to  avoid  any  introduction  of  the  starch  meal  from  without.  The 
granules  were  found  in  the  tissue  of  the  corium  of  the  subcutaneous 
connective  tissue  and  the  muscles  connected  therewith,  but  not  in  the 
depth  of  the  sebaceous  glands  and  hair-follicles.  The  skin  of  children 
also  after  death  showed,  when  examined  in  the  same  way,  that  it  was 
permeable  to  starch-granules  after  infrication  of  the  salve  for  a  quarter 
of  an  hour.  The  presence  of  fat  or  oil,  as  a  general  rule,  materially 
favoured  the  process  of  absorption. 

2.  M.  Genersich  states  that  after  Y.  Recklinghausen's,  Ludwig's, 
and  Schweigger  Seidel's  researches  on  the  lymphatics  of  the  central 
tendon  of  the  diaphragm,  it  appeared  very  probable  that  not  only  this 
but  other  aponeurotic  structures  stand  in  close  relation  to  the 
lymphatic  vascular  system.  In  favour  of  the  same  view  were  the 
observations  of  Ranvier,  which  demonstrated  that  the  fissures  between 
the  tendinous  fasciculi  are  lined  with  a  series  of  smooth  cells.  In 
injection  experiments  of  this  nature  it  is  necessary  for  success  that  the 
tissue  should  be  kept  thoroughly  stretched,  and  that  the  injection 
should  be  driven  in  under  low  pressure.  Grenersich  finds  the  best 
material  for  injection,  for  many  reasons,  to  be  turpentine  coloured  with 
alkanin,  though  he  admits  it  has  also  its  drawbacks.  He  obtained 
the  most  satisfactory  results  from  the  lower  part  of  the  fascia  lata,  the 
fascia  antibrachialis,  cruralis,  and  the  external  lamina  of  the  sheath  of 
the  rectus.  He  adduces  evidence  to  show  that  the  action  of  the 
muscles  plays  an  important  part  in  causing  the  lymphatics  of  the  ten- 
dons to  absorb  by  a  kind  of  suction  the  lymph  secreted  in  and  around 


524  Chronicle  of  Medical  Science,  [April, 

the  muscular  masses.  To  demonstrate  tliis  he  injects  defibrinated  . 
blood  through  the  limb  of  the  animal  from  which  it  has  just  been 
taken,  and  incidentally  enters  into  a  very  interesting  discussion  in 
regard  to  certain  partial  contractions  which  occur  under  these  circum- 
stances in  the  arteries,  and  which  in  some  points  of  view  resemble,  and 
in  others  differ  from,  rigor  mortis.  He  then  ascertains  the  amount  of 
l^^mph  discharged  from  the  thoracic  duct  in  a  given  time,  both  when 
the  muscles  are  quiescent  and  when  excited  to  powerful  and  sustained 
action  by  induction  currents  of  electricity,  and  found  that  this  varies 
from  1  :  4*45  to  1  :  24 '5  in  favour  of  the  period  when  the  muscles  are 
called  into  play,  which  are  thus  shown  to  exert  an  immense  influence 
on  the  flow  of  the  lymph. 

3.  The  results  of  40,000  measurements  on  174  animals  of  different 
species  have  shown  M.  Manassein  that  the  size  of  the  red  blood- 
corpuscles  diminishes  under  the  action  of  septicaemic  poisoning, 
exposure  to  a  high  temperature,  and  to  an  atmosphere  containing  an 
excess  of  carbonic  acid,  whilst  they  enlarge  under  the  influence  of 
oxygen,  and  agents  lowering  the  temperature  of  the  body,  as  cold, 
quinine,  cyanic  acid  and  alcohol.  Morphia,  however,  forms  an  excep- 
tion.    The  corpuscles  enlarge  in  acute  ansemia. 

4.  Dr.  Gratzuck's  observations  were  all  made  on  dogs,  and  the  fol- 
lowing are  the  results  he  obtained  :  1.  Venesection  retards  the 
mean  velocity  of  the  current  of  blood  in  the  carotid  and  crural 
arteries  and  their  branches.  2.  The  withdrawal  of  blood  from  a  vein 
or  artery  of  the  anterior  extremities  exercises  a  greater  influence  on 
the  rapidity  of  the  current  of  the  blood  than  a  like  evacuation 
from  the  posterior  extremities.  3.  The  eff'ect  produced  by  the 
mean  velocity  of  the  blood  current  depends  on  the  quantity  of  blood 
withdrawn.  4.  The  mean  pressure  of  the  blood  falls  under  the 
influence  of  the  withdrawal  of  blood,  although  occasionally  it 
remains  unaltered,  or  may  even  augment  ;  these  variations  depend 
both  upon  the  quantity  discharged  as  well  as  upon  the  rapidity 
with  which  the  blood  is  allowed  to  flow,  5.  After  the  with- 
drawal of  blood  the  rapidity  of  the  current  and  the  pressure 
exerted  by  the  blood  quickly  return  to  their  normal  condition. 
6.  Coincidently  with  the  diminution  of  the  velocity  of  the  blood 
current  and  of  the  lateral  pressure,  the  pulse  usually  increases  in 
frequency.  When  blood  is  withdrawn  in  large  quantities  and 
rapidly,  the  sounds  of  the  heart  (and  especially  the  second) 
are  weakened  in  intensity.  7.  In  consequence  of  the  evacuation  of 
blood  the  temperature  of  the  body  falls  both  during  and  after  the 
venesection  to  an  extent  that,  in  M.  Gratzuck's  experiments, 
amounted  to  1°  or  even  2°  Cent. 

5.  Jakob  "W.  Miiller's  paper  is  a  very  long  one.  He  first  under- 
took to  ascertain  how  far  the  tension  of  the  oxygen  depended  upon 
the  degree  of  saturation  of  the  blood  with  oxygen.  With  this  object 
in  view  he  first  agitated,  under  constant  pressure  and  temperature, 
blood  containing  but  little  oxygen  with  limited  (insufficient  for  satura- 
tion) volumes  of  oxygenated  air ;  the  latter,  of  course,  gave  up  a  certain 
proportion  to  the  former  till  a  condition  of  equipoise  resulted ;   and 


1872.] 


Report  on  Physiology.  525 


secondly,  blood  rich  in  oxygen  was  agitated  with  nitrogen,  when- 
the  blood  yielded  up  a  portion  of  its  oxygen.  He  found  that  no  com- 
plete saturation  of  the  blood  with  oxygen  occurs  if  the  oxygen  pressure 
falls  below  from  20—30  millimetres  at  40°  Cent.  ;  (2.)  that  with 
further  depression  of  the  oxygen  pressure  the  saturation  of  the  blood 
with  oxygen  still  further  diminishes  ;  and  (3),  that  the  pressure 
value  of  the  oxygen  of  the  air,  corresponding  to  one  and  the  same 
degree  of  saturation,  augments  with  elevation  of  the  temperature.  The 
last  two  results,  however. , are  inconstant  and  irregular.  Miiller  then 
undertook  investigations  on  the  relations  of  haemoglobin  and  oxy- 
hsemoglobin  to  oxygen.  His  researches,  he  thinks,  though  he  speaks 
with  great  caution,  furnish  the  key  to  explain  the  dependence  of  the 
absorption  of  oxygen  in  the  blood  of  the  pulmonary  circulation  on  the 
amount  of  that  gas  contained  in  the  air  in  the  lungs.  (2.)  The 
dependence  of  the  amount  of  oxygen  yielded  up  by  the  blood  to  the 
tissues  upn  the  amount  of  oxygen  contained  in  the  blood. 

6.  Jarisch  gives  the  following  as  the  arithmetical  mean  of  four  very 
carefully  conducted  experiments,  made  with  a  view  of  determining  the 
constituents  of  the  ashes  of  the  blood  of  the  dog. 

Phosphoric  acid  anhydride 

Sulphuric  acid  anhydride 

Chlorine 

Potash 

Soda 

Lime 

Magnesia 

Oxide  of  iron 

Digestion — Secretion. 

1.  Dr.    Lepine.     On   the   Origin   and  Distribution  of  the  Animal 

Sugar- Ferment.      ('Ludwig's  Arbeiten  aus  der   Physiologischen 
Anstalt  zu  Leipzig,'  5te  Jahrgang,  1870.) 

2.  E.  Friedinger.     What  Cells  of  the  Peptic  Glands  contain  the 
Pepsin  ?  (*  Wiener  Acad.  Sitzungsber.'  Band  Ixiv.,  October,1871.) 

3.  C.  IJsTiMowiTSCH.     Experiments  on  the  Theory  of  the  Secretion 
of  Urine.     ('  Ludwig's  Leipzigen  Arbeiten,'  5te  Jahrgang,  1870.) 

Dr.  HoFMANN.  On  the  Passage  of  Free  Acids  through  the  Alka- 
line Blood  into  the  Urine.  ('  Zeitschrift  fiir  Biologic.  Band  vii, 
Heft  iii. 

4.  T.    BoGOMOLOFE.     On  the  Composition  of  the  Milk.     ('  Central- 

blatt  fiir  die  Medicinischen  Wissenschaften,'  No.  40,  1871.) 

5.  GscHEiDLEN.      On   the    Origin   of  Urea   in   the  Animal   Body. 

(Leipzig,  1871.     Engelmann,  pp.  44.) 

1.  M.  Lepine' s  investigations  started  with  the  question  whether 
starch  was  converted  into  sugar  within  the  cavity  of  the  mouth  of  the 
frog.  To  determine  this  he  placed  some  boiled  starch  in  a  test  tube 
and  introduced  some  fragments  of  mucous  membrane  from 
the  tongue  and  oral  mucous  membrane  into  it.  In  from 
thirty  to  sixty  minutes  the  presence  of  sugar  was  demonstrable  by 
Trommer's  test.  Mechanical  irritation  of  the  tongue,  or  irritation  of 
the  hypoglossal,  again  caused  the  secretion  of  a  slimy  fluid,  which  pos- 

98 — XLix.  34 


12-32  per  c 

4'01 

>> 

31-43 

>» 

3-83 

» 

42-01 

>» 

1-25 

)) 

0-65 

)> 

8-34 

M 

536  Chronicle  of  Medical  Science.  [April, 

sessed  powerful  catalytic  properties.  When  the  tongue  was  persistently 
irritated,  then  cut  out  and  quickly  immersed  in  Miiller's  fluid, 
sections  of  it  made  when  it  was  hardened  showed  that  numerous  cells  were 
accumulated  in  the  vicinity  of  the  acini  of  the  glands.  The  presence 
of  an  animal  ferment  capable  of  converting  starch  into  sugar  has  been 
shown  by  Magendie,  Nasse,  CI.  Bernard,  Piotrowski,  Thiry,  Wittich, 
and  others,  to  exist  in  the  blood,  in  the  thoroughly  washed  mucous 
membrane  of  the  stomach  and  intestine,  in  the  liver  and  bile,  in  the 
kidneys,  the  mucous  membrane  of  the  bladder,  in  the  brain,  and  in  the 
muscles.  In  addition,  M.  Lepine  has  shown  it  to  be  present  in 
dogs,  rabbits,  and  frogs,  in  the  spleen,  the  ti:^sue  of  the  lungs, 
testicles,  tendons,  serous  membranes,  cornea,  and  vitreous ;  in  the  ex- 
ternal and  internal  surfaces  of  the  skin  of  the  frog,  in  the  mucus  of  the 
ovum  of  the  frog,  and  in  the  mucous  lining  of  its  oviduct.  The  only 
situation  in  which  he  has  sought  for  it  and  has  been  unable  to  find  it 
is  the  crystalline  lens  of  the  eye.  The  ferment  is  not  contained  in 
equal  proportion  in  all  the  tissues,  weight  for  weight  ;  it  is  more 
abundant  in  the  blood,  muscles,  spleen,  vitreous  body,  testicles  and 
brain  than  elsewhere.  The  diffusibility  of  the  sugar  ferment  is 
small. 

2.  Eriedinger,  as  the  result  of  his  researches  on  various  classes  of 
animals,  arrives  at  the  conviction  that  the  older  views  were  correct, 
and  that,  in  opposition  to  the  statements  of  Ebstein,  the  covering, 
investing,  or  superficial  cells  of  Heidenhain,  the  adelomorphous  cells  of 
Bollett,  are  those  which  really  contain  and  form  the  pepsin. 

3.  Ustimowitsch's  paper  is  a  long  one,  and  embraces  many  points  of 
interest.  His  researches  were  undertaken  in  dogs  which  had  taken  no 
food,  either  solid  or  fluid,  for  eighteen  hours,  and  the  urine  was  collected 
from  the  ureters.  He  found  that  the  lowest  pressure  of  the  blood,  in 
the  blood-vessels,  under  which  urine  continued  to  be  secreted,  was 
about  fifty  millimetres  of  mercury,  the  variations  in  pressure  being 
occasioned  by  section  of  the  renal  nerves.  After  pointing  out  that  the 
experiments  of  others  have  demonstrated  that  the  rapidity  with  which 
the  water,  urea,  and  common  salt,  of  the  urine  are  executed  varies  with 
the  pressure  of  the  blood  in  the  arteries,  with  the  section  of  the  renal 
nerves,  with  the  resistance  that  the  urine  meets  with  in  escaping  by 
the  ureters,  and  with  the  amount  of  these  materials  contained  in  the 
blood ;  he  details  his  own  experiments,  showing  the  changes  that  the 
composition  of  the  urine  undergoes  as  a  result  of  the  action  of 
woorara;  he  has  never  been  able  to  find  sugar  under  these  circum- 
stances, though  SchifF  and  others  have  shown  it  to  be  often  present. 
He  remarked  two  points  of  interest — first,  that  just  as  the  animal 
became  fully  under  the  toxic  influence  of  woorara  the  secretion  of 
urine  was  either  arrested  or  reduced  to  a  minimum  ;  and  secondly, 
that  the  proportion  of  urea  and  chlorides,  even  in  the  sparingly 
secreted  urine,  was  decidedly  diminished.  The  diminution  of  the 
quantity  of  the  urine  depended,  in  all  probability,  on  the  change  of 
artificial  pressure  caused  by  the  action  of  the  poison. 

4.  Bogomoloff"  gives  an  account  of  comparative  experiments  he  has 
instituted  between  the  milk  of  the  cow  and  goat  and  that  of  the 


1872.] 


Report  on  Physiology,  527 


human  subject.  He  believes,  from  their  reaction  with  ether,  that  the 
milk- molecules  of  the  cow  and  goat  are  not,  as  is  usually  considered, 
pure  drops  of  oil,  but  a  mixture  of  fat  and  albumen.  Human  milk- 
molecules  present  peculiar  characters,  which  require  further  investi- 
gation. 

5.  Gscheidlen  has  examined  almost  every  tissue  in  the  body  for  urea, 
and  finds  it  universally  distributed,  except  in  the  muscles,  in  which 
it  is  never  present. 


Respiration — Animal  Heat. 

1.  Dr.  N.  O.  Beenstein.  The  Exchange  in  Gases  between  Arterial 
and  Venous  Blood.  Q  Arbeiten  aus  der  Physiologischen  Anstalt 
zu  Leipzig,'  Fiinfte  Jahrgang,  1870.) 

2.  H.  Quincke  and  E.  Peeiefee.  On  the  Blood  Current  in  the 
Lungs.     ('  Beichert  und  Dubois  Raymond's  Archiv,'  1871.' 

A.  H.  GtAEEOD.  On  the  Relation  of  the  Temperature  of  the  Air 
to  that  of  the  Body.  ('  Humphry  and  Turner's  Journal  of 
Anatomy,'  Nov.,  1871.) 

H.  Senatoe.  On  the  Development  of  Seat  and  Disintegra- 
tion of  Tissue  in  Health  and  Disease.  ('  Centralblatt  fur  die  Med. 
Wiss.,'  No.  47, 1871.) 

3.  C.  PiLZ.  The  Normal  Temperature  in  Childhood.  ('  Jahrb. 
fiir  Kinderheilk,'  N.  F.  Band  iv,  p.  414.) 

4.  W.  Manassein.     On  Agents  effecting  a  Reduction  of  the  Tempera- 

ture of  the  Body,     ('  Pfltiger's  Archiv,  Band  iv.,p.  283,  1871.) 

1.  Dr.  Bernstein  remarks  that  no  attempt  has  hitherto  been  made 
to  construct  an  apparatus  approximatively  resembling  the  conditions 
under  which  an  exchange  of  gases  takes  place  in  the  placenta.  He 
gives  the  details  of  an  ingenious  instrument  he  has  constructed  with 
this  object  in  view,  and  represents  it  in  a  plate.  It  consists  essen- 
tially of  a  diffusion  apparatus  composed  of  two  tubes  separated  by  a 
thin  membrane,  on  one  side  of  which  defibrinated  arterial  blood  was 
kept  in  motion,  whilst  on  the  other  was  blood  obtained  from  the  same 
vessel  after  the  animal  had  been  asphyxiated.  Careful  analyses  of  the 
kind  and  quantity  of  gases  contained  in  the  several  specimens  of  blood 
before  and  after  diffusion  were  made.  The  amount  of  oxygen  which 
diffused  from  the  more  richly  oxygenized  to  the  more  highly  car- 
bonized blood,  in  five  or  six  hours,  was  unexpectedly  small,  only 
amounting  to  0*51  per  cent,  in  one  instance,  and  to  0"78  per  cent,  in 
another  ;  nor  was  the  diffusion  of  carbonic  acid  in  the  opposite  direc- 
tion very  great,  the  arterial  blood  only  gaining  1*55  per  cent.,  whilst 
the  venous  lost  about  2  per  cent.  These  experiments  show  that  the 
exchange  of  gases  dissolved  in  fluids  is  extremely  small.  The  following- 
are  two  of  the  experiments : 


;2B 


Chr oracle  of  Medical  Science. 


[Apr 


Original  blood. 

Blood  after  dif- 
fusion. 

Sum  of  the  gases. 

Remarks. 

Arterial. 

Venous. 

Arterial. 

Venous. 

Before  diff. 

After  diff. 

I. 

Oxygen 
Carbonic  acid 
Nitrogen 

II. 
Oxygen 
Carbonic  acid 
Nitrogen 

16-97 

29-80 

1-53 

14-95 

38-00 

1-34 

2-85 

42-97 

1-64 

1-98 

46-77 

1-80 

16-46 

31-76 

1-38 

14-17 

39-55 

1-87 

2-65 

38-02 
2-19 

2-03 

44-89 

1-52 

19-82 

72-77 
3-17 

16-93 

84-77 

3-14 

19-11 

69-78 
3-57 

16-20 

84-44 

3-39 

Duration  of  dif- 
fusion 5  hrs. ; 
Temp.  15°  C. 

Duration  of  dif- 
fusion 5  hrs. ; 
Temp.  18°  C. 

2.  The  practical  outcome  of  Quincke  and  E.  Pfeiffer's  observations 
and  experiments  is,  that  with  each  z'^spiration  the  passage  of  blood 
through  the  vessels  of  the  lungs  towards  the  left  ventricle  is  accele- 
rated. 

3.  Pilz  finds  from  measurements  taken  in  the  rectum  that  the  tem- 
perature rises  from  midnight  to  midday,  though  with  interruptions, 
the  most  rapid  rise  being  between  the  hours  of  7  and  9.  The  tempera- 
ture falls,  on  the  other  hand,  from  midday  to  midnight. 

4.  Manassein  finds  that  swinging  lowers  the  temperature  of  the 
body  in  rabbits,  though  precautions  were  taken  against  the  loss  of  heat 
by  the  contact  of  air. 


Neeves — MrscLE. 


4. 


PoTJCHET.      On    the   Connection   of  Nerves   and 
('  Monthly    Microscopic    Journal,'    vol.    vi,    p. 


M.     G-EOEGES 

Ghromohlasts. 
285.) 

Dr.  Lionel  S.  Beale.  On  the  Belation  of  Nerves  to  Figment  and 
other  Cells  or  Elementary  Parts.  ('  Monthly  Microscopical 
Journal,' vol.  vii.,  p.  45.) 

C.  DiTTMAE.  A  Fresh  Froof  of  the  Fxcitalility  of  the  Centri- 
petal Fibres  of  the  Spinal  Cord.  ('  Arbeiten  aus  der  Physiolo- 
gischen  Anstalt  zu  Leipzig'  during  the  year  1870.  Mitgetheilt 
durch  C.  Ludwig,  1871.) 

O.  ScHMiEDEEEEG.  Researches  on  the  Action  of  some  Foisons  on 
the  Heart  of  the  Frog.  ('  Arbeiten  aus  der  Physiologischen  Anstalt 
zu  Leipzig,'  5th  year,  1870.) 

Mahommed  Eeeendi  Haeiz.  On  the  Motor  Nerves  of  the  Arteries 
of  Transversely  Striated  Muscle.  ('Arbeiten  aus  der  Physiolo- 
gischen Anstalt  zu  Leipzig,'  5th  year,  1870.) 

Dr.  F.  MiESCHEE.  On  the  Conduction  of  Sensory  Impressions  in 
the  Spinal  Cord. 

J.  Beefstein.     Researches  on  the  Frocess  of  Excitation  in  the 
Nerves  and  Muscles.     8vo,  pp.  240.     Heidelberg,  Winter. 
E.   LoNDOLT.     On  the  Distance  of  the  3f acuta  Lutea  from  the 
Nervus    Opticus.      ('  Centralblatt  fiir   die   Medizinische  Wissen- 
chaften.) 


1873.] 


Report  on  Physiology.  529 


7.  A.  Paultjs.  On  the  Tactile  Sensibility  in  regard  to  Space  of  the 
Lower  Limh.  ('Zeitschrift  fur  Biologie,  Heft  iii,  Band  vii, 
1871.) 

Dr.  E.  Klein.  On  the  Peripheral  Distribution  of  Non-mednllated 
Nerve-fibres.  Q  Quarterly  Journal  of  Microscopical  Science,' 
Jan.,  1872.  Also  in  the  same  journal,  and  by  the  same  author,  a 
paper  on  *'  Hemah^s  Ciliated  Vesicles  and  the  Corneous  Filaments 
of  the  Perit07ieum  of  the  Frog. 

M.  Lavdowsky.  On  the  Contractility  of  Muscular  Protoplasm.  ('  Cen- 
tralblatt  fiir  die  Med.  Wissenschaft,'  Nov.  25,''l87l.) 

1 .  M.  Pouchet  gives  a  minute  account  of  the  structure  of  the  chro- 
moblasts  of  fishes,  as  of  various  flat  fish,  which  he  describes  as  being 
essentially  composed  of  a  mass  of  sarcodic  substance  (or  protoplasm) 
usually  surrounding  a  nucleus,  but  being  able,  probably,  to  exist  with- 
out one.  In  the  midst  of  this  sarcodic  substance  is  deposited  the 
colouring  matter,  which  is  consequently  a  true  pigment.  This  is  of 
various  tints — yellow,  orange,  red,  brown,  or  black.  Sometimes  this 
colouring  matter  is  liquid  and  forms — as  may  be  seen  in  the  embryos 
of  Crustacea — a  coloured  drop  in  that  portion  of  the  sarcodic  substance 
near  t^ie  nucleus.  When  it  extends  in  its  amoeboid  movements  it 
draws  over  it  the  coloured  drops.  At  other  times  the  colouring  is  dis- 
tributed in  the  form  of  granulations  throughout  the  mass  of  proto- 
plasm. M.  Pouchet's  observations  were  made  on  chromoblasts  sub- 
jected to  the  action  of  acetic  acid  and  carmine  or  chloride  of  gold.  He 
shows  (a  plate  accompanying  the  paper)  that  delicate  nerve-fibres 
may  be  traced  up  to  the  chromoblasts,  and  conceives  that  these  bodies 
are  interposed  in  the  course  of  the  nerve-filament,  or  are  in  direct  con- 
tact with  it,  in  consequence  of  which  connection  they  enter  into  con- 
traction whenever  the  nerve  is  acted  upon.  If  this  be  true  the  termi- 
nation of  the  nerve-filaments  has  still  to  be  sought  for,  and  he  depicts 
some  suggestive  specimens  in  which  the  nerve  appeared  to  end  in  a 
nucleus  with  pigment  matter  on  one  or  both  sides  of  it,  the  nucleus 
presenting  all  the  characters  of  a  nucleus  of  nervous  fibre,  and  not  at 
all  those  of  the  large  irregular  nuclei  which  usually  accompany  sar- 
codic bodies. 

2.  Dr.  C.  Dittmar  remarks  that  A.  Y .  Bezold,  in  his  treatise  on  '  A 
New  Excitor  Nerve  System  for  the  Heart,'  made  the  observation  that 
the  slightest  excitation  of  the  skin,  or  even  of  the  auditory  nerves,  is 
answered  by  an  exaltation  of  the  arterial  blood  pressure  and  an  increase 
in  the  number  of  the  pulse,  providing  that  the  animal  has  been  placed 
fully  under  the  influence  of  woorara,  and  the  trunks  of  the  pneumo- 
gastrics  have  been  divided  in  the  neck.  These  observations  have  been 
corroborated  and  extended  by  Loven  and  Asp.  Now,  since,  according 
to  the  researches  of  C.  Ludwig  and  Thiry,  the  augmentation  of  the  blood 
pressure  depends  on  the  contraction  of  the  circular  fibres  of  the  smallest 
arteries,  which  contraction  is  produced  reflectorially  by  the  sensory 
nerves,  this  reaction  is  well  adapted  to  the  demonstration  of  the 
sensory  properties  of  a  segment  of  nerve.  Led  by  this  consideration, 
C.  Ludwig  suggested  to  Dr.  Dittmar  the  advisability  of  studying  the 


530  Chronicle  of  Medical  Science.  [Aprils 

much  discussed  question  of  the  excitabillt}'-  of  the  substance  of  the 
spinal  cord.  The  demonstration  of  the  presence  of  such  excitabihty 
could,  up  to  the  present  time,  be  furnished  only  in  the  case  of  the 
anterior  columns,  for  the  excitability  of  which  we  have  a  sufficiently 
certain  and  delicate  reagent  in  the  contraction  of  the  muscles.  No 
one  has  hitherto  even  attempted  it  in  the  case  of  the  sesthesodic 
substance.  Dr.  Dittmar  employed  rabbits  in  this  investigation, 
which  were  subjected  to  the  action  of  woorara,  but  the  vagi  were  not 
divided.  The  pressure  of  the  blood  in  the  carotid  was  registered  by 
means  of  a  mercurial  manometer.  Speaking  generally,  he  had 
frequent  opportunities  of  corroborating  v.  Bezold's  observations.  In 
all  cases,  where  even  a  feeble  excitation  aflfected  a  sensory  nervous 
expansion,  an  increase  of  the  blood  pressure  was  observed  as  an 
expression  of  an  increase  of  resistance  in  the  arterial  region,  caused 
by  reflex  contraction  of  the  vascular  walls.  This  reflex  action  on  the 
vascular  nerves,  as  we  know  takes  place  at  the  medulla  oblongata. 
It  appeared  at  the  same  time  that  the  elevation  of  pressure  increases 
with  the  strength  of  the  excitation,  and  could  thus  be  employed  to 
some  extent  as  a  proportionate  measure  for  the  degree  of  excitation 
applied.  In  experiments  of  this  nature  it  is  of  importance  that  the 
excitation  should  be  of  nearly  equal  duration,  if  the  efl"ect8  are*  to  be 
compared.  It  must  also  be  remembered  that  the  reflecting  organ  is 
susceptible  of  exhaustion,  so  that  if  two  excitations  of  equal  strength 
are  applied  to  the  same  part,  the  eflfect  produced  by  the  second  is 
usually  less  than  that  by  the  first.  Dr.  Dittmar  points  out  the 
importance  of  avoiding  loss  of  blood,  and  the  necessity  of  maintaining 
artificial  respiration,  not  by  hand,  but  by  a  proper  automatic  apparatus. 
It  was  a  matter  of  capital  importance  to  Dr.  Dittmar  to  corroborate 
the  observation  made  by  Asp,  to  the  effect  that  excitation  of  the 
spinal  cord  was  capable  of  setting  free  the  same  reflex  action  on  the 
vascular  nerves,  the  vascular  nerves  given  off*  below  the  point  of 
irritation  being,  of  course,  withdrawn  from  the  direct  action  of  the 
stimulus  by  section  of  the  cord.  Their  direct  excitability  has  not  been 
contested  by  any  one  since  the  researches  of  Ludwig  and  Thiry.  In 
order  to  see  whether  positive  results  could  be  obtained,  in  regard  to 
the  excitabilit}^  of  substance  of  the  spinal  cord,  Dr.  Dittmar  arranged 
the  following  experiment.  He  excited  an  intercostal  nerve  centri- 
petally,  and  compared  the  augmentation  of  pressure  produced  with 
that  induced  by  equally  strong  excitation  of  the  medulla  at  the  point 
of  entrance  of  the  nerve.  If,  he  reasoned,  the  elements  of  the  spinal 
cord  are  really  excitable,  their  excitation  must  produce  a  greater 
effect  than  an  individual  nerve,  which  only  goes  to  form  part  of  the 
cord.  The  result  of  the  experiment  corresponded  to  his  anticipations  ; 
the  irritation  of  the  cord  produced  a  much  greater  effect  than  that 
which  could  be  obtained  by  excitation  of  the  intercostal  nerve. 
Undoubtedly  this  does  not  prove  the  excitability  of  the  spinal  cord, 
since  the  stimulus  may  possibly  have  been  applied  to  nerve-fibres  that 
have  not  traversed  any  ganglion-cell ;  Dr.  Dittmar  therefore  performed 
another  experiment,  of  which  he  gives  the  details  which  essentially 
consists  in  removing  the  posterior  columns  of  the  spinal  cord  ;  and  lie 


1872.]  Report  of  Physiology.  531 

finds  not  only  that  the  cord  is  capable  of  receiving  and  conducting 
centripetal  impressions,  but  that  it  is  one  of  the  most  excitable  struc- 
tures (reizbarsten  Gebilde)  of  the  body.  In  order  to  determine  the  path 
pursued  by  the  excitation,  he  further  separated  the  anterior  from  the 
lateral  columns.  Excitation  of  the  anterior  columns,  and  also  of  the  grey 
substance  alone,  was  never  followed  by  any  effect,  but  that  of  the 
posterior  columns  was  followed  always  by  some,  though  slight,  increase 
of  pressure.  As  the  general  result  of  his  experiments,  he  thinks  it 
unquestionable  that  there  is  a  system  of  fibres  in  the  substance  of  the 
spinal  cord,  which,  though  they  do  not  belong  to  the  nerve-roots,  are 
accessible  to  the  action  of  direct  stimuli,  and  are  capable  of  transmit- 
ting the  impulses  so  generated  along  the  whole  length  of  the  spinal 
cord  to  the  medulla  oblongata,  where  they  are  reflected  upon  motor 
nerves.  They  may  be  regarded  as  excito-motor  nerves.  Dr.  Dittmar 
then  proceeds  to  discuss  the  action  of  stimuli  similarly  applied  upon  the 
pulse. 

3.  O.  Schmiedeberg  states  that  experiments  made  by   Koppe  and 
himself,  and  published  in  1869,  show  that  the  administration  of  the 
smallest  quantity  of  the  peculiar  fungus  termed  muscarin  causes  the 
motion  of  the  heart  of  frogs  to  be  arrested  in  diastole,  without,  how- 
ever, destroying  the  excitability  of  the  organ.     If,  now,  an  extremely 
minute  portion  of  atropine  be  subcutaneously  injected,  the  heart  is 
immediately,  so  to  speak,  released,   and  large  doses  of  musearin  are 
then  inoperative.     It  would  appear,  therefore,  that  atropine  paralyses 
those  parts  of  the  nervous  system,  the  electrical  or  other  excitation  of 
which  induces  an  inhibitory  action,  whilst,  on  the  contrary,  muscarin 
acts  as  an  excitant  of  those  parts  that  are  paralysed  by  atropine,   and 
which  possess  an  inhibitory  power.  The  injection  of  l-3rd  to  l-8th  of  a 
milligramme  of  nicotin  causes  speedy  reduction  in  the  number  of  the 
heart's  beats  and  ultimate  arrest,  which  lasts  from  1  to  1|-  min.,  when 
the  beats  again  recommence.     Arrest  of  the  heart's  action  does  not 
occur  if  atropine  has  been    previously  used.      The   action   of  small 
doses  of  nicotin,  therefore,  resembles  that  of  muscarin  ;  it  occasions  a 
diastolic  arrest  of  the  heart's  action,  which  can  be  prevented  from 
occurring  by  paralysing  the  inhibitory  apparatus  by  atropine.     The 
heart  recommences  to  act  when  small  doses  of  nicotin  have  been  used, 
on  account  of  the  progressive  paralysis  of  the  vagus.     With  larger 
doses  of  nicotin  this  paralysis  sets  in  so  quickly  that  there  is  no  time 
for  the  heart  to  be  arrested  by  the  exciting  action  of  the  poison  on 
the  vagus,  or  at  most  there  is  only  a  retardation   of  its  beats.     A 
curious  point  is  that  a  heart,  of  which  the  vagal  terminations  have 
been  paralysed  by  nicotin,  behaves  like  a  normal  heart  to  muscarin; 
which  at  once  suggests  that  nicotin  paralyses  other  and  different  parts 
of  the  vagus  from  atropine  ;  and  that  these  parts  lie  nearer  to  the  trunk 
of  the  vagus  than  those  acted  upon  by  atropine  is  shown  by  the  circum- 
stance that  a  diastolic  arrest  can  be  excited  by  muscarin,   but  not  by 
electrical  excitation  of  the  vagal  trunk.     Dr.  Schmeideberg  considers 
that   in  the  trunk  of  the  vagus  of  the  frog  besides  the  inhibitory 
nerves,  there  rise  other  nerves  which,  on  being  excited,  cause  accelera- 
tion of  the  heart's  action.     For  if  the  normal  vagus  be  irritated  the 


632  Chronicle  of  Medical  Science,  [April, 

heart's  action  is  never  accelerated,  but  if  the  inhibitory  apparatus  be 
first  paralysed  with  atropine  irritation  of  the  vagus  will  then  cause 
acceleration.  He  thinks,  with  v.  Bezold,  that  the  inhibitory  appa- 
ratus consists  of  ganglionic  elements.  Dahirin  behaves,  as  regardis 
the  heart,  exactly  like  atropine. 

4.  Mohammed  Hafiz  remarks  that  the  vital  properties  of  trans- 
versely striated  muscular  tissue  render  it  a  p^^iori  probable  that  its 
blood  current  should  present  some  peculiarities.  Opposite  conclusions 
might  be  drawn  from  a  consideration  of  the  physical  and  chemical 
changes  occurring  during  contraction,  in  regard  to  the  flow  of  blood 
through  the  muscles  ;  on  physical  grounds  it  would  be  natural  to 
(suppose  that  less  blood  would  traverse  the  tissue,  whilst  the  larger 
amount  of  carbonic  acid  eliminated  would  rather  seem  to  show  that 
more  blood  traversed  it.  Experiments  undertaken  by  Sczelkow,  Al. 
Schmidt,  W.  Sadler  and  Genersich  in  '  Ludwig's  Laboratory,'  are 
opposed  to  the  exclusive  adoption  of  either  of  these  views,  and  show 
that  great  variations  may  occur  in  the  rapidity  of  the  current  of  blood 
traversing  the  arteries  of  muscles,  as  well  as  in  its  pressure,  quite 
independently  of  the  condition  of  contraction,  or  relaxation, 
of  those  muscles  themselves.  Their  experiments  tend  to  show 
that  great  powers  of  contraction  and  dilatation  must  be 
attributed  to  the  arteries  distributed  to  muscle  ;  and  in  accord- 
ance with  this  is  the  anatomical  fact  that  the  arteries  of 
muscular  tissue  contain  a  very  well-developed  circular  muscular  layer. 
Mohammed  Hafiz's  researches  were  undertaken  to  ascertain  the  course 
and  action  of  the  motor  nerves  supplying  the  arteries.  Dogs  and 
rabbits  were  employed  in  the  experiments,  which  were  either  in  their 
natural  state  or  poisoned  with  woorara,  and  the  following  results  were 
obtained : — 1.  During  tetanic  excitation  of  the  spinal  cord  the  circular 
muscular  fibres  of  the  arteries  distributed  to  muscles  contract  slightly 
and  transiently,  and  never  to  so  great  an  extent  as  the  circular  fibres 
of  the  arteries  distributed  to  the  skin  and  abdominal  viscera.  The 
contraction,  if  any,  is  very  slight  in  curarized  animals.  2.  The  nerves 
of  the  circular  muscles  are  ver^-  easily  exhausted.  This  is  well  shown 
by  the  fact  that  a  wound  of  a  muscle,  provided  no  large  artery  is 
injured,  as  a  rule,  bleeds  but  little,  but  severe  haemorrhage  occurs 
under  the  circumstances  if  the  spinal  cord  be  irritated,  the  amount 
depending  on  the  increase  of  blood  pressure  caused  by  the  stimulation 
of  the  cord.  The  more  this  augments,  the  more  the  arteries  of  the 
skin  and  the  abdominal  viscera  contract,  whilst  those  of  the  muscles 
permit  free  bleeding  to  take  place  from  them,  the  haemorrhage  lasting 
as  long  as  the  blood  pressure  is  above  the  normal.  3.  Irritation  of 
the  spinal  cord  caused  distinctly  observable  increase  in  the  rapidity 
of  the  current  of  blood  through  the  muscular  arteries,  as  well  as  by 
augmented  pressure,  cessation  of  the  irritation  being  followed  by  dimi* 
nution  of  the  rapidity  of  the  current.  4.  The  circular  muscular  fibres 
of  the  arteries  distributed  to  muscles  expand  and  contract  independently 
of  the  nerves  supplied  to  them,  and  probably  as  a  consequence  of  the 
direct  excitability  of  their  own  proper  muscular  fibres,  5.  The  nerves 
of  a  muscle,  and  the  nerves  of  the  artery  supplying  that  muscle,  seem, 


I 


1872.]  Report  on  Physiology.  533 

in  some  instances  at  least,  to  have  a  different  origin.  6.  From  a 
medium  condition  the  muscles  of  the  vessels  may  either  contract  or 
dilate  ;  contraction  often  occurs  if  the  vessel  has  been  long  in  a  state 
of  dilatation,  owing  to  augmented  pressure.  It  was  invariably  observed 
after  irritation  applied  to  the  spinal  cord,  thus  producing  first  tempo- 
rary contraction,  then  dilatation,  and  finally  very  strongly  marked  and 
persistent  contraction.  The  increase  of  pressure  in  the  arteries  distri- 
buted to  muscles  is,  no  doubt,4n  part  due  to  the  contraction  that  occurs 
in  the  cutaneous  abdominal  and  other  arteries  when  the  spinal  cord 
is  irritated. 

5.  The  plan  of  Dr.  Miescher's  experiments  consisted  in  determining 
what  influence  section  or  isolated  preservation  of  certain  portions  of 
the  spinal  cord  exercised  upon  the  reflex  action  of  certain  nerves 
arising  below  the  lesion  upon  the  blood  pressure.  He  considers  his 
experiments  lead  to  the  conclusion  that  the  centripetal  fibres  of  the 
sciatic  nerves,  capable  of  reflectorially  increasing  the  blood  pressure, 
run  (in  that  portion  of  the  medulla  which  extends  between  the  third 
lumbar  nerve  and  the  last  dorsal)  either  entirely  or  principally  in  the 
lateral  white  medullary  columns  of  the  medulla.  Again,  he  finds  that 
in  the  same  region  of  the  cord  the  centripetal  fibres  of  the  left  sciatic 
chiefly  run  in  the  right  and  in  smaller  proportion  in  the  left  lateral 
column,  and  vice  versa.  Lastly,  he  shows  that  the  fibres  of  this 
nature  coming  from  the  lower  regions  of  the  cord  run  in  its  outermost 
portion,  whilst  those  that  enter  at  the  higher  plane  run,  wholly  or 
partially,  in  the  neighbourhood  of  the  median  plane. 

6.  Londolt  finds  the  distance  of  the  macula  lutea  from  the  optic  disc 
to  be  3'915  mm.,  in  a  horizontal  plane,  whilst  it  is  0'785  of  a  mm. 
higher.  The  distance  is  greater  in  hypermetropic  than  in  myopic 
persons. 

7.  Dr.  Paulus  shows  that  the  sensitiveness  of  the  skin  of  the  lower 
extremity,  in  accordance  with  the  theory  of  Vierordt,  increases  with  its 
distance  from  the  axis  of  rotation  of  the  limb,  or,  in  other  words,  from 
the  proximal  joint,  and  with  the  freedom  with  which  its  movements 
can  be  executed.  The  leg  is  then  more  sensitive  than  the  thigh,  the 
foot  than  the  leg,  and  the  toes  than  the  foot.  The  sensitiveness  in 
each  division  again  augmenting  from  its  own  proximal  point,  except 
in  the  single  case  of  the  leg  proper,  when  the  minimum  acuity  is 
opposite  the  centre  of  the  tibia  ;  but  this,  as  Paulus  points  out,  really 
favours  Vierordt' s  theory,  since,  under  different  circumstances,  sometimes 
the  upper  and  sometimes  the  lower  part  of  the  leg  moves  through  the 
greatest  arc.  In  the  arm  the  increase  of  sensitiveness  from  the 
shoulder  to  the  tips  of  the  fingers  is  as  1'24  ;  in  the  leg  as  1'8-|-,  which 
may  be  accounted  for  by  the  greater  rapidity  required  in  the  movQ- 
ments  of  the  arm,  as  compared  with  those  of  the  leg, 


634  Chronicle  of  Medical  Science,  [/^w'^^t 


REPOUT  ON  MATERIA  MEDICA  AND  THERAPEUTICS. 
By  RoBEiiT  HuNTEE  Semple,  M.D. 

Member  of  the  Eoyal  College  of  Physicians,  Physician  to  the  Bloomsbury  Dispensary,  London. 


On  the  Application  of  JEIectrolysis  to  the  Treatment  of  Disease.  Bj 
Dr.  A.  D.  EocKWELL,  of  New  York. — After  describing  the  general 
principles  of  electro-chemical  action,  and  its  influence  on  dead 
tissue  and  on  the  blood  circulating  in  the  living  body,  Dr.  Rockwell 
adduces  several  cases,  arranged  in  groups,  illustrating  the  efficacy  of 
electrolysis  in  the  treatment  of  various  forms  of  disease.  Clinical 
experience  shows  that  living  tissue  is  more  readily  electrolysed  than 
that  which  is  dead,  because  the  former  is  more  capable  of  absorp- 
tion, and  its  solutions  are  warmer,  and  therefore  better  conductors 
of  electricity.  When,  therefore,  a  tumour  capable  of  being  elec- 
trolysed is  submitted  to  the  galvanic  current,  its  fluid  constituents 
sufi'er  decomposition,  absorption  is  hastened  by  the  chemical  effects 
of  the  current  and  the  mechanical  and  irritating  effects  of  the 
needles,  and  disintegration  and  atrophy  take  place.  In  the  success- 
ful treatment  of  tumours  much  depends  on  their  character ;  and 
the  general  rule  is,  that  the  harder  the  tumour,  and  the  larger  the 
extent  of  tissue  to  be  acted  upon,  the  greater  are  the  quantity  and 
intensity  of  electricity  required.  Dr.  E-ockwell  states  that  his  own 
practice  in  this  department  of  electro-therapeutics,  although  not 
very  extensive,  has  been  on  the  whole  moderately  successful.  In 
the  treatment  of  some  non-malignant  morbid  growths  his  results 
have  been  very  favorable ;  but  in  cancers  the  success  has  been 
very  questionable,  and  he  gives  no  cases  from  his  own  experience, 
and  only  a  doubtful  one  in  the  practice  of  the  Bellevue  Hospital. 
In  the  case  of  ulcers,  the  continuous  current  will  sometimes  produce 
a  growth  of  healthy  granulations,  after  all  ordinary  means  have 
failed ;  and  some  skin-diseases,  as  eczema  and  psoriasis,  may  be 
treated  electrolytically  by  means  of  broad  electrodes  of  various 
shapes,  covered  with  flannel  or  linen,  or  with  simple  metallic 
plates. — New  Yorh  Medical  Journal,  Ju-ly>  1871. 

On  the  Use  of  Phosphorus  in  Certain  Diseases  of  the  Skin.  By 
Dr.  H.  Eames,  of  Dublin. — It  appears  that  Dr.  Burgess  was  the 
first  physician  who  recommended  the  use  of  phosphorus  in  certain 
skin  diseases,  but  Dr.  Broadbent  has  recently  given  the  same  metal- 
loid with  good  effect  in  some  cases,  and  Dr.  Tilbury  Fox  has  also 
recommended  its  use ;  but  Dr.  Eames  considers  that  phosphorus  is 
much  more  than  a  substitute  for  arsenic,  as  some  previous  writers 
have  regarded  it,  and  he  alleges  that  it  has  been  used  with  marked 
success  in  certain  cases  in  which  arsenic  has  failed.  The  mode  of 
administration  adopted  by  him  was  a  solution  of  the  phosphorus  in 
oil,  and  the  dose  of  the  solution  was  from  5  to  10  minims  three  times 
a  day  after  meals.   Dr.  Eames  relates  the  particulars  of  several  cases 


1872.]        Report  on  Materia  Meclica  and  Therapeutics.       535 

which  were  thus  treated,  and  iu  all  the  results  were  successful. 
One  was  an  instance  of  acne  indurata  of  a  most  severe  character, 
which  had  resisted  all  other  local  and  general  treatment ;  three  of 
the  cases  were  instances  of  lupus  ;  and  two,  of  scrofulo-derma.  In 
psoriasis  Dr.  Eames  found  phosphorus  very  efficacious,  even  when 
arsenic  had  proved  unserviceable,  and  he  gives  three  cases  in  proof 
of  this  statement.  A  case  of  pemphigus  was  also  cured  by  the  use 
of  phosphorus.  Dr.  Eames  found  that  the  drug  produced  a  coated 
state  of  the  tongue,  and  sometimes  symptoms  of  dyspepsia,  loss  of 
appetite,  mental  depression  and  bodily  weakness ;  but  when  these 
symptoms  appeared  the  phosphorus  was  discontinued  for  a  time, 
and  mineral  acids  substituted.  Most  of  the  cases  recorded  by  Dr. 
Eames  had  been  treated  by  arsenic  and  other  drugs  before  they 
came  under  his  care,  and  he  regards  phosphorus  as  far  superior  in 
efficacy  to  that  and  other  vaunted  specifics  in  skin  diseases. — Buhlin 
Journal  of  Medical  Science,  Jauu;iry,  18/2. 

On  Ozoherit  as  a  Therapeutic  Agent.  By  Dr.  H.  S.  Purdo2T,  of 
Belfast. — Dr.  Purdon  was  induced  to  try  ozokerit  as  a  local  applica- 
tion in  cutaneous  affections,  in  consequence  of  its  resemblance  in 
properties  to  petroleum,  naphthaline,  coal-tar,  and  other  similar 
substances,  which  are  found  more  or  less  useful  in  treating  scabies 
and  other  skin  eruptions.  Ozokerit  is  a  vegetable  wax,  being 
chemically  a  hydrocarbon,  and  is  found  in  Moldavia,  Wallachia,  the 
Caucasus,  and  near  the  Caspian  Sea.  At  the  last-named  locality  it 
has  long  been  used  for  illuminating  purposes,  and  it  has  been  lately 
introduced  into  England  for  the  manufacture  of  candles.  In  the 
crude  state  it  is  of  a  dirty  greenish  colour,  but  when  distilled  and 
purified  it  is  a  hard,  white,  waxy  substance,  something  like  sperma- 
ceti. Dr.  Purdon  remarks  that  the  crude  ozokerit  and  the  yellow 
oil  are  the  best  forms  of  this  substance  for  medicinal  purposes.  The 
oil  is  obtained  in  the  process  of  distillation,  and  it  has  a  smell  similar 
to  that  of  paraffin,  but  not  so  unpleasant  nor  so  strong ;  it  also 
appears  to  be  a  slight  deodoriser.  The  therapeutical  action  of 
ozokerit  is  similar  to  that  of  tar,  but  it  is  not  so  dirty.  In  private 
practice  the  refined  material  may  be  combined  with  glycerine,  but 
at  the  hospital  Dr.  Purdon  merely  mixes  the  dark  ozokerit  with  an 
equal  quantity  of  linseed  oil,  and  the  compound  thus  formed,  though 
rather  lumpy,  soon  melts  in  the  hand  when  it  is  well  rubbed.  The 
oil  can  be  used  in  combination  with  lard.  The  action  of  the  ozokerit 
and  the  oil  appears  to  Dr.  Purdon  to  be  that  of  a  stimulant  to  the 
diseased  skin,  and  to  be  superior,  for  practical  use,  to  tar,  Hebra's 
tincture  (a  compound  of  tar,  black  soap,  and  methylated  spirit), 
carbolic  acid,  or  oil  of  cade.  It  is  however  only  suitable  for 
chronic  aff'ections,  as  eczema  of  long  standing,  psoriasis,  tinea  ton- 
surans, and  scabies.' — Dublin  Quarterly  Journal  of  Medical  Science^ 
November,  1871. 

On  Phenic  (^Carbolic')  Acid  and  its  Therapeutical  Properties,  By 
Dr.  Ernest  Labbee. — Dr.  Labbee  commences  a  long  and  elaborate 
paper  on  the  properties  and  uses  of  carbolic  acid  by  remarking  the 


536  Chronicle  of  Medical  Science.  [April, 

difference  of  opinion  which  has  lately  existed  among  medical  writers 
as  to  the  value  of  this  agent,  the  greater  number  extolling  its  thera- 
peutical virtues,  while  others  depreciate  it  so  far  as  to  advise  its 
exclusion  from  the  list  of  the  materia  medica.  Dr.  Labbee  steers 
between  the  two  extremes,  and  while  he  regards  the  universal 
employment  of  carbolic  acid  as  an  illusion,  he  believes  it  to  be  a 
powerful  agent,  which  will  be  appreciated  when  its  physiological 
properties  are  more  fully  known.  After  alluding  to  its  chemical 
characters,  the  writer  refers  to  the  fact  that  it  is  a  violent  poison  to 
all  living  beings,  and  is  especially  remarkable  for  its  toxic  action  on 
microscopic  forms  of  life,  both  animal  and  vegetable ;  and  hence,  as 
is  well  known,  it  has  been  extensively  employed,  on  theoretical 
grounds,  in  the  treatment  of  accidents  or  injuries  or  diseases,  the 
peculiarities  or  complications  of  which  are  supposed  to  be  influenced 
by  the  presence  of  minute  living  organisms.  Dr.  Labbee  treats  at 
length  of  the  experiments  of  modern  observers,  who  are  said  to 
have  traced  living  germs  in  the  ptoducts  of  fermentation,  and  even 
in  the  miasms  from  the  human  body,  but  he  neither  denies  nor 
confirms  their  statements,  and  in  the  same  spirit  he  refers  to  the 
views  entertained  and  published  as  to  the  connection  between  the 
phenomena  of  disease  and  the  development  of  the  morbific  germs. 
Carbolic  acid  has  also  been  strongly  recommended  as  a  disinfectant, 
its  efficacy  in  this  respect  being  supposed  to  be  due  to  the  power  it  has 
of  destroying  the  life  of  the  minute  organisms  which  are  assumed  to  be 
the  causes  of  epidemic  and  infectious  diseases  ;  but  in  this  respect, 
also.  Dr.  Labbee  seems  to  think  that  the  theory  on  which  its  use  has 
been  founded  is  not  well  established,  while  in  practice  its  efficacy  is 
still  doubtful.  The  physiological  effects  of  carbolic  acid  are  local 
and  general ;  when  applied  to  the  skin  or  the  mucous  membranes,  it 
acts  as  a  caustic ;  when  given  internally,  the  effects  vary  with  the 
dose,  but  when  this  is  large  the  acid  acts  as  a  violent  poison. 
Among  other  eftects  which  it  produces,  there  is  a  notable  diminution 
in  the  temperature  of  the  body  ;  and  with  respect  to  its  elimination 
from  the  system,  this  process  seems  to  take  place  from  the  lungs, 
and  perhaps  also  from  the  skin.  Dr.  Labbee  relates  some  experi- 
ments made  by  himself  on  frogs  with  carbolic  acid,  and  the  general 
results  were  that  it  appeared  to  act  on  the  nervous  system,  causing 
convulsions,  which  were  rather  epileptiform  than  tetanic,  and  its 
special  influence  seemed  to  be  upon  the  cerebellum  and  the  medulla 
oblongata.  In  reference  to  the  employment  of  carbolic  acid  in 
surgery  and  medicine,  the  author,  while  copiously  quoting  the 
experience  of  English  and  French  authorities,  expresses  his  own 
opinion  that  in  surgery  it  is  not  superior  in  efficacy  to  other  reme- 
dial agents,  such  as  alcohol,  glycerine,  &c.,  and  that  it  has  no 
decided  influence  in  preventing  complications  in  the  healing  of 
wounds.  At  Sedan,  where  Dr.  Labbee  made  use  of  the  acid  very 
extensively,  he  did  not  find  that  it  prevented  death  from  purulent 
infection  after  amputation,  or  that  it  neutralized  the  fetor  of  the 
wounds.  In  comminuted  and  compound  fractures,  however,  he 
found  that  dressings  of  carbolic  acid  were  very  useful.     In  medical 


1872.]     Report  on  Materia  Medica  and  Therajjeutics.  537 

practice,  Dr.  Labbee  passes  in  review  the  various  applications  of 
the  acid  in  various  forms  of  disease,  and  while  he  does  not  confirm 
the  reports  as  to  its  efficacy  in  intermittents,  typhus,  or  the  erup- 
tive fevers,  he  considers  it  very  useful  in  many  kinds  of  skin 
diseases  ;  and  from  its  slightly  caustic  and  astringent  properties,  he 
thinks  it  may  be  useful  when  given  in  some  forms  of  atonic  dys- 
pepsia. He  also  thinks  that  from  its  power  of  reducing  the  animal 
temperature  it  might  be  given  advantageously  in  febrile  conditions 
attended  with  excessive  calorification.  On  the  whole,  Dr.  Labbee 
arrives  at  the  conclusion  that,  in  spite  of  many  illusions  in  regard 
to  the  acid  and  some  exaggerated  reports  as  to  its  utility,  it  is  really 
an  important  article  of  the  materia  medica. — Archives  Generales  de 
Medecine,  October,  1871. 

On  tlie  Use  of  Oxygen  in  Diseases  of  tJie  Lungs.  By  Dr.  H.  N. 
Eead,  of  Long  Island  College  Hospital.  And  Sugli  Effetti  Tera- 
jpeutici  deJla  Inalazione  d' Ossigeno  {On  the  Therapeutical  Effects  of 
the  Inhalation  of  Oxygen).  By  Prof.  P.  Buiiresi,  of  Siena. — 
Dr.  Eead  publishes  a  series  of  cases  taken  from  observations  ex- 
tended over  about  a  year,  during  which  time  oxygen  gas  was  used  in 
the  Long-Island  College  Hospital  in  the  treatment  of  pulmonary 
phthisis,  acute  and  chronic  pneumonia,  and  chronic  bronchitis.  He 
publishes  only  those  cases  in  which  the  gas  was  used  regularly  and 
for  a  sufficient  time  to  warrant  him  in  drawing  conclusions.  The 
cases  reported  are  twenty-one  in  number,  and  they  comprise  persons 
of  diff'erent  nationalities,  and  it  is  to  be  observed  that  other  treat- 
ment was  always  adopted  in  addition  to  the  inhalation  of  oxygen, 
cod-liver  oil  being  given  in  the  phthisical  cases,  and  a  tonic  and  sup- 
porting diet  being  always  prescribed.  The  results  appear  generally 
to  have  been  very  satisfactory,  the  patients  gaining  in  weight  by  the 
treatment,  the  rational  symptoms  diminishing  or  ceasing  altogether, 
and  the  physical  signs  undergoing  favorable  change.  In  some  cases, 
however,  the  results  were  unfavorable,  but  even  in  these  the  general 
health  is  said  to  have  been  improved,  and  the  lives  of  the  patients 
to  have  been  probably  prolonged.  The  advanced  state  of  disease  at 
the  commencement  of  treatment  and  complication  with  other 
maladies  were  unfavorable  elements  in  the  instances  of  failure. 
Dr.  Eead  submits  his  cases  to  the  profession  for  the  purpose  of 
showing  the  action  of  oxygen  gas,  in  conjunction  with  cod-liver  oil, 
in  diseases  of  the  lungs.  In  the  cases  of  acute  pneumonia  in  which 
it  was  given  it  invariably  had  the  eff'ect  of  relieving  the  laboured 
respiration  in  the  early  stages,  and  of  promoting  resolution  and 
absorption  in  the  later. 

Prof.  Burresi  relates  a  single  case  in  which  the  inhalation  of 
oxygen  was  employed  in  conjunction  with  other  remedies.  The 
patient  was  a  young  Italian  woman,  who  was  suffering  from  chronic 
leucocythaemia,  chlorosis,  hyperplasia  of  the  spleen,  insufficiency  of 
the  mitral  valves,  and  hypertrophy  of  the  heart.  The  treatment 
recommended  consisted  in  a  meat  diet  with  wine  ;  the  administra- 
tion of  carbonate  of  iron  and  manganese  ;  the  inhalation  of  pure 


638  Chronicle  of  Medical  Science.  [April, 

oxygen,  in  the  daily  dose  of  20  litres  at  first,  and  then  of  34  litres, 
which  were  consumed  in  fifteen  or  twenty  minutes  every  morning. 
Tlie  duration  of  the  treatment  was  from  the  18th  of  April  to  the 
16th  of  June,  and  at  the  latter  period  there  was  not  mucii  change 
in  the  general  condition  of  the  patient,  except  that  she  had  gained 
some  appetite,  slept  more  quietly  and  without  oppression  of  the 
breathing,  felt  a  little  stronger,  and  had  a  little  more  colour.  The 
case  does  not  prove  the  therapeutical  efficacy  of  the  inhalation  of 
oxygen,  nor  does  Prof.  Burresi  adduce  it  for  that  purpose,  but  he 
has  carefully  recorded  the  immediate  efi'ects  produced  by  the  gas, 
and  also  the  state  of  the  respiration,  circulation,  and  calorification, 
as  observed  day  by  day  during  the  treatment.  The  immediate 
effects  appear  to  have  been  some  increase  in  the  frequency  of  the 
pulse  and  of  the  respiration,  and  some  augmentation  (though  this 
was  not  always  observed)  of  the  temperature  ;  but  Dr.  Burresi  did 
not  find  any  immediate  change  in  the  quality  of  the  pulse,  as  shown 
by  the  sphygmograph.  As  for  the  more  remote  efi'ects  of  the  inha- 
lation it  is  difficult  to  estimate  them,  because  the  treatment  by  meat 
diet,  and  by  the  iron  and  manganese,  must  have  had  great  influence 
on  the  results. — New  York  Medical  Journal,  October,  1871  ;  and 
Rivista  Scientijica  Siena,  1871. 

On  the  Treatment  of  Diahetes  hy  Lactic  Acid  {Cantani's  Method). 
By  Dr.  Gr.  W.  Balfour,  of  Edinburgh. — The  pathology  of  diabetes, 
although  still  obscure,  is  now  pretty  generally  admitted  to  consist 
in  some  perversion  of  the  glycogenic  function  in  the  body,  and 
the  treatment  has  hitherto  been  mainly  directed  to  the  object  of  de- 
priving the  organism  of  the  pabulum  from  which  the  glucose  is  mainly 
derived,  and  such  remedies  are  employed  as  may  alter  the  nervous 
energy  of  the  organs  at  fault.  Cantani,  however,  considers  that  in 
diabetes  there  is  not  merely  an  increased  production  of  sugar,  but 
an  imperfect  combustion  of  that  principle,  and  he  believes  that  this 
imperfect  combustion  depends  on  the  production  of  a  morbid  form 
of  glucose,  which  he  calls  paraglucose,  a  substance  incapable  of  being 
transformed  into  lactic  acid,  and  which  therefore  cannot  be  burned, 
and  consequently  passes  unchanged  into  the  urine.  As  the  sugar 
and  starch  of  the  food  cannot  now  be  burned,  the  heat  of  the  body 
is  maintained  at  the  expense  of  the  albumen  and  fats,  the  combus- 
tion of  the  former  leading  to  excess  of  urea  which  adds  to  the 
density  of  the  urine  in  diabetes.  The  albumen  and  fats  received 
as  food  being  now  insufficient  for  the  requirements  of  the  body,  the 
tissues  are  employed  also  for  that  purpose,  and  hence  the  rapid 
emaciation  in  the  disease.  In  the  early  stage  of  diabetes  the 
quantity  of  sugar  in  the  urine  varies  with  the  diet,  but  in  the  latter 
stages  Cantani  believes  that  the  inosite  of  the  muscles,  and  even  the 
gelatinous  tissues,  are  converted  into  paraglucose.  He  considers  the 
liver  to  be  the  chief  seat  of  disease,  but  whether  this  be  the  case  or 
not,  he  proposes  to  give  as  complete  rest  as  possible  to  this  organ 
by  withdrawing  sugar-producing  substances  and  subjecting  the 
patient  to  a  rigorous  meat  diet.     But  as  this  is  only  a  temporary 


1872.] 


Report  on  PatJtology  and  Medicine.  539 


expedient,  inasmuch  as  meat  itself  may  ultimately  be  converted 
into  paragliicose,  lie  further  proposes  to  prevent  waste  by  supplying 
a  combustible  agent  in  a  quantity  sufficient  for  the  wants  of  the 
body,  so  that  the  albuminates  and  fats  may  be  spared,  Now,  in  the 
conversion  of  glucose  into  carbonic  acid,  lactic  acid  appears  to  be 
the  intermediate  product,  and  lactic  acid  is  the  combustible  agent 
which  Cantani  recommends.  The  quantity  of  lactic  acid  adminis- 
tered by  this  physician  is  from  77  to  154  grains  daily,  diluted  in 
from  8  to  10  ounces  of  water,  and  his  meat  diet  is  exclusively  one 
of  plain  meat,  roast  or  boiled,  without  any  sauces  of  milk  or  eggs, 
and  without  any  bread,  flour,  or  any  vegetable  matter  whatever,  the 
only  seasoning  permitted  being  salt,  oil,  and  a  little  vinegar.  The 
drink  allowed  is  water,  either  plain  or  with  a  little  of  the  purest 
alcohol  ;  coffee,  tea,  and  wine  being  prohibited.  The  results  are 
said  to  be  surprisingly  successful,  and  Dr.  Balfour  remarks  that 
the  latest  treatment  adopted  in  Grreat  Britain,  namely,  that  by 
skim-milk,  bears  out  Cantani's  views  so  far  as  it  is  a  strictly 
animal  diet,  free  from  amylaceous  matter,  and  containing  three  to 
six  per  cent,  of  lactin,  which,  under  the  influence  of  the  caseous 
matter,  became  transformed  into  lactic  acid.  Dr.  Balfour  has  tried 
both  these  systems,  but  he  finds  that  of  Cantani  the  more  success- 
ful. He  relates  the  details  of  seven  cases  in  most  of  which  the 
treatment  was  attended  with  favorable  results,  and  he  invites  a 
further  trial  of  Cantani's  plan  at  the  hands  of  the  profession.  The 
lactic  acid  employed  by  Dr.  Balfour  is  fluid,  not  syrupy,  of  the  sp. 
gr.  1'027,  and  with  tlie  ordinary  musty  smell  of  sour  milk,  and 
three  to  four  drachms  a  day  appear  to  him  sufficient  for  all  prac- 
tical purposes.  Koumiss  would  probably  be  a  useful  article  of  diet 
for  diabetic  patients. — Edinhurgh  Medical  Journal^  December, 
1871. 

On  the  Use  of  Carhonate  of  Litliia  in  Gout  and  Uric  Acid 
Gravel.  By  Prof  Dittekich,  of  Munich. — Carbonate  of  lithia, 
according  to  Prof  Ditterich,  must  always  be  considered  as  the 
most  powerful  remedy  in  gout  and  the  morbid  conditions  depend- 
ing upon  excess  of  uric  acid,  and  the  salt  has  fallen  somewhat  into 
disrepute  of  late  only  in  consequence  of  being  unsuitably  adminis- 
tered. The  doses  of  five  to  ten  grains,  recommended  by  Aschen- 
brenner,  generally  produce  very  unpleasant  symptoms,  as  dyspepsia, 
catarrh  of  the  stomach  and  bowels,  with  vomiting,  &c.,  which 
require  the  discontinuance  of  the  remedy.  These  doses,  according 
to  Prof  Ditterich,  are  much  too  large  to  act  beneficially,  and  the 
single  dose  should  never  exceed  twelve  centigrammes  (a  centigramme 
is  the  hundredth  part  of  a  gramme,  which  is  about  15  grains)  ai^di 
in  twenty-four  hours  not  more  than  a  gramme  should  be  given  alto- 
gether. The  next  question  to  be  asked  in  the  treatment  of  gout,  is 
whether  the  case  presents  itself  in  the  acute  or  chronic  form,  for  in 
the  former  lithia  is  unsuitable,  but  in  the  latter  the  carbonate  may 
be  given  in  the  proportion  of  half-a-gramme  (about  7|-  grains)  in  a 
hundred  and  fifty  grammes  of  distilled  water,  one  or  two  teaspoon- 


510  Chronicle  of  Medical  Science.  [April, 

fuls  to  be  taken  every  two  hours.  Thus  administered,  the  lithia 
causes  no  inconvenience  and  generally  affords  relief  in  from  eight  to 
fifteen  days,  during  which  the  painful  parts  are  covered  with  socks 
or  linen  coverings.  According  to  Prof.  Ditterich,  the  gouty  swell- 
ings which  have  become  hardened  are  not  affected  by  the  lithia  cir- 
culating in  the  blood,  until  the  adjacent  parts  of  the  limb  have  been 
brought  into  a  state  of  congestion  by  stimulating  embrocations. — 
Schmidt's  JahrhucJier  der  Gesammten  Medicin,  October,  1871. 

On  the  Use  of  Cold  Water  as  an  Oxytocic.  By  Dr.  Gaevin,  of 
Kentucky. — The  efficacy  of  cold  water  in  exciting  contraction  of  the 
uterus  in  post-partum  haemorrhage  has  induced  Dr.  Garvin  to 
employ  the  same  agent  in  promoting  the  action  of  the  organ  in 
cases  of  tedious  labour.  He  gives  the  history  of  four  cases,  selected 
from  a  number  of  others  successfully  treated  by  this  agent.  In  all 
the  cases,  the  uterus  was  inactive,  and  presented  the  conditions  in 
which  ergot  of  rye  or  the  use  of  the  forceps  is  usually  recommended, 
but  they  all  did  well  by  the  application  of  iced  water  to  the  abdo- 
men. Dr.  Garvin  compares  the  value  of  cold  water  with  that  of 
ergot;  and,  while  thinking  that  the  latter  drug  has  been  over- 
estimated, he  believes  that  only  experience  is  needed  to  prove  the 
efficacy  of  cold  water,  by  the  use  of  which,  moreover,  none  of  the 
dangers  are  encountered  which  often  attend  the  use  of  ergot.  Dr. 
Garvin  argues  that  cold,  when  applied  to  the  surface  of  the  body, 
though  locally  depressing,  acts  as  a  stimulant  to  the  whole  system, 
as  is  shown  by  its  effect  in  restoration  from  syncope,  and  in  its 
stimulating  influence  on  the  brain  in  cases  of  narcotic  poisoning. 
It  does  not  exert  a  toxical  power  on  the  nervous  system  as  ergot 
does,  but  it  merely  awakens  and  revives  the  dormant  or  flagging 
energies,  and  re-establishes  a  normal  condition.  The  only  objection 
which  can  be  urged  against  the  use  of  cold  water  as  an  oxytocic  is 
the  liability  of  the  patients  to  take  cold  under  its  use,  but  this 
inconvenience  may  be  obviated  by  a  few  simple  precautions.  "When 
applied  to  the  surface  in  the  manner  recommended,  cold  water 
excites  the  uterus  to  contraction  by  reflex  action. — American  Journal 
of  Medical  Sciences,  October,  1871. 

On  some  New  Properties  of  Quinine,  as  employed  in  Ohstetric  and 
Ophthalmic  Practice. — i'  Union  Medicale  remarks  that,  in  addition 
to  the  well  known  anteperiodic  action  of  quinine,  various  other 
properties  have  been  assigned  to  this  alkaloid,  namely,  stimulant, 
disinfecting,  parasiticide,  &c. ;  but,  in  addition.  Dr.  Monteverdi,  of 
Cremona,  has  lately  declared  it  to  be  superior  even  to  ergot  of  rye 
as  a  special  exciter  of  the  contractions  of  the  uterus,  being  more 
rapid  in  its  action,  and  also  being  harmless  both  to  mother  and 
child.  In  a  medium  dose  of  1  gramme  (about  15  grains),  taken  in 
three  or  four  doses  in  two  hours,  the  drug  will  produce  contractions 
in  cases  of  atony  and  inertia  of  the  uterus,  whether  in  cases  of 
labour  or  uterine  haemorrhage.  Dr.  Monteverdi  was  induced  to 
suspect  this  effect  of  quinine  from  the  aversion  manifested  by  the 
pregnant  women  of  Cremona  to  take  the  alkaloid  from  the  fear  of 


1872.]       Report  on  Materia  Meclica  and  Therapeutics.       541 

abortion  ;  and  he  says  that  he  has  verified  this  action  by  a  series  of 
facts  proving  the  power  of  quinine  to  accelerate  labour  and  to  pro- 
mote the  expulsion  of  the  placenta.  But  another  application  has 
been  made  of  quinine  in  ophthalmic  practice,  especially  in  affections 
of  the  cornea  and  conjunctiva.  Dr.  Grotti,  of  Bologna,  has  employed 
a  quinine  wash,  composed  of  25  centigrammes  of  hydrochlorate  of 
quinine  to  30  grammes  of  water,  in  a  great  number  of  private  and 
hospital  cases  affected  with  maladies  of  the  cornea  and  conjunc- 
tiva, and  he  has  found  the  treatment  very  successful.  The  wash  is 
especially  applicable  to  inflammation  of  the  cornea  and  conjunctiva; 
but  Mr.  Prout,  of  Brooklyn,  has  employed  insufflation  of  dry 
quinine  in  palpebral  granulations.  Two  cases  are  recorded  where 
this  treatment  was  attended  with  partial  success.  In  other  affec- 
tions of  the  eye,  however,  the  results  of  the  treatment  have  not 
been  equally  satisfactory. — i'  Union  Medicale,  September,  1871. 

On  the  Treatment  of  Pneumonia  hy  the  Acetate  of  Lead.  By 
Dr.  Strohl,  of  Strasburg. — Dr.  Strohl  strongly  recommends  the 
use  of  acetate  of  lead  in  pneumonia;  and,  discussing  the  whole 
subject  of  the  treatment  of  that  disease,  he  comes  to  the  con- 
clusion that  lead  is  the  safest  and  best  remedial  agent.  He 
compares  the  results  obtained  by  different  modes  of  treatment, 
such  as  the  expectant  plan,  bleeding,  emetics,  mixed  treat- 
ment of  bleeding  and  tartar  emetic,  &c. ;  and  he  claims  for  his 
own  plan  the  most  satisfactory  results,  for  the  ratio  of  mor- 
tality in  the  cases  he  treated  was  only  1  in  9'66 ;  but,  even  if  the 
mortality  were  the  same,  he  claims  for  lead  certain  advantages  which 
it  possesses  over  other  remedies,  and  especially  its  innocuity  and  the 
rapidity  of  its  curative  action.  Tartar  emetic  causes  vomiting, 
gastro-intestinal  irritation,  and  prostration,  but  acetate  of  lead  does 
nothing  of  the  kind,  and  Dr.  Strohl  found  that  it  did  not  even  cause 
a  threatening  of  colic.  Again,  the  objections  to  other  modes  of  treat- 
ment are  rather  numerous  ;  bleeding  is  inapplicable  in  the  extreme 
of  age  and  in  bad  constitutions  ;  tartar  emetic  is  contra-indicated 
in  cases  accompanied  by  inflammatory  or  other  serious  affections  of 
the  stomach  and  intestines,  and  in  diarrhaea  and  phthisis ;  but  in 
all  these  cases  lead  may  be  given.  Dr.  Strohl  sums  up  his  views  as 
to  the  efficacy  of  acetate  of  lead  in  the  treatment  of  pneumonia  to 
the  following  effect :  It  is  preferable  to  tartar  emetic,  digitalis,  and 
veratria,  because  its  action  is  more  certain,  more  rapid,  and  more 
free  from  inconvenience,  and  it  has  never  caused  any  bad  symptoms. 
It  never  constipates,  but  sometimes  causes  diarrhoea,  and  it  may  be 
given  to  persons  of  all  ages.  Under  its  use  the  pulse  is  lowered, 
and  the  heat  and  the  fever  are  reduced,  and  convalescence  is  very 
rapid  when  there  are  no  persistent  complications. — V  Union  Medi- 
cale, October  12,  1871. 

On  the  Physiological  and  Therapeutical  Effects  of  the  Chlorides  of 
Potassium  and  Magnesium.  By  Dr.  Eabuteau. — Dr.  Rabuteau,  in 
a  series  of  experiments  made  upon  himself,  found  that  the  chloride 
of  potassium  produced  two  distinct  effects,  namely,  as  a  chloride  it 

98 — xLix.  35 


542  Chronicle  of  Medical  Science.  [April, 

increased  oxldatioD,  and  as  a  potassium  salt  it  lowered  the  pulse. 
The  proof  of  its  oxidising  action  was  that  the  excretion  of  urea 
was  notably  increased.  The  salt  has  been  hitherto  very  little  used 
in  medicine,  but  it  is  a  purgative,  and  has  been  sometimes  employed 
externally  in  a  concentrated  solution  or  in  powder  in  cancerous 
affections.  It  has  been  also  prescribed  instead  of  the  bromide  of 
potassium,  in  epilepsy,  and  has  been  said  to  be  in  some  respects 
superior  to  the  latter  salt.  On  theoretical  grounds,  the  chloride  of 
potassium  might,  perhaps,  be  substituted  for  digitalis  in  some  cases. 
The  chloride  of  magnesium,  as  is  well  known,  is  contained  in  sea- 
water.  Experiments  made  upon  the  lower  animals  showed  tliat 
when  injected  into  the  veins  it  caused  constipation,  but  when  intro- 
duced into  the  alimentary  canal  it  acted  as  a  purgative,  and  when 
employed  as  a  medicine  it  was  found  that  its  aperient  properties 
were  well  marked.  Dr.  Kabuteau  considers  it  to  be  as  efficacious 
in  this  respect  as  the  sulphate  of  magnesia,  and  in  some  of  its  pro- 
perties to  be  preferable  ;  for  it  is  not  so  disagreeable  in  its  taste,  it 
produces  no  griping,  and  no  consecutive  constipation,  and  its  purga- 
tive effects  are  secured  by  a  comparatively  small  dose ;  nevertheless, 
Dr.  Kabuteau  does  not  specially  recommend  the  chloride  of  magne- 
sium as  a  purgative,  for  he  objects  to  all  magnesian  purgatives  ;  but 
he  prefers  it  to  the  sulphate.  The  chloride  is  deliquescent,  and,  if 
employed,  the  best  form  is  in  solution;  and  Dr.  Eabuteau  gives 
formulsD  for  what  he  calls  magnesian  ivaters,  to  be  employed  like 
Seidlitz  water. — V  Union  Medicaid,  September  14  and  30,  1871. 

On  the  Therapeutical  Use  of  the  Lacto-Phosphate  of  Lime.  By 
Professor  B.  "W.  McCeeadt. — There  is  reason  to  believe  that  phos- 
phate of  lime,  besides  entering  into  the  composition  of  bone,  has 
some  influence  in  cell  formation,  and  according  to  Lehraann  it  is 
found  in  appreciable  quantity  wherever  cells  or  fibres  are  formed. 
The  phosphate  has  been  recommended  in  cases  of  rickets,  and  the 
experiments  of  Milne-Edwards  seem  to  show  that,  under  its  use, 
fractured  bones  in  dogs  and  rabbits  produce  more  abundant  callus. 
But  in  a  recent  series  of  articles,  published  in  the  Archives  GSne- 
rales  de  Medccine,  Dr.  L.  Dusart  examines  the  whole  subject,  and 
attributing  the  somewhat  unsatisfactory  results  hitherto  obtained  to 
the  great  insolubility  of  the  ordinary  phosphate,  he  recommends  the 
use  of  a  new  preparation,  which  he  calls  the  lacto-phosphate  of  lime, 
in  which  the  lime-salt  is  dissolved  in  free  lactic  acid.  Dr.  Dusart 
made  experiments  both  on  the  lower  animals  and  on  man,  and  he 
found  that  the  union  of  bone,  in  cases  of  fracture,  was  promoted  by 
the  use  of  this  preparation,  which  was  also  useful  in  rickets,  and 
some  other  diseases,  as  diarrhoea  and  indigestion,  In  the  United 
States,  at  Dr.  McCready's  request,  a  syrup  of  the  lacto-phosphate 
of  lime  was  prepared  by  the  pharmaceutists,  and  he  found  the  drug 
useful  in  cases  of  defective  nutrition,  especially  in  the  cases  of  prema- 
turely weaned  children,  in  rachitis,  and  in  atonic  dyspepsia.  Dr.  "W. 
A.  Hammond  found  it  of  very  great  value  in  cases  of  nervous  derange- 
ment. In  forming  the  syrup  of  the  lacto-phosphate,  bone-earth  is 
dissolved  in  hydrochloric  acid,  then  precipitated  by  ammonia,  and 


1872.]      Repoi't  on  Materia  Medica  and  Therapeutics.         543 

tlie  recent  precipitate  is  treated  with  concentrated  lactic  acid;  the 
clear  solution  is  then  mixed  with  syrup,  and  flavoured  with  orange- 
flower  water. — New  York  Medical  Journal,  June,  1871. 

On  tJie  Use  of  Clilorine  Water  in  the  Treatment  of  BipJitheria.  Bj 
Mr.  W.  Gr.  Balfoue,  of  Montrose. — Chlorine  water,  which  is  pre- 
pared by  adding  hydrochloric  acid  to  chlorate  of  potash  and  adding 
water,  has  been  successfully  employed  in  the  treatment  of  scarlet 
fever,  its  efficacy  having  been  supposed  to  depend  upon  its  disinfect- 
ing properties ;  but  Dr.  Matthew  Grairdner,  of  Crielf,  introduced  its 
use  in  diphtheria,  and  Mr.  Balfour,  while  acting  as  his  assistant, 
became  aware  of  its  remedial  powers  in  that  disease.  He  adduces 
several  cases  in  support  of  his  recommendation  of  chlorine  water,  and 
particularly  mentions  the  case  of  a  family  living  near  Crieflf,  where 
four  of  the  cliildren  sufiered  from  diphtheria,  and  were  all  treated 
with  chlorine  water,  stimulants,  and  milk ;  three  recovered,  and 
one  died ;  and  the  unsuccessful  result  in  this  last  instance  is  attri- 
buted by  Mr.  Balfour  to  the  neglect  of  the  mother  in  not  giving  the 
remedy.  In  another  case,  which  was  that  of  a  child  three  years  of 
age,  the  symptoms  of  diphtheria  were  well  marked,  and  a  little  ipe- 
cacuanha wine  was  given  with  temporary  relief,  but  as  the  symptoms 
soon  returned,  the  chlorine  water  was  administered  in  two-drachm 
doses  every  two  hours.  After  several  vicissitudes,  the  child  had  a 
violent  paroxysm  of  coughing,  followed  by  expectoration  of  some- 
thing, which  was  probably  the  false  membrane,  but  v^hich  was  swal- 
lowed, and  immediately  afterwards  the  child  was  relieved,  and  ulti- 
mately recovered.  Mr.  Balfour  thinks  that  the  remedial  action  of 
chlorine  in  diphtheria  and  scarlet  fever  is  more  general  than  local, 
and  that,  when  taken  internally,  it  is  absorbed  into  the  blood,  and 
there  neutralises  the  morbid;poison  ;  but,  whatever  the  theory  may 
be,  Mr.  Balfour  has  found  the  treatment  very  successful  in  practice. 
— Edinburgh  Medical  Journal ^  December,  1871. 

On  the  Physiological  and  Therapeutical  Effects  of  Semloch  and  its 
AlJcaloid.  By  MM.  Martin-Damoueette  and  Pelvet,  of  Paris. — 
The  Gazette  Hehdomadaire  gives  a  resume  of  some  recent  researches 
on  the  physiological  and  therapeutical  properties  of  hemlock  and 
its  alkaloid.  Four  kinds  of  hemlock  are  known,  but  they  belong  to 
four  different  genera ;  they  are,  the  common  hemlock  {conium  macu- 
latwn),  another  kind  of  hemlock  {cicuta  virosa),  the  water  hemlock 
{phellandrium  aq^uaticwn),  and  the  fool's  parsley  {cethusa  cynapiu/m). 
These  plants  are  all  dangerous,  and  contain  an  alkaloid,  called  by 
Brandes,  conia,  but  afterwards  named  by  Giesecke,  cicutia  ;  and  this 
principle  has  been  carefully  studied  by  different  chemists,  whose 
researches,  however,  have  been  chiefly  directed  to  the  properties  of 
the  conium  maculatum.  The  work  in  which  MM.  Martin-Damourette 
and  Pelvet  have  recorded  their  experiments  is  divided  into  three 
parts,  which  comprise  respectively  the  examination  of  the  physio- 
logical properties  of  cicutism  in  the  lower  animals,  the  eff'ects  of 
cicutia  on  the  different  systems  and  organs  of  the  body,  and  a  syn- 
thesis of  the  physiology  and  therapeutics  of  cicutia.     The  general 


541<  Chfonicle  of  Medical  Science.  [April, 

effects  of  hemlock  are — 1.  Excitement,  and  even  convulsions,  if  a 
sufScient  quantity  of  the  poison  is  introduced  suddenly  into  the 
blood.  2.  Paralysis  of  the  voluntary  movements  at  first,  and  then 
involuntary  movements  and  diminution  of  sensibility.  3.  lieturn 
of  convulsions  when  the  clcutism  is  disappearing,  in  cases  where  the 
dose  is  not  fatal.  When  death  occurs,  it  takes  place  from  arrest  of 
respiration,  with  or  without  ultimate  convulsive  movements.  The 
symptoms  exhibited  by  Socrates,  as  described  by  Plato,  present, 
according  to  MM.  Martin-Damourette  and  Pelvet,  the  characteristic 
features  of  poisoning  by  hemlock.  According  to  Plato's  descrip- 
tion, Socrates  was  directed  by  his  gaoler  to  walk  about,  after  taking 
the  poison,  till  he  felt  a  heaviness  in  his  legs ;  the  philosopher  did 
so,  and  when  he  felt  his  legs  heavy  he  lay  on  his  back.  The  person 
who  had  given  him  the  poison,  after  a  certain  time  pressed  his  feet, 
and  asked  if  he  felt  any  pain,  and  he  said  that  he  did  not ;  then  the 
upper  parts  of  the  body  were  successively  shown  to  be  cold  and 
stiff,  and  eventually  Socrates  spoke  a  few  words,  then  had  a  convul- 
sion and  remained  with  his  eyes  fixed,  and  then  died.  Thus,  it 
appears  that  the  first  symptom  was  the  weakness  of  the  lower  limbs, 
afterwards  coldness  and  insensibility,  extending  from  the  periphery 
to  the  centre,  and  lastly  there  was  a  terminal  convulsion.  It  is 
therefore  argued  that  the  doubts  entertained  by  some  authors,  as 
to  the  similitude  existing  between  the  Kujvetov  of  the  Athenians 
and  the  conium  of  the  present  day  are  unfounded,  or  at  any  rate 
may  be  explained  away.  In  reference  to  the  therapeutical  uses  of 
conium,  it  is  unnecessary  to  refer  to  the  empirical  eulogies  of  this 
plant  as  a  cure  for  several  organic  diseases  ;  and  it  must  be  admitted 
that  its  efficacy  as  a  remedy  is  not  very  great.  It  has  been  found 
experimentally  that  conium,  without  much  increasing  the  excitability 
of  the  spinal  cord,  paralyses  the  extremities  of  the  motor  nerves, 
and  hence  it  might  be  serviceable  in  tetanus.  Asthma  and  spasmodic 
cough  and  hooping-cough  have  been  relieved  by  this  drug,  and  neu- 
ralgic pains  have  been  caused  to  disappear  by  injections  of  a  weak 
solution  of  cicutia. —  Gazette  HeMomadaire,  October,  1871. 

On  the  Use  of  Ergot  of  Rye  in  Dysentery.  By  M.  Ltjton,  ot 
Eheims. — During  an  epidemic  of  dysentery  w^hich  lately  prevailed 
at  Eheims,  M.  Luton  employed  in  the  cure  of  the  disease  most  of 
the  remedies  which  are  considered  efficacious,  and  met  with  various 
degrees  of  success.  The  epidemic  was  not  a  very  severe  one,  and 
most  of  the  patients  recovered ;  but,  in  the  majority  of  the  cases,  it 
appeared  to  M.  Luton  that  the  therapeutical  action  was  not  very 
evident  nor  the  relief  rapid ;  and  moreover  some  of  the  patients, 
especially  among  the  most  aged,  died.  It  was  therefore  desirable 
that  some  new  method  of  treatment  should  be  found,  which  might 
give  mory  satisfactory  results,  and  the  opportunity  of  doing  so  Avas 
offered  by  the  case  of  a  female  patient,  who  was  suffering  at  the 
same  time  from  uterine  haemorrhage  and  dysentery.  The  ergot  of 
rye  was  prescribed  successfully  for  the  former  malady,  and  it  was 
found  that  the  latter  was  likewise  benefited  by  the  remedy ;  and,  in 
fact,  as  soon  as  the  first  doses  had  been  given,  a  condition  of  consti- 


1873.]        Report  on  Materia  Medica  and  Therapeutics.       515 

pation  was  induced,  which  lasted  for  four  or  five  days.  This  first 
experiment  led  to  the  use  of  the  ergot  in  simple  dysentery,  and  it 
was  found  that  an  improvement  in  the  symptoms,  and  eventually  a 
complete  cure,  followed  the  new  plan  of  treatment.  M.  Luton  gave 
the  ergot  in  powder,  in  the  dose  of  3  grammes  (about  45  grains)  a 
day,  divided  into  doses  of  50  centigrammes  (about  7\  grains) ;  and 
two  or  three  days  generally  sufficed  for  a  cure  in  ordinary  cases. 
The  ergot  appeared  to  attack  not  only  the  haemorrhagic  element  of 
dysentery,  but  the  whole  disease  ;  and  the  mucous  secretions,  the 
griping,  colic,  and  fever,  were  equally  relieved  at  the  very  com- 
mencement of  the  treatment. —  Gazette  Heldomadaire,  October,  1871. 

On  tJie  Therapeutic  Value  of  the  Nitrite  of  Amyl.  By  Dr.  H.  C. 
Wood,  jun.,  of  Philadelphia. — Dr.  Wood  has  arrived  at  the  con- 
clusion tliat  the  nitrite  of  amyl,  in  its  action  on  the  lower  animals, 
is  an  almost  universal  sedative  on  the  nervous  system,  while  on  the 
circulation  its  uniform  action  is  to  lessen  arterial  blood-pressure  ; 
and  he  thinks  that  it  also  catalytically  arrests  oxidation.  Dr.  Wood's 
views,  however,  are  not  in  accordance  with  those  of  some  other  writers, 
who  believe  that  the  nitrite  acts  on  man  as  a  powerful  stimulant. 
It  is  true  that  the  immediate  effects  of  this  agent  on  man  are  ful- 
ness of  the  head,  flushing  of  the  face,  and  violent  action  of  the  heart, 
but  these  symptoms  are  due  to  the  dilatation  of  the  capillaries,  and 
are  associated  with  lessened  arterial  pressure.  In  answer  to  the 
question  as  to  the  practical  value  of  the  nitrite  of  amyl.  Dr.  Wood 
suggests,  that  as  it  checks  oxidation  and  lowers  temperature,  it  may 
possibly  be  of  use  in  some  fevers,  but  he  has  no  clinical  evidence 
to  adduce  in  support  of  this  view.  In  tetanus  it  ought  to  be  theo- 
retically of  great  value,  because  in  this  disease  there  is  a  condition  of 
exalted  functional  activity  of  the  reflex  motor  centres,  and  of  these 
centres  the  nitrite  is  a  powerful  depressant,  and  there  is  some 
evidence  that  it  has  been  serviceable  in  this  affection.  In  angina 
pectoris  the  nitrite  is  of  very  great  value  in  affording  rapid  and 
permanent  relief,  and  not  only  in  true  angina  pectoris,  but  also  in 
those  cases  where  there  is  well-marked  valvular  disease  of  the 
heart.  Dr.  Wood  has  had  an  opportunity  of  using  the  nitrite  in  a 
case  of  valvular  disease  attended  with  severe  suffering,  and  its 
effect  in  relieving  the  pain,  after  the  failure  of  other  remedies,  was 
astonishing.  With  regard  to  the  mode  of  administration,  it  has 
always  hitherto  been  given  by  inhalation,  and  its  insoluble  and 
highly  volatile  nature  renders  it  unfit  for  exhibition  either  in  solu- 
tion or  mixture,  but  Dr.  Wood  thinks  that  it  might  be  given  when 
dropped  upon  a  piece  of  sugar  ;  when  it  is  to  be  inhaled,  five  drops 
should  be  placed  upon  a  handkerchief  and  held  close  to  the  nostrils, 
the  pulse  being  closely  watched  and  taken  as  a  guide  as  to  the  con- 
tinuance or  withdrawal  of  the  drug. — American  Journal  of  the 
Medical  Sciences,  October,  1871. 


5 16  Chronicle  of  Medical  Science.  [April, 


REPORT   ON   PATHOLOGY   AND   PRINCIPLES   AND 
PRACTICE   OE   MEDICINE. 

By  Eeancis  C.  "Webb,  M.D.,  F.L.S., 

Member  of  the  Uoyal  College  of  Physicians,  Physician  to  the  Great  Northern  Hospital. 


On  Degenerations  occurring  in  Acute  Maladies. — M.  A.  Laveran 
observes  that  the  question  of  the  degeneration  of  certain  anatomical 
elements  (muscular  fibres,  small  blood-vessels,  &c.),  in  acute  mala- 
dies has  hitherto  been  only  studied  from  an  histological  point  of 
view.  He  proposes  to  examine  the  influence  exercised  by  these 
degenerations  on  the  progress  and  termination  of  acute  diseases. 
He  thinks  that  Zenker's  distinction  between  the  granular  and  waxy 
forms  of  degeneration  of  muscle  in  typhoid  fever  is  untenable.  The 
granular  form  is  the  first  degree  of  the  waxy  degeneration,  i.  e.  the 
vitreous  degeneration  of  O.  "Weber,  the  granulo- vitreous  of  M.  Gr. 
Hayem.  He  describes  three  degrees  in  the  alteration  of  muscle. 
In  the  first  the  muscles  are  red,  hard,  brittle,  the  fibres  swollen, 
their  contents  granular,  at  points  the  striae  have  disappeared,  and 
here  and  there  they  present  incomplete  fractures.  In  the  second 
degree,  the  muscles  are  pale,  dry,  and  friable,  the  fibres  are  unequal, 
expanded  at  certain  points,  narrowed  at  others.  In  the  expanded 
parts  are  transparent  masses  (the  masses  vitreuses  of  0.  Weber)  or 
more  frequently  they  are  transparent  at  some  points,  granular  at 
others.  Between  the  swellings  the  fibres  are  granular  and  present 
numerous  fractures.  In  the  third  degree  the  muscle  is  quite  pale, 
of  a  yellowish  dead-leaf  or  waxy  colour.  It  is  more  friable  than  in 
the  second  degree.  Its  histological  structure  is  completely  modi- 
fied. The  greater  number  of  fibres  enclose  granulo-vitreous  masses 
in  juxtaposition  ;  some  are  completely  empty  and  reduced  to  the 
mere  enveloping  sheath.  The  nuclei  of  the  fibres  and  the  cells  of 
the  perimysium  are  in  course  of  proliferation.  Alteration  of 
muscles  is  met  with  in  a  great  number  of  acute  diseases.  Hayem 
has  noted  it  in  22  out  of  24  cases  of  variola,  once  in  scarlatina, 
twice  out  of  3  cases  of  measles,  in  3  cases  of  acute  miliary  tuber- 
culosis, in  2  cases  of  grave  jaundice,  once  in  erysipelas  with 
meningitis,  once  in  2  cases  of  tubercular  meningitis,  once  in  puer- 
peral fever  with  metastatic  abscesses,  once  in  phlegmonous  inflam- 
mation of  the  parotid.  Hoftmann  has  met  w^axy  degeneration  of 
the  muscles  of  the  thoracic  and  abdominal  walls  frequently  in 
pneumonia.  The  author  has  observed  alteration  of  muscles  in  19 
out  of  21  cases  of  typhoid  fever,  in  6  out  of  10  of  variola,  in  3  cases 
of  scarlatina,  and  in  two  out  of  3  of  acute  tubercolosis.  The 
change  is  most  marked  in  typhoid  ;  in  variola  and  scarlatina  death 
supervenes  more  rapidly,  and  the  degeneration  less  frequently 
has  advanced  beyond  the  first  degree.  Degeneration  of  the 
muscles  is  not  the  cause  of  the  great  weakness  w^hich  accom- 
panies typhoid  at  its  onset,  for  the   time  has    not  been  sufficient 


1872.]  Report  on  Pathology  and  Medicine,  547 

to  produce  it ;  but  muscular  lesion  is  probably  the  cause  of  the 
great  weakness  which  accompanies  the  long  convalescence  from 
typhoid.  Alteration  of  the  respiratory  muscles,  although  by  itself 
it  may  not  cause  death,  yet  favours  a  fatal  termination  by  embarass- 
ing  respiration,  hindering  expectoration,  and  favouring  hypostasis. 
Zenker  considered  alteration  of  the  fibres  of  the  heart  rare  in 
typhoid.  Hayem  has  met  it  more  frequently  in  patients  who 
died  suddenly  in  the  course  of  typhoid,  and  in  whom  there  was 
no  other  lesion  to  explain  death.  In  four  out  of  fourteen  cases  of 
typhoid  the  author  has  found  the  heart  in  course  of  granular 
degeneration.  This  condition  may  predispose  to  death  by  embarass- 
iug  the  pulmonary  circulation  and  favouring  bronchitis  and  pul- 
monary oedema,  and  it  may  predispose  to  sudden  death.  The 
author  compares  sudden  death  during  the  convalescence  of  typhoid 
to  the  sudden  death  which  sometimes  overtakes  anaemic  and  leu- 
cocythaemic  patients.  The  author,  with  Hoffmann  and  Hayem, 
has  observed  granular  degeneration  of  small  blood-vessels  in  a 
considerable  number  of  cases  of  typhoid,  of  variola,  and  of  scarlatina. 
Not  only  are  the  vessels  of  the  heart,  but  those  of  the  skin  and  kidneys 
attacked  The  alteration  of  the  vessels  is  a  granular  degeneration. 
The  blood-vessels  becom.e  granular,  break  easily,  and  give  rise  to 
haemorrhages — hence  subcutaneous  and  submucous  ecchymoses. — 
Archives  Gen  de  Medecine,  Juillet,  Aout,  1871. 

LeucocytJicBmia  accompanied  hy  Alteration  of  the  Marroio  of  the 
Bones. — E.  Neumann  relates  the  following  case  : — The  patient, 
8Dt.  30,  presented  during  life  all  the  symptoms  of  splenic  leucocy- 
thaomia  ;  he  died  from  repeated  haemorrhages.  After  death  there 
was  found  considerable  hypertrophy  of  the  spleen  and  liver,  and 
the  usual  alterations  of  the  blood.  The  parenchyma  of  the  spleen 
and  liver  presented  all  the  characters  of  leukaemic  hyperplasia  ;  the 
liver  also  enclosed  a  whitish  nucleus  of  some  size,  in  which  a  col- 
lection of  lymphatic  cells  had  taken  the  place  of  the  hepatic  cells. 
The  marrow  of  the  bones  presented  very  curious  lesions,  especially 
observed  in  the  ribs,  the  sternum,  a  vertebra,  the  diaphysis  of  the 
humerus,  and  the  diploe  of  the  cranium.  At  all  these  points  the 
marrow  presented  a  uniform  greenish  yellow  colour,  traversed  by  a 
few  small  red  veins  ;  it  had  a  ropy  consistence  and  resembled 
creamy  pus.  The  microscope  revealed  white  corpuscles  of  the  blood, 
of  varied  form  and  in  countless  numbers — perhaps,  in  course  of 
transformation  into  red  corpuscles.  These  elements  were  enclosed 
in  a  filamentous  substance,  containing  mucine  and  very  slightly 
vascular.  The  blood-vessels  were  represented  by  some  isolated 
arterioles.  The  walls  of  the  larger  of  these  vessels  were  infiltrated 
with  lymphatic  corpuscles  ;  those  of  the  little  arterioles  were  formed 
by  slender  fusiform  cells,  elongated  as  in  the  spleen.  These  vessels 
w^ere  almost  exclusively  filled  with  red  globules.  The  author  pro- 
poses that  a  myelogenic  leucocythaemia  should  be  admitted  in  addi- 
tion to  a  splenic  and  lymphatic.  The  capillary  network  being  want- 
ing the  blood  is  brought  by  the  arteries  and  thrown  directly  into 


548  Chronicle  of  Medical  Science.  [April, 

tliepulp  oftlie marrow,  which  is  rich  ia  cells,  and  it  is  probably  returned 
into  the  venous  canals  mixed  with  the  elements  of  this  tissue.  The 
presence  in  the  blood  of  red  globules  incompletely  developed,  only  met 
in  the  marrow  of  the  bones  in  health,  is  also  explained. — Arch. 
der  Heilkimde,  xi,  1, — 15  ;  Archives  Gen.  delUd.,  Tevrier,  1872. 

The  Chemistry  of  the  Urine  and  Blood  in  Leulccemia. — Salkowski 
has  collected  seven  observations  of  splenic  leukaemia  in  which  an 
increased  proportion  of  uric  acid  was  remarked.  He  analysed  the 
urine  of  a  patient  suffering  from  splenic  leukaemia  for  thirty  conse- 
cutive days.  The  mean  proportion  of  uric  acid  to  urea  was  1  :  16*3. 
There  was  a  constant  augmentation  in  the  proportion  of  uric  acid. 
"With  regard  to  the  existence  of  hypoxanthine  in  the  urine  of 
patients  attacked  with  splenic  leukaemia,  the  author  is  unable  to 
confirm  the  observations  of  Mosler.  He  has  analysed  large  quan- 
tities of  the  urine  without  finding  it,  and  in  any  case  the  occurrence 
of  hypoxanthine  in  the  urine  is  not  diagnostic.  Lactic  acid,  formic 
acid,  acetic  and  oxalic  acids,  products  of  incomplete  oxidation  may 
be  found.  The  three  first  of  these  exist  in  healthy  splenic  pulp,  it 
is  therefore  not  difficult  to  suppose  that  they  may  occur  in  the 
urine  of  patients  attacked  with  hypertrophy  of  the  spleen.  The 
author  has  never  found  a  trace  of  allantoine.  In  the  blood  after 
death  he  has  found  a  substance  presenting  reactions  analogous  to 
those  of  glutine ;  this  body,  however,  treated  by  sulphuric  acid  only 
furnished  doubtful  traces  of  leucine,  and  not  of  glycocol.  Besides, 
he  found  in  the  blood  hypoxanthine,  formic,  acetic,  and  lactic  acids, 
and  an  organic  acid  containing  phosphorus.  Of  these  the  principal 
abnormal  constituents  were  the  glutine  and  hypoxanthine.  Hoppe- 
Seyler  has  shown  that  formic  acid  is  found  at  the  moment  of 
coagulation  of  haemoglobine.  Glutine  has  been  found  in  some 
cases  of  leukaemia,  but  not  in  all.  Light  may  be  thrown  on  its 
occurrence  by  the  observation  of  Neumann  quoted  above  on  the 
lesions  of  the  marrow  of  bones,  in  certain  cases  of  leukaemia. — 
Virchow^s  Archiv,  1870  ;  and  Archives  G^n.  de  Medecine,  Feb.,  1872. 

On  the  Relations  of  Leucocythcemia  and  Pseiidoleulcaemia. — Dr. 
Horace  C.  Wood,  jun.,  in  a  valuable  paper  on  this  subject,  defines 
pseudoleukaemia  to  be  a  disease  closely  simulating  lympathic  leu- 
cocythaemia,  so  as  to  be  indistinguishable  from  it,  save  only  by  the 
examination  of  the  blood,  which  contains  no  excess  of  white  blood- 
corpuscles.  There  is  the  same  indolent  enlargement  of  the  glands, 
the  same  tendency  to  diarrhoea  and  haemorrhages,  the  same  apparently 
causeless  yet  ever  deepening  anaemia,  the  same  remorseless  march 
towards  death  ;  and  post-mortem  examinations  reveal  no  difierences 
in  the  anatomical  lesions  of  the  glands.  The  formation  of  masses  of 
lymphatic  tissue  in  the  various  viscera,  which  is  frequently  seen  in 
leucocytheemia,  however,  is  rarely  met  with  in  pseudoleukaemia, 
perhaps  because  it  is  not  looked  for.  Pseudoleukaemia  is  the  disease 
known  under  the  names  "ad^nie,"  Hodgkin's  disease,  &c.  In  true 
leukaemia,  the  spleen  generally  finally  becomes  involved ;  so,  in  all 
the  described  cases  of  adeuie,  enlargemeut  pf  the  spleen  has  finally 


1872.]  Report  on  Pathology  and  Medicine.  549 

occurred,  except  where  death  has  taken  place  early,  from  pressure 
of  enlarged  glands  on  trachea.  Dr.  Wilks  has  described  cases  of 
Hodgkin's  disease,  in  which  the  enlargement  of  the  spleen  was  a 
prominent  feature.  The  author  believes  there  is  a  splenic  variety  of 
pseudoleukaemia,  and  relates  a  case  of  splenic  enlargement  and 
disease  with  intense  anaemia,  but  no  increase  of  white  corpuscles,  as 
an  example.  He  then  enters  on  the  question  of  the  relation  ot 
hyperplasia  of  the  leucocytes  of  the  medulla- of  bones  to  leucocy- 
thsemia,  and  adds  a  carefully  observed  case  to  the  literature  on  the 
subject.  From  this  we  extract  the  description  of  the  appearances 
in  the  bones.  The  patient  was  a  German,  and  his  blood  exhibited  a 
marked  increase  in  the  number  of  white  corpuscles,  with  enlarged 
spleen: — ^' Lumlar  vertebra,  on  section, bright  carmine  red.  Micro- 
scopical constituents  of  this  juice  as  follows — 1.  Irregular,  granular, 
distinctly  nucleated  cells,  the  largest  having  a  diameter  of  ^-oW  ^^ 
an  inch.  2.  Similar  cells  or  corpuscles,  often  not  nucleated,  and 
less  distinctly  granular.  3.  Cells,  granular  externally,  clear  in  the 
central  portions.  4.  Cells  distinctly  nucleated,  nucleus  surrounded 
by  a  clear  hyaline  portion ;  these  cells  are  irregular,  or  nearly 
globular  in  shape,  and  between  ^-o-Joo  ^^^  ts^tto  i^^^  i^  diameter. 
5.  Irregular,  granular,  not  distinctly  nucleated  cells.  6.  Cells, 
very  abundant,  exactly  resembling  lymph-corpuscles,  varying  from 
r2^(77T  *^  irfoiy  i^  diameter.  7.  A  very  few  red  blood-corpuscles. 
Right  femur,  sawn  open  longitudinally ;  bone,  as  in  other  long 
bones,  remarkably  dense  and  thick.  Marrow  somewhat  pulveru- 
lent ;  lower  ^-  bright  carmine  red,  mottled  with  yellowish,  shading 
into  the  next  4-,  which  is  of  an  intense,  very  dark,  almost  blackish 
carmine  ;  this  shades  into  the  bright  Indian  red  of  the  next  ^,  which 
above  shades  into  bright  carmine,  gradually  giving  place  to  the 
yellowish  trabeculae  above.  Left  femur  very  similar  to  the  right, 
save  that  the  deep  carmine  portion  is  shorter,  and  the  Indian  red 
correspondingly  longer,  and  that  the  marrow  of  the  lower  \  has  a 
much  more  transparent  gelatinous  look.  Microscopical  examination. 
— Medulla  containing  very  little  oil,  and  very  few  red  blood-corpus- 
cles, made  up  of  an  immense  number  of  cells,  which  are  most  irre- 
gularly globose,  sometimes  larger,  and  altogether  irregular  in  form, 
minutely  granular,  mostly  distinctly  nucleated,  very  rarely  bi- 
nucleated ;  nucleus  with  a  distinct  nucleolus ;  size  of  globular  cells 
1 2  JoTT  "^0  tsJt^^  inch.  Besides  these,  there  are  some  smaller  globular 
cells  entirely  free  from  granules,  and  perfectly  transparent,  but  fur- 
nished  with  a  distinctly  granular  nucleus."  The  medulla  of  the  left 
tibia  was,  in  part,  nearly  natural  in  appearance  ;  microscopically,  it 
was  largely  made  up  of  normal  fat-cells  and  free  fat,  but  with  a 
good  many  cells  similar  to  those  seen  in  femora.  The  author  gives 
two  cases  of  pseudoleukaemia,  in  which  the  marrow  of  the  bones 
exhibited  strikingly  similar  lesions.  He  concludes — 1.  Clinically, 
the  so-called  true  and  false  leukaemia  are  the  same,  save  only  in  the 
matter  of  the  white  blood-corpuscles.  2.  All  varieties  of  leukaemia 
are  represented  in  pseudoleukaemia.  3.  Hyperplasia  of  the  marrow 
of  the  long  bones  is  a  more  or  less  characteristic  lesion  of  leucocy- 


550  Chronicle  of  Medical  Science,  [April, 

thaomia  ;  and  this  lesion,  and  all  the  other  lesions  of  the  solid  tissues 
known  as  characteristics  of  leucocythagmia,  are  equally  characteristic 
of  pseudoleukaBmia.  The  author  asks,  is  it  well  to  consider  these 
two  dyscrasia  distinct  ?  He  thinks  not— 1.  Because  the  increase  of 
white  corpuscles  is  not  peculiar  to  leucocythsemia,  but  occurs  in 
very  different  diseases,  such  as  lymphomia  and  ])yaemia,  and  as  the 
result  of  malarial  poisoning.  2.  That  in  these  diseases,  the  increase 
of  white  corpuscles  is  not  constant.  3.  The  amount  of  increase 
varies  indefinitely  in  leucocythsemia  itself.  4.  There  are  cases 
which  at  one  part  of  their  course  represent  pseudoleuksemia,  at 
another  leukaemia. — American  Journal  of  Medical  Sciences^  October, 
1871. 

On  the  Clinical  Significance  of  the  Presence  of  Leucin  aad  Tyrosin. 
— Dr.  James  Tyson,  in  a  paper  on  the  chemical  characteristics  and 
physiological  and  pathological  relations  of  leucin  and  tyrosin,  after 
noticing  the  various  solids  and  fluids  of  the  body  in  which  leucin  is 
a  normal  or  pathological  constituent,  observes  that  it  is  in  certain 
affections  of  the  liver,  attended  by  impaired  function  of  this  organ, 
as  in  acute  yellow  atrophy  or  chronic  softening,  that  the  presence  of 
leucin  assumes  a  clinical  significance,  being  found  under  these  cir- 
cumstances in  the  blood  and  secretions,  particularly  in  the  urine,  as 
well  as  in  the  substance  of  the  liver,  kidney,  and  spleen.  Its  abun- 
dant presence  in  the  liver,  under  these  circumstances,  leads  us  to 
suppose  that  this  organ  is  the  seat  of  its  destruction,  rather  than  its 
formation,  as  some  suppose ;  and  the  fact  that  it  only,  or  chiefly, 
appears  when  the  function  of  the  liver  is  deficiently  carried  out, 
makes  this  supposition  reasonable;  while  its  elimination  at  such 
times  by  the  kidney,  analogous  to,  and  coincident  with,  the  supple- 
mental action  of  this  organ  in  separating  the  constituents  of  bile, 
affords  confirmation  of  the  same  view.  The  author  has  found  leucin 
abundantly  in  the  urine  of  a  case  of  atrophic  disease  of  the  liver, 
which  continued  almost  a  year  before  it  terminated  fatally.  Beale 
has  found  it  in  the  urine  in  cases  of  chronic  wasting  of  the  liver 
with  jaundice :  but  Stadeler  has  found  it  in  the  urine  in  typhus  and 
smallpox,  where  deficient  action  of  the  liver  is  not  characteristic, 
although  the  action  of  that  organ  may  have  been  deranged.  Coin- 
cident with  the  presence  of  leucin  and  tyrosin  in  the  urine  is  a 
great  diminution  in  the  urea.  "With  regard  to  the  presence  of  tyro- 
sin in  hepatic  affections,  the  author  quotes  the  observations  of  Neu- 
bauer  and  Frerichs,  as  to  its  abundant  presence  with  leucin  in  the 
urine  of  acute  yellow  atrophy  of  the  liver.  Hoppe-Seyler,  however, 
says  that  it  is  only  in  certain  cases  of  softening  of  the  liver  that  it, 
with  leucin,  is  abundantly  present  in  the  urine ;  and  that,  in  the 
ordinary  cases  of  so-called  yellow  atrophy,  neither  tyrosin  nor 
leucin  is  met  in  the  urine.  Hoppe-Seyler  denies  that  it  is  found  in 
the  urine  of  severe  typhus  and  variola.  The  author  states  that  in 
two  cases  of  destructive  disease  of  the  liver  which  have  been  under 
his  observation,  one  of  which,  at  least,  was  a  case  of  true  acute 
yellow  atrophy,  and  both  of  which  afforded  ample  opportunity  for 
the  study  of  leucin,  he  was  quite  unable  to  find  any  evidence  of  the 


1872.] 


Report  on  Pathology  and  Medicine.  551 


presence  of  tyrosin.  His  experience  has  been  confirmed  by  that  of 
two  otlier  observers.  He  concludes  that  leucin  and  tyrosin  have 
only  a  marked  significance  when  present  in  the  urine,  in  connection 
with  symptoms  of  deranged  hepatic  function.  They  are,  then,  of 
grave  import,  as  indicating  destructive  diseases  of  the  liver,  which 
have,  as  far  as  is  known,  always  terminated  fatally.  The  mode  of  death, 
with  coma  or  convulsions,  together  with  the  deficiency  of  urea  in  the 
urine  containing  leucin  and  tyrosin,  points  to  a  condition  analogous 
to,  or  identical  with,  ursemic  poisoning. — American  Journal  of 
Medical  Sciences,  January,  1872. 

Convection  of  Scarlatina. — M.  G-uerard,  in  August  last  year, 
brought  before  the  Societe  Mcdicale  des  Hopitaux  the  following 
remarkable  instance  of  the  transmission  of  scarlatina.  A  young 
governess  during  a  holiday,  in  the  department  of  the  Loire,  was 
attacked  with  scarlatina.  During  her  convalescence  she  wrote  to  a 
pupil  and  told  her  that  she  was  skinning  so  abundantly  that  the 
paper  on  which  she  was  writing  was  covered  with  skin.  Five  days 
after  receiving  her  letter,  the  pupil  was  seized  with  scarlatina.  Her 
mother,  who  nursed  her,  also  took  it  and  died.  There  was  no  scar- 
latina in  the  neighbourhood  where  the  pupil  and  her  mother  were 
residing. — L*  Union  Medicate,  Janvier  23,  1872. 

On  Delirium  Tremens. — Prof.  Laycock  combats  the  opinions 
defended  by  Prof.  Cuming,  of  Belfast,  that  a  distinct  connection 
exists  between  the  withdrawal  of  alcohol,  in  the  case  of  habitual 
drunkards,  and  the  supervention  of  delirium  tremens.  He  adheres 
to  the  conclusion  which  he  had  previously  arrived  at,  "  That  the 
withdrawal  of  alcohol,  or,  more  accuratel}^  of  the  usual  stimulants, 
has  comparatively  little  influence  as  a  cause  of  delirium  tremens  ; 
not  so  much  influence  as  the  want  of  food."  The  observation  of 
about  60  methystic  cases  has  confirmed  him  in  this  conclusion. 
From  an  abstract  of  twenty-four  of  the  methystic  cases,  received  into 
the  Edinburgh  Infirmary  last  summer,  he  finds  they  may  be  classed 
under  three  lieads,  viz. : — As  being  drunk  on  admission  ;  as  in  the 
"  horrors,"  or  first  stage  of  the  delirium  ;  and,  as  in  actual  delirium 
tremens.  In  every  one  of  these  24  cases  there  was  a  withdrawal  of 
alcoholic  stimulants,  to  the  extent  which  Dr.  Cuming  has  found  to 
induce  the  disease  ;  but  none  of  the  drunken  cases  became  horrored 
or  delirious  ;  none  of  those  with  "  the  horrors"  advanced  to  the 
next  stage  ;  and,  all  in  the  delirious  condition  rapidly  recovered. 
Dr.  Laycock  states  that  during  the  three  years  from  1st  October, 
1845,  to  30th  December,  1848,  the  old  procedure  of  giving  stimu- 
lants, with  or  without  opium,  was  followed  in  the  "  D.  T.  "Wards" 
of  the  Edinburgh  Infirmary,  and  the  deaths,  in  delirium  tremens, 
were  at  the  rate  of  35  per  cent.  ;  during  the  eleven  years  ending 
30th  September,  1850,  the  deaths  were  26*0  per  cent.  Since  Oct., 
1858,  the  withdrawal  system  has  come  into  general  use  in  the  Edin- 
burgh Infirmary,  and  in  the  ten  years,  1859  to  1 869,  the  mortality, 
in  cases  returned  as  delirium  tremens,  has  only  been  3"89  per  cent. 
On  the  other  hand,  in  St.  George's  Hospital,  London,  from  1850 — 


552  Chronicle  of  Medical  Science.  [Aprils 

1855,  the  mortality  was  14'6  per  cent.  In  the  army,  in  1853,  the 
mortality  from  delirium  tremens  was,  for  the  infantry,  17-6  per 
cent. ;  for  the  cavalry,  130  per  cent. — Duhlin  Quarterly  Journal, 
Nov.,  1871. 

Paralysis  of  tJie  Fifth  Cerebral  Nerve,  and  its  Effects. — Dr.  H.  D. 
Noyes  has  collected  and  reported  several  cases  of  paralysis  of  the 
fifth  nerve,  which  bear  on  the  question  of  the  influence  of  the  fifth 
nerve  in  the  nutrition  of  the  cornea.  He  concludes  that  destruc- 
tive eftects  take  place  in  the  cornea  when  a  part  only  of  the  trifacial 
is  paralysed,  probably,  if  the  ophthalmic  branch  alone  be  impaired. 
These  eff'ects  occur  when  the  paralysis  proceeds  from  a  cause  exist- 
ing in  the  peduncle  of  the  brain,  or  in  the  nerve  behind  the  ganglion 
of  Gasser, — this  organ  not  being  injured  ;  furthermore,  when  the 
ganglion  is  seriously  damaged,  and  even  when  it  is  simply  irritated 
without  being  destroyed,  the  cornea  is  liable  to  suppuration.  Expo- 
sure of  the  cornea  to  irritating,  or  depressing  causes,  favors  its  de- 
struction, but  the  essential  reason  is  ascribed  to  implication  of  sym- 
pathetic nerves  incorporated  in  the  trifacial.  The  cause  of  paralysis 
may  be  peripheral,  but  it  is  usually  central,  and  in  the  greater 
number  of  cases  is  to  be  found  in  the  growth  of  a  tumour  in  the 
middle  fossa  of  the  base  of  the  skull,  or  in  the  brain. — New  Yorh 
Medical  Journal,  August,  1S71. 

Glossu-Lahio-Laryngeal  Paralysis. — -In  a  clinical  lecture  Dr.  "W. 
A.  Hammond  relates  at  great  length  a  case  of  this  comparatively 
rare  affection,  which  was  first  noticed  by  Trousseau,  but  fully  de- 
cribed  by  Duchenne.  The  following  is  a  short  abstract: — W.  H. 
S.,  set,  32,  book-keeper  ;  temperate,  no  hereditary  taint.  In  the 
winter  of  1867  first  noticed  altered  sensation  at  angle  of  mouth,  and 
inner  canthus  of  eye  on  the  left  side.  This  extended,  and  in  the 
winter  of  1869  the  left  cheek  and  left  temple  were  numb.  There 
was  also  loss  of  sensibility  in  mucous  membrane  lining  left  cheek 
and  gums.  He  chewed  food  on  right  side.  In  May,  1870,  anaes- 
thesia extended  across  the  forehead  to  the  right  orbit  and  malar 
bone.  He  had  ringing  and  impairment  of  hearing  in  left  ear.  In 
September,  1870,  the  numbness  extended  to  naso-labial  fissure  on 
both  sides,  the  eyes  became  congested,  then  there  was  diificulty  in 
deglutition,  vertigo  on  changing  position,  inability  to  walk  in  the 
dark,  trouble  in  making  water,  pain  in  the  occiput  and  vertex,  drib- 
ling  of  salvia,  loss  of  virile  power,  and  embarrassment  of  speech. 
Dr.  Hammond  notices  that  the  starting  point  in  this  case  was  the 
left  trifacial  nerve  ;  in  most  cases  it  is  the  hypoglossal,  as  indicated 
by  loss  of  motility  in  the  tongue.  The  next  nerve  involved  was  the 
auditory  ;  the  disease,  which  commenced  in  the  nuclei  of  origin  of  the 
fifth  nerve,  gradually  extended  until  it  involved  those  of  the  audit- 
ory, then  the  facial.  At  the  time  of  the  report  the  hypoglossal,  the 
pneumogastric,  and  spinal  accessory  had  not  suffered.  In  the  more 
typical  cases,  however,  the  tongue  is  first  aff*ected.  We  have  simply 
progressive  motor  paralysis  in  muscles  innervated  by  the  hypoglossal, 
the  facial,  the  pneumogastric,  and   the  spinal  accessory   (partly 


1872.]  Report  on  Pathology  and  Medicine.  553 

through  the  pharyngeal  plexus),  and  lastly,  by  some  of  the  spinal 
nerves — for  the  phrenic,  and  even  the  intercostal  nerves,  seem  to  be 
sometimes  affected.  According  to  Trousseau,  sensibility  is  wholly 
intact,  and  even  the  reflex  irritability  of  the  paralysed  muscle  is 
retained.  Dr.  Hammond's  case,  however,  proves  that  there  is  another 
type  of  the  disease,  in  which  the  primary  symptom  is  loss  of  sensi- 
bility, attended  sometimes  by  hyperalgesia,  the  motor  paralysis  not 
appearing  until  later.  He  adds  that  one  of  Trousseau's  cases  belongs 
to  this  category.  In  his  remarks  on  the  pathology  of  the  affection 
he  adopts  Duchenne's  theory  of  distinct  sets  of  centric  nerve-cells 
(sensory,  motor,  and  trophic)  having  special  functions,  and  traces 
paralysis  of  various  forms  to  the  disappearance  of  special  centric 
nerve-cells.  Little  is  known  of  the  causes  of  glosso-labio-laryngeal 
paralysis.  The  prognosis  is  wholly  bad.  Treatment  is  useless. — 
New  Yorh  Journal  of  Psychological  Medicine,  July,  1871. 

TJie  Physical  Signs  of  Miti^al  Stenosis. — Dr.  G-.  W.  Balfour  main- 
tains that  systolic  apex-murmur  is  by  no  means  the  most  distinctive 
sign  of  disease  of  the  mitral  valves.  Such  a  murmur  may  be  exo- 
cardial  or  endocardial,  even  produced  by  regurgitation,  and  yet  the 
mitral  valve  be  free  from  disease.  The  murmur,  commonly  known 
as  "  presystolic"  (although  this  is  not  a  strictly  accurate  term)  may 
be  considered  conclusively  pathognomonic  of  mitral  stenosis.  The 
presystolic  murmur  is  most  distinctly  heard  over  the  mitral  area,  i.  e. 
within  a  circle  of  about  a  inch,  described  round  the  point  where  the 
apex  impinges  as  a  centre.  It  is  not  propagated  far  in  any  direc- 
tion, it  is  rarely  heard  above  the  third  rib,  and  in  every  other  direc- 
tion its  distinct  propagation  is  usually  equally  limited.  The  pre- 
systolic murmur,  is  really  an  auriculo-systolic  murmur.  By  timing 
it  with  the  carotid  pulse  (with  which  the  first  sound  of  the  heart  is 
synchronous)  the  murmur  will  be  found  immediately  to  precede  and 
to  run  up  to  the  carotid  pulse.  It  occupies  the  time  of  the  auri- 
cular systole,  preceding  the  ventricular  systole.  "In  timing  this 
murmur  it  is  obvious  that  we  must  employ  the  carotid,  and  not  the 
radial  pulse  ;  for  while  the  former  is  always  synchronous  with  the 
ventricular  systole,  and  apex  beat,  the  latter  is,  even  in  health, 
always  delayed  to  an  appreciable  extent — one-sixth  of  a  second  ; 
while  in  disease,  especially  such  as  interferes  with  the  arterial  con- 
tractility, this  delay  is  notably  increased,  and  sometimes  amounts  to 
an  entire  cardial  pulsation."  The  carotid  pulse  is  a  perfectly  safe 
guide,  provided  our  senses  are  sufficiently  educated  to  appreciate  the 
teachings  obtainable  by  comparing  an  audible  with  a  tangible  phe- 
nomenon. The  true  auriculo-systolic  murmur  is  short,  because  it 
sharply  coincides  with  the  contraction  of  the  auricles  ;  it  is  also 
rough  because  it  is  a  direct  murmr  produced  by  forcible  muscular 
contraction.  The  rough  presystolic  murmur,  more  frequently  thaiL 
any  other,  gives  rise  to  a  distinct  sensation  of  vibration  to  be  felt 
over  the  mitral  area  {fr6missement  cataire).  It  is  capable  of  being 
vocalised  by  the  sounds  represented  by  the  letters  B-r-r-h  or  Voot.  It 
is  separated  from  the  second  sound  by  a  more  or  less  lengthened, 
but  always  readily  appreciable  interval,  and  it  distinctly  precedes 


551<  Chronicle  of  Medical  Science.  [April, 

ilio  apex  beat  aud  the  carotid  pulse,  usually  running  quite  up  to 
them  ;  but  occasionally  separated  from  them  by  an  exceedingly 
short,  though  appreciable,  interval.  Such  a  murmur  is  invariably  an 
evidence  of  mitral  deformity,  of  more  or  less  constriction  of  the 
auriculo-ventricular  opening.  Such  a  murmur  may  disappear,  but 
the  lesion  is  permanent. — Edin.  Med.  Jour.,  Nov.,  1871. 

On  Narrowing  of  the  Fulmonary  Artery,  contracted  after  Birth. — 
Dr.  Constantin  Paul  sums  up  an  elaborate  memoir  on  this  subject 
with  the  following  conclusions  : — 1.  The  pulmonary  artery  is  not 
only  the  seat  of  congenital  affections,  but  may  be  the  seat  of  affec- 
tions acquired  during  extra-uterine  life.  2.  Amongst  these  lesions 
the  most  important  is  narrowing  acquired  after  birth.  3.  This  nar- 
rowing is  sometimes  found  at  the  level  of  the  sigmoid  orifice  ;  it  is 
produced  by  soldering  of  the  valves  with  diminution  of  the  orifice, 
and  sometimes  also  of  the  calibre  of  the  artery  at  this  level.  It  is 
generally  the  result  of  an  endocarditis.  4.  The  narrowing  may  be 
at  the  level  of  the  arterial  cone  and  be  pre-arterial  ;  this  most  ordi- 
narily results  from  a  myocarditis.  5.  The  narrowing  may  have  its 
seat  on  one  of  the  branches  of  bifurcation  of  the  artery,  or  even  on 
both  ;  I  have  not  seen  it  seated  on  the  trunk  of  the  artery,  as  is  the 
case  with  the  narrowing  produced  in  the  early  months  of  intra- 
uterine life.  6.  Beyond  the  narrowing,  the  artery  is  generally 
dilated.  7.  It  is  generally  associated  with  consecutive  hypertrophy 
of  the  right  ventricle.  8.  Valvular  narrowing  of  the  pulmonary 
artery  may  accompany  insufiiciency  of  the  same  valves.  9.  Lesion 
of  the  tricuspid,  or  of  the  valves  of  the  left  heart  may  coexist  with 
pulmonary  narrowing.  10.  The  proper  symptom  of  narrowing  of 
the  pulmonary  artery  is  a  systolic  Iruit  de  souffle,  more  or  less  rasp- 
ing, which  is  heard  over  the  cardiac  region,  but  is  at  its  maximum 
at  the  level  of  the  pulmonary  orifice  and  along  the  vessel.  11.  Nar- 
rowing of  the  pulmonary  artery  does  not  produce  cyanosis.  12.  In 
acquired  pulmonary  narrowing  the  foramen  ovale  is  closed.  13. 
Nevertheless  a  myocarditis,  developed  during  extra-uterine  life, 
may  develope  'at  the  same  time  a  pulmonary  narrowing  and  a  com- 
munication between  the  two  sides  of  the  heart.  14.  Narrowing  of 
the  pulmonary  artery  with  persistance  of  the  foramen  ovale  is  pro- 
bably, but  not  necessarily,  congenital.  15.  The  recent  character  of 
the  lesions  would  be  a  proof  that  a  pulmonary  narrowing  had  been 
contracted  during  extra-uterine  life.  16.  A  frequent  complication 
of  pulmonary  narrowing  is  consecutive  iuberculisation. — L^  Union 
Medicate,  Dec.  23,  1871. 

(Edema  of  the  Lungs. — Dr.  T.  K.  Cruse  remarks  that  oedema  of 
the  lungs  being  intercurrent  with  maladies  of  the  most  opposite 
nature  has  a  varied  etiology.  From  observation  of  many  cases  of 
insolation,  he  regards  it  as  the  cause  of  a  large  proportion  of  deaths 
from  sunstroke.  It  may  complicate  and  render  fatal  the  second 
stage  of  pneumonia.  It  sometimes  supervenes  with  startling  rapidity 
in  Bright's  disease,  and  in  the  temporary  hyperaemia  of  the  kidney 
of  the  puerperal  state.     It  is  sometime's  the  result  of  pressure  on 


1872.] 


Report  on  Pathology  and  Medicine.  555 


fclie  lung  by  intra- thoracic  tumours,  pleuritic  effusions,  pneumo- 
thorax. Aneurism  of  the  ascending  aorta,  hypostatic  congestion 
from  prolonged  decubitus,  obstructions  to  the  systemic  circulation, 
mitral  stenosis  and  insufficiency,  especially  when  complicated  with 
pigment  induration  of  the  lungs,  hepatic,  and  other  abdominal 
tumours,  and  even  intense  tympanites  are  enumerated  as  causes  of 
pulmonary  oedema.  According  to  the  author,  pneumonia  is  the 
disease  in  which  oedema  of  the  lung  most  frequently  arises.  In 
cases  of  sudden  death  from  pneumonia,  it  is  common  to  find  one 
lung  filled  with  inflammatory  exudation,  while  bloody  serum  flows 
from  the  cut  surface  of  the  other.  The  treatment  recommended  is 
by  dry  cupping-glasses  applied  over  the  whole  of  the  chest,  to  be 
left  on  until  large  serous  blebs  appear.  The  author  relates  the  fol- 
lowing case  as  an  instance  of  the  efficacy  of  bleeding.  During  the 
month  of  January,  a  woman  was  admitted  to  the  lying-in  wards  of 
Bellevue,  who  had  a  rapid  and  easy  delivery,  but  during  the  night 
was  attacked  by  convulsions,  which  persisted  during  the  night  and 
morning  of  the  next  day,  in  spite  of  clilorof'orm  and  elaterium.  At 
the  latter  time  her  condition  was  as  follows  :  Feet  and  legs  oedema- 
tous ;  coma  profound ;  urine  loaded  with  albumen,  contains  fatty 
and  granular  casts ;  respirations,  forty  per  minute ;  moist  crepita- 
tion at  every  point  over  both  lungs ;  patient  foams  at  the  mouth ; 
surface  blue.  Dr.  Barker  then  took  from  her  forty  ounces  of  black 
blood,  which  spurted  from  the  vein  as  if  under  great  pressure.  In 
this  blood  the  author  found  one  part  urea  to  every  960  other  con- 
stituents of  the  serum.  The  patient  had  no  more  convulsions  after 
the  venesection,  and,  in  addition,  the  surface  assumed  its  normal 
appearance,  respirations  fell  to  twenty-six  per  minute;  in  five 
minutes  the  normal  vesicular  murmur  was  heard  over  the  whole 
chest,  and  in  half-an~hour  consciousness  returned. — New  Yorh 
Medical  Journal,  June,  1871. 

Tuhercidar  Feritonitis. — Dr.  J.  Kaulich  has  described  with  great 
minuteness  the  pathological  appearances  in  this  disease.  In  con- 
junction with  the  deposit  of  tubercular  matter  in  the  peritoneum, 
there  is  a  copious  serous  exudation  in  the  peritoneal  cavity.  Each 
tubercular  deposit  is  surrounded  by  a  newly  developed  layer  of 
cellular  tissue,  with  a  tendency  in  this  to  simulate  a  layer  of  pseudo- 
membrane,  w^th  a  strong  disposition  to  a  hsemorrhagic  discharge. 
In  the  progress  of  the  disease  these  masses  of  abnormal  cellular 
tissue  have  a  tendency  to  contract ;  their  areolae,  by  contracting, 
often  cause  the  formation  of  areolated  elevations,  which  may  often 
be  felt,  like  a  network  of  cords,  through  the  walls  of  the  abdomen. 
The  separate  tubercular  deposits  may  undergo  changes  in  the  pro- 
gress of  the  disease  of  the  nature  of  anatomical  involutions.  In 
such  cases  the  peritoneum,  in  all  its  extent,  exhibits  no  indication 
of  recent  irritation ;  the  abdominal  cavity  is  free  from  any  exuda- 
tion ;  the  separate  tubercles  are  dry,  solid,  and  surrounded  by  a 
darkish  pigment ;  others,  especially  large  conglomerated  masses  of 
tubercular  matter,  are  of  a  soft  cheesy  consistence,  or  dry,  and  of 


556  Chronicle  of  Medical  Science.  [April, 

the  appearance  of  mortar,  while  others  of  the  conglomerated  masses 
present  the  appearance  of  uniform  masses  of  fat.  In  treating  of 
the  symptoms  and  course  of  the  disease,  the  author  notices  the 
occasional  formation  of  a  painful  oedematous  inflammation  at  the 
umbilicus.  This  chronic  inflammation  usually  disappears,  seldom 
forming  an  abscess.  Sometimes,  however,  an  ulcerative  opening  is 
formed  at  the  umbilicus,  and  the  fluid  in  the  peritoneal  cavity  is 
discharged,  to  the  great  relief  of  the  patient.  Dr.  K.  has  never 
seen  this  occurrence  exercise  any  unfavorable  influence  on  the 
course  of  the  disease.  He  warns  against  paracentesis,  when  the 
peritoneum  is  the  seat  of  inflammation,  or  when  hsemorrhagic 
exudation  has  probably  taken  place. —  Centralhlatt  f.d.  Med.  Wissen- 
schaften,  1871,  No.  30,  from  Prager  VierteJjahr.,  ex.  American 
Journal  of  Medical  Sciences,  January,  1872. 

Hypertrophic  CirrJiosis  of  the  Liver. — Dr.  Paul  Olivier,  in  a 
memoir  on  this  subject,  believes  he  has  established  the  fact  that, 
besides  the  common  form,  atrophic  cirrhosis  of  the  liver,  there  is  a 
rarer  form,  which  is  accompanied  by  increase  of  the  volume  of  the 
organ.  He  regards  hypertrophic  cirrhosis  as  a  distinct  form  of 
disease,  and  not  one  ot  the  stages  of  ordinary  cirrhosis,  or  a  cirr- 
hosis which  has  not  had  time  for  complete  development.  Like  the 
atrophic  form,  it  is  characterised  anatomically  by  a  chronic  irrita- 
tion pervading  the  cellular  tissue  of  the  liver,  whence  proliferation 
of  this  tissue  and  atrophy  by  compression  of  the  glandular  sub- 
stance; but  whereas,  in  the  atrophic  form,  this  production  ceases  at 
a  given  time,  in  the  hypertrophic  form  it  continues ;  after  having 
invaded  the  lobes  of  the  liver,  it  extends  to  the  cellular  tissue  inter- 
posed between  the  acini ;  and  it  is  to  the  incessant  accumulation  of  this 
tissue  the  large  size  of  the  liver  is  due.  Besides  the  ordinary  symp- 
toms of  cirrhosis,  hypertrophic  cirrhosis  presents  an  augmentation 
of  the  volume  of  the  liver,  sometimes  general,  sometimes  partial. 
This  is  its  fundamental  character ;  it  is  accompanied  by  an  earlier 
and  more  profound  alteration  of  the  blood,  whence  various  haemor- 
rhages from  the  mucous  tracts,  and  more  frequent  true  icterus 
than  in  the  ordinary  form.  The  author  notes,  also,  a  particular 
condition  of  the  skin,  the  face  being  the  seat  of  a  papular  eruption. 
The  cause  of  the  condition  is  alcoholic  excess. — L'  Union  Mcdicale, 
September  26,  1871. 

Abscess  of  the  Appendix  Vermiformis. — In  a  paper  containing 
several  observed  cases  of  this  disease.  Dr.  Leonard  Weber  makes 
the  following  observations  on  its  pathology.  After  remarking  on 
the  fact  that  there  are  numerous  cases  on  record  where  foreign 
bodies  in  the  appendix  seem  to  have  produced  no  symptoms  or 
inconvenience  during  life,  he  states  that  faecal  concretions 
found  in  the  cavity  of  the  appendix,  when  dry,  appear,  on  sec- 
tion, to  consist  of  a  central  nucleus,  with  concentric  laminae  around, 
which  are  all  of  the  same  composition,  viz.  phosphate  and  car- 
bonate of  magnesia  and  lime,  &c.  They  look  very  much  like  fruit 
seeds,  and  have  often  been  mistaken  for  them,  although  they  consist 


1872.] 


Report  on  Pathology  and  Medicine.  557 


mostly  of  nothing  but  tlie  ingredients  of  the  human  faeces.  To 
explain  their  origin,  we  must  suppose  that,  by  irregular  contraction 
of  the  coecum,  a  small  portion  of  faeces  is  forced  into  the  appendix, 
and  then  hardened  to  a  concretion  by  gradual  absorption  of  its  fluid 
parts.  The  calculi  so  formed  become  a  source  of  permanent  irrita- 
tion to  the  mucous  lining  of  the  appendix,  inflammations  gradually 
develop,  and  that  portion  of  the  mucous  membrane  particularly 
pressed  upon  by  the  calculus  becomes  thinner  and  thinner  by 
ulceration.  The  muscular  coat  and  peritoneal  covering  are  at 
length  perforated,  circumscribed  peritonitis  takes  place  around, 
adhesions  are  formed  with  neighbouring  parts,  especially  the  ccBcum 
and  omentum.  By-and-bye,  these  adhesions  also  undergo  ulcera- 
tion, and  then  perforation  must  occur  at  one  or  two  points  of  the 
appendix  corresponding  to  the  two  ends  of  the  calculus.  Should 
the  ulceration  eat  around  the  entire  circumference  of  the  process, 
as  has  been  observed  in  a  few  cases,  it  may  even  cut  ofi"  the  appen- 
dix by  gangrene,  the  calculus  remaining  fixed  in  its  extremity,  or 
dropping  into  the  abdominal  cavity,  where  it  may  be  easily  over- 
looked in  the  autopsy.  Tubercular,  and  more  rarely  cancerous 
ulceration,  may  cause  perforation  of  the  appendix  in  a  similar 
manner.  The  abscess  resulting  from  perforation  of  the  appendix 
may  form  and  grow  to  the  size  of  a  man's  fist,  and  larger,  walled 
in  by  the  previously  adherent  neighbouring  parts.  Its  contents 
may  become  solid,  from  the  gradual  absorption  of  the  fluid  parts, 
leading  finally  to  a  firm  fibrous  union  of  its  walls,  in  which  the  cal- 
culus is  imbedded,  with  the  laminae  of  the  appendix  wholly  or  partly 
obliterated;  or  ulceration  may  encroach  upon  the  walls  of  the 
abscess,  when  perforation  will  take  place  either  into  the  peritoneal 
cavity,  rapidly  followed  by  general  peritonitis,  or  outward  through 
the  parietal  muscles,  or  into  the  intestines  when  pus  is  discharged 
per  rectum.  The  proximity  of  the  diseased  appendix  to  the  right 
iliac  vein  has  been  known  to  cause  phlebitis.  In  a  case  recorded  by 
Lewis,  the  coats  of  the  vein  were  thickened  and  contracted  below 
the  appendix,  and  the  vein  filled  by  a  thrombus  in  a  state  of 
decomposition ;  further  up,  above  the  process,  it  was  filled  with 
fresh  coagula.  The  patient's  right  leg  became  oedematous,  as  in 
phlegmasia  dolens.  In  a  case  observed  by  Hennoch,  fatal  haemor- 
rhage into  the  peritoneal  cavity  took  place.  When  the  abscess 
makes  its  way  into  the  parietes,  fistulse  may  result.  Pleurisy,  pneu- 
monia, pneumo-thorax,  and  pericarditis  have  resulted,  from  the 
abscess  penetrating  the  diaphragm.  When,  upon  the  presence  of 
a  foreign  body  in  the  appendix,  inflammation  and  gangrene  do  not 
supervene ;  the  mucous  membrane,  distended  and  thinned  by  accu- 
mulation of  its  own  secretion,  is  gradually  converted  into  a  serous 
membrane,  secreting  a  thin  albuminous  fluid,  the  appendix  itself 
forming  an  hydropic  sac.  Foreign  bodies,  as  orange  pips,  cherry 
stones,  &c.,  finding  their  way  into  the  appendix,  may  produce  similar 
pathological  changes  to  fsecal  concretions;  but  the  latter  are  the 
cause  of  ulceration  in  the  vast  majority  of  cases. — Neio  York  Medical 
Journal,  August,  1871. 
98— XLix.  36 


558 


Books  J  ^c,  received  for  Review. 


[April, 


Bachitic  Pseudo-paraplegia. — Dr.  J.  S,  Parry, in  concluding  a  valu- 
able paper  on  rickets,  calls  attention  to  the  occurrence  of  pseudo- 
paraplegia  as  a  form  of  rachitis.  This  is  important,  since  it  is  often 
mistaken  for  paralysis,  and  the  child  is  subjected  to  a  course  of 
medication  for  disease  of  the  brain  or  spinal  cord.  "  The  child  is 
small,  has  a  large  head  and  a  weak  intellect,  with  the  aged  expres- 
sion common  to  this  affection,  but  there  is  often  very  little  bone 
deformity ;  indeed,  it  seems  as  if  the  disease  had  expended  itself 
upon  the  muscles."  Loss  of  power  in  the  lower  extremities  is  the 
common  form  of  this  variety  of  rickets  (pseudo-paraplegia,  G-ee). 
The  muscles  are  atrophied,  and  the  child  unable  to  stand,  but  it 
moves  its  limbs  a  little  when  lying  or  sitting.  The  muscles  respond 
to  electricity.  That  this  condition  is  due  to  rickets  is  proved  by 
the  fact  that  it  is  preceded  by  the  prodromes  of  this  disorder,  is 
accompanied  by  bending  of  the  ribs,  late  dentition,  open  fontanelles, 
and  it  may  be  followed  by  bending  of  the  bones  of  the  legs  when 
the  child  has  recovered  sufficient  muscular  power  to  walk.  There 
is,  however,  often  no  serious  deformity.  The  disease  most  frequently 
ends  in  perfect  recovery,  provided  there  is  no  serious  defect  about 
the  thorax. — American  Journal  of  Medical  Sciences,  January,  1872. 


BOOKS,  PAMPHLETS,  &c.,  RECEIVED  FOR  REVIEW. 


Ou  the  Treatment  of  Fractures  of  the 
Limbs.  By  Sampson  Gamgee,  F.R.S.E., 
&c.  London,  Churchills.  187L  pp.  296. 
With  Plates. 

Medico-Chirurgical  Transactions.  Pub- 
lished by  the  Royal  Medical  and  Chirur- 
gical  Society  of  London.  Vol.  LIV.  Lon- 
don, Longmans.     1871.     pp.  359. 

Vital  Statistics  of  the  Bengal  Presidency. 
Annual  Returns  of  the  European  Army 
from  1858  to  1869,  &c.  By  James  L. 
Bryden,  M.D.    Calcutta.     1871. 

The  Skim- Milk  Treatment  of  Diabetes 
and  Bright's  Disease ;  with  Clinical  Obser- 
vations on  the  Symptoms  and  Pathology 
of  these  Affections.  By  A.  Scott  Donkin, 
M.D.,  &c.  London,  Longmans.  1871. 
pp.  317. 

The  Half- Yearly  Abstract  of  the  Medical 
Sciences.  Edited  by  W.  Domett  Stone, 
M.D.  Vol.  LIV.  July,  December,  1871. 
London,  Churchills.     1872.    pp.  372. 

A  Manual  of  Zoology  for  the  Use  of 
Students ;  with  a  General  Introduction  on 
the  Principles  of  Zoology.  By  H.  Alleyne 
Nicholson,  M.D.,  &c.  Second  Edition  re- 
vised and  considerably  enlarged.  Black- 
woods.     1871.    pp.  673. 

A  Treatise  on  Ha3mophila,  sometimes 
called  the  Hereditary  Hajmorrhagic  Dia- 
thesis. By  J.  Wickham  Legg,  M.D. 
London,  Lewis.    1872.    pp.  158. 


The  Science  and  Practice  of  Medicine. 
By  W.  Aitken,  M.D.,  &c.  Sixth  Edition, 
greatly  enlarged,  re-modelled,  carefully 
revised,  and  many  portions  re- written. 
In  two  volumes.  London,  Griffin  and  Co. 
1872.    pp.  944  and  pp.  1290. 

Notes  on  Syphilis ;  with  an  Appendix 
on  the  Unity  of  the  Syphilitic  Poison. 
By  S.  Messenger  Bradley,  T.R.C.S.,  &c. 
London,  Churchills.     1872.    pp.  48. 

Clinical  Lectures  on  the  Diseases  of 
Women.  By  Sir  James  Y.  Simpson,  Bart., 
M.D.,  &c.  Edited  by  Alexander  R.  Simp- 
son, M.D.  Edinburgh.  1872.  A.  and 
C.  Black,    pp.  789. 

Diseases  of  the  Hair :  a  Popular  Treatise 
upon  the  Affections  of  the  Hair  System, 
with  Advice  upon  the  Preservation  and 
Management  of  Hair.  By  Benjamin  God- 
frey, M.D.,&c.  London,  Churchills.  1872. 
pp.  183. 

The  Retrospect  of  Medicine.  Edited  by 
W.  Braithwaite,  M.D.,  &c.,  and  James 
Braithwaite,  M.D.,  &c.  Vol.  LXIV,  July- 
December,  1871.  London,  Simpkin,  Mar- 
shall, and  Co.     1872.     pp.  408. 

Cancerous  and  other  Intra-thoracic 
Gro\yths,  their  Natural  History  and  Dia- 
gnosis; being  the  Substance  of  the  Lum- 
leian  Lectures.  By  James  Risdon  Bennett, 
M.D.,  &c.  With  five  Plates.  London, 
Churchills.    1872.    pp.  189. 


1872.] 


Books,  ^c,  received  for  Review. 


559 


On  the  Pathology  and  Treatment  of 
Gonorrhooa.  By  J.  L.  Milton.  London, 
E.  Ilardwicke.     1871.    pp.  219. 

Kecollections  of  Past  Life.  By  Sir  Henry 
Holland,  M.D.,  &c.  London,  Longmans. 
1872.    pp.  346. 

Seventh  Annual  Eeport  of  the  Sanitary 
Commissioner  with  the  Government  of 
India,  1870.  Calcutta.  1871.  pp.  297. 
"With  Appendices. 

A  Report  of  Surgical  Cases  treated  in 
the  Army  of  the  United  States,  fi'om  1865 
to  1871.  Washington,  Grovernment  Print- 
ing OflSce.     1871.    pp.  296. 

Approved  Plans  and  Specifications  for 
Post  Hospitals.  Surgeon-General's  Office, 
Washington.     1871. 

Notes  on  the  Epidemic  Connection  of  the 
Cholera  of  Madras  and  Bombay,  with  the 
Cholera  Epidemics  of  the  Bengal  Presi- 
dency. By  James  L.  Bryden,  M.D.,  Ben- 
gal Army.     Calcutta.     1871. 

A  Report  on  Age  and  Length  of  Service 
as  Affecting  the  Sickness,  Mortality,  and 
Invaliding  of  the  European  Army.  By 
James  L.  Bryden,  M.D.,  &c.  Calcutta. 
1871. 

Transactions  of  the  American  Otological 
Society.  Fourth  Annual  Meeting.  Boston. 
1871.    A.  Mudge  and  Son. 

A  Treatise  on  Human  Physiology, 
designed  for  the  Use  of  Students  and 
Practitioners  of  Medicine.  By  John  C. 
Dalton,  M.D.,  &c.  Fifth  Edition,  revised 
and  enlarged,  with284illusti-ations.  Phila- 
delphia, H.  C.  Lea ;  London,  Trubner. 
1871.    pp.  728. 

The  Urine  and  its  Derangements  ;  with 
the  Application  of  Physiological  Chemistry 
to  the  Diagnosis  and  Treatment  of  Con- 
stitutional, as  well  as  Local  Diseases.  By 
George  Harley,  M.D.,  F.R.S.,  &c.  Lon- 
don, Churchill.     1872.    pp.  376. 

Worms  :  a  Series  of  Lectures  on  Prac- 
tical Helminthology,  delivered  at  the 
Middlesex  Hospital.  By  T.  Spencer 
Cobbold,  M.D.,  F.R.S.,  &c.  London, 
Churchills.     1872.    pp.  178. 

Zymotic  Diseases  :  their  Correlation  and 
Causation.  By  A.  Wolff,  F.R.C.S.  Lon- 
don, Churchills.     1872.    pp.  177. 

St.  Thomas's  Hospital  Reports.  New 
Series,  Vol.  II,  1871.  Churchills.  pp. 
397. 

A  Dictionary  of  Chemistry  and  the  Allied 
Branches  of  other  Sciences.  By  Henry 
Watts,  B.A.,  F.R.S.,  &c.,  assisted  by  emi- 
nent contributors.  Supplement.  London, 
Longmans.     1872.    pp.  1136. 

On  the  Symptomatic  Treatment  of 
Cholera;  with  especial  reference  to  the 
importance  of  the  Intestinal  Lesion.  By 
Dr.  Felix  von  Niemeyer.  Translated  by 
P.  W.  Latham,  M.D.,  &c.  Cambridge, 
Deighton  and  Bell.     1872.     pp.  57. 

A  Text  Book  of  Pathological  Histology  : 
an  Introduction  to  the  Study  of  Patholo- 


gical Anatomy.'  By  Dr.  Edward  Rind- 
fleisch.  Translated  by  Drs.  Kloman  and 
Miles.  With  208  illustrations.  Phila- 
delphia, Lindsay  and  Blakiston.  1872. 
London,  Triibner.     pp.  695. 

First  Annual  Report  of  the  Board  of 
Health  of  the  Health  Department  of  the 
City  of  New  York,  April,  1870,  to  April, 
1871.    New  York.     1871.    pp.  628. 

Transactions]  of  the  Ophthalmological 
Society.  Eighth  Annual  Meeting,  New 
York,  Appleton.     1871.    pp.  145. 

Atlas  of  Diseases  of  the  Skin  :  Eleventh 
Fasciculus.  New  Sydenham  Society.  1871. 


Nouveau  Dictionnaire  de  Medecine  et 
de  Chirurgie  Pratiques,  illustre  de  figures 
intercalees  dans  le  texte.  Tome  xiv. 
Erys— Fl.  Paris,  J.  B.  Bailliere  et  Fils. 
1871.    pp.  780. 

LeQons  de  Pathologic  Experimentale. 
Par  Claude  Bernard,  Professeur  de  Mede- 
cine au  College  de  France.  Paris,  J.  B. 
Bailliere  et  Fils.     1872.    pp.  600. 

Origine  Nouvelle  de  Cholera  Asiatique, 
ou  Debut  et  Developpment  d'une  Grande 
Epidemie  Cholerique.  Par  J.  D.  Tho- 
lozan.  Paris,  V.  Masson  et  Fils.  1871. 
pp.  92.- 

Annali  Clinici^  dello  Ospedale  de  Pelle- 
grini di  Napoli.  Vol.  I,  December,  1871. 
Napoli.     1871.    pp.  99. 

Bericht  der  K.  K.  Ki'ankenanstalt  Ru- 
dolph-Stiftung,  vom  Jahre,  1870.  Wien., 
Kohler.    1871.    pp.  292. 


PamjMeis. 

Journal  of  the  Scottish  Meteorological 
Society  (with  Tables),  for  the  Quarter 
ending  March,  1871.  Blackwood  and 
Sons.     1871. 

Historical  Steps  of  Modern  Medicine. 
An  Address  delivered  before  the  St. 
Andrew's  Medical  Graduates'  Association. 
By  Henry  Day,  M.D.,  &c.     1872. 

The  Prince's  Illness  :  its  Lessons.  A 
Lecture  on  the  Prevention  of  Disease. 
By  B.  W.  Foster,  M.D.,  &c.     1872. 

The  Synthesis  of  Acute  Rheumatism. 
By  B.  W.  Foster,  M.D.,  &c.     1871. 

On  Antisepticity  in  Surgery.  By  Edward 
Lund,  F.R.C.S.,  &c.    Manchester,  1872. 

Suggestions  for  a  Ready  Method  of  Re- 
porting Surgical  Cases  in  Hospital  Practice. 
By  Edward  Lund,  F.R.C.S.     1872. 

The  Power  above  Matter.  An  Address 
by  D.  de  Berdt  Hovell.^  London.     1871. 

Lessons  on  Population,  suggested  by 
Grecian  and  Roman  History.  By  Nathan 
Allen,  M.D.     Boston.     1871. 

The  Effects  of  Alcohol  on  Off'spring.  By 
Nathan  Allen,  M.D. 

Inaugural  Address ;  including  a  Paper 


560 


Books,  ^c.j  received  for  Review.  [Aprils  1872. 


on  Infant  Asylums.  By  A.  Jacobi,  M.D. 
New  York.     1872. 

Eemarks  on  {the  Prevalence  and  Dis- 
tribution of  Fever  in  Dublin.  Illustrated 
by  a  Map,  Tables,  and  Diagrams;  with 
Appendices.  By  T.  W.  Grimshaw,  M.D. 
Dublin.     1872. 

The  Present  Condition  of  Political 
Liberalism  in  England.  By  "W".  Dyson 
Wood.     1872. 

Social  Politics.  By  "W.  Dyson  Wood. 
1871. 

On  the  Relation  of  Therapeutics  to 
Modern  Physiology.  By  Henry  E.  Mad- 
den, M.D.,  &c.    London.     1871. 

On  Chronic  Hypertrophy  of  the  Lips. 
By  R.  W.Taylor,  M.D.   New  York.    1871. 

On  the  Mechanism  of  Accommodation 
for  Near  and  Distant  Vision.  By  R.  E. 
Dudgeon,  M.D. 

On  Diphtheria  and  the  Diseases  allied 
to  it,  &c.  By  R.  H.  Semple,  M.D.,  &c. 
1871. 


Sur  un  Nouveau  Dissolvant  de  I'lodine 
Plombique  et  de  son  Application  a  la 
Pharmacie.  Par  Donate  Tommasi.  Paris. 
1872. 

Storia  delle  Epidemic :  nuove  Docu- 
menti  per  la  Storia  delle  Mallattie  Venere 
in  Italia.  Nota  del  Prof.  Alfonso  Corradi. 
Milan.     1871.     _ 

Delia  PreparazionedellaLabirinto-osseo. 
Memoria  di  Luigi  Porta,  Professor  di 
Medicina  nella  R.  Universita  di  Pavia. 
1871. 


ts,  Journals^  Reviews,  Sec 

Journal  of  the  Scottish  Meteorological 
Society.    October,  1871. 

The  Birmingham  Medical  Review :  a 
Quarterlv  Journal  of  the  Medical  Sciences. 
No.  I,  January,  1872. 

The  Dublin  Journal  of  Medical  Science 
(late  Dublin  Quarterly).  Third  Series, 
No.  I,  1872.     Published  monthly. 

The  Dublin  Quarterly  Journal  of  Medi- 
cal Science.     1871. 


The  Edinburgh  Medical  Journal.  Decem- 
ber, 1871,  January,  February,  and  March 
1872. 

The  Journal  of  Mental  Science.  January 
1872. 

The  Food  Journal.  January,  February 
March. 

Food,  Water,  and  Air.  Nos.  2,  3,  4,  5, 
and  6. 

The  Medical  Press  and  Circular.  January 
and  February,  1872. 

The  American  Journal  of  the  Medical 
Sciences. 

The  Journal  of  Psychological  Medicine. 
New  York. 

The  New  York  Medical  Journal.  Novem- 
ber and  December,  1871. 

The  Medical  Record.     New  York. 

The  Detroit  Review  of  Medicine  and 
Pharmacy :  a  Monthly  Record.  Vol.  VII. 
January,  1872. 

The  Australian  Medical  Gazette. 

The  Madras  Monthly  Journal  of  Medical 
Science.  December,  1871,  and  January, 
1872. 

The  Indian  Medical  Gazette :  a  Monthly 
Record  of  Medicine,  &c.  Calcutta.  Novem- 
ber, 1871. 

Archives  Generales  de  Medecine.  De- 
cember, 1871,  January  and  February,  1872. 

Gazette  Hebdomadaire.  January  and 
^ebruar3^ 

L'Union  Medicale.  December,  1871,  to 
April,  1872. 

Gazette  Medical  d' Orient.  XVme  Annee. 
Constantinople.  May,  1871,  to  January, 
1872. 

Archiv  fur  Gynsekologie.  Band  iii, 
Erstes  Heft.     1871. 

Medizinische  Jahrbiicher.  Redigirt  von 
S.  Strieker.    Heft.  IV.     1871. 

Monatsschrift  fUr  OhrenheiUcunde.  Jan., 
1872. 

Schmidt's  Jahrbiicher  der  Gesammten 
Medicin.  December,  1871,  January  and 
February,  1872. 

Archiv  fiir  Pathologische  Anatomie  und 
Physiologic.     Virchow.     December,  1871. 

0  Correio  Medico  de  Lisboa.  January, 
1872. 


CORRIGENDA. 

No.  XCIV  (April,  1871),  p.  410  (foot-note)  for  "  Notes  on  Nursing,"  read 
*'  Notes  on  Hospitals.^*  P.  411  (foot-note) /or  "  a  suggestion  due  to  Dr.  Ransorae,'* 
read  "  a  suggestion  due  to  Mr.  Lewis." 


INDEX  TO  VOL.  XLIX 


OP   THE 

BRITISH  AND  FOREIGN  MEDICO-CHIRUKGICAL  REVIEW. 


P 


PAGE 

Abscess  of  appendix  vermiformis  .  556 
Absorption  of  insoluble  substances  523 
Aconite  as  a  poison  .  .  .52 
Aconitine,  action  of  .  .  .  255 
Adams's  (W,)  operation  for  bony 

anchylosis  ....  465 

Adulteration  of  food  detected  .  271 
Albumen    and    casein,    differences 

between 252 

Albumen  of  egg  ....  252 
Albuminoids  in  ruminants  .  .  251 
Albuminuria  ....  206 

Aldridge    (Dr.  C.)  on  ophthalmo- 
scope in  mental  disease       .         .     35 
Allbutt  (Dr.)    on  ophthalmoscope 

in  nervous  diseases     .         .         .  429 
Alkaloids,  synthesis  of  .         .  255 

Allen    (Dr.    Nathan)    on  physical 

degeneracy         .         .         .         .62 

Amnion,  annexes  of       .         .         .  244 

Amyl-nitrite,  value  of  .         .  545 

Anatomy,  comparative,   notes  on, 

by  Dr.  Ord        .         .         .         .  133 

* and  Physiology,  Journal 

of 168 

Andrew's  (St.)  Graduates'  Associa- 
tion '  Transactions'     .         .         .  454 
Aneurism,  rapid  cure  of        .         .  464 
Anchylosis,  bony,  operation  for      .  465 
Angioma,     galvano-caustic    treat- 
ment of 277 

Animalcular  generation,  substances 

preventing         ....  268 
Animal  kingdom,  organization  of, 

by  Eymer  Jones  .  .  .  135 
Animal  plagues,  Fleming  on  .  136 
Animal  starch  ....  256 
Anaemia  in  pregnancy  .  .  .  242 
Anstie  (Dr.)  on  neuralgia  .  .117 
Antimony  in  small  doses  .  .  221 
Appendix  vermiformis,  abscess  of  556 
Arachnoid  cysts  .  .  .  .42 
Arsenic,  distinction  of,  from  mer- 
cury, in  Reinsch's  test        .         .  256 

in  menorrbagia  .         .  240 

Arsenical  poisoning  in  India           .     48 
Arsenic,   volumetrical    determina- 
tion of       261 

Arteries,  capillary,  their  influence 

in  disease 370 

Assam  poison  .  .  .  .53 
Asylum,  West  Riding,  '  Reports'  .  25 
Atthill  (Dr.)  on  diseases  of  women  459 
Auspitz  on  absorption  of  insoluble 

substances  ....  523 

Bacteria,  origin  of  .         .         .  450 

Balfour  (Dr.  G.  W.)  on  treatment 
of  diabetes  by  lactic  acid  .  538 

. (i'>Y.)  on  mitral  stenosis    553 

(Mr.)  on  use  of  chlorine 


PAGE 
Bealc  (Dr.)  on  protoplasm  .  .  338 
Belladonna,  action  of  .  .  .  211 
Bernstein  on  gases  in  the  blood  .  527 
Bethencourt  (Jacques  de)  on  sy- 
philis          149 

Bile  and  urine  pigments  .  .  254 
Bilroth,  on  resection  of  oesopliagus  279 
Bladder,  exfoliation  of  .         .         .  241 

palsy  of  .         .         .         .  129- 

Blood- corpuscles     of     birds     and 

snakes 251 

corpuscle,  various  sizes  of  .  250 

corpuscles,  affected  in  size 

by  reagents        ....  524 


-ci'ystals,  mode  of  obtaining    249 

physiology  of         .     90 

current  in  lungs  ,         .         .  528 

discs,  tension  of  oxygen  in     524 

gases  in  the       .         .         .  527 

globules,  action    of    carbo- 
nic oxide  on       .         .         .         .  250 

letting,  value  of  .         .  382 

loss  of,  effects  of        .         .  524 

movement  within  skull      .  524 


Avater  in  diphtheria 


543 


Bastian  (Dr.)  on  low^est  organisms   448 


Bones,  marrow  of,  alteration  in, 
in  leucoeythaimia       .         .         .  547 

Books  received      .         .         .   281,  558 

Botany,  medical,  of  the  Southern 
States,  by  Dr.  Porcher       .         .  141 

Brain  disease,  cases  of,  treated  by 
mercury 472 

Brodhurst  (Mr.)  on  deformities  of 
human  body       .         .         .         .87 

Bronchocele,  removal  of,  cases       .  274 

Browne's  (Dr.  Crichton)  '  West 
Riding  Asylum  Reports'    .         .     25 

on  cra- 
nial injuries  and  mental  diseases     28 

(Mr.  J.  H.  B.)  on  medi- 
cal jurisprudence  of  insanity      .  331 

Buchan's  '  Text-book  of  Meteoro- 
logy'   139 

Buchanan's  (Dr.)  camp  life  .         .  469 

Burman  (Dr.  J.  W.)  on  the  statis- 
tics of  general  paralysis      .         .     37 

Burresi  on  diabetes        .         .         .  418 

(Prof.)   on  the  inhalation 

of  oxygen 537 

Burton  (Capt.)  on  diseases  of  Zan- 
zibar   451 

Calcareous  substances  of  organism  257 
Calcutta,  drainage  of  .  .  .  272 
Camp-life,  by  Dr.  Buchanan .  .  469 
Cancer,  primary,  of  tonsil      .         .  478 

cases  of  tonsil  ,  .         .  478 

of  tonsil,  treatment  of        .  489 

secondary,  of  tonsil    .         .  493 

— of  uterus,  cause  of  death    .  239 

Cantani    on  use  of  lactic  acid  in 

diabetes 425 

Carbolic  acid,  its  therapeutical  pro- 
perties        535 


562 


INDEX  TO  VOL.    XLIX. 


PAGE 
Carbonic  oxide,  action  of,  on  blood- 

globiUcs 250 

Casein,  artificial  digestion  of  .  251 

Causes  of  death  following  lithotomy  103 
Cell-doctrine,  Dr.  Tyson  on    .         .  338 

Cells,  nature  of 340 

Cerebral  disease,  use  of  ophthal- 
moscope in         .         .         .         .     35 
— — —  -  tumours,  ophthalmoscopic 

signs  of 442 

Chambers  (Dr.  T.  King)  Harveian 

oration 159 

Chemistry  of  blood  and  urine   in 

leukaemia 548 

Chemistry,  report  on     .         .         .  249 
Chevers   (Dr.  N.)   medical   juris- 
prudence for  India     .         .         .46 
Chinese  materia  medica,  treatise  on  322 
Chloral  hydrate  as  a  poison  .         .258 

remedies  for,  acting 

as  a  poison  ....  259 

death  from     .        .  271 

Chlorine  as  a  disinfectant  .  .  270 
Chlorine-water  in  diphtheria  .  543 

Cholera,  pathology  of  .  .  .  376 
Chronicle  of  medical  science  .  522 

Church's  (Prof.)  report  on  physio- 
logical chemistry        .         .         .  249 

Chyluria 203 

Cicutia,  the   alkaloid  of  hemlock, 

efeects  of 543 

Chyluria,  blood  and  urine  in  .  .  250 
Climate,  effects  of .  .  .  .253 
Clinical  Society's  '  Transactions'  .  158 
Colic,  hepatic,  on,  by  Senac  .  .  154 
Comparative  anatomy,  on.  Dr.  Ord  133 

by   Rymer 

Jones 135 

Conception  under  unusual  circum- 
stances        242 

Constituents,  inorganic,  of  blood  .  525 
Consumption  contagious  .  .  273 
Contagious  Diseases  Acts  .  .  388 
Copeman  (Dr.)  on  use  of  mercury 

in  brain  diseases  .  .  .  471 
Corrigenda  ....  284, 560 
Craniotomy,  notes  on  .  .  .  246 
Croup,  forms  of  .  .  .  .  375 
Cruse  (Dr.)  on  cedema  of  lungs  .  554 
Cui'arine,  detection  of  .  .  .  255 
Dalton  (Dr.)  on  sugar  formation  in 

the  liver 418 

Datura  used  for  poisoning     .         .     54 
Decomposition     of    animal     sub- 
stances        251 

Defects  in  sanitary  legislation  .  3 
Deformities  of  human  body  .  .  87 
Degeneracy  of  town  populations    .  272 

physical,  in  the  United 

States 62 

Degenerations  in  acute  disease  .  546 
Delirium  tremens,  Dr.  Laycock  on  551 
Dengue,  or  red  fever  .  ,  .  151 
Diabetes,  pathology  of  .         .         .  418 

treatment  of  .         .425 

■ treated  by  lactic  acid      .  538 

~ respiratory  theory  of       .  425 


PAGE 


Dictionnaire   de   Medccine  ct    do 

Chirui'gie',         .... 
Digitalis,  uses  of.  Dr.  Fothergill     . 
Diphtheria,  Gulia  on     . 
treated  by  chlorine - 

water 

Disease  treated  by  electrolysis 
Disinfection  with  chlorine     . 
Dittmaz     on    excitability   of   the 

spinal  cord         .... 
Dittrich  on  lithia  in  gout 
Donkin  (Dr.)  on  diabetes 
Duncan  (Dr.  J.  M.)  on  mortality  of 

lying-in  hospitals 
Dynamics  of  nerve  and  muscle 
Dysentery  treated  by  ergot    . 
Eames  (Dr.)  on  phosphorus  in  skin 


of 


Dr. 


Electricity  of  muscles    . 

Electrolysis  in  the  treatment 
disease       .... 

Electrotonus  in  nerve    . 

Embolism      .... 

Epizootics,  hyposulphites  in . 

Ergot  of  rye  in  dysentery 

in  mental  diseases 

Essentials    of   medicine,    by 
Hartshorn  e        .         .         .         . 

Eulenberg  on  functional  nervous 
disorders 

Factory  medical  officers 

Fat,  purification  of       .         .         . 

Fever,  pathology  of       .         .         . 

Fibroid  tumours  of  uterus     . 

Fish,  absorption  of  oxygen  by 

Fleming  on  animal  plagues  . 

Fatation,  conjoined  extra-  and  in- 
tra-uterine         .         .         .         . 

Foetal   malposition   in   connection 
with  filaments  of  the  amnion     . 

Food,  mineral  constituents  of 

Forceps,  midwifery,  forms  of 

mode  of  appli- 
cation         

power  of 

Fox  (Dr.  E.  C.)   on  ergot    in  in- 
sanity         

(Dr.  Wilson)  on  cold  in  hyper- 

pyi'exia 

Fothergill  on  digitalis  . 

Fracastor  on  syphilis     . 

Fractures  and  dislocations,  Hamil- 
ton on 

Eraser  (Dr.)  on  action  of  mercury 
on  the  liver        .... 

Frequency  of  doses 

Friedingcr  on  the  peptic  gland 

Functional  nervous  disorders 

Fungi  used  for  poisoning 

Galvano-caustic  treatment  of  an- 


164 

457 
468 

543 
534 
270 

529 
539 

418 

359 

308 
544 

534 
310 

534 
314 
373 
266 
544 
45 

168 

117 
17 
257 
379 
238 
256 
136 

245 

244 
249 

178 

183 
173 

45 

153 
457 
149 

160 

458 
209 
526 
117 
61 

277 


gioma        ..... 
Cant's  'Science    and  Practice  of 

Surgery'  ....  467 

Garvin  (Dr.)  on  cold  water  as  an 

oxytocic 54 

Gases,  exchange  of,  in  the  blood   .  52 
Gatzuck,  effects  of  loss  of  blood    .  52 


INDEX  TO   VOL.  XLIX. 


563 


PAGE 
Gencrsicli,  absorption  of  lymph  by 

tendons  and  fascia?  .  .  .  523 
Germs,  aninialcular  .  .  .  268 
Glosso-labio-lai'yngeal  paralysis  .  552 
Glycosuria  artificially  produced     .  422 

on       .         .         .         .207 

Gout  treated  by  lithia  .         .  539 

Greene    (Dr.)    on   extirpation    of 

bronchocele  ....  274 
Gross  on   ulceration    of    jugular 

vein 277 

Gulia  on  diphtheria  .  .  .  468 
Hffimatin,  composition  of  .  .  249 
Haimatometra,  cases  of  .  .  237 
Ha3moglobiu,  Preyer  on  .  .95 
Hafiz  on  nerves  of  arteries  .  532 
Hamilton  on  fractures  and  disloca- 
tions   160 

(Dr.)  on  tedious  labours 

171,  247 
Hammond  (Dr.)  on  a  case  of  glosso- 

labio-laryngeal  paralysis  .  552 

'Handy-book     of    Women's    and 

Children's  Diseases'  .  .  .  165 
Hartshorne's    (Dr.)    essentials   of 

medicine  ....  168 

Harveian  oration  by  Dr.  T.  King 

Chambers  ....  159 

Haviland  on  distribution  of  heart 

disease  and  dropsy     .         .         .  162 
Heart  disease  and  dropsy,  distribu- 
tion of 162 

Hemlock,  effects  of  .  .  .  543 
Henry   (Dr.)    on    amputation    of 

scrotum 281 

Hereditary  transmission  of  struc- 
tural peculiarities      .         .         .  500 
Hey  sham  (Dr.),  life  of  .         .  147 

Hofman  (Dr.  K.  B.)  on  the  progress 

ofuroscopy  ....  193 
Holmes's  *  System  of  Surgery'  .  346 
Hospitals  and  their  critics  .  .  359 
Hospital  construction    .         .         .  360 

salubrity  .         .         .  359 

Hygiene,  report  on  .  .  .  266 
Hyperpyrexia,  use  of  cold  in  .  153 

Hypertrophic  cirrhosis  of  liver  .  556 
Hypodermic  injection,  perils  of  .  271 
Hyposulphites  in  epizootics  .  .  266 
Huxley  (Professor)  on  life  .  .  338 
Impaction  as  a  cause  of  vesico-va- 

ginal  fistula  ....  246 
Induction  of  labour  in  contracted 

pelvis  .  .  .  .  .  247 
Inflammation,  process  of  .  .  347 
Insane,  feeding  of  the  .  .  .42 
Insanity  and  phthisis    .         .         .43 

■ morphia  used  hypodermi- 

callyin      .         .         .         .         .39 

-  medical  jurisprudence  of.  331 

Jaccoud's  hypothesis  of  glycosuria  224 

on  saccharine  diabetes   .  418 

Jarisch   on    constituents    of    the 

.  525 
.  524 


on 
ashes  of  blood    .... 
Jolly  on  pressure  of  brain 
Jones  (Rymer),  outline  of  compara- 
tive anatoluy     ,        ,        ,        .  135 


PAGE 


*  Journal  of  Anatomy  and  Phy- 
siology'       

Jugular  vein,  ulcerations  of  . 

Jurisprudence,  medical,  manual  of, 
for  India  ..... 

Kaulisch  on  pathology  of  tuber- 
cular peritonitis 

Labbee  on  properties  of  phenic 
acid 

Labour,  tedious.  Dr.  Hamilton  on 
management  of         .         .         . 

use  of  cold  water 


induction  of,  in  contracted 

pelvis 

Lactic  acid  treatment  of  diabetes . 
Lacto-phosphate  of  lime  as  a  me- 
dicine         

Laveran  on  degenerations  in  acute 

maladies 

Lawrence    (Dr.    W.)  on  artificial 

feeding  of  the  insane 
Laycock  (Dr.)  on  delirium  tremens  551 

541 
265 
270 
525 


168 

277 

46 

555 

535 

171 

540 

247 
538 

542 

546 

42 


Lead  acetate  in  pneumonia 

poisoning  by  acetate  of 

from  snuff     . 

Lepine  on  animal  sugar  ferment    . 
Leucin  and  tyrosin,  clinical  signi- 
ficance of 

Leucocythfflmia,    its    relations    to 
pseudo-leukajmia 


accompanying  al- 
teration of  the  marrow 
Lying-in  hospitals,  works  on 
Lymph  absorbed  by  tendons . 
Leukhffimia,  blood  and  urine  in 

chemistry  of  urine  and 


550 

548 
204 

547 
359 
523 
251 

548 


blood  in 

Lime,  lacto-phosphate  of,  in  me- 
dicine         542 

Lithia,  use  of,  in  gout  and  gravel .  539 
Lithotomy,  causes  of  death  in  .  103 
and  lithotrity,  Sir  H. 


Thompson  on 

indi- 
cations for          .         .         .         . 

Lithotrity,  Sir  H.  Thompson  on   . 

causes  of  death  in 

complications  in  operat- 


ing 


conditions  favorable  for 

results  of 

where  indicated     . 

instruments^ 


100 

413 
395 
411 

406 
397 
408 
413 
397 


Liveing  (Dr.)  notes  on  skin  diseases  164 
Liver,  hypertrophic  cirrhosis  of  .  556 
*  Liverpool  Medical  Reports' .  .  156 
Local  Government  Board  .  .  1 
Locomotor  ataxy  in  the  insane  .  41 
Lombroso  (Dr.)  on  pellagra  .  .113 
Lonsdale's  (Dr)  *  Life  of  Dr.  Hey- 

sham' 147 

Londolt  on  distance  of  the  macula 

from  optic  nerve  .  .  .  533 
Lunacy  practice,  use  of  sphygmo- 

graph  iu  .        «        «        .        .33 


564 


INDEX  TO   VOL.    XLIX. 


PAGE 

Lung-ocdema,  cauiscs  of         .        .  554 

disease,  use  of  oxygen  in      .  537 

Lungs,  current  of  blood  in    .         .  528 

earthy  matter  in        .         .  250 

Lusk  (Dr.)  on  origin  of  diabetes  .  418 
Luton  on  ergot  of  rye  in  dysentery  544 
Maas  on  treatment  of  angioma  .  277 
Magnesium  chloride,  effects  of  .  541 
Management   of    tedious  labours, 

by  Dr.  Hamilton         .         .        .  171 
Manassein  on  agents  reducing  tem- 
perature      528 

■ — variations    in    size    of 

blood-corpuscles 
'Manual  of  Practical  Therapeutics,' 
by  Dr.  Riuger  .... 
Materia  medica,  report  on 

of  Chinese,  by  Dr. 


524 

166 
534 

322 


Porter  Smith 
Mayhew  (Dr.)    on  acute  delirious 

melancholia        .... 
Meat,  extract  of,  its  value     . 

fluid  Darby's 

McCready  on  vises  of  lacto-phos- 

phate  of  lime    . 
*  Medical  Courier,'  the,  of  Lisbon  . 
•Medical    Reports    of    the    West 

Riding  Asylum' 
Medical  jurisprudence  of  insanity .  331 
Medicine,  report  on       .         .         .546 
Medicine,  clinical  lectures  on,  by 

Trousseau  .... 

Medicines  in  small  doses,  by  Dr. 

Spender 

'  Medicine,    System    of,'    by    Dr. 

Reynolds 

*Medecine  et  Chirurgie,  Diction- 

naire  de' 

Melancholia,  acute 

Meningitis,  ophthalmoscopic  signs 

of 

Mental  diseases,  use  of  ergot  in     . 
in  relation  with 


45 
249 
271 

542 
157 

25 


154 

209 

285 

164 

45 

440 
44 


cranial  injuries 
Meteorology,  text-book  of,  by  Dr. 

Buchanan 

Mercury,  action  of,  on  liver  . 
■  in  small  doses . 

use  of,  in  brain  diseases    . 

Miescher   on    conduction  of    sen- 
sory impressions 

Milk,  albuminoids  of     . 

composition  of     . 

constitution  of     . 

production    of,    in    relation 

to  food      .         .         .         .         . 

skim,  in  diabetes . 

Mitchell  (Dr.  S.)  on  nitrous  oxide . 
Mitral  stenosis,  physical  signs  of   . 
MoUities  ossium,  Mr.  Pedler  on 
Morphia  in  small  doses  . 

solutions,     decomposition 


of 


used 


hypodermically  in 

insanity 

Mortality,   cause 


hospitals 


of,    in  lying-in 


28 

139 

458 
225 

472 

533 
252 
526 
253 

252 
427 

30 
553 

40 
214 

256 

39 

365 


PAGE 
Mucin  of  submaxillary  gland         .  253 
Miiller  on  oxygen  in  blood-discs     .  524 
Murray  (Dr.)  on  rapid  cure  of  aneu- 
rism   464 

Muscle,  dynamics  of      .         .         .  308 
Muscular  contractility  and  electri- 
cal force  • 311 

Muscular  action,  theory  of    .         .  309 
Mushrooms,  edible  and  poisonous, 

distinctions  between  .  .  .  262 
Mutilation,  effects  of  transmitted .  509 
Narrowing  of  pulmonary  artery  .  554 
Nerve  and  muscle,  physiology  of 
Nerves  of  arteries  of  muscle  . 

and  electric  force 

and  chromoblasts 


Nervous  disorders  and  neuralgia   . 

diseases,  use  of  ophthal- 
moscope in         ...         . 

Neumann  on  leucocytha?mia  and 
alterations    in    the    marrow    of 


532 
315 
529 
117 


429 


bones 


on  skin  diseases 


547 
465 

117 
121 
125 

41 


Neuralgia  and  functional  nervous 
disorders 

its  nature 

causes  of       .         . 

Nicol  (Dr.  P.)  on  locomotor  ataxy 

in  the  insane     .... 
handy-book  of  treat- 
ment of  women's  and  children's 
diseases 165 

and  Dove  on  phthisis  and  in- 
sanity         43 

Nicholson's    (Dr.)     text-book     of 

zoology 135 

Nightingale's     (Miss)     notes     on 

lying-in  institutions  .  .  .  359 
Nitrogen  of  albuminoids        .         .  252 

elimination  in  relation  to 

diet  and  exercise  .  .  .  253 
Nitrous  oxide,  action  of  .  .30 
Nosology  of  Zanzibar  .  .  .451 
Noyes  (Dr.)  on  effects  of  paralysis 

of  the  fifth  nerve  .  .  .552 
Objections  to  Contagious  Diseases 

Acts 389 

Obstetrics,  report  on     .         .         .  237 
Obstetrical   works    of    Sir    J.   Y. 

Simpson 73 

(Edema  of  lungs,  etiology  of .         .  554 
Oesophagus,  resection  of        .         .  279 
Officers  of  health  .         .         .         .12 
Ogle   (Dr.    J.  A.)    on    hereditary 
transmission  of  structural  pecu- 
liarities       500 

Olivier  on  hypertrophic    cirrhosis 

of  liver 556 

Operation  of  lithotrity  .         .         .  400 

for   removing   broncho- 

cele 274 

Ophthalmoscope  in  renal  diseases  445 
its    use   in    ner- 
vous diseases     ....  429 
Ophthalmoscopic    signs    of    brain 

disease 439 

Opium  in  treatment  of  diabetes     .  427 


INDEX  TO   VOL.    XLlX. 


565 


Optic  ischaomia  and  neuritis   dis- 
tinguished        ....  434 

nerve,  its  distance  from  the 

macula 533 

Ord,    Dr.,  notes    on    comparative 

anatomy ]83 

Organisms,  lowest  .      '  .         .  448 

Origin  of  lowest  organisms    .         .  448 
Ovarian  fibroid  tumour  .         .  241 

Oxygen  absorbed  by  fish        .         .256 

in  lung  diseases         .         .  537 

Ozokerit  as  a  therapeutic  agent    .  535 
Paralysis,  general,  statistics  of      .     37 

glosso-labio      laryngeal, 

case  of 552 

of  fifth  nerve,  efEects  of  552 


546 

167 

554 
533 
419 


40 
113 
181 
177 


Pathology,  report  on     . 
Pathological     Society's      '  Trans- 
actions'       

Paul  (Dr.)  on   narrowing  of  pul- 
monary artery  .... 
Paulus  on  tactile  sensibility  . 
Pavy's  theory  of  sugar  formation  . 
Pedler  (Mr.    G.    H.)  on  mollities 

ossium 

Pellagra,  Lombroso  on  . 
Pelvic  outlet,  form  of  . 
Pelvis,  its  relation  to  delivery 
Pepper  (Dr.)  on  uterine  displace- 
ments         238 

Pepsine,  its  origin  in  stomach  .  526 
Perineal  rupture,  operation  for  .  239 
Perinseum,    management     of,     in 

labour 246 

Peritonitis,  tubercular,  its  patho- 
logy   555 

Pharmacy,  '  Year  Book'  of  .  .  146 
Phenic  acid,  its  properties  .  .  535 
Phosphorus       jioisoning,       tissue 

changes  in         ...         .  256 
■  ■ turpen- 
tine as  an  antidote    .         .         .  263 

use  of,  in  skin  disease  534 

Phthisis  and  insanity  .  .  .43 
Physic,  principles  and  practice  of, 


369 

62 

156 
90 


by  Sir  T.  Watson 
Physical  degeneracy  in  the  United 

States        

Physiological  anatomy  of  man,  Dr. 

Todd's 

Physiology  of  blood-crystals  . 

report  on,   by  Mr.  H. 

Power 522 

Pigments  of  bile  and  urine  .  .  254 
Pilz,  temperature  of  childhood  .  528 
Placenta,  calcification  of        .         .  244 

cysts  of.         .         .         .245 

Playfair's  (Dr.)  report   on   obste- 
trics  237 

Pneumonia  treated  by  acetate  of 

lead 541 

Poggio  on  red  fever  .  .  .  151 
Poisons,  action  of,  on  heart  of  frog  531 

used  in  India  .         ,         .46 

Poisonous  fungi  of  India  .  .  61 
Poisoning  by  mercurial  ointment  .  270 
Poland  (Mr,)  on  cancer  of  tonsil    .  477 


PAGE 
Poland's  (Mr.  A.)  report  on  sur- 
gery   274 

Porcher  (Dr.),  medical  botany  of 

the  Southern  States  .  .  .  141 
Porter,    Smith  (Dr.),  on   Chinese 

materia  medica ....  322 
Potassium  chloride,  effects  of  .  541 
Pouchet   on   nerves   and  chromo- 

blasts 529 

Power's  (Mr.  H.)  report  on  phy- 
siology        522 

Pregnancy,  extra-uterine       .         .  243 
Presentation,  obstetrical  varieties 

of 171 

Preyer  on  blood-crystals        .         .     90 
Protoplasm,  what  it  is  ?  .         .  338 

Pseudo-leukaemia  and  leucocythse- 

mia 548 

Puller's    translation   of  Neumann 

on  skin  disease  ....  465 
Pulmonary  artery,  narrowing  of  .  554 
Purdon  (Dr.)  on  ozokerit  as  a  the- 
rapeutic agent  ....  535 
Pus,  composition  of  .  .  .  254 
Putrefaction  and  disinfection  .  257 
Quadruplets,  case  of  .  .  .  243 
Quinine  in  obstetric  practice  .  540 

in  ophthalmic  practice     .  540 

Rabuteau  on  effects  and  uses  of 
chlorides  of  potassium  and  mag- 
nesium       541 

Radcliffe   (Dr.)    on    dynamics   of 

nerve  and  muscle       .         .         .  308 
Read  (Dr.)  on  oxygen  in  lung  dis- 
ease   537 

Renal  disease,  ophthalmoscopic  ap- 
pearances in       ...         .  445 
Report  on  medicine       .         .         .  546 

on  pathology     .         .         .  546 

of  Royal  Commissioners  on 

the  Contagious  Diseases  Act       .  388 

on  materia  medica     .         .  534 

on  toxicology,  forensic  me- 
dicine, and  hygiene  .         .         .  258 
on  physiological  and  patho- 
logical chemistry        .         .         .  249 

on  surgery         .         .         .  274 

on  obstetrics      .         .         .  237 

on  physiology    .         .         .  522 

'  Reports,  Liverpool'      .         .         .  156 
Resources  of  the  Southern  fields 

and  forests,  by  Dr.  Porcher        .  141 
'Reynolds's  System  of  Medicine'  .  285 
Richardson's  (Dr.  B.    W.)  report 
on  toxicology     ....  258 

(Dr.  W.)  on  diabetes  418 

Ringer's  (Dr.)  'Manual  of  Practical 

Therapeutics'  ....  166 
Rockwell  (Dr.)  on  electrolysis  in 

the  treatment  of  disease     .         .  534 
Rotunda    Lying-in     Hospital    re- 
port .       ' .         .         .         .         .359 
Salkowski  on  urine  and  blood  in 

leuka3mia 548 

Sanderson  (Dr.  B.)  on  inflamma- 
tion   347 

Sanitary  areas       ....      5 


bm 


INDEX   TO   VOL.   XLIX. 


PAGE 
Sanitary  legislation  ,  .  .  1 
Sarcolactic  acid  in  urine  .  .  254 
Scarlatina,  conveyance  of  .  .  551 
Sclimiederberg  on  action  of  poisons 

on  heart  of  frog]        .         .         .  531 
Scrotum,  redundant  amputation  of  281 
Semple's  (Dr.)  report  on  therapeu- 
tics     534 

Senac  on  hepalic  colic  .  .  .154 
Sensibility,  tactile,  in  lower  limb  .  533 
Sewage,  phosphate  process  with  .  272 
Silvester  on  the  spleen  .  .  .  143 
Simpson's   (Sir   J.  Y.)  obstetrical 

works         .         .         .         .         .73 
proposi- 
tions on  hospitalism  .         .         .  359 
Skin  diseases  (Neumann)       .         .  465 

notes    on,     by   Dr. 

Liveing  .....  164 
Smallpox  encampments  .         .  271 

Smith's  Chinese  materia  medica  .  322 
Snake  poison  ....  263 

Spence's  lectures  on  surgery  .     18 

Spender  (Dr.)    on   administration 

of  small  doses  .  .  .  .209 
Spinal  cord,  its  excitability  .  .  529 
Spleen,  nature  of  the,  byDr.Silvester  143 
*  St.  Andrew's  Medical  Graduates' 

Transactions'  ....  454 
Starch,  subcutaneous  absorption  of  251 

animal       ....  256 

Stenosis,  mitral  signs  of         .         .  553 
Stirling  (Dr.)  on  protoplasm .         .  338 
Stohl,  on  acetate  of  lead  in  pneu- 
monia         541 

Strychnine  compounds  .  .  .  255 
Sugar  ferment  in  animals      .         .  525 

formed  in  the  liver      .         ,  419 

in  urine       ....  207 

Sulpho-cai'bolates,  use  of       .         .  238 
Summary  of  papers  on  hygiene      .  269 
Surgery,   science  and  practice  of, 
by  Mr.  Gant      .         .         .         .467 

report  on  .         .         .         .  274 

system  of,  by  Holmes       .  346 

Spence's  lectures  on  .     18 

Sutherland  (Dr.  H.)  on  arachnoid 

cysts 42 

Syphilis,  works  on  ...  149 

Temperature  of  childhood  .  .  528 
Tetanus,  urine  in  .  .  .  .  203 
Therapeutical  effects  of  hemlock  .  543 

value  of  nitrite  of 

amyl  .....  545 

Therapeutics,  report  on         .         .  534 
Thompson  (Sir   H.)   on    practical 
lithotomy  and  lithotrity     .         .  100 

on    lithotomy 

and  lithotrity     .         .         .         .395 

(Dr.  G.)  on  sphygmo- 

graph  in  lunacy  .         .         .33 

Tlu-ombosis 373 

Thuggee  by  poison  .  .  .54 
Tissue  changes  in  acute  disease  .  546 
Tobacco-smoke  alkaloids  .  .  254 
Tonsil,  cancer  of,  by  Mr.  Poland  477 
Toxicology,  report  on   .        .        .  258 


rAGE 
'  Transactions'  of  the  Pathological 

Society  of  London     .         .         .  167 

of  Clinical  Society    .158 

Transmission  of  structural  defects 

consequent  on.  mutilation  .  .  509 
Trousseau's  '  Clinical  Medicine'  .  154 
Tubercular  peritonitis  • .  .  .  555 
Turmeric,  how  detected  in  rhubarb 

and  mustard  ....  257 
Tyrosin,  clinical  significance  of  .  550 
Tyson  (Dr.)  on  the  cell  doctrine  .  338 
on  clinical  significance 

of  leucin  and  tyrosin  .         .  550 

Urea,   formation   and  elimination 

of 193 

Union  medical   officers  as  health 

officers 12 

Urea,  elimination  of,  in  fever  and 

starvation  ....  196 

origin  of       ...         .  527 

estimation  of         .         .         .  254 

a  constituent  of  bile      .         .  253 

Uric  acid,  elimination  of  .  .  200 
Urine  in  acute  atrophy  of  liver      .  201 

in  leucocythaemia  .         .  204 

in  phosphorus  poisoning       .  201 

theory  of  secretion  of  .         .  526 

in  tetanus    ....  203 

Uroscopy,  progress  of  .  .  .  193 
Ustimowitsch      on     secretion     of 

urine 526 

Uterine  diseases  of  constitutional 
origin 240 

inertia  from  a  tumour       .  247 

displacements,  varieties  of  238 

Uterus,  catheterization  of  .  .  246 
double,  with  pregnancy    .  243 

dilation  of  cervix  in  pain- 
ful menstruation        .         .         .  240 

fibroid  tumours  of    .         .  283 

Vagina,  nerves  of .  .  .  .  240 
Vertex  presentations,  varieties  of  .  171 
Vesico-vaginal  fistula  .  .  .  246 
Vessels,  blood-,  minute  pathology  of  370 
Ward  (Dr.  J.  B.)  on  the  treatment 
of  insanity  by  liypodermic  in- 
jection        39 

Water,  cold,  as  an  oxytocic  .  .  54-0 
Watson's   (Sir    T.)   '  Practice    of 

Physic' 369 

Webb's  (Dr.)  report  on  pathology 

and  medicine  ....  546 
Weber    on    abscess   of    appendix 

vermiformis  ....  556 
Welsh  fasting  girl,  history  of  .  269 
Whiskey,  poisoning  by .  .  .  264 
Women,  diseases  of,  by  Dr.  Atthill  459 
Wood  (Dr.)  on  relations  of  leucocy- 
thasmia  and  pseudo-leuksemia     .  548 

on  uses  of  nitrite  of 

amyl 545 


'  Year-book  of  Pharmacy' 
Yeast  plant,  nutrition  of 
Zanzibar,  diseases  of 
Zoology,    text-book    of,    by 
Nicholson .        .        .        . 


Dr. 


146 
257 
451 

135 


BIN 


X