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BRITISH AND FOREIGN

MEDICO-CHIEURGICAL
RETIEW

QUARTERLY JOURNAL

PRACTICAL MEDICINE AND SURGERY.

VOL. LX.

JULY—OCTOBEE, 1877.

LONDON:
J. & A. CHUECHILL, NEW BUELINaTON STEEET.

MDCCCLXXVII,

^.^

CONTENTS OF NO. CXIX.

BRITISH AND FOREIGN
MEDICO-CHIRURGICAL REVIEW.

JULY, 1877.

Enalptical anti (Eritical i^ebiebs.

Rev. I. — Researches on the Chemical Constitution of the Brain. By J.
L. Thtjdichum, M.D. Reports of the Medical Officer of the Privy
Council and Local Government Board. New Series, No. III. . 1

Rev. II. — 1. Observations on the Diseases of the Rectum. By T. B.

CuELiNG, F.R.S. Fourth Edition. London, 1876 . . 17

2. The Surgery of the Rectum ; being the Lettsomian Lectures on
Surgery delivered before the Medical Society of London. By Henry
Smith, F.R.C.S. Fourth edition. London, 1876 . . ib.

Rev. hi. — Cyclopedia of the Practice of Medicine.. Edited by Dr. H.
VON ZiEMSSBN. Vol xi. Diseases of the Peripheral Cerebro*spinal
Nerves. By Professor W. H. Ebb. Translated by Mr. Henry
Power. A. H. Buck, M.D., Editor of English Translation. London,
1876, 8vo, pp. 623 . . . . . . 23

Rev. IV. — 1. Handbook to the Physiological Laboratory. Histology. By

E. Klein, M.D., F.R.S. . . . . .32

2. Practical Histology. By E. A. Schafee . . . ib.

3. Outlines of Practical Histology. By Professor Rtttheefoed . ib.

4. Practical Physiology. By M. Foster, M.D., F.R.S., and J. N. Lanqley ib.

5. Demonstrations of Microscopic Anatomy. Harley and Brown . ib.
Rev. V. — Cyclopeedia of the Practice of Medicine. Edited by Dr. H. von

ZiEMSSEN. Vol. iii. Article on Syphilis. By Professor Cheistian
Batjmlbr, of Erlangen. 1875 . . . .40

Rev. VI. — 1. Hanot. — Cirrhose Hypertrophique du Foie. Thesis. Paris,

1875 ... . . . . .59

2. Charcot and Gombault. — 1. Note sur les Alterations du Foie Con-
secutive k la Ligature du Caual Choledoque, ' Arch, de Phys.,' Mai,
Juin, 1876. 2. Contributions k V fitude Anatomique des differentes
Formes de la Cirrhose du Foie. Ibid., Sept., Oct., 1876 . . ib.

3. CoRNiL and Ranvibr.— Manuel d'Histologie Pathologique. Paris,

1876 . . . . . . . ib.

4. Kelsch and Kiener. — 1. Contribution h I'Histoire de I'Adenome
du Foie, ' Arch, de Phys.,' Sept., Oct., 1876. 2. Note sur la Neoform-
ation de Canalicules Biliares dans I'Hepatite. Ibid., Nov., Dec, 1876 ib.

Rbv. VII. — 1. A System of Medicine. Edited by J. Russell Reynolds,

M.D., F.R.S. Vol. iv., containing Diseases of the Heart. 1877 . 74

11 CONTENTS OF NO. CXIX.

PAGE
2. Cyclopsedia of the Practice of Medicine. Edited by Dr. H. VON

ZiEMSSEN, Professor of Clinical Medicine in Munich. Vol. vi, Diseases

of the Circulatory System, &c. English translation, edited by A. H.

Buck, M.D. New York. London, 1876 . . .74

Eev. VIII. — On the Functional Diseases of the Urinary and Reproductive

Organs. By D. Campbell Blace:, M.D., L.R.C.S. Edin., &c. Second

edition, revised . . . . . .96

Rev. IX.— The Functions of the Brain. By David Feeeier, M.D., F.R.S.

London, 1876. Pp. 323 . . . . .99

Rev. X. — 1. An Examination of the Modern Theories of Automation and

Evolution. By Charles Elam, M.D. Pp. 163 . . 114

2. Text-book of Structural and Physiological Botany. By Otto W.
Thome, of Cologne. Translated and edited by Alfred W. Bennett,
M.A., F.L.S., Lecturer on Botany at St. Thomas's Hospital. 1877 • ib.

3. Article Amphibia in the Encyclopaedia Britaunica. Ninth edition.

By Professor Huxley, F.R.S., &c. . . , . ib.

iSitUograpijiral i^ecorlJ.

Art. 1.— 1. On the Personal Care of Health. By E. A. Paekes . 129

2. Public Health. By E. A. Paekes, M.D., F.R.S. Revised by W.

Aitken, F.R.S. London . . . . . ib.

Aet. II. — 1. Report of the Royal Commission on the Practice of Subjecting

Live Animals to Experiments for Scientific Purposes. London, 1876 133
2. Vivisection. By George Macilwain, F.R.C.S. London, 1877 . ib.
Aet. III. — An Introduction to Human Anatomy. By W. Turner, M.B.

Part ii, 1^77. Edinburgh, pp. 504 .... 138
Aet. IV. — 1. Reports on Leprosy. (Second Series.) By H. Vandyke

Carter. M.D. Published under the sanction of H.M. Secretary of

State for India. London, 1876 .... 139

2. Modern Indian Leprosy. Being the Report of a Tour in Kattiawar.
(Printed at the expense of the Chiefs of Kattiawar.) Bombay, 1876 ib.

3. Report on Leprosy in the North-western Provinces. By C. Planck,
Sanitary Commissioner N.W.P. October, 1876 . . . ib.

4. Leprosy in India. A Report by T. R. Lewis, M.B., and D. D.
Cunningham, M.B., Special Assistants to the Sanitary Commission.
Calcutta, 1877 . . . . . . ib.

Aet. V. — 1. The ' Oriental Sore ' as observed in India. A Report by T. R.
Lewis, M.B., and D. D. Cunningham, M.B., Special Assistants to
the Sanitary Commission. Calcutta, 1877 . . . 144

Aet. VI. — The Vivisection Question Popularly Discussed. By Dr. L. Hee-

MANN. Translated and edited by Dr. Aechibald Dickson. Pp. 59 146

Aet. VII. — The Treatment of Spina Bifida by a New Method. By James
MoETON, M.D., Professor of Materia Medica, Anderson's Uuiveisity,
and Surgeon and Clinical Lecturer on Surgery in the Glasgow Royal
Infirmary. Glasgow, 1877 ..... 148

CONTENTS OF NO. CXIX. /\)j iH^

PAGE

Aet. VIII. — Diseases of the Bladder, Prostate Gland, and Urethra ; in-
cluding a Practical View of Urinary Diseases, Deposits, and Calculi ;
being the fourth edition of the * Irritable Bladder,' revised and much
enlarged. By FREDEfiiCK James Gant, F.R.CS. London, 1876 . 149

Art. IX.— On Rest and Pain, By John Hilton, F.R.S., F.R.C.S., Surgeon-
Extraordinary to Her Majesty the Queen, Consulting Surgeon to
Guy's Hospital, &c., &c. Edited by W. H. Jacobson, F.R.C.S.,
Assistant-Surgeon to Guy's Hospital. Second edition. London, 1877 151
'Art. X. — A Directory for the Dissection of the Human Body. By John
Cleland, M.D,, F.R.S., Professor of Anatomy and Physiology in
Queen's University. London, 1876 . . . , . 153

Art. XI. — A Course of Operative Surgery, with Plates drawn from Nature,
by M. Leveille, and coloured by hand under liis direction. By
Christopher Heath, F.R.CS. London. Parts i, ii, iii, and iv.
1876-7 . . . . . . .155

Art. XII. — Les Eaux Minerales du Mont-Dore, Typographic Proprietes,
Physiques et Chimiques, Clinique Medicale. Par le Docteur Boudant,
Inspecteur- Adjoint ces Eaux. Paris, 1877. 8vo, pp. 523 . . 157

Art, XIII. — Etude sur des Resultats Definitifs des Amputations. Par H.

ViARD. Paris, 1877. Pp. 114 . . . . 158

Art. XIV. — Lectures on the Physical Diagnosis of Diseases of the Heart.

By Arthur Ernest Sansom, M.D. London, 1876 . . 159

Art. XV. — The Electric Bath. By George Schweig, M.D. New York,

1877 . . . . . . .160

Art. XVI. — A Treatise on the Theory and Practice of Medicine. By John

Syer Bristowb, M.D., &c. London, 1876 . . . 161

Art. XVII. — Sea Air and Sea Bathing; their Influence on Health. A
Practical Guide for the Use of Visitors at the Seaside. By Charles
Parsons, M.D., Honorary Surgeon to the Dover Convalescent Home 162

Art. XVIII. — The Nurse's Companion, a Manual of General and Monthly

Nursing. By C. J. Cullingworth. London, 1876 . . 164

Art. XIX. — A History of Asiatic Cholera. By C. Macnamara, F.C.U.,

Surgeon to the Westminster Hospital. Pp. 472. London, 1876 . 165

Art. XX. — Theory of Medical Science. The Doctrine of an Inherent Power
in Medicine a Fallacy. By William Dunham, M.D. Pp. 150.
Boston, 1876 . . . . . .168

Art. XXI. — Tables of Materia Medica. A Companion to the Materia

Medica Museum. By T. Lauder Brunton, M.D., F.R S. . 169

Art. XXII. — Infant Feeding and its Influence on Life; or, the Causes and
Prevention of Infant Mortality. By C. H. F. Routh, M.D. Third
edition. London, 1876 ..... 170

Art. XXIII. — 1. A Manual of Percussion and Auscultation of the Physical
Diagnosis of Diseases of the Lungs and Heart, and of Thoracic
Aneurism. By Austin Flint, M.D. London, 1876 . . 171

2. Nutrition in Health and Disease. A Contribution to Hygiene and to
Clinical Medicine. By James Henry Bennet, M.D. London, 1876 ib.

Art. XXIV. — Notes on Asylums for the Insane in America. By John C.

Bucknill, M.D., F.R.S. London, 1876 . . .173

Art. XXV. — 1. Hints to Mothers for the Management of Health during
the period of Pregnancy and in the Lying-in Room. By Thomas
Bull, M.D. New edition, thoroughly revised by R. W. Parker . 174

iv CONTENTS OF NO. CXIX.

PAQK
2. The Maternal Management of Children in Health and Disease. By

Thomas Bull, M.D. New edition, thoroughly revised by R. W.

Paeker ....... 174

Aet. XXVI. — 2. Sciatica, Lumbago, and Brachialgia; their Nature and

Treatment. By Heney Lawson, M.D. Second edition. Loudon,

1877 . . . . . . .175

2. Nouveau Dictionnaire de Medecine et de Chirurgie pratique ; illustre

de figures intercalees dans le texte. Directeur de la redaction, le

Docteur Jaccoud. Tome xxiii. Mol-Nev . . . ib.

Art. XXVII. — Surgical Emergencies, together with the Emergencies attend-

ajit on Parturition, and the Treatment of Poisoning. A Manual for

the Use of General Practitioners. By W. P. Swain, F.R.C.S.

London, 1876 . , . . . .176

Art. XXVIII. — Transactions of the Medical and Physical Society of Bombay.

No. xii, new series. For the year 1876 . . .177

Aet. XXIX. — Transactions of the Pathological Society of Philadelphia.

Vol. V. Edited by James Tyson, M.D. Philadelphia, 1876 . 178

Aet. XXX. — 1. Researches on the Action and Sounds of the Heart. By

Gkorgb Paton, M.D. Pp. 105. London . . . 179

2. Guida Pratica alia Conoscenza e alia della Difterite. Per il Dottore

Giovanni Faealli, di Firenzi . . . . ib.

AsT. XXXI. — 1. Lectures on the Diseases of the Nervous System, delivered

at La Salpetri^re. By J. M. Charcot. Translated by Geoegb

SiGEESON, M.D. Sydenham Society. London, 1877 . . 181

2. Transactions of the Clinical Society of London. Vol. ix. London,

1876 . ..... ib.

(Original iiTommunicationg.

I.— Invalid Criminals and their Diseases. By Day. Nicolson, M.D., late

Senior Medical Officer, H.M. Prison, Portsmouth . . 182

II. — Urea and its Relation to Muscular Force, By Heney Beietzcke,

F.R.C.S. Eng. . . . . . -190

^fjxmitU of i^letiical ^titmc.

Report on Surgery. By W. Johnscit Smith, F.R.C.S., Surgeon to the

Seamen's Hospital, Greenwich . . [[ , , , .201

Eeport on Physiology and Histology. By Heney Poweb, F.K.C 3., M.B.

Lond 217

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

RiCHABDSON, M.D., F.R.S. . . . . .232

Books received for Review ..... 249

Reclamation of Dr. J. W. Moore , . . • .252

CONTENTS OF NO. OXX.

BRITISH AND FOREIGN
MBDIC0-CHIRUR6IGAL REVIEW.

OCTOBER, 1877.

analgfical antr (Critical i^ebietois.

FA&E
Rev. I. — 1. JocHMANN (P. A.) — Beobachtungen iiber die Korperwarme in

chronischen fieberhaften Krankheiten. Berlin, 1853 . • 253

2. RiNGEE (Sydney).— On the Temperature of the Body as a means of
Diagnosis in Phthisis and Tuberculosis. London, 1865. Also, Second
Edition, London, 1873 . . . . -it.

3. WuNDEELiCH (C. A.). — Das Verhalten der Eigenwarme in Krank-
heiten. Leipzig, 1868. Translated from the Second Edition by Dr.
Woodman. On the Temperature in Diseases. London, 1871 . ib.

4. BoiLEAU (Assistant-Surgeon). The Correlations of Temperature,
Pulse, and Respiration in Phthisis. 'Army Medical Reports' for 1868.
London, 1870 . . . . . . ib.

5. EiNLAYSON (J.). — On the Temperature of Children in Phthisis and
Tuberculosis. ' Glasgow Medical Journal,' November, 1869 . ib.

6. Fox (Ed. Long). — Clinical Observations on Acute Tubercle. ' St.
George's Hospital Reports,' vol. iv, 1869. Also, Clinical Observa-
tions on the Temperature of Disease. ' Medical Times and Gazette,'
1870 . . . . . . . ib.

7. EuDE. — De la Marche de la Temperature dans la Fievre hectique.
' Gaz. Med. de Strasburg,' November 8, 1871. (Canstatt's ♦ Jahres-
bericht,' 1871, p. 219.) . . . . . ib.

8. Ro&EE (H.). — Recherches Cliniques sur les Maladies de I'Enfance.
Tome i, Paris, 1872. (De la Temperature chez les entants. Pp.
203-466.) ^. . . . . . ib.

9. BiLHAUT (M.). — Etude sur la Temperature dans la Phthisic Pulmo-
naire. Paris, 1872 . . . . . ib.

10. Bettelheim (K.), — Bemerkungen iiber einige Eigenthiimlichkeiten
des Fiebers im Beginne Phthisicher Zustande. ' Deutsches Archiv fiir
klinische Medicin.' Bd. x. Leipzig, 1872 . . . ib.

11. Alcock (N.). — On the Nature and Variations of Destructive Lung
Disease. ' Army Medical Reports ' for 1872. London, 1874 . ib.

12. Lebeet (Prof.) — Veranderungen der Korperwarme im Laufe der
Tuberculose. * Deutsches Archiv fur klin. Medicin.' Bd. xi. Leip-
zig, 1873 . . . . . . .254

13. Fox (Wilson). — On the Temperature, Pulse, and Respiration in
Phthisis and Acute Tuberculization of the Lungs. ' Medico- Chirur-
gical Transactions.' Vol. Ivi. London, 1873 . . . ib.

14. Williams (C. Theodoee). — On the Temperature of Phthisis Pul-
monalis. ' Medico-Chirurgical Transactions.' Vol. Iviii. London,
1875 . . . . . . . ib.

15. SCHWAE7 (Albeet). — Ueber den Fieberlauf. bei Phthisis Pulmonalis.
• Verb ungen der Physikal-Medicin. Gesellschaft in Wurzburg.'

N. F. iiJ. ix, 1876 . . . . . ib.

Rev. II. — Cyclopaedia of the Practice of Medicine. Edited by Dr. H. von

Ziemssen, vol. xii. Diseases of the Brain and its Membranes. By

Prof. H. Nothnagel, of Jena; Prof. E. Hitzig, of Zurich; Prof. F.

Obeeneiee, of Bonn ; Prof. O. Heubnee, of Leipsig ; and Prof. G.

HUGUENIN, of Zurich. English translation. London, 1877 . 269

Rev. III. — 1. Lumleian Lectures on the Muscular Arterioles. By Geoege

Johnson, M.D., F.R.S. London, 1877 . . . .279

2. Diseases of the Kidney and Urinary Derangements. By W. Howship

Dickinson, M.D. London, 1877 • • . . ib^

U CONTENTS OF NO. CXX.

FAQS

3. Ziemssen's Cyclopaedia of Medicine, vol. xv. Diseases of the Kidney.
London, 1877 . . . . . .279

Rev. IV. — Essai D'Urologie Clinique; la Fievre Typhoide. Par Albert
Robin, Ancien Interne des hopitaux de Paris, chef des travaux chi-
miques au laboratoire de la Charite, &c. Paris, 1877 • . 298

Rev. V. — lEtude Medico-Legale sur la Folic. Par Ambeoise Taedietj,
Professeur de Medecine Legale a. la Faculte de Medecine de Paris,
Medecine de I'Hotel Dieu, Membre de PAcademie de Medecine. Paris,

1872 . . . . . . .306

2. Contributions to Mental Pathology. By I. Ray, M.D., Author of

Medical Jurisprudence of Insanity and Mental Hygiene. Boston,

1873 . . . . . . . ib.

Ret. VI. — 1. Eleventh Annual Report of the Sanitary Commissioner with

the Government of India, 1874. Calcutta, 1875 . . . 328

2. Twelfth Annual Report of the Sanitary Commissioner with the Govern-
ment of India, 3875. Calcutta, 1877 . . . . ib.

3. Eleventh Annual Report of the Sanitary Commissioner for the
Government of Bombay, 1874. Bombay, 1875 . . . ib.

4. Report of the Sanitary Commissioner for Madras, 1874. Madras,
1875 . . . . . . . ib.

Ret. VII. — Traite des Maladies de la Prostate. Par le Dr. Henbi Picaed,
Professeur libre de Pathologic das voies urinaires k I'ecole pratique.
Paris, 1877 . . . . . .341

Rev. VIII. — On Idiocy and Imbecility. By William W. Ireland, M.D.

Edin. Pp. 413. London, 1877 . . . .345

Rev. IX.— Diseases of Women'. By Lawson Tait, F.R.C.S., Surgeon to the

Birmingham Hospital for Women. London, 1877 . . 359

Rev. X. — On Alcoholism : the various forms of Alcoholic Delirium and their
Treatment. By Dr. V. Magnan, translated by W. S. Geeeneield,
M.D. London, 1876 . . . . .364

Rev. XI. — The Care and Cure of the Insane ; being the Reports of the
•Lancet' Commission on Lunatic Asylums, &c. By J. Mortimer
Granville, M.D. In 2 voluiues. London, 1877 . . 371

Rev. XII. — 1. A Handy Book of Forensic Medicine and Toxicology, By W.
Bathuest Woodman, M.D., F.R.C.P., and Charles Meymott Tidy,
M.B., F.C.S. London, 1877 . . . . .381

2. Sanitas Sanitatum et Omnia Sanitas. By RiCHAED Metcalfe, F.S S.
Vol. i. London, 1877 . . . . . ib.

3. House Drainage. By Rogers Field, C.E. London, 1877 . ib.

4. Societe Fran^aise d'Hygiene, sa Taison d'etre, son but, son avenir. Par

M. le Docteur de Pietre Santa. Paris, 1877 . . . ib.

5. Functions of a General Police Force for the extinction of fires and
administrative improvements especially needed in the metropolis. By
Edwin Chadwick, Esq., C.B. London, 1877 . . . ib.

6. Report on the Air of Glasgow. By E. M. DixON, B.Sc. Sanitary
Department. Glasgow, 1877 . . . . ib.

7. Our Medical Charities. An Address delivered by Sampson Gamgee,
F.R.S.E. London, 1877 . . . . . ib.

"8. Contagious Diseases and the Insufficiency of the measures adopted for
their prevention. Pamphlet. Loudon, 1877 . . . ib.

9. Statistical Sanitary Report of Margate. By W. Knight Teevees,
F.R.C.S., Medical Officer of Health. Margate, 1877 . . ib.

10. " Dust to Dust." Sanitary Modes of Burial. By Samuel Phillips
Day. London, 1877 . . . . . ib.

11. The Quarterly Journal of Inebriety. Published under the auspices
of the American Association for the Cure of Inebriates. Vol. i. Nos.

1, 2, 3. Hartford, Connecticut, 1876-7 . . . ib.

12. Restriction and Prevention of Scarlet Fever. Document issued by
the State Board of Health of Michigan. 1877 • • , ib.

CONTENTS or NO. CXX. V WhT^

PAas
Rev. XIII.— 1. T. Maclagan.— The Germ Theory applied to the Explana-
tion of the Phenomena of Disease. London, 1876 . . 391

2. Reports of the Medical Officer of the Privy Council. New Series.
No. vi . . . . . . . ib.

3. Bkaidwood and Vachee. — First and Second Contributions to the
Life-History of Contagium. ' Brit. Med. Journal,' 1875, 1876, and
1877 . . . . . . . ib.

4. W. RoBEETS. — On Spontaneous Generation and the Doctrine of Con-
tagium vivum. 'Brit. Med. Journal,' August 11th, 1877 . . ib

13ttliosrapf)ical HecottJ.

Aet. 1.— 1. Photographs illustrating rare books in the National Medical
Library (International Exhibition of 1876, Medical Department U.S.
Army). Two vols., fol. Philadelphia, 1876 . . .408

2. Catalogue of the Library of the Surgeon- General's Office, United
States Army. Three vols., 4to. Washington, 1873-74 . . ib.

Aet. II. — Theophrastus Paracelsus. Eine kritische Studie von Fe. Mook.

Wurzburg, 1876 . . . . . .413

Aet. III. — Catalogue of the Radford Library, St. Mary's Hospital, Man-
chester. By C. J. CuLLiNGWOETH. Manch., 1877, pp. vi and 258 . 415

Aet. IV. — The Bath Thermal Waters, Historical, Social, and Medical. By

John Kent Spendee, M.D. 8vo, pp. 300. London, 1877 . 416

Aet. V. — Chronic Diseases best fitted for Treatment by the Harrogate
Mineral Springs. By A. S. Mtetle, M.D. London, 1876. 8vo,
pp. 92 . . . . . . .417

Aet. VI.— 1. International Exhibition of 1876. Philadelphia, 1876. 2. De-
scription of the Models of Hospital Cars. 3. Description of the
Models of Hospitals. 4. Description of the Models of Hospital
Steam Vessels. 5. Description of Perrot & Co.'s Improved U. S.
Army Medicine Wagon. 6. Description of the U.S. Army Medical
Transport Cart Mode of 1876. By D. L. Huntington and G. A.
Otis, Assistant-Surgeons, U.S. Army . . . . ib.

Aet. VII. — The Microscopist, a Manual of Microscopy and Compendium of
the Microscopic Sciences. By T. H. Wythe, A.M., M.D. Third
edition ....... 419

Aet. VIII. — A Handbook of Medical and Surgical Electricity. By Hee-
BBET TiBBiTS, M.D. Sccoud edition, revised and enlarged. London,
1877 . . . . , . .420

Aet. IX. — Report of the First Congress of the International Otological
Society, New York, September, 1876. Published by a Committee
composed of C. J. Kipp, A. Mathewson, J. S. Peout, and J. D.
Rtjshmoee. New York, 1877 .... 421

Aet. X. — Handbuch der Gesammten Augenheilkunde. Redigirt von Prof.

A. Geaefe und Prof. T. Saemisch. Leipzig . . • 422

Aet. XI. — 1. Geschichte des grauen Staares. Von Dr. Hugo Magnus.

Leipzig, 1876. 8vo, pp. xii and 315 .... 428
2. History of Cataract. By Dr. H. Magnus . . . ib.

Aet. XIL— 1. Myelitis of the Anterior Horns. By E. C. Seguin, M.D.

New York, 1877 . . . . . . ib.

2. Transactions of the American Neurological Association. Vol. i. New
York, 1875 . . . . . . ib.

3. Considerations pratiques sur le traitement des Neuralgies. Par le Dr.
Feoissac. Paris, 1877 . . . . . ib.

Aet. XIII. — On some Undetermined Points in Typhoid Fever. By David

CULLBN, M.D., Surgeon-Major A.M.D. .... 425

Aet. XIV. — Clinical Lectures on the Curability of Attacks of Tubercular
Peritonitis and Acute Phthisis. By Dr. McCall Andeeson, Pro-
fessor of Clinical Medicine in the University of Glasgow . . 426

Abt. XV. — The Endemic Diseases of Tropical Climates, with their Treat-
ment. By John Sullivan, M.D. London, 1877. Pp. 211 . 427

IT CONTENTS OF NO. CXX.

PAGE

Aet. XVI.— Clinical Records of Injuries and Diseases of the Genito-TJrinary
Organs. Ry Cheistophee Fleming, M.D., &c. Edited by William
Thompson, M.B., M.D. Dublin, 1877 . • • .431

Aet. XVII.— Lectures on Bright's Disease. By D. Campbell Black, M.D.

London, 1875 . . . . _ . .434

Aet. XVIII. — Transactions of the American Gynaecological Society for the

year 1876. Vol. i. Boston and London . . . ib.

Aet. XIX. — Goutj its Cause, Nature, and Treatment, with Directions for
the Regulation of the Diet. By John Paezin, F.R.C.P.E., &c.
Second edition, pp. 144. London, 1877 . . . 438

Aet. XX. — Studies, chiefly Clinical, on the Non-Emetic Use of Ipecacuanha,
with a Contribution to the Therapeusis of Cholera. By Alfeed A.
WooDHULL, M.D., Assistant- Surgeon U.S. Army. Pp. 155. Phila-
delphia, 1876 . . . . . . ib.

Aet. XXI. — An Essay on Hospital Mortality ; based upon the Statistics of
the Hospitals of Great Britain for Fifteen Years. By Lawson Tait,
F.R.C.8. London, 1877 . . . . .439

Aet. XXII. — A Practical Treatise on Diseases of the Skin. By Louis A.

DuHEiNG, M.D. Philadelphia, 1877 . . . .443

Aet. XXIII. — On the Transport of Sick and Wounded by Pack Animals.

By Geoege a. Otis, Assistant- Surgeon U.S. Army. 4to, pp. 32 . 446

Aet. XXIV. — What is Vital Force ? or a short and comprehensive sketch,
including Vital Physics, Animal Morphology, and Epidemics ; to
which is added an Appendix upon Geology : is the Detrital Theory
of Geology tenable? By Richaed Fawcbtt Battye. London,
1877 . . . . . . .447

Aet. XXV. — Traitement Rationnel des Plaies. Methode d'aeration. Moscow,

1877. Pp. 44 . . . . . .448

Aet. XXVI. — Clinique Chirurgicale des Hopitaux de Paris. • Par le Docteur

P. Gillette, Chirurgien des Hopitaux, &c. . . . 449

Aet. XXVII. — Excision of Elbow-joint, showing results. From a series of
twenty-one cases operated on at the Massachusetts General Hospital.
By H.A. Beech, M.D. . . . . .450

Aet. XXVIII. — Clinical Studies of Disease in Children. By Eustacb

Smith, M.D. London, 1876 . . . .451

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

Atthill, M.D. Dublin, 1876 . . . .452

(©rifiinal OTommunication.

On the Transmission of Syphilis from Parent to Offspring, with an
Appendix of Cases. By Jonathan Hutchinson, F.R.C.S., Senior
Surgeon to the London Hospital .... 455

OTiironicle of iBietrical Science.

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

Report on Pathology and the Practice of Medicine. By John T. Aelidge
M.D., A.B. Lond., F.R.C.P. Lond. ; Physician to the North Stafford
shire Infirmary, &c. ....

Report on Midwifery Diseases of Women and Diseases of Children. By
Aleeed Wiltshiee, M.D., M.R.C.P. Lond., Joint Lecturer on Mid
wifery and the Diseases of Women and Children at St. Mary's Hos
pital; Vice-President of the Obstetrical Society of London; formerly
Medical Inspector to Her Majesty's Privy Council, &c.

Books, &c., received for Review ....
Title, Contents, Index.

477

491

501
609

BRITISH AND FOREIGN

MEDICO-CHIRURGICAL REVIEW,

JULY, 1877.
Enalptical ana (Critical l^cbietog.

I.— Thudiclium on the Chemistry of the Brain.i

Before attempting to analyse and criticise the very elaborate
article in which Dr. Thudichum has incorporated the results of
his laborious researches on the chemical composition of the
brain, we shall endeavour to give our readers as clear and accu-
rate an account as we can of the state of our knowledge on this
subject at the time when Dr. Thudichum commenced his work,
pointing out as briefly as we can how much is due to the chief
workers who immediately preceded him. At the same time our
endeavours will be directed rather to giving the reader some
knowledge of the subject of brain chemistry than to furnish
him with a complete historical account of all that has been
written in reference to it.

Of the early writers on the chemistry of the brain we mean
to say very little, but would refer the reader to the really full
and accurate historical account which Dr. Thudichum has given
of previous researches.

We may merely mention that Vauquelin was the first to show
that alcohol extracts from the brain a fatty substance which
separates when the solution is cooled and which contains phos-
phorus as an essential element. He was followed by Gmelin,
who was the first (in spite of Couerbe's attempt to claim the
discovery for himself) to prove the existence of cholesterin in
the brain ; by Couerbe, who, in a memoir which, we think. Dr.

^ Researches on the Chemical Constitution of the Brain. By J. L. W.
Thudichum, M.D. Reports of the Medical Officer of the Privy Council and
Local Government Board. New series, No. III.

119— LX. 1

S Reviews. [July,

Thudichum greatly overrates, announced that the fatty matters
of the brain are far more numerous than Vauquelin had
imagined, and who by the names of stearocenote, cephalote,
eleencephol and cerebrote, designated various impure products
which he extracted from brain by the action of solvents.^
Couerbe's researches were followed by those of Fremy.^ This
writer criticised, and, as we think, very justly, the attempts of
Couerbe to establish his brain-products in the position of proxi-
mate principles. A definite proximate principle must, M.
Fremy reasons, always possess the same chemical composition,
and analysis, therefore, aifords one cf the best means of estab-
lishing the purity of a substance. Couerbe analysed his bodies
and obtained discordant results ; but instead of concluding from
these that he was dealing with impure substances, with mixtures
rather than with isolated principles, he assigned to the brain
coijstituents a certain mutability of composition or a modifica-
tion of composition corresponding to their physiological func-
tions. Fremy's own researches led, however, to the most
unsatisfactory results ; he states the brain constituents to be —

1st. A white matter which he terms cerebric acid.

2nd. Cholesterin.

3rd. A particular acid fat which he terms oleo-phosphoric
acid ; and

4th. Traces of oleine, margarine and fatty acids.

These researches of Fremy must be stated to have led to no
other results than to confirm the previous statements as to the
brain containing phosphorus in the form of an organic compound,
and to establish that similar bodies are contained in the nerves
and in the liver.

Gobley^ now engaged in a series of researches on the sub-
stances contained in the yolk of egg, in the brain, and in the
milt of the carp, and extracted from them by boiling with
alcohol and ether two phosphorized principles, to one of which
he applied the name of lecithine (from \sKi6og, pulse-por-
ridge, presumedly because of its glutinous character when
moist and impure), and to the other that of cerebrine; the
latter body, viewed by the light of subsequent researches, ap-
pears to have been certainly no definite proximate principle, but

1 " Du Cerveau, considere sous le point de vue chimique et physiologique." Par
J. P. CoTJERBE. Presente h rAcadeniie des Sciences ' le 30 Jjjin, 1834. 'An-
nales de Chimie et de Physique,' 1834, p. 160-193.

^ " Reclierches sur le Cerveau," par M. Edmond Feemy (Memoire lu a
1* Academic des Sciences'). 'Annales de Chimie et de Physique,* 1841, p. 463-
488.

3 ' Journal de Pharm. et de Chimie,' t. ix, 1846, p. 1, 83, 161 ; t. xi, p. 409 ;
t. xii, p. 5 J t. xvii, 1850, p. 401; t. xviii, p. 107; t. xix, 1851, p. 406; t. xxi,
p. 241.

1877.] Thudichum on the Chemistry of the Brain. 3

a mixture of a substance not containing phosphorus with
lecithine.

Gobley, however^ was the first to give clear and correct infor-
mation as to the phosphorized body which he had separated.
His lecithine was little soluble in cold, but abundantly soluble
in hot alcohol, from which it was deposited on cooling. This
lecithine from yolk of e^g, when ignited, left an acid charcoal,
the residue containing phosphoric acid. When boiled with
water it did not decompose, but under the influence of weak
acids and heat it yielded margaric and oleic acids, and glycerin-
phosphoric acid. Gobley subsequently corroborated the state-
ments of Fremy by discovering the phosphorized constituents
in blood and in bile.

In spite of the immense labour of the investigations which
had been made in the interval, we must look upon Gobley^s
identification of lecithine by the study of some of its chief pro-
ducts of decomposition as the one important step made in the
study of brain chemistry since the day when Vauquelin first
announced the discovery of his white fatty matter. The expe-
riments of John, of Couerbe, of Fremy, may, for any facts
with which they have enriched science, be left out of conside-
ration except by the actual investigator, who in the fruitless
experiments of his predecessors in research may often find pre-
cious guides in his work.

After Gobley^s work on the phosphorized principles of brain
came the researches of Liebig, of Von Bibra, and of Miiller.
These researches added nothing to the knowledge which had been
furnished by Gobley of the phosphorus-containing body or bodies
of brain, but they succeeded in demonstrating that brain con-
tains many of the proximate principles which are found in the
juice of flesh, as creatine, xanthine, hypoxanthine, and inosite.
To these the attention of the reader will be again called.

In 1865 Liebreich, who was then assistant to Professor
Hoppe-Seyler, at Tiibingen, published a paper entitled ^' Ueber
die Chemische Beschaffenheit der Gehirn-Substanz." In this
paper he stated that the various bodies which had by various
writers been designated cerebrine, cerebric acid, lecithine, or
phosphorized fats, did not exist as immediate principles of brain,
but that from the brain could be extracted by an easy process a
body to which, as indicating its probable importance, he as-
signed the name of Protagon (jrpb)TayoQ, the leader).

In order to obtain this substance the following process was
followed. An animal was bled to death from the carotid, and
a stream of water was allowed to flow through the vessels of

1 * Annalen der Chemie und Pharmacie,' Bd. cxxxiv, 1865-6, p. 29-44.

4 Reviews, [July,

the head so as to remove all hlood-colouring matter. The
brain was then removed^ freed from its membranes, pounded in
a mortar to the condition of a pulp, and then shaken in a flask
with ether and water. It was allowed to stand at a temperature
of 0° until the ether had separated.

The ether and water were removed as far as possible by fil-
tration from the insoluble brain matter, which was then treated
with 85 per cent, spirit and heated in a water bath to 45° C.
The fluid was filtered through a hot funnel, and the filtrate
cooled to 0° C. A flocculent precipitate then separated, which
was collected on a filter and treated with cold ether until it
ceased to dissolve any cholesterine. The insoluble mass was
dried in vacuo, and dissolved in spirit at 45° C. From the
alcoholic solution protagon separated in microscopic needles,
difiering a little in arrangement and form according to the
concentration of the solution. The substance admitted of
being crystallized over and over again. The results of nine
carbon and hydrogen determinations were remarkably concor-
dant, and the same remark applies to three nitrogen and three
phosphorus determinations. The results of these analyses led
Liebreich to give to the new body the formula Cj^gH24iN4022P.

Below is exhibited the composition of Liebreich's protagon
according to this formula :

Theory. Found.

C . . . . 67-21 66-74

H
N
P
O

100-00 100-00

According to Liebreich protagon is soluble with difficulty in
cold but more easily in warm alcohol and ether. At higher
temperatures than 55° C. alcohol appears to decompose pro-
tagon. In water protagon swells and presents the appearance
of an opaque jelly, ultimately dissolving so as to form an
opaque solution. Liebreich found that protagon was soluble
in glacial acetic acid, from which it was deposited, if subjected
to the long-continued action of cold, in a crystallized form.

By far the most important of the observations made by Lie-
breich had reference to the products of decomposition of
protagon. He found that when boiled with a solution of barium
hydrate for twenty-four hours it yielded as products of decom-
position glycerine-phosphoric acid, fatty acids of which he
isolated in a state of approximate purity stearic acid, and a
base to which he gave the name of neurine, and to the platinum
compound of which he ascribed the formula CgHj^NClaPt.

11-59

11-74

2-70

2-80

1-50

1-23

17-00

17-49

1877.] Thudichum on the Chemistry of the Brain. 5

This base was afterwards, by the researches of Dybkowsky,^
shown to be identical with choline^ which had already been
separated from bile by Strecker.^

Diakonow/ another pupil of Hoppe-Seyler's, had undertaken
the examination of the phosphorized proximate principle of
the yolk of eggs, which had received the name of lecithine
from Gobley. His investigations showed that this body yielded
the same products of decomposition as Liebreich's protagon,
but that it was richer in phosphorus. According to him, leci-
thine has the following per-centage composition :^

C 64-27

H 11-4

N 1-8

P 3-8

And from these numbers he derived the formula for lecithine

When heated with a solution of barium hydrate, lecithine,
according to Diakonow, yielded as products of decomposition
glycerine-phosphoric acid, stearic acid, and neurine, according
to the following equation .

C^HgoNPOg + 3H2O = C3H9PO6 + BCClsHgeOs) + C5H15NO2

Lecithine. Glycerine-phos- Stearic

phoric acid. acid.

The lecithine which he had at first obtained from the yolk of
eggs was now obtained by Diakonow from brain.^ This organ
was, after repeated treatment with ether, digested at a tempera-
ture of 40° C. with absolute alcohol. The alcoholic solution
was then cooled to 0° C, when a precipitate separated which
was collected on a filter, washed with a little cold absolute
alcohol, and treated with ether. The ethereal solution (con-
taining all the lecithine) was evaporated to dryness, and the
residue dissolved in absolute alcohol at 40 C. On being cooled
to — 7° C. or — 10° C. the solution deposited lecithine.

Lecithine, according to Diakonow, was distearyl-glycerine
phosphate of neurine.

Strecker, who had already in his study of the lecithine of
bile come to the conclusion that this body was a derivative of
glycerine-phosphoric acid, in which two atoms of hydrogen had

1 Dybkowsky, "Ueber die Identitat des Neurin und des Cholin '* (' Erdmann's
Journal,' Bd. c, s. 153).

2 * Annalen der Cbemie und Pharmacie/ Bd. 123, 356).

3 Diakonow, " Ueber die Phosphorbaltigen Korper der Hiihner und Storeir
Medicinisch-Chemiscbe Untersuchungen herausgegeben von HopPE-SEYjiiE.
% Heft. Berlin, 1867.

4 ' Centralblatt f . d, Med. Wissenschaften,' 1868, No. 1.

5 ' Centralblatt,' 1868, No. 7.

6 Reviews. [Jiity^

been replaced by the radicals of fatty acids,"" now wrote a paper^
on the constitution of lecithine. In this paper he homologated
the opinion of Diakonow that Liebreich's protagon is lecithine
mixed with a body containing no phosphorus (almost certainly.
Miiller^s cerebrine) ; but stated that his own experiments on
lecithine from the yolk of eggs had shown him that this body
yields not only stearic acid, but oleic acid and palmitic acid.
Just as there are several fats and several mixtures of fats, so
Strecker contended there may be and are many lecithines.

Diakonow had looked upon lecithine as a neurine salt of a
glycerine-phosphoric acid, in which two of the hydrogens of the
hydroxyl groups had been replaced by the radical of stearic
acid. Now, Strecker suggested that these two hydrogens might
be replaced by two different fatty-acid radicals, or by one
radical of a fatty acid and one of oleic acid ; and further, he
maintained that in all probability neurine was not a salt of
distearyl-glycerine-phosphoric acid, but an ether-like compound
of neurine and distearyl-glycerin-phosphoric acid.

The researches of Wurtz had established the constitution of
neurine to be trimethyl-oxyethyl-ammonium hydrate. To the
lecithine which he had separated from the yolk of egg
Strecker assigned the rational formula—

A jo

O, ClgHglO

2H4N(C:

^^{o,C2H4N(CH3)|q

According to this view lecithine is glycerine-phosphoric acid :

roi
C3HJ0]

0H»
OH*

^^1 OH

in which the two atoms of hydrogen in the hydroxyl group
(marked by asterisks in the above formula) are replaced by the
radicals of oleic and palmitic acids ; whilst choline, a compound
which is at the same time an ammonium base and an alcohol,
forms with glycerine-phosphoric acid an acid compound ether.
Lecithine is, therefore, at the same time a fat, a base, and an
acid.^

f We may now, that we have alluded a little in detail to some
of the more salient points in the history of the phosphorized
principles of the brain prior to the time when Dr. Thudichum

1 'Ann. Ch. Pharm/

* " Ueber das Lecithin," * Zeitschrift fiir Chemie/ von Beilstein, Vittig, und
Hiibner,. 1868, p. 437.
3 See Schwlemmer's * Chemistry of Carbon Compounds,' p. 259.

1877.] Thudichum on the Chemistry of the Brain. 7

commenced his researches, summarise the whole of the positive
knowledge which had been accumulated on brain chemistry.

It had been shown by many observers that the grey matter of
the brain was richer in water than the white -^ that the phos-
phorized organic constituents are more abundant in the grey
matter than in the white, whilst the latter contains the greater
part of the cholesterin. The albuminous matters of the
brain had been examined (Hoppe-Seyler) and shown to
contain a casein-like body, in addition to the gelatigenous
constituents of the neuroglia. Many of the substances which
had been looked upon as characteristic of muscle meta-
morphosis, specially inosit and creatine, had been proved
to be regular and not insignificant constituents of brain
matter, whilst from the mass of bodies which, under the
different names of white fatty matter (Vauquelin), cerebrine
(Couerbe), cerebric acid (Fremy), protagon (Liebreich),
various writers had described as containing phosphorus, one
had been sufficiently studied to give us a clear idea of its
constitution ; chemists had been able, as a result of their re-
searches, to arrive at the conclusion that one, at any rate, of
the mysterious phosphorized bodies of the nervous system was
a fat, bearing so close a relationship to the well-known fats of
the body that without any great stretch of the imagination its
formation in the economy might be conceived.

And here, leaving for the moment our purely critical func-
tions, let us pause to consider whether it is conceivable that
such a body as lecithine can be built up in the animal organism.
It is usual to speak of the chemical operations of the animal
organism as being operations in which complex are broken up
into more simple bodies, and on the whole this is true ; the pro-
cesses of disintegration which go on in the body are far more
obvious and on a more obvious scale than those of integration, yet
processes of integration — true syntheses — do occur even in the
animal body. How else could we explain the building up of iron
into the complex molecule of haemoglobin? But actually syn-
theses are known to occur; the animal swallows benzoic or chinic
acids, and linking the aromatic nucleus to glycocine forms hip-
puric acid ; or, to take an illustration which is of greater use to
us here, the animal can assimilate a soap and convert it into a
fat, i.e. may link the radicals of fatty acids to glycerin.

Similarly, it is most conceivable that the animal may actually
form the fat called glycerin-phosphoric acid ; and, assuming
this, there is no difficulty in conceiving of the further produc-
tion of lecithine.

^ Petrowski, * Archiv f . gesammte Phys./ Bd. vii, p. 367.

8 Reviews. [July

Perhaps we shall have noticed all that is worth noting as
having been definitely ascertained before Dr. Thudichum's
research, if we say that Miiller had, by the action of baryta
water and heat on the substance of brain, obtained a body called
cerebrine of apparently definite composition, having the formula
C17H33NO3, and capable of explaining by its admixture in
various proportions with lecithine many of the discrepant results
of the investigators who preceded Diakonow and Strecker.

The survey which we have made of the work done by Dr.
Thudichum's predecessors in research will have stimulated the
curiosity of the reader, who will feel anxious to know how far
their discrepant statements could be reconciled.

Is lecithine the only phosphorised ingredient of brain ? Does
no such crystalline phosphorized principle as Liebreich's protagon
exist? Is Miiller's cerebrine actually a proximate principle of
brain, or nothing more than a product of the action of barium
hydrate on certain organic constituents ? These and many
other similar queries naturally suggest themselves as we com-
mence the study of the elaborate investigation which Dr.
Thudichum has carried on.

But when we have read Dr. Thudichum's formidable paper
we find that none of our doubts are solved. Dr. Thudichum's
paper bristles with new names for old facts, and with the names
of numberless new substances which the author discovered at
each step of every investigation. Every substance, however im-
pure, or rather however inconclusive the evidence of its purity,
is subjected by Dr. Thudichum to organic analysis, every analysis
furnishes the materials for a new formula, and every formula the
excuse for a new name. No wonder, then, that in alphabetical
list of chemical educts and products stated to have been found
in or produced from the brain of man and animals there are
eighteen marked with an asterisk, indicating that they " are
believed to be now described for the first time as ingredients in
brain matter."

These are, in alphabetical order —

Apomyeline, Kephalic acid.

Base new, from kephaline, Myeline,

Buttery matter, Oily last, matter,

Cerebrinie acid, Oleate of ethyl,

Glyceramine, Oxykephaline,

Hydrothion, Paramyeline,

Kephaline, Peroxykephaline,

Kephaloidine, Phrenosine,

Kerasine, Pyrokephole.

We cannot pretend to give a detailed account of all Dr.

1877.] Thudichum on the Chemistry of the Brain, 9

Thudichum's results^ but we shall analyse with considerable
care some of the chief of these.

Dr. Thudichum's researches are always conducted on a large
scale. ** As material for the present very large inquiry ox
brains have in most part been preferred, and of these more
than a thousand have been used.''

The paper commences by an account of the methods used in
the isolation of the various proximate constituents of the brain,
followed by their classification. To this succeeds the description
of certain chief principles which have been isolated. We shall
select for special examination the author's research on myeline
(p. 156).

The author commences by distinguishing his new body from
the myeline of Virchow, which is a mixture of various substances.

Preparation of myeline, — Brains are washed in water, broken
up, and kept in alcohol for some time. After hardening, the
brains are triturated and heated for some time in 85 per
cent, alcohol. The alcoholic fluid is cooled, whereby a
crystalline and granular precipitate of so-called ''white matter "
is obtained. This is dissolved again in cold alcohol ; the
solution is concentrated and cooled until a precipitate is ob-
tained, and the process is repeated until crystalline myeline
is obtained. Other methods of preparation by precipitation
with lead acetate and with platinum chloride respectively are
described. In his remarks on the " differences and separation
from other cerebral principles " the author states that " from
lecithine myeline can be separated by cold absolute alcohol, in
which this body is more soluble than myeline ; also by cold
ether, in which it is also more soluble than myeline." It has
never occurred to the author that it would have been of the
first importance to place this statement on a firm foundation,
and that a research which appears to be of the most elaborate
character might have included a determination of the relative
solubilities of lecithine and myeline in alcohol and ether, even
if such determination had not been absolutely required in
order to disprove that which we believe all physiological
chemists will conclude after reading Dr. Thudichum's research,
viz. that myeline is hut impure lecithine.

Before describing the reactions of myeline or the results of
his analysis Dr. Thudichum devotes two pages to the considera-
tion of the probable constitution of myeline, a consideration
which might almost be imagined to have been facetiously as an
intended parody on those chemists who are rather inclined
to indulge their imagination too freely in their speculations on
its constitution.

" Myeline contains," says the author, " four principal or proxi-

Reviews.

[July,

mate radicals, of which one is the radical compound itself, common
to all the cerebral phosphorized substances, namely, glycero-phos-
phoric acid. To this is attached a nitrogenized radical, choline or
neurine, and to these radicals are attached two fatty acid radicals, of
varying value and composition, but most commonly found consisting
of margaric acid, with 16C, or of the amidated form of this acid.
Myeline combines with lead like a dibasic acid, with PtCl4, and
CdClg, like an ammonium base. From these facts we must attribute
to its radicals positions which permit them to act alternately, if not
together. These I have endeavoured to represent in the following
diagram :

Substitution pole.

Acid pole.

E + P

R + N

Basic pole.

Substitution pole.

" We find sometimes myelines which contain more nitrogen than
phosphorus in the proportion of 2 : 1, or 3 : 2, or 5 : 3. In these
cases I assume the increase of the nitrogen to be due to the presence
o£ an amidated fatty acid radical, such as I have proved by chemo-
lysis to occur in the rarer forms of kephaline. To such amidated
forms I attribute the following constitution :

E + Amide

R + P

R+ N

" This most simple form 1 have never directly isolated, but I am
compelled to assume its existence by the observation of salts, which
could only be explained by any of the following schemes :

R + Amide

R+ P

R + N

R + P

R + N

PtCl42HCl.

1877.] Thudichum on the Chemistry of the Brain. 11

" Such a compound was sometimes united with PtCl4 only, or
with PtCl4 and one HCl, or with PtCl4 and 2 HCl, variations
which made the preparations and analysis of these bodies extremely
difficult and laborious.

" But I have also met with compounds which contained when
fully expressed six molecules of myeline, of which four were amidated
(or two twice amidated), and which require the following diagram
for representation :

E + Amide

E + P

E + N

E + P

E + JN"

E + Amide

}*PtCL

E .

E + P

E + N

E + Amide

+ P

E -

hN J

l^PtCl^

E + P

E + N "^

•

+ P

E -

f ]sr

PtCl

" I am yet doubtful whether the formula of myeline as above given
must not be doubled, and whether the molecules are of equal value,

13 Reviews, [July,

or if isomeric are not somewhat diflferently constituted. At least
myeline, like kephaline, yields to chemolysis products in which the
constituting radicals are presented in two difterent forms. The
further study, confirmation, or refutation of the hypothesis I must
reserve to the future."

After these misty speculations the author gives the results of
his analyses of myeline compounds or of myeline. It must here
be remarked that, although the author gives numerous analyses of
various compounds of this supposed chemical individual, he
never gives the results of two analyses of the same sample.

The first analysis is of a lead compound ; the mode of ob-
taining this compound will give an idea of Dr. Thudichum's
method of preparing the pure substances which he analyses.

" Myeline-lead. C4oH73PbNPOio. — The ether solution from white
matter, after exhaustion by freezing, was precipitated by alco-
hol ; the bulky precipitate was filtered, washed, and dried in vacuo,
and during this process repeatedly pounded in a mortar. It was
now dissolved in water and subjected to fruitless dialysis ; it formed
a thick, sticky, gummy, or starch-like emulsion, in which many
small crystals formed like mica. The addition of watery Pb. acetate
produced a dense curd, which separated easily from fiuid ; it was
placed on a cloth filter, and allowed to drip over night. The pre-
cipitate was placed in alcohol and warmed, whereby little else but
water was extracted (one litre alcohol left on evaporation to dryness
a little brown matter). More warm strong alcohol now extracted
much cholesterine and a little cerebrine. Hot boiling absolute
alcohol extracted much cholesterine and a little yellow smeary lead-
salt. The insoluble part was soft, waxy, but on cooling granular.
It was now placed in ether, whereby a yellowish fluorescent lead-
salt of kephaline was extracted. This latter salt was precipitated
by absolute alcohol, deposited as a yellowish oily body, which
became hard on standing. This has been treated under kephaline.
A white pulverulent salt remained insoluble in the ether, was
thoroughly washed with ether on the filter, also shaken with ether
in a bottle, and again washed on filter. It shrunk much on drying.
It was insoluble in benzole."

Then follows a single analysis of this salt, and from this
analysis Dr. Thudichum deduces for the body combined with
lead the formula C40H75NPO10, and to it he assigns the
name of myeline. Then follow a series of analyses either of
separated myeline, or of some compound of myeline, such as the
compounds of myeline with platinum and with chloride of
cadmium ; Dr. Thudichum's analyses show that no definite
compounds with these salts exist. Calculating the amount of
carbon in 100 parts of myeline from all his analyses of the
supposed isolated substances and its compounds the following
percentages are obtained : — >

1S77.] Thudichum on the Chemistry of the Brain. l3

63-409 per

cent.

of carbon.

62-651

65-266

66-101

61-990

63-460

63-500

63-09

J»

64-66

And yet Dr. Thudichum speaks of a definite individual
myeline !

After the description of the supposed compounds of the hypo-
thetical myeline there follows an account of the products of
its " chemolysis," or decomposition by means of caustic soda,
from which it appears that these consist of glycerin-phosphoric
acid, choline and neurine, and fatty acids.

After reading this research on myeline it is curious and in-
teresting to find that Dr. Thudichum was unable to separate
lecithine from the brain ; it always decomposed so rapidly that
he was only able to obtain products of decomposition of this
body. " Perhaps the above processes followed by me, if carried
out with the greatest despatch by working it during night and
day without intermission, would lead to the desired result "
(to obtain lecithine).

But is it not obvious that if myeline is anything it is
Diakonow's lecithine ? The process by which it is obtained is
such as would yield lecithine; the appearance of the pre-
cipitated myeline resembles that of lecithine ; its chemical
composition agrees closely with that of lecithine, and its pro*
ducts of decomposition are the same.

Below are given the percentage of composition of Thudichum's
mveline and lecithine :

Thudichum's

myeline.

Lecithine.

(C^H,,NPO,„.)

G44H90NPO9 (Diakonow)

63-409

64-27

9-833

11-40

N .

1*794

1-80

4-087

3*80

20-874

18-73

But myeline is only one of thirteen entirely new bodies
discovered by Dr. Thudichum, of which we append a list.
Apomyeline.

A new base from kephaline*
Cerebrinic acid.
Kephaline, C42H^sNPOi3*
Kephaloidine.
Kerasine.
Kephalic acid.

14 Reviews. [July*

Myeline.

Oxykephaline.

Paramyeline.

Peroxykephaline.

Phrenosine.

Pyrokephole.

Kephaline is described as the principal and most remarkable
phosphorized ingredient of the brain of man and the ox. It
was contained in the cephalote of Couerbe, but missed or neg-
lected by all subsequent inquirers. It occurs in part regularly
combined with K, Na, Ca, Mg, Fe, Cu. To it Thudichum at-
tributes the formula C42H7yNPOi3.

It is obtained from the *' white matter " referred to in the
preparation of myeline, by treating it with ether, which dis-
solves kephaline and cholesterine. To the fluid alcohol is
added, which precipitates crude kephaline.

To purify it, this body is dissolved in water and precipitated
as a hydrochlorate by means of HCl. It is a strange property
of this hydrochlorate that the hydrochloric acid is removed
from it by washing with water, pure hydrated kephaline (! !)
being left.

This supposed chemical individual forms indefinite com-
pounds with CaClg and PtCl4.

A critical mind fails to make out what kephaline can be,
certainly no definite substance. It would be as rational to
analyse bread and butter and attribute a formula to it as to do
so with kephaline.

Oxylceplialine. — " When the white matter of ox's brain has been
extracted with ether and the kephaline removed from the ether
solution by precipitation with absolute alcohol, there remains a
bulky solution containing all lecithine (?), much myeline, and some
kephaline, together with cholesterine previously contained in the
white matter. When to this solution CdClgis added, a voluminous
precipitate ensues, which, after washing, yields to ether a quantity
of coloured salt. This, after concentration, is precipitated by alcohol
and purified by repetition of this treatment. It was of interest to
know the composition of this precipitate."

The analysis led Dr. Thudichum to the formula €421179
NPOi4CdClo. Nowa as the results of the analysis of this compound
chanced to agree with the composition of the theoretical CdClg
salt of kephaline, plus one atom of oxygen. Dr. Thudichum
thinks it "necessary to consider this substance as a genuine com-
pound of a kephaline containing an atom of oxygen more than
the normal kephaline, to which it will be convenient to apply
the term oxy-kephaline."

1877.] Thudichum on the Chemistry of the Brain. 15

According to Dr. Thudichum, then, the brain substance
contains two new phosphorized constituents, viz. —

Kephaline and
Myeline,
in addition to lecithine, if, indeed, this substance be present.

In addition to the new phosphorized constituents Dr.
Thudichum's list includes —

Cerebrine, in its several varieties.
Kerasine, in its several varieties.
Phrenosine, in its several varieties.

Extractive acids and secretory [sic) acids and their salts,
such as uric acid and congeners.
But, after all Dr. Thudichum's toil in the laboratory, after
all the trouble of writing out the innumerable experimental
data, after all the ingenuity which he has expended in framing
rational formulae which we venture to think no chemist will
ever be able to decipher, when we ask what has been gained
to science we must answer, without hesitation, little or
nothing.

The mantle of Couerbe, as an investigator of brain chemistry,
seems to us to have fallen oh Dr. Thudichum ; he has not only
adopted many of the names which that observer assigned to his pro-
ducts, but also the methods of investigation which he proposed; he
has imitated him, too, in his habits of rash reasoning and in his
tendency to speculate where no speculation is possible, for
according to the criteria which guide chemists in their deter-
minations of the purity of chemical substances not one of the
numerous bodies described by Dr. Thudichum has been proved
to be a definite chemical individual.

Interpreting Dr. Thudichum's researches in our own way,
we should summarise the most important facts as follows : — He
has by his experiments and observations confirmed the existence
of lecithine in the brain, though he applies to it the new name
of myeline ; he has, however, shown that, besides lecithine, there
exists a distinct phosphorized body, which is chiefly distin-
guished from lecithine by its solubility in ether, but which has
not yet been isolated in a state of purity ; this is the body
termed kephaline by Dr. Thudichum.

We confess that we are not yet prepared to throw over
LiebreicVs researches on protagon as completely as Diakonow
Strecker and Thudichum have done. We think it would be of
great service to physiological chemistry were some one to repeat,
in all their minuteness, the experiments of Liebreich, and were
frankly to avow whether the statements of that observer as to
the crystalline nature of the proximate principle which he
believed he had discovered are absolutelv untrue.

16 UevtetvL t'^"V>

The trustworthiness and the undoubted correctness of most of
the subsidiary facts which Liebreich published cannot be dis-
puted, and it therefore seems to us to require very much stronger
evidence than any we have adduced before the cardinal fact can
be denied.

As Liebreich's protagon is a body which contains far less
phosphorus than lecithine, it has been assumed that he analysed
as a definite chemical principle what was nothing but a me-
chanical mixture of lecithine and cerebrine ; but we are alto-
gether at a loss to accept this explanation. Liebreich's
descriptions of the crystalline nature of protagon, of the possi-
bility of recrystallizing it repeatedly from alcohol, of dissolving it
in glacial acetic acid and again crystallizing it, are, unless he be
altogether untrustworthy, better evidences of the individuality
of protagon than any characters assigned to lecithine by
Diakonow or Strecker.

Then none of the facts with which we are acquainted in
reference to Miiller's cerebrine render it at all likely that it can
be the body which, mixed with lecithine, constituted Liebreich's
protagon.

We cannot help thinking that the method employed by
Liebreich was far less likely than that of subsequent observers
to lead to the decomposition of brain substance. What right
have we to assume that, after being hardened in strong alcohol
until the water has been in great part removed, the proximate
constituents of brain remain undecomposed ? None whatever.
Let us ask ourselves what would have been discovered as to
the nature of myosine by Denis and Kiihne had they commenced
by hardening the muscular tissue which they investigated in
alcohol ; or what Hoppe-Seyler, Stokes, and Preyer would have
learned in reference to haemoglobin if blood coagulated by
alcohol had been employed to prepare the raw material of their
researches, and we shall be in a position to estimate whether
we can look upon the products of an alcohol extract of brain
which has been hardened in alcohol as at all likely to repre-
sent the actual chemical individuals occurring in the nerve
centres ?

1877.] CvRLivG and SMtTH on Diseases of Rectum. 17

II. — Curling and Smith on Diseases of Rectum.'

As in many other branches of surgery, it is difficult to con-
ceive in what direction any great advance can be made in the
treatment of diseases of the rectum. A perusal of the two
works before us clearly illustrates this fact, as we may truly
say, that, although each has been carefully revised and enlarged
since the appearance of the former editions, there is nothing in
either that can really be said to be new. Increased experience
has not led either of the authors to alter to any great extent
the views expressed in the earlier editions of their works.

Mr. Henry Smith has, indeed, added to his small work a
chapter on *' Painful Ulcer of the Rectum,'^ in which he states his
belief that many such cases may be successfully treated by the
local application of solid nitrate of silver, or by " an ointment
made of the cinereous oxide of mercury in the proportion of
half a drachm of the mineral to one ounce of lard,^' without
having resort to operation. The conditions necessary for success
he considers to be an absence of spasmodic contraction of the
anus and an ulcer easily within reach. We think, however,
that the majority of the profession will agree with Mr. Curling
that such cases are rare, and that as the patient's sufferings are
usually very great and the operation for their relief is so slight
and so certain, it can seldom be worth while to waste time over
less efficient means. The operation of simple dilatation of the
anus, or rather forcible rupture of the floor of the ulcer and the
superficial fibres of the sphincter, which seems to be somewhat
popular at the present time with the French and German sur-
geons, finds but little favour either with Mr. Curling or Mr.
Smith. The advantage claimed for it is, that after a few hours'
rest the patient can follow his usual occupations without any
confinement to bed, but against this Mr. Curling quotes some
cases mentioned by Giralde, in which the operation failed, and
therefore he sees no reason, as the treatment " by incision is so
simple, so effectual, and so harmless," '^ to substitute for it a
proceeding so rough and uncertain as forcible dilatation" On
the other hand, we find that M. Le Fort, in the new edition of
Malgaigne's ^Medecine Operatoire,' speaks of forcible dilatation
as the only justifiable mode of treatment, and mentions a case
operated on by Laugier in which the simple incision terminated

1 1. Observations on the Diseases of the tectum. By T. B. CUELlNa, F.R.S.
Fourth edition. London, 1876.

2. The Surgery of the Rectum ; being the Lettsomian Lectures on Surgery
delivered before the Medical Society of London. By Heney Smith, F.R.C.S.
Fourth edition. London, 1876.

119— iX. 2

18 lleviews. ' [July,

fatally from pysemia. With such opposite views before us it is
evident that further experience is required before it can be
finally determined which operation is to be preferred.

The treatment of internal piles is discussed at considerable
length by both authors.

Mr. Henry Smith's increased experience has led him to speak
more strongly than ever in favour of the operation by means of
the clamp and cautery, which in this country is so intimately
connected with his name, while, on the other hand, Mr.
Curling sees no reason to discontinue his preference for the
ligature. On this subject he says :

" I continue to give the preference to the ligature at
venient to the surgeon and less alarming to the patient. .
tion by the cautery is more tedious than by ligature, a ^^

little moment when the patient is insensible, and spc
necessary in using the cautery to guard against after-haBu.
In a favorable case the patient is able to leave the couch somew^
sooner, and the recovery is, on the whole, somewhat more rapid than
after ligature, as the healing of the sores does not commence till
after the separation of the ligature, a process occupying four or five
days, whereas the eschar, or superficial slough produced by the
cautery, is cast off" sooner."

On the ground of convenience to the surgeon no one can
doubt the superiority of the ligature over the clamp and cautery ;
but if any real advantage to the patient can be shown to arise
from the use of the latter method no surgeon would hesitate to
put himself to a little inconvenience during the performance of
the operation. The first question which requires to be settled
is the relative mortality of the two operations, but we know
of no statistics at present before the profession sufficiently
extensive and sufficiently detailed finally to settle it. In
the hands of Mr. Smith there can be no doubt the cautery
has proved extremely successful, while he seems to have been
somewhat unfortunate with the ligature. Mr. Curling states
that in his lengthened experience only one fatal case has oc-
curred to him after the use of the ligature, and in that one the
patient died after five months' illness from chronic blood-poison-
ing. He also states that erysipelas and pyaemia have followed,
" though very rarely, the operation by the cautery." There is
probably a general impression in the profession that these grave
accidents are less frequent after the use of the cautery, but we
do not know of any direct evidence in proof of the idea. It is
probable that the frequency of pyaemia after the use of the
ligature varies with the mode in which it is applied. Except
in very large and broad piles, Mr. Curling simply notches the
base of the pile and ties the ligature tightly in the notch. Mr.

1877.] Curling and Suimn on Diseases of Rectum. 19

Smith, on the other hand, in describing the operation of ligature
in Holmes's ^ System of Surgery/ vol. iv, first edition, recom-
mends that a needle should be passed through the base of the
tumour, carrying a double ligature with which each half is to
be tied. Now, it is well known that almost every internal
pile contains a large dilated vein in its centre, and it is quite
evident that if the needle be passed through this and the vein
tied open instead of being occluded, not only will there be an in-
creased danger of haemorrhage, but pyaemia would be very likely
to occur from the entrance of septic matter into the circulation.

Another danger accompanying the operation for piles is
haemorrhage, either primary or secondary. As regards the
former, the advantages are decidedly on the side of the
ligature, for if it be applied with ordinary care and skill
haemorrhage is almost impossible during the operation, or
until the ligature has separated. The application of the clamp
and cautery, however, is not free from this danger except in
experienced hands. Thus, we find in several of the cases re-
corded by Mr. Smith that smart haemorrhage occurred on un-
screwing the clamp, or that the bleeding was very free but was
ultimately arrested by the cautery. If such accidents occur to
Mr. Smith it is evident that they would be more frequent in
less experienced hands, and on this account alone it is not likely
that the clamp and cautery will ever completely supersede
the ligature. Secondary haemorrhage is a rare occurrence after
any operation for internal piles, and occurs probably with equal
frequency after the ligature and the cautery.

The minor troubles which follow the operation, such as reten-
tion of urine, pain in the rectum, and delayed healing of the
sores, are decidedly less frequent after the operation by the
cautery than after the ligature, and this forms the chief argu-
ment in favour of the former method of treatment. On the
whole, we should feel inclined to think that, although there is
not sufficient evidence to justify us in assuming that in equally
skilful hands one operation is more likely to be followed by
grave or fatal complications than the other, yet the cautery
presents the great advantage of being a speedier and less pain-
ful mode of treatment than the ligature, and is on this ground
to be preferred. On the other hand, it requires special instru-
ments, which are not always at hand, and to comparatively
inexperienced operators presents many difficulties and dangers.
It is not probable, therefore, that with the ordinary practitioner
it will ever displace the ligature.

In treating of fistula in ano both authors adhere to the com-
monly received view that in almost all cases the fistula pene-
trates beneath the external sphincter, and that the division of

20 Reviews. [July,

this muscle is a necessary part of the cure. This view we
believe is not absolutely correct. Not a few fistulse commence
as small submucous abscesses which borrow downwards in the
submucous tissue until they reach the anus, and then extend
beyond this into the subcutaneous tissue superficial to the
sphincter, and in such cases the operation would not involve
the division of the fibres of that muscle. Many more certainly
open externally at a point considerably internal to the outer
margin of the internal sphincter, and in these the whole muscle
will not be divided in the operation. It is probably due to this
that incontinence of flatus and faeces is such an uncommon
occurrence even for a short time after the operation for fistula.
Mr. Smith, however, thinks that in such superficial fistula? the
operation will be generally useless unless the sphincter is divided
after laying the fistula open, and states that " in order to get
it thoroughly cured it is necessary to paralyse the action of the
sphincter for a time by dividing it." In proof of this statement
he mentions a case which occurred in his own practice, in which
the first operation entirely failed in consequence of the sinus
only being laid open, but he does not tell us in what condition
he found the parts. Was there a new fistula, or was it a super-
ficial sore ? If the former, probably by slitting it up and cutting
away the thinned edges of the mucous membrane and skin, a
cure would have been obtained, and if the latter, we see no
reason why it should be necessary completely to divide the
sphincter so as to paralyse its action any more than it is in the
treatment of painful ulcer and fissure of the anus, in which, as
is well known, a superficial incision, only affecting a few fibres
of the sphincter, is sufficient to cure. In the treatment of
fistula? which pass for a considerable distance upwards along
the side of the rectum above the internal opening, Mr. Curling
differs from Mr. Syme and Sir Benjamin Brodie, in believing
that it is not always sufficient to connect the inner and outer
openings by an incision to effect a cure.

"My own experience," he says, "does not enable me to coincide
altogether in these views, for in many cases I have found that the
sinus running up the rectum will not close without a free division
of the parts. The wound below is apt to assume an unhealthy aspect,
and a free discharge continues. In a case of this kind with a sinus
burrowing close to the mucous membrane, I have sometimes passed
up to its extremity a straight director, and carried along its groove
one of the blunt-pointed blades of a pair of knife-cutting scissors,
whilst the other has ascended the rectum, and, by closing them,
have divided the intervening membrane and exposed the sinus."

He states that these sinuses are so superficial that there is
but little fear of haemorrhage after the operation. We cannot

1877.] Curling and Smith on Diseases of Rectum. 21

but think that such an operation must be very rarely necessary,
and that it falls to the lot of but few surgeons to meet with
such cases as Mr. Curling describes. Mr. Smith thinks that a
high division of the gut, involving, as it may, a complete division
of the internal sphincter, is a cause of the want of control of the
bowels occasionally met with after the operation, and advises,
therefore, that the incision should be kept as low down as
possible. We should be inclined to think that this view is not
correct, and that the internal sphincter is much more often
completely divided than the external. The opportunities of
dissecting a fistula in ano are not frequent, at any rate in cases
which come under the care of the surgeon, and its accurate
pathological anatomy and exact relation to the sphincter would
form an interesting subject for investigation. Mr. Smith lays
great stress upon the frequent coexistence of fistula in ano and
stricture of the rectum. He states that his own observations
have led him to believe " that in a considerable proportion of
cases a stricture will be found to exist with fistula in ano, and
that a failure to cure the latter disease by operation has simply
been the result of overlooking the other morbid condition of
the bowel.'^ In many of these cases Mr. Smith thinks the
contraction of the gut is secondary to the fistula. We do not
think that the experience of most surgeons would justify such
statements as the above. Few operations are more successful
than that for fistula, and few surgeons find it necessary to
employ bougies in the after-treatment of a *^ considerable pro-
portion " of their cases ; and yet Mr. Smith tells us that it is
useless to try to cure a fistula, complicated with stricture,
without treating the latter as the chief disease, and that the
coexistence of the two occurs in a '' considerable proportion '^ of
cases. The treatment by the elastic ligature finds favour with
neither author, and in this they are in accord with the great
majority of surgeons.

One of the most interesting parts of Mr. Curling's work is
that which treats of colotomy. During the last few years this
operation has doubtless been performed with much greater fre-
quency than formerly. Many surgeons no longer look upon it
as a last resource to be employed only when complete obstruc-
tion of the bowels threatens speedily to end in death, but as a
means of relieving the sufferer in an early stage of malignant
disease, or even in extensive syphilitic ulceration, from the con-
stant pain and anxiety which such conditions give rise to. The
statistics furnished by Mr. Curling are so favorable as fully to
justify this extended employment of the operation. Out of
twenty-one operations in which he has taken part fourteen were
successful. In two of the fatal cases the death was chiefly

22 Reviews. [July,

attributable to chloroform^ in one the obstruction had lasted
thirty days, another died from peritonitis springing from the
cancerous disease for which colotomy was performed, two more
died from exhaustion shortly after the operation, and one from
pyaemia. It is but reasonable to suppose that some of these
fatal cases might have recovered had the operation been per-
formed earlier. It will be noticed that only two of these cases
died from peritonitis, and that in one of these it existed before
the operation, and in the other sprang, not from the wound, but
from the original disease. It is clear, therefore, that the danger
of peritonitis is not so great as could at first be supposed, and if
this can be avoided the risk of the operation is but slight when
performed before the patient is exhausted by prolonged pain and
obstruction of the bowels.

The treatment of cancer of the rectum by any operative in-
terference with the disease itself is, in Mr. Curling's opinion,
very rarely possible, no such case ever having come under his
observation. Epithelioma of the anus is, however, more man-
ageable, and he mentions some interesting cases in which the
disease was successfully treated by excision, and in which it was
observed that, although a large part of the sphincter muscle was
excised, the retentive power of the anus was not seriously
weakened, nor was there any inconvenient contraction of the
anal opening.

The final chapters of Mr. Curling's book are devoted to the
congenital imperfections of the anus and rectum, a subject on
which he is a well-known authority. After discussing the treat-
ment of those cases, in which the gut can be reached from the
perinseum, the question of the advisability of colotomy and the
best method of performing it when the simpler operations have
failed is considered at some length. There can be no doubt
that the operation in the left groin is considerably easier of
performance in a new-born infant than that in the loin. In
order to prove this point Mr. Curling performed both operations
twenty times on the dead body. In eighteen out of the twenty
the colon was easily found and opened in the groin. In the two
in which difficulty was found the colon passed across the body
of the fourth lumbar vertebra, the rectum commencing on the
right instead of on the left side, a condition which, according to
M. Boucart, occurs only once in twenty-five subjects. On the
other hand, in only eight of the twenty cases was the operation
easily performed in the left loin. In six it was rendered diffi-
cult by the depth of the gut, its empty condition, and the pre-
sence of the kidney in front of it. In six the gut was completely
surrounded by peritoneum, forming a long mesocolon. In re-
spect to the comparative dangers of the operations, Mr. Curling

1877.]

Diseases of the Peripheral Nerves. 23

thinks the number of cases too few for the purposes of accurate
comparison, but is inclined to consider that in the groin the safer.
There is ample evidence to show that, if the infant survive, the
artificial anus, whether in the groin or loin, is amply sufficient
for its purpose, and that the inconvenience arising from it is
surprisingly small. It would seem, therefore, that both on
account of the greater ease of performance and greater certainty
the operation in the groin is to be preferred to that in the loin,
and from the great success that has followed it in some cases
no surgeon would be justified in letting a child die without the
attempt being made to establish an artificial anus.

There is much more of interest in both these works that we
would gladly notice did space permit. The fact that each has
reached its fourth edition shows that it is highly appreciated by
the profession, and it is satisfactory to note that neither book is
the work of a specialist, both the authors holding high positions
in connection with general hospitals.

III.— Diseases of the Peripheral Nerves.'

This is one of the fifteen volumes of the cyclopaedia which
the eminent professor of Munich is editing for the profession.
What a learned man this professor must be who is capable of
supervising the work of fifteen or more specialists ! Does he
really do so we wonder, and has Professor Erb possibly been com-
pelled to submit to the editorial pruning of his chief, to sug-
gestions, criticisms, and emendations? Or is Von Ziemssen
merely the scientific adviser of a firm of German publishers,
whose work is limited to the selection of authors for the men
who find the capital ; or does he stand in the light of a director
who lends his great name to " float " some scheme into popular
favour? All this does not concern the reader, and we should
not enter into the discussion of the subject did it not strike us
as a monstrous absurdity that the name of the author of a
book, does not appear on the cover, while the " editor's " does.
Even on the title-page the editor's name is twice as big as the
author's, and, following the same principle, the name of the
American editor of the English translation is printed in letters
twice as big as those which serve for the English translator.
Did Mr. Power's proof sheets go to America and back ?

1 Cyclopcedia of the Practice of Medicine. Edited by Dr. H. von Ziemssen.
Vol. xi. Diseases of the Peripheral Cerebrospinal Nerves. By Professor W. H.
Eeb. Translated by Mr. Heney Powek. A. H. Buck, M.D., Editor of English
Translation. London, 1876, 8vo, pp. 623.

24i Reviews. [July,

We are, in short, quite at a loss to understand the craze
which exists at present for systems, cyclopaedias, and diction-
aries, where jackal authors do all the work for lion editors,
who get the glory. An author is certainly placed at a great
disadvantage in having to appear in company which is not
of his choice, and it has not unfrequently happened that a
good article has foundered in the sea of learning because the
craft was overloaded with ponderous ballast. We think that
Professor Erb is to be pitied because his book can only be
purchased in company with fourteen other volumes, and we
think that the medical public may justly complain that so great
an obstacle is placed between them and an author who has
much that is valuable to teach.

This particular volume of the ' Cyclopaedia ' is, on the whole,
excellent, and the translation leaves nothing to be desired. Mr.
Power has done his work in a finished and scholarly manner,
and the book reads as if it had been originally written in English.
This translation is a great contrast to the miserable productions
in Hans Breittmannese which the Americans have given us of
Rindfleisch and Wagner.

The one fault of the book is its length, and there are parts of
it in which the author may fairly be asked for " more matter and
less words." This is particularly the case in the first chapter,
*^ On Neuralgia,^' which is, we think, the worst chapter in the
book, and contains so little that is new that it will not convey
any information to a student of average diligence. On the first
page we are told that neuralgia is a disease " the chief and most
important symptom of which is pain. The pain appears to be
localised in particular nerve-trunks or branches, with all their
ramifications; it is characterised by its remarkable acuteness,
and is either intermittent or at least undergoes very well-
marked remissions." On the opposite leaf we are again informed
that the pain of neuralgia is limited to definite nerve-trunks
and their ramifications, and that it is paroxysmal and inter-
mittent. A few lines further on and the announcement is
made for the third time the *' pain, then, is the most prominent
symptom in neuralgia." On page 37, and again on page 40,
we have the chief facts about the pain recapitulated twice over.
Having had the disease dealt with '' generally " and at length,
it is next entered upon particularly, and the various kinds of
neuralgia are described with a tedious recapitulation of what
we have previously been told, and the other needless applica-
tion of generalities to particulars, till we feel inclined to say as
did the Vicar of Wakefield when listening to Mr. Jenkinson,
" Surely I have heard all this before."

But now that we have exercised the critic's right in the way

1877.]

Diseases of the Peripheral Nerves.

of grumbling and fault-finding, we will endeavour to give a
few samples of what appears to us in every way good. The
account given of diaphragmatic or phrenic neuralgia will be a
novelty to most readers. Erb does not seem to make himself
responsible for the facts concerning this disease, but gives them
on the authority of Peter, who in a paper in the * Archives
Generales de Medecine,^ in 1872, drew attention to ** nevralgies
diaphragmatiques.^'

We must confess that the grounds upon which certain sym-
ptoms are referred to a disorder of the phrenic nerve seem to
us to be scarcely sufficient, and the assertion that they are so
referable must, we think, be received with great caution.

Neuralgia of what has always been looked upon as a motor
nerve is something so contrary to ordinary experience that we
have a right to demand before accepting it that the sensory
functions of the phrenic shall be fully demonstrated. To say
that '' its mode of origin from several branches of the cerebral
plexus renders it highly probable that it contains sensory
fibres,'^ or that '' Peter regards it as a mixed nerve,'' or
that Henle is " satisfied that it contains sensory fibres,"
is hardly sufficient. Again, the course of the phrenic nerve
through the neck or thorax is so deep and removed from
ordinary methods of investigation, and the reference by patients
of their subjective symptoms to certain internal regions of their
body is always such a matter of very great doubt, that we
should only be justified in referring subjective phenomena
to disease of the phrenic upon the maximum amount of evi-
dence.

*^ Pain in a line corresponding to the course of the phrenic
through the chest " might surely be caused by a multitude of
different things. The same may be said of " acute pain at the
lower and especially the anterior part of the thorax," of " pain
at the point where the nerve rises," or of " pain in the shoul-
der." The point where the phrenic arises is a term we are
seldom justified in using, for it, as often as not, arises from
two or even three of the cervical nerves. We are at a loss to con-
ceive upon what grounds, physiological, clinical, anatomical, or
pathological, pain in the shoulder and lower jaw can be regarded
as indicative of phrenic disease. Again, the " painful spots "
which help to diagnose this neuralgia seem to be situated
in very doubtful quarters. They are — 1, the spinous processes
of the cervical vertebrae from the second to fifth ; 2, the phrenic
nerve itself as it pursues its course along the supra-clavicular
fossa ; 3, the line of attachment of the diaphragm ; and 4, a point
over the cartilage of the third rib. The first and last seem quite
valueless as indicating phrenic disease, and as for tenderness of

26 Reviews. [July,

the nerve itself in the neck, the difficulties of accurately com-
pressing it without at the same time compressing many other
nerve-twigs and trunks are so great, that it would be rash to
attribute much diagnostic importance to this point.

" Now, although phrenic neuralgia is not unfrequently an inde-
pendent and primary disease (especially in nervous and anaemic
individuals, with whom it is a consequence of exposure to cold, &c.),
it is the more commonly a concomitant of some other disease,
especially of angina pectoris and of cardiac and vascular lesions,
Basedow's disease, enlargement of the spleen, and hepatic disease ;
and Peter is inclined to refer a part of ordinary or extraordinary
pains occurring in these affections to neuralgic implication of the
phrenic, and supports his view by the histories of numerous cases.
Phrenic neuralgia especially affects the left side."

All these facts or alleged facts are to be borne in mind, no
doubt ; but, nevertheless, the grouping of them together does
not strike us as something familiar — something of ordinary
occurrence. We must suspend judgment for a time in the
matter of this neuralgia ; and if Peter be correct in his asser-
tions, confimatory evidence will, no doubt, be forthcoming from
many quarters. In the mean time we do not think that a strong
prima facie case has been made for the introduction of a new
disease into our plethoric catalogue, and our impression is that
to talk of *^ phrenic neuralgia" is to give to an " airy nothing"
a local habitation and a name which it does not deserve.

The section on neuralgia is followed by an '' appendix^' on
headache, the most remarkable feature of which is the fact that
Erb has evidently never read Liveing's splendid and thoughtful
monograph on megrim.

In the diagnosis of headache no directions are given for the
use of the ophthalmoscope, which is certainly a most remark-
able oversight for an author who writes in these times, and
we think we are right in saying that not once in the whole
volume are any directions given for the employment of this the
faithful and constant companion of the neuro-pathologist. It
is true that the work deals with *' peripheral lesions," but it is
no less true — as, indeed, is constantly admitted throughout the
book — that peripheral symptoms are often caused, in whole or in
part, by central change, and yet this valuable instrument for
the detection of central lesion meets with the most astonishing
neglect at the hands of our author.

In all doubtful cases of headache, ocular spasm and paralysis,
trigeminal neuralgia or anaesthesia, and facial paralysis or spasm,
it should be a matter of routine to use this instrument ; but we
have not found advice of this kind anywhere in the volume before
us. We are quite ready to admit that so dazzling has been the light

1877.] Diseases of Peripheral Nerves. 27

thrown of late on the physiology and pathology of the central
nervous organs, that there appeared to be some danger that the
peripheral nervous system would be forgotten, and that men's
minds would be devoted too exclusively to the more fascinating
but less practically useful problems which belong to the study
of the highest cerebral functions. On this account we welcome
Professor Erb's volume, but it is certainly strange that he should
have so completely neglected that valuable aid to diagnosis
which we have in the power of exploring the fundus oculi by
means of the ophthalmoscope.

The section on neuroses of the gustatory nerves is chiefly
interesting for the discussion on the part which the chorda
tympani has in conveying gustatory impressions. After weigh-
ing the evidence, both clinical and anatomical, the conclusion
arrived at is that " the greater part of the fibres ministering to
the sense of taste pass from the nervus lingualis into the chorda,
and by means of the latter into the fascialis, but finally return
again into the trigeminus." The route which the fibres of the
lingual take to get from the facial to the trigeminal is a matter
of doubt, and Erb very wisely leaves the question open.

The testing of the sense of taste is a very difiicult matter, and
the methods ordinarily employed are very inadequate for the
purpose. The galvanic method of testing the sense of taste is
strongly recommended by Erb, and the following are his
directions for this mode of investigation :

" Two fine wires, provided with small knobbed ends, and carefully
isolated from one another by means of sealing-wax, are to be attached
at a distance of a few millimetres from each other to a non-conducting
handle, such as a glass rod or an elastic catheter ; these wires,
which form the electrodes, are then connected with the poles of
one or several galvanic elements. If these are placed upon the
tongue a slight burning sensation is felt, with a distinct sensation
of taste, which is described as being sourish, saline, metalHc, coppery,
&c., and which is somewhat stronger at the anode than the cathode.
By this means a very exact locaHsation of the galvanic gustatory
stimulus is obtained, and it is possible to determine to a hair's
breadth, by moving the small pair of electrodes over the surface of
the tongue and palate, the limits of the gustatory and non-gustatory
area, as well as to form an accurate conclusion in regard to the
intensity of the sense of taste in symmetrically situated parts."

The neuroses of the olfactory nerves are treated of at some
length, and this part of the book is enriched by the valuable
investigations of Dr. W. Ogle. It is pointed out that what we
call "flavour" is a quality which we appreciate by the help of
two senses, smell and taste, and it is asserted that olfactory
paralysis affects the sense of taste far more than gustatory. The

28 Reviews, [July,

fact also is alluded to that, though in some cases we may be un-
able to appreciate odours through the anterior nares by the
blocking of the nostrils, that, the passage from the pharynx to
the posterior nares remaining open, the sense of " flavour" is
not lost.

In paralysis of the trigeminus it is well known that the sense
of smell is impaired owing to the diminution of the secretion of
nasal mucus, and in facial palsy the same effect is produced
owing to the tears escaping over the cheek instead of finding
their way into the nasal cavity.

Diseases characterised by the loss of the olfactory sense are
grouped together under the name of anosmia, a word which has
been in general use now for some time. We do not know who
was answerable for loading medical science with this piece of
unnecessary Greek, and we should not stop to notice the word
had we not doubts of its correctness from an etymological point
of view. We have very grave misgivings as to the wisdom of
adhering to the old fashion of cloaking our ignorance in the
dead languages, but surely if there is any useful purpose served
by such a course it is this, that a scholar may find in the word
some clue to the condition which the word connotes. Now,
when we were at school, the Greek work oo-jut) was said to
signify scent or aroma, as of a flower, and the word anosmia
would, therefore, mean without scent or aroma, which should be,
practically speaking, a healthy condition in the human being,
although with beavers, musk-deer, foxes, and skunks, the case
would be otherwise. The sense of smell is represented by the
word odwdi], so that, if we are to have a Greek word at all for
paralysis of the olfactory and other conditions which deprive us
of the pleasures of aroma and flavour, it should surely be
anododia, and not anosmia.

There is one point in which all writers should try to imitate
Professor Erb, viz. the progressive improvement which each
section of his work shows on that which precedes it. The
various subjects are handled throughout in a scientific spirit,
but with some he necessarily seems more conversant than with
others. The chapter on spasms is a thoughtful one, and a com-
prehensive review on the whole subject forms a most acceptable
introduction to the study of this difficult and obscure department
of nerve pathology. The old division of spasms into clonic and
tonic is adhered to.

" The essential difference between these two forms of spasm is
perhaps this, that in tonic spasms the several motor excitations are
so closely approximated to one another in point of time that they
coalesce to produce a continuous tetanic contraction, whilst in
clonic spasm the several excitations are separated from one another

1877*.] Diseases of the Peripheral Nerves, 29

by intervals of sufficient duration (varying also in intensity and the
part affected) for each excitation to be separately recognised."

These two main divisions of spasms are again subdivided —
the clonic spasms into tremor and convulsion^ and the tonic into
cramp and contracture. The etiology of spasm is touched upon
with characteristic German precision. Thus, it is said that
spasm may depend upon — I, increase of strength of stimulus^
and 2, increase of excitability of motor apparatus. Again, it may
be produced by direct, indirect, or rejlecc stimulation. Then
we are told that direct spasm may originate in many ways, as

(1) by irritation of the fibres themselves or the motorial plates ;

(2) by irritation of the motor nerves ; (3) by irritation of the
cord ; and (4) by irritation of the brain. Reflex spasms in a
similar way may be due to increased excitability of the centri-
petal fibres or of the reflecting centre. What is meant by indirect
spasm apart from reflex spasm is not very clearly made out. In
this chapter we notice, as elsewhere in the book, a great want
of knowledge of English work, and in dealing with the subject
of convulsions Reynolds's contribution to the pathology of epi-
lepsy and Hughlings Jackson's (to use a horrid. German expres-
sion) " path-breaking " and " epoch-making " investigations
into the cause and localisation of " discharging lesions " are
alike ignored. Interesting as this chapter on spasm undoubtedly
is, we wish it bore a little more strongly the stamp of clinical
observation and rather less the appearance of having beeii..
evolved from an inner consciousness.

The section on writer's cramp and allied neuroses will be read
with interest, although in this chapter, as in the last, there is
too much of the inner consciousness and too little of clinical
observation. There is not much, if anything, that is new in this
subject, and here, again, there is evidence of want of knowledge
of the work which has been done in this country and America,
and it is evident that Erb has never perused the observations
either of Poore or Weir Mitchell. The old-fashioned nebulous
theory is again given. Thus :

"It is probable that the co-ordination of these voluntary im-
pulses occurs at different and definite points at the central organs
(apparatuses of co-ordination), or it may be that the associated
excitations of the will pass at certain points of the grey substance
over routes which, from long and frequently repeated exercise, offer
only a small resistance, so that ultimately the excitations of the will
pass at once along these co-ordinating fibres."

Is it not, we ask, very much out of harmony with the spirit
of the times to waste words in idle speculations on matters con-
cerning which our knowledge is absolutely nil, albeit that we

30 Reviews. [July,

may make-believe to write learnedly concerning these co-ordi-
nating apparatuses! Where are they? What are they? Is
there any evidence for their existence ? What is their number^
size, shape, and composition? Do we need a co-ordinating
apparatus for every conceivable combined movement, and can
they be bred up and trained at will ? When any of these ques-
tions can be answered, then, we think, will be time enough to
indulge in speculative theories which benefit neither doctor nor
patient nor physiological science. If medical writers would
limit themselves to a discussion of facts^ or at least to theories
founded upon facts, how very much time would be saved !

A considerable amount of space is devoted to the discussion
of *^ tetany," a disease which was first described by Dance in
1831, and was popularised by Trousseau in his famous clinical
lectures. The spasms affect chiefly the muscles of the arm, and
very often the muscles supplied by the ulnar nerve, so that the
hand is drawn together like the hand of an accoucheur. It is
particularly stated that the disease is not a " business neurosis,"
although the malady which Clemens described as Schuster
hrampf^ or the spasmodic contraction, occurring in shoemakers,
is included under the heading of ^' tetany." The fact also that
the disease affects principally the arm, and is (as was pointed
out by Trousseau) very liable to occur in nursing women, in
which the arms are often subjected to the strain of nursing,
Avould at least make it doubtful whether this troublesome
malady is not, at times, dependent on the occupation of the
patient. An interesting point in this disease is the relationship
which it apparently has to the state of contraction of the arteries.
The observations of Bauer have shown that poisoning with
secale cornutum is capable of directly inducing tetany, and Dr.
Moxon has also recently called attention to the fact that the
symptoms of ergotism and of tetany are strikingly similar.

Kussmaul observed in one case that an attack of spasm could
be induced by pressing upon the large artery of the limb. These
are interesting points, and seem clearly to show that there is
some relationship between tetany and the amount of blood
traversing the arteries.

The section on paralysis shows a more intimate knowledge of
clinical facts than any of those which precede it, and may fairly
be looked upon as the best chapter in the book. With the im-
portant subject of the degeneration of nerve and muscle which
results from disease or injury of the peripheral nerves Professor
Erb shows himself completely at home, and talks with that
clearness which is the sure evidence of accurate knowledge.
The degeneration of nerve and muscle are essentially alike.
Both consist of the degeneration of the tissue elements of high

1877.] t)iseases of the Peripheral Nerves, 3l

function, the fatty degeneration of the medullary sheath of the
nerves and the atrophy and waxy degeneration of the muscular
fibres, and the abnormal growth of the connective tissue elements
which ultimately amounts to a state of " cirrhosis " both of nerve
and muscle. Upon these points histologists seem very generally
agreed, but the matter in doubt is the behaviour of the axis
cylinder of the nerve during these degenerative changes ; and
while some say it persists, others deny that it does so.

It is certainly a very great advance in the diagnosis of ner-
vous diseases that we are able with tolerable accuracy to
estimate by means of electricity the degree of degeneration to
which nerve or muscle has reached ; and the " degenerative
reactions " which Erb was the first, we believe, to place lucidly
and coherently before the profession, are now recognised as
points which have to be settled in the examination of every case
of paralysis. The account which is given of these reactions is
accompanied by very useful diagrams, which are the only illus-
trations in the book ; and here we would suggest that a future
edition would be very much improved by a few woodcuts to
supplement the text. The price of the volume is certainly such
that the publishers might well afford a few pictorial helps to the
better understanding of the work.

The last fifty pages of the book, we think, ought to have come
first ; and, indeed, we have wondered why the whole arrange-
ment has not been reversed. The author begins with ^^func-
tional " diseases, concerning whose pathology we know nothing
that is sure, and scarcely anything that is even doubtfully pro-
bable ; and, opening with neuralgia, he passes on to ansesthesia
and spasms, and then, after considering paralyses, concludes
with the study of definite histological changes affecting nerve
trunks, hypereemia, neuritis, and the neoplasms, and the
symptoms which result from them. If the last chapter had
been placed first the student, in studying the physiological
results of definite nerve lesions, would have formed an acquaint-
ance with neuralgia, ansesthesia, paralysis, and spasm, which
would have proved of great service to him in studying these
groups of symptoms more fully.

The treatment of the diseases which form the subject-matter
of Professor Erb's volume is based upon common sense and
a sound physiological basis. He does not push this method of
therapeusis or that, and is not unduly wedded to any doubtful
theories to warrant a line of treatment or to account for results.
In this matter the work stands in very favorable contrast to
many others, and we believe the practitioner may safely turn to
this work for very wholesome, sound, and practical advice in
the matter of managing patients afflicted with lesions of the

33 Reviews. [July,

peripheral cerebro-spinal nerves. In conclusion, we would say
that, although we have exercised the critic's right of growling,
perhaps a little freely, our general impression of the book is
good, and that the reader who can peruse it without adding to
his knowledge must be exceedingly well informed.

IV. — Text-Books on Practical Histology.^

The publication of several manuals of practical histology is
a natural outcome of the general resolution of medical examin-
ing bodies throughout the kingdom that an acquaintance of
the main facts of structural anatomy shall, as far as possible,
be acquired by students themselves from a study of their own
preparations, instead of being, as formerly, picked up more or
less correctly from looking at woodcuts copied and recopied
into the various physiological handbooks, from the classical
works of KoUiker, Frey, Bowman, and others.

Practical histology having thus become part of the regular
curriculum of a medical student, it may be worth while to
inquire what knowledge of microscopical details it is fair to
expect the average second or third year man to acquire from
his own work, with the time at his disposal, and whether this
knowledge, when gained, is of such an extent as to be of practical
value to him in after life.

As Latham eloquently says, " It is a truth, that the whole
circle of sciences is required to comprehend a single particle of
matter ; but the most solemn truth of all is that the life of man
is threescore years and ten"

Now, this point is one which it is very important not to over-
look, having regard to the fact that there is but a limited time
at the disposal of many students, not only to get enough ana-
tomical and physiological knowledge to pass their examinations,
but also to lay in such a stock of clinical experience as must,
at least, be sufficient to make them safe practitioners, and recol-
lecting also that a course of practical physiology in addition to
histology is now added to the programme.

We shall probably be safe in assuming that a course of
demonstrations lasting from four to six months, the average

1 1. Handbook to the Physiological Laboratory. Sistology. By E.* Klein,
M.D., F.R.S.

2. Practical Histology. By E. A. Schafee.

3. Outlines of Practical Histology. By Professor Rutheefoed.

4. Practical Physiology. By M. Fostee, M.D., F.R.S., and J. N. Langley.

5. Demonstrations of Microscopic Anatomy. HablEY and Beown.

1877.]

Text -Books on Practical Histology. 33

attendance of each student being twice a week, and the length
of these demonstrations being at most three hours, will be as
much time as it will be found possible in medical schools to
allow for the subject of practical histology.

In what respects will the average student, fairly diligent,
but having no special taste for the subject, be the better at the
end of such a course ?

In answering this question, it must be remembered that
microscopical work is in many respects a peculiar study ; putting
aside some of the most complicated methods of preparation
of tissues (such as gold preparations of the cornea), and the
various ways of injecting, it will be found that one or two
lessons are sufficient to teach the ordinary working methods of
hardening, cutting, and mounting the common tissues. But
this is not enough ; the hand and eye have to be educated,
and for the latter, especially, is this education difficult, for not
only do we find that many men are incapable of recognising
differences of structure which to others are quite apparent, but
the infinite number of deceptive appearances produced by posi-
tion, slight obliquity of section, dragging of the specimen, &c.,
have all to be recognised almost instinctively before the con-
clusion drawn by the observer can have any value.

Further, when the student is sufficiently advanced to under-
stand his preparations, the structure of the various simple tissues
and compound organs of the body is required to be studied,
and here again the ground to be covered is of such an extent
that if the investigation is to be done thoroughly a far longer
time will be required than it is fair to demand of one and
all alike.

It is, then, well worth consideration whether the practical teach-
ing of histology could not be done better and with greater economy
of time by a well-arranged course of demonstrations by skilled
workers, in which the methods of preparations of tissues were
explained and the structure of the various organs shown in
specimens, the study of which would serve to make clear those
points which must always be imperfectly understood if left to
mere word painting.

If such a course as this were made imperative on all, we
believe that there would be no lack of students who would be
stimulated to work for themselves with the microscope, and it
is for thdse, and these only, that a good course of practical his-
tology is capable of being a training which will be useful to
them in their professional work.

Those students who have to pass the earlier part of their
medical education at the universities, and those who under
other conditions have time to take their professional course

119— Lx. 3

B4 Reviews. [•^ii^y,

leisurely and to win the higher qualifications, would probahly
come under this head in any case, but it will be understood
that our remarks do not apply to these favoured ones, but to
the greater number, whose circumstances render it advisable
that they should pass their examinations and become qualified
practitioners with as little delay as may be.

The first text-book which it is necessary to notice as at all
representing the recent methods of working and recent opinions
on disputed points in structural anatomy, is that portion of
* The Handbook to the Physiological Laboratory 'i which deals
with practical histology, the author of which has deservedly a
very high reputation as a microscopic worker. Though this
book appeared so far back as 1873, it has not hitherto been
noticed in this Review, and we are glad to be able to compare
it with later works, some of which bear evident marks of its
influence.

Too high praise can hardly be given to the beauty and faith-
fulness of the engravings, and to the careful way in which
many of the processes of preparing and examining specimens
is described in this work; its general plan and arrangement also
seem in some respects better than that adopted in some more
recent text-books.

But altogether we cannot but think that the author has
missed a great opportunity.; the book is neither a complete
account of histological methods nor a text-book of structural
anatomy, but a mixture of both these subjects, in which, while
some structural points are described with very great care and
detail, many more are of necessity either briefly noticed or
omitted altogether.

For example, while the lymphatic system of the central tendon
of the diaphragm is described at very great length, the histology
of the whole of the respiratory tract is not mentioned at all;
and the methods of preparation of the organs of respiration are
dismissed in a little over a page.

We think, also, that too great prominence is given to the silver
method of preparation, for, beautiful and valuable as the results
of this process undoubtedly are, yet they are somewhat unsafe,
and the conclusions arrived at from them should be as far as
possible checked by the employment of other methods.

The first part of Dr. Klein's book — that which deals with
the elementary tissues — is, we think, certainly the best. Espe-
cially admirable is the chapter on the connective tissues, which
is not only very clear and precise, but is so arranged that the
reader readily understands the grounds on which tissues appa-
rently so essentially different, as, for instance, fatty tissue and
bone, are properly placed under a common heading.

1877.] Text-Books on Practical Histology, 35

In the chapter on muscular tissue we find a very elaborate
account of the optical properties of striped muscular tissue, in
which the author, although almost painfully accurate, yet fails
to render his description easily intelligible to students who have
no previous knowledge of the subject.

The structure of the cardiac muscle-fibres and the methods
for its demonstration are, on the other hand, dismissed in a few
words, the impression conveyed being that the muscle-fibres of
the heart in no way differ essentially from ordinary striped mus-
cular tissue, but are only peculiar in dividing. This, of course,
is not the case, and the omission is somewhat unfortunate, inas-
much as the cardiac musculature forms the link which establishes
the homology of striped muscular fibre with other varieties of
nucleated cell-formations.

The description of the nervous tissues and the illustrations
accompanying it leave little to be desired, especially noteworthy
being the drawings of the nerves of the substance of the cornea
and those of the distribution of nerve-fibres to muscular tissue
and blood-vessels.

Before describing the compound tissues, to which the second
part of this practical histology is devoted, an account of the
various methods of injecting, hardening, and cutting sections is
given, and here we are glad that preference is given to the razor
rather than to any form of microtome.

In the description of the lymphatic system the histology of
the endothelium of the serous membranes is very fully described,
to the exclusion of much else of great importance, as, for example,
the lymphatic sheaths of arterial vessels. The plates illus-
trating this part of the work also bear an unfairly large
proportion to the whole number.

From this point the proofs of want of space become plainer at
every page; the respiratory and digestive systems, the skin,
genito- urinary apparatus, and the organs of special sense, are all
discussed in less space than is given to the study of blood-cor-
puscles and epithelium, and the work concludes with two short
chapters on embryology and the process of inflammation.

Mr. Schafer's recently published text-book (2) is in many ways
a marked contrast to the one we have just noticed ; in it, micro-
scopical drawings are conspicuous by their absence, and there is
a careful abstention from descriptions of tissue-structure, while
throughout the book the author rigidly keeps to his purpose of
affording " to those engaged in the practical study of histology
plain and intelligible directions for the suitable preparation of
the animal tissues.'*

And it is, we believe, owing to this wise resolution that Mr.
Schafer has produced an exceedingly valuable work within a

36 Revieius. [July*

very reasonable compass, for from beginning to end, wherever a
lengthened description of any process has been required, fulness
of detail is rarely if ever wanting.

The following extract will serve as a good example of the
author's careful way of going to work :

" The animal having been killed by bleeding, the skin is snipped
through around the upper part of the fore limb, and is then forcibly
reflected from the limb. In this operation care must be taken to
avoid besprinkling the subjacent parts with the cut hairs of the animal.
A piece of the tissue over or between the muscles is then seized with
the forceps, and snipped off with fine, sharp scissors. The snipped-
off tissue shrinks immediately around the end of the forceps, and
appears very unsuited for microscopical examination. But place it
on a clean slide without the addition of any fluid, and with a pair of
mounted needles. Endeavour, by drawing out first this corner and
then that, to again reduce the gelatinous-looking piece to the con-
dition of a thin film, and it will be found that this can be effected
without much difficulty, for when not floated up by fluid the thin
edges of the film tend to stick to the glass, and cease to shrink away
from the position to which they are drawn by the needles. At the
same time, while it is important not to add fluid to that which
naturally moistens the piece of tissue, it is equally important never,
during the whole process of stretching, to let the film become actually
desiccated, for this would altogether ruin the tissue for micro-
scopical purposes. The best way to prevent such an untoward
result is to breathe now and then on the object while it is being
prepared."

As to the order in which the tissues are examined, with some
changes, the plan is similar to that followed by Dr. Klein ; thus,
the cornea is described with the rest of the eye instead of being
used as an example of the connective tissues. The structure
of the heart is given a chapter to itself, and embryonic
and inflamed tissues are purposely omitted.

Purely as a matter of arrangement, it would surely have been
better to group the spleen with the circulatory system rather
than tack it on to the genito-urinary tract, with which its only
obvious connection is that the so-called Malpighian bodies are
found in both the spleen and the kidney.

The subject-matter of the book proper, naturally begins with
the study of the blood and the application of various reagents
to it ; mammalian blood is first taken, and then that of the
frog or newt. This order would, we think, be better reversed,
owing to the greater ease with which amoeboid movements can
be studied in the corpuscles of the amphibia.

If a student, at the commencement of his histological edu-
cation, can be induced to spend two or three hours at a
stretch watching and drawing the movements of a colourless

1877.] Text'Books on Practical Histology. 37

blood-corpuscle, he will have made a great step towards that
education of the eye which is necessary to make him an ob-
server ; and it is, therefore, as well to avoid harassing him
at first with the complication of a warm stage, which for the
observation of mammalian blood is indispensable.

To the description of the blood follows that of the various
kinds of epithelium. The action of reagents on the phenomena
of ciliary motion is well described, but the student will hardly
find it worth while to attempt to preserve ciliated epithelium
in the manner described on pp. 53; 54.

The silver method of staining is described apropos of the
preparation of the connective tissues ; but we do not think that
the rationale of the process, which, after all, is a sufficiently
simple matter, is made plainer by the rather lengthy and con-
fused explanation given in the text.

In this description the author uses the word epithelioid to
express an epithelium-like arrangement of connective-tissue-
cells. "The appearance is similar to what is observed in an
epithelial tissue after the silver process." Here the word is
used in a sufficiently limited sense ; but we find later that all that
group of cell-membranes generally known as endothelium are
called " epithelioid cells," thus introducing a needless source
of confusion, and substituting a clumsy word for one which is
in very common use, and which serves its purpose well enough.
In the article on cartilage an account of the potash method
of preparation described by Dr. Thin^ would have been useful,
and we are somewhat surprised to find no mention of cellular
cartilage, which although in a sense an embryonic tissue, still
has such an important relation to the other members of the
cartilage group that its omission is to be regretted. The de-
scriptions of the methods of examination of muscular tissue
are very clear and possess more than ordinary interest, since
this is a subject which the author has made peculiarly his own,
and on which he is entitled to speak with authority.

The processes of embedding and cutting sections are detailed
in the chapter on the circulation. This part of the subject is very
completely treated, the description of the circulation in the
frog's tongue being especially admirable. We have not found,
however, any demonstration of the nerve plexuses in vascular
walls, and a few words on the method of staining and clearing
delicate sections without removing them from the slide on which
they have been originally placed would have been useful, as it
is a procedure which is not very troublesome and is sometimes
valuable as a means of diminishing the chances of error by
over-manipulation .

' ' Journal Microsp. Sci.,' p. 1, vol. xvi.

38 Reviews, [July*

It is rigTit, however, to say that this proceeding is inci-
dentally referred to later on.

For the injection of blood-vessels the pressure-bottle appa-
ratus is recommended ; for that of lymphatics acupuncture.

Up to this point we have followed Mr. Schafer rather closely
through his book because to the student the first is by far the
most important part. Any one who conscientiously works
through the programme here laid down for the examination of
the simpler tissues will be nearly or quite able to stand alone
by the time he comes to study the structure of the compound
ones, and if, indeed, we were to discuss fully that part of the
work which deals with the latter, there would be little but a
monotonous reiteration of praise to give. Omissions, as a matter
of course, there must be, and among the more noteworthy we
would mention the examination of the renal epithelium when
treated with monochromate of ammonia as described by Heid-
enhain. Eberth's method of examining the muscular substance
of the heart by the silver process also might have been men-
tioned. The chapter on the central nervous system seems to
us to be too short ; that on the eye, however, is singularly com-
plete and clear, being, indeed, quite the best account of the in-
vestigation of the organ which we have ever read.

In taking leave of Mr. Schafer's ^ Practical Histology ' we
feel that the thanks of both demonstrators and students of mi-
croscopical work are due to him for the conscientious way in
which he has fulfilled his task.

We may fairly assume that the work just noticed reflects
pretty accurately the manner in which a course of practical
histology is desired to be carried out at the only medical school!
in London which possesses a physiological laboratory worthy
the name. It would be interesting, therefore, to compare Mr..
Schafer's plan with that on which the class for practical histo-
logy is conducted at Edinburgh. Professor Rutherford's
manual (3), is, however, professedly nothing more than a bare
outline of the work there done, and a comparison would be
manifestly unfair ; the " outlines'^ being, indeed, in most parts
little more than a carefully drawn up list of the various tissues
to be examined. Professor Rutherford evidently finds that in
order to render his course at all complete, a very careful arrange-
ment of the work to be done and a rigid economy of time is
requisite. Even as it stands, although the pruning knife has
been used with no unsparing hand, we cannot but think that it
must be nearly impossible to teach, in ''thirty lessons of from
an hour to an hour and a half each," the histology of the various
tissues and organs mentioned in the text.

As regards the detail of the preparations we find the freezing

1877.] Text 'Books on Practical Histology, 39

method is largely employed in investigations ; this, though un-
doubtedly a most valuable means of hardening many structures,
and especially muscular tissue, is a somewhat dangerous
method for general use, for there can be no doubt that it does
alter, often to a considerable extent, the structural relations of
parts. As might have been expected, a greater prominence is
given to the microtome for section cutting than either of the
previous authors have accorded to it, but we are glad to see that
the razor is recommended for all ordinary purposes.

To the histological notes proper is appended a very concisely
written chapter on " Microscopical Methods," in which quite a
wonderful amount of information is given in a small space.

The students of the physiological class of Edinburgh will find,
no doubt, their labour of note-taking much lightened by having
this little book ; away from there, however, it will probably be
of more value to teachers, by affording hints how best they may
arrange the time at their disposal, than to the students them-
selves.

Turning to Cambridge, in Professor Michael Foster's ' Prac-
tical Physiology' (4) we have presented the histological and
physiological work done in his elementary class, the subject-
matter of this book being worked over in about five months.
The most noteworthy feature of the scheme is, that in it histology
is regarded as one method only of physiological investigation,
and the study of the structure of tissues and organs forms a
part of the study of their physiological properties. It would,
indeed, be a great thing if all elementary physiological teaching
could thus be associated with rational microscopic work, and
we cannot but hope that the publication of this plan of blend-
ing practical histology with practical physiology will cause it to
be, in part at least, generally adopted. The difficulties of such
a course will, we think, be found to lie rather with the teachers
than the students, for while men fairly well qualified to teach
structural anatomy and practical microscopic work are common
enough, good practical physiologists are rare, and the combina-
tion of both these qualifications in one man rarer still.

While thus freely admitting the merits of Professor Foster's
position so far as elementary teaching is concerned, we do not
think it is advisable to carry the combination further, or to
attempt to mix demonstrations of advanced physiological work
with the more difiicult and obscure histological investigations.

Indeed, the paths diverge at a wide angle after running but
a short way together, and the best microscopical work is, and we
believe must for a long time yet be done by workers whose
single idea is to make out facts of structure in whatever way they

40 Reviews. [July*

best can, without preconceived notions of what the physiological
bearing of these facts ought to be.

A histological fact being once found out^ he who has seen it
is as well, but no better, qualified to reason on its meaning,
as another to whom it has been described by drawings or in
some other way. In the present state of our knowledge it is,
we believe, choosing the safer if not the more excellent way to
regard the practical study of microscopical anatomy as a skilled
labour by means of which facts are to be established without
regard to their physiological significance.

One other recent publication, or rather new edition, we should
notice before closing this article. The 'Demonstrations of
Microscopic Anatomy' (5), by Dr. Harley and Mr. Brown, pro-
fesses to be an account of both normal and morbid histology.
It, however, fails altogether to give even the most elementary
account of modern microscopical science. The descriptions of
tissues are often quite extraordinarily inaccurate, and when not
that, are couched in such general terms as to render them value-
less, while the illustrations in very many cases are copies of old
figures, and the comparatively few original ones are in no way
praiseworthy.

The student will be ill-advised who trusts to these " demon-
strations" when he has text-books to choose from which show
such honest work as those of Klein, Schafer, Michael Foster,
and Rutherford,

V. — Baumler on Syphilis.'

The pathology of syphilis has lately been prominently brought
before the profession by the two discussions at the Pathological
Society, of which the last, on visceral syphilis, was, we think,
by far the most valuable. There is a decided advantage in
bringing together a number of specimens illustrative of the
pathology of a particular subject ; and even if no great addition
be thus made to ascertained facts, such discussions serve the
useful purpose of defining more clearly the limits of our certain
knowledge, and indicating the directions in which future in-
vestigations may most usefully be pursued.

The most notable advance has certainly been made in the
pathology of visceral syphilis, and it is only during the last

1 CydopcBdia of the Fractice of Medicine. Edited by Dr. H. VON Ziemssen.
Vol. iii. Article on Syphilis, By Prof. Chbistia» JBaumlee, of Erlangen,
X875.

1877.] Baumlbr on Syphilis. 41

few years that the real character of many of the late manifes-
tations of the disease has been recognised. Herein, too, our
clinical knowledge has been much improved, and especially
that concernin«: the remote and modified symptoms both of
acquired and inherited syphilis. The value of such knowledge
will be apparent when we consider how rapidly many such
symptoms yield to antisyphilitic remedies, and how obstinately
they resist any other treatment. For those, then, who have not
the time nor opportunity to collect and master the various
contributions that have thus been made to the literature of
syphilis, a clear and concise statement of our present know-
ledge of the disease and its treatment becomes very desirable.
Dr. Baumler^s essay admirably supplies this need ; it is written
with great clearness and impartiality, is exceedingly complete,
and, besides exhibiting a thorough acquaintance with the work
of others, it gives evidence of much careful observation on the
part of the author himself.

Syphilis is defined as ^^ a chronic infectious disease, whose
course, though protracted, is not on this account less typical
than that of other infectious diseases." And further on it is com-
pared particularly with the exanthemata, so that in this respect
the author looks upon syphilis, much in the same way as Mr.
Hutchinson and others, as strictly comparable to a specific
fever; diifering, however, from Mr. Hutchinson's view of the
sequelae. Mr. Hutchinson's definition is that " in syphilis we
have to deal with a specific fever of prolonged but definite
stages, which is produced by contagion only, which has a period
of incubation, a period of outbreak (known as primary sym-
ptoms), a period of efilorescence or exanthem (known as the
secondary stage), and which in exceptional cases differs some-
what from its more short-lived congeners, by being followed
by sequelae to which we give the name of tertiary symptoms."

To a considerable extent we admit that this comparison
holds good, but we think in the present state of our knowledge
it should be taken rather as a comparison than as a definition ;
for there are numerous important points in which syphilis
differs from the ordinary specific fevers, and those who adopt
such a definition are obliged to allow important exceptions, on
the part of syphilis, to the rules to which they wish to make
that disease conform.

For instance, as Sir William GuU^ said, " It is a fever with-
out pyrexia;" also, " if it be placed among fevers, it is a fever
not limited in time as they are," or, as Dr. Baumler puts
it, " the different stages are so far removed from each other

1 'Path. Trans./ vol. xxvii, p, 414,

42 Reviews. [J^V*

that the connection between their symptoms is not at once
manifest."

Again, its effect on the offspring of those who suffer from it
is quite unlike anything we see in other fevers ; so also is its
mode of propagation, *^ by contact and by hereditary trans-
mission," as Mr. Berkeley Hill pointed out.^

Mr. Hutchinson^ is, moreover, obliged to admit that the
irregularity of the fever is due to treatment, and that *^if
mercury were entirely put aside we should soon see that sy-
philis is quite as regular in its stages as variola, and also that
it varies quite as little in its degree of severity in different
persons. When mercury does not cure, it delays, and the re-
tardation of stages sometimes witnessed under its use is very
remarkable."^ But recent researches into the subject of vis-
ceral syphilis have shown that gummata, which Mr. Hutchin-
son regards as sequelae, may occur quite early in the disease,
and in cases of inherited syphilis which have undergone no
treatment. " Some of the most typical of visceral gummata
are seen in still-born children."*

Again, Mr. Hutchinson speaks of tertiary symptoms as ex-
ceptional,^ and corresponding to the occasional sequelae of
fevers ; but surely tertiary symptoms occur with much greater
frequency in syphilis than the so-called sequelae in ordinary
fevers.

A better definition, we think, is that of Dr. Baumler: — ** The
disease consists essentially in an intoxication, which proceeds
from a local infection, and gradually pervades the entire organ-
ism, manifesting itself in all the various tissues of the body
under the form of an inflammatory process, of greater or less
intensity, which, to a certain extent, pursues a course peculiar
to itself." " The only conditions necessary to the inception of
the disease are the presence of the specific poison, and its in-
oculation at any part of the skin or mucous membrane of a
healthy, that is, not yet syphilitic person, though the disease
may also be inherited."

It must be remembered, however, that, " etiologically speak-
ing, syphilis and morbus venereus are not synonymous terms ;
syphilis may be a morbus venereus, as in fact it is in the great
majority of instances, but not necessarily."

In the chapter on the history of the disease Dr. Baumler shows
that although syphilis may probably have existed at an earlier
period, it was not recognised as a distinct disease until the severe
outbreak in Italy at the end of the fifteenth century. At first

1 ' Path. Trans.,' vol. xxvii, p. 387.
» Ibid., p. 342. 3 Ibid., p. 342.

4 Ibid., p. 386. 5 Ibid., p. 342.

1877.] Baumler on Syphilis, 43

gonorrhoea and other local affections of the genitals were dis-
tinguished from the constitutional disease, syphilis ; hut after
a time "all affections of the genitals springing from sexual
intercourse were included in common under morbus gallicus.^^
Then, in the latter half of the eighteenth century, Balfour and
Benjamin Bell maintained the non-identity of gonorrhoea and
syphilis, but their views were not generally accepted, in con-
sequence of the great authority of John Hunter being in
favour of the identity of gonorrhoea, chancre and lues venerea.
Hunter's opinion was founded on his well-known experiments,
in which constitutional syphilis followed the inoculation of a
urethral discharge. But E-icord's experiments, made in 1831,
have conclusively proved that the matter of gonorrhoea will
not produce syphilis. He made many hundreds of such inocu-
lations, and failed to produce a chancre or constitutional sy-
philis in a single instance, his explanation of Hunter's experi-
ment being that a chancre concealed in the urethra had
furnished the syphilitic virus. Mr. Lee, however, has shown
that among the secondary symptoms of syphilis is a urethral
discharge which is capable of communicating syphilis ; and he
supposes, we think with good reason, that Hunter's inocula-
tion was made from such a case. Whatever may be the ex-
planation, however, of Hunter's observation, the experiments of
Ricord have led to a definite separation of gonorrhoea- from
syphilis. Subsequently, in 1852, Bassereau proposed to separate
from syphilis the soft chancre and its accompanying bubo.

The history of the disease shows, moreover, that its virulence
has varied at different periods, and that there are now few parts
of the world where it is not to be met with.

Dr. Baumler's general description of the course of syphilis
is exceedingly good.

After about three weeks from the period of inoculation, '^ a
little red papule makes its appearance, which slowly increases
in elevation and circumference, and after a few days may be
felt with the finger as a distinct induration. The redness and
hardness of this papule are quite sharply defined from the
surrounding parts." This is the primary lesion. A few days
later the lymphatic glands in whose district the infected part
lies, take on the characteristic indolent swelling. Then upon
the papule, at the point of inoculation, there forms a slight
crust, which, being removed, reveals a small ulcer exuding a
scanty secretion. Then, in from six to eight weeks, come the
symptoms of constitutional infection ; the patient becomes pale
and indisposed, eruptions occur upon the skin, the throat ul-
cerates, and flat condylomata appear upon the mucous mem-
branes. Later follow the periostitis, alopecia, the iritis, and

44 Reviews. [July,

the general indolent swelling of the lymphatic glands. In
favorable cases the disease may now subside, and in about a
year may have come to an end. Usually however, fresh crops
of eruption come and go, papules appear on the tongue, or
psoriasis upon the palms, and in debilitated persons ulcerations
occur both of the soft parts and the bones.

The disease may, however, become latent for an indefinite
period and then break out afresh, manifesting itself, after
perhaps many years, by some form of tumour development,
the growths of which exhibit a marked tendency to disintegra-
tion and necrosis. These "gummata^' may occur in any
organ, the necrosis of those superficially situated leading to
indolent serpiginous ulcers and osseous caries, while those in
the deeper parts undergo central degeneration, the periphery
of the tumour becoming thickened into a fibrous envelope of
connective tissue. " The internal organs which are most
commonly attacked by gummy tumours are the liver, the
testicles, and the brain with its membranes. The gummata
proceed from the connective tissue, and especially from the
adventitia of blood-vessels; they not unfrequently occasion
grave symptoms, particularly when occurring in the brain."
*' Besides these local processes, in numerous cases, though by
no means in all, a high grade of marasmus takes place, with
marked pallor and great emaciation; and often, especially in
affections of the bones, accompanied with fever of a decided
remittent type." Amyloid disease may also ensue, and ^' at
length the patients succumb either to anasarca, sometimes with
dysenteric affections, or to uraemia or caseous pneumonia,
unless beforehand some syphilitic local process implicating an
important organ, as the brain or heart, puts a speedier termina-
tion to life." Thus, the course of the disease is as follows : —
1. The infection. 2. The local affection. 3. The acute general
affection^ the period of whose manifestation lasts for six or
eight months, and is then followed by either a termination of
the disease or — 4. By a period of latency, liaving a variable
duration, and passing into — 5. The period of gummous forma-
tions and ulceration. 6. Syphilitic marasmus.

Ricord divides the disease into — " 1. A primary period, com-
prising the development of the local process of infection, and
the indolent glandular swellings." 2. A secondary period,
including the early superficial manifestations of the general
infection. 3. A tertiary period, the symptoms of which occur
late in the disease and affect the deeper tissues. Ricord considers
that the disease in the tertiary stage is *' not transmissible by in-
heritance, but may very likely give origin to scrofula and
rachitis in the succeeding generations," Such a division, viewed

1877.]

Baumler on Syphilis. 4

from the clinical point of view, is doubtless attractive and
convenient, and indeed has been widely adopted ; but no such
sharp divisions in reality exist, any more than those which
Zeissl and others have founded upon the type of the lesion (the
condylomatous and the gummous) ; for, as Virchow has pointed
out, many of the symptoms allotted to each of these stages
may in some cases be seen simultaneously ; and in inherited
syphilis the most marked changes of the tertiary period may
be seen in the viscera, while the skin exhibits equally well-
marked secondary eruptions. Moreover, " it has been estab-
lished by numerous observations that a man who at the time is
apparently free from disease, or has been so for a number of
years, but at some former time was syphilitic, is still capable
of transmitting syphilis to the child he begets^' (Baumler, p. 5S) ;
and Mr. Pollock has quoted a case in which a woman suffering
from tertiary syphiHs gave birth to a syphilitic child.i We
know of no facts which support Ricord's assumption that
syphilis is the parent of scrofula or rickets; on the contrary,
there are abundant reasons for believing the diseases to be per-
fectly distinct. At the same time we agree with Sir James
Paget,2 that syphilis may modify, or be modified, by other
diseases, and that such mixed cases are by no means uncommon.
Others, again, have founded a distinction between the stages of
syphilis upon the effects of remedies, maintaining that the
symptoms of E-icord's secondary stage are cured by mercury,
while iodide of potassium has but little effect upon them ; and
that those of the tertiary period yield rapidly to the iodide,
but that for these mercury is even pernicious. This division
does not hold good, however, for it must be rerhembered that
when the tertiary symptoms appear, mercury has usually already
been administered for the secondary, and also that many of the
late symptoms yield only to a combination of the two medicines.
Mr. Hutchinson, again, has separated the tertiary from the
other stages in a still more decided manner, and maintains
that at this period syphilis ceases to be a blood disease at all,
and that " the gummata of the tertiary stage are purely local,
and result from renewed growth in formations left over from
the exanthem stage. "^ This view is not, however, by any
means generally accepted, as the discussion at the Pathological
Society showed. In a recent number of this review* we gave
our reasons for difiering from Mr. Hutchinson upon these
points. We cannot but think that this careful observer, for
whose work we have the greatest admiration and respect,
has in this case allowed his judgment to be warped by a too

1 ' Path. Trans.,' vol. xxvii, p. 441. ^ i^^^ ^ p_ 3^0.

^ Ibid., p. 341 et seq. ^ No. cxv, p. 40,

46 keviews. [July^

great desire to taring the phenomena of syphilis into an exact
correspondence with those of the specific fevers. Mr. Pollock
has made some very striking remarks upon this subject/ in
which he shows by the relation of cases that " the tertiary
disease gives rise to the secondary in the offspring, and that the
offspring that has secondary disease produces the primary sore
on the breast of a healthy woman ;" and he pertinently asks
how this sequence of events is explained on the theory that
the tertiary stage is not a blood disease. We confess ourselves
also unable to conceive that the power of hereditary trans-
mission can persist after the cessation of blood contamination ;
that — as Mr. Thomas Smith plainly stated it^ — '' a man may
beget syphilitic children when he himself is no longer the
subject of constitutional syphilis." Mr. Smith disposed of the
objection that this happened in gout; t. e. "that a man may
transmit to his son a something which may give no sign of
existence until it becomes gout in the grandson ;" by showing,
as Mr. Simon did also, that the two diseases were not really
analogous. The hereditariness of gout depends upon the sperm
giving a potentiality of development —

" Which requires years to breed the fully developed disease, for a
man generally grows up into gout, or, perhaps, more often down
into it ; and, indeed, it may require more years than there are in one
man's lifetime, for in the ease where gout survives a generation this
potentiality takes one whole lifetime and part of another to produce
the actual disease.

*' In strong contrast to this are the circumstances attending the
hereditary transmission of syphilis, in which, from the earliest con-
tact of the parental sperm with the ovum, there is distinct evidence
of the existence and transmission of a deadly disease, which may
destroy the fertility of the seminal fluid, may blight the ovum, may
kill the foetus in utero, may attack the newly born infant, may
poison the mother through the foetus, in her pregnancy or during
parturition."

Syphilis does not miss one generation and appear in the
next, and, as Mr. Smith says, no one ever heard " of a mother
contracting gout by bearing in her womb the child of a gouty
father;" yet —

" Who has not known of syphilis communicated in this way ; and
how is the disease passed to the mother ? Through the blood of the
foetus and in the placental villi, to the blood of the mother in the
uterine sinuses."

We agree with Mr. Smith that these facts indisputably show
syphilis, even in the tertiary stage, to be a blood disease in any
reasonable sense of the term.

1 * Path. Trans./ vol. xxvii, p. 441.

» Ibid., p. 411. 3 Ibid., p. 418.

1877.] Baumler on Syphilis, 4ii

As Mr. Simon"' stated it^ " the hereditariness of gout is like
the hereditariness of a Roman nose, it is part of the family
likeness ;" but that of syphilis more resembles the case of the
silkworm disease, " it is like the passage of a parasite in the
ovum from one generation to another. It is not the case of the
law of development inherited from one to the other, but the
case of a material something passing from one to the other."

Then, against Mr. Hutchinson's view of the tertiary sym-
ptoms being sequelae and not the manifestations of a blood disease,
we have the fact that the so-called tertiary gummata may be
developed quite early in the disease ; for instance, there may be
gummata in the liver at the same time that there are secondary
eruptions on the skin. Now, if the secondary eruption is a
manifestation of a blood disease, surely the gummata are also.
Moreover, as Mr. Pollock pointed out, there is nothing specific
about the sequelae of ordinary fevers ; they are accidental, and
may be symmetrical or not, as, for instance, the nodes on the
tibia after typhoid ; but the gummata of syphilis are specific,
they are seen in syphilis, and nothing else.

Mr. Hutchinson maintains that the gummata of the tertiary
period '' result from renewed growth in formations left over
from the exanthem stage," and he says they show by their
non-symmetry that the blood is not concerned. But if sym-
metry is the test of blood disease, and if the secondary symptoms
are symmetrical, Mr. Hutchinson has to explain, as Sir James
Paget suggested, how it is that these residues, in which the
tertiary gummata occur, are not symmetrical, although they
belong to the secondary period ; " why, being symmetrical in
the forms of the secondary period, it becomes unsymmetrical in
the manifestations of the third." Mr. Simon pointed out that
this hypothesis involved the existence of an active sequela, and
" when any one talks of a morbid process as the sequela of a
given cause that means that the cause is still operative."
Besides, if symmetry be taken as characteristic of a blood dis-
ease (though so great an authority as Sir William Jenner dis-
putes this, instancing the non-symmetry of the typhoid eruption)
we should still hold the facts to be against Mr. Hutchinson,
for tertiary syphilitic ulcers and cerebral gummata are very fre-
quently symmetrical, while secondary lesions are often not at
all so. We have gone at some length into this question, for we
consider it to be one of much importance. It seems to us a
dangerous thing to teach that tertiary syphilis is not a commu-
nicable blood disease ; on the other hand, we consider that there
is abundant evidence to show that it is a blood disease which is

* Path Trans./ vol. xxvii, p. 419.

48 - Reviews. fJulyy

communicable to the offspring, and may, through the offspring,
be conveyed from father to mother.

Passing to the pathology of syphilis, Dr. Baumler shows
that we know little or nothing about the changes which take
place in the blood, but that the distinctive character of its
local manifestation is a cellular infiltration of the con-
nective tissue. The cells have a close resemblance to those of
lymphoma, and have no specific microscopic character; Virchow
has compared thee ntire formation to granulation tissue. One
of the most noticeable of the local manifestations of syphilis is the
gummy tu?nour or syphiloma so frequently seen in 'Uhe subcutane-
ous cellular tissue, the skin, in and upon the bones, the liver, the
testicles, the brain, the kidneys, and, especially in children, the
lungs."

These growths '' present the appearance of a greyish-red, soft,
homogeneous mass, either without fluid contents or yielding a
scanty juice-like mucus." They are seen either as minute infil-
trations scattered throughout an organ, or as more or less
defined tumours of varying size. As they develop externally,
central degeneration takes place, into either a gummy or
caseous material, which eventually becomes surrounded by a
peripheral layer of fibrous tissue.

Of the etiology of syphilis, it can only be said that all we know
of the disease, points to its being due to the introduction into the
body of a specific contagium. But we know this contagium at
present only by its effects ; it has never yet been isolated.

There has been much discussion about the possible vehicles of
the syphilitic contagium. It is certainly proved that the secre-
tion of both primary and secondary syphilitic sores is highly
contagious. Ilicord for many years contended that the primary
ulcer was the only source of syphilis, and denied the inoculability
of the secretion of secondary sores. But this opinion was based
upon experiments made on persons already syphilitic, and it
has now been conclusively shown that secondary syphilis can be
inoculated upon healthy persons, a fact which Ricord subse-
quently admitted. Dr. Baumler, indeed, asserts " that the
condylomata lata are the most common source of syphilitic
contagion," a statement in which we are inclined to agree.

Von Rinecker, of Wiirzburg, has also related an instance of
the successful inoculation of the secretion from an acne pustule
in a child the subject of inherited syphilis.

The blood of syphilitic persons has also been proved to be
capable of conveying the poison of syphilis, and this is probably
the medium by which the disease has been conveyed, in those
unfortunate cases in which syphilis has been communicated by
vaccination. Dr. Baumler goes carefully into this question of
vaccino-syphilis, and shows that an investigation of Mr. Hutchin-

1877.] Baumler on Syphilis. 49

son's and other carefully recorded cases, points to the separate
transmission of the syphilitic and vaccine poison ; and he states
that " the negative results of experimental inoculations of
healthy persons, from vaccine vesicles in persons manifestly
syphilitic, so far as the transmission of syphilis is concerned,
speak on behalf of the supposition that the pure contents of a
vaccine vesicle developed in a syphilitic child, do not comprise
the syphilitic poison."

Mr. Hutchinson believes, however, " that vs^hen the vesicle
has been irritated for some time the serum of the blood trans-
udino^ from the vessels may contain the syphilitic poison;^'
and Dr. Baumler has repeatedly convinced himself " that a few
blood-corpuscles, both red and white, occur in the purest lymph
that first exudes from a seven-day-old vaccine vesicle.^' The
physiological secretions of syphilitic persons, with the exception
of the semen, do not appear to be vehicles of the syphilitic
poison. The milk, for instance, does not seem to convey the
disease. How far the pathological non-syphilitic secretions of
syphilitic persons, are capable of conveying the disease is not yet
clearly known, for in the hitherto recorded cases bearing upon
this point, there has usually been an admixture of blood with
the material which has been inoculated. Mr. Lee and others
believe that the secretion of any mucous membrane in a syphi-
litic person, if in a state of irritation, is capable of conveying
syphilis, and it has been proved by experiment, that the inocu-
lation on a healthy person of a blennorhagic discharge from a
person with constitutional syphilis may produce the disease.

Mr. Lee has, besides this, drawn attention to the fact that
there is a syphilitic urethral discharge, which is sometimes the
result of primary infection, and is also one of the secondary
symptoms, and that such a discharge is a medium of contagion.

With regard to the question of infection by the semen. Von
Barensprang considers that this takes place only in the event of
conception ; but Mr. Lee is of opinion that the seminal fluid
may cause infection, without conception, not by means of the
semen itself, but by the admixture with it of syphilitic virus
from the urethra.

That the semen of a syphilitic father will produce syphilis in
the child he begets is indisputably proven, as is also the fact
that when the ovule is developed in a syphilitic mother, the
foetus will be syphilitic even though the ovule be impregnated
by healthy semen. These are the conditions which give rise to
inherited syphilis. The influence of the father seems more
potent in this respect than that of the mother, the infection of
the foetus being most severe when both parents are diseased, and
in the earlier stages of the parental disease. Usually the severity
119— Lx. 4

50 Reviews. [July,

of the foetal infection decreases with the lapse of time from the
parental infection, excepting in those cases where the mother,
by successive pregnancies, becomes more and more infected, so
that in the later children the influence of the mother is added
to that of the father. The women who are infected in this way
exhibit a modified form of the disease, and often escape most of
the secondary symptoms, suffering more often from a general
deterioration of their health, with alopecia, glandular enlar<ye~
ment, gummata, and other late symptoms. It seems probable
that when a mother acquires syphilis during gestation she does
not infect the child, unless she acquires the disease before the
seventh month.

That syphilis is transmissible to the third generation, is proved
by a case related by Mr. Hutchinson.

The virulence of syphilis is usually considered to be most in-
tense in the primary lesion, though we think it probable that
some of the secondary lesions, as the flat condylomata, furnish a
secretion almost, if not quite, as infectious. Opinions differ as
to the inoculability of tertiary secretions ; we do not doubt that
the poison is less active in these, but it must be remembered
that many tertiary lesions are characterised by degenerative and
ulcerative processes, which would probably be destructive of
their infective qualities.

The period of incubation in syphilis is established by numer-
ous observations, to have an average of from three to four
weeks, and is not afi'ected by the part of the body which re-
ceives the poison. Dr. Baumler gives a table of thirty-one
accurately recorded cases, which exhibit a striking uniformity
in the incubative period.

After an excellent description of the primary lesion. Dr.
Baumler devotes a section to the consideration of " the doctrine
of the unity and duality of the syphilitic and chancre poisons."
We think the authorities and facts herein adduced, are sufficient
to show that Mr. Hutchinson is not justified in saying that
" dualism is dead." The question is argued with great care
and impartiality, and some of the sources of error clearly pointed
out. For instance, it is shown that hard sores, being irritated,
furnish a secretion which is inoculable upon syphilitic subjects,
producing, without incubation, soft sores, the secretion of which
is further inoculable; also, that ordinary non-specific pus, when
inoculated on syphilitic persons, will sometimes produce precisely
similar ulcers. Again, Kaposi has proved that " non-syphilitic
pus, such as we find in acne and scabies pustules in non-sy-
philitic persons, produces pustules whose pus proves to be inocul-
able in generations; that loss of substance was caused by the
pustules, which healed by cicatrization, and that with the in-

1877.]

Baumler on Syphilis. 51

crease in the number of pustules produced by the inoculations,
the contagiousness of the pus diminished and finally became
quite extinguished/^ characters exactly those of the soft chancre.
From \^hence it follows, that certain kinds of pus have an irri-
tative quality which renders it inoculable, and capable of pro-
ducing sores which furnish an inoculable secretion. But "the real
syphilitic viriis, that is, the scanty, thin, transparent secretion
of an induration, when inoculated upon the bearer, has really
a quite different effect from that produced by the abundant
purulent discharge which is excited in the sore by means of
artificial or other irritation." The real syphilitic secretion is,
however, only auto-inoculable before constitutional infection
has taken place, i. e. during the first few weeks after the ap-
f pearance of the sore. The soft chancre, therefore, is regarded as
a purely local contagious affection, which, while it may stand in
some remote relation to syphilis, does not necessarily do so.
" There has never yet been a single instance where syphilis
was caused by inoculation of the chancre-pus (soft chaticre) from
an individual who had only chancre and not syphilis."

Doubtless the distinction between the two kinds of sores may
be sometimes obscured, but this is no argument against their
being essentially different ; and the observations of Mr. Lee have
done much to explain the manner in which these confusions-
have arisen. He has shown that twofold inoculation may occur^
from the mixture of the secretion of a suppurating sore with
that of an infecting sore, for the two actions do not exclude
each other. In such a case the suppurating sore (having the
shorter period of incubation) appears first and it runs its course,
and subsequent induration will occur at the seat of inocula-
tion, and be followed by constitutional syphilis. Bassereau
based his distinction, not so much upon the form of the sore,
as upon the fact that the local sore will only give rise to a
local disease, while the sore which is accompanied or followed
by constitutional symptoms, will communicate the constitutional
disease. The doctrine of unity, on the other hand, affirms that,
'^ under whatever form the poison manifests itself, this form may
become again converted into the other," as Dr. Baumler clearly
expresses it. " Practically, the doctrine of unity can only mean
that the venereal poison is capable of producing sjphilis,
whether the primary affection appears under the form of a soft
chancre, or after a considerable period of incubation, under the
form of a papule, with subsequent superficial ulceration and in-
duration; and hence that an infection from the secretion of a soft
chancre, may be either followed by a soft chancre again, or by an
induration and constitutional syphilis ; and that, on the other
hand, an infection from the secretion of an induration or other

53 Reviews. [July>

syphilitic local affection may be followed by a simple soft
chancre."

We do not agree with Mr. Hutchinson that this is the generally
accepted view, neither do we think with him, that it is a far
simpler creed to believe that the soft chancre is attributable
" to contagion with inflammatory products produced by syphilis,
but not, as a rule, containing its germs," than that there are
two distinct kinds of sores, one of which gives rise to a local,
the other to a constitutional disease.

The conclusions to be drawn from the ascertained facts relat-
ing to this question are formulated with admirable clearness
by Dr. Baumler, who concludes this portion of his treatise as
follows :

" When we remember the multiplicity of secretions which are
often mingled together at the injecting source, there is no wonder
that, in practice, syphilitic infection does not preserve the pure and
simple character which is observed in pathological experiments.
Hence we accept only one syphilitic poison, but in another sense
from that given to it in the doctrine of unity. We do not regard
the contagious principle of chancre as identical with this poison. It
is a pathological agent by itself, but a far less constant and uni-
form one than the poison of syphilis, since we have seen that it may
be generated de novo under the co-operation of certain influences, and
quite independently of syphilis."

The microscopical character of the indurated tissue of the
primary lesion is that of a dense cellular infiltration. Nucleated
cells are closely crowded together in the tissues of the part, and
especially in the adventitia of the blood-vessels.

The induration varies very much in amount and area, the
differences depending chiefly upon the tissue affected. Dr.
Baumler has ascertained that well-marked induration is not so
uncommon in females as has been by some asserted. The time
required for the hardness to disappear is also very variable; it
may leave no vestige of its existence, or may be marked by a
scar, often pigmented. In some few rare cases a relapse of the
induration may take place, long after its apparent removal, and
without any fresh contagion.

The characteristic enlargement and induration of the lymph-
atic glands first in order from the primary lesion, usually be-
comes evident in about a week after the appearance of the
latter, and is often valuable as an indication of the situation of
the original infection.

Dr. Baumler does not agree with Mr. Lee that the glands
second in order never become aff'ected from the primary lesion,
and quotes two cases in which this was observed; it is doubt-
less, however, a very rare occurrence.

1877.] Baumler on Syphilis, 53

The period which elapses between the appearance of the
primary affection, and the eruption of general symptoms, the
so-called second incubation, may vary from two to twenty
weeks, but is usually from six to seven weeks. Then comes
the eruptive fever, which precedes the appearance of the se-
condary symptoms. It varies much in intensity and is often of
a remittent type ; sometimes it is absent, or at least is not noticed.
The disease has now become constitutional.

The earliest constitutional symptom is usually an eruption
upon the skin and mucous membranes. These eruptions have
certain characters which are often valuable aids in the diagnosis.
The coppery red colour of syphilitic eruptions is well known ;
it is especially seen when the eruption is fading, but is not
absolutely peculiar to syphilis ; a striking feature also is their
polymorphous character ; ** it is very common to see macules,
papules, vesicles and pustules side by side." The anatomical
basis for them all is a cellular infiltration, and the most diverse
may ultimately assume the same form. Syphilitic eruptions are
often of annular form, especially those of later appearance and
chronic character ; they give rise, as a rule, to very little itching.
After giving the usual division of syphilides into exanthematous,
vesicular, pustular, papular, squamous, and tubercular, Dr.
Baumler proposes a more anatomical nomenclature as follows :

I. Circumscribed hyperaemias with but slight infiltration.
Macular syphilide — Roseola,

II Marked infiltration of the papular body.

1. In the form of papules. Papular syphilide.

2. In large patches — squamous syphilide on mucous mem-
branes or at favorable points on the cutis. Moist papules.
(Condylomata lata.)

III. Especial implication of the immediate vicinity of the
hair or sebaceous follicles.

1. Simple infiltration with either scanty or no exudation
in the follicles.

Lichen syphiliticus.

2. With acute suppuration in the follicle.
Acne syphilitica.

3. Exudation into small, markedly infiltrated groups of
follicles, with rapid formation of crusts.

Impetigo syphilitica.

IV. Infiltration with sub-epithelial suppuration and super-
ficial ulceration.

Pustular syphilide.
Varicella syphilitica.
Pemphigus syphilitica.
Ecthyma syphilitica.
Rupia syphilitica.

54 Reviews, [July,

V. Infiltration with disintegration to a considerable depth
(gnmmous development).

Tubercular syphilide (lupus syphiliticus).

We think this a very good arrangement, and much better
than the absurd attempts to give a name to each of the innu-
merable varieties which syphilitic eruptions present.

Dr. Baumler gives an admirable description of the syphilides,
with the modifications they exhibit on the mucous membranes,
and points out the highly contagious character of the secretion
of the condylomata lata. We are sure that these are a common
source of contagion. In speaking of the bone affections, a dis-
tinction is drawn between the early swellings leading to the
formation of tophi, and the later gummous tumours, ending in
ulceration or absorption and corresponding depressions. The
increase in the pain of the early peiiosteal affections which
occurs at night, is attributed to the exacerbation of the fever
which takes place in the evening, causing a dilatation of the
peripheral blood-vessels and a determination of blood to those
parts of the periosteum and bones which lie nearest the skin.

A short description is given of the peculiar epiphysial disease
which is met with in inherited syphilis, and of which Dr. R.
W. Taylor has lately published an elaborate description. This
disease, which has only lately been recognised as a manifesta-
tion of syphilis, and of which the present writer has seen a
considerable number of cases, is one of great interest, inasmuch
as it is sometimes almost the only symptom of inherited syphilis,
and if seen early, yields with great rapidity to mercurial treat-
ment. As no other treatment is of any avail, the recognition
of its true character is very important. The aff*ection consists
of an inflammatory affection of the ossifying layer at the epi-
physis, which leads to the formation of a granulation tissue
instead of the natural osteo-blastema, and consequently to a
separation of the epiphysis from the shaft of the bone. It is
sometimes accompanied by suppuration in the surrounding
tissues, though the joint itself is not usually involved. Clini-
cally it is distinguished by a pseudo-paralysis of the affected
limbs, which hang down as if powerless or fractured, or are
sometimes held fixed as in articular disease. There is a swelling
to be felt just above the joint, and the epiphysis can often be
distinguished as entirely separated from the diaphysis. Accord-
ing to Parrot the bones are affected in the following order of
frequency — the femur, humerus, tibia, ulna, radius, fibula, ribs,
ilium, scapula, clavicle, tarsal and carpal bones.^

It usually develops within the first few months of infancy,

1 See No. cxii of this Review, p. 420 ; also No. cxi, p. 30.

1877.] BaUxMLEr on Syphilis. 55

and Dr. Baumler asserts that it is not met with in acquired
syphilis. Dr. Taylor has recorded a case, however, in which
the disease was observed in a child who acquired syphilis by
means of an inoculation upon the lip. The rheumatoid joint
affection sometimes seen in syphilis, is characterised by pain and
effusion into a joint, accompanied by a distinctly remittent fever.
The general enlargement of the lymphatic glands is a very
constant symptom of constitutional syphilis.

*' These glands vary in size from a shot to an almond, seldom
larger j are elastic, firm, movable, defined, isolable, painless, and
remain for a long time without alteration ; they do not tend to casea-
tion. Although, therefore, on a single examination they may closely
resemble other forms of glandular enlargement, yet if they are watched
they are seen to differ from these by their indolence ; they do not
grow like those in lymphadenoma, nor caseate like the scrofulous. "^

Enlargement of the spleen is seen both in inherited and in
acquired syphilis.

The liver may be affected by a general or a circumscribed
interstitial hepatitis, the latter of which is the cause of the
fibrous cicatrices met with in the organ, in cases of syphilis.
Gummata also are common in the liver.

A good description is given by Dr. Baumler of the condition
of the teeth found in inherited syphilis, for the knowledge of
which we are indebted to Mr. Hutchinson. Allusion is also
made to the occurrence of retro-pharyngeal gummata, an impor-
tant point to remember in the surgery of this region. Syphilitic
ulceration occurs rarely in the small intestine, very frequently in
the large, especially the rectum, of which it is often the cause of
stricture.

Ozsena is common both in inherited and acquired syphilis,
and when occurring in the tertiary stage, usually depends, we
think, on bony necrosis. Such cases are only curable by the
removal of the sequestra, for which we would point out that
Rouge's operation, of lifting the soft parts of the nose from their
bony framework, affords great facilities.

The nasal catarrh, or '* snuffles," of inherited syphilis is one
of the most constant symptoms.

Ulceration of the larynx, trachea, and bronchi, is seen both in
the secondary and tertiary stages, and may lead to necrosis of
the cartilages.

The lungs of children with inherited syphilis are liable to a
change described by Virchow as " white hepatization," which is
due to a diffuse infiltration of the alveolar septa ; it is probable
that similar changes occur in adults, and lead to the formation

I No. cxiii of this Review, p. 201.

56 Reviews, [^^^^Yy

of fibrous cicatrices. Gummata are also seen in the lungs, and
in their degeneration may closely resemble tuberculous disease.
We are hardly yet justified in speaking of a syphilitic phthisis ;
but cases are unquestionably met with clinically in which syphilitic
persons exhibit the ordinary symptoms of phthisis, which clear
up under the administration of mercury and iodide of potassium. '
Such cases were alluded to by Dr. Pye-Smith at the discussion
on visceral syphilis at the Pathological Society ; and on the
same occasion Dr. Green and others exhibited specimens of
lungs from syphilitic persons, which seem to point to the
existence of a chronic inflammation of the lung, of a truly
syphilitic character. The histology of such cases is certainly
not yet conclusive of their syphilitic character. The small
arteries of the lung do not exhibit the changes in the inner coat
seen in those of the brain, and which are, perhaps, more than
aught else, histologically characteristic of syphilis ; yet the
specimens exhibited appeared to indicate that the new growth
originates around the small arteries, and not around the
bronchi, which only become secondarily involved, that it begins
around the interlobular vessels and not in the alveolar walls,
and that it exhibits an extraordinary vascularity — characters
which, with the analogy such changes present to syphilitic
lesions in other organs, and their clinical histories, make their
syphilitic origin at least probable.

It must be remembered that our diagnosis of the specific cha-
racter of a lesion, must often depend very much upon the asso-
ciated symptoms and the effect of treatment, and also that there
are syphilitic affections, as, for instance, the enlargement of the
spleen, which may leave behind nothing that can be recoo^nised
post-mortem. The heart and pericardium are the seat of gum-
mata, which probably also affect the large blood-vessels ; by the
degeneration of the latter it is supposed that syphilis may be
indirectly the cause of aneurism.

Very important are the changes which occur in the small
blood-vessels, and which, by their disturbance of the nutrition
and function of the affected organ, often give rise to serious
symptoms. This is especially the case in the brain, wherein
these changes have been most carefully studied.

Heubner has published a careful description of syphilitic
disease of the cerebral arteries, and at the discussion at the
Pathological Society on visceral syphilis excellent specimens
were exhibited by Drs. Greenfield, Barlow, and Gowers, illus-
trative of this condition. The essence of the disease is a
thickening of the adventitia and of the intima, especially the
latter, due to infiltration with a small-celled growth. This
growth becomes organized, and may subsequently undergo rapid

1877.]

Baumler on Syphilis. 57

degeneration. The lumen of the vessel becomes narrowed or
occluded, either by the growth alone, or partly by the growth
and partly by thrombosis, and thus the blood supply is cut off
from that portion of the brain to which the vessel is distributed,
and the part undergoes consequent softening. Dr. Greenfield
showed that the same changes occur in the vessels of the kidney
and of other organs in cases of syphilis. This is one mode in
which the brain becomes diseased in syphilis ; it is also invaded
by the small-celled growth extending into its substance along
the vessels, and leading to the formation of gummata, with
consequent secondary changes of the tissues pressed upon or in-
terfered with. The ganglia of the sympathetic are also liable to
connective tissue growth and consequent atrophy of the nervous
elements.

Besides these forms of disease, there may be a chronic, slowly
progressive meningitis, a specimen of which was exhibited by
Dr. Barlow from a case of inherited syphilis. In this case there
were characteristic changes in the cerebral vessels and dissemi-
nated syphilitic growths in the chorio-capillaris. The nerves
may also suffer injury by narrowing of the bony or membranous
sheaths through which they pass, owing to syphilitic disease.
The organs of special sense are variously affected by syphilis.
The nerves may be interfered with by pressure in the manner
just described, or by the necrosis of surrounding or adjacent
bone ; in this way the sense of smell or sight may be destroyed.
Iritis is usually a secondary symptom, and the result of ac-
quired syphilis, but it has been also occasionally but rarely
seen in the inherited disease. Syphilomata are also met with
in the iris, usually near its margin. Interstitial keratitis
Hutchinson has shown to be almost exclusively confined to the
inherited form of the disease ; it is seen about the time of the
second dentition or puberty. The choroid, the retina, and the
optic nerve may, any of them, be affected by syphilitic infiltra-
tions. Deafness may result either from inflammatory destruc-
tion of the tympanic structures, starting often from the throat
affection, or from some obscure lesion of the labyrinth or auditory
nerve. *

Syphilis causes, besides gummata in the kidney, a diffuse
interstitial infiltration, accompanied by albuminuria. Several
cases are on record of complete recovery from syphilitic albu-
minuria. It must also be remembered that syphilis may in-
directly lead to amyloid degeneration of any of the viscera.

Syphilis of the testicle is met with either in the form of gum-
mata or as an interstitial growth; it is usually a late symptom.
It is well to bear in mind that gummata are sometimes met

58 Reviews. [July,

•with in the breast, where they may simulate other growths
less amenable to treatment.

The placenta is not always the seat of disease when the foetus
is syphilitic; it may, however, exhibit either gummata or a
cell-infiltration of the villi.

The subject of inherited syphilis has recently been treated in
this Review,! and many of its manifestations have been
alluded to in the course of this article, so that our space will
not allow of our entering further into its consideration. Dr.
Baumler has a short chapter in which he enumerates the usual
symptoms ; his treatment of this part of his subject is, however,
less full than we could have desired.

The question of how far syphilis may be a cause of scrofula
or tuberculosis was one of those introduced for discussion at
the Pathological Society by Mr. Hutchinson. Both Dr. Baum-
ler and Mr. Hutchinson believe that there is no connection
whatever between these diseases and syphilis, an opinion which
•we think is amply justified by the facts of the case, among the
most striking of which, are the results of treatment.

We are not inclined, however, to go so far as Mr. Hutchinson
in his belief that syphilis and other constitutional diseases do
not, as a rule, modify each other, although he was supported
herein by so weighty an authority as Mr. Simon. We are
rather inclined to the opinion expressed by Sir James Paget
and Mr. Pollock, that syphilis does undergo very considerable
modifications in persons of different constitutions who contract
it ; and we believe a very useful study is that of mixed and
diluted constitutional diseases, and of the variations to be ob-
served in them. As to the possibility of the cure of, or recovery
from, syphilis. Dr. Baumler gives a favorable opinion, based
upon the fact that there are on record cases in which a second
infection has occurred ; but he admits the difficulty in deciding
when such recovery is complete, and the necessity, therefore, of
a cautious prognosis. '* It is to be regretted," says our author,
" that we possess no criterion of the actual cure of syphilis ;
when we see, after the acute stage, a period of many years of
undisturbed health, and the procreation of healthy offspring,
it is highly probable that there has been a complete and per-
manent cure, but there is no absolute certainty as to the future."
Mr. Lee, however, believes that in the condition of the inguinal
glands we have a very important index of the presence of or
recovery from the constitutional disease, although in any given
case he would not rely upon any one indication exclusively.
Mr. Lee has paid especial attention to this point, and as the

1 No. cxi, p. 23.

1877.] Hijpertrophic Cirrhosis of the Liver. 69

result of his inquiries says, "If these glands have become en-
larged in the manner described (amygdaloid) at the time the
patient contracts syphilis, and if they remain enlarged, as they
very often indeed do, then the patient is still syphilitic and
cannot be reinfected. If, on the contrary, the enlargement has
disappeared, as I am satisfied it has done in a number of well-
marked cases, then the patient may again be subject to the
constitutional form of the disease."

The treatment of syphilis is well described by Dr. Baumler,
and may be summed up in the word mercury. The adminis-
tration should be commenced as soon as the nature of the
primary lesion is determined, and prolonged over several months.
There are good reasons for believing that in some cases secon-
dary symptoms may be thus prevented. Dr. Baumler lays
great stress upon the danger of a too early cessation or inter-
ruption of the treatment, but we think he does not give quite
due weight to the advantages of introducing mercury through
the skin, over any other method. How often when it is given
by the stomach has its administration necessarily to be inter-
rupted on account of the digestive disturbance it sets up, a
trouble the more desirable to be avoided seeing that we wish
to keep the patient for a long time under the influence of the
drug.

Due value is given to the iodide of potassium also, which is
shown to have a remarkable and rapid influence upon the fever,
as well as upon the later manifestations of syphilis.

The practice of so-called "syphilization " is alluded to, and
Dr. Baumler shows that it has no recommendation either
theoretical or practical.

VI.— Hypertrophic Cirrhosis of the Liver.^
RoKiTANSKY,^ under the head of ' Cirrhosis of the Liver,' describes
the first form as " a morbid development of the capillary gall-
ducts; an accumulation of their secretion and probably also a
hypertrophy of the parietes of those vessels;^' in this disease he

^ 1. Hanot. — CirrTiose Hypertrophique du Foie. Thesis. Paris, 1875.

2. Charcot and Gombault. — 1. Note sur les Alterations du Foie Consecutive
a la Ligature du Canal Choledoque, 'Arch, de Phys.,' Mai, Juin, 1876. 2. Con-
trihutions a I'J^tude Anatomique des differentes Formes de la CirrJiose du foie.
Ibid., Sept., Oct., 1876.

3. COBNIL and Ranvibr. — Manuel d' Hlstologie Pathologique. Paris, 1876.

4. Kelsch and Kieneb. — 1. Contribution a I'Histnire de I'Adenome du foie,
* Arch, de Phys.,' Sept., Oct., 1876, 2. Note sur la Neoformation des Canalicules
Biliares dans I' Hepatite, Ibid., Nov., Dec, 1876.

^ Rokitansky, ' Path. Anat.,' Syd. Soc, vol. ii, p. 141.

60 Reviews, [J"ly,

says, ''the liver is frequently enlarged, but certainly not diminished
in size." On the other hand Frerichsi writes : —

'* Rokitansky refers one form of cirrhosis to a morbid development
of the capillary bile-ducts. I have never met with cases which
would admit of such an explanation. In the various grades or
forms of obstruction to the flow of bile which have come under my
notice the liver never presented any granular character. The en-
largement of the bile-ducts did not extend to their origin, but appa-
rently terminated earlier in the form of elongated hollow spaces,
surrounded by hepatic cells, loaded with pigment. Thus we regard
the various conditions just described as essentially different from
cirrhotic induration which we refer to a chronic interstitial hepa-
titis."

Such a contradiction from so eminent an authority must have had
weight, and it is apparent when we read the first edition of Dr.
Murchison^s 'Lectures on Diseases of the Liver* that, although in
certain cases of jaundice the account of the autopsy describes " a
granular appearance,*' or a " remarkably firm and tough'^ condition
of the liver (see cases 29 and 30), he does not give it any place
even among the spurious forms of cirrhosis. Oa the Continent
there was a gradually growing opinion that there existed a form of
cirrhosis not conforming to the dictum of Bichat, " cet etat ne se
complique jamais du volume extraordinaire du foie."

In 1866 Wyss published an account of the structural changes in
jaundice, and recognised the existence of some degree of new growth
of connective tissue which, he says, never invades the lobules ; his
researches did not give much support to the theory of a biliary
form of cirrhosis. Still, many observers, especially in France, from
time to time noticed cases of enlargement of the liver per-
sisting up to the last, and in which the organ presented manifest
appearances of cirrhosis, but the microscope was not employed to
explain these changes. In 1871 M. Ollivier^ in a series of papers
contributed to ' L'Union Medicale' sought to establish the existence
of a hypertrophic cirrhosis differing clinically from the common
form, and deserving to be considered not a mere variety or stage,
but an independent pathological condition. In 1872 Heinrich
Mayer, experimenting on animals, found in jaundice an increase of
the connective tissue, both around the vessels and in the lobules.

In 1874 M. Hayem^ supplemented OUivier's work by adding
the anatomical details of two cases which he had studied. In only
one of these cases was jaundice present, and that was accounted for
by the presence of inflamed glands in the fundus of the liver com-

1 Frerichs, * Clin. Treatise on Dis. of the Liver,' New Syd. Soc, vol. ii, p. 32.
3 ' L'Union Med./ 1871.

* Hayem, " Contribution h TEtude de I'Hepatite Interstitielle Chronique,**
• Arch, de Phys./ 1874, p. 126.

1877.] Hypertrophic Cirrhosis of the Liver. 61

pressiug the ducts ; he did not connect the disease in any way with
obstruction to the bile-ducts, but considered it a chronic inflamma-
tion following the course of the blood-vessels, and he pointed out
that it not only circumscribed but invaded the acini. Ascites was
absent in both cases ; he describes the ducts as normal ; the new
growth was a formation of connective tissue with abundant nuclei,
in which no development or dilatation of biliary canaliculi is de-
scribed or figured. In the same volume some months later M.
CorniP drew especial attention to the numerous biliary canaliculi
present especially in cases of ''hypertrophic cirrhosis" of the liver.
In a previous article (' Archives de Phys./ 1871, p. 462) he had
described a similar appearance in a case of acute yellow atrophy, and
in the present paper he correlated the various observations and
adopted the view that these are pre-existing intralobular bile-ducts
which have become visible by the destruction of the hepatic cells.
He says :

'* These canals, hollowed out in the midst of connective tissue,
possessed a very then, not isolable tunica propria, and, in their
interior they have little cuboid cells arranged very regularly, planted
perpendicularly on their wall and leaving a central empty lumen.
As you approach the centre of an acinus they become a little more
slender and the cells have a less regular form, often elongated in the
direction of the vessel and irre*^ularly pavement-like. In the parts
where there are liver cells the ducts are very difficult to discover."

These appearances had been observed by Waldeyer and by Klebs ;
the first of these writers considered them to be a proliferation of the
cells of the bile- ducts destined to replace the loss of substance
caused by the distinction of the liver-cells ; Klebs, on the other hand,
regarded them simply as altered or atrophied liver cells and not
ducts at all.

Dr. Beale has published a case, entitled " Liver presenting many
of the characters of cirrhosis, resulting from the obstruction of
common duct ;'^ the obstruction was caused by an enlarged lymph-
atic gland compressing the duct ; the liver was a little larger than
normal, hard, pale, with uneven surface, the newly formed tissue
surrounded each lobule and seemed to be substituted for an equal
amount of liver substance destroyed ; the bihary canaliculi were
distended and formed a sort of network. Dr. Beale distinctly
ascribed the cirrhosis to the obstruction of the ducts.

In 1873 Dr. Wickham Legg published his paper ''On the
Changes in the Liver which follow Ligature of the Bile-ducts."2
This described the results of ligature of the common duct in sixteen
experiments on cats, and the general result was to show that this

1 Cornil, ♦• Note pour servir a I'Hist. Anat. de la Cirrh. Hepatique," 'Arch, de
Phys.,' 1874, p. 265.

■•' • St. Bartholomew's Hosp. Reports,' 1873, p. 161.

62 Reviews. [July,

was followed by enlargement of the liver and a formation of new
connective tissue in the portal canals and around and within the
lobules. He makes no mention of any abnormal appearance of
bihary canaliculi. Unfortunately Dr. Legg, although comparing
these changes to those which occur in obstruction of the duct from
congenital inflammation, attributes the new growth to the extension
of an inflammatory process set up in the fibrous sheath of the duct
by the irritation of the ligature. This view is disproved by certain
of his own experiments, as in two cases the bile found its w^ay into
the intestines in spite of the ligature and as changes resulted, while
in another case in which the left duct was tied the changes were
found only in the left lobe. Indeed this explanation, if true, would
render the contribution valueless, as it would introduce an element
seldom present in the pathological processes of the human subject, to
elucidate which we presume the experiments were undertaken.

The appearance of M. Hanot's thesis in 1875 marks an epoch in
the history of cirrhosis of the liver, not only by its intrinsic value,
but by the researches by which it has been followed. M. Hanot's
personal observations extend to four cases which clinically presented
the phenomena of chronic icterus associated with hypertrophy of
the liver. He was unable to study the development of the hyper-
trophy. When the patients presented themselves the condition was
already well marked ; the liver was resistant to palpation ; its sur-
face was generally smooth, and the organ distended the abdominal
walls; sometimes the presence of chronic perihepatitis gave the
organ a rugged feel. The spleen was also hypertrophied; ascites
was notably absent or supervened to a slight degree late in the
disease. There was no abnormal distension of the subcutaneous
abdominal veins. The general symptoms, as the disease progressed,
were pain in the hypochondrium, fever, anorexia, wasting, constipa-
tion, tympanitis, with periodical exacerbations ; death was preceded
by augmentation of these, delirium, intestinal and gastric hsemor-
rhages, extreme marasmus, and finally coma.

Macroscopic Appearances. — The enlargement of the liver was very
great, weighing in two of the three cases over 2500 grammes.
There was generally perihepatitis, with adhesions to the diaphragm,
to the anterior wall of the abdomen, and to the stomach, the intes-
tine, &c. The surface of the liver, apart from the perihepatitis, was
granular, covered with little yellow or greenish projections, but gene-
rally not so marked as in atrophic cirrhosis. In some cases the
liver was coloured buff, greenish, yellow, or olive green ; on section
grey fibrous bands were seen passing through the liver substance.
The form of the liver was not altered, although enlarged ; there were
no cicatrices. The external bile apparatus presented slight changes ;
sometimes some thickening of the mucous membrane was present.
In those cases associated with calculi a marked catarrhal inflamma-

1877.] Hypertrophic Cirrhosis of the Liver. 63

tion of the bile passages was present. In his cases he never saw
hypertrophied or inflamed glands in the hilus.

Microscopical Appearances — The Cells. — Very generally their
shape was little altered, but they were granular and fatty ; some con-
tained clear yellow granules of bile pigment. They were separated
from each other by spaces as great as their own diameters, in which
were embryonic elements and pigment granules. Towards the peri-
phery of the lobules bands of fibrous tissue separated the cells,
which were flattened and compressed by zones of connective tissue
often two or three times their diameter, the cells being reduced to
small irregular masses of granular protoplasm. In the olive-green
livers the cells were, for the most part, only masses of pigment,
granules, mingled with oil-globules, and showing no nuclei.

The Connective Tissue. — In some parts the interlobular connec-
tive tissue appeared scarcely modified ; generally the lobules were
separated by bands of fibrillated connective tissue, in which ramified
a more or less abundant plexus of bile-ducts. Between two neigh-
bouring lobules these bands were sometimes three times as broad as
the average diameter of a lobule, and rarely less than a millimetre in
breadth. Prom these extralobular bands processes passed within
the acini, separating and compressing the cells as described above ; in
some places no interlobular invasion was apparent, in others the
acini were reduced to some atrophied, granular, pigmented cells, lost
amid a fibrillar tract which traversed everywhere the remains of the
lobule. Generally at the exterior of the lobule the sclerosis was
marked, whde towards the centre embryonic elements alone occupied
the spaces between the cells. Sometimes small masses of embryonic
tissue were found between the bundles of the hypertrophied connec-
tive tissue within and without the lobules. The distribution of the
connective-tissue bundles was parallel to the course of the bile-ducts.
The Bile-ducts. — The most striking appearance in the sections
was the great development of biliary canaliculi in the extralobular
connective tissue ; these formed a very abundant network forming
loops ; they mostly divided dichotomously and joined neighbouring
loops or doubled on themselves, making figures of eight ; they were
irregularly dilated, and sometimes moniliform. These ducts con-
tained a varying number of polygonal cells, heaped one upon the
other, and which contained nuclei and granules; in some places
cells were arranged along the inner surface of the duct in one or two
rows, leaving a distinct lumen ; in others they completely filled the
whole interior. Here and there the cells were coloured greenish
yellow, and contained granules of bile pigment. In the olive-green
livers these cells were infiltrated with bile pigment^ which also was
free in the lumen of the ducts. Often around the canaliculi the
connective tissue was closer and formed a sort of fibroid sheath ; the
arrangement of the bundles of connective tissue seemed to follow the

64) Reviews, [July,

course of the ducts. These abnormally developed canaliculi could
be traced to the periphery of the lobules, where they became very
fine capillary tubes and were lost in the fibrous zone which en-
croached upon the lobules.

The Vessels. — No important modifications were found in these
structures; often they were quite normal, frequently they were di-
lated ; the divisions of the portal vein appeared as sinuses hollowed
out of the perilobular connective tissue, their walls being often in-
distinguishable from the surrounding tissues ; the young cells were
not more numerous around the blood-vessels, while they were greatly
multiplied around the bile-ducts which seemed to constitute forma-
tive centres. The hepatic artery showed no alterations. The lym-
phatic system presented nothing noticeable except well-marked
lymph spaces in the newly formed tissue.

M. Hanot believes that the point of departure of the cirrhosis is
an inflammation of the ducts and their fibrous tissues. In support
of this he quotes two cases ; the first, examined by M. Pitres in the
laboratory of Professor Charcot, was a case of chronic jaundice, and
the liver showed islands of newly formed connective tissue in the
interlobular spaces which contained dilated interlobular bile-ducts,
and radiating from those smaller canals which lost themselves in the
adjoining acini. The second case is one of Professor KussmauFs,
taken from the Berl. Kim. Wochenschrift, in which a certain
amount of cirrhosis is described following chronic obstruction of
the ducts by a gall- stone. M. Hanot considers the disease he has
described to be characterised clinically by the enlargement of the
liver, the early and marked jaundice, and the absence of ascites ;
microscopically, this form of cirrhosis takes its point of departure
from the bile-ducts, originating in an inflammation of their coats;
he looks upon the hq^ formation of bile-ducts as a result of this
inflammation which leads to obstruction to the passage of bile, dila-
tation of the capillary ducts, and the extension of a catarrhal inflam-
mation which fills them with small cells, and subsequently their
dilated canals become lined with epithelium ; consequently he con-
siders this new formation as characteristic of the condition. Besides
these features, he lays stress on the invasion of the lobules by the
new growth of connective tissue.

In support of M. Hanot's views, and in order to give substantial
proof of the true relations of the changes, MM. Charcot and
Gombault undertook a series of experiments similar to those of Dr.
Wickham Legg.

These experiments, seven in number, were made on guinea pigs; of
these seven animals, five died between the fifth and the twelfth days,
the sixth was killed on the tenth, and the seventh on the twenty-third
day. In no case did the bile find its way again into the intestines.
During life the animals presented no special phenomena; they wasted,

1877.] Hypertrophic Cirrhcsis of the Liver. 65

lost their appetites and died ; there was in no case any trace of jaun-
dice ; the urine never gave a reaction with the nitric-acid test.

Macroscopic Appearances, — There was usually only a slight degree
of peritonitis localised about the inferior surface of the liver and
the abdominal wound. The liver seemed in every case larger than
normal, its colour was pale, yellowish, often nutmeggy; in the
latter case the central substance was yellow and translucent, while
the peripheral zones were slightly red ; there were never any granu-
lations. The external bile apparatus was always dilated, sometimes
considerably ; its walls were thickened, and had lost their normal
transparence. The gall-bladder contained thick bile mixed with a
large quantity of mucus and bile-stained epithelium. In one case
in which the bile was examined microscopically immediately after
killing the animal by pithing, it was found to contain vibriones,
which manifested active movements.

Microscopical Appearances, the cells. — Although the lobules were
extremely atrophied by the connective-tissue changes to be immedi-
ately described, the cells which remained in most examples preserved
their form, volume, and regular arrangement ; frequently the cells
possessed two nuclei — a circumstance, the authors say, is normal in
animals, and even in man ; fatty degeneration was observed excep-
tionally only ; usually the cells atrophied by diminishing in volume,
assuming an angular shape, their contents becoming homogeneous,
brilliant, and slightly yellow, or glass-like ; this changed protoplasm
resisted carmine-staining, and took no special tint when tested
with the reagents of amyloid matter or with osmic acid. This
vitreous change was only found in the neighbourhood of micro-
scopic abscesses, or of appearances which they consider due to the
rupture of a small bile-duct and the extravasation of biliary
matter.

The Connective Tissue. — In the portal canals the connective
tissue had become embryonic without having augmented notably
in quantity ; in the interlobular fissures and spaces, however, there
was a very great increase which enlarged the areas of these spaces
at the expense of the surrounding gland-structure, and completely
filled the spaces themselves. This new growth circumscribed the
lobules and invaded them from all points, penetrating towards their
centres. It accompanied the changes in the bile-ducts, being
embryonic and infiltrated with lymphoid cells, where these w^ere
little marked, and became organised in proportion to their develop-
ment. The lobules were not simply compressed by the new growth,
but destroyed piece by piece as it advanced, following the rows of
cells.

The Bile-ducts. — In the portal canals the large ducts were greatly
dilated, attaining a diameter larger than the accompanying portal
vein ; they were lined with large cylindrical epithelial cells : their

119— Lx. 5

66 Reviews. [July,

cavities generally were empty, sometimes they contained concretions
of bile pigment. Their walls were confounded with the connective
tissue around. In the interlobular fissures and spaces the canali-
culi were dilated, generally empty, sometimes containing microscopic
calculi ; they were lined with cylindrical epithelium like that of
the larger ducts. In some cases, in place of these canals, or
accompanying them, other smaller ones were seen whose cavities
were filled with small polygonal cells compressed together ; in the
sections these appeared to be like circles or rows of epithelium, and
they were often observed passing from the spaces into the fissures,
which they more or less greatly distended. Where the new growth
in the fissures and spaces was great these canaliculi were observed
in great numbers ; they formed irregular meshes by frequent anasto-
moses, and their contents left no doubt as to their being bile-ducts.
Often three zones could be distinguished ; first, the great canals,
few in number, near the vein ; next, separated from these by a
band of connective tissue, smaller canals running at right angles
to the rows of the hepatic cells ; and lastly, a third zone of short
ducts, running perpendicular to the last, directed in a course
parallel to the rows of hepatic cells, witk which they seemed in some
places to be continuous. These canals contained a more or less
irregular lining of epithelium, presenting all the intermediaries
between the small square epithelium of the lesser interlobular ducts
and the cylindrical epithelium of the large ones. When they
possessed a free cavity it was sometimes narrow, sometimes dilated ;
in the former case the epithehum was bulky, in the latter flattened ;
often the cavities were filled by a mass of bile pigment.

The Vessels. — The branches of the portal vein presented dif-
ferences in their conditions ; sometimes they were dilated and filled
with clots containing abundant leucocytes ; in these cases the endo-
thelium was undergoing proliferation, but the other coats preserved
their normal structure. The central veins of the lobules were
sometimes dilated and contained many leucocytes, which were also
abundant in the radiating vessels. There was nothing to note con-
cerning the arteries or the lymphatics.

They compare these results with the following appearances
observed by M. Charcot in the liver of an old woman aged 80, who
died after jaundice due to partial obstruction of the duct by a
calculus.

Macroscopic Appearances. — The liver was of normal size, deep
olive colour, distinctly lobulated, but nowhere granular on section.
The gall bladder and external ducts were dilated and filled with
bile.

Microscopical Appearances — the Cells. — Almost all the cells were
small, thinned, angular, with distinct nuclei, sometimes containing
yellow granules ; the vascular spaces between them were dilated.

1877.] Hypertrophic Cirrhosis of the Liver. 67

TAe Connective Tissue. — In the portal canals the vessels were
surrounded by thickened zones of connective tissue poor in cells ;
in the fissures and spaces the growth was greater, sometimes
fibrous, sometimes cellular, in parts there were true miliary
abscesses.

T/ie Bile-ducts. — In the portal canals these were dilated and
their epithehum had disappeared; there were many accessory ducts,
provided with cylindrical epithelium. The canaliculi in the fissures
and spaces were abundant, but much less numerous than in the
guinea pigs ; they sometimes contained cuboid cells, sometimes they
were lined by cylindrical epithelium, and possessed a very narrow
central lumen, in which there were never any bile concretions. The
intralobular canaliculi were not observed to be dilated, nor were
there any masses of bile pigment in them.

Tke Vessels. — The branches of the portal vein were dilated and
their muscular walls were thin ; the arteries were not altered ; both
were surrounded by connective tissue poor in cells ; generally the
vessels had fibrous walls which were not distinct from the neigh-
bouring connective tissue. The central veins of the lobules were
notably thickened.

These facts undoubtedly support M. Hanot's view of the possible
bihary origin of cirrhosis, and the identity of the lesions in the liver
after ligature of the ducts with those in chronic obstruction from gall
stones, seem sufficient to have induced MM. Charcot and Gom-
baultto endorse M. Hanot^s views, and to claim for biliary cirrhosis
certain distinguishing anatomical characters which differentiate it from
all other forms. In their second paper they elaborate these views,
and divide cirrhosis into three classes distinguished anatomically by
the distribution of the newly-formed tissue, and they connect these
with the clinical varieties. According to them biliary cirrhosis is
mainly distinguished by the occurrence of the new formation around
each lobule, to which they give the name of monolobular cir-
rhosis. In the second or venous form the connective-tissue zones
circumscribe several lobules at once, hence called multilobular ;
while in the third variety the liver substance is destroyed cell
by cell, or monocellular cirrhosis. Besides these names they
also use the terms intralobular to denote the first, perilobular
for the second, and intercellular for the third variety. They
quote two new cases of cirrhosis following obstruction of the ducts,
in one case by a calculus, in the other by cancer of the head of the
pancreas. In the first case the liver was of normal size and smooth ;
the large bile-ducts were dilated, there was embryonic connective
tissue in the spaces, with leucocytes accumulated around the ducts ;
these, however, were not dilated, nor more numerous than usual.
In the second case there was dilatation of the perilobular spaces in
which was fully-formed connective tissue ; in some of the spaces the

68 Reviews. [Ju^y?

bile-ducts were numerous. In addition, they reprint some cases
fromM. Hanoi's thesis, and they conclude that they have established
the existence of a form of cirrhosis which takes its origin in an
inflammation of the ducts ; this primary affection is often due to an
obvious cause {e.^. calculus), but at other times develops under the
influence of general conditions which they are unable to indicate
precisely. Venous cirrhosis, on the other hand, following certain
observations of Klebs and Cornil, shows itself first around the veins,
and they instance the experiments of M. Solowief, who induced
cirrhosis of the liver by ligaturing the portal vein. They say that
although usually venous cirrhosis is accompanied by diminution in
the size of the liver, it is not so always, and they give the details of
a case which, during life, had presented the symptoms of common
or venous cirrhosis ; in this the liver was enlarged, granular, tough,
and pale ; the cirrhosis was in many places mouolobular, and
invaded the acini ; in certain places they found a considerable
number of bile-ducts, but this was only occasional. This is followed
by a second case, in which the liver presented the ordinary macro-
scopic appearances of common atrophic cirrhosis, and was reduced
in size, the cirrhosis was intralobular, and there was in the new
tissue an abundant network of bile-ducts. The disease in this case
commenced by an attack of jaundice, and MM. Charcot and Gom-
bault regard it as a case of biliary cirrhosis, gone on to the (excep-
tional) last stages of shrinking and atrophy. As to the monocellular
form they simply indicate it, and say that it is seen in, amongst
others, some cases of congenital syphilis, as had been already noticed
by MM. Cornil and Ranvier.

Prom this short account it may be seen that MM. Charcot and
Gombault beheve bihary cirrhosis to be usually, but not always,
accompanied by enlargement of the liver, there being a rare final
atrophic stage; anatomically the intralobular disposition of the
new growth is its chief characteristic; but they are of opinion
that the multiplication of the canaliculi is no less important, and
they explain its absence in certain cases by assuming that the
ducts undergo fatty metamorphosis and disappear; in support of
which view they quote a case of chronic jaundice which had lasted
eight years, wherein "the biliary canaliculi were abundant and
formed true networks, but were difficult to distinguish, as they
were only represented by very slender moniliform bands, in which
the cuboid epithelium was replaced by some heaps of fatty
granules. '^

The respect which M. Charcot's lectures in pathology have

justly earned for him, his untiring zeal and energy, and his great

ability, give to all that comes from his pen a right to earnest

consideration, so that criticism is difficult. Locke^ tells us, " Some

' ' The Conduct of the Understanding,' sect, xxxiii.

1877.] Hypertrophic Cirrhosis of the Liver, 69

embrace doctrines upon slight grounds, some upon no grounds,
and some contrary to appearance. Some admit of certainty, and
are not to be moved in what they hold ; others waver in every-
thing; and there want not those that reject all as uncertain. What
then shall a novice, an inquirer, a stranger do in this case ? I
answer — Use his eyes.^'' We have endeavoured to follow this advice
so far as our opportunities have permitted. Last summer we
examined the liver of a man who during life had suffered from
jaundice, which had persisted five months. There was no ascites.
The organ was much enlarged, its surface was slightly granular, it
was dense and tough on section, and the cut surface showed yellow
granulations surrounded by greyish zones of connective tissue ;
under the microscope the portal canals and the interlobular fissures
and spaces were dilated and filled by an embryonic tissue, consisting
of small highly refracting nuclei, which passed into the acini where
it lay between the rows of cells, some of which were cut off from
the rest by circumscribing zones of the new formation. The
appearances were very like those figured by Hay em (' Archives de
Physiologic,^ 1874, pi. vii, fig. 1), and the grottth seemed to
follow the course of the capillary blood-vessels in the acini. M.
Hanot attempts to dispose of Hayem's facts by saying jaundice was
not present, but this is not exact ; M. Hayem's first case dated the
commencement of his illness from "jaundice and dysentery,"
fifteen years before, and on admission " there was a yellow straw-
coloured subicteric colour of the skin,^' though there was no bile
in the urine ; the second case had been " attacked by jaundice for
some months" before admission, and the urine contained a little of
the bile-colouring matter, which, however, passed off. We cannot
admit that in our case MM. Charcot and Gombault's explanation
suffices, as the affection was too recent to have undergone every-
where atrophic changes, and no traces of such were visible. The
hepatic cells showed no signs of atrophic changes, and M. Hayem
says of his first case '^ in all the preparations, without exception,
and even in the most irregular lobules the hepatic cells have a
completely normal aspect ; " of the second he says " the hepatic
cells are remarkably preserved." In the descriptions of M. Hanot
and MM. Charcot and Gombault, changes in the cells are always
noticed. We shall see that this difference explains the discrepancy
between the various observations. We believe that the evidence is
incontrovertible that chronic obstructive jaundice, or the resulting
inflammatory changes, cause a form of cirrhosis of the liver, and
we admit the truth, at least provisionally, of M. Hanot's three
clinical features, [a] jaundice, {b) enlargement of the organ, and (c) ab-
sence of ascites as characterising this special form. Moreover, from
a careful review of a large number of specimens of cirrhosis we
admit that the growth differs from ordinary cirrhosis by extend-

70 Reviews. [July*

ing within the lobules more frequently and to a greater extent
than in the latter. But we are not inclined to admit that this new
formation of canaliculi is essential or pathognomonic, but is related
to certain secondary changes which may or may not be present. It
will be remembered that these appearances were first seen in cases
of malignant jaundice or yellow atrophy, which had run a somewhat
chronic course, and were associated with some hyperplasia of con-
nective tissue. We have quoted the opinion of M. Cornil, who
considered them to be pre-existing ducts brought into view by the
destruction of * the hepatic cells, and we have referred to the
opinion of Klebs, who considered them simply rows of altered
hepatic cells, and of Waldeyer, who held them to be newly formed
canaliculi destined to replace the destroyed hepatic tissue. In
looking over our preparations we came upon some of syphilitic
cirrhosis of the liver ; in these sections the number of biliary
canaliculi seen in the midst of the new formation was most re-
markable ; they were often lined by distinct epithelium, in other cases
the lumen was partially filled by an irregular mass of small cells.
In specimens of ordinary cirrhosis, too, an augmentation in the
number of the canaliculi is by no means uncommon, certainly to as
great an extent as is represented in M. Hanot's figures. MM.
Cornil and Eanvier do not deny this, but describe them as more
numerous in hypertrophic cirrhosis. In the third part of their
' Manuel d'histologie Pathologique,' published last year, they
devote a section to the discussion of these appearances, and inform
us that there is a difi'erence of opinion between them as to their
real nature. We may hazard a guess that M. Cornil retains his
already published opinion ; but in the text the view for which
they contend is substantially that already given by MM. Hanot,
Charcot, and Gombault; namely, an inflammation of the larger
ducts spreading to the smaller ones, which are thereby dilated
and brought into view, their lumina being at first filled with
irregular cells, and afterwards lined by definitely arranged epi-
thelium.

Fortunately for the solution of this question the observations of
MM. Kelsch and Kiener supply the missing link. They have been
able to show the development of these canaliculi, and they explain
their true nature, their anatomical relationships, and genesis. In
their first paper they describe two examples of adenoma of the liver;
the second alone interests us : it is the case of a man who was
admitted with ascites, and signs which led to the diagnosis of cir-
rhosis of the liver, perhaps hypertrophic. He died five weeks after
admission, having latterly become jaundiced.

Macroscopic Appearances. — The liver weighed I860 grammes;
it was adherent to the diaphragm ; the capsule was thickened ; the

1877.] Hypertrophic Cirrhosis of the Liver, 71

surface was covered with soft yellowish granulations and little
nodules from the size of a pea to that of a nut. On section the
appearance was that of cirrhosis plus the tumours. The state of
the external bile apparatus is not noted.

Microscopical Appearances. — The tumours were composed of
cylinders or hollow tubes formed of cells like those of the normal
liver ; these cylinders frequently anastomosed, were bent upon them-
selves and often presented lateral offshoots. A delicate fibrous
capsule surrounded the growth. The interstitial hepatitis was every-
where young and embryonic, but the most striking point was the
extraordinary development of bile ducts in the inflammatory tissue;
these canals formed a network around the atrophying lobules and
were lined by a single row of cells which in the smallest ducts were
very small, embryonic, and elongated in the axis of the lumen, in
those somewhat larger cuboid or slightly cylindrical definitely cirr
cumscribing the central cavity, and in the largest forming a perfect
cylindrical epithelium with yellow protoplasm and nuclei coloured
red. In fortunate sections it was possible to trace a continuity
between these canals and the rows of hepatic cells in the lobules
they surrounded; near the point of transition the hepatic cells
diminished in size, lost their yellow and granular appearance ; their
nuclei multiplied and took up carmine more readily, and little by
little the hepatic cells passed into cylinders of small cells with
round nuclei, brightly coloured, surrounded by a thin zone of proto-
plasm coloured reddish brown ; a transverse section of such a tube
showed in parts biliary epithehum in process of formation, in others
perfect hepatic cells. In some places masses of irregularly sized
bile-ducts were seen, and here the hepatic tissue had entirely dis-
appeared.

In their second paper they add two other cases, the first,
" shghtly hypertrophic cirrhosis of the liver, jaundice, ascites and
coma." The jaundice existed only six weeks before death ; the
ascites occurred in the last stages. The liver was of normal size,
surface nodulated and the nodules covered with granulations ; on
section the organ was dense and coloured by bile. Microscopical
examination showed newly formed embryonic tissue around the
lobules, and an abundant network of biliary canaliculi. In these
acini, when the degeneration was slight, they saw " trabeculae larger
than normal, sometimes tubular, composed of hepatic cells of
unequal size and poly nucleated. The periphery of these lobules, sur-
rounded by cirrhosis, showed trabeculae undergoing transformation
into biliary canaliculi. The second case was one of " malarial cir-
rhosis of the liver, ascites, and slight jaundice." The jaundice and
ascites occurred about two months before death ; the liver was not
enlarged ; its size and shape were normal ; its colour was yellow ; its
surface was granular ; on section it was hard and elastic. The cut

72 Reviews. [July>

surface presented the same appearances of yellow masses surrounded
by white dense connective tissue ; microscopical examination showed
the new formation to consist of zones of connective tissue circum-
scribing regions of hepatic substance and sending in processes
which passed between the trabeculse. The liver substance was gene-
rally fatty and undergoing atrophy where the lesions were far
advanced ;j " in the morbid tissue^ intercalated between the acini or
substituted for them, numerous biliary canaliculi ramified, seen both
in longitudinal and transverse section, forming a true network with
large meshes" which in their details conformed to the general
descriptions given previously. They discuss the pathogenic condi-
tions of these appearances, and point out that the true one is to be
found in the alteration of the hepatic cells themselves which become
polynucleated, lose their protoplasm, and present the aspect of
the little cuboid cells found in the new canals. They conclude
that—

" The new formation of a network of biliary canaliculi appears
to depend upon many conditions, o£ which the most important and
the most general is an alteration of the hepatic parenchyma cha-
racterised by nuclear proliferation of the cells and atrophy of their
protoplasm."

They draw attention to the observations of Hanot and Charcot,
and they remark that the tendency of the new material in hyper-
trophic cirrhosis to invade the acini and surround single trabeculse
explains the frequency of the occurrence of these newly formed
ducts in that affection ; moreover, an inflammatory affection of the
ducts spreading along them to the acini might, in the same way,
excite these changes, but they declare, nevertheless, that these are
not efficient or pathogenic causes, as the network may be seen in
acute yellow atrophy without interstitial hepatitis or catarrh of the
bile passages.

They complete their work by certain physiological deductions ;
according to them there are two opposite evolutions possible for
the hepatic trabeculae, both resulting in the formation of tubules ;
in adenoma the cells of a trabecula, hypertrophied, and multiplied,
arrange themselves in stratified layers upon a wall of connective
tissue, and a central lumen appears in the axis of the trabecula,
thus transformed into a true gland-tubule ; in interstitial hepatitis
the epithelium, atrophied and multiplied, arranges itself also on a
wall of connective tissue. A central lumen appears too in this
case, and the trabecula becomes a tubular duct, making part of the
excretory apparatus of the bile. In other words, a hepatic trabe-
cula transforms itself by hypertrophy into a gland-tubule by
atrophy into a bile-duct. Since the researches of Ewald, Hering,
and E berth it is generally admitted that in birds, fishes^ and

1877.] Hypertrophic Cirrhosis of the Liver. 73

the amphibia the structure of the liver recalls that of a gland
with branching tubes. According to Hering, the structure of the
liver of a new-born human infant presents striking analogies with
that of the amphibia, especially the frog, and it is possible to meet
with trabeculse presenting a distinctly tubular arrangement. In
the adult human being Eberth and Biesadecki assert that the liver-
cells affect a tubular arrangement, while Kolliker and Hering
believe that they form a continuous mass, traversed only by the
capillary plexus. All admit the continuity of the bile-ducts with
the rows of hepatic cells. MM. Kelsch and Kiener consider that
their observations are strongly in favour of the tubular hypothesis,
which we in England always associate with the labours of Dr. Beale,
and it is interesting to read over again his careful descriptions, and
to look at his rather invisible, but yet truthful drawings, and com-
pare them with this recent work. It seems to us that the problem is
by no means solved at present. MM. Kelsch and Kiener ignore
Chrzonszczewsky, possibly because his observations are rather
difficult to reconcile with their opinions, but we may recollect that
the intercellular ducts have never been demonstrated to possess any
proper wall, and have been considered by many to be merely spaces
between the cells.

We have looked through the second edition^ of Dr. Murchison's
' Clinical Lectures on the Diseases of the Liver ' in order to see
what he says in reference to these researches, and we were dis-
appointed to find no allusion to them whatever.

Dr. Murchison writes (p. 140) —

** Habershon has met with an inflammatory induration of the
liver in which the organ became greatly enlarged, and Duckworth
has described a ' hypertrophic cirrhosis.' Erom my own experience
I have been led to believe that in a considerable proportion of
cases of cirrhosis the liver is still much enlarged (very often from
the presence in the liver of a considerable quantity of fat), after
ascites and other symptoms of portal obstruction have set in, and
that patients often die in this condition with jaundice, haemorrhages,
and symptoms of blood-poisoning, the prognosis being no better
than if the liver were contracted. In this opinion I am confirmed
by the independent observations of Professor Leudet, of Houen,
who observes : — ' On est arrive par I'aoatomie pathologique a
reconnaitre que I'augmentation du volume de la glande n'etait
pas toujours I'indice d'une lesion recente du foie, d'un pro-
cessus aigu encore curable.' This is the reason why I have
brought the disease under your notice on the present occasion,
but I shall have occasion to return to it in a future lecture. It

1877.

74s Reviews. I July,

is a matter for investigation, whether, if the patient lived long
enough, the enlargement in all these cases would be followed by
marked cirrhotic contraction. M. OUivier, in fact, is of opinion
that cirrhotic enlargement is a distinct affection from cirrhotic
contraction. There can be no doubt, however, that it occurs under
the same conditions, and gives rise to the same symptoms. It
seems probable, therefore, that the same causes sometimes lead to
contraction, and sometimes to enlargement of the liver."

. He then gives four causes of interstitial hepatitis : — 1, congestion
from abuse of alcoholic drinks ; 2, congestion from venous engorge-
ments ; 3, syphilitic inflammation ; 4, a chill. On referring to the
first edition we find that the section from which we have quoted
is new, and has been inserted in the chapter on enlargements of the
liver, between congestion and inflammation of the bile-ducts. Under
the heading of Obstruction of the Common Duct Dr. Murchison
says that this may lead to enlargement " by inducing inflammation
of the biliary passages associated with more or less congestion and
an overgrowth of the connective tissue,^' but he apparently does
not recognise this as a form of cirrhosis. This book will probably
form a standard text-book on liver diseases for some time to come,
and we cannot help regretting the omission of all reference to these
researches, and the scanty and altogether inadequate mention of
hypertrophic cirrhosis.

VII. — Diseases of the Heart.^

In studying the history of special places and periods a clear prac-
tical view is best attained by grasping first one prominent person or
leading event, around which the others range themselves, contribut-
ing causes or effects, and owing their importance, in the student's
mind, to their nearness of relation to the central object. The great
mass of geography and history collected by Herodotus bears entirely
upon the check of the Asiatic conquest by Greece; the failure of
Democracy at Athens is always on the mind of Thucydides, every
event and person is important to Macaulay according as it assists in
the development of Whiggery ; and what the English Monarchy is

1 1. A System of Medicine. Edited by J. Russell Reynolds, M.D., F.R.S.
Vol. IV, containing Diseases of the Heart. 1877.

2. Cyclopcedia of the Practice of Medicine. Edited by Dr. H. von ZiEMSSEN,
Professor of Clinical Medicine in Munich. Vol. vi, Diseases of tJie Circulatory
System, Sfc. English translation, edited by A. H. Bt7C£, M.D. New York.
London, 1876.

1877.J Diseases of the Heart, 75

to Clarendon, that Eubens is to the Art history of Antwerp, and
Rafael to that of Eome. It is history thus treated which makes a
practical impression upon human life, and not records like the
' Saxon Chronicle' or ' Whitelock's Memorials/ however deep the
interest of the pictures they preserve, and however graphic the
details. So it is in the pathology of local diseases which we know
best ; the student gets clearest ideas of them by keeping in mind
always the point by leading to which they aie of chief importance,
or by being its consequence are valuable as signs.

In heart disease the main point to be kept always in view is
dilatation or enlargement of the area occupied by the blood as a
cistern, and thus brought under the influence of the contracting
muscle. The only business of the heart is to discharge its load of
fluid, and in proportion as it fulfils this duty its efficiency is rated.
The importance of cardiac lesions is in a direct ratio to the quick-
ness, certainty, and degree in which they induce dilatation. And
again, upon the dilatation depend directly or indirectly all the con-
secutive derangements originating in the heart which interfere with
health and life. A clear understanding of this point simplifies
our views, so much so as to render prognosis in life insurance capable
of arithmetical and financial estimate ; and it gives a definite single
aim to the treatment, prophylactic or curative. While without it
mere minuteness of diagnosis will be too highly valued, and lesions
will be mainly interesting to the investigator for the facility with
which they are found out.

The reader of the great works whose titles head this article could
not turn to better advantage the time he allots to the task than by
using it in analysing and classifying the masses of facts they record, ac-
cording as they bear upon dilatation. He will improve his own mind
certainly ; and if he is a teacher he will be able to communicate his
knowledge in a form peculiarly instructive. He will find in the new
volume of Dr. Reynolds' ' System' a collection of monographs of
various degrees of merit ; all, indeed, carrying information on their
subject matter to the degree of accuracy it has attained up to the
present time, but some distinguished above their fellows by an
amount of original matter which will entail a reference to them upon
all future handlers of their speciality. Allusion is intended to the
articles by the late Dr. Sibson, whose sudden removal from us has
left a blank very difficult to fill up in medicine and science. The
reason for the order in which the editor has placed the treatises is
not obvious. It does not follow the anatomical arrangement of the
R.C.P. Nomenclature, neither is it a Natural or Physiological series,
for " Endocarditis" is separated by " Carditis," " Hydro-pericar-
dium" and " Angina Pectoris" from " Diseases of the Valves" ; it
is evidently not alphabetical, and from our former experience of Dr.
Reynolds we may be sure it is not accidental. There might seem

76 Reviews. _ [Ju^y,

to be some intention of commencing with primary lesions, but then
the last article of all is on Fibrosis, after Dilatation and Fattv
Degeneration, and with the latter is mixed up the utterly discon-
nected subject of Hypertrophy of the adipose tissue. Stranger
still is the disorder in Dr. Ziemssen's Cyclopsedia, where we begin
with endocardial and valvular diseases, pass through the structural
changes in the muscle, leave the heart altogether for the arteries,
and afterwards go fully into diseases of the veins and lymphatics,
and then suddenly are brought back to Pericarditis. It is needless
to say that this leads to much overlapping of material and to repeti-
tion. What is of still more importance is that it leads us to think
more of the points in which diseases differ than of the points in
which they agree, and to leave clinical experience a disjointed mass
of raw observation rather than a harmonised interpreter of natural
law.

We should advise the student of heart diseases to gain, first of
all, clear ideas on the subject of dilatation, which is treated of by Dr.
Gowers, assistant physician to University College Hospital, in our
native work, and intheGerman by Dr. Leopold Schrotter, for six years
clinical assistant to the well-known Professor Skoda, and frequently
his representative in teaching at Vienna. Of the two, Dr. Gowers is the
most practical writer, seeing the main points of each question most
clearly, and dealing with them most directly. Dr. Schrotter indeed
tells us very fully and correctly the various lesions and physiological
conditions which are apt to result in dilatation, and allows that
sometimes they do so result and sometimes they do not, leaving
prognosis to the statistician and the doctrine of chances. But Dr.
-Gowers leads us much farther, and, in a section on what he calls
the ' Mechanism' by which dilatation is effected, aims at a concep-
tion of the way in which the morbid state is related to its causes.
It is a brilliant little example of physiological reasoning, condensing
into about three pages considerations which make us sure that his
theory of the process is the true one, and that the gaps which he
boldly leaps will be in due time safely bridged over by observation.
" Dilatation of the heart is produced in every case by over-distension
with blood." But there will occur to the reader a crowd of cases
in which the heart is over-distended with blood frequently, habi-
tually, and for 'considerable periods, not only without risk, but
apparently with an increase of efficiency. All those whose work
involves either voluntary holding of the breath, or forced bodily
efforts, over-distend their auricles. Those who are not used to such
efforts suffer from a stitch in the side and shortness of breath, but
by perseverance they lose their stitch and get their wind. There is
no reason to believe that the healthy heart of a healthy man is ever
injured by bodily exertion ; for the voluntary muscles give in first,
and thus put a check on dangerous strains. And there are some

1877. J Diseases of the Heart. 77

organic lesions also, notably contraction of the aortic orifice, which,
by delaying the flow of blood, must abnormally distend the left
ventricle, yet do not usually induce dilatation. On the other hand,
regurgitation even slight through the same orifice inevitably and
quickly brings on the fatal change of form. Dr. Gowers points out
that the difl'erence lies in the period in the cycle of cardiac action at
which the abnormal pressure of blood occurs. If it be during the
systole, the contractile fibres are in a state to resist the pressure,
and to overcome it by putting into action their reserve force. If it
be at the beginning of the diastole, it simply stretches the cardiac
parietes rather quicker than usual, not to an excessive degree. But
at the end of the diastole it obliterates the interval of rest for the
muscle, and thus paralyses the tissue by too continuous work. The
wearied fibre gives way quickly if the obstruction to the circulation
has suddenly supervened on previous health, even though it may be
slight, and more slowly, and with less functional disturbance, when
the lesion is of gradual growth, in spite of the proportions it may
finally assume.

The overstraining of the heart walls by blood pressure, even
though they are, as above described, unable to resist it, does not
immediately result in their degeneration. If they are supplied by
their blood-vessels with healthy nutriment, they follow the example
of the uterus, which, as the pressure and the area within increase,
takes on substance. So that a dilated heart is always heavier than
natural, and indeed the cases where the walls have not retained
their previous thickness are of doubtful occurrence. No instances
are cited by Dr. Peacock, who writes on the " Weight and Size of
the Heart,'' in Eeynolds' System, or by Dr. S. Kosenstein, who has
undertaken the same department in Ziemssen's Cyclopaedia, of
dilated hearts failing to be heavier than the average, and increased
weight impHes increase of tissue. The muscular fibres must
have grown in length, if not in number or breadth. Growth
usually goes beyond this, and, still pathologically following the
physiological lead of the other muscular hollow viscus, it produces
a thickness of parietes approaching to, equal to, or even in excess
of that which is required to restore the normal proportions in the
form of the vessel. It is pleasant to think that sometimes hyper-
trophy may be truly compensatory, and like that of the pregnant
womb be exactly equal to the occasion. And thus we are fain to
account for those numerous instances of mitral regurgitation, with
or without an increased area of dulness, where the sufferers are
condemned by the family doctor, rejected by army boards, pre-
posterously overcharged by insurance offices, spurned by families
with which they wish to be connected, and yet live to the full term
of life, are useful in it, and sometimes enjoy it in defiance of the
Cassandras. After death, from some accidental intervening cause,

78 Reviews. [July,

the valves are truly found incompetent, and the heart is large, but
with a thickness proportioned to its size. ^ " Hypertrophy/'' when
it proceeds thus far, is rightly regarded by Dr. Gowers not as a
disease but a cure. A long train of evils ascribed by Dr. Hope and
others to it are " in no way related to its occurrence, but are the
result of the dilatation," — nay more, they are " remotely the cause
of the hypertrophy.^'

But the reparative process may not stop here ; either the dilata-
tion may be so great, or so continuously augmented, that the
overgrowth which aims to compensate it may deform the heart out
of acting shape; or perhaps the process once started goes on
Ioniser than it is wanted.

Four conditions of health are enumerated by Dr. Gowers as
predisposing to hypertrophy —

(1.) General nutritive energy of the system.
(2.) Nutritive quality of the blood.

(3.) The supply of the cardiac walls of a due quantity of blood.
(4.) A full condition of rest, that is to say, an infrequent pulse,
with a necessarily long diastole.

We would wish, as an additional important point in the pathology,
to draw attention to the enormous local increase of capillary vessels
which must take place when even a quarter of its weight is added
to a heart — and a quarter is a very moderate hypertrophy. This is a
necessary collateral consequence of the sanatory conditions stated.
We wish especially to draw attention to it, because in the cases
where hypertrophy leads to evil, this anatomical state may reason-
ably be credited as the weak point. The nutrient arteries of the
heart not growing in the same proportion as the districts dependent
on them, the supply is liable to be insufficient, and atrophy is the
result. Fibrous tissue, which can develop itself with a limited
blood-supply, grows instead of muscle, and many of the already
existing bundles of the latter are changed into molecular fat.
Hence fibrosis and fatty degeneration, some patches of which are
found in the substance of enlarged hearts at post-mortem examina-
tions in almost every instance.

1 The due proportion of thickened walls required to do the work of a dilated
area is a problem which must of ti n have occurred to the morbid anatomist, and
not much as>istatice towards its solution is obtained from tlie measurements
contained in treatises on the subject. To measure in millimetres the four areas
and their respective walls, takes too long, and requires too much mathematical
calculation for a trustworthy report to be possible under ordinary circumstances.
The readiest way would be to find the quantity of water the heart will hold, and
to compare that with the weight of the solid. In an efficient heart so many
ounces of flesh move so many ounces of fluid.

.1877.] Diseases of the Heart. 79

The nature of the change in the muscular fibre in hypertrophy-
has been the subject of much discussion. The general view is, accord-
ing to Dr. Schrotter, that the increase in mass is produced by an in-
creased thickness of the primitive bundles, though the amount of
increase has not often been reduced to figures. Hepp's Zurich Dis-
sertation (1858) is still quoted as authoritative, in which the nor-
mal thickness of the primitive fibres is put at 0*007 mm., and the
thickness in an hypertrophied heart at 0*03 ; that is to say, that the
latter are more than quadrupled in diameter. Dr. Gowers points out
that this is proving too much, since the cardiac walls certainly do not
receive that amount of augmentation. And several pathologists have
failed to find this swelling in bulk, to corroborate which Dr.
Gowers has directly counted the fibres in a transverse section of the
wall, and finds their number in the main proportioned to its thick-
ness. And again, in the fourth edition of Zielonko's ' Pathology of
Tissues,' it is stated that the author has found the fibres of hyper-
trophied hearts smaller than the average of natural fibres. Professor
Rindfleisch suggests that the new material may be produced by the
splitting of old fibres. Each of the square cells of which they
are made up contains in abnormal hearts several nuclei or centres
of growth ; and these under the influence of disease might revert
to the fcetal or developmental state and generate a new tissue. On
the whole the conclusion seems justified that overgrowth is depen-
dent on the formation of tissue in a lower and less perfect condition,
less capable of performing its duties than it ought to be.

Has not the attention of microscopists been too exclusively
directed to the contractile elements in the diseased part ? Dr.
Eobert Lee states, in his * Memoir on the Ganglia of the Heart,'
that there takes place a thickening of the nerves ; and this is
probably due to an increase in the connective tissue of their sheaths.
The firmness of the flesh of hypertrophied hearts, and the frequency
of obvious local cirrhosis, would seem also to point in the direction
of the interstitial framework of the whole muscle.

Dr. Schrotter has done well to put hypertrophy and dilatation
together into a single article, seeing that for all practical purposes
they cannot be considered separately; still less should they be
contrasted with one another, as their nomenclature tempts some
students to believe is in accordance with just pathology. A per-
manently dilated heart which has not increased in growth beyond
the standard weight is not likely to be seen by any of us ; it would
prove so rapidly fatal as to have no clinical importance. If the
patient has lived long enough it is sure to exhibit some amount of
hypertrophy. On the other hand, concentric hypertrophy, en-
croaching on and removing the hollow area, is of extremely doubtful
occurrence. One can easily understand its rarity, on making the re-
flection that it cannot fail to cure itself ; for the diminished supply of

80 Reviews, [July,

blood sent out from the limited cavity would starve the tissues very
quickly, and put a stop to all exaggerated nutrition.

It may be a small matter, but would it not be wise in our teaching
to speak of " dilatation and hypertrophy " as a description of a
given case, rather than of "hypertrophy and dilatation?"" The
first is the order of importance and of occurrence in respect of time,
and words are not, and ought not to be, without influence on the
mind. Both dilatation and hypertrophy lead equally to atrophic
degeneration, and derive from thence their importance, so that
practically they are parts of one and the same morbid process, ms
much as the papula and the scab are parts of the same morbid
process in smallpox.

Degeneration may be a consequence of a general diathesis, instead
of following an organic lesion; and then it causes dilatation. And
in such cases, often a much smaller amount of deformity is found in
the heart than its fatal effects would have led one to anticipate. In
fact, in some instances of sudden death the cavities are normal in
appearance. Is it not probable that the gravity of the symptoms
depends upon a suddenness in the supervention of the lesion ? We
know how through a gradually acquired habit the circulation may
be carried on by a heart which in course of years has stretched and
grown to a monstrous size. But a rapid loss of function, though
much less in extent, is immediately dangerous to life. Immediately
dangerous, but only temporarily so, for if time be gained reparation
may to a certain extent be made, and the previous state of health
restored — cito mors venit, aut victoria laeta. "We would venture to
call to this point the attention of Professor Gairdner, who has con-
tributed in Dr. Eeynolds' volume a deeply interesting article on
*' Angina Pectoris and Sudden Death." Without dogmatising, we
would suggest it as open to discussion whether the common feature
uniting the diversified morbid lesions found after breast-pang, or
sudden death without breast-pang, may not be a tendency to pro-
duce a paroxysmal sudden dilatation of the heart-walls, very dif-
ferent in its result from that chronic dilatation with which physicians
are more familiar. The tracings of the pulse made by the sphygmo-
graph during the paroxysms exhibit a diminished amplitude and
impetus in the blood wave ; which, though explained by Dr. Brunton
as indicating increased arterial resistance,^ will bear equally well, if
not better, the interpretation of dmiinished force in the heart.

The slower dilatation supervenes upon its cause the less dangerous
it is to health and life, and the greater likelihood there is of its
being accurately balanced by the hypertrophy, to such an extent
that the form of the muscle and its efficient pressure upon its
contents should be preserved. And the slower the hypertrophy the

1 ' Transactions of Clinical Society/ vol iii, p. 191.

1877.]

Diseases of the Heart. 81

more likely is the added tissue to continue eificient, and to avoid the
risk of atrophy run by organs which have outgrown their blood-
supply. A wide field, therefore, lies open for rational treatment, and
it must not be trod by careless or despairing feet. We have no
hesitation in saying that, in a young person afflicted with any of
the causes of enlarged heart, it makes all the difference between life
and death whether they follow good advice or hve recklessly. It is
great encouragement to hope more from treatment, when we see that
in each new work on the heart it becomes more simple, that the
pharmacopoeial aids to it are fewer in number, and that those whose
promise of giving relief are vague are omitted altogether.

The causa causans of the lesion is the failure of the heart to
empty itself and to secure that interval of rest between the beats
wherein lies its only opportunity for laying in nourishment. It
beats quickly and inefficiently, and the more quickly the more in-
efficiently, because the mass of blood stays too long in contact with
its walls. Our object, then, should be to strengthen the contractile
power of the muscles, so that it may do an extra stroke of work,
and then get the repose which will strengthen it for future exertion.
To this end tend all the specific remedies which are backed by the
authority of these our most recent monographists, and which (their
array being reduced in bulk by the discarding of pretended allies)
are not too numerous to forbid quotation. In Dr. Schroetter's
words —

" The first is the persistent and faithful use of cold. This simple
remedy is fitted most wonderfully to quiet the severe activity of the
heart, and is best applied by the temporary or continuous use of
ice-bags laid over the chest. The second is digitalis, which most
decidedly diminishes the frequency of the heart's action, and since
it usually is only required temporarily, it is quite in place here . . .
Together with the use of digitalis, quinine in large doses is often of
great value." ^

Dr. Gowers has also a proper confidence in lessening the bJoo^
pressure afronte, by the reduction of the volume of the circulating
luid :

" This may be accomplished in more than one way. The most
ready method is by the abstraction of blftod by venesection or cup-
)ing. The relief which it affords is often immediate and striking.,
^he ultimate effect, however, is that the volume of the blood is soon*
reproduced, while the heart is permanently weakened. "^

We are not disposed to be alarmed by the last consideration.. Rr,
is unlikely that a patient will be overbled in the present day, and*
dthin moderate limits the new blood which is made so transcends m

\ i^iemssen, p. 218.

* ' Reynolds' System,' article oa '* Dilatation," p. 753.

8a Heviews. [July,

nutritive power the old dark blood which is drawn off that we ques-
tion the weakening result. We cannot, however, say the same in
regard of the substitutes which Dr. Gowers proposes, ^' in less urgent
cases purgation and diuresis.''^ The relief from them is less, and
they are liable to depress unduly the nervous system.

The general treatment aims at the same object as the specific.

" The general nutrition must be as far as possible improved. A
very bracing air is useful, and gentle exercise should be taken which
does not increase materially the work of the heart ; food must be
nutritious and easily digested. Iron is of great service, and seems
to aid directly the production of the needful hypertrophy. Excited
action of the heart must be calmed by avoiding the causes of excite-
ment and by sedative medicines. Moral emotion must be avoided,
and the sources of gastric disturbance guarded against or relieved;
A distended stomach easily excites an attack of palpitation."

The test of the effects of these expedients is diminished frequency
of pulse ; and it is a satisfaction to many minds to represent these
effects numerically. Dr. Milner Pothergill calculates that to a heart
which is contracting 144 times per minute the period of rest is in-
creased by one third if the pulse is reduced to 72.^ Thus, the heart
is saved a considerable portion of the work of moving its own mass,
and gains one third more time for filling itself with blood for
nourishment.

On the alleviation of special cardiac symptoms the English
manual is much fuller than the German. Dr. Schrotter, in fact,
would lead a practitioner to neglect it altogether. He refers entirely
to the treatment of the primary lesion,^ a teaching against which we
feel bound to protest, as it shows an ingrained misconception of the
objects of medicine. Dr. Gowers^ has devoted four very useful
pages to this subject. We would, however, take leave to suggest a
few additional details as a safeguard against abuse. For example,
we should be glad to know the doses of several drugs, and when he
says, " headache is best relieved by posture,^' a hint as to what pos-
ture is recommended would be desirable. A description of the
''heart-bed'' and of the '^ reclining chair" (is it rightly named
'^'^ reclining?") might enable a country carpenter to construct them,
.and if the principles on which they are beneficial are explained, a
patient with a taste for mechanics might suit himself with a cardiac
table, a heart carriage or pony trap, or perhaps a heart saddle.
It is right also to express our dissent from the advice given in Dr.
Gower's last paragraph on dilatation : — " In all cases of dropsy as
little fluid as possible should be taken." Yet he had just before
recommended stimulating diuretics — juniper, broom, copaiba — all

1 ' Diseases of the Heart/ p. 4.

» Ziemssen, p. 219. 3 Reynolds, p. 756.

1877.] Diseases of the Heart. B3

likely to induce such a congestion of the kidney, as water, and water
alone, can relieve. Water has been shown, by the experiments of
Boecker and others, to be a true diuretic, emptying the renal vessels
of more aqueous fluid than is taken in by the mouth, augmenting
both the fluids and the solids of the urine beyond the bulk ingested.
We think that to follow Dr. Gowers' advice in this particular would
be positively injurious to his patient.

Eound the subject of dilatation there group themselves all the
various lesions which lead to it. Poremost among these is valve
disease, divided in the one volume between Dr. Sibson, who takes
the acute lesions under the heading of "Endocarditis,''^ and Dr.
Pagge, who has charge of the chronic ; in the other cyclopsedia the
whole subject is united under Dr. Sigmund Eosenstein, with the
heading, "Diseases of the Endocardium." Upon Dr. Sibson^s
articles we are disposed to look with a hypercritical eye, for we
learn by the preface that they were the cause of the long delay that
has occurred in the production of the work; and, moreover, they
are (alas !) the last words which will be addressed to the public by that
earnest, enthusiastic worker and genial friend. Much care has been
spent upon them, the reader expects much ; and it may be said with
confidence that he will not be disappointed. The entire originality
of the material, the carefulness of the observations, the subtlety of
thought which the analysis displays, the catholicity of the views
which are expressed, the honest criticism which they contain of the
opinions of other workers, render Dr. Sibson's Endocarditis and
Pericarditis the most complete examples of monographs in our
medical literature.

Dr. Sibson does not think it necessary to repeat again the ob-
servations of the anatomical appearances found after death in cases
of endocarditis, which he says are readily available in the manuals of
Eokitansky, Moxon, Payne, and others, but sketches shortly and
graphically his own idea of the pathological process. He assumes
^^ the reader to have surrendered the view once entertained, that the
^■, granulations are formed of an exudation of plastic lymph on the
^^B surface of the membrane, and to be ready to consider them as pri-
^^H marily sweUings of the tissue itself. Their position on the valve and
^^H the relative frequency of their occurrence in the various valves he
^H explains by an anatomical demonstration that these are the points
^^H where the parts are most strongly pressed against one another when
^^L closed, and he concludes, therefore, that pressure is the main motive
^^m cause of endocarditis, and that the liability of each valve to inflam-
^^m matory lesions is in direct proportion to the degree of compressing;
j^B force to which its structure is subjected.

^^ This is exactly what might have been expected from the behaviour
of other tissues, notably those of the joints, under the action of
such a morbid process as that (say) of rheumatic fever going on in-

84 Reviews. [July^

the body. If the limbs are kept perfectly quiet from the first occur-
rence of pain the rheumatic swelling moves about, and finallf moves
away altogether, without leaving a trace behind ; but should these
joints be exercised or pressed upon, the rheumatic inflammation is
apt to turn into common inflammation, to remain fixed in the
affected organ, and to leave a permanent fibrotic scar or adhesion,
and even to cause ulceration of free surfaces. The difference between
the joints and the cardial valves hes in this, that the limbs can rest
and the heart cannot.

Still, an approach to a comparative state of rest may be made by
appropriate treatment, and Dr. Sibson puts this first in the list of
preventive and curative measures. He says —

"The absolute rest of every joint and limb, and the soothing
application of the belladonna and chloroform liniment sprinkled on
cotton wool to the affected joints, supported by flannel applied over
the seat of pain with uniform and comfortable pressure, are the most
important measures in the treatment of acute rheumatism for the
prevention of pericarditis. The rest and support of the affected
joints should be strictly maintained for several days after the disap-
pearance of the local inflammation, for the too early use of an affected
joint or limb, after the relief of pain or swelling, often leads to a
relapse, first attacking the joints of the over-used limb, extending to
other joints, and often producing endocarditis and pericarditis."

Next in importance, but at a long interval, he places a moderate
abstraction of blood by leeches and the use of opium, which, indeed,
might both be included under a fulfilment of the indication of tem-
pering the pressure upon the sore valves. He does not allude to
the sedative effect upon the circulation of an even high temperature,
which, under the name of '^ blanketing,^'' is so warmly insisted upon
by his colleague at St. Mary's, Dr. Chambers,i and which again may
be considered a carrying out of the same principle.

Death as an immediate consequence of acute endocarditis is so rare
that neither of the writers whose works are under review allude to
the subject. In Dr. Sibson's table two of his cases of pure valvular
inflammation are marked as having been fatal (with a little figure of
a coffin), but the cause of decease is not mentioned in the text, and
may have been unconnected with the heart. Still, there are cases
'Of this termination on record, and it would be useful to know
whether embolism, congestion of the luags, or sudden enlargement
•of the cardiac walls, were the results most to be feared. It is a
question that can be decided only by systematic writers, for no man's
:single experience can be extensive enough to comprise many instances
of so rare an occurrence, and he wouid be glad to know if his one
•or two instances are accidental or representative ; and it is a practical

^ •' Lectures chiefly Clinical ;' lect. xiit.

1877.] Diseases of the Heart. 85

question too ; as is the mode of death in all diseases ; for thus we
learn what is specially to be guarded against in our management
of the patient. It is possible that the fatal instances of endo-
carditis are of a different nature from the ordinary lesion, that
the process may be of a more destructive kind, ulcerative or diph-
theritic, and may not be dependent upon pressure or friction, as
is the endocarditis of rheumatism. If so the mode of death is
probably diagnostic of the nature of the disease.

The risk of immediate death is not the most serious of the evils
entailed by endocarditis. Its tendency to induce chronic or scle-
rotic lesion as a scar of the acute inflammation makes it much
more interesting, for thus it permanently cripples the valves and
induces dilatation.

On the subject of crippled valves there is an enormous mass of
information for the student, so that he is fain to use it rather as a
library of reference than to hope to gain by reading a clear view
of the subject, such as may serve him in good stead in view of the
patient immediately before him, or in estimating the past history
about which he is anxious. We will restrict ourselves here to
points upon which in practice knowledge is really desired.

In the first place, what are the different effects in nature and
degree of lesions of the several valves, especially as to the causa-
tion of dilatation ? The concurrence of opinion which might fairly
have been expected on this point is not to be found. According to
one of the most recent of French writers, Jaccoud, stenoses in
general are more serious than regurgitations ; and mitral stenosis is
more so than aortic stenosis. Again, Friedrich, in the * Handbuch
der Spec. Path, und Therap.,' 1867, says, that the prognosis in
obstructive is less favourable than in regurgitant affections as a
rule. And Dr. Eosenstein in the volume which is now before us
(page 141) rates the prognosis in aortic insufiiciency as more
favourable than in any other valvular disease. On the other hand
Dr. Walshe estimates all the regurgitations as much more serious
than the constrictions, and in particular regards aortic stenosis as
admitting of a far better prognosis than aortic regurgitation. Dr.
Peacock agrees with him, stating that in the former disease life may be
prolonged for many years, and a large amount of health and vigour
be enjoyed ; whereas in aortic regurgitation it is very rare to find
life long sustained. Dr. Fagge (in ' Eeynolds^ System,' p. 678)
criticises the data upon which these opinions are founded, but con-
fesses himself quite unable to reconcile their differences. He is,
however, inchned to believe that the English pathologists are right,
and this feeling appears in general to guide the medical referrees of
our insurance offices, to whom the question is a very vital one. It
would seem, then, that statistics, even when collected by the most
competent observers, fail to solve the problem proposed. The

86 Reviews. [J^ily>

reason of their failure seems to us that from the nature of the case
they, do not record the real point that affects the issue. To the
arithmetician a valvular lesion is a valvular lesion, and he takes no
note of its degree or the effect it has in crippling the functions of
the part. Now, there are valvular lesions, notably lesions of the
mitral, glaring enough in the post-mortem room, and others which
make a great noise in the ear of the auscultator, which yet produce
no clinical symptoms, and do not bring a patient into doctors'
hands ; whereas lesions of that same orifice among hospital patients
are quite as serious as any other valvular affection. Indeed, Dr.
Walshe considers the auriculo-ventricular regurgitations as the most
serious of all mechanical derangements of the circulation among
those who have come under his care as a physician. Yet in a table
of cases these would be reckoned together as each a mitral lesion.
Would not a physiologist's way of viewing the matter lead to a
truer estimate than that of a morbid anatomist or of a clinical
observer ? He would suggest that the different forms of injury
are proportionally serious in accordance with the period of the cycle of
cardiac action at which they derange it, and not at all in accordance
with the amount of abnormality they present to the eye, or the
loudness of the vibration by which they are clinically detected.
Thus a moderately contracted aortic orifice will at the beginning of
the systole cause the stream to flow slower and less forcibly through
the arteries, but by the end of the stroke it is overcome by the
vigorous ventricle, and the heart gets emptied of blood. The
patient may be anaemic and sluggish, but is not liable to dila-
tation unless the ansemia is so great as to weaken the heart walls
along with the other muscles. But if the contraction of the same
orifice is very great, still more if it is accompanied by regurgitation
even in a slight degree, the pressure is continuous, the heart-walls
entirely lose their rest, and yield to distension. Thus an aortic
lesion may be either the least important or the most important of
all the valvular abnormalities. Again, a mitral valve may have its
curtain stiffened so as to shut slowly, and present to the regurgi-
tating stream a vibrating edge, which like a jewsharp makes a
noise out of all proportion to its size, and yet by the end of the
systole it shuts close enough for practical purposes. Or on the
other hand it may be affected in such a way as to remain wide open
throughout, and let 'a backstream distend the auricle to its rapid
injury. Of warts, too^ the mechanical impediment must vary im-
mensely with their position.

Another burning question is what can be done by way of pro-
phylaxis to stay acute endocarditis from becoming chronic deformity ?
Dr. Fagge adduces facts which tend to prove that it not rarely sub-
sides without leaving any injurious effects behind it; in particular,
that a large proportion of the cases of rheumatic inflammation of

1877.] Diseases of the Heart. " 87

the aortic valves in women must terminate in a restoration of normal
structure. This comparative immunity from the chronic conse-
quences which are so frequent in men can be ascribed only to the
fact of the social position of the weaker sex exempting them from
muscular exertion. The plain inference drawn by Dr. Fagge is,
that " in either sex the way to prevent future injury, after endo-
carditis in rheumatism or chorea, is to keep the patients for many
months, or even years, as perfectly as possible at rest ; to insist on
abstention from violent exercise, athletic sports and games of all
kinds ; to direct the choice of a light sedentary employment, and to
urge the avoidance of all emotional excitement." Dr. !Fagge also
does not despair of the influence of drugs, and sees no reason to
disbelieve that " iodide of potassium, mercury, or arsenic may be
able to arrest or prevent these changes, as much as those which
belong to certain skin diseases, or the chronic inflammations of parts

accessible to the sight or touch Similar principles must be

applied in the endeavour to prevent forms of valvular disease which
are from the first of gradual origin." To this latter clause we
must demur, for the last-named lesions would seem to be commonly
of degenerative nature, and to originate in causes which lower the
vital powers and produce anaemia, such as alcoholic indulgence, pre-
mature old age, syphihs, imperfect nutrition, &c. A different treat-
ment would here be needed.

The prevention by anticipation of future injury from valvular
disease is a touchstone of the utility of the sphygmograph to the
physician. If it fails, it is only a scientific toy. There is no doubt
that it enables us to appreciate "much more delicately than is possible
by the tactus erucUtissimus variations in the pulse, indicative of
the degree of efficiency with which the circulation is carried. The
mere fact of a diseased valve can be ascertained more easily, and as
certainly, by the stethoscope, but in the tracings from the pulse the
degree in which it affects the general circulation should be made
evident. Mr. Mahomed gives in his papers in the ' Medical Times
and Gazette' for 1872 some valuable illustrations of the way in
which the instrument may be used in cases of this kind, to deter-
mine the degree of valvular incompetency, the amount of compen-
satory hypertrophy of the left ventricle, and of resistance or tension
in the arteries. It is probable that more is to be learned from these
phenomena, in respect both of prognosis and treatment of mechan-
ical derangements of the circulating apparatus, than from clinical
and anatomical statistics. Dr. Eosenstein seems to expect from the
sphygmograph nothing beyond assistance in diagnosis, which is really
the least important of its uses ; as in localisation of lesions it is not
strong. But in prognosis, that is to say, in estimating the value of
the vital force which has to resist the disorganising force of disease,
it is of gre^t and increasing use.

88 Reviews, [July^

The bearings of "Pericarditis'' on the condition of the heart-muscle
constitute its claim to a prominent position in monographs of car-
diac disease. Its influence is twofold, first during its acute, and
secondly, during its chronic stages. In acute pericarditis there are
few thorough observations as to the immediate cause and mode of
death ; Dr. Sibson does not even allude to it ; but " Wagner''
(? Rudolf), is quoted by Dr. Bauer, in his article in Ziemssen's
* Cyclopsedia/ as having found fatty change in the cardiac substance
in seventeen out of thirty-five cases of this disease. The estimate
is probably too low, but it afl'ords a proof that the morbid action
is not confined to the surface, and that it penetrates interstitially the
more essential parts of the organ. Indeed unless it does so, and
unless it paralyses the contractions of the muscular fibre, there is
no suificient reason why it should prove fatal.

The best-marked cases of myo-pericarditis answer to the de-
scription by Yirchow.

" The surface of the pericardium w^as very rough with layers of
fibrin. The substance of the heart throughout seemed ftabby, pale
and somewhat spotted. Beneath the v.hole extent of the peri-
cardium the outermost layer had assumed a cloudy, pale-yellow
appearance. This layer was from one to two lines in thickness, and
within it were groups of primitive bundles in such an extreme con-
dition of fatty metamorphosis tliat their internal structure could
no longer be made out, even in the slightest degree. In the deeper
layers this metamorphosis gradually decreased, but in no part of the
muscular substance was the interior of the primitive bundles en-
tirely free from fat-granules. Towards the surface layers of pro-
liferating connective tissue were met with, which extended into the
thickened pericardium and the visible fibrinous layer, and which were
thickly strewn with numerous masses of nuclei and cells, closely
crowded together and in the act of subdividing."

A muscle in condition like that must be quite unequal to its
function of propelling the blood, and with this interpretation the
frequency of death in pericarditis is easily understood, as also the
frequency of such a degeneration of the substance as leads to atrophy,
hypertrophy, and conversion into fat in cases where the immediate
complete failure does not occur. " Implication of the muscular
tissue," as Dr. Bauer observes, *^ must be considered not merely as
a complication, but rather as a result of the pericarditis. It may
either appear and cause death in a few days, or it may lead to a
chronic wearisome illness." Under either circumstances it is the
inability of the heart-wall to compress and expel its contents which
is the point whither our anxieties tend. The forms of pericarditis
most prone to this result are the worst; those unlikely to have such
a termination are of minor moment. The grave .symptoms are dis-

1877.] Diseases of the Heart, 89

turbed respiration and circulation^ redaction of the arterial pressure
in the pulse, dyspnoea, venous congestion or cyanosis.

"It is hard to say," remarks Dr. Bauer, " in how many cases and
under what circumstances complete restitutio ad integrum ensues,
and in how many cases lasting changes remain. We can compare
the frequency of pericarditis during life with the number of autop-
sies in which pathological changes of that nature are found. We
can also arrive at some conclusion from appearances presented at
the autopsies on the bodies of persons in whom during life pericar-
ditis is known to have occurred, but from which they have recovered,
and subsequently died from other causes."

The source of fallacy in the first mode of reckoning arises from
what are commonly known as " milk-spots/^ which are held by
M. Willigk, Louis, &c., to be results of cured pericarditis, whereas
they are now traced in many instances to remoter agencies.

But there are a great number, perhaps a majority of patients, in
whom though a technical renewal of the typically normal heart has
not followed, yet practical health has been restored and the life not
shortened or burdened. It may be suggested that a careful inquiry
into the records of insurance offices would show a considerable
crowd of these cases, who, from their own statement or from leech-
marks on the cardiac region, are known to have had inflammation
there during rheumatic fever, and yet are very good customers to
the society.

Considering pericarditis in general as inflammation of a serous
membrane, our first indication of treatment should be to limit the
extent of the process. With this intent Dr. Sibson appHed leeches,
followed by cotton wool or poultice sprinkled with belladonna and
chloroform liniment during the early period. He gives notes of
thirty- six cases where a record of this treatment has been preserved.
In twenty-nine of these there was pain in the inflamed pericardium,
in seven no note of it. In twenty -four of the twenty -nine marked
relief, not to the pain alone, but also to the dyspnoea and oppression
in the chest, so speedly followed the bleeding, that the advantage
could not but be attributed to it.

In five instances the assuagement of the pain was not appre-
ciable, yet in all but one the action on the patient's state seemed
favourable. In that one, a girl of twenty, the heart was already
tumultuous on admission to the hospital, and the bleeding from
one of the leech-bites could not be stayed, so that a serious loss of
blood occurred, and then she caught smallpox and died. The
haemorrhage was, however, evidently more debilitating than it would
have proved to a stronger frame.

We cannot think that against evidence of this sort Dr. Bauer is
justified in denouncing the taking of blood as '^useless and dan-
gerous/^ in entirely omitting the most moderate employment of it from

90 Reviews. [July^

his metkodus medendi, and still less in stating that " it has been
generally abandoned/' He may feel quite sure it will not be gene-
rally abandoned in England and her colonies for many years to come.

The use of digitalis in acute pericarditis has not been sufficiently
well known in this country of late years for us to found an opinion
about it on experience; but at Munich it has been found a sovereign
remedy to control the rapidity and violence of the heart's action and
the high fever secondary upon the serious inflammation. The quan-
tity of the leaves administered is from 15 to 30 grains daily, in
divided doses ; and it is usually found that the full influence is not
developed till from 30 to 45 grains have been taken. As soon as
the pulse grows smaller and quieter it must be left off. The ad-
vantage of stilling the turbulence of the heart is incalculable, and is
not only quite consistent with leeching, but has the possible advan-
tage, in reference to that treatment, of preventing the excessive
hsemorrhage, of which there is a risk, alluded to just now. To
recommend the application of an ice-bag over the cardiac region
has a startling sound to practitioners who have been used to em-
ploy hot poultices, cotton wool, and the like. But the two treat-
ments are not so opposite as may seem at first thought. There is
no doubt that the main advantage of either lies in maintaining
unchanged an artificially even temperature, independent of surround-
ing circumstances. This is most soothing to the nervous system,
just as the strongest stimulant to the dormant powers of life is
sudden alternation : witness the cold water dashed on the stillborn
child and the sinking mother, and the invigorating effects of shower-
baths. In order, therefore, to try fairly the German use of the ice-
bag, it is necessary to apply it uninterruptedly. It may be expected
to allay the pain and palpitation, and does not interfere with either
leeches or digitalis.

Blisters and mercury are not without reason denounced by both
systems of medicine. Opium has hardly received from either suffi-
cient attention, in our opinion, for it certainly has a most powerful
effect in diminishing the quickness of the pulse.

The list of cases in which paracentesis pericardii has been per-
formed is as yet too small for a verdict to be given on its results.
Of course it would not be proposed unless there is immediate dangei
to life from the amount of the effusion, or the certainty of an un-
favourable end from a stationary jowr?^^^?^^ effusion. Dr. Sibson has
collected the records of five patients on whom it has been done of
late years, of which three died. His observations are very valuable,
for his well-known accurate anatomical knowledge is a safe guide m
the selection of a proper place for puncture, naturally a moot point
in an emergency which occurs so seldom. Dr. Sibson does not
appear to have ever witnessed it, though he records here sixty-three
cases of pericarditis in his practice at St. Mary's Hospital alone, and

1877.] Diseases of the Heart, 91

from his well-known interest in the subject had many other oppor-
tunities of seeing the disease in consultation and elsewhere. He
advises that the trochar should be inserted into the distended
pericardium ^* just above the upper edge of the sixth cartilage at the
lowest part of its curve, more than an inch within the mammary
line ; and that the instrument should penetrate gently invt^ards with
a direction slightly downwards, so that it may advance into the col-
lection of fluid below the level of the heart, and that the liquid
should be slowly extracted by the use of a syringe or aspirator."
Dr. Bauer is more vague; he simply says he would penetrate
the thoracic wall close to the edge of the sternum in the
fourth or fifth intercostal space, laying the patient on his back
to avoid wounding the heart. This is supposing the heart to
be of normal size. But Dr. Sibson points out that it may be
enlarged, and the apex may consequently be low down, and the
dulness on percussion of the fluid extend into the epigastrium, as is
shown by a diagram he gives, page 340.^ Under such a circum-
stance he would select a space between the left edge of the ensiform
cartilage and the right border of the seventh costal, or else he would
perforate the ensiform itself. Clearly the success of the operation
depends very much on the place of puncture, and we cannot com-
mend Dr. Bauer's off-hand manner of treating the subject, though he
seems not ignorant of the recent English experience of Mr. Teale, Mr.
Wheelhouse, and Dr. Allbutt, on which his observations are based.

" Adherent Pericardium^' receives in Dr. Reynolds' ' System'
a separate article ; and " Hydropericardium" is restricted by its
author, Dr. Begbie, to an effusion of fluid in the sac as a part of
general dropsy, while in " Pericarditis" we are concerned with the
acute affection only. So that the chronic collection of pus or serum,
or sero-pus, as a consequence of previous local inflammation, or the
coating of the membrane with fibrin, without adhesion, escapes
notice altogether. This is a serious omission, for though the disease
is not common, yet fevv^ pathologists have failed to see a certain
number of cases, and its treatment deserves consideration. In
Ziemssen's ' Cyclopsedia' we hear about it as chronic pericarditis, but
it is somewhat swamped by the relatively greater importance of the
acute affection. In our own limited experience a collection of fluid
in the sac has not led to dilatation or hypertrophy, and we should
have been glad to have known if that were the general observation.
Its chief danger would appear to be the threatening of sudden death
from compression, a contingency in which the operation of tapping
would seem appropriate.

To the usually given physical signs of " adherent pericardium '*
(viz. systolic depression in place of deficient apex beat, return shock

^ The reference to this diagram in the part about paracentesis is an erratuna
omitted from the printed list.

92 Reviews. [July,

over previously retracted space, increase upwards of cardiac dulness^
and its immobility during inspiration and expiration) Professor
Eriedrich has recently^ added another, sudden collapse of the cervical
veins during diastole^ sometimes even so marked as to deepen the
shadow in the supra- clavicular fossa. So that more cases are
capable of detection during life than was possible twenty years ago.
But yet so often are these symptoms absent or masked by more
serious evils, that it is very seldom indeed that warning can by
their aid be given to a patient before degeneration of the heart
muscles commences. So that practitioners in whose minds prudence
predominates try and persuade all that have ever had pericarditis to
live as if the membrane were adherent ; and against this discipline
they have many rebels ; while others of a sanguine cast let all go on
in a happy-go-lucky kind of way, and must in old age have several
shortened lives on their consciences. The importance of adherent
pericardium lies in its impediments to the contraction of the heart
inducing dilatation and hypertrophy, and its seriousness in direct
ratio to the rapidity with which these supervene. Is an adherent
pericardium a more or a less injurious lesion than valvular degenera-
tion, in respect of those heart walls whose integrity we have made
the pivot round which all our anxieties revolve? Dr. Sibson's
researches enable us to give an answer somewhat rough and ready,
yet probably not far from the scientific truth. He found that the
average weight in thirteen cases of valve disease with adherent
pericardium was 24i ounces, while its weight in sixty -three cases
of a like kind, in which the pericardium was not adherent, was
19 ounces or 5J less than the first series. It may be concluded,
therefore, that in cases of valvular disease the existence of adherent
pericardium tends to increase the size of the heart, but not to a
great extent. Again, in 16 cases in which the valves were competent
while the pericardium was adherent, in one third there was no
enlargement, and in two thirds it seems to have been so slight as
not to have been estimated by weight. This would appear to
place the gravity of adherent pericardium between that of mitral
and aortic regurgitation, somewhat worse than the first and not so
bad as the last.

Dr. Reynolds is quite right in putting together in one article all
he adventitious morbid products occasionally found in the heart,
^hey are interesting to the pathologist merely by not often appear-
g in this situation, and so showing how well some occult influence,
^ich it is his business to find out, defends the heart against the at-
•ks of such foes. But to the practitioner it appears unphilosophical
to\ make separate subjects of tubercle, cancer, hydatids, &c., in
heart and in the pericardium, and the whole together united do

J •' VircUow'9 Arcbiv/ Bd. xxix, 1864.

1877.]

Diseases of the Heart. &^

not possess the clinical importance of any of the least of the
already discussed lesions.

*' Pneumo-pericardium" is made the subject of an article in
both the 'System' and the 'Cyclopaedia.' Surely this is not a
disease. Directly any ulceration into a neighbouring viscus occurs_,
such intense pericarditis is set up that there is no room for air
before death. And then, indeed, what collects is probably, as
Eokitansky thought, a 'post-morteyn appearance, the result of de-
composition.

An evidence of this is that the serum is not churned up into frothy
as it would be did the heart beat even for a i^^ minutes in such a
thick albuminous fluid.

One of the cases cited by Dr. Bauer happens to have been
under the care of the present writer, aud it is certan that what
he speaks of pneumo-pericardium arose from the decay of chewed
food which had escaped through a fistulous ulcer from the oesophagus
and was not in the sac before death, or it would have been
detected by percussion.

The most interesting pages in these large volumes are those
which contain the thoughtful essay of Professor Gairdner on
Angina Pectoris. This peculiar group of symptoms is the most
deserving of study, in relation to other forms of cardiac disorder,
of any which have to be considered. The paroxysm is quite sui
generis distinguished from everything else by its agony of pain,
not so remarkable in its acuteness as in its '^ imhearable?iess/' and
by its sense of impending death combined with full use of the
perceptive and intellectual faculties. There is no feeling of feai*,
and out of deference to others the expectation of an immediate
fatal termination is usually concealed by educated persons. Pahi
is of course a comparative symptom, and may be present in any
degree, even so slight as to make Dr. Gairdner suggest as a class of
allied cases "angina sine dolore " : but the excessive and indescrib-
able distress that marks the presence of the pain does not seem to
be ever absent. So that there is no difficulty about the identification
of the disease. Dr. Gairdner also pertinently suggests that many
cases of sudden and lonely death, the wreck of a ship in mid-ocean
with none but the lost crew to have marked its breaking up, are
probably due to breast-pang. Several pathological changes in the
centre of circulation have been found after death, of which the
most frequent is fatty atrophy ; but their variety, and the impossir
bility of tracing any direct connection between them and the
symptoms, do not allow us to think that the morbid anatomy of
the disease has been approached. Most observers will agree \vitU
the author in viewing the paroxysm as a neurosis, attributing its
phenomena partly to vaso-motor spasm and partly to inhibitory
influence transmitted through the vagus nerve from the medulla

&4 Reviews. [July,

oblongata. A confirmation of this view is found in a peculiar
symptom often to be found in sufferers, namely, a loss of voluntary
nerve-power without warning under moderately exhausting circum-
stances. A man, for example, has continued out walking a little
beyond his usual luncheon hour ; suddenly his legs refuse to support
him, and till he can get something to eat or drink he is impotent to
taove. But with dietetic help he is soon right again.

Of the constitutional causes of Angina Pectoris Gout is the only
'one which appears to Dr. Gairdner to have evidence in its favour.
Gout is unquestionable, indeed he suggests that the majority of
the suddenly fatal endings of irregular and atonic gout, called
^* gout in the stomach," or " gout in the heart,'' are hj angina
pectoris. He connects the diathesis with its cardiac results through
the degenerative changes in the heart and arteries closely associated
with the retention of uric acid in the system.

The progress must depend mainly on the detection of organic
changes in the circulatory apparatus. If there is reason to suppose
that these are not present, or that they do not tend to increase, it
is much more favourable than the patient is fain to believe. And
it is satisfactory to know that invalid habits and a useless life are
not required, nor indeed do they appear conducive to length of
days. For proof thereof to the cases cited the following may be
added : — upwards of twenty years ago an hospital physician in going
round his wards was seized with breast-pang, entirely prostrating the
body, but leaving the mind perfect. His colleagues sent for his wife,
and when she arrived next day he was still so ill that he took a
solemn leave of her. He has had two or three minor paroxysms
since, as also an attack of gout, but is still practising his profession.

As to treatment during the fit Dr. Gairdner accepts the recom-
mendations of former English physicians as to use of stimulants,
and the practice is probably correct, though in point of fact
sufferers do not speak of being much benefited. He refuses to
endorse the disapproval of opiates expressed by Professor Niemeyer,
except in cases of uraemia, dropsy, bronchial or central congestions.
Both opium and chloral should, however, be given in moderate
doses and stopped directly their effects are produced upon the
disease, before the toxicological results follow. (One would be glad
to apply as far as possible this rule to the use of all drugs in all
diseases.) Qf late years the nitrite of amyl in vapour has com-
riiended itself to the profession for the relief of the spasmodic
contractions of the peripheral blood-vessels to which breast-pang
has been attributed ; and the personal experience of Dr. Madden,
of Torquay, quoted iu detail from ^ The Practitioner ' by Dr.
gairdner, is cQncli\sive as to its efficacy. Nitrite of amyl can be
carried about the person in a small stoppered bottle, and from 5 to
10 drops inhaled when an attack threatens*

1877'.] Diseases of the Heart, 95

Dr. Gairdner does not here allude to a remedy whose action is
physiologically similar to nitrite of amyl, and which gives singular
relief in breast-pang, namely, rapid friction of the external surface
of the body and limbs with a hair-brush. The flush which follows
its employment shows how readily the capillaries dilate, and it does
not cause cerebral disturbances like amyl. The reHef is very great.
The action of galvanism is somewhat similar to that of the hair-
brush, but very inferior, and seldom so readily applicable.

On the inter-paroxysmal treatment Dr. Gairdner's remarks are
judicious. On two points perhaps we should pronounce him too
trenchant; namely, on the subjects of marriage (page 585) and of
continuing the usual occupations of life (page 595). He would
have the patient submit, like a confirmed invalid, to the loss of
these. Doubtless the stormy rapture of lust, with its shame and
sorrow, and unsatisfied longings and futile repentances, is a most
depressing influence ; but the same cannot be said of the invigo-
rating exercise of married love ; besides which the feeling of
having some one always at hand with the needful remedies is in
itself a tonic, and keeps off the demand for them. An even warmth
by night is also a great safeguard against attacks. We hold that
there are many cases in which marriage is decidedly to be advised,
especially where there is no organic lesion to be detected. Then as
to the continuance of occupations, in Dr. Gairdner^s cited cases the
patients have not given them up : " toiling, rejoicing, sorrowing, on-i
ward through life they go,'' and have not to complain of its bein^
thereby shortened. Even amusements which " hurry the breathing,'/
such as scrambling over glaciers, seem rather beneficial than otherwise
Eor it must be remembered that, not the field^labourer or navvy, bi
the poring sedentary scholar and the hard thinker is the most usul
sufferer from angina-pectoris.

Dr. Gairdner's brilliant essayls a type of excellence of which ^e
would fain see many disciples. Dr. Sibson's " Pericarditis " is als/ a
model : yet how different ! Perhaps never before were such a number
of minutely described cases of any one local disease coUecied
together. In observations the author never seems to have considered
his pains and labour as of any account, if a point were to be made
out ; and the titles and diagrams to illustrate it fairly take away
one's breath. Truth was his aim, and truths of all sorts were so
superlatively beautiful in his eyes, that he could see no degrees of
comparison. The consequence is that information which you very
much want is apt to be smothered and made to appear unimportai^t
by an overlying mass of facts of which you are content to remain
ignorant. One cannot fail to admir,e the perfection with which
this plan is carried out., Nevertheless a questioi^ arises — Bo wpj
wish to set up the model for imitation ? Is the profession to b*
congratulated on the best years of a valuable life having been con»

^^ Reviews. [July^

sumed in " serving tables," in proving platitudes, and slaying again
slain fallacies ? Micliael Angelo designed the pretty livery which
makes the halberdier of the Vatican a thing of beauty, and Julio
Eomano decorated the ointment-pots of the Loretto dispensary :
but the world would have been the poorer if these irapepya had
impeded the execution of the Last Judgment or the Martyrdom
of St. Steohen.

VIII. — Diseases of the Urinary and Reproductive Organs.^

This second edition is altered from the preceding one by the
omission of that portion of the work which had to do with the
kidney, so that more room was left for the discussion of the so-
called functional derangements of the reproductive organs in both
sexes. The first edition contained little about those affecting the
female sex.

" Qui s'excuse s' accuse " is a wise and expressive if somewhat pes-
simist proverb. So the somewhat apologetic preface is not en-
couraging, and a somewhat enigmatic sentence which is its pero-
ration prepares the reader for the worst :

" To succeed in elevating the literature of the subjects herein
treated from the mire in which it has been permitted too long to
remain would have been a not unworthy triumph, to hasten the
accomplishment of this end, ample reward for the trouble which the
oreseut undertaking has entailed."

A careful perusal of the work, however, will agreeably surprise
he reader. In spite of an inflated somewhat obscure style, many
nannerisms, and a little egotism, there is a large amount of useful
iiformation in the book. The author has evidently read a good
dtal and also can think for himself, and with comparatively few ex-
ceptions the work seems to have been written by a professional man
for professional men, not by a charlatan for the public.

We would not too severely criticise, though we can hardly agree
with his classification of functional diseases. It is confessedly
difficult to draw hard and fast lines, but the cystitis of paraplegia is
with some difficulty allocated as a functional disease of the bladder.
On that subject Dr. Black has some excellent observations. He
joins issue with Mr. Hutchinson as to the proper treatment in
cases of retention in paralysis, Mr, Hutchinson inclines to adopt
the plan of allowing the bladder first to fill and then to overflow of
itseji in these eases, because cystitis constantly follows the use of
catheters. Dr. Black agrees that cystitis does frequently follow

1 On the Functional Diseases of the Urinary and Reproductive Organs. By Q
Campbell Black, M.D., L.R.C.S. Ediii., &c. Second edition, revised.

1977.] Diseases of Urinary and Reproductive Organs. 97

catheterisation in such cases, but explains it by the depressed state
of the nervous system acting and reacting on the condition of the
urine and of the bladder. Neither authority seems to be aware that
in cases where the catheter is frequently used, the decomposition and
alteration of previously healthy urine is actually caused by the
mechanical introduction on the catheter itself of germs of putrefac-
tion, bacteria — call them what you like — and can be with almost
absolute certainty prevented by the simple expedient of using hot
water to purify the catheter and carbolised oil, instead of rancid
oil, or questionable lard, to grease the catheter.

Eetention of urine from shock is described and illustrated by a
case in which we have distinct evidence that there was enough local
injury, apart from shock, to account for all the symptoms :

"In this case there was considerable ecchymosis over the lower
part of the abdomen ; the penis, particularly the glans, presented
a similar appearance of greater intensity, and the scrotum was
similarly affected. The catheter was passed with ease ; the urine
withdrawn was perfectly normal, but the power of micturition was
in perfect abeyance."

The chapter on nocturnal emissions and spermatorrhoea and their
relations is rather a transcendental one. It begins with a quota-
tion from Eeuchtersleben, and culminates in the fine old crusted
proverb, ^'Castus raro minget," which is, we hope by a typo-
graphical error only, curiously misquoted; then, through a good
many pages of ill-arranged material, from seminal secretion in ad-
vanced life, and Old Parr, and Pliny on the productive climacteric to
Sir A. Cooper's case of castration and Sayer's cases of phymosis, we
are at last led into a very doubtful argument on the physiological
relations of continence and incontinence, in which we fear continence
gets the worst of it.

We are pleased to find that one of the best bits in the chapter is
a long quotation from our own columns in a review of Lallemand's
work in 1848 :

" M. Lallemand, in our opinion, attributes far too great an im-
portance to prolonged continence as a direct cause of spermator-
rhcEa. That a moderate exercise of the genital organs is the con-
dition most favorable to the maintenance of their healthy condition
and the general well-being of the economy is a fact which requires
no proof; but we conceive that M. Lallemand greatly exaggerates
the ill consequences which ensue on withholding such exercise."

So said our reviewer in 1848, in what Dr. Black calls a very able
review; and so would we in 1877 re-echo his words, even with
additional force. We believe, from a very large experience of treat-
ment of school lads and college young men, that the whole question
of the efi'ect on health of continence has been much exaggerated.

The "sera juvenum Venus, ideoque inexhausta pubertas" is true

112— LX. 7

9S Reviews. {j^^^J,

still j and most healthy, manly cricket-playing lads, working students
and dressers, and many young officers, really trouble their heads very
little about their generative organs.

It is the pasty-faced, slouching, smoking, and drinking lads, who
can neither look each other or any decent woman in the face, half
mad and quite stupid, for whom such books as this require to be
written. They will be pleased with arguments on the evils of con-
tinence, not the men who are to do the work of the world.

We are no advocates for prudery or concealment. Let boys be
warned of sexual temptation and sexual dangers, but let them be
told, when the unsavoury subject has been broached, that the less
they think about the state of their genital organs the better, that a
nocturnal emission now and then is not a thing to whimper about,
that the loss of mucus from a cold in the head is quite as exhaust-
ing and much more offensive, that perhaps there have been too
many bed-clothes, or the bed-room window has not been opened
enough.

Teach them to swim, box, play cricket, and speak the truth ;
feed them simply, and show them that smoking, drinking, and
sweetmeats will spoil their training, and then books of this kind
will not be so much needed, even for the profession.

The chapter on "Anomalous Urethral Discharges" deals with
a subject presenting many difficulties. Dr. Black faces them as
follows :

" As in the female, in the present state of our knowledge, it is next
to impossible to distinguish between leucorrhoea and gonorrhoea
except by such surmises confessedly inexact, as general considerations
afford, so in the male it may be equally impossible to discriminate
between a case of simple urethritis and one of gonorrhoea with any
degree of well-founded assurance.

" To such an extent, indeed, is this difficulty recognised, that it is
contended by certain modern authorities that gonorrhoea is capable of
being communicated by females who are themselves perfectly free from
the disease. This, if admitted, would practically amount to the con-
clusion that there is no such disease as specific gonorrhoea, an alterna-
tive to which we cannot assent, even admitting, as we do, the extreme
difficulties of diagnosis. The relation of the two affections is not
more remarkable than that which subsists between the suppuration
of pyaemia and that of a healthy surface ; yet no one will contend
that there does not exist some specific distinction, unrecognisable by
any chemical or microscopical test which we possess.

" Professor Kuss, of Strasbourg, in examining Lock cases, was in
the habit of collecting the secretion of the vagina and cervix uteri
on a glass rod, depositing it upon small pieces of glass, and examining
it microscopically.

" If the liquid exhibited pus-globules the patient was detained for
gonorrhoea ; if simply vaginal cells, she was believed to be free from

1877.] Ferrier on the Functions of the Brain, 99

the specific disease. But this distinction is, we fear, too absolute.
The absence of pus-cells might be presumption of a non-gonorrhoeal,
but their presence, we submit^ would not necessarily prove the
existence of the specific disease" (pp. 245, 246).

We may quote also a sentence on another interesting subject, to
show that Dr. Black has some humour, and can speak his mind
freely. Speaking of functional diseases of the female organs causing
sterility, he says —

" The position of the uterus in the pelvic cavity, — one of the
most graphic sources, by the way, of professional charlatanism and
of groundless feminine solicitude, has unquestionably an intimate
bearing on the facility or the reverse of impregnation, though I very
much doubt if many of the constitutional symptoms ascribed thereto
have any relation therewith, save in the perverted brain of the too
fussy brain of the gynaBcologist" (p. 268).

On the whole we are disposed to regard the book as a good, well-
intentioned one, which would be improved by pruning, by more
care in the composition, and even in the corrections of the press.

IX. — Ferrier on the Functions of the Brain.^

The general bearing of Ferrier's work is, doubtless, familiar to
almost all our readers, and it will hardly be expected here that we
should give any detailed analysis of the contents. The work, as a
whole, may be taken as marking a distinctly new direction, which
the study of nervous physiology and pathology has taken of late
years, and it may be regarded as altogether remarkable that, some
half dozen years ago, almost all the great results embodied here were
only guessed at. We say they were only guessed at, but it is in
the highest degree to the credit of the sagacity of Hughlings
Jackson that they were guessed at, and that the results of experi-
ment have been to a great extent merely confirmatory of speculations
which he had already given forth to the world on the basis of clinical
and pathological experience. It is very appropriate, therefore, that
this work is dedicated to the distinguished physician of the London
Hospital, whose researches it so wonderfully illustrates and
confirms.

We shall pass over that part of Ferrier's work which discusses
the structure and functions of the spinal cord and medulla oblongata.
There is nothing new in these chapters, and we are not sure that
much care has been exercised in putting the facts as accurately and
systematically as might be.

1 The Functions of the Brain. By David Fbeeieb, M.D., P.R.S. London,
1876. Pp. 323.

100 Reviews. ||«Tuiy>

If we were to put in a few words what we consider to be the essen-
tial results of the work it would assume a form something like this :
hitherto, the endeavour to arrive at the functions of the central
nervous system has mostly stopped short at the corpus striatum and
optic thalamus. Most were agreed as to the general functions of the
spinal cord, medulla oblongata^ and pons, and it was universally
acknowledged that the corpus striatum is a motor ganglion, while
most were inclined to believe that the optic thalamus is a sensory
centre. In the work before us it is distinctly asserted that the
corpus striatum is a motor and the thalamus opticus a sensory gan-
glion, but the author goes much further than that. He attempts to
expand these ganglia, as it were, into the cerebral hemispheres. He
asserts that while voluntary motion of all parts of the body is repre-
sented in a comparatively small space in the corpus striatum, it is
again represented, but occupying a larger space, in certain of the
cerebral convolutions ; and, again, while the various sensations are
represented and massed together in the thalamus opticus, they are
expanded and separated in certain other of the cerebral convolutions.
This seems to us to be the great advance in the attitude of observers
towards the functions of the brain, and it is just that the working
out of it should occupy the bulk of this book. There are, in addi-
tion, three chapters on the functions of the middle brain, including
the corpora quadrigemina and cerebellum ; but we confess that these
chapters do not carry to us the same conviction as those on the
cerebrum, and we are by no means sure that all the views enunciated
in them will turn out to be correct.

Erom what we have said above it will be understood that, accord-
ing to our author, there is a certain portion of the surface of the
hemispheres which is to be looked upon as motor in function, as
made up of motor centres, and it will be convenient for us to discuss
certain points related to this in the first place. The determination of
the function of these parts rests upon two different, but, to a certain
extent, comf)Hmentary sets of experiments. It is possible, in the
first place, to irritate these parts in living animals ; and we can, in
the second place, destroy them. Now, it may be regarded as cer-
tain that irritation by electricity of what we may call the motor
region in vertebrate animals, from the frog up to the monkey, pro-
duces movements of the muscles of the opposite side of the body,
and not only so, but different parts of the body are, as it were,
represented in distinct and separate parts of the motor convolutions.
Differences of opinion may and do exist as to the exact significance
of these movements, but their production on electric irritation, first
described by Eritsch and Hitzig in 1S70, has been confirmed by
so many competent observers that it is no longer doubtful. Various
objections are taken to the view entertained by Ferrier, that the

1877.1 Ferrier on the Functions of the Brain, 101

regions concerned are true motor centres, and it may be right here
to refer to some of these.

As a possible objection, it is obvious that, in using electricity, the
current may be conducted from the surface of the brain to the deeper
parts, particularly to the corpus striatum. This view receives some
degree of plausibility from the fact that, as has been shown by Her-
mann, by Burdon- Sanderson, and by Carville and Duret, the move-
ments are still produced if, after destruction of the grey matter of
the convolutions, the underlying white substance is irritated. All
that these observations prove is that the fibres passing from the
grey substance are irritable, and that their irritation produces similar
movements to those which occur from irritation of the grey substance
itself. We may, with Hitzig, admit it as possible, or perhaps pro-
bable, that when we try to irritate the intact surface it is in reality
the underlying white substance or the transition zone between the
grey and white substance which is affected by the current.

As a matter of fact it is not proved that the grey substance is
irritable, because the white substance lying beneath is so near that
it may be regarded as doubtful whether we can stimulate the former
without the latter. But this does not in the least interfere with
the view that the grey substance is actually the seat of motor
centres ; and if the destruction of the grey substance in these regions
produces paralysis, then the existence of such centres may be regarded
as determined. We shall return to this latter point, but we mention
it now in order to show that, though it were proved that the grey
substance as grey substance is not irritable to electric stimulation,
yet it may, none the le^ss, be really motor in its functions. We
are not aware that the irritability of grey substance, in any locality
to such stimulation, has ever been proved, yet no one doubts the
existence of motor centres in the grey substance, unless it be Mr.
G. H. Lewes.

As to the conduction of currents applied at the surface to the
corpus striatum, we think that this may be dismissed from considera-
tion. When it is possible, by a comparatively mild current applied
at a given defined spot to produce definite and predictable move-
ments of (let us say) the mouth, and by moving the electrodes to an
immediately neighbouring spot to produce equally definite and pre-
dictable movements of the fingers and wrist, then we think the ob-
jection of possible conduction to the basal ganglia may be treated as
simply a bugbear. If anything further were needed to overturn this
objection it is the fact pointed out by Ferrier, that irritation of the
island of Eeil, which is immediately outside the corpus striatum,
causes no movement, " while the more distant parietal regions at the
same time react, actively and definitely, to the same stimulus."
We take it, therefore, that though Ferrier is hardly warranted in
assuming the irritability of the grey substance, yet this does not

103 Reviews, [July,

detract from the view that it contains actual motor centres. The
fact that irritation of the white fibrous substance coming from
these grey regions produces movements renders it_, on the other hand,
exceedingly probable that these grey regions are motor centres.

It being granted that the regions of the cerebral hemispheres
referred to are, in a certain sense, motor, and that irritation pro-
duces muscular movements, the question arises as to the interpreta-
tion of these movements. When Eritsch and Hitzig made their
important discovery they described the motions produced as contrac-
tions of groups of muscles, different regions of the convolutions being
related to different groups of muscles in the body. Terrier, on the
other hand, has always insisted that it is possible to produce not
merely contractions of muscles, but very definite combined move-
ments, which have all the appearance of purposive acts. This is, of
course, a very important difference of opinion, but it is movements
of the kind described by Terrier, which would be expected a priori
if the motor part of the convolutions is to be looked upon as a
higher organisation of the corpus striatum. The difference in the
results of these two sets of observations is explained by Ferrier by
the fact that the German observers used galvanisation while he used
faradisation. " The closing or opening shock of the galvanic current
applied to the region of the brain, from w^hich movements of the
limbs are capable of being excited, causes only a sudden contraction
in certain groups of muscles, but fails to call forth the definite pur-
posive combination of muscular contractions, which is the very
essence of the reaction and the key to its interpretation."'^ There is
the further objection to the galvanic current that it by and bye pro-
duces by its electrolytic action decomposition of the brain substance,
as is shown by the evolution of gas. On the whole, we way say that
it is hardly possible to read the details of Terrier's experiments
without being impressed with the highly organised character of the
actions produced by stimulation of the surface of the brain. When
we read that stimulation of a certain part of the ascending frontal
convolution of the monkey produces '^ extension forward of the oppo-
site arm and hand, as if to reach or touch an object in front,'* and
of a certain other part of the same convolution, " supination and
flexion of the forearm, by which the hand is raised to the mouth,"
we cannot but be struck with the eminently voluntary appearance
of the actions, and this is confirmed when we find, for instance, that
in the dog it is sometimes possible, by stimulating the region con-
cerned in the movements of the mouth, to produce barking or
growling.

The experiments hitherto referred to, in which irritation of the
surface of the brain was used, although as experiments they may
be regarded as tolerably complete, can hardly be taken by themselves
as proving the existence of motor centres in the cortex of the brain.

1877.] Ebrrier on the Functions of the Brain, 103

Other explanations might be suggested, and the significance of the
experiments may be expected to become much clearer if the check
of others in which these supposed centres are destroyed be applied.
And this check has been frequently used with results which appear
at first sight somewhat unsatisfactory. The reasonableness of such
complimentary experiments could not fail to suggest itself at once,
and we find at the end of Fritsch and Hitzig's original paper that
they had already entered on this line of enquiry. They give the
results of experiments on two dogs, in which they removed the
grey substance from the spot which they had determined to be the
centre for the fore limb. They found that though the limb was
not in any proper sense paralysed, yet its movements were to a
certain extent interfered with. '^ In running the animals set down
the right fore-foot in unsuitable positions, sometimes further in and
sometimes further out than the other, and they readily slipped with
this foot outwards, but never with the other, so that they fell to
the ground. There was no movement entirely lost, but the right
limb was somewhat weaker than the other." Then followed Noth-
nagel who destroyed small portions of the brain by injecting with a
perforated needle a drop of solution of chromic acid. These ex-
periments were made on rabbits, and the result seemed to be an
afi'ection of motion which the author refuses to call paralysis, but
believes it to be '' an imperfect appreciation of the situation and
disposition of the extremities," which manifests itself chiefly in an
imperfect use of the afi:ected leg ; it slides out very readily, and the
animal allows you to put the leg in awkward positions. These
lesions, it is to be remarked, disappear in from six to twelve days
after the operation. It is of some consequence for what follows to
remark here that Nothnagel has made experiments on the lenticular
nucleus of the corpus striatum using a similar method ; and he
finds that the paralysis which results from destruction of this
ganglion is also evanescent, disappearing two or three weeks after
the operation. Experiments in which the motor centres were destroyed
have also been made by Schiff, by Hermann, and by Carville and
Duret, and lastly, some recent observations have been published by
Goltz. To these last experiments we shall refer hereafter, but
Perrier sums up the others as well as his own at pp. 206 and 207,
and the following are the principal facts.

In dogs and cats, if the motor region on one side be destroyed by
excision or cauterisation, the animal shows certain well-marked
motor affections. The limbs on the opposite side double up under
the animal so that it falls over. There is no absolute paralysis, but the
animal cannot at first walk without the limbs continually slipping
from under it and causing it to fall. Gradually, however, the power
of control of the limbs returns, and even in a comparatively short
time there may be no apparent paralysis except on making a sudden

104 Reviews, [July,

movement, and even this may ultimately disappear if the animal
survive. In rabbits the affection of motion is even more transitory
than in dogs,- and comparatively soon the animals are apparently as
able to move as before the operation.

Now, if these experiments were taken alone it might be very
difficult to explain their true significance and to determine what
light they throw on the nature of the regions of the cerebral hemi-
spheres under consideration. There is no proper paralysis of motion,
or it is only of temporary duration, and from these facts sundry
conclusions have been deduced. It has been inferred by Hitzig and
by Nothnagel that the phenomena indicate not a loss of power of
motion, but of the muscular sense, or muscular consciousness. It
.is assumed that there is, apart from the sense of touch, a muscular
sense, by virtue of which impressions are conveyed from the active
muscles to the brain, giving information of the state of these
muscles as to the amount of contraction and relative position.
The condition of the animals under consideration would indicate a
loss of this muscular sense, and this, as the authors expressly state,
without any loss of common or tactile sensibility. But the existence
of such a muscalar sense, apart from tactile sensibihty, is purely
hypothetical, although it does exist as a part of tactile sensation,
and is lost when anaesthesia is produced by destroying certain
sensory centres. Our author asserts — and this part of his work
presents much that is interesting — that there is not the slightest
evidence for supposing that the motor nerves which convey impulses
to the muscles are also the paths by which we derive impressions
from the muscles as to their state of contraction. There are, how-
ever, certain facts which seem at first sight to indicate that, in the
mere voluntary effort at muscular exertion, we have a kind of index
of the amount of muscular exertion put forth. For instance, a
patient with muscular paresis of a limb is still capable of having
an impression of great muscular effort, although the limb is hardly
moved, and a patient with a complete hemiplegia may express
himself as conscious of putting forth great energy to move the
paralysed limb, while the limb remains absolutely motionless. This
looks very much as if the mere effort to produce muscular move-
ment gave the subjective impression of muscular action. But the
author explains these cases which apparently contradict his view in
a very ingenious way. Taking first the case of muscular paresis,
there is here with great efi'ort a slow or small movement.
But we are accustomed, in our experience, to associate a slow
and difficult movement with great resistance, and so ''the patient
who can only move his limbs slowly and with difficulty thinks his
arm is weighted with lead or some heavy substance."" The case of
complete paralysis may seem more difficult to explain, for here the
limb is HQt moved at all, and no impression of movement can be

1877.] Ferrier on the Functions of the Brain. 105

conveyed from the motionless limb. This looks as if the mere
will to move gave the impression of muscular exertion, but the
author accounts for this sense of muscular exertion in a way
which must strike one as at once simple and convincing. For
though the hemiplegic cannot move the. paralysed limb, he will be
found to be making powerful muscular exertion of some kind. If
he be desired to close the paralysed fist, it will be found that he
unconsciously closes the sound one.

*' It is, however, easy to make an experiment of a simple nature,
which will satisfactory account for the sense of effort, even when
the unconscious contractions of the other side, such as hemiplegics
make, are entirely excluded.

" If the reader will extend his right arm, and hold his forefinger
in the position required for pulling the trigger of a pistol, he may
without actually moving his finger, but by simply making believe,
experience a consciousness of energy put forth. Here, then, is a
clear case of consciousness of energy without actual contraction of
the muscles either of the one hand or the other, and without any-
perceptible bodily strain. If the reader will again perform the
experiment, and pay careful attention to the condition of his respi-
ration, he will observe that his consciousness of effort coincides
with a fixation of the muscles of his chest, and that, in proportion
to the amount of energy he feels he is putting forth, he is keeping
his glottis closed and actively contracting his respiratory muscles.
Let him place his finger as before, and continue breathing all the
time, and he will find that however much he may direct his attention
to his finger, he will experience not the slightest trace of conscious-
ness of effort until he has actually moved the finger itself, and then
it is referred locally to the muscles in action. It is only when this
essential and ever-present respiratory factor is, as it has been, over-
looked, that the consciousness of effort can with any degree of
plausibility be referred to the outgoing current. In the contraction
of the respiratory muscles there are the necessary conditions of
centripetal impressions, and these are capable of originating the
general sense of effort."

Other considerations, into which our space here does not allow
us to enter, still more completely indicate that not only the general
sense of muscular effort, but even fine muscular discrimination,
depends not on the amount of outgoing motor impulse, but on
sensory impressions derived from the parts moved. Thus it is
shown that differences of weight can be almost as accurately discri-
minated when the hand is raised by causing the muscles to contract
by the galvanic current as by voluntary effort.

It would therefore appear that, apart from the ordinary paths of
sensory impressions, there is no proper muscular sense; and in
Hitzig's and NothnagePs experiments, sensation being intact, the
affection of motion is not to be accounted for by the loss of the

106 Reviews, [July,

muscular sense. How, then, are we to account for this very partial
interference with motion, and especially its transitoriness ? Is it that
these are only a small part of the motor centres ? And further,
when one set of centres is destroyed, can their functions flit off
to some other part of the brain ? Nothnagel seems to come to a
conclusion somewhat like that expressed in the last of these queries
when he doubts whether any strict localization of the mental
functions in distinct centres of the cortex exists.

These apparently contradictory results receive very great illumi-
nation from experiments on monkeys ^ and pathological observations
in man, as well as from certain other considerations. It is to be
remembered that the lower we go in the animal scale the higher is
the organization of the inferior nervous centres in proportion to the
superior. We know that the frog is capable of performing actions
by means of the spinal cord alone which higher animals require
much higher parts of the nervous system to accomplish. The well-
known experiment in which the decapitated frog raises its leg to
scrape off a piece of mustard from its thigh, and may even use the
other leg if the first one is amputated or has become tired, is an
example of this. And so it is with other functions. " In the fish,
the frog, and the pigeon, the removal of the hemispheres exercises
little or no appreciable effect on the faculties of station and locomo-
tion.^' In these low animals almost all the actions are automatic,
or at least such a large proportion are so that the absence of purely
voluntary movements may hardly be missed. The ordinary actions
of life are for these animals organised in the centres beneath the
cerebral hemispheres, which we may suppose to contain the strictly
voluntary centres. But as we ascend the scale the voluntary come
more and more to dominate the automatic actions. 'Qn proportion
to the degree of independence, complexity, and variety of the forms
of motor activity of which the animal is capable, the more volitional
and less automatic are its movements, and the longer is the period
of infancy during which the animal is slowly acquiring volitional
control over its limbs.'' *^ Where voluntary control is speedily
acquired, or automaticity inherited or rapidly established, as in the
rabbit and dog, the centres of voluntary motor acquisition may be
removed without completely or permanently interfering with the
powers of locomotion. Locomotion is still possible through the
agency of the lower centres, in which this mode of activity is
mechanically organized, and may be set in action by various forms
of external or internal impulse."

^ It may here be remarked that Farrier's experiments on monkeys seem to us
to enhance the value of his studies to an almost incalculable extent, and to place
them in a much better position than those of the German observers, who have
not got beyond dogs. It is to be regretted that such a distinguished observer as
Goltz seems hardly to have read, much less appreciated, the importance of
Ferrier's work.

1877.] Ferrier on the Functions of the Brain, 107

It is, therefore, most interesting to find that in monkeys destruc-
tion of the motor centres in the convolutions produces complete
and probably permanent paralysis of the opposite side of the body.
Here are the details of an experiment which illustrates these points
extremely well : —

" The right hemisphere of a monkey had been exposed and sub-
jected to experimentation with electrical irritation. The part exposed
included the ascending parietal, ascending frontal, and posterior
extremities of the frontal convolutions. The animal was allowed to
recover, for the purpose of watching the effects of exposure of the
brain. Next day the animal was found perfectly well. Towards the
close of the day following, on which there were signs of inflammatory
irritation and suppuration, it began to suffer from choreic spasms
of the left angle of the mouth and left arm, which recurred
repeatedly, and rapidly assumed an epileptiform character, affecting
the whole of the left side of the body. Next day left hemiplegia
had become established, the angle of the mouth drawn to the right,
the left cheek-pouch flaccid and distended with food, which had
accumulated outside the dental arch, there being also total paralysis
of the left arm and partial paralysis of the left leg. On the day
following the paralysis of motion was complete over the whole of the
left side, and continued so till death, nine days subsequently.
Tactile sensation, as well as sight, hearing, smell and taste, were
retained. On post-mortem examination it was found that the
exposed convolutions were completely softened, but beyond this, the
rest of the hemisphere and the basal ganglia were free from organic
injury.

" In this we have a clear case, first, of vital irritation producing pre-
cisely the same effect as the electrical current, and then destruction
by inflammatory softening, resulting in complete paralysis of
voluntary motion on the opposite side of the body, without affecting
sensation."

The experiments on monkeys — while showing this marked con-
trast between these animals and those lower in the scale, that
destruction of the motor centres in the cortex produces complete
paralysis — are in one respect incomplete. As long as the animals
could be kept alive after destruction of the centres, there was no
recovery from the paralysis, but this period was comparatively short,
and it could not be said that recovery would not ultimately have
taken place. This gap is to some extent filled up by observations
on man. There are a few cases on record where there was softening
of the cortex, involving the homologous motor regions of the human
brain, and in these the resulting paralysis has been permanent. Our
author gives a summary of some of these cases, and since atten-
tion has been called to the subject our readers may have noticed
the record of other cases of this kind in the journals.

From these considerations the conclusion seems more than war-

108 Reviews. [J«ly>

ranted, not only that there are motor centres in the cortex cerebri,
but that these centres represent, as it were, the corpus striatum, in
what HughHngs Jackson calls a ' higher power.' As we ascend in
the animal scale these highly developed and voluntary centres come
more and more to dominate the lower ones, and in the monkey and
man motion seems so intimately bound up with them, that when
they are removed only the most automatic and rudimentary actions
can be performed. This view entirely obviates the necessity of
resorting to the rather clumsy device of supposing that one part of
the brain can take up vicariously the functions of another. There
is a certain sense in which this may be true. Certain actions which
are at first purely voluntary may become organised in the corpus
striatum, and may possibly continue to be performed after the
removal of the cortical centres. There are also certain functions
which in a certain sense are bilateral, and which, though involving
movements on both sides of the middle line, appear to be related to
one of the hemispheres — such functions as that of speech. These
functions may be organised in one of the cerebral hemispheres, and
we know that speech is probably localised in the left, but if this
centre be destroyed it is very possible that the similar region of the
right hemisphere may through time acquire the power which has
been lost.

The experiments of Goltz, recorded in two articles in * Pfliiger's
Archiv,' the last of them published since the appearance of Terrier's
work, demand very particular attention, both from the eminence of
the observer and from the fact that they appear to lead to conclu-
sions different from those of Perrier. We shall return to these
experiments again when considering the seat of vision in the cerebral
hemispheres, but in relation to motion there are some points calling
for notice here. We must premise that having read these papers very
carefully we cannot see that any statements can be properly founded
on them as to the localisation of functions in individual parts of the
hemispheres. The experiments are most valuable, as showing what
motor and other functions have their place in the hemispheres, but
as to the localisation of these functions we consider that nothing
can be seriously asserted or denied on the basis of them. The
animals used were dogs, and, in order to destroy portions of the
brain, apertures were made in the skull with a trephine and a jet of
water forced against and into the brain. The water burrowed among
the brain substance, and if there were (as in most of the cases) two
or more apertures, channels were made from one to another plough-
ing through the brain substance. Such a serious operation as this
would, in all likelihood, nearly abolish the functions of the hemisphere
concerned for a time, and would probably interfere with lower
centres, and Goltz very properly rejects the symptoms occurring
immediately after the operation as not due immediately to loss of

18!^7.] Ferrier on the Punctions of the Brain. lOd

brain substance, but rather to inhibition of centres from the irrita-
tion succeeding the operation. It is rather the lesions which remain
after the animal has lived some time, and which may be regarded as
permanent, that he considers important. These latter he calls
phenomena of defect (Ausfallserscheinungen) while the others are
phenomena of inhibition (Hemmungserscheinungen). In regard to
the former of these it is of importance to note that a dog may have
almost the whole cerebrum washed away and yet be able to walk
about, move the head, eyes, &c. The permanent phenomena are a
certain tendency to slip with the foot, especially in walking on a
smooth surface, and a loss of the power of using the fore paw as a
hand. This last point is of special interest in relation to the subject
we have been more specially considering, as it gives a rather striking
confirmation to a speculation of Terrier's. In commenting on the
fact that after removal of the cortical motor centres in the dog the
paralysis will be recover from, so far as actions which have become
automatic are concerned, Ferrier proceeds to remark :

" It may be confidently asserted, and perhaps it may be one day
resolved by experiment, that any special tricks of movement which
a dog may have learnt Avould be as effectually paralysed by removal
of the cortical centres as the varied and complex movements of the
arm and hand of the monkey by the same lesions" (p. 215).

And now we find that Goltz experimented on some well-bred dogs,
which before the operation would give either paw on demand. After
one side of the brain had been operated on, however, the animal had
no longer the power, when asked, of giving the paw of the side
opposite the lesion in the brain, and if both sides had been destroyed
there was a permanent loss of this power altogether.

We have dwelt at considerable length on the motor functions as
w^orked out by Terrier, because it seems to us that this is the part
which has been thoroughly mastered by the author. It remains to
us to make some remarks on the centres which he supposes to be
sensory, and on certain of his observations on the cerebellum and
corpora quadrigemina.

The endeavour to prove that the various senses are represented in
distinct parts of the cortex is in the nature of things a much more
difficult task than where movements are concerned. Irritation of the
centres is here of much less use, for though it might be expected
that irritation of an auditory centre, for instance, would produce
reflexly movements indicative of the reception by the animal of some
unexpected sound, yet this method of procedure will not carry us
far, and it is chiefly experiments in which the various parts of the
cortex have been destroyed that are trusted to here. We may there-
fore anticipate that the results so obtained will hardly be so complete
or trustworthy as those which we have already passed under review.

110 Reviews. [July>

It strikes us that the most convincing of these endeavours to localise
sensations is that which concerns the centre for vision.

Perrier believes that he has determined the existence of a centre
for sight in the convolution which curves round the upper extremity
of the fissure of Sylvius, and is called in Ecker's nomenclature
the '^angular gyrus ^^ (Pli courbe). Stimulation of this region pro-
duced movements of the eye-balls, frequently associated with move-
ments of the head to the opposite side, and very often contraction
of the pupil. But these phenomena seem all referable to the re-
ception by the animal of visual impressions which have secondarily
induced these movements. Destruction of this convolution produced
total blindness of the opposite eye. There is, however, one fact
connected with this centre which may be of considerable conse-
quence, especially in relation to human pathology ; it is, that the
blindness caused by destruction of the convolution on one side was
only temporary, compensation rapidly occurring if that on the other
side was intact ; but destruction of the angular gyrus in both sides
produced total blindness in both eyes. This is a fact of great im-
portance as affecting human pathology. It is only immediately after
a lesion has destroyed the centre on one side that blindness of the
opposite eye is produced, and this is rapidly recovered from, the
other angular gyrus taking up the impressions from both eyes.
We should expect, therefore, in cases where there has been gradual
destruction of the angular gyrus in the human subject, that blind-
ness would not be observed at all, but where its destruction has been
rapid, as by embolism, thrombosis, or injury, then a temporary blind-
ness would be looked for.

Goltz's experiments somewhat amplify these observations of
Terrier on the loss of vision when one side of the cerebrum is de-
stroyed, and his papers are nowhere more interesting or suggestive
than when describing the results obtained in this direction. Like
Terrier, he finds that both eyes are related to each cerebral hemis-
phere, so that when the centre of vision has been destroyed
on one side the bhndness of the opposite eye is only tempo-
rary. But the other hemisphere by no means completely replaces
that which has been lost. The affected eye recovers sight
for some things but not for others ; and it is most instructive
to observe the kind of things for which vision is lost. A dog
was able with the eye whose cerebral centre had been destroyed
(the other or sound eye having been enucleated) to see or avoid
obstacles, but it was not able to recognise a piece of flesh put
right in its Hue of vision, nor did it show any proclivity towards
a duck put into the box with it till this animal began to make
the noise peculiar to it. It did not show signs of fright wlien a
servant appeared suddenly to it dressed in a style which had pre-
viously filled it with terror; and it also showed inability to appreciate

1877.] Ferrier on the Functions of the Brain, 111

the height of a table from the floor, or to understand the use of a
chair placed near the table to assist it to descend. Croltz suggests
that the explanation of this may be that the animal has to a great
extent lost its sense of colour and of the position of images on the
retina. It seems to us a much more likely explanation that the
centre of vision in the cerebral hemispheres forms for each eye what
Eerrier calls an " organic memory," and that this memory being
destroyed objects formerly familiar are no longer recognised. This
would seem to indicate that the " organic memory '' for each eye is
situated separately from that of the other in the opposite cerebral
hemisphere., These observations ought to be capable of being
checked by clinical observation; and we may look forward to careful
observations of the state of vision in cases where it is presumed that
the cerebral centre of vision has been destroyed.

The determination of a centre for hearing in the convulutions is
an exceedingly difficult task, and we observe that the results come
to by Goltz, in the papers alluded to, are directly contrary to
some conclusions of Ferrier. The latter believes that he has
localised the centre of hearing in the superior temporo-sphenoidal
convolution, or the convolution which runs along the fissure of
Sylvius forming its inferior boundary. It is very difficult in an
animal to distinguish between a mere reflex reaction to auditory
impressions and a true auditory sensation, and after the destruction
of the auditory centre the former may be mistaken for the latter.

Tor instance, Mourens found that animals deprived of their hemi-
spheres started when a pistol was fired close to the head, but this
was merely a reflex action, and no evidence of the retention of
hearing. Bearing these facts in mind, Terrier believes that —

" When the two sets of experiments are taken together, viz. the
positive reactions to electric stimulation and the absence of reaction
to the usual forms of auditory stimuli, when the superior temporo-
sphenoidal convolutions were destroyed, the evidence of the local-
isation of the centres of hearing amounts to positive demonstra-
tion."

We shall not follow the author into the other sensory centres,
thosa of touch, smell, and taste. It may be admitted that he
has established a strong presumption that touch has its special
centre in the hippocampus major and uncinate gyrus, and that he
has made it probable that smell and taste are related to the tip of the
temporo-sphenoidal lobe or subiculum cornu ammonis. But these
cannot be looked upon as established ; and it will be the part of
clinical observers and pathologists to look out for facts bearing on
this part of the subject.

In entering on the considerations of the functions of the corpora
quadrigemina and cerebellum we come upon ground which has been

lis Reviews. [July,

frequently under investigation, but in regard to which opinions
can hardly be said to have attained to any fixity. It appears
certain, to begin with^ that some animals, after being deprived of their
cerebral hemispheres, are able to retain their equilibrum and possess
the power of locomotion, although their movements are devoid of spon-
taneity. Such animals also exhibit emotional phenomena ; for
instance, rabbits so treated may be made to give out that plaintive cry,
" with which all sportsmen are familar who have gone hare or rabbit
shooting." There is no doubt that the corpora quadrigemina and
cerebellum are the ganglia concerned in these three functions, and
clinical and pathological observations in man give a general support
to this conclusion.

When we come, however, to particulars we are met with serious
difficulties. No one has any doubt that the corpora quadrigemina
(called in lower animals the optic lobes) are in close relation to the
optic nerves, and it has been concluded that they are the centres
of vision. The real centre of the sensation of sight is, however, as
has been already seen, in the convolutions, and it seems probable
that the intimate relation of the external organ of vision to the
corpora quadrigemina, is explained by the fact that visual im-
pressions are an important factor in the retention of equilibrium.

In regard to the cerebellum, the author brings out some most
interesting facts as to the result of stimulation of this organ by elec-
tricity. Whatever be the explanation of the fact, irritation of the
cerebellum produces muscular movements, to which we shall refer
more particularly immediately. We observe that since the publica-
tion of Terrier's work, Nothnagel has described the effects of
irritation of the cerebellum by needles, and he also concludes that
it is in a certain sense a motor ganglion, irritation producing
certain movements of the head and body. In Terrier's original
experiments on rabbits it was chiefly movements of the eyes that
were observed as a result of irritation of the cerebellum, but in
these the head was held fixed. It appears, however, that movements
of the head and limbs accompany those of the eyes, although the
eyes afford the easiest index of the direction of the movements.
It is in the highest degree interesting to find that irritation of difi'erent
parts of the surface of the cerebellum produces movements in
different directions. Tor instance — and here we quote from experi-
ments on monkeys — irritation of the upper vermiform process at its
posterior extremity in the middle line, causes bot/i eyes to move
Hraight downwards ; irritation of the vermiform process at its an-
terior extremity in the middle line causes doth eyes to move direct^
upwards ; irritation of this process to the left of the middle line, if
at its posterior extremity, causes both eyes to move downwards and
to the left ; and if at the anterior extremity, upwards and to the
left; and so on. It seems in fact possible to patch out the surface

1877.] Yerkier on the Functions of f, he Brain. 113

of the cerebellum into areas, irritation of each of which is capable
of producing a distinct movement of the eyeballs, and when the
animal is free, of the head and limbs. These movements, be it
observed, are movements in specific directions, upwards, downwards,
to one side or the other. It may be added that after the application
of the electrodes, a condition of nystagmus often comes on and
lasts for some time.

These experiments throw considerable light on certain facts
observed in disease or injury of the cerebellum in man. In these
cases nystagmus and persistent ocular deviations have been
frequently found, along with disturbances of equilibrium. It has
been shown also by Purkinje and Hitzig that when a galvanic
current is passed through the head by placing the electrodes behind
the ears, a feeling of vertigo is experienced, and external objects
seem to alter their position relatively to the person experimented on.
Along with this the head, body, and eyes move in particular directions
at the moment of the application of the current, and these move-
ments vary, according to the direction of the current through the
head. There seems little doubt that here the cerebellum is irritated,
and the experiments are a strong confirmation of Ferrier's observa-
tions.

And now, as to the explanation of thefee phenomena, our author
has some most suggestive observations. The cerebellum is composed
of automatic centres, which regulate the equilibrium of the body.
When the body is rotated to the left, equilibrium will be maintained
by movements towards the right, and when an attempt is made to
overturn the body from before backwards, equilibrium will be main-
tained by antagonistic movements which move the head forwards.

" The cerebellum would, therefore, seem to be a complex arrange-
ment of individually differentiated centres, which in associated
action regulate the various muscular adjustments necessary to
maintain equilibrium of the body ; each tendency to the displace-
ment of the equilibrium round a horizontal, vertical, or intermediate
axis, acting as a stimulus to the special centre, which calls into play
the antagonistic or compensatory action.

" Every form of active muscular exertion must tend to overthrow
the balance, and we should, therefore, expect, on the above hypothesis,
that the cerebellum would be developed in proportion to the variety
and complexity of the muscular activity of which the animal was
capable, a relation which is fully borne out by the facts of com-
parative anatomy (Owen)." (p. 109).

" The displacement of the equilibrium in any direction not only
calls into play, by reflex action, the compensatory motor adjustments,
but also induces conscious or voluntary efibrts of a similar antago-
nistic or compensatory nature. Thus, a tendency to fall forward,
while reflexly calling into action the muscular combinations which
pull the body backwards, may also excite consciousness and cause

113— LX. 8

114 Reviews. [Jul.v,

voluntary effort in the same direction. The same mui^cular
adjustments which are capable of being effected by the cere-
bellum, are also under the control of the will, and may be car-
ried out by the cerebral hemispheres independently of the cere-
bellum."

This last observation points to an explanation of the fact that
lesions of the cerebellum may produce no very appreciable symptoms
during life. There are, undoubtedly, many cases on record in which
disease of the cerebellum has produced unsteadiness of gait,
due to imperfect retention of equilibrium. But this loss of the
power of retaining equilibrium may be in great part compensated
by voluntary effort. Of course this will entail a great exertion, or,
we may say, a great waste of voluntary effort, and movements will
be accompanied by much more fatigue than when the automatic
apparatus for preserving equilibrium is in action. As a matter of
fact, it was observed by Weir-Mitchell, that in pigeons whose cere-
bellum was destroyed, and which lived some considerable time after,
great fatigue was produced by active muscular exertion. On this
fact Weir-Mitchell founded his theory that the cerebellum is a
source of energy to other nerve centres; but, as our author remarks,
it is only by sparing higher centres that it can be regarded as a
source of energy.

There are many other parts of this work which we had noted for
observation, such as the speculations — for they cannot be regarded
as anything more — on the functions of the occipital and frontal
lobes of the cerebrum, the psychological aspects of the question,
&c., but the review has already reached large enough dimensions,
and we have, we hope, sufficiently shown that the subjects treated of
are discussed with a wonderful degree of force and perspicuity, while
the experiments which form the basis of the work show an ingenuity
and resource which can hardly be too highly estimated.

X. — Kecent works on Evolution, Botany and Natural History.^

Admitting that the theory of evolution is that which is usually
received by scientific men as the best explanation of progress in

^ 1. An Fxamination of the Modern Theories of Automation and JEvolution.
By Chaeles Elam, M.D., pp. 163.

2. Text-book of Structural and Physiological Botany. By Otto W. Thom^,
of Cologne. Translated and edited by Alfred W. Bennett, M.A,, F.L.S.,
Lecturer on Botany at St. Thomas's Hospital. 1877.

3. Article Amphibia in the JSncyclopcedia Britannica. 9tb edition. By Prof.
Huxley, F.B.S., &c.

1877.] Elam on Evolution 115

nature, we must expect that its professors will have their vagaries
and occasionally run riot^ and will therefore be subject to such
downfalls as Dr. Elam has the full power of giving. Evolution
and Darwinism have been constantly attacked, but never before has
the assault been so generous and free from abuse and the terrors of
theology, as in the present instance. Half-educated naturahsts,
enthusiastic theologians, and some few highly educated geologists
and botanists, have rather increased the value of these theories by
the misapplication of facts and by careless reasoning. But the
accomplished physician, whose former works have always had a
great charm, attacks the Huxleyo-Tyndallian-Hackelismus on its
own ground, and shows the inherent absurdity of this particular
phase of evolution, and proves it to be a mere hypothesis. The
following quotation will at once explain how he treats his subject: —
" An automaton endowed with free will is certainly a pleasing and
interesting novelty in physical science, and Mr. Huxley deserves
great credit for his ingenious invention. It would have been an
intellectual treat to listen to him replying to any unfortunate
opponent who had committed himself so profoundly.^' Dr. Elam
thus seizes upon a statement, and with a little banter proceeds to
demolish its value instead of indulging in scolding and insisting
upon certain awful consequences. He shows that this ingenious
invention, taken as a proposition, is simply suicidal, and states,
"for as no one to my knowledge ever considered free will to signify
anything else but the power to do as we like, the definition of man
as being an automaton endowed with free will leaves him exactly
where it found him ; that is, as an intelligent free agent.-'"' Further
on, we find Professor Tyndall is crushed with his own words. As
a philosopher. Professor Tyndall discerns in matter, the promise and
potency of all terrestrial life ; that is to say, he believes in a
doctrine of evolution. Dr. Elam shows that this belief may be
summarised as follows: — 1. That the earhest organisms were the
earliest product of the interactions of ordinary inorganic matter and
force. 2. That all the forms of animal and vegetable life were
successively and gradually developed from the earliest and simplest
organisms. 3. That the doctrine of evolution derives man in his
totality from the hiteraction of organism and environment through
countless ages past. The Professor states that the conclusions of
pure intellect point this way and no other ; he sees with the eye of
imagination a primitive nebular haze, gradually contracting into a
molten mass, in which are latent and potential, not only all the forms
of life, noble or ignoble, but the human mind itself, emotion,
intellect, will, and all their phenomena ... all our philosophy,
all our poetry, all our science, and all our art — all are potential in
the fires of the sun. This is an extract from the celebrated Belfast
address, and most of its former critics have given it the value of an

116 Reviews. [July,

imaginative hypothesis of a not very profound man, and have conveyed
their opinion in a very decided and somewhat rude language. This
is not Dr. Elam's method ; he praises the ingenuity of the teacher,
and then proceeds with a cruel logic to disprove his right to convey
any of these assertions, except in the form of guesses. He separates
the professor into the philosopher and into the man of science, and
considering what the philosopher has spoken he quotes what the
man of science has written, and then judges the philosophy by the
science. He quotes Professor Tyndall as follows : — " Without veri-
fication a theoretical conception is a mere figment of the intellect :
the region of theory lies behind the world of the senses, but the
verification of theory occurs in the sensible world. To check the
theory we have simply to compare the deductions from it with the
facts of observations. If the deductions be in accordance with the
facts, we accept the theory; if in opposition, the theory is given
up." This is, of course, true philosophy and true science; and
Dr. Elam then quotes the Professor to show that the grand theory
he has accepted must be given up. Professor Tyndall writes : " If
you ask me whether there exists the least evidence to prove that any
form of life can be developed out of matter without demonstrable
and antecedent life, my reply is, that evidence considered perfectly
conclusive by many has been adduced ; and that were some of us
who have pondered this question to follow a very common example
and accept testimony because it falls in with our own belief, we also
should eagerly close with the evidence referred to. But there is in
the true man of science a desire stronger than the wish to have
his beliefs upheld, namely, the desire to have them true.^' " In
reply to your question they will frankly admit their inability to
point to any satisfactory experimental proof that life can be deve-
loped save from demonstrable and antecedent life." Here, then, is
a distinct want of accordance between philosophic theory and
scientific observation. In fact. Professor Tyndall's theory is no
such thing ; it is a jumble of conjectures of the vaguest possible
kind, w^hich would require very much explanation to give them any
scientific value. Hackel is pounced upon in the same logical
manner for having inserted in our genealogical tree a form of
animal which he calls Chordoma, which develop themselves from the
Annelida by the formation of a spinal marrow and a chorda dorsalis.
The details of the structure of these interesting animals are given
very systematically, and it is shown how they became the parents of
the nearest now living genera, the Ascidians. Unfortunately, Hackel
does not even profess to have any evidence to produce that such
animals ever existed ; there is no living representative of them, there
is no fossil evidence of their early existence. They are, of cour.<e,
required to fill up a gap in Professor Hachel's argument, but on
applying the above Tyndalhan statement, "without verification, a

1877.] Elam on Evolution. 117

t1>eoretic conception is a mere figment of- the intellect to Professor
HackeFs dictum, he is shown to be fertile in invention, false to
science, and perversely unreasonable.

In fact, this proceeding of HackeFs is most dangerous to science,
and really may be said to be impudent. It is in this same spirit
tliat Hackel pronounces upon man's pedigree with the most unhesi-
tating confidence, and Dr. Elam shows that this confidence is folly.
Dogmatism and folly are twin sisters and support the Professor's
coat of arms. Dr. Elam shows us that, according to Hackel, the
Monera were formed in the Laurentian epoch by spontaneous gene-
ration from inorganic matter although Tyndali and Huxley have
shown that spontaneous generation cannot be ; but we are comforted
by the assurance that the acceptance of one of the Monera as our
earliest ancestor rests oyi the most weighty grounds. Of course.
Amoeba came next. Then came ciliated animalcules, which pre-
ceded a group Gastrcea, but these are imaginary, and like
Chordomas, are inferred to have existed. Then comes the worms,
and finally, these imaginary Chordomas, which are, undoubtedly,
the progenitors of all the Vertebrata. When we get to the
fifteenth stage we come to the Protamniota or the general stem
of the Mammalia, Eeptiles, and Birds. Hackel writes, "I do not
suppose any one is in a position to say what these were like, but
they are proved to have existed, because they were necessary fore-
runners of the pro-Mammalia."

After passing over some other steps we are gravely told there are
the Anthropoids or man-like apes, represented by the modern
Orang, Gibbon, Gorilla, and Chimpanzee, amongst which, however,
we are not to look for the direct ancestors of man, but amongst the
unknown extinct apes of the Miocene ; then out of these came
dumb ape-men, an unknown race, the nearest modern representation
of which are cretins and idiots. They must have lived as a neces-
sary transition to the Homines who develope dthemselves from the
last class by the gradual conversion of brute bowlings into arti-
culate speech. To all this Dr. Elam adds with great force the
following quotation, which is eminently instructive regarding the
exaltation of the Hackelian intellect. This opinion :

" The direct descent of man from ape-like ancestors, is never held
bv thoughtful supporters of the descent theory, though often by
their thoughtless opponent. Our ape-like ancestors are long since
extinct. Perchance their fossil remains may some time be found in
the tertiary deposits of southern Asia or Africa. They must,
nevertheless, be ranked amongst the tailless catarhine anthropoid
apes."

It is greatly to the credit of our author that he does not burst, as
most reasonable beings feel disposed to, do into a diatribe; it is

118 Reviews. [July,

typical of his style, that this should not be done, and he contents
himself by stating :

" Such a scheme of progression has no existence in nature. There
is no evidence of it in existing forms of life, and there is no indi-
cating of it in fossil remains. There is no possibility of such a
progression, even as a matter of theory in accordance with the
recognised laws of morplology — that is, if morpheology be a science
at all, or anything beyond an incoherent aggregation of irrelevant
and unconnected details of structure."

One of the great advantages of being an uncompromising evolu-
tionist of the dominant school is, that you will be well backed up by
your fellow-believers. Thus it was much to the advantage of Mr.
Herbert Spencer that he took up evolution. He has written much,
and in a style beautiful in the eyes of those who enjoy long words
and involved sentences. Science owes him one doubtful botanical
fact, but his volumes increase year by year. Not an original inves-
tigator of nature, he is an original thinker, as the term is, that is to
say, he puts odd constructions on the discoveries of others and
.evolves evolutionary dogmas from his inward self. It is the fashion
' to admire Herbert Spencer, to speak of his works with subdued
reverence, and generally for the very good reasons involved in the
words "Omne ignotum pro magnifico.'^ But although ordinary
mortals, who like proofs better than inferences, may think with Dr.
Elam that many of Mr. Herbert Spencer's " irresistible inferences''
are " unverified assumptions,'' still he is loved and honored by the
distinguished professor at the Eoyal Institution, who calls him tne
" Apostle of the Understanding." Let us see what this apostle tells
us about the beginning. He tells us that " organisms are highly
dift'erentiated"" portions of the matter forming the earth's crust and
its gaseous envelope, and that organisation consists principally in
" the formation of an aggregate by the continued incorporation of
matter previously spread through a wider space;" and also that this
formation depends upon " an integration of matter and concomitant
dissipation of motion, during which the matter passes from an
indefinite, incoherent homogeneity to a definite coherent hetero-
geneity, and during which the retained motion undergoes a parallel
transformation."" These quotations from the "first principles"
influence the understanding according to the behef we may
have in this *' apostle.'' The school which likes the infe-
rential, rejoices at the hollow sound they convey ; but the inde-
pendent in thought are apt to consider that these grandiloquent
sentences will apply to the manufacture of a snowball quite as well
as to that of an Amoeba, in fact rather better. The apostle of the
understanding is rather severely taken to task by our author, who
finds endless holes in his armour. Thus, after summing up the

1877.] Elam on Evolution. 119

opinion of Tyndall and Darwin regarding their development of
evolution, Dr. Elam writes as follows : — " This, although meagre and
bare, is, I believe, a tolerably faithful outline of a system which is
now known to afford the only possible solution of the mystery of the
universe, a conclusion the grounds of which will never be shaken,^'
a doctrine not founded " on the basis of vain conjecture, but of
positive knowledge.''^ (The italics represent the words of the dis-
tinguished physicist and naturalist.) This is contrasted with the
doctrine of special creation by Mr. Herbert Spencer, whose com-
parison concludes thus : — " The belief which we find thus question-
able, both as being a primitive belief and as being a belief belonging
to an almost extinct family, is a belief that is not countenanced by
a single fact. No one ever saw a special creation ; no one ever
found proof of an indirect kind that a special creation had taken
place. It is significant, as Dr. Hooker remarks, that naturalists,
who suppose new species to be miraculously originated, habitually
suppose the origination to occur in some region remote from human
observation." " If this,^"* writes Dr. Elam, " be intended for argument,
it is certainly double-edged. Did any one ever see an organic
evolution? or did any one ever see proof of such evolution having
taken place ? The answer must be. No ! however circuitous and
veiled it may be. In the remaining allegations there is an uncon-
scious and childlike innocence that almost disarms criticism. The
system that demands ten or a hundred thousand generations for the
development of the distinguishing characters of a single species, and
a world so different from its present state that not even a trace of
its existence remains, can scarcely object logically or consistently to
the relegation of certain phenomena to a " region remote,'^ whether
in time or space. And with all this, those who do not or cannot
accept this evolution doctrine are denied the possession of the very
faculties of thought and behef. To any one who says he thinks i\\Q
universe was created, Mr. Herbert Spencer replies, "No ! you do not
think so, for such a doctrine is not thinkable.^' And to those who
say they believe in a Creator and creation, Mr. Spencer replies,
" No, you do not beUeve, you only believe you believe." Surely
this is the very Dundrearyism of philosophy."

In continuation. Dr. Elam declines to discuss anything but
evolution, as that is his point of attack, and he wishes to know
whether evolution is true or not. He writes : " It is not altogether
easy to approach this question so as to obtain a decisive answer.
If we treat it as a scientific inquiry, and ask for some confirmatory
evidence, we are told, almost plaintively, that the strength of the
doctrine of evelution consists not in experimental demonstration
(Tyndall). If we further inquire how it is to be approached, and in
what its strength does consist, we fail to get any definite answer,
except some vague statement as to "its general harmony with

120 Reviews, * [«J^uly,

scientific thought." Indeed, the attitude of evolution is entirely
exceptional. It seems to be taken for granted that the doctrine
possesses some esoteric and mysterious principle of utility and credi-
bility which makes it independent of any support from science
or certain (exact) knowledge."

Dr. Elara is very happy in his explanation of how the " con-
structive philosophy" termed evolutionism is built up, and how the
studies are made from conjecture to certainty in its interests. He
notices how Mr. Spencer, having seen reason to sujopose such and
such things, without any further botheration, as the unscientific
might call it, treats the suppositions as ascertained facts, and
proceeds to build up another, as if they were realities. He notices
that Tyndall '* expects to find," on philosophic grounds, such and
such physical conditions, and then commences an introduction from
the same with the phrase, ^' the relation of physics to consciousness
beirig thus invariable," &c. '' Such," writes our author, " being
the received method of evolving science out of personal consciousness
at the present day, it ceases to be subject for surprise that so many
volumes of portentious dimensions should have appeared containing
so little absolute addition to our certain knowledge of nature."

In considering the great difficulty of evolution, the impossibility
of the synthesis of organic matter — a subject rather ignored by
Professor Huxley— Dr. Elam is cruelly sharp upon Mr. Herbert
Spencer, who has felt that it must be met with some form of words
at least, and has written : " The chasm between the inorganic and
the organic is being filled up. On the one hand, some four or five
thousand compounds, once regarded as exclusively organic, have
now been produced artificially from inorganic matter, and chemists
do not doubt their ahillty so to produce the highest forms of organic
matter. On the other hand, the microscope has traced down organ-
isms to simpler and simpler forms, until, in the Protogenes of
Professor Hackel there has been reached a type distinguishable
from a fragment of albumen only by its purely granular character."
Dr. Elam notes that it seems incredible that this should be intended
for serious argument, and he shows the untruth of the statement,
suggesting, moreover, that not one grain of albumen has ever been
made. After explaining how Professor Huxley elaborates his
notions on the physical theory of life, in which the idea of vital
energy is abolished and asserted to be identical with ordinary
physical and chemical energies, our author very happily seizes upon
the weak point in the Professor's argument about the differences of
dead and living protoplasm. Huxley is driven, then, to assert that
the protoplasm without life is subjected to subtle influences; and
when he is required to state that there is any difference in the
molecular or chemical constitution of dead and living protoplasm he
pronounces the idea "frivolous," unless Dr. Elam misapprehended

1877.] Elam on Evolution, 121.

" the meaning of the writer's (Huxley) rather obscure and perhaps
quaquaversal expressions." Subtle influences and automata en-
dowed with free will are singular evolutions, but "evolution is
forbidden to be judged by any ordinary standard ; it has privileges,
a language, and an inviolability all its own, and those who think or
believe otherwise do not, as w^e have before seen, think or believe at
all, but only think they think, and believe they believe.-'' After a
very able exposition of the fallacy of the doctrine of the '^evan-
escence of evil^' under the evolution hypothesis, Dr. Elam requires
the withdrawal of the Darwinian notions on the following plea (in
which his own words are mainly used) : " In the 'Origin of Species'
we are more than once told that it would be fatal to the theory
if the discovery were made of characters or structures which could
not be accounted for by numerous successive slight modifications ;"
but in the * Descent of Man ' there is the following passage : " No
doubt man, as well as every other animal, presents structures
which, as far as we can judge with our little knowledge, are not now
of service to him, nor have been so during any former period of his
existence. Such structures cannot he accounted for hy any form of
selection, or by the intended effects of the use and disuse of parts."
Immediately after this passage Mr. Darwin refers to their production
by unknown causes, which, obviously, like Professor Huxley's subtle
influences as a source of life phenomena, involves a relinquishment
of the entire position. The conclusions which necessarily follow from
the foregoing observations may be briefly summed up in one
syllologism, embracing not only natural selection but also the larger
theme of organic evolution generally. Without verification a
theoretic conception is a mere figment of the intellect (Tyndall).

But the theory of organic evolution is an unverified theoretic
conception (that is to say, Huxley states that the only way in which
such an hypothesis can be proved to be true is by observation and
experiment upon existing forms of life).

Therefore organic evolution is a mere figment of the intellect.

This is the candid expression of a thoughtful man of high
culture, and as we live in an age of opposition to popes of all kinds
it merits much attention. There is no doubt that evolution has
run mad under the hands of its very enthusiastic developers, and
that an hypothesis which explains things better than any other has
been assumed to be of the value of a theory — of a fact. All this must
be kept in mind whilst reading this interesting book, and it must
be remembered that a theory must stand or fall upon its intrinsic
merits, and that it is not just or useful to say that such and such
an hypothesis must be left alone because all others relating to the
subject are unreasonable, or fail in their applicability.

Nevertheless, at the present age of zoology and comparative
anatomy, studied, as these sciences are, by the light of embryolof^y^

12,2 Reviews. [July,

there must be a theory upon which to hang facts and satisfy the
longing for causation. The Palaeontologist insists upon including
his ideas in some theory which will render his facts of subjective
value, and requires that the one particular hypothesis which
relates to repeated acts of special creation shall be struck out. He
claims t he lesson tau^jht by geology and the continuity of struc-
tural detail through long lines of animals and plants as evi-
dence of the continuous progression of organic forms, and as a
proof of the prohahility of an evolution. The last authoritative
suggestion, emanating from the President of the Geological Society,
requires something over and above evolution as ordinarily taught.
He may be thus quoted : " It (the mind) is, moreover, dissatisfied
with the belief that all the wonderful art in nature, the limited
direction of variability, the parallelism of form, ornament, and
physiology, in contemporaneous and successive groups of fossils,
sometimes so widely separated zoologically, are due to the action
of physical changes and heredity alone. It is true that the physical
change is not fortuitous, but relates to the inevitable, and thus its
influence on life is part of a great philosophy ; but is that source of
the action of the mysterious energy on matter which we call life,
simply passive and only alterable by external conditions? Ac-
cording to the prevailing theory, if all the external conditions
remain the same, the individuals of a species, or the species of a
genus, will retain their classificatory character ; but if change takes
place in the physical condition, or if alterations occur in the struggle
for existence, then the variability will bear a relation to the intensity
of the opposing forces. Extinction, or the removal of the fitness,
results, and this is accompanied by a loss of specific identity. Is
this all the truth ? Is there not some positive energy in living
things which, if uncontrolled and uninfluenced by externals, will
produce progressive change.''' "It was not competition or the in-
fluence of external conditions alone that enabled the structures of
the marsupial to meet the habits and the method of life of the
quadrumana, bats, insectivora, rodentia, herbivora, carnivora, and
even of the pachydermata, but the operation of a law of variation
in definite directions, potential in the organism, and irrelative of
physical conditions." Clearly there is a movement to get out of the
dogmas of the so-called advanced school — a school which unfor-
tunately cannot distinguish between the proximate and the ultimate,
and is ever ready to move out of its path to attack those opinions
which are quite beyond its aspirations, and which have been the
guides of the pathway of the men who have really and efl'ectually
elevated humanity.

That the hypothesis of evolution is highly probable, there is no
doubt ; that it can be proved from demonstration is not possible ;
and hence it is advisable for the chemist to wait until he can

187/.] Thome on Physiological Botany, ]23

synthesize albumen, the physicist to try successfully to combine
energies and forces so as to turn dead protoplasm into living pro-
toplasm, and the zoologist to show the transition of one species to
another, before they deal with the subject of the great first cause
that at any rate did create energy and moving molecules — not
more incomprehensible than the moral government of the world.

2. This is the text-book which is used in many of the German
schools, where it is very popular on account of its elaborate yet con-
densed treatment of morphological and histological botany, and
doubtless also an account of the numerous (more than 500) wood-
cuts which embellish the work. But why should this closely-written
manual be introduced into England in opposition to the manuals of
Masters, Bentley, and others. The answer appears to be, firstly, that
either Dr. Bennett or a Rev. Alexander Irving, of Wellington
College, was not aware that a work of this same scope was to be
found in the English language ! We are informed, moreover, in
the preface, that " in editing the present work, the object especially
kept in view has been to make it useful to candidates preparing for
the Science Examination conducted by the Educational Department
at South Kensington, or for those of the University of London.^'
The editor believes that this book will suffice for the examination as
high as the second Bachelor of Science pass examination, but then
a better will be required for the honours. He advises for the
highest examination such books as Sachs's, Le Maout'sand Decaines'.
The German text of Thome, has been, for the most part, translated,
but the scheme on the classification of the flowering plants has been
rewritten, and the orders arranged in accordance with Hooker nnd
Bentham. The two chapters which relate to geological and geo-
graphical theories have been cut down, and the writer has taken
pains to avoid, " as far as possible, the putting forward of geological
or geographical theories," as demonstrated truths. It will be
observed, that the editor desires to teach well and to do no harm,
and especially to keep the young, from the evil counsels of those
dreadful geologists. There is no doubt if this book could be mas-
tered, for it is ably and conscientiously translated, any examination
could be passed and the mind left settled in comfort, the old skele-
tons being carefully locked up in nice little closets. But is the
passing a South Kensington or London University examination
the ultimate expression of the botanical intellect ? Suppose that
the student had passed gloriously in Thome. W^hat then ? probably
he or she, as the case may be, will turn out priggish, mild, un-
original and learned, or will be content with the success of " cram/'
and will botanize no more. It is a remarkable fact that ever since
these examinations have been so much in vogue, and so many well-
educated botanists have been sent out into the world, England has not

124 ' Reviews. [Jiily>

celebrated for research into botanical histology and physiology.
In fact, these parts of the science are nearly extinct with us_, and
they are kept alive by Darwin, Burdon-Sanderson, Masters, and
one or two others, all of whom, by the bye, got their primary
instruction from British writers, such as Lindley, Forbes, and
Henfrey, and men of that grand stamp. Everything in the present
dominant botanical school must be foreign, and when English
workers find that their labour is in vain, and that their research
is absolutely ignored by such men as Thome, it is not likely that
they will persist. Now suppose our good Enghsh text-books are
compared with this work of Dr. Bennett's is the comparison to
tlieir disadvantage or not ? Most certainly not, and therefore the
Eev. Alexander Irving, of Wellington College, doubtless a very able
man, had better learn a little more of the work of his own country-
men before he says that there is "no work of the same scope''
as that now under consideration in the English language.

In the introduction to the book, there is an interesting history
of the progress of botanical science, and of course, from the German
point of view, but so much reduced that the translator adds a note
introducing some English names, but strangely forgets Henfrey,
Masters, and the host of our microscopic botanists. Thoroughly
German, as the book is, we were not prepared for the following :

*' But when we descend from the higher animals and plants to the
less perfect organisms belonging to these two kingdoms of nature
we come eventually on the boundaries of each to organisms so small
and so imperfectly developed that it is scarcely possible to pro-
nounce an opinion whether they are of animal or vegetable
nature."

This is bad teaching. Take one of these organisms such as Volvox
globator, it is not the imperfection which makes it impossible of
classification or the minuteness. Consider Actinophrys with its won-
derful hfe-history, or the wonderful moving Kaviculse; it is not the
minuteness, and certainly it is not the imperfection which has any-
thing to do with the classification. There is no imperfection. The
development is perfect, and even in Amceba, there is the nucleus,
contractile vesicle, endosarc, entosarc, and a definite life-cycle. Why
does Herr Thome not assert at once that the division of organic
nature into the vegetable and animal is arbitrary, and that what was
taught in England thirty years ago, and what Germans have imitated
of late is true, namely, that in the simplest forms of living things
there is perfection, and that there is a group to which the term
animal or vegetable does not apply. There are several instances of
that unscientific inexactitude which characterises these examination-
passing books to be found in the early pages of Thome's book,
matters of small importance, but leading to slip-shod work. Take

1877.] Thom]^ on Physiological Botany. 12^

one or two, " If a small quantity of the green mould which com-
moLly appears on articles of food that have been kept for a few
days is examined/' Such articles may be kept for ever in some
places and decompose or dry up, and yet no peuicillum glaucum
form. In treating of nuclei there is the following :

** In the living condition (cell, we suppose, is meant) tbey are very
difficult to recognise, but as far as we know at present, they are
larger than when dead, and of variable irregularly jagged form. They
creep about in the protoplasm in which they are embedded after the
manner of an amosba, and certainly take the largest share in the
continuous shifting and transformation of the bands of protoplasm
which start from them."

Firstly, did Dr. Bennett ever see amceba in movement; if he did,
he will have observed something utterly unlike any nuclear faint
undulation and passive movement ; and secondly, is it a fact that
most nuclei are so irregular in shape ; and lastly, it is a fact that
the nuclei has energies by which it moves anything. In the
page from which the above quotation is taken, there are some
figures which are very remarkable ; a Coscinodiscus and a stellate cell
are interesting. If the student, after passing the tremendous ordeal
of South Kensington and earning his teacher a microscopic gratuity,
were to see a real Coscinodiscus and a real stellate cell, he would be
much surprised. Equally iunny and inexact are the figure of Euas-
trum crux-Melitensis (which is certainly a queer way of spelling the
latin for Maltese cross) — of the wood cell of the Scotch fir — of a spiral
cell of a cactus— of conjugation and spore formation — of intercellular
substances — of pediastrum, and again of stellate parenchyma. The
figures of scalariform vessels, dotted ceils, and of a leaf section of
Cycas, and of hairs, are like the rest, diagrams and bad woodcuts, and
therefore in every way objectionable. They cannot bear comparison
with the drawings in our standard British books.

The chapters on the external forms of plants are very good, and
even painfully minute, for even a carrot and a radish are figured, and
there is no excuse for the student not being thoroughly aufait
with the terminology. The leaves and their shapes are very well
explained, and the greater number of the figures of them are
admirable; and the same remark appHes to the flower and fruit.
Some excellent descriptions of the lower plants follow. Good
chapters on physiological botany and the special type of vegetable
life, the development of Torulais, is explained according to Professor
Huxley, but from whom he derived his information is not men-
tioned.

In the chapter on what is called palseo-phytology the naughty
geological theories are considered, and we are told that water has
acted by mighty convulsions, and that the Cambrian system contains

126 Reviews. [J'llv*

but few remains of organic life. Then it is stated that in the
Devonian period the variety and luxuriance of vegetable forms far
surpassed our existing vegetation. These extraordinary statements
are supplemented by a miserable description of the Carboniferous
vegetation, and a worse of the wonderful development of plantae in
the Trias. The writer appears to ignore the upper cretaceous flora,
and indeed to know little of the subject which has excited the
geological world for a long time past, namely, the wonderful per-
sistence of plant types during changes in the fauna and the physical
geography. If this is the way geology is treated by Thome, the
learners will not be troubled with anything that demanded the
criticism noticed in the commencement of this notice. In the
chapter on Botanical Geography we turn naturally to Australia to see
how the author treats the strange isolation of the floras of the south-
east and south-west, and the African affinities of the last and the
Asiatic affinities of the northern flora. No information is given.
If this is the kind of book which is to rear the future official
botanists a good time is coming for the British writer. Dr. Bennett
is a hard working, able botanist, and could write an admirable
manual, aiid one which would meet the real requirements of the day.
It is a })ity that he does not do so ; and he must be aware that
translations, however well and conscientiously performed, do not
bring much credit.

3. If any proof were required to demonstrate that anatomy has
progressed wonderfully as an exact and comparative science during
the last ten years, the admirable essay of Professor Huxley's would
afford it. There are few encyclopsediacal articles which may be
read, or rather closely studied by those medical men who have had
a modern training with greater satisfaction, and indeed pleasure,
than this elaborate description of a group comparatively unknown
on account of its having been jumbled with the reptiles. Formerly
the term amphibia was very widely used, and in as unphilosophical
a manner as the division of the vertebrate into warm and cold-
blooded animals. It was made to include snakes, and even some
fishes ; but the discovery of the fossil remains of huge vertebrates
with frog-like affinities rendered the careful study of the osteology
of the Batrachia necessary for purposes of comparison, and this led
to the admirable work of so many British and foreign naturalists on
the embryology of the groups. Not to be grouped with mammals,
birds, true reptiles, or with fish, the amphibia present in their own
principal divisions a singular separateness which impedes a positive
definition of the class. As a class, they are intermediate between
the fish -like (Ichthyopsida) and the sauran-like (Sauropsida), and
are distinguished very sharply by having the visceral arches of the
embryo developed into gills, which temporarily or permanently

1877.] Huxley on Amphibia 127

perform the respiratory functions. In the amphibia, there is no
trace of an amnion, and the basi-occipital region of the skull is
either incompletely or not at all specified. They differ from the
Sauropsida in having two occipital condyles. Prom the fish-like
they may be distinguished by the characters of the locomotive
apparatus only. When they possess median fins and limbs these
never present fin rays ; and the limbs exhibit in full development
the type of structure which obtains among the Ganoids and Mam-
mals, and differ widely from the fins of any other fish at present
known. Even among the long extinct amphibia of the Carboniferous
spot this difference prevails. But the lowest of the amphibia
approach the Ganoid fish and the Dipnoi, and they present various
approximations to the Marsupibranchia.

As a class, the amphibia may be divided into four families, the
Urodela, the Anura, the Peromela, and the Labyrinthodontia ; and
these are of course sub-divided. The Urodela have branchiae per-
sistent throughout life — the old-fashioned Perennibranchiate, and
these are divided into two groups, the Siren being the type of one,
and the Proteus of the other. But even here the extraordinary
biological fact of one group having pelvic arches and limbs, and the
other being deficient in them, explains how slight is the cohesion
of the whole zoologically. Two other groups of the Urodela
have the branchise caducous ; in one the gill clefts are persistent
(Amphioma and Menopoma), and in the other these structures are
closed in the adult condition (salamanders).

The Anura — all of which have, like the Urodela, a horny beak
in the young condition — are sub- divided on the principle that the
phases through which the frog passes in the course of its develop-
ment show that the Anura, which are devoid of a lymphatic cavity,
are of a more embryonic character than those which possess one.
The abnormal habit is so evidently adaptive that it can hardly be
regarded as a safe basis for classification. "Even Hana iemporanciy
at a year old, will climb up the vertical side of a glass vessel, flat-
tening out the ends of its toes and applying its belly against the
surface of the glass like a tree frog."" So the Anura are sub-divided
into two divisions, those with the tympanic cavity with its Eusta-
chian tube present or absent ; when present, the oval apertures of
the tube are separated, and the pterygoid bones do not furnish a
floor to them ; and in the other division the Eustachian tubes have
a common median aperture in the mouth and the pterygoid bones
extend beneath, and form a floor to them. The toads are types of
the first, and the Pipa of the last.

The Peromela are recognised by their snake-like bodies, and are
totally devoid of limb arches. In most the integument is provided
with transverse rows of embedded cycloid scales, but there are
no pectoral plates. The vertebrae are amphicoelous, and the

128 Reviews. [J'^^y,

hyoidean arch is attached neither to the suspensorium nor to
the skull ; it is followed by several slender hoops, like branchial
arches. The young have branchial clefts with rudimentary branchial
filaments. The well-known genus CoeciHa may be called as the
type. Next come the extinct Labyrinthodontia, so named from the
elaborate intricacy of the markings on the transverse section of the
teeth. For the most part they resembled the Urodela in the pro-
portions of the tail and limbs to the body, but some as Ophiderpeton,
were serpentiform, and apparently without legs. They had digits
to the hand and foot, and sculptured pectoral plates, besides small
armour plates and an elegant grooving and gyration of ornament on
the skull. The Labyrinthodont skull had great analogies with
that of Peromela; and considering what limb bones, vast jaws
and teeth, and huge bodies they had, it is certainly obvious
that the amphibia were fully developed during the later Palaeozoic
and earlier Mesozoic ages.

The biological articles in this edition are most satisfactory.

18^7.] I2ft

asifiliograpfeual ^^rora.

Public Health.!— The returns of the Kegistrar-General for the
past year have just been published, and it is satisfactory to find from
them that the state of " pubhc health '' is yearly improving. It
is evident that this result is entirely owing to recent legislation,
and to hygienic knowledge disseminated by various means through-
out the length and breadth of the land ; for we observe on all sides,
with very few exceptions, towns and districts undergoing changes
of some sort — old houses are being demolished to give place to more
improved dwellings, narrow streets are being widened to increase,
amongst other advantages, that of ventilation ; sewerage, drainage^
and water supply are being improved, and trees, useful and orna-
mental, are being planted in our populous towns ; and though
these changes are necessarily slow, yet when they are effected they
will be sure to be attended even with a still further improvement in
the state of public health. There is no greater evidence of the
beneficial results of applied sanitary laws to urban and rural popu-
lations than the fact that the deaths from fevers during the short
space of six years have been gradually reduced from 79 in 1870 to
43 in 1876 per 100,000 living, and, moreover, this includes a
diminution in the deaths from enteric fever, which is at present one
of the most fatal of the diseases of the zymotic class.

As the conditions which influence the state of public health are
as varied as the occupations, tastes, and habits of the people, so are
sickness and mortality influenced, and just in proportion as
knowledge, even of simple sanitary laws, are diffused and under-
stood, so will be the health rate. Officers of health and other
sanitary authorities have, however, much to contend against in the
performance of their duties, and it is frequently no easy matter to
overcome, without the aid of the law, prejudices and ignorance ; for
instance, in a case where the water supply was found to be un-

^ I. On Personal Care of Health. By E. A. Paekes.

2. Public SealtK By E. A. Pabkes, M.D., E.R.S. Revised by W. AiTKBlf,
P,R.S. London.
119— LX. 9

130 Bibliographical Record. [Ji^ly^

doubtedly contaminated with sewage, strong opposition was
offered to its improvement on the ground that as the water had
been in use for some time, no case of sickness was directly traceable
to it.

Besides, we all know of the violent opposition occasionally offered
to the Vaccination and other Acts of no less utility ; and we can
account for such opposition only on the score of sheer ignorance
which, it is hoped, will vanish sooner or later as people become
better informed.

With this object lectures on state medicine are now given in most
of our universities, as well as popular illustrated lectures on hygiene,
in the various towns in the United Kingdom, in addition to an
immense amount of practical information conveyed by the public
journals, especially those devoted to the numerous departments of
public health and sanitary science. We look forward, however,
principally to the results of careful observation and continued ex-
periments with the view of further finding the best means of pre-
serving health and happiness ; and here we must deplore that the
State holds out so little inducements to the unselfish scientific
labourers, to whom this country in particular owes so much of her
greatness.

These considerations lead us naturally to feel the loss of one of
the most earnest investigators and one of the greatest public bene-
factors of his age — the founder of hygiene — the late Dr. Parkes,
whose unselfish life was principally spent in endeavouring to find
out under all conditions nature's secrets, and by means of experi-
ments and close observations, deducing and framing from them
rules and regulations for improving the condition of the whole
human race.

We shall here briefly refer to some of his last writings, in which
he has also indicated lines of research for future investigators.
During the course of his fatal illness he found time to write a
small manual ' On the Personal Care of Health ' for the Society for
the Propagation of the Gospel, and after his death a short treatise
of a more general character was found in manuscript amongst his
papers, both of which are now published.

That of the last, entitled ' Public Health,^ has, we are informed in
the preface, been revised by his friend and colleague at Netley, Dr.
Aitken, who has very wisely made no material alteration or addition
beyond writing a table of contents.

These two little books taken together contain in a condensed form
a vast amount of information, conveyed in plain, intelligible
language, and should be regarded by the public, as no doubt
they eventually will be, as legacies of no mean value.

The manual * On the Personal Care of Health ' is, as its title
indicates, addressed to individuals, pointing out how they are to

1877.] Public tiealtL 131

manage and keep the precious gift of health during puberty, man
or womanhood, and old age; because, as the author truthfully
remarks,

" There is, so to speak, an individual or personal hygiene which
must also be brought into action, and without which half the work
mast remainundone, and the burden of sickness and suffering be but
half removed."

The chapters on the management of the body during the periods
of growth and manhood are especially useful, and the author im-
presses in forcible language how errors in diet and regimen are to
be avoided, and how life is to be prolonged. He also shows clearly
the comparative value of animal and farinaceous foods, and that the
poor man makes a great mistake in paying a high price for beef or
mutton, which he cannot well afford, when he could obtain the same
amount of nourishment in oatmeal, maize, &c., for less than one
fourth of what he now pays for animal food.

This is proved by chemical knowledge, and the well-known ex-
amples of the hardy races that used to inhabit the North of England
and Scotland, the splendid races of Northern India, and the ancient
Roman soldier and gladiator, all of whom were principally vege-
tarians.

His advice about alcohol should not be lost sight of, for he
advises every young man and woman to be a total abstainer, since
it is proved to be of no use in health, and may be injurious; and
Dr. Eichardson also asserts that it is positively hurtful.

With such evidence against alcohol it is no wonder that there is
at present such a wide-spread feeling in favour of temperance.

What a marked difference there is now in the mortality in India,
compared with the beginning of the century, during the Mahratta
war for instance, when the annual death rate of our soldiers was
101 per 1000; and when one reads in the Wellington despatches
of the period such orders as '^ Urge the gentlemen there to send
forward 3000 or 4000 gallons of arrack," no surprise need be
expressed at the high rate of mortality in those times. In fact, to
quote Dr. Parkes' own words, "The immense disease- making of
intemperance is appalling " even now.

In the last chapter he asks the question, ^' Will men follow the
rules of health ? " He answers it by asking —

" May we not receive it as a sure principle that when men are
once convinced that a certain course will bring them a material
good they will eventually pursue that course, and if once the princi-
ples of health can become implanted and taught to each generation,
the tendency to follow the guidance of these principles will grow
by transmission and inheritance ?"

In conclusion, he holds out great hopes that men will follow those

132 Bibliographical Record. [July,

rules, and by education, moral, intellectual, and physical, the
health will be improved in proportion.

This little manual, which should be read and remembered by
everybody, ends with a few simple sanitary hints for working men,
as regards ventilation, cleanliness, water supply, food and drinks.

His work on ' Public Health ' is, as we have said, of a more
general character, and gives an outline of the various health acts
now in force in England, and also of the points which are engaging
or should engage the attention of our legislators and medical
officers of health. He begins by showing the importance of forests,
and the necessity of drainage in preventing ague and dysen-
tery, both of which were common in certain parts of England
at one time, and he regrets that there is at present no complete
" Land Drainage Act." The importance of healthy sites for
towns and villages is then referred to ; but it frequently happens
that other considerations than those of health, such as the con-
veniences for trade, vicinity of water supply, and strategical reasons
become paramount.

Of the various kinds of roadway recommended for streets, Dr.
Parkesj on the score of health, is in favour of wood and asphalt laid
in a peculiar way ; and now that such pavement is becoming general,
it will be interesting whether and in what way it will influence
public health in our large towns. We hear a great deal occasionally
about the rights of citizens, the liberty of the people, &c., but there
can be no question that the state in the broadest sense as possessing
the highest degree of intelligence, and being the representative of
the people, is quite justified in interfering with private enterprise
and dishonest speculation.

Why should there not be Government supervision, for instance,
in the building and arrangement of houses in town and country,
so as to insure good, substantial, and well-ventilated houses being
built ? Surely it is ultimately to the advantage of the owner to
have his houses fulfiling every sanitary condition which is not
necessarily incompatible with architectural design ; they would then
be diligently sought after ; but unfortunately by far the largest
class of people have really no choice in the matter, and often must
take whatever sort they can find, hence the necessity of some
legislation.

Practical and useful hints are given as to the purity and amount
of the water supply to towns, the various systems of conservancy,
&c., and also as regards the various kinds of food and its adultera-
tions. Alcohol and its effects on the masses of the people are again
noticed at length, but as the State looks on its sale, and as it really
is, a very important source of revenue, there will be great difficulty
and opposition in restricting its use. However, he writes : " A
remedy ought to be and must be found for this state of things or

1877.] Vivisection. 133

else sanitary legislation will still present the absurd spectacle of
raising up with one hand what it is smiting down with the other.*^

His opinions should be valuable on one of the great problems of
the age, viz. the prevention of venereal diseases, and under this
head he states that in some military and naval stations where the
"Contagious Diseases Acts'*' are carried out the effects have been
to lessen primary syphilis by one half, and to abate its virulence,
and also that the Acts have a beneficial influence on the women, not
only in curing but reclaiming them.

There is no doubt, if such be the case, that the Acts are beneficial ;
but, on the other hand, a very considerable number of persons deny
that they have been so productive of good as has been stated, and
moreover contend that prostitution and venereal diseases in general
have very much increased in consequence of the Acts. The Acts
are possibly wrong in principle, one-sided, as they do not apply to
men as well as to women, and sometimes shamefully abused and
frequently imperfectly carried out ; but then a great and terrible
contagious disease is increasing in our midst, and some measures to
prevent its spreading must be adopted. What a pity it is that
the opponents of these Acts do not give a little of their time,
money, and talents towards improving the morals of the people, and
bringing up the young in the way they should go, for we fear that
there is no hope that prostitution will be lessened until men and
women are made better.

A wide-spread movement is taking place in England for the total
and unconditional repeal of the " Contagious Diseases Acts," and a
similar movement has extended to the Continent, especially to
Prance and Switzerland.

One of the best accounts that we have seen of prostitution
considered in its relation to health, morality, and the laws of the
various nations, is that of Dr. Mireur, Medecin-inspecteur du Dis-
pensaire de Salubrite Publique of Marseilles.

In conclusion, we earnestly recommend the perusal of these two
little works of Dr. Parkes, especially to our legislators, and all
others who may wish to benefit themselves as well as their fellow
men and women.

Vivisection.! — The professed object of Mr. Macilwain is to
criticise the exidence given before the Eoyal Commission " on the
practice of subjecting living animals to experiments for scientific
purposes.' ' At the same time it is obvious throughout that Mr.
Macilwain has a strong bias towards the views of certain associa-

1 1. Report of the Royal Commission on the Practice of subjecting Live
Animals to Experiments for Scientific Purposes. London, 1876.
2. Vivisection. By GioE^m Macilwain, F.R.C.S. London, 1877,

134 Bibliographical Record. [July,

tions, or self-styled societies of anti-vivisectionists. The author's
set purpose, however, is to show that, even where experiments seem
to have been justified, a more certain result might have been arrived
at by the slower process of awaiting pathological changes. But,
apart from this, an animus reveals itself by the selection of cer-
tain cruel experiments recorded in the appendix, with the too evi-
dent object of arousing sensational excitement. The sting of this
appendix is, however, removed by the perusal of the evidence
contained in the Parliamentary Blue Book. "For if there be any
one fact brought out therein more prominently than another, it
is that such atrocities as are described are not met with within
the Hmits of the four seas, and are without parallel in the
present-day investigations. In an experiment by M. Bouillaud,
an opening was made into the forehead of a young dog, and a red-hot
iron forced into each of the anterior lobes of the brain, &c., &c.^
After some days, M. Bouillaud added, " I was obliged to kill it,
as its irrepressible cries disturbed the whole neighbourhood." M.
Brochel, " after inspiring strong aversion in a dog by plaguing it,
and inflicting pain on it, first put out its eyes, and then destroyed
its hearing by piercing the drum of the ear, and filling up the
cavity with wax." This, Mr. Macilwain adds, was done to discover
whether the animal would evince the same aversion as before.
Majendie opened the body of a bitch with young to know if the
mother, on seeing them in her dying state, would show parental
feeling, which it appears she did by applying her tongue to them !

Mr. Macilwain fears that such narratives may divert the attention
from the scientific bearing of the subject. The fear, we admit is by
no means groundless, and furnishes the additional reason that it
might have been wisdom not to have revived them. We have referred
to them here in order to show the unwisdom of the course adopted
in the reiteration of such painful narratives, since the non-profes-
sional mind fails to distinguish these horrors from the comparatively
painless and wholly justifiable experiments upon living animals, made
with the object and intention of conferring immediate benefit upon
suffering humanity. Some benevolent but misguided people cannot
bring to the consideration of this subject a calm judgment ; they
allow their feelings and emotions to carry them off on the hue and
cry of mere emotional sentimentality, confounding with barbarous
vivisections, indispensable and cautiously conducted experimentation
upon animals. That we are not overstating this view of the matter,
let bear witness the balderdash that is circulated in handbills and
broad sheets by the so-called anti-vivisectionists ! In these
appeals, for which the sanction of religion and morahty is per-
vertedly sought, there is a persistent and wilful misrepresentation

in the use of the word vivisection.

' We forbear to quote the whole paragra ph.

1877.] Vivisection. 135

How this word has been misused may further be learned by a
study of the evidence given before the Commission. The names of
the greater proportion of the witnesses^ taken together with the
opinions expressed by them with regard to the intent and the modes
of their experiments, afford sufficient guarantee that they were not
disposed to be parties to wanton cruelty, or the infliction of needless
suffering. The restrictions these witnesses would place upon
experiments upon animals would preclude the infliction of torture,
whilst they reluctantly assert the superior claims of human suffering
for ultimate relief through those means.

Mr. Macilwain lends the weight of his professional reputation,
and all the force of his pen, to the cause of a mere sentimentality,
which puts forth the petitio principii, that life was never given to be
experimented upon ; that to experiment upon animals is to outweigh
by the strong, the right of the defenceless ; that it is the abandon-
ment of mercy by those who expect mercy ; that —

" Eestriction sanctions the principle of vivisection, which is the
admission of torture, under the inhuman arguments that the
claims of humanity demand the sacrifice of living, quivering, muti-
lated animals : this necessarily suggests the hypothesis that mankind
should stand prepared to be dissected alive for the superior rights
of organizations next in ascending gradations, rising to the loftiest
of created beings."

With such illogical and fanciful notions before him well might
Mr. Macilwain fear lest " such narratives may divert the atten-
tion from the scientific bearing of the question.^' We opine that
Mr. Macilwain is himself in this predicament when he takes upon
himself to become the advocate and champion of those who boldly
assert that experiments upon animals are wholly unnecessary, and
who, in the face of the testimony of men of highest renown in science,
unhesitatingly deny the accuracy of the statements on which
are based the opinion that such experiments are justified by the
benefits bestowed upon mankind. In asserting roundly that this
mode of research is altogether fallacious, and a source of serious
practical error, Mr. Macilwain seems to forget that he sets his word
against that of such members of his own profession as Sir Thomas
Watson, Sir George Burrows, Sir James Paget, Professors Sharpey,
Humphry, Taylor, Eolleston, and others equally distinguished for
endowments of head and heart.

The sum of Mr. Macilwain's counterblast amounts to this, that
all the witnesses who favour experimentation are in error, whilst he
and those who think with him are in the right. He supports this
conclusion by long dissertations conveying his own views of the
pathology of certain affections — dissertations the connection of
which with the matter in hand we fail to see, or in which we can
only detect a very remote or indirect relation thereto. Mr. Macil-

136 Bibliographical Record. [July,

wain must pardon us if, without consenting to yield to him the
palm of benevolence, we decline to concur in his special pleading,
which would throw upon a large section of the profession the slur
of wanton cruelty and indifference to suffering.

As corrective of the positive and one-sided conclusions of
'^ anti-vivisectionists " we cite a few passages from the Report of
the Eoyal Commissioners. It should be borne in mind that among
these seven gentlemen are two of the most distinguished ornaments
of physiological and medical science.

"The conviction has been arrived at/' the reporters observe,
" that no teaching of physical science is complete unless illustrated
by practical instruction. Physiology in particular is now for the
first time assuming the position of a separate science." The num-
ber of persons, however, systematically engaged in the performance
of experiments in physiological laboratories does not appear to be
more than from fifteen to twenty at the utmost, and in the hands
of these the experiments are performed with every human precaution
and means for the diminution or entire suppression of pain and
suflfering. The use of anaesthetics has enabled the experimenters
to attain this most desired end. Previous to the discovery of
anaesthetic agents there is no doubt but that much torture was
inflicted upon animals, and at times even upon men; but this
cannot be predicated of modern experiments, in which the in-
duction of insensibility is the almost universal rule. Medicine,
the reporters continue, rests upon the triple basis of clinical
observations and pathological and physiological research; and
they remark that experiments upon animals and men also have
been coeval with the commencement of medical science. It is
further shown in the report that while instances of cruelty in past
time may be adduced, that yet a general sentiment of humanity
pervades all classes of society, and has been strikingly manifested
in the statements of the witnesses examined by the Commission.
There is a general concurrence in the evidence of lecturers and
teachers of medical schools that no infliction of pain not absolutely
necessary is tolerated by the students, who would instantly resent
either careless or deliberate cruelty if perpetrated, or even indiffer-
ence to the sufferings of the subjects of experiment. The Secretary
of the Society for the Prevention of Cruelty to Animals readily
acknowledges that he does not know a single case of wanton
cruelty, and that in general the English physiologists use anaesthetics
where they can do so with safety to the experiment.

The Commissioners classify experiments upon animals under three
different heads, viz. :

" {d) Operations. — These are performed for the purpose of
examining, either for original research or for demonstration to
etudents, the procegges of life.

1877.] Vivisection, 137

" (b) The adminiBtration of poisonous or dangerous drugs. — IPop
the purpose of exhibiting the effect, or of discovering the cure, or
for the purpose of assisting legal investigations.

" (c) The production of disease. — For the purpose of observing
its progress, and discovering the means of preventing, mitigating, or
curing the effects of the same or similar diseases in men or animals."

Abundant illustrative instances will doubtless occur to our readers
under these several headings. Many of these are referred to by the
reporters, e, g. Sir Charles BelFs discoveries, Harvey's experiments,
Jenner's researches, &c., &c. One very forcible illustration is
quoted : —

" Who," says Helmholtz, " when Galvani touched the muscles of
a frog with different metals, and noticed their contraction, could
have dreamt that all Europe would be traversed with wires flashing
intelligence from Madrid to St. Petersburgh with the speed of
lightning ?

" Had these investigations and experiments been abandoned on
the ground that they promised no immediate practical result we
should be ignorant of the most important and most interesting
links between the various forces of nature. Whoever, in the pursuit
of science, seeks after immediate practical utility may rest assured
that he will generally seek in vain."

Mr. Macilwain makes this very apposite observation : — " I
believe there is nothing which so successfully elicits the credulity of
the public as bold assertions, especially if they have the advantage
of not being easily intelligible. The very boldness of the assertion
seems to produce a kind of senseless astonishment, and people
fancy they must be true which they have not the power to ex-
amine.'^ This ready credulity, as we all well know, is at the bottom
of the success of the endless forms of quackery, and it is none
the less applicable to the matter before us. Charges of wanton and
cold-blooded cruelty are freely handed about, and instead of a
deliberate judicial inquiry we are treated to the intemperate raving
of an ill-regulated benevolence, and invited to an anti- vivisection
crusade through sensational placards by which the walls of the
metropolis are disfigured. At this moment there may be seen on
advertising boards, &c., the foulest misrepresentation and exaggera-
tions in the shape of huge drawings of " live " rabbits and
/^ live '* dogs, under the instruments of the experimentalist, and
beaded, " This is vivisection ! ! ^' Most sincerely it is to be hoped
ti^'.t the author of the criticisms on the evidence contained in the
BliLj Book is not associated with the perpetrators of such scandal-
ous and libellous outrage upon the members of a profession that
has ever been foremost in all the benevolent movements of the past
and present time, and to whom, despite the odium thus sought to
be cast upon them, the distressed and the suffering look up for
comfort and alleviation.

138 Bibliographical Record, [July,

Turner's Introduction to Anatomy.^ — The appearance of this
second part of Professor Turner's 'Introduction to Human
Anatomy' will be welcomed by every student of the science. It
completes the work as originally planned for the n^w edition of
the ' Encyclopaedia Britannica/ now in course of publication. It
presents the reader with an admirable outline of human anatomy,
and is, in the strict sense of the word, an introduction to the science ;
as such, therefore, it is not the complete treatise on descriptive
and regional anatomy, nor a handbook for the dissecting-room,
such as a medical student must possess himself of, in order to
qualify himself for examinations and for the exigencies of practice.
Nevertheless, it is a volume that every student ought to have and
to make himself master of, as preliminary and auxiliary to the
more complete works which he must study.

Professor Turner has contrived to include, in a comparatively
small compass, no mere superficial amount of descriptive anatomy,
but a very substantial portion ; this he has effected by terseness
and lucidity of style, bringing to his aid the use of numerous
diagrams, commendable as being for the most part original, and not
mere copies of well-known and well-worn engravings.

This second part is occupied by chapters on the vascular system,
on the larynx, on the respiratory system, on the organs of diges-
tion, on the urinary and reproductive systems, and on the placenta.
These chapters are supplemented by others descriptive of the general
and minute structure of the different organs and tissues in which
the author's own researches are brought under notice.

No individual can lay claim to greater fitness to produce an ana-
tomical treatise than the author, wholly engaged as he is in the
teaching of anatomy in the largest medical school in the United
Kingdom, and also an assiduous worker in and contributor to ana-
tomical science ; consequently his readers will have the full convic-
tion that he is a master of his subject, their only regret being,
possibly, that he has not presented them with a more complete
account of it. The scientific world would be, indeed, deeply in-
debted to Professor Turner for a more comprehensive treatise on
anatomy. There is a scope for one constructed on a more enlarged
plan than any anatomical work we have in this country, wherein
anatomy should be presented to us not as a mere portion of technical
knowledge addressed to medical students, but as a portion of bio-
logical science, wherein human structure should be viewed in rela-
tion to animal structure at large, and human anatomy treated not
as a dislocated fragment of comparative anatomy.

1 An Introduction to Human Anatomy, By W. Tttbnee, M.B. Part II,
1877. Edinburgh, pp. 504.

1877.] Reports on Leprosy, 139

Eeports on Leprosy .^ — Since the subject of leprosy was last dis-
cussed at some length in the pages of this Journal^ there have been
several contributions to it, with an outline of the contents of which
we should like to keep our readers acquainted.

Passing by an elaborate essay on the history of leprosy by Dr.
Munro, which is appearing in the ' Edinburgh Medical Journal/ but
which is not yet completed, the longest and most important reports
are those whose titles appear at the foot of the page.

Of Dr. Vandyke Carter's two reports, the second, which we are
glad to see was printed at the expense of the chiefs of Kattiawar,
gives a detailed account of his tour through that province of
Western India. This volume is essentially a supplement to his first
report.

Ia both papers Dr. Carter shows indefatigable industry ; in the
first he gives clinical details of some cases running a comparatively
acute course, which he observed in Bombay, and in the second a
short history of each case which he examined in his tour through
Kattiawar.

He thus sums up his results : — 1. It has been shown that leprosy
is frequent, sometimes very frequent in the part of Kattiawar under
review, and to an extent scarcely anticipated. 2. The malady is
not, however, uniformly distributed over the land, being most pre-
valent in the populous coast districts and westward ; and its mode
of dissemination is everywhere highly suggestive of communication
by human agency. 3. So large a proportion too is recent disease,
that the influence seems inevitable of an actual overspreading as it
were of the pest ; and besides the form of the disease is often severe.
4. There is absolutely no public provision for the leprous sick and
poor. His main suggestion is, that a convenient refuge be offered
to all vagrant lepers, whose further wanderings should then be inter-
dicted, and that a similar asylum be open to the poorest class of
peasantry whose compliance with the wishes of the state is to be
insisted on; thirdly, that those who are willing to provide separate
maintenance for their leprous sick, must insure the isolation proposed
to be an efiicient one. In short, he practically repeats his recom-
mendation of compulsory segregation.

We have formerly observed that Dr. Carter, on his visit to Nor-

J 1. Reports on Leprosy. (Second Series.) By H. Vandyke Caetee, M.D.
Published under the sanction of H.M. Secretary of State for India. London.
1876.

2. Modern Indian Leprosy. Being the report of a tour in Kattiawar. (Printed
at the expense of the Chiefs of Kattiawar.) Bombay, 1876.

3. Report on Leprosy in the North-western Provinces. By C. Planck, Sanitary
Commissioner N.W.P. October, 1876.

4. Leprosy in India. A Report by T. R. Lewis, M.B., and D. D. Cunninq-
HAM> M.B.> Special Assistants to t;he Sanitary CommisBiou. Calcutta, 1877<

140 Bibliographical Record. [July,

way, acquired a bias in favour of contagion, and doubts as to the
extent of the influence of heredity.

Dr. Carter now says that individually he is unable to furnish any
demonstration of the accuracy of the view of contagion ; still he
considers that he has furnished new collateral evidence of the trans-
mission by man, and entertains the hope that perhaps some day
affirmative facts respecting contagion will be eHcited. In like
manner, he says that heredity, as the exclusive agent in the propaga-
tion of this disease, hardly having been maintained by observation in
Kattiawar, does not seem entitled to the position once occupied by
it. As to the aetiology of the disease, Dr. Carter indicates a not
very probable mode in which the system may be contaminated with
leprous poison, the use of c/iass or whey, as sour or impure milk is
known to be a suitable medium for the retention and conveyance of
animal poisons. He seems to regard disordered digestion as one of
the causes of leprosy. Dr. Carter is indisposed to believe that
leprosy ever arises in a purely spontaneous manner.

Dr. Planck, the Sanitary Commissioner of the N.W. Provinces of
Bengal, has furnished a very interesting report on the disease within
that large area, within which he says that probably considerably
more than 10,099 persons (the return given by the Census) are
afflicted with leprosy. The following are his main conclusions :
Leprosy in the north-west is known in all parts of it, although best
known in Kumaon, Ghurwal, and Banda. It is so diffused that it
is difficult to entertain the idea that local conditions have any in-
fluence as a cause of disease. But these, he admits, require to be
studied more carefully. It is a disease of man specially as distin-
guished from woman, not peculiar to persons of any employment
or religion, affecting in about equal proportions the well-to-do and
the poor. It results, however, in reducing to beggary at least one
third of those attacked.

As a rule leprosy assumes outward and hurtful appearance at the
age of from twenty to fifty years, or after children have been born
to those afflicted ; lepers, or those who are to suffer from it, being as
prolific as mankind in general, and living as long.

Its attacks result so little from contagion that only about 1 per
cent, of 855 cases of cohabitation between a leprous husband and
healthy wife, or leprous wife with healthy husband, resulted in
showing leprosy of both husband and wife. It is probable that in
some instances of leprosy of both man and wife there had been in-
termarriage of parties in both of whom leprosy was hereditary. The
people do not practically believe in contagion. Leprosy is essen-
tially a hereditary disease, as shown by the testimony of about 20
per cent, of the persons examined, and probably in far greater pro-
portion, if the whole histories could have been made out.

There seem undoubtedly to be cases which arise in persons

1877.]

Reports on Leprosy. 141

remote from contagion and who belong to healthy families. The cir-
cumstances of these de novo cases require further study. Any
measure of sequestration of lepers with a view to the eradication of
the disease, such as is understood to be in force in Norway, is not
likely to attain its object in India. Seeing that in the great majority
of cases the disease has been transmitted to the coming generation
before any accurate knowledge of its existence in the constitution
can be attained to, it is not possible to sequestrate an apparently
healthy man because his grandfather or father have been lepers.
While Dr. Planck's report is somewhat general, and does not deal
in the minute examination of cases, and embraces a vast extent of
country, that of Drs. Cunningham and Lewis, after giving some
statistics of the general prevalence of the disease in India and a ,
valuable map of its distribution, confines itself chiefly to the small
area of Kumaon in the Himalayas, and to a study of leprosy as it
occurs in the leper asylum of that district. Their general convic-
tions, though professedly not final, are these :

According to the census returns there are some 99,000 lepers
under British rule, yielding a proportion of 54 lepers to every 1000
of the entire population, or I leper to every 1845 persons ; but in
some districts the proportion is vastly greater, there being in them
as many as 1 leper to 384 persons.

This was about the proportion in the district of Kumaon, of the
leper asylum of which district the 80 lepers were subjected to the
closest scrutiny. Eorty-nine proved to be cases in which anaesthesia
was the predominating feature, twelve in which tubercles of the skin
were most marked ; in 15 cases those two conditions were so equally
evident that they may be classed as mixed, and in four cases erup-
tions were the most pronounced feature.

The average age at which the onset of the disease was observed,
was found to be between twenty-three and twenty-four years. There
was, however, a range from three to sixty. The average duration of
the disease was nearly fourteen years. The anaesthetic cases were
the most chronic, the tubercular being shorter by nearly six years.
The history of the asylums gave no support to the doctrine that
leprosy is a contagious disease, but strong evidence to the contrary.

With reference to the possible influence of heredity in the propa-
gation of leprosy, the facts elicited give forth no uncertain sound .
Taking into consideration the prominent part undoubtedly played
by heredity, and the fact that the disease but seldom manifests
itself until after puberty, it is evident that any attempts at stamp-
ing it out by the segregation of leprous persons would prove wholly
impracticable ; for it would be necessary to segregate not only those
suffering from the developed disease, but those also who were
hereditarily disposed to it. How and by whom could the pre-
disposition be determined ?

142 Bibliographical Record, [July,

There appears to be no dread of the amount of leprosy increasing
in Kuraaon, so far at least as it is increased by heredity, and this
partly because the disease induces a tendency to sterility, and partly
because the mortality among children of lepers appears to be abnor-
mally high.

Before leaving Kumaon, we may observe that the authors of the
report are inclined to attribute the excessive prevalence of leprosy
partly to an influx from Nepal. Leprosy appears to be very com-
mon in Nepal, and also in the Trans- Himalayan regions and in the
whole of the central area, where Schuyler recently describes it in
the more western portions which he visited. Lepers are obliged
to live by themselves, but he saw numbers of them near the Gate of
Samarkand.! About China, Wong^ reports that the great seat of
leprosy is in the provinces of Canton and Tuking. There are fewer
in the interior and in the northern provinces. In Canton there are
believed to be over 10,000 lepers. Yet the people in the south
are better off than those in the north, and eat more butchers'' meat.
The poor probably suffer most frequently, but the richer also suffer
from it. Heredity is universally believed in. All this is interesting,
for Chinese labourers carry leprosy with them to our colonies, as do
the Indian coolies.

The question how far leprosy is indigenous, and how far intro-
duced in some of the islands of the Pacific, and the behaviour of
leprosy where introduced, are subjects on which we hope some light
will soon be shed ; as yet little has been done.

Mr. Hogg, of Sydney, has written, November 5th, 1875, to the
College of Physicians, that leprosy is unknown among the aborgines
of New South Wales^ but that leprosy has been spread beyond the
colonial population; that it is not uncommon in the Malenican
Islands, where it is probably indigenous.

To our scanty information about Africa, where, however, we
believe there is much leprosy, besides at the Cape and in Abyssinia,
Mr. Cameron^ adds a notice of a leprous district or village west of
Lake Tanganyika. The leprous village is kept as much apart from
the rest of the population as possible.

Besides visiting its sites near Jerusalem, Dr. Carter has
given us, chiefly in his first report, an account of leprosy as he
saw it in the islands of the Levant, where it still prevails in Scio,
and especially in Crete ; but we do not know that he has gathered
anything throwing new light on the disease.

With its tendency to linger on in islands, it is not surprising
that leprosy is still to be found in Sicily and in some of the Lipari

1 ' Turkestan,' by E. Schuyler, vol. i, p. 147.

2 Abstract in Virchow and Hirsch, ' Jahresbericht,' Band i, Abth. 2, Berlin,
1876, s. 431.

3 ' Across Africa/ vol. ii, p. 90.

1877.] Reports on Leprosy, 143

islands Profetai had seen 114 cases of leprosy, SO men and 34
women. He says that there are only two out of the seven pro-
vinces of Sicily ,that furnished no leprosy ; that leprosy does not
prevail so much on the coast as inland; that it by no means
attacks the poorest people only ; that malaria is out of the question
as a cause of it ; that in three fourths of the cases heredity was
proved; while he never met with any fact favouring the idea of
contagion.

Prom St. Eemo in the Eiviera we have a report one year more
recent than Dr. Carter's visit to it. Mr. Thaon, of Nice,^ describ-
ing a case of anaesthetic leprosy which is more frequent than
the tubercular, says that the disease is dying out ; that at St. Eemo
they used to have forty lepers in the asylum, sent from various
places along the coast, and that now they have only six ; and the
managers have resolved to admit cases of ordinary skin disease
into the leper hospital. It may be remembered that when the leper
hospitals were closed in France it was found that there were few or
no lepers remaining in them, their places having been taken by
beggars and by patients suffering from skin diseases. This was
also the case at Exeter as late as 1835. Thus, history repeats
itself.

To this short summary we fear it must be added, that leprosy
has of late years been more frequently observed in Europeans who
have visited the East or West Indies. Distressing cases of this
kind are every now and then appearing in London and in large
continental cities. Some such cases have also occurred in New
York in persons who have not visited the tropics. Unfortunately,
in almost all these cases there is no satisfactory explanation to be
had. In some there is a very strong suspicion of heredity, but
there is an extreme unwillingness on the part of European
patients to acknowledge it. It is not a little remarkable that
we as yet have heard of no cases of leprosy among European
soldiers in India. Its occurrence in officers is better known.

Eeviewing the facts and opinions that have now been brought
together, can it be said that they throw much light on the subject ?
We fear it cannot be said that they do.

As to the etiology of the disease, it would appear that diet,
occupation, habit of life, social condition, have wonderfully little
influejice. One point only has been brought into strong relief
in India — the extreme localisation of the disease. Possibly, some
leprosy-inducing conditions may be detected in the specially affected
localities. This would be an important aid to our aetiology. The
evidence in favour of heredity is gaining strength. The fact of
the early development of leprosy being exceptional, points to the

1 Abstract in Virchow and Hirscli, loc. cit.

2 'Nice Medical/ No. 3, 1876.

l44 Bibliographical Record, [Juiy>

uselessness of compulsory segregation with the view of preventing
hereditary transmission. The age at which the tendency to
procreate is greatest is usually anterior to that at which the
signs of leprosy are detected. The evidence, on the whole, leans
towards the comparative sterility of lepers. There is no evidence
of the contagiousness of the disease ; most evidence seems to point
the other way. Some few believe in a connection with syphilis.

On the treatment of the disease nothing new can be said. It is
sometimes retarded, nay, sometimes arrested, by improved hygienic
arrangements, by careful local treatment, by the use of alteratives
or tonics, but there is no specific ; and the hopes raised in the minds
of some respecting the special efficacy of Gurjun oil have not been
realised.

The * Oriental Sore.'i — The authors commence by giving a large
amount of statistics respecting the prevalence of sores and ulcers in
various parts of India. But the classification in the tables which
furnish the statistics is so rude and imperfect, that an examination
of these returns does not lead to any conclusion of importance,
bearing either on the Delhi sore as it is usually called, or on other
forms of tropical ulcers and sores.

An accurate history of the various forms of ulcers which occur
in different parts of India would be valuable for comparison with
the ulcers that prevail in Cochin China, in the Mozambique, in New
Caledonia, in Senegal, Guiana, in Fiji, and in many other tropical
countries, some of them having analogies with the Delhi boil, and
others running almost into the framboesia or yaws.

But these statistics are of little use for any such purpose. The
following is a summary of the results at which the authors have
arrived respecting the Delhi boil, the special subject of their inves-
tigation :

There is no evidence of any parasitic agency in the production of
the disease ; and it appears probable that the deleterious effects are
due to the chemical constituents of the drinking water of Delhi,
which is of extreme hardness and is impregnated largely with salts.

With regard to the nature of the Delhi boil, they have no hesitation
in saying that the disease is in no way distinguishable from one or
other of the various forms of lupus. It may, however, be modi-
fied from its European prototype,^ as is suggested by its local dis-
tribution, and they would, therefore, recommend that the disease
should be called Lujous endemicus. Although most of the micro-

• The • Oriental Sore * as ohserved in India. A Report by T. R. Lewis, M.B.»
and D. D. Cunningham, M.B., Special Assistants to the Sanitary Commission.
Calcutta, 1877.

^ Tilbury Fox thinks it may be a f urunculus modified by locality, and Dr. Carter
insists strongly on its parasitic character.

1877.]

JT/^e * Oriental ^ore.^ 145

scopic appearances they have seen, are common to many cutaneous
affections, it seems to be practically on them that they so confi-
dently base their conclusions ; and they have also been influenced by
consulting the most recent works descriptive of the forms of disease
known under the head of lupus. But some of these forms differ
much in their nature from the ordinary lupus, so much so that
their classification can scarcely be regarded as settled.

Drs. Lewis andCunningham appear to have been hastyin their gene-
ralisations, founded chiefly on book knowledge, and we are not inclined
to agree with them in regarding the Delhi boil as a form of lupus.

We are not aware that any form of lupus is especially prevalent
in particular places at particular seasons ; whereas this is a charac-
teristic of what has been called the Oriental Sore.

Common lupus is a disease chiefly of the young. It very rarely
commences after the age of twenty. The Delhi boil attacks at any
age, not, indeed, sparing the young. Lupus has been considered in
Europe sometimes to have a connection with syphilis or with
scrofula. This is never the case with the Delhi boil.

Every described form of lupus, even the erythematous, the
most diffused one, is more chronic than the Indian sore. Lupus is
much more destructive of tissues and is much more difficult to cure.
Its ordinary forms attack specially the nose, and ears, and cheeks ;
probably not oftener than once in five cases the extremities, while
the sore appears as readily on the arms or hands or legs, as on the
face. Such are some of the obvious differences.

Messrs. Lewis and Cunningham are inclined to attribute the
disease to the Delhi water ; but considering that an affection closely
similar, if not identical, prevails in a variety of places differing much
from each other in soil, climate, and water, such as Biskara, Crete,
Aleppo, Bagdad, and Scinde, we can scarcely be convinced that the
inhabitants of all these places suffer through the water, simply by
their general assertion, that in many of these places the water is noto-
riously brackish, nor do calcareous waters elsewhere produce boils.

We cannot say that this report appears to us to prove either that
the Delhi sore is lupus, or that its main cause is the badness of the
Delhi water ; nor does it add much to the accounts of the disease
collected by Drs. Tilbury Eox and Earquhar, materially aided by
Dr. Carter, and illustrated by his drawings.

We would close this notice by calling attention to one or two
facts respecting the occurrence of the sore in the lower animals,
not indeed novels but which are worthy of further investigation.

Tlie dogs in Delhi appear to get the sore occasionally, but almost
exclusively on the nose, as is also the case in Algiers.

The historians of the Biskara bouton, describe a disease in horses,
which they believe to be a form of the bouton. A similar disease
is well-known in horses in the East, and we believe in parts of

146 Bibliographical Record. [July,

India where the Scinde or Delhi sore is unknown. The disease is
characterised by large fleshy vegetations on the trunk and the
extremities, and it is worth observing that the Prench have described
in Algiers one form of the bouton which, from its strawberry-like
granulations, resembles yaws.

It is commonly said that one attack of the Indian boil gives
immunity against subsequent ones in man. This is certainly not
the case with the disease in horses now alluded to. Though,, with
care a healing of the sores may usually be effected, they are tolerably
sure to occur next rainy season.

The Vivisection Question Popularly Discussed.^— To Dr. Dickson
the thanks of all interested in the question of vivisection are due
for his excellent translation of the recent pamphlet on this subject
by Dr. Hermann, the well-known physiologist of Zurich. This latter
work has special interest in its being a contribution from the hands
of an intelligent foreigner, and of one vs^ho writes rather from a
strictly scientific than from a medical and professional stand-point.
During the recent agitation in this country, the attack of the anti-
vivisectionists was, in consequence of the conditions of physiological
teaching here, directed mainly against the medical profession, and
the defence consisted for the most part in arguments concerning the
relation of physiological experiments to practical medicine and the
treatment of human suffering and disease. Both Dr. Hermann and
Dr. Dickson take their readers out of this region of utihty and
attempt to justify vivisection on the ground of the claims of just
science. The translator holds that " before we can take a right view
of any question relating to science, we must recognise that she must
be pursued not merely where we see a prospect of some special ap-
plication of knowledge, but even where we have nothing to encourage
us with general faith in the elevating power of all knowledge." Dr.
Hermann, himself, speaks plainly on this point, and gives it as his
opinion that " the advancement of our knowledge and not practical
utihty to medicine, is the true and straightforward object of all vivi-
section. We fail not, however, to find in the course of the argument
full recognition of the utility of vivisection to medicine, all branches
of which, it is stated, avail themselves directly of experiments on
living animals, and do so with infinite advantage.

Dr. Hermann argues that experiment is an essential condition
of the advance of the natural sciences. Though it is not every
physiological experiment that necessitates interference with life,
or even injury to the creature, still the numberless minute de-
tails as well as the fundamental facts of modern physiology can be

^ The Vivisection Question, Popularly Discussed. By Dr. L. HeemaNK.
Translated and edited by Dr. Archibald Dickson. Pp. 59.

1877.] The Vivisection Question Popularly Discussed, 147

apprehended only by vivisection. Physiologists, it is asserted, are still
at work on the further examination of the mechanism of the circula-
tion, and of the influence of the nervous system on the maintenance
and regulation of this arrangement, an influence which would never
have been understood or even noticed without numerous vivisec-
tions. The anti-vivisectionists who deny all merit to research by
means of experiments on animals are assured by those who grant
that vivisection, though no longer needed, has done service. Scientific
vivisection. Dr. Hermann contends, is as justifiable as the killing of
animals for food, the destruction of noxious animals, the mutilation
of animals for cattle-breeders' purposes, or even for mere fancy, and
their torture and destruction through love of amusement. It cannot
be proved that science has been guilty of various excesses in cruelty.
In the vast majority of vivisections the animal is, by very efficient
anaesthetics, wholly spared suffering. It may be assumed that the
sensations of pain diminish in intensity as we descend m the scale
of animals, and it may be doubted whether all animal organisms are
endowed with the power of feeling pain. There is, moreover, the
psychological consideration that in most animals there can be no
expectation of pain or anxiety with regard to future suffering.

We meet in this pamphlet with vigorous opposition to the pro-
posal of abolishing vivisection as a means of instruction, and of
banishing it from the lecture room. In the fears of Dr. Hampton
and other British teachers. Dr. Hermann can see nothing but bad
and ill-considered testimony to the character of students on this
side the channel. It would be impossible, it is held, in academical
education — not in primary schools — to banish experiments on living
animals from physiological instruction without degrading it. The
following brief extracts will indicate clearly the author's views on
this point :

" The student that has never, by vivisection, looked into the in-
nermost maehinary of animal life, will always remain a bungler in
medicine."

*' The experiments concerned (in lectures) are just of as remark-
able utility, perhaps even of more utility, than the individual experi-
ments of actual research."

Dr. Hermann objects as strongly to the proposals that vivisection
should be confined to recognised physiological laboratories, and that
only teachers of physiology should have the right of performing
such experiments.

Dr. Hermann concludes with an expression of his views on the
agitation against vivisection in this country, and with an elaborate
criticism of the different sections of the recent Act. These remarks
show that the author possesses full knowledge of our political and
moral conditions, so that the force of his judgment is not weakened,

l48 , Bibliographical Record. [•'^uly,

as is so often the case with foreign critics, by a grotesque and self-
complacent ignorance. The author's criticism, though vigorous and
unsparing, is not, in our opinion, unjust; and in his defence of
science, he seems to recognise fully the equal claims of justice and
humanity.

The Treatment of Spina Bifida^ — Dr. James Morton holds
with the majority of surgeons that injection is the most promising
mode of arriving at the radical cure of spina bifida, and in
accord with Velpeau and witli Brainard of Chicago, regards
iodine as the most suitable active agent for the injected fluid.
Novelty, however, is claimed for the method described in this
book, as the author uses as an injection, not a simple solution
of iodine or a combination of iodine and iodide of potassium, but
a fluid called iodo-glycerine solution, so named from its components,
which are ten grains of iodine and thirty grains of iodide of po-
tassium, dissolved in an ounce of glycerine. It was thought that
as this fluid is less diffusible than either a spirituous or watery
solution, it would be found less likely to permeate the cerebro-spinal
fluid with rapidity, and so to cause shock or bring on convulsions.
The injection of the iodo-glycerine, solution in order to be suc-
cessful, must be practised under certain precautions, the most
important of which is, in the opinion of Dr. Morton, the prevention
of the continuous loss of the subarachnoid or cerebro-spinal fluid.

The results of this method, as shown in this book by the reports
of fifteen cases treated by the author and by other surgeons, appear
to be most satisfactory and certainly far surpass those obtained by
any previous plan of treatment. Of the seven cases treated by
Brainard before the publication of his paper in 1861, in these only
was there a permanent and complete recovery. Dr. Morton states
that of the fifteen cases treated by his method, twelve were successful,
and three fatal, and that all his own lumber cases have hitherto
been fortunate. In the operative treatment of spina bifida some
care must of course be taken in the selection of cases. Some cases,
as the author points out, are so complicated by other defects, as
paralysis, hydrocephalus, &c., as to be hopeless. In subjects who
have no paralysis either of limbs or sphenatus, and no deformity of
importance, and who, apart from the presence of the tumour consti-
tuting a spina bifida, ought to be sound, this new method of treatment
may, according to Dr. Moore, be undertaken and recommended, in
lumbar cases at least, with very little fear of an unfavorable result.

It is to be regretted that those engaged in the preparation of
this useful and, in other respects very creditable book, have received
so little help from the draughtsman.

I The Treatment of Spina Bifida hy a New Method. By James Morton,
M.D., Professor of Materia Medica, Anderson's University, and Surgeon and
Clinical Lecturer on Surgery in the Cl-lasgow Royal Infirmary. Glasgow^ 1877»

1877.]

Gant on Bladder Diseases, 149

Gant on Bladder Diseases.^ — This book consists of Mr. Gant's
monograph on irritable bladder^ with a few chapters from the same
author's ' Science and Practice of Surgery^ added to it, so that it
has now become a work on urinary diseases in general. Mr. Gant
gives as his reason for thus enlarging his former treatise that at
the present time, and in fact, since Mr. Coulson's book on diseases
of the bladder and prostate has been out of print, now ten years
ago, no standard work on this subject has existed in British medical
literature, and that during that time the state of pathology and
surgery in this department has been "greatly altered and ex-
tended.''^ Mr. Gant seems strangely to have forgotten the existence
of the works of Sir Henry Thompson.

The work commences with an anatomical introduction illustrated
by some borrowed drawings. As, however, this part contains
nothing that cannot just as well be found in an ordinary text- book
of anatomy, it requires no notice. The first chapter is devoted to
functional disorders. The exact definition of functional disease is
never easy, most men of science, we believe, considering the term
merely a cloak for our ignorance concerning the structural change
of which the altered function is a symptom. We are not much
aided by the opening sentences of this chapter : " I scarcely need
observe that pathology recognizes two forms of disease — derange-
ments of the function and alterations of structure, both forms of
deviation being estimated by comparison with a presumed standard
of health. Alterations of structure, including those of physical
character and chemical composition, are together represented by
pathological anatomy, while pathology proper is thus restricted to
disorders of function. Such, then, is the general nature of
pathology, and such its more limited and usual signification.''' We
find the author includes paralysis, engorgement and overflow of the
bladder, and retention of urine under * afunctional disorders/' and
the treatment of these various conditions is briefly indicated, so
briefly that we fear the reader would derive but little benefit from
it. More than one-third of the book is composed of the chapters
taken from the ' Science and Practice of Surgery,' and these we
need not notice. The subjects included will be found in every
student's text-book, treated of as fully as they are here, and much
in the same way. The last 130 pages — nearly another third of the
work — is devoted to urinary diseases, deposits, and calculi. Mr.
Gant employs throughout the old notation in giving the formulae of
the various chemical components of the urine. As a sample of how

1 Diseases of the Bladder, Prostate Gland, and Urethra; including a Practical
View of Urinary Diseases, Deposits, and Calculi ; being the Fourth Edition of
the ' Irritable Bladder,' revised and much enlarged. By FbedEBICK JameS
Gant, F.R.C.S. Lonaon, 187^.

150 Bibliographical Record. [July,

that part of the work is executed we will give a brief extract of the
information to be found concerning albumen in the urine. A table
of the diseases with which it is associated is first given, commencing,
of course, with Bright's disease, acute and chronic. Then follows
a long list of ailments, including subacute rheumatism, diarrhoea,
bronchitis, peritonitis, and paralysis. Beyond the enumeration
of these diseases in the table nothing is said as to the conditions
under which albuminuria may coexist with them, Bright's disease
is, however, treated of at greater length. We are informed that
structural changes in the kidney are the immediate cause of the
symptoms. These changes are congestion and its consequences,
which has been named by Dr. George Johnson acute desquamative
nephritis ; degeneration — fatty or waxy, which has been named
chronic non-desquamative nephritis; and lastly, ^'partial absorption
and contraction, producing a small, firm, remnant kidney, having
an irregular puckered surface and granular aspect when the adherent
capsule is withdrawn — granular degeneration." This " condition
might be termed the atrophied or remnant kidney." These are all
included under the name Bright's disease ; and Mr. Gant seems to
consider it an open question whether they are all stages of one
disease or independent forms. The symptoms, he tells us, are
essentially the same. " The blood and urine have, in respect to
each of their prominent constituents — albumen and urea — changed
places. While, therefore, the nutrition of the body is undermined
by the constant abstraction of the one, the system, through the
blood, is poisoned by the retention of the other.'' The symptoms
of uraemia and of " febrile oppression '' (whatever they may be) set
in. The urea in the blood causes meningitis, pleurisy, irritation of
the gastro-intestinal mucous membrane, &c. The retention of
water in the blood causes dropsy. Then comes a paragraph passing
the wit of man to understand. " The essential symptoms of
Bright's disease of the kidneys are connected also with the altera-
tions of structure which occur in consequence, or perhaps inde-
pendently, of congestion; but the albumen returns to the blood,
and the water, about proportionately, to the urine, the urea and
other solid urinary constituents being still retained in a progres-
sively greater proportion in the blood, thus reducing the urine to
mere discharge of water, and often in greater quantity.'' This is a
fair summary of what is said of Bright's disease, and anything more
useless, inaccurate, and unscientific, it is difficult to conceive. Under
physical characters of the urine in Bright's disease we are told
that the colour is smoky brown, quantity small, and specific gravity
low, but subsequently the urine becomes pale and opalescent, specific
gravity falls perhaps to 1004, there is much less albumen, and the
quantity is greatly increased. I^o doubt the first part is true of
acute Bright's disease, and the last of some form of the chronic

1877.] Hilton on Rest and Pain, 151

disease ; but with our present knowledge what can be the possible
use of such muddled scraps of information ? Any well-educated
fourth-year student possesses more accurate and extensive informa-
tion. After five lines on casts the author goes on to chemical tests^
under which we find the usual reactions briefly given. The well-
known fallacy caused by the addition of a single drop of nitric acid
to albuminous urine before boiling is explained by Mr. Gant by
supposing that a nitrate of albumen is formed which is uncoagulable
by heat, and he states that the condition can only occur when " just
so much acid be added to the albuminous urine as shall combine
with all the albumen present and form this nitrate. Nitrate of
albumen being insoluble in nitric acid appears when more acid is
added." We suppose this is intended to be a representation of the
views of Dr. Bence Jones, although his name is not mentioned.
Now, we believe that Dr. Jones's explanation of this condition was
that the nitrate of albumen which he supposed to be formed was
soluble in dilute nitric acid, but insoluble in a solution of moderate
strength. The accident of adding the exact equivalent of nitric
acid to form a nitrate of albumen evidently could not occur once in
a thousand times: whereas this pecuHar reaction can be obtained
with the greatest ease in any highly albuminous urine. Dr. Beale's
explanation that it is due to the liberation of phosphoric acid is not
mentioned.

We believe the small portion that we have thus examined forms
a fair sample of the whole of this section of Mr. Gant's book, and,
we fear, of a great deal of the other chapters as well. We cannot
see what purpose the book is to serve. A great part is avowedly
taken from a text-book intended for students, and is consequently,
we should think, hardly adapted to a special treatise on a single
group of diseases. The work is essentially theoretical in character,
scarcely a case being mentioned from one end to the other. We
can but look upon it as an encumberance to medical literature, and
we think, if Mr. Gant is well advised he will let the book rest wliere
it is, supposing the present edition sells out, or will re-write it,
introducing more original matter and more clinical illustration,
which we feel sure his ample experience would enable him to do.

Hilton on Rest and Pain.i— The first edition of this well-known
work appeared in 1863, and was soon out of print and Mr. Hilton,
tells us that it was his intention at that time to have '^ enlarged the
volume by additional matter derived from other and different surgical
diseases, but all having the same purpose in view — namely, to show

1 On Rest and Pain. By John Hilton, F.R.S., F.R.C.S., Surgeon-Extra-
ordinary to Her Majesty the Queen, Consulting Surgeon to Guy's Hospital, &c.
&c. Edited by W. H. Jacobson, F.R.C.S., Assistant-Surgeon to Guy's Hospital.
Second Edition. London, 1877.

152 Bibliographical Record. [July,

how largely we are indebted for our professional success in surgical
practice to the recuperative power of Nature ;'* but insuperable dif-
ficulties presented themselves, and at last it has been allowed to appear
again without any material change or addition. Mr. Jacobson has
not altered the original text to any extent, but has confined himself
chiefly to the addition of a few interesting notes and some new
drawings. His work is, however, admirably done, and we have no
doubt this present edition will meet with a success equal to that of
the first. There can be no doubt that the value of rest in the treatment
of disease is more fully recognised at the present time than it was four-
teen years ago, and that all surgeons are coming more and more to
trust to the vis medicatrix naturae, and to recognise more fully the fact,
that in the vast majority of surgical cases there is a natural tendency to
cure which cannot be increased by any artificial means, but which
can be greatly helped by removing obstructing causes and warding
off complications. This is observable, not only in surgery, but in
medicine also, the physician as well as the surgeon having come to
recognise how little he can really do beyond aiding nature in the
cure she is effecting.

The term ^^rest^' as employed by Mr. Hilton, has a rather wide
significance. He does not mean only mechanical but physiological
rest — not only absence of movement, but cessation of function. The
use of the word may at times seem strained, as when he speaks of
the object of the operation for hernia being to give rest to the
strangulated gut, and the opening* of an abscess giving rest to its
walls, but it is always quite clear what he means by it. In the
majority of cases the treatment by rest involves letting the patient
alone as much as possible, the avoidance of violent counter-irritants
and such remedies, and one of the most valuable features of the
book is the protest it enters against *' meddlesome surgery."

The value of pain from a diagnostic point of view occupies a
large portion of the work, and here Mr. Hilton does invaluable
service by pointing out the vast importance of an accurate know-
ledge of anatomy, showing that the distribution of the cutaneous
nerves, the nervous supply of joints and muscles, the communica-
tions between one nerve and another, although so often looked upon
by the student, and even by the practitioner, as merely useless details,
often serve as the only means of guiding the surgeon to a correct
diagnosis.

The work is so well known that it is needless for us to review it
at any length. Although the text is scarcely altered in the present
edition, and consequently here and there the phraseology may seem
antiquated to the modern student, and possibly be at variance with
recent pathological doctrines, the greater part of the work can never
grow old, being founded on clinical observation and the application
of the undisputed facts of anatomy to actual practice. It is a work

1877.]

Cleland on Dissection. 158

which every one should read, and when we say this we are not, as it
were, setting a task to the reader, for the style of the writing is such
that it reads as pleasantly as a novel, the interest being constantly
kept up by the descriptions of actual cases from the author's prac-
tice, graphically told, always instructive, and often amusing.

Cleland on Dissection.i— Dr. Cleland, in the preface, thus explains
the object of this small work — "The following pages have not
been written with the view of interfering with any works of
anatomical demonstrations or systemic anatomy, already in exis-
tence, but are intended to supplement such books. The student
ought to study the '' subject '^ in the dissecting-room and his books
at home, and he ought never to be encouraged in the too common
error of looking on his dissections as mere illustrations for the
statements of the text- book. Yet it is necessary that he should
be guided in his dissections, both that he may make them in such a
manner as to display the anatomy to the greatest advantage, and
that he may recognise the structures by the names by which they
are known. To these two purposes of guidance these pages

are exclusively devoted The author's effort has been, by

the omission of all description, to give to the student who seeks to
learn, scalpel in hand, a fuller assistance in the practical difficulties
which he is likely to meet with than could be afforded in a work
devoted to description either in the systemic form of arrangement
or that of demonstrations. It is expected of the student that,
before coming to the dissecting-room, he should glance over, each
evening, a portion of work in this book, and consult his descriptive
manual sufficiently to have an intelligent idea of what he is to
exhibit on the subject next day. Taking with him this book to
the dissecting-room, he will with its aid cultivate his manipulative
powers and his observation ; and on his return home he will recur
to his text-book, and find how far his own observations agree with
those of more experienced men.'' We may at once state that the
directions are clear and accurate, and in every way admirably
adapted to the purpose for which they are intended, but it may be
doubted whether the system of teaching advocated by Dr. Cleland
is that calculated to enable the student most readily to acquire a
sound knowledge of anatomy. Every teacher of anatomy will agree
with the author when he says that the student should study the
" subject " in the dissecting-room ; but it is not quite so clear that
he should use his books only at home. Suppose a student to
follow Dr. Cleland's plan, what would be the result ? Having

' A Directory for the Dissection of the Suman Body. By John Cleland,
M.D., F.R.S., Professor of Aiiatomv and Physiology in Queen's University^
London, 1876.

154 Bibliographical Record. [Jalyj

obtained, by a process of pure cram, an indistinct notion of the
region he is about to dissect, he would proceed with no further aid
than is afiForded by these directions, perfectly free from description,
to attempt the dissection of his part. In all probability he would
commit many errors, cut away many structures, and fail to observe
many important details. He is then advised to make notes of his
imperfect observations and to go home and see how far the de-
scriptive works agree with him. Supposing he finds that his
observations are greatly at variance with those of the authors of
his text-books, what is he to do ? In all probability it will be
impossible for him to refer again to his part as in the process of
dissection he will have cut away many structures and displaced
others. He must, therefore, be content to accept the statements
of the text- book in opposition to his own ideas, or to adhere to
his own views in spite of the immense probability that they are
inaccurate. The one would involve the acquisition of anatomical
knowledge by a process of pure cram, and the other a degree of
self-sufficiency, which we hope is rare amongst students of anatomy.
It is possible the student might be able, by studying the dissections
of his fellows, to correct his errors of observations of the day
before ; but this would, we fear, be more conducive to wandering
about and gossiping, the two greatest snares of the student in the
dissecting-room, than to diligent study. Moreover, we firmly
believe that the student derives immense benefit from reading the
description with the part actually before him ; not merely using
the dissection as an illustration for the statements of the text-book,
but actually verifying every statement as he reads it, and then, if
he is unable to agree, make a note to that effect in the margin of
his book. After he has thus read over the dissection a few times
with the part actually before him, he is able to derive some benefit
from the process of reading at home, as the picture of the dissection
will rise before his mind's eye. It has taken hundreds of years,
and the dissection of thousands of bodies, to arrive at the present
accuracy of detail which characterises our best manuals of dissec-
tion, and how can we expect a student to attain the same in the
comparatively short time allotted to the study of practical anatomy,
unless he avail himself to the fullest possible extent of the labours
of those who have gone before him ?

We believe, therefore, that although theoretically it is very ad-
vantageous for a student to cultivate his powers of observation by
attempting to acquire a knowledge of all the minute details of
anatomy by a process of discovery, practically he would fail to
observe a vast number of important facts, which he could only
acquire afterwards by artificially learning them from books or
plates, and that his knowledge of anatomy would lose more than
his faculty of observation would gain.

1877.] Heath's Operative Surgery, 155

In his advice to dissectors Dr. Cleland does not mention the
great advantage a student derives from making drawings of his
own dissections. However rude and inartistic they may be, nothing
serves so well to recall dissections to the mind as drawings
actually made by the student from his own parts. The accurate
and prolonged study of the part, required to make even a rude
sketch, impresses it upon the mind in a way that nothing else can.
Nor do we think the author sufficiently impresses upon the reader
the necessity of cleaning a part perfectly. The picture left upon
the mind's eye by a perfectly clean dissection is sharp and distinct,
like that of a view seen on a bright clear day, whilst that left by
one in which the various structures are half concealed by fragments
of fat and fascia, although the outline of every one may be visible,
is hke the impression left by a view seen through a haze or mist.

The author states that his object has been to give a "fuller
assistance in the practical difficulties which the student is likely to
meet with, than could be afforded in a work devoted to description,
either in the systemic form of arrangement or that of demon-
strations.'^ We do not find, however, that the directions here
given are fuller than those to be found in at least one well-known
work in the form of demonstrations. Yet they are so good, clear,
and accurate, that we regret that our firm belief in the value of
reading descriptive anatomy in presence of the dissection itself
prevents our recommending this work to the student.

Heath's Operative Surgery .i— There is probably in this country
no man alive at present who has a better right than Mr. Heath to
take the responsibility of publishing a work of this character.

Por nearly twenty years he taught operative surgery, or at least
a selection of the operations of surgery on the dead body. He has
also for many years operated frequently, brilliantly and successfully
on the living, and has contributed his share to current surgical
literature.

Now that he finds his position in his hospital is elevated above
the pleasant drudgery of teaching relays of students to operate on
the dead body, which, after all, is a little apt to pall, after the
repetition of many sessions, he is leaving as a legacy to his succes-
sors and the profession an expression of his opinion as to the best
procedure for many of the capital operations of surgery.

Here we may remark that perhaps it is as well that by the
arrangements of medical schools the teachers of operative surgery
should be often changed, for if not, the tendency is that the
wearied teacher, tired of his routine drill, either becomes a lifeless

1 A Course of Operative Surgery, with Plates drawn from Nature, by M.
Leveille, and coloured by hand under his direction. By Cheistopheb Heath
P.E.C.S. London. Parts I, II, III and IV, 1876-7.

156 Bibliographical Record. [July,

machine giving the same old story without zest or life, or, still more
dangerous to the pupils, seeks variety for himself by making his
puzzled scholars' practice operations new, strange, and varied.
Though the student of history may succeed in unearthing, perhaps,
twenty-five different methods of amputating at the hip joint, there
is really only one best method of taking off a finger, and this,
drudgery though it may seem, must be shown year after year, day
after day, till the class know it.

It is more than probable that Mr. Heath's pictures are of those
operations that he himself has found most valuable in practice and
most easy to teach.

We find, in his first part, that the first plate contains some clear
diagrammatic pictures of operations on the eyeball and eyelids,
Graefe's operation for cataract being the one figured. The remain-
ing three plates of this part contain the ligatures of the arteries of
the upper extremity and the operation of excision of the mamma.
The ligatures are admirably described ; the pictures are so clear and
well dissected as to be misleading to the young surgeon, who wants
to know what he will really see, though instructive to the student,
who merely wants to cram and impress his memory through
the eye.

The incision for ligature of subclavian will be too small in many
cases if it is made only to extend from sterno -mastoid to trapezius;
it should often overlap the ^dge of each of these muscles, and
sometimes be supplemented by a small incision along the posterior
border of the sterno-mastoid.

One dictum in the operation of excision of the mamma we must
dissent from most emphatically. Mr. Heath says, " when diseased
axillary glands exist in connection with mammary disease they are
close beneath the pectoral muscle, and not in the neighbourhood of
the axillary vessels, unless the disease is very extensive^' (p. 25).

We have found the opposite of this often, and believe that in
every case the surgeon must be prepared to face the difficulty of
removing glands in close contact with the axillary vessels, and that
to do this safely and thoroughly he may often have to divide a large
portion of the sternal division of the great pectoral muscle.

Part II contains ligatures of head and neck; the carotid is
admirably described, short, precise, and accurate. Mr. Heath
brings out the doctrine, only lately fairly recognised, that the whole
course of the common carotid is overlapped by the edge of the
sterno-mastoid, and as a consequence of this doctrine he makes his
incision along the edge of that muscle.

In describing the operation for ligature of posterior tibial artery
Mr. Heath selects the one along the edge of the tibia, and does not
allude to the method between the heads of gastrocnemius.

Tracheotomy is given in Part III, Mr. Heath prefers the upper

1877.] BouDANT on Mineral Waters of Mont -Dor e, ISt

operation (above the isthmus) as easier and more satisfactory-
easier certainly, more satisfactory for the surgeon, but, we beUeve^
in many cases, less safe for the patient.

The operations on jaws teach the student much, the surgeon
little. Eor the upper jaw Mr. Heath, rightly we believe, recom-
mends the central lip incision to be carried upwards as far as
necessary.

Lithotomy and colotomy are beautifully drawn and excellently
described, as also are castration, amputation of penis, and opera-
tions for phymosis ; the latter are about the most perfect diagrams
of any operations we have ever seen. The remainder of Part IV
contains the amputations of the upper extremity ; skin flaps, with
circular division of the muscles, seems to be the key-note of this
excellent description.

The work is an admirable one. The illustrations are beautifully
executed and lavishly coloured. It does not profess to give histo-
rical details nor describe varieties of operations, but gives what
it proposes to give — a detailed account of what Mr. Heath con-
siders a good series of operations on the dead or living body.

Boudant on Mineral Waters of Mont-Dore.^ — This is an ex-
cellent book and a valuable contribution to our knowledge of the
treatment of pulmonic affections by mineral waters aided by moun-
tain air. Although the Prench had long sent that class of affections
to altitudes such as Eaux-Bonnes 2300 feet, or Mont-Dore 3300 feet
above the sea, and the Spaniards had sent their cases to Panticosa, a
height of 5000 feet, yet the proposal to treat pulmonic patients at
Gorbersdorf, and still more at Davos, that is, at heights of from 1700
to 5000 feet, came on the English and Germans, especially on the
latter, as an entire surprise. The special value of Dr. Boudant's
work consists in its being the result of twenty years'* clinical intel-
ligent observation, and in his cases being given in detail. Although
various other ailments are treated at Mont Dore besides pulmonary
ones, yet their predominance is borne witness to by the fact, that of
the clinical observations 300 pages are devoted to the air passages,
and only sixty to other subjects.

Dr. Boudant is naturally influenced by the current medical
opinions of Prance, and he attrbutes the virtues of his waters to
their operation on the various diatheses. Those on which their in-
fluence is most marked are the arthritic, the dartrous, the scrofulous,
the secondary syphiHdes ; it is less marked in the tubercular dia-
thesis ; it modifies chloro-ansemic and lymphatic diatheses, although
Dr. Boudant does not admit that these diatheses are independent

^ Les Eaux Minerales du Mont-Dore, Topograjphie Proprietes, Physiques et
CMmiqueSy Clinique M^dicale. Par le Docteur Boudant^ Inspecteur-Adjoint
ceg Eaux. Paris, 1877) 8vo, pp. 523.

ISS bibliographical Record. [July,

entities as the others are. Some of his remarks on phthisis are well
worth quoting. Phthisis consequent on pneumonia is scarcely ever
preceded by haemoptysis or laryngeal phthisis.

When cases of pneumonic phthisis are not complicated by tubercular
diathesis, the waters of Mont-Dore are very efficacious, while in
true tubercular disease it is only occasionally and exceptionally that
they are of use. The caseous form of pneumonic phthisis is the
most dangerous and also the most common.

When the waters do not cure, they at least have the advantage of
calming the cough, of dispelling the evening febrile exacerbation, of
stopping the morning perspiration, of favoring the conditions of
nutrition, and of opposing colliquative action. They very often retard
the progress of a case, which is obviously a clear gain, especially
in those who are approaching to middle age, when there is some
hope of the injurious constitutional action ceasing.

The conclusions respecting asthma seem to us judicious. The
waters of Mont-Dore are very useful in nervous asthma if the case
comes early under treatment, or is connected with an asthmatic
herpetic or hsemorrhoidal diathises. They are very advantageous in
bronchial or catarrhal asthma.

All emphysematous cases are greatly soothed, and some of them are
cured, especially if the patients are young and the malady is recent.

It is more difficult to procure absorption of any oedema of the
lung ; indeed it is rare, but the health of the patients improves,
and they are able to struggle against it longer.

Cardiac asthma requires very careful treatment, but with certain
precautions some benefit is derived ; if some few are cured, the dys-
pnoea must have been dependent upon a diathesis which has
been counteracted. Dyspeptic asthma is usually cured, but of course
precautions are required to prevent a relapse.

We have not space to offer any opinions of Dr. Boudant on
the treatment of neuralgia, rheumatism, and gout, but we observe
that he gives some detailed cures of very obstinate cases of diarrhoea
at Mont-Dore.

The work contains a full account of Mont-Dore and its climate,
of its several sources, and of the various arrangements for baths and
drinks, embracing the pulverisation of the water, the inhalation of
its vapours, gargling the throat, and nasal irrigations.

Study on the Definite Results of Amputation.' — This pamphlet
contains much information, compiled from various sources, mainly
Prench, on certain points of interest connected with the subject of
amputations. Dr. Viard deals in the first place with the question

1 Etude sur des JResultats Befinitifs des Amputations. Par H. VlASD. J« B.
Bailliibbb bt Fils. Paris, 1877. Pp. 114.

1877.] Sansom On Diseases of the Heart, l6d

of the influence of diatheses and pathological and physiological con-
ditions amputations and other surgical traumatisms. Here, as
in other parts of this work, we meet with full proof that the author
has studied with much industry the surgical literature of his own
country. No allusion, however, is to be met with to the work that
has been done in this direction by English surgeons, especially by
Sir James Paget and Mr. Callender. The second chapter is devoted
to the subjects of anaesthesia and the prevention of hsemorrhage
during amputations, and the concluding portions of the work deal
with the comparative merits of the different methods of dressing.

The flap operation, M. Yiard thinks, gives the best permanent
results, but has no influence in favoring or preventing the develop-
ment of secondary conicity in the stump. Cicatrization of the stump is
believed to take place more rapidly after amputations for injury than
after amputations for disease. Antiseptic dressings ought to be
preferred because they favour immediate union; they have no influ-
ence, however, on the remote results of the amputation.

These conclusions have been based on fifty cases of amputation,
brief records of which are given at the end of the pamphlet.

Lectxires on the Physical Diagnosis of Diseases of the Heart. —
We owe Dr. Sansom many apologies for not having accorded an
earlier notice to his really valuable little book. When authors
strive one against the other to be diffuse and obscure, and try to
hide what they have to teach beneath a huge and cumbrous
structure of words — when writers on heart diseases find a thousand
octavo pages too small a space into which to compress their subject —
and when a monograph on pericarditis exceeds in size the books
which taught our fathers the whole science of medicine, it is re-
freshing to encounter a work which is concise, clear, and to the
point. Dr. Sansom writes as only a man who is a thorough master
of his subject can write, and he gives abundant proof that his
reading has been as extensive as his practical experience. He
rides no hobbies and airs no crotchets, but is content to give us as
shortly as possible all the well-established facts connected with the
physical diagnosis of heart disease.

We are glad to observe that Dr. Sansom teaches his students to
rely largely upon their unaided faculties, and that he wisely com-
mences by devoting a chapter to the more general and less special
of the symptoms which sufferers from heart disease present. The
value of pain, palpitation, dropsy, dyspnoea, cyanotic complexion,
hoarseness, &c., are all reviewed, and the student is warned that he
is not at once to rush to his stethoscope for the sake of exactly

1 Lectures on the Physical Diagnosis of Diseases of the Reart. By Aethub
Ebkest Sansom, M»D. London^ 1876.

led Bihiiogtaphical Uecord* ["^uly,

diagnosing the seat of a trouble, without attending to the com-
plaints which a patient makes, and which, although they are the
real cause of his seeking medical advice, have often very little
apparent connection with his pathological condition.

The whole subject of physical examination in heart disease is
treated at length, and although we do not notice any new facts, we
commend the admirable judgment with which the facts given have
been selected, and the clearness with which they are set forth.

The chapter on auscultation has about it a highly practical tone,
and we are glad to see that the author has adopted the graphic
method of representing murmurs which we owe to Dr. Gairdner.
Dr. Sansom's rules for forming a diagnosis in difl&cult cases are
worthy quoting :

"In the first place, do not be content to write in your notes
'rhythm of the heart irregular and tumultuous,' but let there be
order in your record of such irregularity, and system in your treat-
ment of the seeming chaos. Eecord all the signs which you have
observed previously to those derived from auscultation. Describe the
sounds, normal and abnormal, heard over the situations of each of the
orifices. Note first the characters of first sound and second sound
at the aortic cartilage. Eeduce these to diagrammatic form indi-
cating murmurs where present. Kepeat the process at the pulmonary,
tricuspid, and mitral areas successively. Compare the observations
and diagrams only after they have been completed, and then fill in
the lines of conduction of normal and abnormal sounds. Do not
hasten your conclusions, but obtain all the evidence before you give
your verdict."

The Electric Bath. — The medical world would be glad of some
real information concerning a therapeutic measure of which it has
heard much. It is not to be found in the present volume, which
is more remarkable for its assertions than its scientific reasoning.
When a patient is immersed in a tub of water, which is part of an
electric circuit, what results, other than those attributable to the
water and the warmth, are likely to be obtained ? Does the
electricity prefer to take the highly resisting course of the patient's
body, or the path of slight resistance offered by the water ? These
are among the questions we want answered before serious attention
is invited to the electric bath, and Dr. Schweig certainly does not
answer them satisfactorily. The bath seems to be almost a panacea,
and is said to cure rheumatism, cholera and paralysis, and, of course,
nervous exhaustion and impotence. This work, however, is more
likely to decrease than increase the belief of the profession in a
therapeutic agent, which has had the misfortune to be introduced
by persons with more 2eal than judgment.

1 The JSlectric Bath, By Geobgb ScfiWBiG, M.D. New York, 1877.

1^77.] Bristowe on the Thedry and Practice of Medicine, 161

Bristowe on the Theory and Practice of Medicine.' — The work
before us is an 8vo volume of 1100 pages, and has been written
for students and junior practitioners. It is intended to give, in a
moderate compass, the results of the author^s reading and ex-
perience. The first 120 pages are devoted to general pathology,
and contain a well written exposition of its doctrines. Here and
there a statement may be met with, to which some exception may
be taken, as, for example, that on page 41, affirming the probable
existence in the blood-vessels of a distinct power of active dilata-
tion. But such instances are rare.

The rest of the book is given up to special pathology, nearly the
whole field of which is embraced. As this is too wide for minute
culture by a single labourer, or for minute description in a single
volume, there is inevitably some inequahty in the completeness of
its different parts. Some are full and carefully elaborated ; others
are mere summaries.

Dr. Bristowe defends himself, by anticipation, against the com-
ment that his directions as to treatment are less ample and specific
than is desirable, and we agree with him that the inculcation of
sound general principles is of more importance than an enumeration
of therapeutic details. But in some cases, it would have been
satisfactory to have had a more positive expression of opinion
as to the value of certain medicines and modes of practice.

Thus, as regards the management of cases of pneumonia, we are
left in doubt whether or not Dr. Bristowe approves of the early
employment of alcoholic stimulants. We presume that he does not,
as their administration receives no distinct sanction, and as he gives
a qualified recommendation of bleeding from the arm. On the
same subject, he mentions that, for the purpose of reducing tempera-
ture, recourse may possibly be had with advantage to veratria,
digitahs, or aconite.

Holding as we do, with Juergensen, that the great risk in
pneumonia is from failure of cardiac power, we doubt much the
admissibility of the, first or last of these remedies. Dr. Bristowe
maintains the old doctrine as to the relationship between miliary
tubercle and caseous matter, and regards them as stages of the
same morbid process. He considers that caseous pneumonia, or the
ordinary form of phthisis, has a right to the name of tubercular.
We do not share this opinion, but believe that phthisis may
exist without tuberculosis, either existent, or antecedent. Hence
his chapter on tubercular disease of the lungs fails to satisfy us,
not giving, as we think, an adequate idea of the weight of evidence
on the question.

A Treatise on the Theory and Practice of Medicine. By John Sybe Beistows,
M.D., &c. London, 1876.

119— LX. 11

162 Bibliographical Record, [July,

The section on Bright's disease of the kidney is too short and
restricted to permit the author to do justice to his subject^ some
eight or nine pages only being allotted to it. The disease is con-
sidered as simply inflammatory, and as the result of general acute
or chronic nephritis. The fact that it is often the result of a de-
generative change, and of gradual origin is mentioned incidentally.
Descending to smaller matters, we note that Dr. Bristowe invariably
uses the word aphtha, instead of aphthse. As far as we know, the
word can be only legitimately used in the plural.

Having pointed out a few shortcomings, which may be easily
made good in the next edition, we have pleasure in stating that the
book, on the whole, is an excellent one. Many of the articles are
admirably written, as those on diphtheria, thrombosis and embolism,
thoracic aneurism, and the introductory remarks on diseases of the
heart. They are full_, clear, and terse.

The division containing the diseases of the nervous system is
one of the best in the work. Here the student will find informa-
tion which he would seek without success in any other English
treatise, except the translation of Ziemssen's ' Cyclopaedia.'

The author has laid under contribution, and largely profited by
the writings of Duchenne, Charcot, Jackson, Clarke, and other
modern workers in this department of medicine.

The sections on sclerosis, lateral and disseminated, locomotor
ataxy, glosso-labio-laryngeal palsy, infantile spinal paralysis, and
progressive muscular atrophy, contain a carefully written abstract
of all that has been established respecting these interesting, but,
until lately, unstudied maladies.

We have said sufficient to show that we estimate Dr. Bristowe's
treatise highly as an introduction to the study of pathology.

Sea Air and Sea Bathing.i— This little work, by Dr. Parsons,
contains many useful hints for those who are seeking for recreation
and health by the sea. The author first traces the various stages
of action of sea water on the body from the first coldness and
shock, on immersion, to the glow of reaction. He then proceeds
to a chapter of general directions for bathing by different classes of
bathers. The best time of the year for sea bathing in England is,
he says, between the first day of June and the last day of Septem-
ber. The most suitable time of the day for sea bathing, is about
two or three hours after breakfast, when the morning meal is
digested, and the system is beginning to feel the efiects of the con-
version of food into fuel. No person should bathe more frequently
than once in the day, and a daily repetition of the open sea bath is

1 Sea Air and Sea Batldng ; their Influence on Health. A Practical Guide for
the use of Visitors at the Seaside. By Charles Paesons, M.D., Honorary Sur-
geon to the Dover Convalescent Home.

1877.] Sea Air and Sea Bathing. 163

not suitable for all persons. Eor the majority of persons bathing
on alternate days will be found amply sufficient, and quite as much
as the average seaside visitor can sustain. Some very correct and
useful hints are given as to the way to bathe. It is recommended
that all who can make up their minds should go into the sea with
a plunge. Those who cannot do this, should go in rapidly and
duck as quickly as possible under the first advancing wave. The
author most justly states, that bathers who go into the water
timorously, knee-deep, and stand hesitating before they proceed
further, with their teeth chattering and their bodies cold, had
better not practise bathing at all, unless they can amend their ways.
Such persons, after the bath, suffer from congestive headache, and
sometimes from sickness ; no good reaction, but it may be that
a long sensation of chilliness and depression, follows. We agree
entirely with this advice, and we would push it a little further. It
not unfrequently happens that when young children are first taken
to bathe, they are undressed and put into the water while in a
state of great fear. They resist, and then, by persuasion or force,
are made to take half a bathe. The effect is often most injurious.
When a young child for the first time is brought to the sea^ he
should be taken into it as quickly as possible, without exciting his
or her fears. If fears actually arise and the little bather become
at all nervous and faint, he should not be taken at that time into
the sea at all, but should be quickly dressed again, and allowed to
run to his play without either being scolded or teased. In time,
by familiarity with the sea, and by observation of other bathers
the fear wears off, and the bathing is accomplished satisfactorily.

To this bit of practical advice, we would add another bit, viz.
never, in excess of zeal for teaching the healthy plunge, take the
young bather by surprise and throw him into the sea. This is a
most dangerous practice, both to mind and body. In a future
edition of Dr. Parsons^ book we would suggest to him to add a
short paragraph or two on this subject of bathing by the young
and uninitiated.

Some instruction is given about the necessity of keeping up
muscular exercise while in the open sea, and as to the state of the
body in respect of its temperature. It is very correctly taught
that when the body is warm from exercise, and is not reduced by
excessive exercise or other reducing cause, there is no harm from
bathing, rather the contrary ; but that no one who is perspiring, and
at the same time wearied, should enter the cold sea bath. Exercise
before and after the bath is, nevertheless, in all cases good, provided
that it be moderate. Prolonged bathing in the sea at one time is
very practically and clearly denounced. The bather should* not
stay in the sea until he is beginning to feel cold. For those in
health, a bath of from five to six minutes is, as a rule, sufficient;

164 Bibliographical Record. [July,

those who are weak should not exceed four minutes, and the really
invalided should be content with two or three dips and out again.
"We second heartily the advice here given, as well as the further
advice, that good swimmers should not exceed a quarter of an hour
at a time in the sea, and should not, on any pretence of seeking
health, bathe more than once in the twenty-four hours.

There are some ailments which follow at times the use of the
sea bath, such as bilious attacks, constipation, diarrhoea, irritation
of the skin, boils, nettle-rash, congestive headache, faintness, and
vomiting, and in women, caitamenial discharge. To these induced
ailments Dr. Parsons draws the attention of the reader in a special
chapter. His direction here are explicit, and at the same time
brief. If we have a fault to find, it is in the recommendation for
treatment of those who suffer from congestive headache of a severe
kind, with deficient reaction, after bathing. In such cases the
author recommends, when the collapse is alarming, as in rare in-
stances it is, a warm bath and friction, preceded by a glass of hot
brandy-and- water. We demur to the hot brandy- and- wdter in a
case where there is failure of power from congested nervous centres.
It is bad physiology — it is worse practice. A draught of hot-milk-and
water or of soup is the proper addition here to the warm bath, and
friction. The great paralyser of nervous function, alcohol, is simply
so much added evil.

On the whole, we commend heartily Dr. Parsons' book. It
is a good book for professional men to put into the hands of those
whom they may send to the seaside. It is plain, practical, and
sincere.

The Nurse's Companion.^— This is a small and, on the whole,
pretty sensibly arranged compilation. It will, no doubt, be found
very useful by beginners or unskilled nurses. The directions are
for the most part given in clear language, and it is seldom that any
room occurs for misinterpretation. It strikes us as singular, how-
ever, that scarcely a word is said respecting the best methods of
administering medicines to children, nor reference made to the
peculiarities of sick-child nursing, as distinguished from the manage-
ment of infants which properly belongs to monthly nursing. The
author will, no doubt, in a future edition, make his little work
more complete on this and several other points which call for fuller
treatment. What he has given the reader is in the main so good
that we wish there were more of it. Some portions of the book
can hardly be said to consist of teaching for nurses, and, however
valuable the information given may be, it would more appropriately
belong to a work on domestic medicine. For example, some of the

1 The Nurse's Companion, a Manual of General and Monthly Nursing. By
C. J. CuLLiNGWOETH. London, 1876.

1877.] History of Asiatic Cholera. 165

chapters on "Nursing during Pregnancy, Labour, and the Puerperal
State,-*' have reference to points concerning which a medical man is
pretty sure to be consulted long before any skilled nurse is in
demand; ^.^.haemorrhage, or discharge of blood during pregnancy,
and the precautions to be taken against miscarriage. Herein, as in
some other parts of the work, the author has, no doubt with most
praiseworthy motives, somewhat confused the respective provinces
of the medical attendant and the nurse, and he consequently
occasionally lectures over the heads of those for whom the work is
ostensibly intended. Fortunately, the information given is trust-
worthy, and it is best that a high standard should pervade the
pages of a work of this kind. Some very sensible, and ordinarily
much needed, advice is given as to the behaviour of a nurse in the
lying-in chamber ; and altogether the very full directions given for
the management of mother and child are highly to be commended.
This department of practice is evidently familiar to the author, and
monthly nurses cannot have a better guide, ^e hope to see
another edition of the work, and would suggest that it might
profitably be amplified in several respects. It strikes us that a
glossary of medical terms would prove very useful to the class for
whom the book is intended.

History of Asiatic Cholera.^ — Notwithstanding all that has been
said and written on the subject of Asiatic cholera, Mr. Macnamara's
work will be read with interest by all those who desire to make
themselves thoroughly acquainted with the history of the myste-
rious disease of which his pages treat. The author makes no pre-
tension to the discovery of any special remedy for cholera, nor,
indeed, does he lay down any rules of treatment at all ; and, with
reference to what may be called the theory of the malady, his views
are advanced with due caution and upon a full consideration of all
the facts bearing upon each matter discussed. His work is^ in fact,
only what it professes to be, a liistory of Asiatic cholera, and as
such it possesses very high merits, being the result of great labour,
of much personal experience, and of mature judgment.

In order that there may be no mistake as to the disease described,
Mr. Macnamara desires it should be clearly understood that by
" cholera Asiatica" he means an affection of a most fatal nature,
generally destroying about 50 per cent, of its victims, and cha-
racterised by a train of well-known symptoms^ which we need not,
therefore, specify in detail. This prelimmary caution is, no doubt,
given by Mr. Macnamara in order to exclude from the category of
true cholera all those allied maladies which, although resembling it
in some of its features, are really of a much milder type and of a

^ A History of Asiatic Cholera. By C. Macnamara, F.C.U., Surgeon to the
Westminster Hospital, pp. 472. London, 1876.

166 Bibliographical Record, [July,

totally different nature. It is well known that some authors have
regarded the bowel-complaints usually prevalent in the summer in
our own and other temperate climates as forms of cholera, differing
from the Asiatic only in intensity and capable of passing into it if
neglected, but it is evident that Mr. Macnamara holds no such
opinion.

The origin of all diseases is obscure, and cholera is no exception
to this general statement; and although Mr. Macnamara displays
much research in tracing the earliest records of its appearance, he
admits that the ancient descriptions of the disease are but few and
vague. But he strongly maintains that cholera had its cradle in
the East Indies, and especially in British India, and that all the
outbreaks which have appeared in Europe, the New World, and
elsewhere, are traceable to this primary source. He produces
abundant evidence, with much of which the medical profession is
already acquainted, to prove that cholera prevailed in British India
at the close of the last century and at the commencement of the
present, the most remarkable epidemic having occurred in 1817.
From this time, as is well known, the disease has travelled in
various directions, and it made its appearance in our own country
in 1831 and 1832.

Mr. Macnamara takes great pains in proving the limitation of
the disease to India in the first instance, and in showing how it was
subsequently propagated to other regions. He seems to be clearly
of opinion that as far, at least, as our own country is concerned,
the malady was unknown until the years just mentioned, and that
the descriptions of authors who hold a different view are probably
to be discarded as based on insufficient grounds.

He argues that the immunity of England and of Europe gene-
rally from cholera before the second quarter of the present century
is explicable by the difficulty, formerly existing, of the voyage
from Europe to the East, the long sea passage round the Cape
being calculated to destroy any germs of infection, if any such were
likely to be transmitted from the Indian settlements. But in 1830
a steamer for the first time sailed from Bombay up the Arabian Gulf
to Suez; in 1834 it was reported by a committee of the House of
Commons that it was practicable to carry on steam communication
between Suez and Bombay during the north-east monsoon; and it
is well known that, after a series of trials, a regular communication
by steam was instituted and still exists by this route between India
and Europe. But Mr. Macnamara also adverts to the international
communications formerly existing by land, or at least along the
western shores of India and the Persian Gulf, and he shows that
this mode of travelling was once so tedious that disease was not often
transmitted from one country to another. Besides this route from
India he mentions another by land to several cities in China.

(

1877.] History of Asiatic Cholera. 167

Mr. Macnamara then explains in detail the bearing which such
observations have upon the history of Asiatic cholera ; and he
maintains that the facts elicited by studying the operations of trade
between India and other countries account for the non-appear-
ance of the disease in Europe before the year 1832. Admitting
that cholera existed in India before that date, and that it is com-
municable by means of the excretions of people affected by it to
healthy persons, it is alleged that the disease was not communicated,
because the channel of direct intercourse between the nations of
India and foreigners was of an extremely restricted nature, and for
many centuries was absolutely almost impracticable. It is hardly
conceivable, the author argues, that cholera, or any such disease,
could be carried from Hindostan to England by men passing over a
long sea voyage of several months^ duration ; but now that regular
steam communication takes place from India, both into the Eed
Sea and into the Persian Gulf, the propagation of the disease can
easily be accounted for.

It is, of course, quite impossible for us to follow Mr. Macnamara
into the multitudinous details with which his pages abound, or to
trace with him the numerous channels by which cholera was pro-
pagated to Europe and to America, but we may observe that, with
regard to its invasion of England, it is proved that it came to this
country from the continent of Europe in the year 1831. In 1829
it began to travel from India northward, and appeared on the
Eussian frontier ; in 1880 it broke out in Persia and in Russia;
in 1831 it travelled through Asia Minor, Egypt, Constantinople,
Bulgaria, and Germany, and, as will be remembered, it appeared
about the end of October at Sunderland, being supposed to have
been imported from Hamburg. In March,' 1832, it broke out in Paris,
and with such extraordinary malignity that of the first ninety-eight
cases admitted into the Hotel Dieu no less than ninety-six were
fatal, and in eighteen days 7000 persons had died of the disease.
In this same year the disease visited England in an epidemic form.
Up to the date now mentioned, America had been free from Asiatic
cholera, the progress of the disease having apparently been checked
by the intervention of the Atlantic Ocean. On the 8th of June,
however, the disease broke out at Quebec, and two days afterwards
at Montreal, and the visitation is readily explained by the fact that
a vessel had sailed from Dublin, then affected with cholera, in the
previous April, having 173 emigrants on board, of whom 42 died
of cholera during the voyage. The remainder were allowed to
land a few miles from Quebec, and no rigid measures were taken to
prevent intercourse between them and the city. But, besides this
vessel, it appears that several others arrived at Quebec with cholera
patients on board, and large numbers of emigrants from cholera-
infected quarters arrived upon the St. Lawrence, and thence were

168 Bibliographical Record. [July,

distributed throughout the province. " This was the beginning of
cholera in America/' writes an American physician, quoted by Mr.
Macnaraara, and the magnitude of the results as affecting a great
part of the New World constitutes a sufficient excuse for this
brief allusion to the first appearance of cholera at Quebec.

Although, as we have observed, we are unable to follow Mr.
Macnamara through the different threads of his historical researches,
it will be gathered from the above remarks that he has a definite
idea as to the propagation of the disease, althoug;h he has no ex-
planation to offer as to its original cause. He seems to disbelieve
the possibility of its development de novo from any known and
recognised sources, and he assumes its original and endemic exist-
ence ill India from all antiquity merely as an established and in-
controvertible fact. If India had remained isolated from the rest of
the world by the interposition of seas, and deserts, and mountains,
and if steam had not instituted rapid and regular communication
for the purposes of commerce, cholera might have remained a
stranger to Europe and to America; but as it is, the germs of the
disease are carried from one port to another by persons, by clothing,
and by merchandise, and by the influence of drinking-water, and
hence there are but few nations of the earth which have remained
free from its epidemic visitations. For many mysterious or capri-
cious_ features exhibited by cholera no explanation can be ofi'ered,
such as its unequal and very partial distribution, its absence for
some periods, its presence at others, the immunity of some localities
which might seem most open to its attacks, and the invasion of
other regions which, it would be supposed, were exempted. Still,
with all the difficulties of the subject, some general principles may
be laid down to guide the inquirer and the sanitarian in their re-
searches into this dreadful malady, and in reference to preventive
medicine much has, no doubt, been already done in wardinp- off
many threatened invasions.

We cannot, perhaps, pass a higher eulogium on Mr. Macnamara^s
book than to state that he has had to grapple with great difficulties
and has overcome some of them, and that even those who do not
agree in his conclusions will have ample reason to admire the
industry and zeal which he has displayed in massing together a
multitude of facts and arranging them in admirable order.

Theory of Medical Science.^— We have read this little volume
with some care, but are unable to understand the object of its pub-
lication. That Dr. Dunham is dissatisfied with the present con-
dition of medical science is evident from the following passao-e at

* Theory of Medical Science. The Doctrine of an Inherent Power in Medicine
a Fallacy. By William Dunham, M.D, pp. 150. Boston, 1876.

1877.] Lauder-Brunton : Tables of Materia Medica. 169

p. 102: — '*I have long maintained/^ be says^ "a great contempt
for our medical philosophy, but it is practically wise not to con-
demn a principle without superseding it with a better substitute.'^
But he does not tell us what our " medical philosophy '' is, and we
are ourselves ignorant upon the subject. He is right, however, in
not condemning a '^principle,'' whatever it may be, without super-
seding it with a better (?) substitute, but we fail to find that Dr.
Dunham has provided or suggested any intelligible substitute for
the shadowy '^philosophy ^■' or '^ principle '^ for which he has so
great a contempt. We are glad to find that Dr. Dunham regards
the homoeopathic theory with the same contempt as that which he
bestows on "our medical philosophy.''^ The doctrine of an inherent
power in medicine (or, as Dr. Dunham seems to interpret the term, in
drugs) may be, and probably is, a fallacy, but we are not aware that
any rational persons hold such a doctrine, and its refutation, there-
fore, is a work of supererogation. We can find nothing in Dr.
Dunham's pages but a jargon of words without any definite mean-
ing, and put together, we may add, without much regard, in many
instances, to grammatical accuracy.

Tables of Materia Medica.^ — This book belongs to the class of
well-intentioned productions, intended to facilitate the acquisition
by students of the modicum of knowledge required by the medical
examining bodies. We quite sympathise wdth the author in " the
weary mechanical work involved in the preparation of these tables,"
and may be allowed to express the regret that the amount of time
and w^ork expended upon them had not been applied by Dr.
Brunton to the investigation and elucidation of some of the in-
numerable questions in the therapeutics of which we are profoundly
ignorant.

However, we doubt not that students will duly appreciate the
book, which is a sort of condensed summary of the principal facts
in materia medica, arranged in a tabular form and stated with ex-
treme brevity. It is, in fact, just a '^ cram-book,' ' defying perusal,
and, in our opinion, entailing more labour on a student reaJly
desirous of learning materia medica than the diligent study of the
ordinary text-books on the subject, which have some context to
make their perusal practicable and possibly interesting — which

I present some flesh on the bones, and not the dry bones only for
digestion. Of the many columns of the tables before us, those
relating to the therapeutical action and uses of the drugs are the
least satisfactory. The notes on these matters are crude and super-
ficial, faults due partly to the brevity demanded in the tabulation of
the facts. But they present also a lamentable commentary on our
^ Tables of Materia Medica. A Companion to the Materia Medica Musevm,

170 Bibliographical Record. [Julj%

therapeutical knowledge by their vagueness, the contrariety of their
statements, and the looseness of terminology.

However, our standpoint in estimating the value of this treatise
is wholly different from that of the student, who, the more the pity,
is driven, by the accepted policy of medical examinations, to cram
his head with hosts of facts and statements, which he has to learn
to forget when admitted into the ranks of the profession, before he
can be an intelligent, rational practitioner of medicine.

Routh on Infant Feeding.^ — The Hippocratic aphorism adopted
by the Eoyal College of Physicians of London, and cited in all the
documents put forth by that learned body, viz. " that life is short,
but art long," does not, judging from the work before us, seem to
sufhciently impress itself on all its members. Now, we are not about
to find fault with the matter contained in this book, which is well
enough in its way ; nor with the style, except so far as to say it
might be better ; but we do object to the compilation of books of
several hundred pages on subjects which may be sufficiently treated
in a tithe of the number. Here we have a volume of above five
hundred pages on infant feeding, a subject on which a skilled
writer could say all that is of importance in far less compass. To
make up the quantity of matter requisite to fill these many pages, a
vast deal of collateral information has been collected, information
culled from mortality statistics, from physiological and therapeutical
treatises, from the Materia Medica, from works on children's diseases
and their treatment, and from books on diet and regimen.

We admit that we cannot affirm that the whole of the varied
topics dealt with in this volume are not legitimately covered by the
the full title of the work ; but, at the same time, we are of opinion
that even in this case they need not to have been treated with so
much prolixity. The book is certainly not addressed to medical
men, but rather to the public ; and it may be contended that the
public want all this miscellaneous information, and have shown
their appreciation of it by the purchase of two previous editions.
But if so, we would reply that there is much in it needlessly written,
as far as the wants of non-professional people are concerned, and
that many medical details might well have been omitted. More-
over, we question whether among its many purchasers it has had
many readers — many who have followed the author through his
discursive pages. However, there are those with whom time is
long and occupation scant, and such of those as possess themselves
of the volume will find in its fulness of matter much worthy their
attention and study.

1 Infant Feeding and its Influence on life, or the Causes and Frevention of
Infant Mortality. By C. H. F. RoiTTH, M.D. Third edition. London, 1876.

1877.] Bennet on Nutrition. 171

Austin Flint's Manual of Percussion and Auscultation.^ — A work
of this kind, addressed to students, written by a highly experienced
physician and teacher, calls for no extended notice in the shape of
a review. Its purpose is sufficiently represented in the title ; whilst,
on the other hand, the competency of Dr. Austin Mint to teach
percussion and auscultation will be admitted by every one acquainted
with the recent literature of chest diseases. Indeed, the diagnosis
of these diseases has been a special study with him, and his position
as lecturer and physician of the large Bellevue Hospital^ New
York, has afforded him a wide field for observation.

As a matter of course, the author has little novel to teach on
the oft-written subject of auscultation and percussion. Yet he
can refer to some personal research and opinions, as, for instance,
to the recognition and naming of broncho-vesicular respiration, a
sign of a certain degree of solidifying disease of the lung, consisting
of a combination of the vesicular and tubular quality in the in-
spiratory sound. So again, he claims credit for pointing out the
distinctive characters of the cavernous respiration from bronchial or
broncho-vesicular.

His manner of teaching is full and precise ; and he has advisedly
abstained from troubling his readers with disputed questions re-
specting the mechanism of signs, " taking the ground that our
knowledge of the significance of signs rests solely on the constancy
of their connection with the physical conditions which they repre-
sent,^' relating immediately, not to diseases, but to the physical
conditions incident thereto. Moreover, he urges, that exclusive re-
liance is not to be placed on physical signs, but these are always to
be taken in connection with pathological laws, the history and the
symptoms, otherwise they become sources of error.

In conclusion, we can confidently recommend this treatise to all
who would learn auscultation and percussion, and rightly value
these modes of exploration of disease. If we may venture on
noting any deficiency in the work, it would be by remarking on the
entire absence of diagrams, which serve greatly to illustrate verbal
teaching, more especially in making clear the nature of cardiac
sounds.

Bennet on Nutrition.^ — It is some years since Dr. Bennet pro-
duced this work, which has now reached a second edition ; the
delay, however, in its re-issue being due, as he tells us, to personal

1 A Manual of Percussion and Auscultation of the Physical Diagnosis of
Diseases of the Lungs and Meart, and of Thoracic Aneurism. By Austin Flint,
M.D. London, 1876.

2 Nutrition in Sealth and Disease. A Contribution to Hygiene and to
Clinical Medicine. By James Hbney Bennet, M.D. Second edition. Lon-
don, 1876.

172 Bibliographical Record. [July,

circumstances. His purpose in writing it was to impress on the
profession and the public the fact that the imperfect performance of
the digestive and nutritive functions leads, slowly but surely, to ill-
health, to disease, and to death.

The text was a good one, though not new, nor discoursed upon
for the first time. Nevertheless, it is one that can well bear iteration
and illustration, and, in the hands of Dr. Bennet, has obtained very
adequate and satisfactory treatment. We may, therefore, wish this
new edition the same popularity and ready sale that attended the
former one, for if read, marked, and inwardly digested, it cannot fail
to be of service to the public. To professional men, instructed in
physiology and dietetics, it will present no novel teaching. Yet, as
a record of the author's long observation and experience, it will
have a value even to them as confirmatory evidence of some impor-
tant truths recognised in practical medicine.

On one point, indeed, Dr. Bennet believes he differs from
generally accepted views. He considers too much importance has
been attached to the differential diagnosis of the several morbid
salts found in the urine as a result of disordered digestion and
nutrition. He thinks that the presence of uric acid and of lithates
in the urine, in such abnormal quantities as to constitute a deposit,
is very much more frequently the result of defective digestion than
of defective metamorphosis of tissue, especially of dyspeptic indi-
viduals. The like opinion he holds with regard to oxalate of lime
deposit, which, also, he cannot recognise as indicative of a peculiar
diathesis. But if the author thinks little of the differential diagnosis
of urinary sediments, he has the most profound conviction of the
importance of examination of the urine as a guide to diagnosis,
particularly to that of imperfect digestiou, believing it to afford the
most delicate and best test of the condition of the digestive and
nutritive functions, and thereby also the safest and most tangible
guide in the dietetic, hygienic and medicinal treatment of patients.
As a consequence of this conviction. Dr. Bennet is very precise as
to the method of examining the urine, particularly so with regard to
the time after food at which the examination is made.

In these days of promiscuous and unrelenting onslaught on all
alcohohc drinks, it is well to find an author point out that all the
ills which afflict humanity are not the product of intoxicating bever-
ages, but that in no small proportion over-indulgence in solid food
is chargeable for them. Or, as Dr. Bennet writes, "the fact is
probable that in the middle and upper classes of society more
human beings suffer in health and strength from taking too much
food than from taking too little;^' and *' over- feeding is a much
more baneful error than is generally supposed."

The author's remarks on " food requirements in ill-health " are
marked by sound sense and the fruit of experience. He gives a

1877.]

BucKNiLL on American Asylums.

173

very necessary warning against the too prevalent custom of cram-
ming the sick with the view of supporting strength, and utters a
protest against the exaggerated notions in vogue as to the vast
superiority of animal food, and points out that density of structure
in aliments is a more important condition to be kept in view tlian
merely their animal or vegetable nature. In his observations on
alcohol he raises the question of its value as food, but does not enter
into the controversy that has raged on the matter. Whilst judi-
ciously pointing out the errors and abuses in the use of alcohol as a
dietetic for the sick, he does not fail to recognise its occasional
utility. But his general deduction is, " that, as a rule, the con-
firmed dyspeptic should be all but a water-drinker, until he have
recovered his health.'''

What is now written must suffice for a notice of this work. It
abounds in sound instruction and advice, and cannot fail to benefit
the non-professional reader, for whom we assume it to be primarily
intended.

Bucknill on American Asylums.' — These notes previously ap-
peared in the pages of a contemporary, and called for sharp dis-
cussion and severe comments in the United States of America, the
asylums of which constituted their subject-matter. In the opinion
of those whose feelings are not aroused by disagreeable criticism
these notes will possess a high value. They come from a physician
than whom none could be better qualified to form an opinion as to
the structural arrangements, and the management of asylums, and the
treatment of the insane. If he have found fault with the institu-
tions for the insane in the United States and in Canada, it has been
in no carping spirit but in fairness and honesty, and his censures
should be received with respect and attention — not resented as in-
flicting an injury. No unprejudiced reader of the notes can come
to any other conclusion than that American asylums are far from
the complete and satisfactory condition which their own reports
would suggest; that much is wanting in the arrangements made for
the comfort and convenience of their inmates, and that greatly
more restraint is resorted to than is really needed. Moreover, the
lunacy laws in several of the States are most defective and unsatis-
factory, and a great responsibility rests upon some of the
State legislatures for the many abuses and defects Dr. Bucknill
has pointed out, and which have been referred to by other writers.
In fact, Dr. Bucknill appears disposed to attribute many of the
faults he observed to defective legislation and administration, and to
the absence of a healthy public opinion as to the requirements of the

^ Notes on Asylums for the Insane in America. By JoHK C. Bucknill, M.D.,
F.R.S. London, 1876.

174 Bibliographical Record. [July,

insane. With the generally miserable condition of asylums in Lower
Canada we have been long acquainted, and can but wish that the go-
vernmental influence of the parent country may be brought to bear on
this important colony, in favour of placing Canadian asylums on a
proper footing and of making them more in accordance with our own
institutions in structural arrangements, management, and treatment.
We should not fail to observe that, whilst noting faults in struc-
ture and management. Dr. Bucknill rightly awards all praise to the
asylum superintendents of America for their skill, zeal, and humanity
in their responsible position.

Bull's Hints to Mothers.^ — The former of these two works comes
before us as the twenty-fifth edition; the latter, also, has passed
through many editions, but the number is not stated. However,
it is clear enough that these two volumes are highly appreciated by the
public, for whose benefit they were written. And from our know-
ledge of their contents, and of the manner in which these are handled,
we consider that the popularity they have achieved is well deserved.

The volume on the maternal management of children is a sequel
to ' Hints to Mothers,^ and without doubt owes its origin to the
success attending the publication of the latter. The two cover much
of the same ground, and consequently we find many repetitions
of the same statements in both. They, however, appear as inde-
pendent works, to be separately purchased, and consequently no
objection need be taken against this circumstance.

The manner in which the incidents of pregnancy and labour are
treated is most unobjectionable. It awakens no prurient curiosity,
and is suggestive of nothing to which the most sensitive woman can
object. This volume was most unwarrantably referred to in a recent
trial — where a scandalous book, professedly put forth to convey le-
gitimate information to women on some kindred subjects, was the
object of prosecution — as a work belonging to the same category,
and sinning in the same direction. But the proceeding had not the
least justification furnished by the contents of the present treatise.

It is a further commendation of both volumes that they do not
encourage their readers with the notion that they can afford to do
without the aid of medical men ; that armed with the books, they can
alone undertake the treatment of the diseases written about. As a
further praiseworthy feature, it may be stated that the style is
simple and clear, and scientific and inflated verbiage alike avoided.
It is with much satisfaction we recommend these two volumes to
those of the public for whose information they have been written.

^ 1. Hints to Mothers for the Management of Health during the period of
Pregnancy and in the Lying-in Eoom. By Thomas Bull, M.D. New edition,
thoroughly revised by R. W. Paekee.

2. The Maternal Management of Children in Health and Disease. By THOMAS
Bull, M.D. New edition, thoroughly revised by R. W. Paekee.

1877.] Dictionary of Medicine and Surgery, 175

Lawson on Sciatica. — We noticed favorably, in a previous num-
ber of this ^ Eeview/ the first edition of this work ; what we have
now before us is professedly a second edition, although, in fact,
nothing but a re-issue of the former one, with a new title-page and
a concluding chapter, of a miscellaneous character with regard to
its contents. This is not what the pubKc look for when invited to
purchase a new edition ; and surely Dr. Lawson might have revised
what he had first written, and have corrected certain references
which now appear incorrect. Moreover, instead of writing Part XI
as a supplementary chapter, he should have incorporated most of it
in the body of his work. His subject, indeed, was a limited one in
the first instance, viz. the advocacy of hypodermic injections of
morphia as the true treatment of sciatica, and admitted of no more
extended consideration than he had given it. And whatever addi-
tion was made to our knowledge of the pathology and treatment of
the disease was made in the original edition, which, therefore, for
all practical purposes is of equal value with this so-called second
one. The new matter found in Part XI consists in a statement of
the author's continued confidence in the treatment recommended ;
a reference to the eff'ects of morphia injections when bleeding fol-
lows puncture of a vein ; to the not infrequent swelling up of the
lymphatic glands ; and to the occasional curious disturbance of
vision by the morphia injection. There is also a brief discussion of
the relative effects of morphia and atropia, from which we learn that
the author agrees with Dr. Harley, that the two drugs are not ^^ in
the least way antagonistic in their general effects on the body." Of
injections of atropia he does not approve; they are attended by
unpleasant consequences and are far inferior in the relief afforded to
morphia. As to subcutaneous injections of cold water, advocated
by Lebert and others, he does not believe in them.

Dictionary of Medicine and Surgery, by Jaccoud.^ — The prin-
cipal articles contained in this comprehensive cyclopaedia of medi-
cine (which has, to the great credit of its editor and publishers,
been produced so uninterruptedly, notwithstanding its magnitude
and the number of writers employed on it) are — on the structural
anatomy, physiology and pathology of mucous membranes, of
muscles, and of nerves, by J. Straus, Math. Duval, Labadie-Lagrave,
Le Dentu and Poinsot. Hallopeau treats of neuralgia, and A.
Luton of neuroses. Dieulafoy writes of death in its physiological
aspects, and A. Tardieu and Laugier of death in its medico-legal
bearings ; other noteworthy articles are contributed by Hirtz on

^ Sciatica, Lumbago, and Brachialgia ; their Nature and Treatment. By
Heney Lawson, M.D. Second edition. London, 1877.

^ Nouveau Dictionnaire de Medecine et de Chirurgie pratiques, illustr^ de
figures intercalees dans le texte. Directeur de la redaction, le Docteur Jaccoud,
Tome xxiii. Mol-Nev.

176 Bibliographical Record. [July,

narcotics; by J. Simon, on thrash; by Yerneau, on monstrosities;
by A. Tardieu and Martineau, on glanders and farcy in the lower
animals and in man. There are several minor articles on the natural
history and therapeutical properties of the myrtacea? ; on myrrh,
monesia, mucilages, mustard, &c. ; and others again on nsevus,
neoplasm, moxa, and moUuscum. The experienced pen of M.
Hardy is employed on the articles on cutaneous diseases.

As we have observed before, this dictionary of medicine and
surgery reflects the position of those sciences rather from a French
point of view than from one embracing a survey of the state of
knowledge existing in the several principal countries of the world
in which they have been long and assiduously cultivated. This
purely French handling of the subjects is much more observable in
some articles than in others. The impression left on the minds of
the reader of the volume now before us, and, indeed, of other
French medical and scientific works, is that in France the languages
of other nations of importance are not widely cultivated, and conse-
quently that the literature of those countries is unknown, or cannot
be used, and that an unfortunate indifference to it is promoted to
the national prejudice and the injury of science.

After allowing for this defect of a too limited and peculiarly
national representation of the state of medical science, it is only
just to say that this dictionary stands foremost among the publica-
tions of the day for its fulness and value.

Swain's Manual for Emergencies.^ — Mr. Swain's book on emer-
gencies is so well known to the profession, and has been so well
received, that it suffices to remark the appearance of a new
edition and to note the chief additions made ; what these additions
are is thus stated in the preface: — "In the chapter on 'Injuries
of the Eye ' I have given the symptoms and treatment of acute
diseases of that organ, whilst to that on ' Emergencies connected
with Parturition,' amongst other things, the signs of pregnancy have
. been added. The last chapter, on ' Apparatus and Dressings ' will
be found much fuller, and to contain an account of some of the most
recent improvements in surgical apparatus."

In future issues of his work, which are sure to be called for, it
will be desirable for Mr. Swain to weigh well the additions to be
made to the matters treated, so as not to overstep the precise object
signified by its title, a manual for '' emergencies," and so deprive
the treatise of its distinctive character.

^ Surgical Emergencies, together with the Emergencies attendant on Parturi-
tion, and the Treatment of Poisoning. A Manual for the use of General Frac-
titioners. By W. P. Swain, F.R.C.S. London, 1876.

1877.] Transactions of Bombay Medical Society, 177

Transactions of Bombay Medical Society.^ — The extent of work
now carried on in all parts of the world by intelligent practitioners
to stem the progress of disease and obviate its consequences, and to
devise and improve sanitary means and therapeutical agents to
accomplish those ends, we may fain hope will, sooner or later, meet
with its reward. In every city where a group of medical men are
found we find them forming themselves into associations to promote
medical science. The volume before us is the outcome of the
labours of the members of the Medical and Physical Society of
Bombay, a society which, within our knowledge, has existed above
twenty years, and has put forth a large number of volumes, by
which no inconsiderable additions have been made to our stock of
knowledge.

As a volume proceeding from medical men actively engaged in
their profession, and most of them connected with the public
service as military or civil medical officers, we have in it, as
might be anticipated, a series of papers characterised rather by their
practical, than their theoretical matter; and, bearing in mind
the land of its origin, we are prepared to find that cholera con-
stitutes its piece de resistance. Unhappily, however, although
cholera occupies the foremost place in Indian publications, among
topics for inquiry and discussion, we discover no positive advance
in the right understanding of its pathology; no approach to a
rational and successful treatment.

This fact Civil surgeon G. Bainbridge refers to in his paper on
the " Cholera Epidemic of ISTS,'' in Dhulia. In his opinion we
have no real evidence that the various therapeutical agents resorted
to are of any value in arresting or curing the disease ; and he advo-
cates *'a reconsideration by the medical authorities of the thera-
peutics of cholera,^' by a sort of test process of the value of the
several plans of treatment recommended, by carefully putting them
into practice, in the hands of different physicians, who should report
on their action and results.

Dr. W. G. Hunter, first physician of the Jamsetjee Jejeebhoy
Hospital, was led by the appeal of Surgeon A. E. Hall, in the
'Practitioner' (July, 1875), although not a believer in the theory of
contracted pulmonary arterioles, to try the sedative treatment
recommended by chloral hydrate. " Thirty-two cases were accord-
ingly treated by hypodermic injections of chloral hydrate, in strict
accordance with the plan laid down by Mr. Hall. The results were
so disastrous — viz. 53' 1 per cent., or, roughly speaking, 20 per
cent., more than by the stimulant plan — that I did not feel justified
in further pursuing this treatment, and abandoned it. Apart from

1 Transactions of the Medical and Physical Society of Bombay. No. xii, new
series. For the year 1876.
119-LX. 12

178 Bibliographical Record, [July,

these unsatisfactory results, a farther danger was introduced by this
method of treatment, which in a hot climate should not be lost sight
of. A patient who had been discharged as cured was brought back
to hospital three or four days afterwards, suffering from traumatic
tetanus (which ended fatally), the result of the punctures by the
hypodermic syringe."

Dr. Henry Cook, a hospital colleague of Dr. Hunter, contributes
a paper advocating the use of belladonna as a remedy for salivation.
After giving his clinical experience, he embarks on a description
of its modus operandi, which will repay examination. He follows
with another paper, of physiological interest, *'0n the Diminished
Elimination of Urea in Cases of Hepatic Abscess."

Among other instructive articles may be named Surgeon G. Bain-
bridge's "Experiences in Lithotomy and Lithotrity," the " Report on
the Plague in Turkish Arabia/' by Surgeon-Major Colvill ; a " Me-
dico-Topographical Eeport of Muscat," by Surgeon G. F. Peters, M B. ;
and a ^' Eeport of a Journey from Bushire to Kazeroon and back,"
by Surgeon George Waters. We must note, in addition, among the
valuable contents of the volume, the " Medical Eeport of the Jam-
setjee Jejeebhoy Hospital," by S. Hunter, and the "Annual Eeport
of the Civil Hospital, Aden,^' by Dr. Nolan. An appendix follows,
containing records and jottings of cases by several writers; and
bound up with the volume are the " Abstract Proceedings" of the
society in session monthly, recording briefly the papers read before
it, and the discussions thereupon.

The society needs no praise from us : it has long established its
reputation as an active agency for advancing medical knowledge,
and its volumes of ^ Transactions' should be found in every medical
library of reference.

Philadelphia Pathological Transactions.!— The production of]
this considerable volume of above 200 pages as the record of the
work done within a period of eighteen months by the Pathological
Society of Philadelphia^ and the long array of names of members
who have contributed specimens and notes of cases, indicate much,
activity and industry in clinical observation, and an ardent desire to
extend the boundaries of medical science. As a series of brief
notes of morbid specimens, severally accompanied by a short notice
of symptoms preceding death, the volume cannot be, in the strict
sense of the word, reviewed, or have its principal features pourtrayed
by extracts from its pages ; but it, nevertheless, commends itself to
those who are pursuing inquiries in pathology and morbid anatomy,
and reflects great credit on the society which has issued it. Some
few woodcuts are introduced in illustration of cases recorded.

^ Transactions of the Pathological Society of Philadelphia. Vol. v. Edited
by James Tyson, M.D. Philadelphia, 1876.

1877.] Practical Guide to the History of Diphtheria. 179

Eesearches on the Action and Sounds of the Heart.^ — We are
informed that this little book is a re-issue of certain papers and
treatises which have appeared in various forms in previous years.
Tlie author states that the views advanced are based on a series of
carefully conducted experiments on turtles, performed for several
successive summers in Canada, during the highest temperature of
the season, where every opportunity was afforded of listening to the
sounds of the heart. The hot season was selected because at that
time the circulation in these reptiles most resembled that of warm-
blooded animals. The author, guided by these researches, arrives
at a totally different conclusion, as to the causes of the sounds of
the heart, from those drawn by most modern writers in this depart-
ment of physiology, and he maintains that the first sound of the
heart is produced by the contraction of the left ventricle and the
impulse of the aorta, and that the second sound is caused by the
contraction of the auricles. Thus^ it will be seen that Dr. Paton
rejects the views advanced by Dr. Hope, Dr. Williams, and others,
as to the cause of the second sound of the heart, and reverts to the
explanation offered by Laennec, and that he believes the first sound to
be really due to the ventricular systole and the shutting of the aortic
valves. Admitting the great difficulty of determining accurately
the succession, either of the actions or of the sounds of the heart,
it must be allowed that the observation of the phenomena, occurring
in the heart of the living turtle, is a novel and interesting mode of
investigation, the slowness of the pulse in these animals affording
more time for arriving at precise data than would be allowed in the
case of more highly organised beings. We must observe, however,
that, whatever may be the merits of Dr. Paton's investigations, they
are very carelessly recorded in the work now before us, and, in the
discussion of a subject avowedly of great intricacy and difficulty,
where precision of language is indispensable, it is to be regretted
that the composition of the sentences is so faulty that many of
them are nearly unintelligible.

Practical Guide to the History and Treatment of Diphtheria.^ —
This little treatise is one of a series of articles in an Italian
dictionary, the Biblioteca Economica di Medicina Pratica, and the
author is well quahfied to write upon the subject, not only from the
care he has bestowed on the literary examination of works re-
lating to diphtheria, but from his own practical experience in the

1 Eesearches on the Action and Sounds of the Heart. By Geoege Paton,
M.D, Pp. 105. London.

^ Ouida Pratica alia Conoscenza e alia Cura della Difterite, Per il Dottore
GiOTANNi Faealli, di Firetizi.

(Practical Guide to the History and Treatment of Diphtheria. By Dr. Faealli,
of Florence.) Pp. 163. Florence, 1876.

180 Bibliographical Record. [July,

study of the disease, which, as is well known, has visited Florence
of late years with great and indeed appalling severity. In the
present work, which consists of a preface and eleven chapters.
Dr. Faralli treats successively of the definition of the word diph-
theria, and of the history of the disease from ancient periods down
to the present day ; of the etiology of the malady ; of its symptom-
atology, both when it attacks the larynx, and is called croupj and
when it affects other parts of the body ; of its sequelse, such as
paralysis, and other nervous disorders ; of its diagnosis and pro-
gnosis ; of its treatment, both medical and surgical ; of its patho-
logical anatomy ; and of its pathogenesis and its nature.

From the numerous points of investigation thus presented, it is
only possible to refer to a few of the conclusions at which Dr.
Faralli has arrived ; but we may mention generally that he agrees
in the main with the views entertained by Bretonneau and other
French writers as to the nature, the diagnosis, and treatment of the
disease. He has, however, also examined the German literature of
the subject, and he gives due weight to the opinion which has been
offered as to the parasitic nature of the malady. He is evidently
inclined to believe that diphtheria and the so-called croup are
merely modifications of one and the same disease, or, in other
words, and to state the matter more accurately, that, excluding
laryngismus stridulus and the inflammations of the larynx, what is
usually called croup or membranous croup, is only the laryngeal or
laryn go -tracheal form of diphtheria. In his chapter on laryngeal
diphtheria, therefore, he treats this afi*ection as synonymous with
croup. As to the nature of the disease, he regards it as partly
miasmatous and partly contagious, and although its contagious
character has been fully demonstrated, he believes that it very often
developes itself spontaneously, and is then propagated in a truly
epidemic form, and such is the power of the poison that it appears
to be but little affected by the common conditions of seasons
or climate, or the social position of the patients. Some authors,
whom he quotes, attach much importance to hygienic influences, but
others, on the contrary, deny the existence of any relations between
the salubrity of places or families and the development or difi'usion
of the disease. With regard to the treatment of diphtheria,
local applications and general hygienic appliances are recommended,
and tracheotomy is admitted to have been the means of saving many
cases which, without its adoption, would in all probability have
succumbed.

Lectures on the Diseases of the Nervous System. ^ — This
volume will be highly prized by the members of the Sydenham

^ Lectures on the Diseases of the Nervous System^ delivered at La Salpetriere.
By J. M. Chaecot. Translated by Geobge Sigbeson, M.D. Sydenham Society.
;London, 1877.

1877.] Transactions of the Clinical Society. 181

Society. M. Charcot's name ranks among the very foremost of
those who have advanced the knowledge of nerve-pathology. The
work he has done is marked by great accuracy and close observation,
and by great acumen in interpreting facts and drawing inferences.
He has had, moreover, at the Saltpetriere Hospital, a most extensive
field of research afforded him. The use he has made of it has
speedily brought him a world-wide reputation.

We are consequently quite prepared to learn, as stated in the
translator''s preface, that, "although but recently published, the
lectures of Professor Charcot on diseases of the nervous system
have already taken a place amongst the classic works of medical
literature, and been translated into several Continental languages. "''
The present volume consists of thirteen lectures, devoted to the
consideration of disorders of nutrition consequent on lesions of the
nerves and of the spinal cord and brain, paralysis agitans, dissemi-
nated sclerosis, apoplectiform seizures in disseminated sclerosis,
hysterical hemiasesthesia, ovarian hypersesthesia, hysterical con-
tracture, and hystero-epilepsy. Some woodcuts are intercalated in
the text by way of illustrating facts or hypothesis, and there are
foot-notes introduced by the translator, and also by Dr. Bourneville,
the able reporter of Charcot's lectures in ' Le Progres Medical,' of
Paris.

Clinical Society.' — Apart from the lists of officers and members
prefixed, the present volume, issued by the Clinical Society of London,
is entirely made up of "communications" submitted to the meetings.
On the whole, the surgical members have produced the most
papers.

The subjects brought before the society have been of the most
miscellaneous character, but scarcely any of them afford material
for the advancement of therapeutical knowledge. The skill of the
surgeon in cutting short and removing disease, and in processes of
repair, is well represented ; but the skill of the physician in dealing
with disease by therapeutical agents is scarcely brought under
notice. The great majority of the medical communications are
simply records of cases viewed from a pathological stand-point, and
might have been equally well addressed to the Pathological Society.

Judging from this and preceding volumes of the society — which,
by the way, we highly esteem for what they do contain — there seem
small prospects that the Clinical Society will, as some of its original
distinguished members hoped, contribute very appreciably to the
improvement of our knowledge of the treatment of disease.

' Transactions of the Clinical Society of London. Vol. ix. London, 1876.

182 [July,

©rigmal CcimmunitatiansJ*

I. — Invalid Criminals and their Diseases. By Dav. Nicolson,
M.D., late Senior Medical Officer, H.M. Prison, Portsmouth.

The standing army of convicts in England numbers some eight
or nine thousand men and about twelve hundred females, and
they are by no means an uninteresting group of human beings.
If convicts are at once the scum and the dregs of society, they are,
too, the crack or master-hands, the elitei I might say, of the
criminal circle, and as such, they possess a collective and a real
interest not at all akin to that which attaches to the " consummate
villain '' of the three-volume heroic. It would be a curious point,
for instance, to work out the underlying cause of criminality in the
various members of this group of social rebels — what proportion
of their defection from the moral standard is due to original
mental inferiority ; what to physical defect or disease ; what to
positive misguidance and neglect in early life; what, later in life,
to the demoralizing influence of intemperance and debased social
surroundings, or to the mere pressure of misfortune and want.
Looking at crime as a possible effect having relation to one or
more such causes, or as a result of certain antecedent conditions,
whether personal or social, it is not difficult to conceive that
something of the nature of kinship exists between minds which
are undoubtedly insane, on the one hand, and minds which are
merely criminal on the other. In both cases a deviation from
a given standard is implied, but in the one case, the area (however
arbitrary) of responsibihty is departed from ; in the other, it is
not : and the issues and subsequent treatment are therefore, and
justly, widely different in the two cases. So that, whatever
alliance may be conceivable between crime and insanity in the
matter of causation, or, indeed, as to the actual conditions in
some cases, I would not be understood to say that the basis upon

1877. j Invalid Criminals and their Diseases. 183

which crime stands is by any means identical with that upon which
insanity stands. In short, criminals are not lunatics. But to
approach our subject. The coexistence, in the same individual,
of mental pecuHarity or infirmity with bodily imperfection or
deformity has often been remarked and demonstrated. There is,
for example, a self-assertion, a bumptious arrogance, a vanity and
irritability, and a guerulousness in some very diminutive or hump-
backed men which one passes over as little more than a pardonable
weakness hardly worth noticing under the circumstances. But an
exactly corresponding display of character^ in a man of large and
proportionate physique would be so much out of keeping with
what we would naturally expect, that we could scarcely avoid
looking upon it as an indication of mental derangement. We
have come to accept a certain self-importance and crabbedness of
disposition as not unnatural accompaniments of physical dwarfish-
ness; and happy are we as students of human nature if we have
schooled ourselves to accept in the same light the petulance and
peevishness of our dyspeptic friends and patients. And who is
there that will deny such a companionship of mental and bodily
condition as that here indicated ?

Again, no one doubts that some attacks of insanity are distinctly
due to physical causes in the way of bodily suffering and disease;
and although the same prominence has never been claimed for the
operation of bodily infirmity in the causation of criminal acts,
1 may state m)' conviction that the defective physical condition
of criminals has in many cases much to do with the off'ences and
misdemeanours committed by them. It was not with the intention
of working out this point that this paper was written; but I
mention it as worth keeping in mind in connection with the
subject of disease among criminals. Bodily disease in the criminal,
when at large, may be taken as acting for the most part in two
ways : either indirectly through its unhealthy influence upon the
mind, which it tinctures with a morbid disaff'ection for the in-
dividuaPs circumstances and surroundings ; or more directly by
incapacitating the individual for turning anything in the way of an
honest livelihood for himself. Nothing struck me more in my
work, as assistant medical officer, among the invalid convicts at
Woking Prison than the extensiveness with which disease mani-
fested itself, not in one but in many, of the bodily organs, and
its extreme chronicity. The full tenaciousness of such lives was

' The " bullying " of the " big *' man bears a different interpretation, and
arises from a feeling of (at least) physical superiority. The bumptiousness and
quevulousness of the little and dwarfish individual are due partly to self-con-
sciousness of physical inferiority, and partly to a fear and 8uspici(»n that his
(possibly legitimate) social and intellectual importance is estimated (especially
by strangers) by the size of his body.

184 Original Communications. [July,

revealed only after death, when a healthly organ would be sought
for in vain, and when each organ seemed more degenerate and
corrupt than the other. In his last report (for the year 1875)
Dr. Campbell, the Senior Medical Officer of that establishment,
says— "Owing to the varied and complicated nature of the dis-
eases observed in many of the invalids received here, it is some-
times difficult to assign them a proper place in the nomenclature,
two or more maladies frequently coexisting in a well-marked form
in the same individual. A large proportion appear to belong to
the habitual criminal class, or the greater number have previous
convictions recorded against them ; indeed, the invalid class may be
looked upon in a great degree as the dregs of the different convict
prisons, with constitutions impaired by a long course of profligacy
and vice."

The "invaliding" of prisoners is. a provision of the English
onvict system, by which the more established and chronic cases of
disease or ill- health are transferred (or " invalided " to special
hospital prisons in some healthy locality, where they may have a
better chance of recovery. By this means the labour prisons are
kept apart as far as possible for the able-bodied and healthy. I
may explain that the first nine months of penal servitude are
passed in what is called *' separate confinement," and that at the
end of that period the normal course is for the convict to be
removed to a public works prison for the rest of his sentence.
There he is employed at such work as he is fit for, and has
latterly an opportunity of learning some useful trade or occupation.
The great mass of convicts are employed at excavating, stone-
quarrying, brickmaking, building, &c., a certain proportion being
utilised as smiths, carpenters, tailors, painters, bakers, and the
like. If the convict is unfit for public works at the end of his
separate confinement, or if, at any time after, he becomes incapaci-
tated, he is drafted to Woking or Parkhurst as an invalid. The
" invaliding " that takes place among convicts must not be taken
to have the same significance as that which takes place among
soldiers or sailors. In the army or navy, the recruits are all
healthy and up to a certain standard of physical strength and
capacity, but the convict recruit must be accepted whatever may
be his physical condition or the state of his health, and many of
them are invalids on reception. It will be asked — What relation
exists between the influence of imprisonment and the necessity for
invahding ? And this is a question that may fairly be asked, and
there is no reason why an attempt should not be made to answer it.
Of course, no one is to claim for penal servitude or imprisonment
the merits of an enlivening or fattening process ; and surely no
one will expect that the circumstances attending such punitory
confinement are to exempt criminals from the wear and tear that

1877. J Invalid Criminals and their Diseases. 185

attach to all social occupations, and even to the mere process of
living. No do I think anyone can reasonably object if pressure —
or more expressively, the *^ screw'' — is put on a little, with the
view of exerting a health-giving impression upon minds not the
most susceptible. This being so, if I were asked my opinion of
the physical influence of the deterrent hard labour portion of our
present system of penal servitude upon the convicts who undergo
it, I would state it thus — If its full pressure were exerted and in-
discriminately upon the prisoners, that pressure would undoubtedly
be hurtful and unjust. But if, on the other hand, with a fair and
reasonable dietary, the pressure is exerted with a due recognition
of the principle that the labour-task of each individual must be
adapted to his physical capacity for work, then it is not only just
but salutary. If pressure is to be put on, this principle of
adaptation (of labour to capacity) must be insisted on as a safety-
valve ; and happily our Government convict prisons provide the
means whereby the operation of the principle may be secured.
No doubt, men break down under the influence of the work and
discipline of penal servitude, and, no doubt, within the same
scope of work and discipline, the health of others improves. But
the deterioration of some few is no more reason for introducing a
relaxation of a penal system than is the improvement which takes
place in certain others a reason for increasing its severity. So
long as the numbers keep within bounds, the remedy must be
applied to the individuals and not to the whole convict body.

The adaptation of labour to physical capacity is attainable at
public works prisons, owing to the existence of a variety of forms
and degrees of labour. So that, while, on the one hand, care is
taken to prevent imposition, a man may, if he becomes incapacitated
for the hard labour at which he has hitherto been employed, be
transferred, on medical grounds, to labour of an easier or more
suitable description, either permanently or until he recovers his
strength. But in order to the due carrying out of the principle,
the medical officers, with whom lies the responsibility,' have to
carry on their work with close attention and care; repeated in-
spections of more than perfunctory character, and reasonable
opportunities for personal interviews, being absolutely necessary.

Convicts may be invalided either from bodily or from mental
infirmity or disease ; for, although a man may be physically fit for
the work at any prison, he may on mental grounds be unfit for

1 It is at this point, and in connection with the numerous grave and often
trying responsibilities of medical officers of convict prisons, that public opinion
and the public purse should be found willing to stretch towards an increase of
the totally inadequate pay of officials, whose whole time is devoted to the duties
of their department under circumstances which are frequently very conflicting.

186 Original Communications. \^w\jf

the discipline. Erom tables given by Dr. Guy/ the mental and
bodily condition of the convicts in confinement on the 31st March,
1873, is expressed as follows : —

Per 1000.

/ ^ ,

Males. Females.

Weak mind, insanity, and epilepsy . . . . 30 "j . 38 )

Scrofula and chronic disease of lungs and heart . . 109 > 370 . 90 > 327
Deformities or defects, congenital or acquired . . 231 J . 199 J

No infirmities or defects 630 . 673

That is to say, of the male convicts 370 out of every 1000
(considerably over one-third) were either deformed, defective, or
diseased. There is not wanting evidence to show to what an
extent this amount of infirmity is brought into prison by the
criminals, and not acquired there.

In their report for the year 1868 the directors of convict
prisons state that, "by returns made in April, ] 869, it appears
that of 6458 convicts who have passed the period when they were
eligible for removal to public works, 176sJ were invalids or in-
capable to such an extent as to be fit only for light labour, and 16;i
were permanent invalids hardly capable of any labour at all^' —
i.e., 5 out of every 14 convicts (1 in 2'8) were invalids or fit only
for light labour. And in their report for the following year (1869)
the directors tell us that "the number of men of weak or en-
feebled constitutions received still continues to bear a large
proportion to the total number, as many as 370 males out of 784
received at Millbank being of that character on reception/^ And
Mr. Gover, the Medical Officer of Millbank (Report for 1868)
makes the following statement — " The great majority of the
prisoners who were removed to Dartmoor and Woking as invalids
were suffering on reception from the diseases or infirmities marked
as the cause of removal. Many of them improved very consider-
ably in the interval between their reception and removal ; and I
may here observe, with reference to the population of the prison
as a whole, that the general tendency to improvement, which has
previously been the subject of remark, has been as manifest during
the year just ended as in former years. Nevertheless, taking the
population of this prison, exclusive of the imbeciles and epileptics,
as affording a fair standard of comparison, I have reason to believe
that the proportion of convicts afflicted with mental and bodily
diseases is greater than would be found in any other section of the
community."

In the Report for the year 1870, this important and trustworthy
evidence is supplemented by the same authority as follows —
" Many of the prisoners arrived in an enfeebled and emaciated

^ ' Results of Censuses of the Population of Convict Prisons in England.'
1875.

1877.] Invalid Criminals and their Diseases, 187

condition from the comity and borough gaols, and suffered from
diseases not only rendering them unfit for discipline, but, in many
cases, necessitating their admission into hospital. Tubercular dis-
eases, scrofula in various forms, indolent ulcers, and excessive
general debihty, have been of frequent occurrence. The number
of convicts (males) removed to other prisons as invalids was 341,
or 264 per 1000, calculated on the total population. In but few-
cases did the disease or infirmity, which was the ground of in-
validing, arise after transfer to this prison. It will be seen from a
reference to Table IV, that 74, or 21 "7 per cent., were upwards of
50 years of age.""

In reference to the opinion that criminals as a class, are
essentially ill-conditioned j I may quote the following paragraph
from a former communication^ to this ' Eeview ' — " It is plain, then,
that a large proportion (probably over one-third) of criminals bring
with ikem into prison impaired constitutions. This impairment or
defect manifests itself, first, in the form of positive disease or
infirmity ; secondly, in a predisposition to certain forms of disease,
mostly of a constitutional or phthisical nature ; and thirdly, '\\\ a
want of ability to resist the destructive influences ot certain other
diseases which are more active and local in their character.^'

Coming more particularly to the diseases that necessitate in-
validing among convicts, it will be recollected that Dr. Guy showed
that 370 per 1000 male convicts were the subject of some infirmity
or defect (such as, I presume, would interfere to some extent with a
fair labour capacity). Of these, 30 were mental and epileptic
cases — the relative proportion of mental to bodily cases of in-
firmity being as 1 to 11 Leaving out the mental aspect of the
question, I propose to show the nature of the bodily diseases
and infirmities of invalid convicts. For this purpose, I have taken
1000 cases of men invalided to Woking; and as they are taken
consecutively, in the order of their reception, they form, I think, a
fair basis for judging the prevailing causes.

I have arranged them in eight classes, so as to give first of all
an idea of their general distribution.

Causes of Invaliding in 1000 Actual Cases,

1. Constitutional and general diseases and infirmities .... 363

2. Diseases of the respiratory system 255

3. „ circulatory system 112

4. Crippled and deformed 87

5. Diseases of the digestive system 59

6- „ urinary and generative system . , , . . 38

7. „ brain and nervous system 18

8. Anomalous 68

1000

1 " Statistics of Mortality among Prisoners," * Brit, and For. Med.-Chir.

Review,' July, 1872.

188 Original Communications, [July,

It is not to be forgotten that not unfrequentJy more than one
disease was present — but the most important is entered in the
above list.

The constitutional and general diseases and infirmities are
necessarily the most numerous, as they have a wider scope and
involve a greater variety of conditions. They include 176 cases of
debility, 60 of struma and abscess, 40 of old age, 36 of defective
vision, 19 of rheumatism. Syphilis shows only 8 cases, and I
may state that this disease does not show itself so prominently as
one would expect in such a class of men. No doubt, the presence
of the taint is pretty frequently made out as a complication, but,
joer se, it cannot be said to prevail. And I think this may be taken
as an evidence of the great value of regular, temperate, and whole-
some living in preventing or restraining the progressive develop-
ment of syphilis into its more active and loathsome phases.

Taking the various bodily "systems,^' it is found that the
respiratory organs invalid a fourth, and the circulatory a ninth, of
the number, while the other special organs show a much smaller
proportion. The least numerous class is that of the brain and
nervous system, which gives only 18 cases out of 1000. Of
the 18, 12 were cases of paralysis. But I have found that
although least frequent as a cause of invaliding, diseases of the
brain and nervous system stand second in point of fatality among
prisoners. Their sudden appearance, gravity, and often speedy
ending, no doubt limits the possibility of invaliding such cases
from one prison to another. Coming to the individual causes
of invaliding the following are the most prevalent in the 1000
cases : —

Debility 176

Phthisis 124

Bronchitis ........ 90

Heart disease 80

Struma and abscess 49

300
219

Age 40 519

Hernia - 39

Asthma 30

The five first mentioned in this list— viz., debility, phthisis,
bronchitis, heart disease, and struma, contribute fully one-half of
the cases. And the first two, debility and phthisis themselves,
contribute 300 cases, and they undoubtedly constitute the niost
important element of consideration in the question of a convict's
relationships. The lungs are the convict's weak point, and con-
sumption is his bane. The occurrence of *' debility " in convicts
employed on public vv^orks is a signal of distress that should not
be overlooked. It tells us that the pressure of his work is too

1877.]

Invalid Criminals and their Diseases.

189

great for him, and it betokens a liability to break down under
some active form of disease — usually inflammation of the lungs.
The approach of debility implies a necessity for active interference
on the part of the doctor.

Recurring, in conclusion, to the subject started early in this
paper — viz. the influence of physical defect or disease in leading
on to the commission of criminal offences, I give a list which
shows the number of convictions recorded against the 1000
invalid convicts with whose diseases we have just been making
ourselves acquainted : —

Total

231 were undergoing their 1st sentence .... 231

152 „ „ 2nd

304

149 „ „ 3rd

447

125 „ „ 4th

500

85 „ „ 5th

425

77 „ „ 6th

462

46 „ „ 7th

322

30 „ „ 8th

240

15 „ „ 9th

135

12 „ „ 10th

120

7 „ „ 11th

6 „ „ 12th „

8 „ „ 13th

104

3 „ „ 14th

5 „ „ 15th

2 „ „ 16th

3 ,. „ 17th

2 „ „ 18th

1 „ „ 19th

1 „ ,, 22nd

1 „ „ 24th

1 „ „ 26th

1 „ M 28th

1 „ „ 33rd „

.000 male invalids. Toti

x\ con

victic

3827

3827 convictions among 1000 invalid criminals! Close upon an
average of four convictions each. And these unhealthy beings
are from a class who live and propagate their moral and physical
degeneracy in our midst.

190 Original Co mmwii cations, [July,

II. — Urea and its Relation to Muscular Force.

Bj Henry Brietzcke, F.R.C.S. Eng.

The experiments which have recently been conducted by
eminent physiologists, with a view of deciding the question
whether the urea contained in the urine is a product of the
disintegration of muscular tissue during the active exercise of the
human body, and may thus be taken as a measure of force expended
in mechanical work, or whether this organic compound is mainly
produced from, and regulated in amount by, nitrogenous food
ingested, have led me to submit for publication a course of experi-
ments recently prosecuted at Millbank Prison, through the kind-
ness of Dr. Gover, the Senior Medical Officer, in hope that some
facts which may assist in the solution of the problem may be
placed on record. The circumstances under which the experiments
were carried out, were deemed to be unusually favourable for the
following reasons : The men were strong and healthy. The amount
of work performed could be accurately calculated, as it consisted in
turning a crank. The exact quantity of food taken daily was also
known. The whole of the urine was easily collected. The
experiments could be performed on a number of men, all under
the same conditions, and continued for a considerable time.

The quantity of urea excreted was calculated according to the
directions given in the most recent books on the subject, and the
results are recorded rather as a collection of reliable data than an
attempt to decide the question, or enter into any new theories. It
will be seen, by referring to the tables, that six healthy men were
taken, weighed at the commencement of each period, the daily
amount of urine collected and tested for urea by the nitrate of
mercury process described in Neubauer and Yoge^s book on the
urine ; the amount of nitrogen ingested was recorded ; the work
performed calculated in foot tons raised, and the force producible
by oxidation of the food consumed worked out according to
Professor Prankland's tables. The observations extended over
three periods of ten days each. The first during the performance
of measured work, the second during rest on the same amount of
food, and the third during rest on an increase of food. In most
of the experiments performed by physiologists, the total amounts
of nitrogen in the urine have been estimated, since it was supposed
that without this calculation, the results would not be sufficiently
accurate, as nitrogen might pass off in the urine uncombined with

1
i

.1877.] Urea and its Relation to Muscular Force. 191

urea; this was not done in the present series of cases. The
relative amount of nitrogen, however, escaping as urea under the
conditions of muscular work, rest, and rest with extra food, are
worthy of record. The late Dr. Parkes, in his experiments, did
not estimate the nitrogen escaping by the bowel, on account of its
being present in so small a quantity, and probably derived from
unassimilated food which had not entered the system. I will call
attention to some of the points brought out by the present experi-
ments, and then make a few comments on them as a whole. The
average amount of urea excreted by a healthy man on a mixed diet
is .tOO grains in twenty-four hours ; but this, according to Dr. Pavy,
is subject to much variation, even when no work is done, and such
was the case in my experiments; for instance, when at rest, on the
usual diet F. S. excreted on an average for ten days only 849 grains
in twenty-four hours, whereas the other five men all passed more than
the average, as will be seen by the accompanying tables ; a difference
in the height or weight cannot account for this, for the second
man, S. A., weighed about the same, and was the same height, yet he
passed 219 grains more urea daily as an average for ten days;
they were both much lighter than the remaining four, weighing
only about nine stone each. A point, perhaps, worth mentioning
is, that F. S. and S. A. were, at the commencement of the experiment,
considerably below their usual weight, for they had been some
weeks at crank labour, whereas the remaining four were subjected
to experiment soon after their reception at the prison. It is well
known that when the food is not sufficient to supply the tissue
waste going on in the body, loss of weight takes place on account
of the nitrogenous tissues being drawn upon, and urea continues
to appear in the urine to the last, even during complete abstinence
from food; neither of the six men sustained any appreciable loss of
weight during their work, therefore, excessive tissue waste cannot
account for the amount of urea excreted above the normal standard
in all except F. S. The quantity of nitrogen and carbon contained
in the diet is given in the tables : it was only during the first two
periods that the daily average nitrogen ingested was 248 grains;
during the last ten days on \ lb. of extra bread per diem, the
nitrogen ingested amounted to 292 grains ; the force-producing
value of the diet, calculated from Professor Frankland's tables, is
3615 foot-tons — that is, 3615 tons lifted one foot high. Oq
comparing the nitrogen ingested with that excreted, it will be seen
that F. S. excreted much less nitrogen than he ingested, and he did
not lose quite so much weight as the rest; the others excreted
more nitrogen than they ingested ; it will be noticed also that F.S.
and S. A. passed more urea during the second period on no work
than they did during the ten days of hard work. I cannot explain
this, but Dr. Pavy in his book notices this fact in Dr. Parkes'

192

Original Communications,

[July,

second series of experiments. He remarks, page 54, " It is curious,
and also, it must be owned, does not appear explicable, that during
the periods of both rest and active exercise the daily amount of
nitrogen eliminated was in excess of that eliminated during the
first two periods of ordinary employment, the figures at the same
time for the associated periods respectively agreeing very closely
with each other/' And now, with regard to the relation of the
urea in the urine to the muscular force expended. It will be seen
by these experiments, that in all six cases, except S. H., more urea
was passed during the ten days of extra diet without'work than
during the work period. In S. H., I noticed during the last ten
days on extra diet that the urine was loaded with crystals of uric
acid, and I believe this accounts for the exception to the rule
in his case. Uric acid is known to be a product of malassimilation;
by some fault in the digestive process, the nitrogen falls short of
the production of urea and uric acid is formed. In the last four
cases, although more urea was passed during work than when no
work at all was done, on the same diet, yet in every case, except
the one mentioned, the diet had more influence over the amount of
urea than the work, the addition of \ lb. of bread daily to the
food producing a much larger excretion of urea during bodily rest
than the heavy mechanical work on a reduced diet.

Exp. 1. F. S.

Exp. 2. S. A.

Exp. 3. J. B.

1st. 10 days' average,

1st. 10 days' average.

work

2nd. Do. do., no work

3rd. Do. do., no work.

3rd, Do. do., no work.

3rd. Do. do, no work.

extra diet

Exp. 4. H. A.

Exp. 5. S. H.

Exp. 6. B. A.

Ist. 10 days' average,

1st. 10 days' average.

1st. 10 days' average,

work

work .

2nd. Do. do., no work

3rd. Do. do., no work.

3rd. Do. do., no work,

extra diet

It has been stated recently that mechanical work has no influence
upon the quantity of urea, but it undoubtedly had in four out of
six of my cases; and I should think the small loss of weight
which occurred during the work could hardly account for the in-
crease of urea, on the theory that the tissues were drawn upon to
supply a deficiency in nitrogenous food. In experiment 4, H. A.
was laid up for three days out of the ten days' work period with an
inflamed foot ; this does not seem to have aff'ected the quantity of
urea ; perhaps, however, the fact of his having slight febrile

1877.] Urea and its Relation to Muscular Force. 1^3

symptoms during the attack, by temporarily augmenting the
amount of urea from excessive tissue waste, obviated any diminu-
tion which might have otherwise occurred. I could not detect any
material difference in the quantity of urea excreted during the
Sunday day of rest in any of the six cases. In conclusion, I will
remark that, besides the crank work, each man walked daily 1*54
miles, and on Sunday, during one hour^s exercise, 3'08 miles ; this
is added to the calculation of crank work in each case^ in foot-tons
raised. The crank work has been calculated by multiplying the
weight in pounds required to bring down the handle, by the cir-
cumference of the circle described by it in feet, and then by the
number of revolutions a minute, giving a product which is equal
to the number of pounds raised one foot high per minute. The
celebrated experiments of Pick and Wislicenus and others, tend to
show that the urea in the urine is not a product of the disintegration
of muscular tissue during mechanical work ; the non-nitrogenous
ahmentary principles supply the force by oxidation in the body, and
the muscles are merely the instruments through which this force is
converted into motive power ; the nitrogenous alimentary principles,
as explained by Dr. Pavy, are " rendered applicable indirectly to
force production, but instead of passing into a state of tissue, and
thence by oxidation, giving rise to the evolution of force, they
undergo (probably by the action of the liver) a splitting up into
urea for the one part, which carries off the nitrogen as an un-
available element, and into a slightly oxygenated hydro-carbonaceous
residue for the other, which may be looked upon as applicable in
the same way as primarily ingested non- nitrogenous matter to force
production." Nitrogenous food ingested forms the principle source
of the urea in the urine during health. It has been proved that a
strict adherence to non-nitrogenous food rapidly diminishes the
quantity of urea passing off by the kidneys, and the accompanying
tables tend to show that, although muscular work has some slight
influence over the excretion of urea, nitrogenous food is by far its
most important source. An American physiologist. Dr. Mint,
while experimenting on the celebrated pedestrian Weston, found a
very large increase of urea during prolonged muscular effort, but
these results have been very much disputed, and every one interested
in the subject will be anxious to hear the final results of Dr.
Pavy's recent experiments, now being published, on the same man
during his feats in London.

Henry Brietzcke, P.R.C.S., &c.,

H.M, Convict Prison, Portsmouth,

December, 1876.

119— Lx. 13

194

Original Communications,

[July,

Experiment 1. — F. S — , aat. 24. Height 5 ft. 5^ in. Weight 123 lbs at com-
mencement of experiment. Crank, 11,000 revolutions, 14 lbs pressure. Urine,
neutral, no albumen. Eats all his food ; sleeps well ; does not sweat ; drinks 1
quart of water daily.

Date. 1875.

Quantity
of urine

Specific

Urea
24 hours.

Nitrogen
excreted.

Body
weight.

24 hours.
Cubic c.

gravity.

Gram.

Grains.

lbs.

i"i

Sat., Dec. 11th .

2750

1010

28-875

445-599

207-946

123

525

Sun. 12th. .

2575

1010

18-025

278-161

129.808

Mon. 13th .

2700

1010

21-600

333-331

155-554

525

Tues. 14th .

2125

1010

19-125

295-137

137-730

525

Wed. 15th .

2635

1010

17-127

264-303

123-341

525

Th. 16th

2410

1010

19-280

297-528

138-846

525

Fri. 17th .

2050

1009

14-350

221-449

103-342

525

Sat. 18th .

2250

1010

19-125

295137

137-730

525

Sun. 19th .

2000

1010

16-000

246-912

115-225

Mon. 20th .

1700

1010

14-450

222-992

104-062

...

525

1st 10 days' total .

23195

...

187-947

2900-549

1353-584

122

...

Tues. 21st .

1828

1015

25-592

394-935

184-303

Wed. 22nd .

2700

1014

29-700

458-330

213-887

Th. 23rd

2600

1010

18<200

280-862

131-068

Fri. 24th

2470

1009

16-055

247-760

115-621

Sat. 25th

2060

1009

15-450

238-424

111-264

Sun. 26th .

2290

1011

22-900

353-392

164-916

Mon. 27th .

2450

1011

23-275

359-179

167-616

Tues. 28th .

2480

1011

27-280

420-984

196-459

Wed. 29th .

2640

1010

25-080

387-034

180-616

...

Th. 30th

2390

1011

22-705

350-383

163-502

2nd 10 days' total .

23908

226-237

3491-283

1629-252

122

Fri. 31st

2065

1011

19-617

302-729

141-273

Sab., Jan. 1st, 1876

2070

1013

25-875

399-303

186-341

Sun. 2nd

2210

1015

27-625

426-309

198-933

Mon. 3rd

2000

1012

22-000

339-504

158-424

lues. 4th

2400

1011

26-400

407-404

190-122

Wed. 5th .

2400

1013

26-400

407-404

190-122

Th. 6th

2895

1013

26-345

406-556

189-721

Fri. 7th

2155

1015

23-705

365-815

170-708

Sat. 8th

2170

1012

20-615

318-130

148-455

Sun. 9th

1780
21645

1012

16-910

260-955

121-773
1695-872

3rd 10 days' total .

235-492

3634-109

126

...

Average.

1st 10 days .

2319

18-795

290-054

135-358

...

■ .<

2nd 10 days .

2390

22-623

349-128

162-925

...

3rd 10 days .

2164

23-549

363-410

169-587

...

Action of heart, &c.

. 2260 foot tons.

Diet represents .

. 3615 foot tons

11,000 revolutions

. 503

Deduct

. 2785 „

Exercise

. 22 „

Total

830

Total

2785

1877.]

Urea and its Relation to Muscular Force,

195

Experiment 2. — S. A — , sot. 20. Height 6 ft. 5f in. "Weight, 124^ lbs. at com-
mencement of experiment. Crank, 11,000 revolutions, 14 lbs. pressure. Urine,
neutral, no albumen. Eats all his food, sleeps badly, does not sweat ; drinks about
a quart of water daily.

Date. 1875.

Quantity
of urine

Specific

Urea
34 hours.

Urea
24 hours.

Nitrogen
excreted.

Body
weight.

24 hours.
Cubic c.

gravity.

Gram.

Grains.

lbs.

r-i

Sat., Dec. 11th .

1850

1020

33-300

513-885

239-813

124i

525

Sun. 12th .

1870

1021

41-140

634-872

296-273

Mon. 13th .

1300

1021

33-800

521-601

243-408

525

Tues. 14th .

2130

1018

36-210

558-792

260-769

525

Wed. 15th .

2140

1017

40-660

627-465

292-806

522

Th. 16th

2025

1016

33-412

515-613

240'615

525

Fri. 17th

1432

1023

34-368

530-416

247-498

525

Sat. 18th .

1640

1020

34-440

531-478

248-023

525

Sun. 19th .

1440

1024

36-720

566-663

264-442

Mon. 20th .

1550

1020

34-875

538-191

251-155

525

1st 10 days' total .

17377

358-925

5538-976

2584-802

1241

Tues. 21st .

2470

1015

37-050

571-755

266-819

Wed. 22nd .

1650

1020

37-950

585-644

273-300

Th. 23rd

2500

1013

33-750

520-830

245-054

Fri. 24th .

2330

1016

40-775

629-239

293-640

Sat. 25th .

2430

1016

38-880

599-996

279-998

Sun. 26th .

1566

1021

37-584

579-996

270-661

Mon. 27th .

2000

1017

39-000

601-848

280-862

Tues. 28th .

2350

1017

36-425

562-110

262-313

Wed. 29th .

2255

1016

36-080

556-786

259-828

Th. 30th

2490

1014

31-125

480-321

224-149

2nd 10 days' total .

22041

368-619

5688-525

2654-624

127

Fri. 31st

1850

1020

37-925

585-258

273-115

Sat., Jan. 1st, 1876

2265

1019

38-505

594-209

277-297

Sun. 2nd

2120

1020

42-400

654-316

305-337

Mon. 3rd

1465

1021

39-555

610-412

284-859

Tues. 4th .

2210

1019

43-095

665042

310-352

Wed. 5th .

2125

1020

40-375

623067

290-754

Th. 6th

2155

1015

30170

465-583

217-267

Fri. 7th

2350

1020

42-300

652-773

304-627

Sat. 8th

2420

1017

33-880

522-836

243-979

Sun. 9th

1845

1022

41-512

640-613

298-948

3rd 10 days' total .

20805

389-717

6014-109

2806-535

128

...

Average.

1st 10 days .

1737

35-892

553-897

258-480

, .

2nd 10 days .

2204

36-861

568-852

265 462

...

3rd 10 days .

2080

38-971

601-410

280653

...

Action of heart, &c.
11,000 revolutious
Exercise

Total

2260 foot tons. Diet represents . . 3615 foot tons.

503 „ Deduct . ■ . . 2785 „

22 „

Total . 830 „

2785

196

Original Communications.

[July.

Experiment 3. — J. B— , set. 18. Height 5 ft. 5 in. Weight 141 lbs. at com-
mencement of experiment. Crank, 10,500 revolutions, 10 lbs. pressure. Urine,
neutral, no albumen. Eats all his food except the gruel.

Date. 1876.

Quantity
of urine

Specific

Urea .
24 hours.

Urea
24 hours.

Nitrogen
excreted.

Body i-gi
weight. *>.2S

24 liours.
Cubic c.

gravity.

Gram.

Grains.

lbs. 82.

Fri., Jan. 21st

1450

1025

42-050

648-915

302-822

141 ! 368 1

Sat. 22nd .

1100

1025

39-600

611-107

285-183

.. 368 I

Sun. 23rd .

625

1032

28-125

434-025

202-545

Mon. 24th .

800

1034

34-400

530-860

247-729

368

Tues. 25th .

820

1034

34-440

531-478

248-023

368

Wed. 26th .

1100

1031

42-350

653-545

304-982

368

Th. 27th .

910

1028

30-030

463-422

216-264

368

Fri. 28th .

1113

1031

37-842

583-977

272-513

'.; 1 368

Sat. 29th .

873

1034

31-428

484-996

226-325

.. 1 368

Sun. 30th .

1015

1031

36-540

563-885

263-146

1st 10 days' total .

9806

...

356-805

5506-210

2569-532

139

Mon. 31st .

540

1035

22-680

349-997

163-332

...

Tues., Feb. 1st .

1250

1027

37-500

578-700

270-060

Wed. 2nd .

1500

1021

30-750

474-534

221-449

Th. 3rd

1255

1020

32-630

503-546

234-983

Fri. 4th

1200

1025

34-800

537-033

315-430

Sat. 5th

1505

1023

37-625

580-629

270-955

Sun. 6th

965

1032

38-600

595-675

277-976

Mon. 7th .

700

1036

30-100

464-503

216-757

Tues. 8th .

1020

1030

37-740

582-403

271-788

Wed. 9th .

1195

1029

38-240

590-119

275-384

2nd 10 days' total .
Th. 10th

11130

...

340-665

5257-139

2518-114

136

...

715

1036

27-170

419-287

195-667

Fri. 11th

1200

1030

39-600

611-107

285-183

Sat. 12th .

1745

1019

34-900

538-576

251-335

Sun. 13th .

2215

1020

42-085

649-455

303-079

Mon. 14th .

1425

1022

37-050

571-755

266-819

Tues. 15th .

1870

1018

41-140

634-872

296-273

Wed. 16th .

2350

1016

37-600

580-243

270-780

Th. 17th .

1600

1020

35-200

543-206

253-496

Fri. 18th

2150

1014

34-400

530-860

247-734

Sat. 12th

2250

1020

42-750

659-718

307-868

3rd 10 days' total .

17520

...

371-895

5739079

2678-244

140

Average.

1st 10 days .

980

...

85-680

550-621

256-953

...

2nd 10 days .

1113

34-066

525-713

251-811

...

3rd 10 days .

1752

...

37-189

573-907

267-824

...

Action of heart, &c.
10,500 revolutions
Exercise

Total

2260 foot tons. Diet represents . . 3615 foot tons.

343 „ Deduct . . . 2628

25 „

Total . 987 „

2628

1877.]

Urea and Us Relation to Muscular Force.

197

Experiment 4.— H. A—, set. 18. Height 5 ft. 9i in. Weight 156 lbs. at com-
mencement of experiment. Crank, 14,500 revolutions, 14 lbs. pressure. Urine,
faintly acid, no albumen. Eats all his food ; sleeps well. This man was attacked
with inflammation of the big toe-joint, from a badly fitting boot, and failed to do
work or exercise for the 3 days — 22nd, 23rd, 24th — of his first ten days ; he also
was excused from daily exercise during the remaining part of the experiment.

Date. 187(

Quantity
). of urine

Specific

Urea
24 hours.

Nitrogen
excreted.

Body

weight.

Il^

24 hours.

gravity.

Gram.

Grains.

lbs.

§2s

Cubic c.

(^ p.

Fri., Jan. 21s

t . 1670

1026

51-770

798-914

372-821

156

691

Sat. 22nd .

. 2300

1017

40-250

621-138

289-859

...

no wk

Sun. 23rd .

. 1570

1024

48-670

751-075

350-491

Mon. 24th .

. 1325

1027

45-050

695-211

324-426

...

Tues. 25th .

. 2660

1017

42-560

656-785

303-917

...

691

Wed. 26th .

. 1800

1022

43-200

666-662

317-899

...

691

Th. 27th

. 1550

1025

37-200

574-070

267-899

691

Fri. 28th .

. 1195

1030

43-020

663-884

309-812

691

Sat. 29th

. 1500

1022

36-000

555-552

259-257

691

Sun. 30th .

. 820

1036

37-720

582-095

271634

...

no ex.

1st 10 days' t

otal . 16390

...

425-440

6565-386

3068-015

154

Mon. 31st .

. 1000

1033

48-000

740-736

345-676

no ex.

Tues., Feb. 1

3t . 1500

1028

48-000

740-736

345-676

...

Wed. 2nd

. 1600

1022

32-000

493-824

230-446

Th. 3rd

. 1700

1020

37-400

577-156

269-134

...

Fri. 4th

. 1255

1030

38-905

600-381

280-167

Sat. 5th

. 2015

1022

40-300

621-909

290-214

„

Sun. 6th

. 2227

1021

46-767

721-708

336-787

...

„

Mon. 7th

. 1100

1022

28-600

441-355

205-955

Tues. 8th

. 1900

1020

41-800

645-057

301-016

...

„

Wed. 9th

. 1060

1028

32-860

507-095

236-634

...

2nd 10 days'

total. 15357

...

394632

6089-957

2841-705

151

Th. 10th

. 1840

1022

47-840

738-266

344-524

no ex.

Fri. 11th

. 1615

1021

41-990

647-989

302-394

Sat. 12th

. 1750

1023

43-750

675-150

315-070

...

Sun. 13th

. 1610

1022

43-470

670-829

313-053

...

Mon. 14th

. 2255

1021

46-435

716-584

334-405

...

„

Tues. 15th

. 1610

1025

46-690

720-520

336-246

>»

Wed. 16th

. 1315

1029

40-765

629-085

293-573

...

Th. 17th

. 1670

1026

45-925

708-714

330-733

...

Fri. 18th

. 1555

1026

45-095

695-906

324-756

...

„

Sat. 19th

. 1500

1028

46-500

717-588

333-941

...

3rd 10 days'

total. 15720

448-460

6920-631

3228-695

151

...

* Averag

1st 10 days

. 1639

...

42-544

656-538

306-801

...

2nd 10 days

. 1535

...

39-463

608-995

284-170

... !

3rd 10 days

. 1572

...

44-846

692-063

322-869

...

Action of heart, &c. . 2260 foot tons. Diet represents . . 3615 foot tons.

14,500 revolutions . 663 „ Deduct . . . 2951 „

Exercise ... 28 „ „

Total , 664 „

Total . 2951

198

Original Communications.

[July,

Experiment 5.— S. H— , set. 21. Height 5 ft. 7 in. Weight 149 lbs. at com-
mencement of experiment. Crank, 14,500 revolutions, 14 lbs. pressure. Urine,
acid, no albumen. Eats all his food ; sleeps well. During the last 10 days large
quantities of uric acid crystals were passed.

Date. 187(

Quantity

5. of urine

24 hours.

Cubic c.

Specific
gravity.

Urea

24 hours.

Gram.

Urea

24 hours.

Grains.

Nitrogen
excreted.
Grains.

Body

weight.

lbs.

Th., May 25t

d . 1875

1025

61-875

954-855

445-599

149

690

Fri. 26th .

. 1659

1022

41-475

640-042

298-686

...

690

Sat. 27th .

. 1700

1022

47-600

734-563

342-796

...

690

Sun. 28th .

. 1114

1027

36-762

567-311

264-745

...

Hon. 29th .

. 1651

1020

49-530

764-346

356-694

...

690

Tues. 30th .

. 1420

1022

39-760

613-576

286-335

...

690

Wed. 31st .

. 1024

1024

35-840

553082

258-104

690

Th., June Ist

. 1077

1027

42-003

648-190

302-488

690

Fri. 2nd

. 1277

1025

45-972

709-439

331-077

690

Sat. 3rd

. 1400

1023

42-000

648-144

302-467

146

690
54

1st 10 days' t

otal. 14197

...

442-817

6833-548

3188-985

Sun. 4th

. 1087

1026

38045

587-110

273-984

Mon. 5th

. 1572

1020

45-588

703-514

328-306

...

Tues. 6th

. 2167

1017

43-340

668-822

312-116

Wed. 7th

. 2070

1017

39-330

606-940

283-238

...

Th. 8th

. 1850

1017

33-300

513-885

239-813

Pri. 9th

. 1830

1017

32-940

508-330

237-220

...

Sat. 10th

. 2277

1017

33016

509-502

237-768

Sun. 11th

. 2239

1017

38-063

587-388

274-114

Mon. 12th

. 1361

1021

40149

619-579

289-137

Tues. 13th

. 1952

1019

38-064

587-403

274-121

147i

27
27

2nd 10 days'
Wed. 14th

total. 18405

...

381-835

5892-473

2749-817

. 2150

1019

38-700

597-218

278-701

Th. 15th

. 2122

1017

33-952

523-916

244-494

...

Fri. 16th

. 2400

1017

36000

555-552

255-590

...

Sat. 17th

. 2200

1019

37-400

577-156

269-339

Sun. IStU

. 2431

1014

26-741

412-667

192-577

Mon. 19th

. 1300

1029

46-800

722-217

337-034

Tues. 20th

. 2062

1019

47'426

731-878

341-543

Wed. 21st

. 1961

1020

43-142

665-767

310-691

Th. 22nd

. 1468

1020

39-636

611-662

285-442

...

Fri. 23ra

. 1866

1021

42-918

662-310

309-078

...

3rd 10 days'

total. 19960

392-715

6060-343

2824-489

149

Averag

1st 10 days

. 1419

44-281

683-354

318-898

...

2nd 10 days

. 1840

38-183

589-247

274-981

...

3rd 10 days

. 1996

39-271

606-034

282-448

Action of heart, &c.
14,500 revolutions
Exercise

Total

2260 foot tons. Diet represent* . . 3615 foot tons."

663 „ Deduct . . . 2950

27 „ „

Total . 665

2960

1877.] Urea and its Relation to Muscular Force, 199

" Experiment 6.— B. A — , aet. 34. Height 5 ft. 4^ in. Weight 142 lbs. at com-
mencement of experiment. Crank, 14,500 revolutions, 14 lbs. pressure. Urine,
acid, no albumen. Eats all his food ; sleeps well.

Date. 18'

Quantity

^6. of urine

24 hours.

Cubic c.

Specific
gravity.

Urea

24 hours.

Gram.

Urea
24 hours.
Grains.

Nitrogen
excreted.
Grains.

Body

weight.

lbs.

Toot tons

raised
per diem.

Th., May 25t

h . 1090

1031

41-420

639-193

298-290

142

688

Fri. 26th

. 1050

1029

38-850

599-533

279-782

688

Sat. 27th

. 868

1027

30-380

468-824

218-784

688

Sun. 28th

. 675

1034

35-100

541-663

252-776

Mon. 29th

. 860

1030

42-140

650304

303-475

688

Tues. 30th

. 1000

1028

39-000

601-848

280-862

688

Wed. 31st

. 1052

1026

38-924

600-675

280-315

688

Th., June Is

b . 800

1031

34-400

530-860

247-734

688

Fri. 2nd

. 725

1033

37-700

581-786

271-500

688

Sat. 3rd

. 400

1033

18-000

277-776

129-628

...

688

1st 10 days' 1

:otal . 8520

...

355-914

5492-462

2563-146

139i

Sun. 4th

. 805

1032

40-250

621-138

289-864

Mon. 5th

. 1400

1021

43-400

669-748

312-548

Tues. 6th

. 1540

1020

36-190

558-484

260-625

Wed. 7th

. 1647

1020

36-234

559-163

260-942

Th. 8th

. 1435

1020

30-135

465-043

217-020

Fri. 9th

. 1400

1020

32-200

496-910

231-891

Sat. 10th

. 1845

1018

32-287

498-252

232-518

Sun. 11th

. 1483

1017

27-435

423-376

197-575

Mon. 12th

. 1000

1023

31-500

486-108

226-850

Tues. 13th

. 1210

1024

37-510

578-854

270-132

2nd 10 days' 1

botal . 13765

...

347-141

5357-076

2499-965

141^

Wed. 14th

. 1445

1022

36-847

568-622

282-024

Th. 15th

. 1300

1023

31-200

481-478

224-689

Fri. 16th

. 1400

1023

33-600

518-515

241-973

Sat. 17th

. 1735

1021

34-700

535-490

249*895

Sun. 18th

. 1615

1021

35-530

548-298

255-872

Mon. 19th

. 1070

1028

38-520

594-440

277-405

Tues. 20th

• 1372

1025

43-904

677.526

316-179

Wed. 21st

. 1134

1029

43-092

664-995

310-331

Th. 22nd

. 1005

1031

38-190

589-348

275-029

Fri. 23rd-

. 1315

1030

46-025

710-257

331-453

...

3rd 10 days'

botal. 13391

381-608

5888-969

2764-850

142

Average

1st 10 days

. 852

35-591

549-246

256-314

...

2nd 10 days

. 1376

...

34.714

535-707

249-996

...

3rd 10 days

. 1339

...

38-160

588-896

276-485

...

Action of heart, &c. . 2260 foot tons. Diet represents . . 3615 foot tons.

14.500 revolutions . 663 „ Deduct . . . 2948

Exercise ... 25 „

Total 667

Total . 2948

200

Original Communications.

[July,

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1877.] 1^01

€l)vonitU of ileirical ^neure^

REPORT ON SURGERY.
By W. Johnson Smith, F.E.C.S.,

Surgeon to the Seamen's Hospital, Greenwich.

On Surgical Fever after Antiseptic Operations. — Dr. Benno
Crede holds that in many of the instances in which, after operations
performed under antiseptic conditions, there is high fever which
cannot be accounted for by local changes, this febrile state is the
result of chilling from prolonged exposure of an extensive surface to
the cold spray. In order to determine the degree of chilling pro-
duced by the antispeptic spray this surgeon made the following obser-
vations on two patients who were similarly affected with large lymph-
glandular tumours in the inguinal region. The enlarged glands
were enucleated and extirpated under antiseptic conditions on the
same day, and in the same room the temperature of which was
maintained at 52° F. The first patient was uncovered from over
the lower margin of the last rib to the middle of the thigh, and on
the whole of the surface were directed two carbolic acid sprays, the
temperature of which was about 52° F. From a thermometer fixed
in the right axilla the temperature was read off every five minutes
during the operation. At the commencement of the operation it
was 99 2° F. ; twenty minutes later, when the dressings were being
applied, it was 97*6° F. The pale, prostrate, and cold patient was
then placed in a warm bed at noon, and one hour after the opera-
tion the temperature was 97° F. ; in the evening it was 98*8° F. On
the following day the patient complained of headache and was
chilly, the morning temperature being 100-4° F., the evening tem-
perature 100.8° F. On the the third day the condition of the patient
was normal. In the second case the buttocks and lower limbs of
the patient were covered by wadding and flannel bandages, and only
the seat of operation was left exposed. The fluid of the spray was
warmed. At the commencement of the operation the temperature
of the body was 98° F. At the conclusion of the operation, which
lasted for twenty-two minutes, it was 98*8° F. On the following
day the temperature and general condition of the patient were quite
normal. In addition to these, other cases are recorded, in order to
show the chilling effect of the antiseptic spray. The author states
that he is not able from his small experience to assert positively that
in every antiseptic operation in which the patient is not carefully
protected, a depression of temperature will take place. He allows

!E02 Chronicle of Medical Science, \^'^Ji

that the extent of surface exposed and the individual capacity of re-
sistance may vary in different cases. It is shown, however, that chilling
may and often does take place after antiseptic proceedings. The
spray acts most injuriously in this way when it is applied to the
head, trunk or abdominal cavity. "When used in the dressing of
large wounds of the extremities it may also cause general chilling,
especially if the application be prolonged and a considerable surface
be exposed and played upon. So long as this chilling is of slight
degree the result to the patient is not serious, but if it consist in a
lowering by several degrees it may, especially in a patient debilitated
by loss of blood, lead to a fatal termination of the case. — Centralhlatt
fu/r CUrurgie, No. 12, 1877.

On the Value of Sponges in Surgical Dressing. — Dr. Charles
B. Brigham, of San Francisco, recommends the use of clean sponge
as an application to open surfaces, and thinks that there are several
reasons why this new dressing should be of value. " In the first
place," according to the author, " sponges having a remarkable
resistance to decomposition allow the dressing to remain untouched
for a certain length of time ; secondly, absorbing liquids with great
facility and in considerable quantity, they keep the wound dry, and
thus favour union by first intention ; thirdly, they are so elastic
that they make an equal and continuous pressure about a wound, and
not only prevent pus collections from forming, but by pressing
gently, surface to surface, they favour immediate union." Peculiar
freshness of a wound has often been remarked by Dr. Brigham after
the removal of a sponge dressing that had been retained for a week
or longer. The discharge from the surface of the wound is trans-
mitted by the sponge and deposited in the outside bandage. The
wound, it is stated, remains free from all the the excoriations which
are so frequent with charpie or cotton-wool dressings. To those
who have had any experience of sponge as a dressing two objections
to the agent will at once occur. In the first place, there is tlie close
adhesion between the sponge and the surface of the wound to which
it has been applied, which causes, at every change of dressing, much
pain and free bleeding ; secondly, there is the offensive odour. On
this latter point Dr. Brigham remarks, that though it may be
objected to the use of sponges in dressings that the odour is offen-
sive after the sponge has been left for some time in the wound, it
depends a great deal upon the amount of the discharge whether
there be any odour or not. In cases of immediate union of the sides
of the wound, it is asserted, a sponge will be inoffensive, no matter
how long it may remain in place, and in cases where there had been
offensive odour it was not found that this had any influence on the
appearance of the wound or on the condition of the patient. —
Surgical Gases, 1876.

On Trephining for Injuries to the Head. — Dr. S. Pozzi, of Paris,
in a recent memoir on ' Cerebral Localisations, and on the Relations
of the Cranium to the Brain, with regard to Trephining,' has sup-
plemented a very clear description of the cerebral convolutions and
*issures by some remarks on the bearing of these anatomical data on

1877.] Report on Surgery, 203

the operative treatment of head-injuries. After an allusion to
the differences of opinion amongst French surgeons as to the expedi-
ency of trephining in cases of head-injury in which there is persistent
hemiplegia, with an absence of any external lesion, he puts the
question whether the surgeon in the application of the trephine can
be better or equally well guided in determining the precise seat of
the operation by internal in contradistinction to external signs, and
whether, disregarding fractures, depressions, wounds, and local signs
of contusion and inflammation, he should rather search for a collec-
tion of functional signs sufficiently pathognomonic to supply the
absence of a local lesion ; or, if such exist, to be put in the balance
with it, and to modify to some extent the determination of the point
to which he might apply the trephine. If similar results occurred
in a wounded man as in an animal under experimentation, the
surgeon would often find a valuable auxiliary in his knowledge of
cerebral localisations. According to the appearance of disturbance
in this or that group of muscles, he might determine with precision
what particular motor centre had been injured. Unfortunately,
things are not so simple on the bed o£ the patient as they are in the
laboratory, as the surgeon cannot control the disturbing phenomena.
It is especially to cases of recent traumatism, and to such as require
primary trephining, that these remarks apply. On reading the
reports of such cases one will be struck with the extent and diffusion
of the symptoms and their erratic character under the influence of
concomitant concussion and contusion. Cases in which there is a
record of localised convulsions, or circumscribed paralysis, are very
exceptional. If, as very often happens, partial convulsions or
hemiplegia appear in a more or less rapid manner, those symp-
toms cannot be regarded as pathognomonic. Indeed, such disturb-
ances of motility have been observed, rarely, it is true, but still
positively, after injuries to the temporal and occipital regions which
are not in immediate relation with the motor centres. In a case
communicated by M. Marvaud to the Societe de Chirurgie, a man
who had received a gun-shot wound in the left temporal region and
a compound fracture of the squamous portion, presented, first, con-
vulsive movements of different parts of the body, especially the
lower limbs, afterwards right-sided hemplegia and aphasia, and
finally, after an interval of some days, prolapse of the upper eyelid,
external strabismus, and dilatation of the pupil on the left side.
The first set of symptoms indicated, according to theory based on
recent anatomical and physiological data, trephining over the
summit of the fissure of Sylvius ; and the second set indicated
trephining over the third frontal convolution on the left side.
M. Marvaud, on the appearance of the third set of symptoms, tre-
phined at the seat of fracture, that is to say, the temporal bone,
and with complete success. Immediately after the operation the
patient opened his eyes, the prolapse of the left upper eyelid dis-
appeared, the right hand, previously paralysed, regained its moti-
lity, and finally, the patient, in despite of all theory, made a good
recovery. This case indicates that the primary symptoms, and

204 Chronicle of Medical Science, [July,

those that occur during the first few days, represent complex lesions
due to the propogation to a distance of the effects of traumatism.
The circumstances on which are based the indications for secondary
trephining are not affected to any great degree by disturbing pheno-
mena. The lesion that gives rise to the symptoms (intracranial
suppuration) is evolved slowly and independently, and its effects
consequently present a simplicity through which they resemble, up
to a certain point, the results of experiments on animals. Indirect
experimentation supplied by clinical observation has not, as yet,
done much to establish, in the case of man, the certain existence and
the exact topography of the motor centres that have been recognised
in animals. But one region of the cerebrum can at present be dis-
tinguished, viz. the third frontal convolution on the left side, — the
so-called convolution of Broca. This is the only region of the
surface of the cerebrum, lesion of which can be diagnosed with suffi-
cient certainty to enable the surgeon in his inquiry to be guided
solely by rational signs. In a remarkable case reported by M. Broca,
the trephine was applied over a purulent collection about the third
frontal convolution, symptoms indicating the nature and seat
of the lesion having appeared on the twenty-ninth day after
an injury to the head. The condition of the patient was much
improved for some hours after the operation, but in the course of
the same day he became comatose, and died. The autopsy revealed
inflammatory softening of the third frontal lobe, and signs of diffuse
meningo-encephalitis, which had doubtless started at the seat of the
abscess, between the bone and dura mater, near the convolution of
Broca. Trephining, as M. Broca states in his report, was resorted
to at too late a period, the abscess having already set up irreparable
complications. The evacuation of the pus had produced but a
temporary amelioration, and the patient succumbed to a diftuse
meningo-encephalitis, which could not be removed. According to
M. Pozzi, this is the only case that has hitherto presented a real
application to surgical therapeutics, of our present knowledge of
cerebral localisations, and of cranio-cerebral topography. Hecent
cases, reported by MM. Proust and Terrillon, and by M. Lucas
Championniere, are regarded by M. Pozzi as instances in which the
surgical treatment and the seat of trephining were indicated rather by
external lesions, such as a wound and fracture, than by any observed
relation of symptoms to cerebral localisations. In conclusion, it is
argued that, with regard to the treatment of injuries to the head, we
cannot, in the present state of our knowledge, expect physiology to
throw any light on clinical surgery, but rather the reverse. "A day
will come, M. Pozzi believes, when our scientific knowledge will
occupy a higher place than it does at present in the art of healing,
and then will the surgeon, instead of giving simple relations of
his successes or his failures as contributions to the study of cerebral
localisations, be able to affix to them this legitimately ambitious
title — trephining guided by the localisations of the cerebrum.^^ — Ar-
chives Qenerales de Medecine, April, 1877.

On Wounds of the Brain from the Auditor^/ Canal. — In a paper

1877.]

Report on Surgefy, 20t

read at the fifth Congress of the German Society of Surgery, held at
Berlin in April, 1876, Professor Roser, of Marburg, communicated
the results of some investigations that had been made by him in
order to determine the topographical relations of the auditory canal
to the brain. The object of such investigations was to throw some
light on those cases of injury to the head, in which, notwithstanding
a discharge of cerebro-spinal fluid from the ear and an extrusion of
small portions of brain-substance, no other serious symptoms result,
and the patient makes a good recovery. The author reports four
kinds of variation in the above-mentioned anatomical relations. The
partition between the auditory canal and the cranial cavity may be
unusually thin, or it may be much increased in thickness, being there
composed of spongy bone. In some instances the tympanic cavity
was found to be extended upwards and outwards over the roof of
the meatus, and in others this roof contained air-cells in communi-
cation with the tympanum. The author's observations show that
the roof of the auditory canal is in close proximity with the middle
cranial fossa and the inferior temporal convolution of the cerebrum,
and that but little force is required to penetrate the skull in this
region and to wound the meninges and the brain. It is shown also
that the middle cranial fossa may be perforated and the middle
cerebral lobe wounded through the ear. The author points out
that the prognosis in cases of head injury, with aural discharge of
cerebro-spinal fluid and extrusion of brain substance, is not so
unfavorable as it is generally supposed to be, since these symptoms
do not necessarily indicate extensive fracture of the petrous process
and of the base of the cranium. This conclusion had been pre-
viously derived from clinical observation. Three cases of head
injury had been observed by Professor Eoser, in which there was a
discharge of cerebro-spinal fluid from the ear, and one case in which
there vvas extrusion through the meatus of cerebral substance, in
all which cases recovery took place, contrary to expectation. In
one of these cases it was found, on examination by means of the
aural speculum, that the tympanic membrane remained intact, and
that in the roof of the meatus there was a small penetrating slit.
Two other cases of recovery from head injury after discharge of
brain substance from the ear, are briefly recorded. The author
alludes to the possibility of mistaking in such cases blood-clot for
brain-matter, and he asserts at the same time that the objection
sometimes made, that the matter extruded cannot be brain-tissue,
when there is no discharge of cerebro-spinal fluid, does not hold
good, since in some undoubted cases of injury to the brain this co-
existence has failed. Professor Eoser allows that the surgeon cannot
expect to find a perforation of the same part of the skull-wall in every
case of injury to the head with discharge of cerebro-spinal fluid and
of brain substance. There is, probably, it is admitted, a lesion of
typanic membrane in the majority of such cases. Variety in the
nature and situation of the lesion is the more to be expected if it be
considered that in the comparative study of many crania much
difference will be found in the structure and thickness of the

206 Chronicle of Medical Science. [July,

osseous parts usually involved. In most individuals the wall of the
skull about the membrana tympani is very thick ; in very few of
two hundred crania examined by the author was the bone at this
situation found to be translucent. It is thought that a discharge of
cerebro- spinal fluid may be due, in some instances, to traumatic
diastasis of the petro-squamosal suture. There may be, as is well
known, an aural discharge when the lesion consists in but an incon-
siderable fissure of bone with rupture of the meninges. The author
thinks it possible that the discharge may exist independently of any
direct lesion of bone, and that the cerebral meninges having been
ruptured and the surface of the bone exposed, the cerebro-spinal
fluid may transude into the auditory canal. As in osteo-myelitis
of a long bone, the medullary fat may be forced into the caniculi,
so, thinks Professor Hoser, may cerebro-spinal fluid, through intra-
cranial pressure, be driven through the pores of a cranial bone. —
Von Langenheclc's Archiv fur hlinische Chirurgie, Bd. xv. Heft 3.

On jRanula. — In a contribution giving short clinical reports of six
cases of ranula observed by himself. Prof. Michel, of Nancy, discusses
the nature and situation and the surgical treatment of this form of
new growth. In each of these cases excision of the cyst was prac-
tised with complete success. Prom observations made during these
six operations, and also from dissection of a ranula in a dead subject,
the author has been convinced that, in the majority of instances of
this affection, the cyst in its development has no connection with any
of the salivary ducts. The view that ranula may be due to dilatation
of the ducts of the sublingual or submaxillary glands is not altogether
rejected ; but it is held that, in the majority of cases, the cyst has
some other seat of origin. In all the seven specimens examined by
the author there was an absence of any connection between the cyst
and the salivary canals, and in each case the tumour had evidently
originated in the areolae of the connective-tissue about the frenum
of the tongue. The so-called capsule of Fleischmann, fluid distension
of which is supposed by Tillaux and other French surgeons to con-
stitute ranula, consists, according to Prof. Michel, in nothing more
than an occasional and abnormal dilatation of one or more of
the areolae of the sublingual connective tissue. On microscopical
examination of the contents of the cyst in the above-mentioned seven
cases, tesselated epithelium and crystals of cholesterin were found
in some, and globular epithelium in others. In no specimen was
the author able to obtain a reaction resembling that produced by
saliva. Prof. Michel holds that extirpation by the knife ought to be
regarded as the general method of treatment for ranula ; and he
argues that this proceeding, first recommended by Heister, is free
from many of the objections that have been raised against it by
Sedillot. Far from being an impracticable operation in ordinary
cases of ranula, it may, even in cases of severity and long duration,
be readily and safely performed. Excision, though more difiicuit
than the usual methods of surgical treatment, such as injection of
o^ iodine, batrachosioplasy, and incision and cauterization com-
bined, is attended with speedy as well as with most permanent
results. No relapse had occurred in any of the six cases treated by

1877.]

Report on Surgery. 207

the author, five of which have been under his observation from time
to time during many years. Two methods of extirpation are men-
tioned ; in one, the ranula is first freely incised and the walls of the
emptied cyst then dissected away ; in the other, the cyst is removed
intact, together with its contents. The choice between one and the
other of these methods should be guided by the thickness of the
cyst-walls. When this wall is thin, preliminary incision is to be
preferred ; when it is thick, extirpation without incision should be
practised. — Gazette Sehdomadaire, No. 16, 1877.

On jRupture of the (Esophagus. — Dr. Reginald H.Pitz has recently
recorded at much length and with interesting comment, a case treated
by Dr. Greorge Allen, of Boston, which is regarded as one of excep-
tional importance, from its proving, as is believed, that a previously
healthy cesophagus may be suddenly ruptured by muscular action.
The patient was a man aged 31 years, debilitated through excessive
use of alcoholic stimulants, and subject to frequent attacks of
gastritis. He was quite free from stricture or ulceration of the
cesophagus. One evening, after having by long-continued and
violent efforts expelled a large piece of tough, gristly meat, which had
remained in his throat for about three hours, he ejected from the
mouth a small quantity of blood unmixed with food or air, and
became very prostrate. Emphysema was soon observed in the
upper part of the neck, and this swelling spread rapidly downwards.
On the following morning the whole neck and the upper part of the
chest were swollen, and in the course of the following day the subcu-
taneous cellular tissues of the whole body had undergone a process
of inflation. The patient remained in a state of prostration ; he com-
plained of no pain save slight tenderness, on pressure, over the left side
of the trachea, and was able to swallow fluids without any difficulty or
uneasiness. On the fifth day he had delirium tremens, and on the
eighth day from that of the commencement of his disease he died
after several severe attacks of tetanic convulsions. At the autopsy,
made forty-eight hours after death, there was found a longitudinal
rent of the oesophagus, two inches in length, extending through all
its coats in front and to the right, opposite to and below the bifurca-
tion of the trachea. The edges were sharply defined, and there was
no evidence, microscopic or otherwise, of pre-existing ulceration or
disease of the oesophageal wall. There was much emphysema near
the surface of the left lung and in old adhesions between this organ
and the chest-wall, indicating rupture of the air-passages on the left
side. The author, after careful consideration of the clinical reports
of supposed rupture of the healthy oesophagus, to be met with in
surgical literature, has come to the conclusion that the number of
cases of this lesion may be reduced to two. Most of those state-
ments, it is held, are based upon errors of observation, insufficient
testimony, and superficial generalisation ; and two clinical records
only, viz. that of Dr. Allen, given in this contribution, and one
published in 1S56 by Meyer, are to be regarded as those of indis-
putable cases from which a knowledge of this class of spontaneous
ruptures can be obtained. Dr. Titz next gives a statement, based on

206 Chronicle of Medical Science. t^^^Vt

these two reports, of the conditions and symptoms of the lesion
called by him "spontaneous rupture of the oesophagus." This
lesion, however, as represented in each of these cases, is really a
compound one, rupture of the air-passages playing a far more impor-
tant part than rupture of the gullet in the production of symptoms
and in forming the whole character of the affection. For the occur-
rence of rupture of the healthy oesophagus, as understood by Dr.
Fitz, there are two essential factors : first, impaction of a foreign
body in the oesophagus ; secondly, the exercise of great muscular
force in the attempts to remove this. The rupture takes place
between the bifurcation of the trachea and the diaphragm, in the
anterior or lateral wall of the oesophagus, and corresponds in direc-
tion with the long axis of this tube. Such rents lie wholly within
the thoracic cavity, and are from one to two inches in length.
" There is no good reason," the author states, " for considering that
the act of vomiting can in any way produce this result, nor is it
essential that the foreign body should remain in contact with the
oesophageal wall long enough to give rise to inflammation from pres-
sure. The fact of muscular action alone being sufficient as the active
agent, is of considerable value from a medico-legal point of view, in
those cases where the introduction of a probang or a bougie may be
asserted as the cause of the rupture." In both the cases on which
the author relies there was intense anxiety, associated with impaction
of a foreign body in the gullet, and violent straining efforts were
made to expel the fixed mass by the action of the respiratory
muscles, the chest having been fully inflated. In both cases, also,
rupture of the air-passages was indicated by haemoptysis and
emphysema, and laceration of the oesophagus by the regurgitation
into the mouth of unmixed blood. Pain is not a very prominent
early symptom ; when present, it is referred to the region of stomach.
What suftering there may be of this nature is due entirely to injury
of respiratory organs and subsequent pleurisy. Nausea and vomit-
ing are not constant or permanent symptoms. A small quantity of
blood is occasionally ejected by the oesophagus. Fluids can be
swallowed without pain. The lesion terminates in death, after
gangrene of the posterior mediastinum and gangrenous pleurisy. The
tetanic attack in Dr. Allen's case is attributed to inflammation in
the posterior mediastinum, involving the spinal nerves. — American
Journal of Medical Sciences, January, 1877.

On Gastrotomy. — M. Lanelongue, of Bordeaux, has recently com-
municated to the French Academy of Medicine the following report,
with comments on a case of cancer of the oesophagus, in which
gastrotomy was performed :

" A man, aged 59 years, without hereditary antecedents of disease,
and previously in good health, was suddenly taken with difficulty in
deglutition, which continued to increase in degree, so that at the
time of his admission into hospital, six months from the commence-
ment of the disease, he was but just able to swallow small quantities
of milk. It could be made out that near the middle of the thoracic
portion of the oesophagus there was a very resistent and absolutely

1877.] RepcH bn Sufgeri): ^6§

impassable obstacle. There was extreme emaciation, but no cachetic
tint. All the other organs of the body were healthy. To prevent
death from inanition it was found that no treatment short of gastro-
tomy could be effectual. The operation was performed with strict
observance of all the rules laid down by M. Yerneuil in a communi-
cation to the Academy of Medicine in April, 1876. The immediate
results of the operation were satisfactory. The patient remained
free from pain and inflammatory phenomena, and was fed regularly
through the fistula, which, however, allowed a considerable quantity
of fluid to escape. After a time, however, thoracic symptoms super-
vened, and the patient ultimately died on the twenty- sixth day from
that of the operation. At the autopsy it was found that the
primary lesion (epithelioma) of the cesophagus had caused i a
bronchial perforation, and led to fatal phenomena of asphyxia.
The stomach was found to be firmly fixed to the abdominal wall,
and the gastric fistula well established.

*' Conclusions. — 1. Gastrotomy is a rational operation, based on
the history of gastric wounds and fistulse formed experimentally in
animals, and established accidentally in man. 2. It is indicated
whenever death from inanition is rendered imminent through
aphagia. 3. The operation should be performed in exact conformity
with the rules laid down by M. Yerneuil, who insists on this among
other points : that the stomach should not be opened until it has
been well fixed to the abdominal wall by the careful and close appli-
cation of many sutures. The surgeon may thus prevent effusion,
whether primary or secondary, into the peritoneal sac. 4. In
incising the integuments the surgeon should not carry his knife
below the inferior margin of the eighth costal cartilage on the left
side. In consequence of long abstinence, the stomach of a patient
on whom gastrotomy is performed is always retracted and elevated
towards the diaphragm. 5. The anterior wall of the stomach should
be opened near the small curvature, so that the secreted and injected
fluids may find a space in which to accumulate, and be thus pre-
vented from running away externally. 6. The operator should
avoid applying foreign bodies, such as haemostatic forceps to
the margins of the gastric orifice. These may give rise to lacera-
tion and sloughing, and lead to undesirable enlargement of the
fistula." — Bulletin de VAcademie de Medecine, No. 15, 1877.

On Injuries of the Subcutaneous Structures of the Lower Extremity.

The following conclusions are given at the end of a memoir by
Prof. Yerneuil, on the severe forms of injury to subcutaneous soft
structures of the leg {coups defouet) : —

" 1. Under the influence of an extension movement of the foot
made suddenly and unexpectedly, and with more or less violence,
rupture may be produced of the subcutaneous soft parts of the:
posterior region of the leg. 2. These ruptures, which vary in extent,
and situation, within the limits of the region, do not always involve
the same tissues. There is no doubt that tendon in some cases^
muscular aponeurosis in some, and fleshy parts in others, and even*
two or all of these parts together, may be involved. In some cases^

119— Lx. 14i

210 Chronicle of Medical Scieitce, [July,

vessels and nerves are at the same time ruptured. 3. Notwith-
standing the undoubted diversity of the anatomical seat and of the
histological lesions, the mode of production and the immediate
phenomena present a sufficiently close similarity to justify surgeons
in confounding all the varieties, save in the case of complete rupture
ot the tendo Achillis, which has been described apart, and applying
to these the common denomination of sprain {coup de fouet). This
term, like many vulgar appellations, has its advantages and its in-
conveniences ; it may be preserved for a time, but sooner or later
patholological anatomy and precise diagnosis, based on anatomy,
will cause it to be removed from surgical nomenclature. 4. The
secondary phenomena, on the other hand, vary in a marked degree,
according to a multiplicity of conditions, such as extent, situation,
histological nature of the lesion, antecedent conditions of the parts
of the injured region, constitution of the patient, and character of
the treatment. Hence the necessity for the recognition of forms
that are distinct from the first, or that subsequently become distinct
through the supervention of complications. 5. Of these conditions
one of the most important, though least known, is, without doubt,
the existence in the posterior region of the leg of deep-seated varices,
and especially of intra-muscular venous dilatations. These con-
ditions fully account for certain unfavorable symptoms which more
or less retard recovery, such being large effusions of blood, circum-
scribed hsDmatomata, considerable and persistent oedema, ag-
gravation of persistent and previously disregarded j^hlebectasis.
6. This condition of varicosity accounts especially for the develop-
ment of formidable symptoms, having as their starting-point and as
the seat of their ulterior development the venous system. The
names of these morbid phenomena will at once indicate their gravity
— extensive thrombosis, simple or double phlegmasia, alba dolens,
embolism, phlebitis and pyaemia. The occurrence of these pheno-
mena, which cannot readily be admitted. as consequences of simple
rupture of tendon or muscle and of injury of healthy tissues,
can at once be explained when we know that a deep-seated vari-
cose net work of the leg has been involved in the primary
lesion, and that through phlebectasis of the lower limbs the
muscles are riddled by enormously dilated veins, with thin and
tender walls. 7. It will probably be demonstrated, ere long, by
pathological anatomy, that a certain form of sprain consists exclu-
sively in rupture of an inter-muscular or intra-muscular venous
dilatation. 8. The preceding conclusions, in showing the pathology
of the morbid phenomena may be taken to explain and justify the
excessive but well-founded fears of surgeons of old. The prognosis
is assisted, and we learn how great a part is played by antecedent
pathological conditions in the course and termination of local lesions
apparently of but little consequence. 9. Practical surgery may also
profit through these conclusions. The surgeon, when called to treat
an injury of the kind described ought carefully to determine whether
varices do or do not exist. In case of an affirmative, he should
endeavour to prevent and to contend against thrombosis, or to

1877.]

Report on Surgery. 211

ought, as a rule, to abstain from any mechanical action that might
excite irritation." — Archives Generales de Medecifie,'Fehr\isiry, 1877.

On Sympathetic Ophthalmia. — Dr. Adolf Alt, of New York, in a
paper ' On the Anatomical Causes and the Nature of Sympathetic
Ophthalmia,' presents statistics of 100 enucleated eyes. These
statistics, it is stated in the conclusion, show the cause of the
sympathetic affections, necessitating enucleation, to be traumatisms
in 83 1 per cent., leaving 16^ per cent, of the cases attributable to
idiopathic inflammation. In 63f per cent, of the injured eyes there
were injuries in the hard membranes, with incarceration of a part of
the uveal tract. Two thirds of the eyes destroyed by idiopathic
inflammation presented ulcerations of the cornea, with incarceration
of the iris, or the formation of staphyloma. The proportion of eyes
which had caused sympathetic troubles without presenting cicatrices
in the hard membranes was about 5 per cent. In 44J per cent, of
the cases of injury to the hard membranes no part of the uveal
tract was incarcerated in the wound. Cicatrices and foreign bodies
in the ciliary body, or incarceration of it, were found in I7i per
cent, of the cases, while the affections of the ciliary body altogether
amounted to 76^ per cent. The iris was found changed in 68 per
cent., and the choroid in 73 per cent. Almost the same number of
changes is thus shown in each of the parts of the uveal tract, with
only a slight percentage in favour of the ciliary body. The retina
was aff'ected in 73 per cent, of the cases, and in 58 per cent, of these
the membrane was detached.

" What part," the author asks, " transmits the affection from one
eye to the other ? If it were the ciliary nerves, diseased in structure
or function, V. Grraefe's proposition to divide them would have led
to a favorable result. If it were the inflamed optic nerve and
retina the section of the optic nerve would have proved more suc-
cessful. From the preceding statistics I conclude that the views of
many earlier authors, i. e, that the optic nerve plays a great part in
the transmission of sympathetic ophthalmia, is strongly sustained,
and its action in this respect is attributable as much to inflammatory
as to functional changes. ' Transmission of inflammatory changes
appear quite possible, if we bear in mind the semi -decussation of
the optic nerve fibres in the chiasm, as demonstrated by the cases of
Hirschberg and others, who all, moreover, gave the supposition of
functional changes a very plausible explanation ; but it seems to me
that he underrates the influence of the optic nerve. The transfer of
affections by the ciliary nerves can only be accomplished by reflex
action, since their tissue possesses a great power of resistance. It
appears to me that the entire nervous apparatus of the eye has the
power of transmission ; and even the influence of the sympathetic
system must not be left out of view in this consideration. In more
than 99 per cent, of the cases we have to deal with changes in the
vascular membrane of the eye, consequently wath disturbances of the
entire circulatory system, it is hardly presumable that these dis-
turbances should not exert an influence upon the sympathetic fibres
of the uveal tract."

312 Chronicle of Medical Science. [J^uly,

" The individual varieties of sympathetic aiFections in the second
eye are certainly nothing but difference of degree. There can be no
incontrovertible assertion that the locality of the primary affection
would determine a certain fixed kind of affection in the other eye.
Still it is worth mentioning that in 13 of the cases where eyes were
enucleated for sympathetic irido- choroiditis, the other had been lost
by panophthalmitis purulenta, and that of the five enucleated for
neuroretinitis sympathetica, three showed retinal detachment."

The following practical deductions are drawn from the author's
statistics and foregoing remarks: — (1) The entire nervous apparatus
of the diseased eye participates in the transmission of the affection
to the other. (2) Scars in the hard membranes, whenever combined
with alterations in the other parts of the eye, particularly in the
uveal tract, retina, or optic nerve, are capable of calling forth
sympathetic affections of the other eye at any time. (3) Purulent
panophthalmitis makes no exception. (4) Consequently its artificial
production, as a prophylactic measure against sympathetic affection,
is reprehensible. (5) The time at which sympathetic affections
most frequently manifest themselves varies between seven days and
eight weeks after the beginning of the disease of the first eye.
(6) As soon as the first trace of a sympathetic affection manifests
itself (a diagnosis which should be made with the greatest care)
therapeutic measures should be resorted to. (7) The only eflBcient
means consists in enucleation of the eye first affected. (8) When
it is fairly presumable that the affection haa extended to the optic
nerve, the removal of a large piece of the nerve, together with the
globe, should not be omitted. (9) Should a case come under our
treatment in which the ins or capsule of the lens is incarcerated,
the incarcerated iris or capsule should be freed before sympathetic
irritation has made its appearance. In recent cases an abscision of
the prolapse, with or without iridectomy, will obviate, in most cases,
the impending danger of sympathetic ophthalmia." — Archives of
Ophthalmology and Otology, New York, December, 1876.

On Cancer in the Male Breast. — Mr. Wagstaffe, of St. Thomas's
Hospital, in some comments on a very rare case of cancer in both
breasts in a man, states *' that mammary cancer in the male is very
commonly infiltrating, and dissiminated rapidly through the system,
but one of the features of this case was the excellent health and
apparent freedom from further disease in the patient. It seems
that the occurrence of what appears to be primary cancer at so short
an interval in both breasts affords support to the constitutional
view of its origin ; but why does this not appear oftener, if so ? and
the fact of its occurring in a male breast gland bears out Sir James
Paget's opinion of its origin in unused or eflete structures and
organs. But it may be fairly asked. Why does not cancer occur
frequently in the male breast ?' "

The following analysis is given of seventy-one cases of cancer of
the male breast, ten of which cases had previously been unpublished.
In sixteen of the thirty-one cases where mention is made of which
moderate its progress. If the varicose veins be filled by clots, he

1877.J Report on Surgery, 213

breast was affected, the right organ was cancerous, and in twelve
the left organ ; in the remaining three cases both breasts were
affected. The age of the patient is given in forty cases. The
youngest is 25 years of age, the oldest 84 years ; two were 30
years old, three between 30 and 40, eleven between 40 and 50, nine
between 50 and 60, seven between 60 and 70, six between 70 and
80 ; so that the largest number of cases occurred between 40 and
50. In eleven out of the thirty cases in which the direction of the
disease is mentioned it was under one year, in eight rather more
than a year ; in one it was over three years, in five over five years,
and in two as much as eight years. At the time when the cases
came under observation an open wound had formed in more than
half the number. Of forty cases in which a sufficient description is
given for a judgment on this point twenty-one had an open wound.
The result of surgical operation is reported to have been successful
in twenty out of the twenty-three cases that had been operated on.
Of fifteen not operated on, twelve are stated to have died shortly.
"Probably," Mr. Wagstaffe states, "in these last-mentioned
cases disease had extended beyond the possibility of interference."
One successful case, under the care of Mr. CaBsar Hawkins, is
alluded to, in which the patient died nine years after the operation,
without any evidence of return of the disease. " The most extraor-
dinary case, however," it is pointed out, " is one recorded by Dr.
Warren in his work on tumours, for a scirrhous mass is reported to
have been removed by him from the right breast of a gentleman 30
years of age, and, eleven^ years after, the patient was still well. —
Transactions of the Pathological Society, vol. xxvii.

On Infra-patellar Sygroma. — According to Professor Trende-
lenburg, of Eostock, dropsical distension of the deeply-seated infra-
patellar bursa cannot be regarded as a very rare affection. Two
cases of this form of hygroma are reported, and a description is
given of its symptoms. The infra-pallellar bursa, the contours of
which are too small, under healthy conditions, to be distinctly seen
or felt, forms, when distended by fluid, a well-marked tumour. The
distension of the bursal sac takes place chiefly in the upward and
lateral directions, an abnormal protrusion being thus formed on
each side of the ligatmentum patellsB. The change thus produced
in the external form of the knee may escape notice if the cor-
responding bursa in the other limb be similarly affected. The
lateral swellings are best marked when the leg is semi-flexed. In
this position of the limb each of the lateral depressions that are
observed under normal conditions is replaced by a prominent
fluctuating tumour. In cases of hygroma of this deeply-seated
bursa, flexion of the leg cannot be caused to its full extent. In
hydrops genu, on the other hand, flexion at the knee is not inter-
fered with, even when there is considerable intra- articular effusion.
There is usually some tenderness in the region of the swollen bursa,
and some pain and a feeling of stiffness in front of the knee after
active movements of the leg. The author made out in each of his
cases a tender spot at the inner side, and just above the level of the

214 Chronicle of Medical Science. [July,

tubercle of the tibia. Pain often comes on spontaneously in the
affected region, and the patient complains at times of a sensation of
tension below the patella and of weakness in the joint. There is
slight lameness, and the affected limb speedily becomes fatigued
after exercise. In advanced cases there is a constant feeling of
UDeasiness in the knee-jojnt, perfect rest of the whole limb giving
no relief. In a female patient having a thick layer of subcutaneous
fat the bursal swelling may fail to be distinctly made out, so that
the nature of the case may be overlooked, and the subjective sym-
ptoms be regarded as those of an articular neurosis. The progress
of infra-patellar bursa is usually very slow. The treatment recom-
mended by the author is that of compression of the affected region
by means of Esmarch's elastic baodage.

In the concluding portion of his contribution Prof Trende-
lenburg states it as his opinion that the pain and tenderness in the
infra-patellar region, so often complained of after injury to the knee,
may be due to an haemorrhagic or an acute serous effusion into the
deep-seated bursa. — V. Langenbeck's Archiv fur klinische Chirurgie.
Be. xxi. Heft 1.

On Acute Cellulitis of the Orbit. — Dr. Sonnenburg, of Strasburg,
in an article on acute cellulitis of the orbit, states that this is not
an affection of frequent occurrence, although it might be assumed
that the orbitar cavity, from the abundance of fat and cellular tissue
contained therein, and from its richness in vessels and nerves, would
present very favorable conditions for the origin and development of
phlegmonous inflammation. The cases that have been recorded in
surgical literature show that acute orbitar cellulitis may be due to
one or other of very many causes. In some instances the affection
occurred in the course of an infectious disease, as typhus, variola,
scarlatina ; it has not unfrequently been observed as a complication
of suppurative meningitis, and has occasionally coexisted with or
followed facial erysipelas. Traumatism, surgical as well as
accidental, has, in many cases, given rise to this form of inflammation.
Instances have been recorded of orbitar cellulitis consequent on
operations for squint and on enucleation of the eyeball. The pro-
longed presence of a foreign body in the orbit, periostitis or necrosis
of some portion of the walls of the cavity, and inflammation of the
lachrymal gland, have been recorded as occasional antecedents of the
orbitar cellulitis. In two cases of rapid and destructive phlegmon
of the orbit recorded by the author of this contribution no cause for
the affection could be discovered. Acute orbitar cellulitis may occur
at any period of life, but has been most frequently met with in young
and middle-aged subjects. The most favorable seasons seem to be
the spring and the autumn. This affection of the contents of the
orbit has, according to the author, well-marked clinical characters,
and may in most instances be readily diagnosed. Prom the facts
that the inflamed tissues are enclosed on all sides but one within
unyielding osseous walls, and that they are mixed up with many
blood-vessels and nerves, the symptoms of acute orbitar cellulitis are,
as may be imagined, very severe, and the pain intolerable. The

1877.] Report on Surgery. 215

inflammation is usually preceded by rigors, general uneasiness, and
fever. The more prominent symptoms during the attack are, intense
pain in the orbit, exophthalmy, swelling and congestion of the
eyelids, oedema of the conjunctiva, especially of tarsal folds, which
extend to and overlap the margins of the cornea. The movements
of the eyeball are usually abolished in consequence of participation
of the recti muscles in the inflammatory action. If proper care be
taken in establishing the diagnosis, acute cellulitis of the orbit ought
to be distinguished without difficulty from any other alfection of this
region. In general inflammation of the eye exophthalmy is due to
distension and enlargement of the globe itself, whilst in cases of
genuine inflammation of the adipose tissue of the orbit there is simple
dislocation of the eyeball forwards. From acute inflammation of the
lachrymal gland, ceJlulitis of the orbit may be distinguished by the
acuity of its process, by the severe pain attending it, and by the
position of the eyeball, which is dislocated directly forwards, and is
not, as in cases of the former aff'ection, forced downwards and inwards.
In periostitis of a portion of the orbital wall the margin of the orbit
is generally tender on pressure, the skin and subcutaneous connective
tissue of the eyelids and cheek are not so readily and so speedily
involved, consecutive inflammation of the orbital fat is generally
localised, and the eyeball is dislocated laterally rather than in a
forward direction.

In the opinion of Dr. Sonnenburg the phenomena and symptoms
attending genuine phlegmon of the orbit indicate that this affection
is an infective inflammation. He holds that in those cases where no
other cause is to be made out, the orbitar inflammation is connected
with inflammatory processes in the deeper parts of the face, as the
pharyngeal and nasal cavities. This infective phlegmon is attended
with such severe local phenomena, in consequence of the special con-
ditions— pain, pressure symptoms, swelling, and fever — being inten-
sified to the highest degree by the unyielding nature of the walls of
the orbit and by the abundance of vessels and nerves coursing its
cavity. The occurrence of consecutive meningitis is not so frequent
as one might be led to anticipate by a knowledge of the free com-
munication of the lymph spaces of the orbit with those of the crauial
cavity. Facial erysipelas is a much more frequent complication. In
orbitar phlegmon the eye is generally in much danger. In the two
cases reported by Dr. Sonnenburg the functions of this organ were
speedily destroyed. There was considerable retinal extravasation
of blood in one case, and ulceration with opacity of the cornea an
the other. In many cases vision is destroyed through neuritis optici ;
sometimes, though less frequently, through detachment of the retina,
or through suppurative irido-choroiditis. Orbitar phlegmon ter-
minates most frequently in suppuration, and often in necrosis of the
soft tissues of the cavity. The most important details of treatment
are deep incisions and the application of moist warmth. — Deutsche
Zeitschriftfur Ghirurgie, Bd. vii, Hft. 5, 6, 1877.

On Perineal Lacerations. — Dr. Montrose A. Palleu, of New
Yrok, holds that " an operation for laceration of the perinasum

216 Chronicle of Medical Science. ["^uly,

ought to be performed in every case where we can hope for union
of the wounded surfaces. The restoration of a conjoined and sym-
metrical action of the muscles, aponeuroses, vaginal tissue and in-
teguments, which make up the perineal structure, is the object
sought to be obtained ; and, while we can hardly hope for complete
action in an artificial perina^um, yet, under certain circumstances,
we can obtain a much stronger one than existed previous to the
laceration, one which gives sufficient vaginal support, and insures
freedom from the discomforts and ills attending the loss of the base
of support to the entire utero-vaginal structures."

The forms of perineal rupture requiring operation are — 1. Peri-
neal sundering, when the submucous structures are sundered. 2.
Vagino-perineal laceration, when the pre-anal tissues are torn. 3.
Perineo-rectal laceration, when the sphincter ani is involved. 4.
Eecto-coccygeal laceration, when the foetus is expelled through the
bowel and lacerates the sphincter to its coccygeal attachments, the
pre-anal perineum being left intact.

Perineal sundering depends on defective muscular action and
atrophy and degeneration of muscular tissue consequent on lesion
of the superficial branches of the pubic nerve, or may be the
result of direct violence during delivery, which severs the union of
the transverse perinei muscles from their attachments to the bulbo-
cavernous in front, the sphincter ani behind, and the levator ani
above and around. When sundering takes place the vaginal mucous
membrane and the skin of the perineal raphe remain intact, and the
posterior portion of the vaginal outlet forms a thin patulous bag
without any sustentative power. This irritation is accompanied
with a greater or less amount of cystocele and rectocele, and con-
sequently, often results in retroversion of the uterus. In conse-
quence of the pouching and sinking of the vagina towards the
coccyx intractable lencorrhoea often results. The only method of
treating cases of this kind consists in rolling the pouch forward
from the rectum in order to cleanse the sac and ap])ly lotions. In
some of these cases of perineal sundering virification of the pos-
terior vagino-vulvar perineal space and approximation, as in other
operations for perineal rupture (except that the integument is not
divided but folded npon itself), not only cures the leucorrhoea but
relieves the patient of the distressing pain and inconvenience of
cysto-rectocele.

Perineal rendering is often met with as a result of the treatment
of retroversion of the uterus by large pessaries, which crowd the
rectum backwards to the hollow of the sacrum or press the bladder
against the pubes. No pessary, the author insists, should ever be
used that is longer than the distance from the sub-pubic ligament
to the posterior fornix of the vagina, which, in an average-sized
woman, rarely exceeds two and a quarter inches. AVith the use of
a pessary of large size, hyperaemia of the vaginal mucous membrane
and consequent leucorrhoea, vesical tenesmus, and dysuria are kept
up. "A pessary," it is stated, "is nothing more nor less than a
splint, and, like all other splints, should not interfere with the nu-

1877.]

Report on Physiology and Histology. 217

trition of the parts or impede their functions." The author states,
in conclusion, " that he is inclined to believe that when the predis-
posing causes of perineal laceration exist, no skill upon the part of
the accoucheur can avoid the accident, unless he relieves the perineal
tension by vulvar liberating incisons." — Neiv Yorh Medical Journal^
No. 5, 1876.

EEPORT ON PHYSIOLOGY AND HISTOLOGY.
By Henry Powee, F.E.C.S., M.B. Lond.,

Senior Ophthalmic Surgeon to St. Bartholomew's Hospital.

Spontaneous Generation.

1. Dr. N. Roberts and Prof. Tyndall. The Influence of Liquor

JPotasse and an elevated tem'perature on the origin and growth of
Microphytes. ' Nature,' Feb. 1, 1877.

2. Dr. D. MiJLLER. Mn Beitrag zur Archebiosis. In * Centralblatt

fur Med. Wiss.,' No. 18, May 5, 1877.

3. M.M. Pasteur and Joubert. On the Alteration of Urine in

reference to recent communications of Dr. Bastian. ' Nature,'
Feb. 8, 1877, abstract of paper read before Academy des
Sciences.

4. Bastian, Dr. C. On the Fermentation of Urine. 'Nature,'

March, 1, 1877, and ' Researches illustrative of the Physico-
chemical Theory of Fermentation read before the Roy. Soc.,'
June 15, 1876. No. 172.

5. W. H. Dallinger. Spontaneous Generation. Abstract of lecture

delivered at Roy. Institution, published in ' Nature,' May 10,
1877.

1. Dr. Roberts' comments on Dr. Bastian's statement that while
an acid urine usually remains barren after being boiled for a few
minutes, the same urine becomes fertile when similarly treated if
previously neutralized or rendered alkaline by liquor potassae, es-
pecially if it be afterwards maintained at a temperature of 115° F.
or 122° F. This, Dr. Roberts says, is quite in accordance with the
general rule he has himself laid down, viz. that slightly alkaline
liquids are always more difficult to sterilise (by heat) than slightly
acid liquids, for hay infusions if acid were always rendered barren
after a few minutes' boiling,whilst the neutralized infusion invariably
became fertile after a similar boiling. He thinks the addition of
the liquor potassae after the boiled liquid had cooled opens a source
of fallacy. Both he and Professor Tyndall found no signs of life
appeared if the tubes containing the potash were kept for some
hours at a temperature a little above that of boiling water, M.

218 Chronicle of Medical Science. [July,

Pasteur instead of using a solution of potash, as Dr. Bastian did,
employed the solid caustic potash to neutralize the urine. Dr.
Bastian replies that liq. potassse, which has been raised to a tem-
perature of 100° C. (212°r.), must be regarded as a sterile fluid,
and this was the material he added to ^the urine in his experi-
ments. To settle the point, M. Pasteur has proposed a commission
composed of MM. Dumas, Milne-Edwards, and Boussingault.

2. M. Miiller's observations have not been favorable to Dr.
Bastian's views.

5. Mr. Dallinger and Dr. Drysdale have followed continuously
under high powers the life of some of the objects contained in septic
infusions, and have satisfied themselves that even in cases where
reproduction appeared to be effected by fission, prolonged research
showed that spores were produced. They also ascertained that
whilst a temperature of 140° F. was sufficient to cause the death of
adults, the spores were able to grow after having been heated to
300° F. for ten minutes. Can it be philosophical, Mr. Dallinger
asks, with the life-history of Bacteria still unknown, to assume for
it a different mode of propagation ?

Absorption. Lymphatics. Blood.

1. A. Budge. Bie Lymphwurzeln der Knochen. ' Archiv f. Mic.

Anat.,' B. xiii, p. 87; ' Cbl.,' 1876, 958.

2. Gr. ScHWALBE. TJeber die Lymphwege der Knochen. In ' Zeit-

schrift f. Anatomic und Eatwicklungsgeschicht,' Band ii,
p. 131 ; ' Cbl.,' 1876, p. 947.

3. R. Geester. TIeler die Lymphgefasse des Hodens. ' Zeits. f. Ana-

tomie u. Entwicklungsgeschichte,' B. ii, p. 36 ; * Cbl.,' 941.

4. H. Nasse. Das Blut der Schwangeren. 'Archiv f. Gynaecol.'

Band x, p. 315.

5. S. V. Basch. Die volumetrische Bestimmung des Blutdrucks heim
Menschen. In ' Wien. Med. Jahrbuch,' 1876. No. 4.

1. Budge has found that the blood-vessels contained in the
smallest Haversian spaces are surrounded by perivascular lymph-
sinuses, which possess a special epithelial investment adhering
to the internal wall of the Haversian canals. These perivascular
lymph-sinuses are, on the one hand, directly continuous with the
lymphatics of the periosteum, and on the other hand, with the stel-
late processes of the lacunae which can be injected through them.
Budge therefore admits that the roots of the lymphatics of bone are
in the lacunae, and that the lymph of the bones is transmitted from
the lacunae into the perivascular sinuses of the Haversian canals,
from whence it passes into the periosteal lymphatics.

2. According to Schwalbe, true lymphatic vessels belonging to
bone are only found in the outer layers of the periosteum. Lym-
phatic spaces or sinuses, however, in connection with them occur in
the layer of loose connective tissue between the outer and inner

1877.] Report on Physiology and Histology. 219

layers of the periosteum, and these again communicate with spaces
lying between the periosteum and the surface of the bone. The
subperiosteal sinuses are lined by epithelium. Schwalbe finds in the
compact substance of bone a system of canals corresponding to
the bone corpuscles, and these processes either communicate
directly with lymph-sinuses on the inside or outside of the bone or
indirectly through the perivascular spaces contained in the Haversian
canals. Schwalbe also describes peri-myelar spaces.

3. Gerster states that the lymphatics of the testes form a closed
vascular plexus with membrana propria that never communicates
directly with the interstitial tissue of the gland.

4. Nasse's experiments extended over a long period, and were
made both on man and the dog, blood being taken from the veins
of the same individual before, during, and after pregnancy. He
found the specific gravity of the blood of healthy women to be
1055-3, the amount of water 802'4 per 1000, and of fibrin 2-36,
The specific gravity of blood serum amounted to 1026 '5, and its
proportion of water 910'44. In opposition to this, the specific
gravity of the blood of pregnant women underwent a diminution.
It amounted from the commencement of the second to the sixth
month to 1052 ; from the sixth to the end of the eighth months
10497 ; ninth, 1051*3 ; in parturient women (ten observations)
1053*3. The specific gravity of the blood serum also diminished to
some extent, but the amount of fibrin increased to 3*67 per 1000
in the ninth month, and to 3*82 in parturient women. Similar
results were obtained in bitches.

5. Basch has investigated, with the aid of Mosso's plethys-
mograph, the changes of volume which the arm, when supported in
a position of complete rest, undergoes when the body generally is
also kept at rest. He finds that long waves of unequal weight can
be observed which correspond to a rhythmical swelling, and dimi-
nution of volume of the arm occur. The subject of the experiment
was placed on a bed in a horizontal position, and might even go
to sleep without interfering with the occurrence of the waves.
y. Basch does not agree with Mosso in attributing the waves to
contractions of the vessels, but to changes in the tension of the
aorta, since he was unable to observe any synchronous reddening
or pallor coincident with the waves. He regards them as analogous
rather to the well-known curves of Traube and Hering. Several of
the curves, taken just as the subject dropped off" to sleep, showed a
distinct fall in the curve, which, however, did not last longer than
a minute, and which was then replaced by the previously observed
waves. V. Basch refers this to a relaxation of the vaso-motor centre ;
so that the aortic blood chiefly fills the blood-vessels of the abdo-
minal viscera ; and as a consequence, the aortic pressure sinks, and
the volume of the arm diminishes. In opposition to Mosso, Y. Basch
finds no variation in the volume of the arm during strong exertion
of its muscles. "When strong pressure was applied to the abdomen,
so that the vessels contained in it could not dilate, the volume of
the arm augmented ; a similar effect was produced during strong

220 Chronicle of Medical Science. [July,

action of the abdominal muscles. All conditions that lowered the
blood pressure in the abdominal vessels caused a diminution of the
volume of the arm.

Gland. Secretion.

1. "W. BiEDEEMANN. TTntersucliungen ilber das Mag en- epithet.
' Wien. Akad. Sitzungsber.* B. Ixxi, Heft 3, p. 377.

2. F. Kretscht. Beohachtimgen und Versuche an einen Magenjlstel

Kranken. ' Deutsch. Archiv f. Klin. Med.' Band, xviii, p. 527.

3. W. KrHNE and A. Lea. JJeher die Ahsonderung der Fancreas in
Heidelberg Natur-hist. Verhandlungen, B. 1, H. 5.

4. E. KtJLZ. Zur Kenniniss des menschlichen Leber glycogens.

' Pfliiger'g Archiv,' B. xiii, p. 267.

5. E. KuLZ and E. Ekeeichs. Tleber den Einfluss der TJnter-

binding des Ductus Gholedochus auf den Glycogengehalt der
Leber. ' Idem,' p. 460.

6. C. M^Htr. Be la Non- Existence du Mucus de V Urine. ' Bullet.

Gen. de Therapeutique,' 1876. Band Kci, p. 161.

7. L. Kleinwachter. Das Verhalten des Harnes im Verlaufe des

normalen Wochenbetts. ' Archiv. f. Gynaecol,' B. Ix, p. 370.

8. Prof. Quincke. The Influence of Sleep on the Activity of

the Kidneys. In ' Archiv ' f. Exp. Pathol.,' Band, vii, H. 2, and
' Academy,' June 9, 1877.

9. J. Duval. Sur un Acide nouveau pre-existant dans le lait frais

dejument et nommS acide equinique.

1. Biedermann finds that the gastric epithelium of most Yertebrata
consists of conical or cylindrical cells, bounded laterally by a mem-
brane, but open above in every phase of life. The open free extre-
mity is filled with a round or oval body (bung), which proceeds
from a peculiar modification of the cell protoplasm, and is gene-
rally histologically, but always physically and chemically, diff'er-
entiated from the remaining cell substance. The bung,which is
characterised by its singular power of swelling up by imbibition,
and by its relation to a watery solution of aniline blue, for which it
has a strong affinity, exhibits when treated with osmic acid (though
not in all animals) a peculiar fine longitudinal striation. He con-
siders, therefore, that the view of Heidenhaiu and Ebstein, that it
is merely a portion of cell contents converted into a kind of mucus,
is untenable. The mucus cells found by Heidenhain at the entrance
of the stomach in Eana esculenta are only morphologically different
from the superficial epithelium. The gastric cells subserve the
purpose of secreting the gastric mucus, and possibly aid in the
resorption of certain products of digestion. The gastric epithelium
of a fasting and a digesting animal differ only in the size of the bung
closing their orifices.

2. Kretschy's observations were made on a servant-girl, aged 25,
who was otherwise healthy, but suffered from a gastric fistula, con-
sequent on the bursting into the stomach of an abscess originating

(

1877.] Report on Physiology and Histology, 221

in disease of the seventh rib of the left side. The opening was
three centimeters in diameter (one inch), and from it protruded a
red and easily bleeding fold of mucous membrane. A sound could
readily be introduced into the alimentary canal, and conversely a
portion of any food that was swallowed immediately made its appear-
ance at the external orifice of the fistula. When Kretschy com-
menced his experiments the opening had already existed five
months. Kretschy sought to determine the duration of normal
digestion ; and as the activity of digestion is dependent on the
degree of acidity of the contents of the stomach, he endeavoured to
ascertain how soon after food the stomach gave an acid reaction;
when the formation of stomach reaches its maximum ; how it rises
and falls, and how the alimentary canal behaves. He found that
the digestion of breakfast lasted five and a half hours, the acid
reaction attaining its maximum in the fourth hour, and falling to
neutral in the course of the following hour and a half. The digestion
of the mid-day meal (dinner) lasted seven hours, the maximum acid
reaction occurring about the sixth hour, and the stomach becoming
neutral at the end of the seventh hour. Examination of the con-
tents by means of the microscope at the end of the fifth hour demon-
strated the presence of numerous muscular fibres and starch granules.
The digestion of supper lasted from seven to eight hours. At the
catamenial period the stomach never at any time of the day pre-
sented a neutral reaction. The addition of 3 ccm. of alcohol
prolonged the period of digestion of dinner; coff'ee prevented the
acidity from becoming so great, and prolonged the duration of
digestion one hour. Pepsin in 7-grain doses did not shorten the
period of digestion. Distilled water did not cause the stomach to
become acid. Alcohol becomes converted into aldehyde in the
stomach.

3. Kiihne and Lea examined the delicate and almost transparent
pancreas of the rabbit almost in the normal living state, by drawing
the duodenal loop of intestine through a small wound in the
abdomen, and placing the mesentery under the microscope. They
found that the short tubes and club-shaped extremities of the
gland ducts are either smooth externally, or present well-marked pro-
jections and sulci which eorrespond with the number of the subjacent
secretory cells. In the former case the limits of the cells are not
defined, in the latter each cell is sharply defined by a usually double
contour line, the inner border of which bounds the lumen of the
lobule. The smooth-walled condition is characteristic of the fasting
state, the lobulated of the process of digestion ; so that they alternate
with one another during life. The lobulated condition could be
induced by injecting the ducts with fluid, by irritation of the
gland, by means of moderate induction currents, by the injection of
jaborandi ; the smooth condition by cooling, by strong induction
currents, and by poisoning with atropine. They find also that the
granules within the cells described by Bernard change their position
during secretion, advancing towards the lumen of the tube, and
after the process of secretion was continued for some time become

S2^ Chronicle of Medical Science. [ July*

smaller, and ultimately disappear. In the axial canal of the gland
small particles of albumen (blood-corpuscles) may be observed
undergoing digestion. No digestion, however, of such corpuscles is
observed if they were situated between the cells. They describe
peculiar cell heaps which are accumulated in certain parts of the
pancreas. They do not appear to have been able to follow the
nerves into the cells of the gland.

4. Kiilz obtained from the tenth part of the liver of a diabetic
patient, in addition to sugar, 0'685 gramme of glycogen, notwith-
standing that the post-mortem was made twelve hours after death,
and that the last food taken was thirty-four hours before death.
The glycogen obtained exhibited the normal reactions, and the
sugar obtained from it by boiling with dilute hydrochloric acid ro-
tated light to the right, and was capable of fermentation.

5. Kiilz and Frerichs found that in three guinea-pigs the amount
of glycogen obtained after ligature of the ductus communis chole-
dochus 0088, O'l, and 0'112 gramme; in a control experiment it
amounted to 0*356 of a gramme. From the livers of rabbits, seven-
teen to twenty-nine hours after ligature, the quantities obtained
were 0095, 0 053, 0'115, 0123, and 0088. There was, therefore, a
considerable diminution of the amount of glycogen. The urine of
all the animals contained blood, colouring matter, albumen, and
biliary colouring matter, but no sugar as Wittich has stated. In
a subsequent series of experiments the rabbits were first made to
fast for six days before the ductus choledochus was tied, and a
solution of sugar was now injected to see whether the formation of
glycogen ceased. The amounts of glycogen obtained from the
different animals were 0069, 0039, 0079. 0115, and 0066 of a
gramme. Similarly, even in well-nourished animals, without ante-
cedent fasting, if the duct were tied and sugar injected, the amount
of glycogen contained in the liver was small.

6. According to M. Mehu, the cloudy deposit which takes place
in urine after standing for a little while, is composed, not of mucus,
as is generally believed, but of epithelial cells, derived from the
bladder and detritus of the same. In the female, some of the cells
are derived from the vagina, or may be pus cells. No mucus is
found in this cloudy material, nor is any contained dissolved in the
urine. M. Mehu refers to the behaviour or urine containing pus-
cells, or a considerable quantity of the colourless elements of the
blood. Such urine, if filtered, becomes cloudy on the addition of
acetic acid to it in the cold, a reaction which we consider to be
due to the presence of pyin, or some substance analogous to
myosin. Acetic acid produces a cloud when added to the urine,
even when the bladder is only slightly irritated, but not with
normal urine.

7. Klein wachter's observations on the behaviour of the urine
during the first eight days of the puerperal state, were made upon 179
cases, with the following results. The quantity of urine is increased
during the first twenty -four hours (being 1325 c.cm. on the average),
which he considers to be due to the change of pressure that has

187^.] Report on Physiology and Histology, 223

occurred in the vascular system, and perhaps, also, to the psychical
excitation of the act of delivery. The quantity falls from the
second to the fourth day, in consequence of the commencing
secretion of milk and the loss of fluid by perspiration, and by the
lochial discharge, but it subsequently augments again. The amount
of urea excreted in the course of twenty-four hours is nearly normal
(26*5 grammes), though it undergoes some diminution during the
first and second days after delivery. The excretion of salt (14 "0
grammes) is normal, and is in proportion to the quantity of urine.
The amount of phosphoric acid runs parallel with the quantity of
urea eliminated, and is somewhat diminished during the first eight
days on the whole (the average being 2*2 grammes per diem). On
the first day it is augmented (2'5 grammes), on the second and
third day diminished (1*7 grammes), on the fourth and fifth days in-
creased (2-3 grammes), and again, on the last three days it falls.
The specific gravity of the urine is, on the average, 1015 — 1016. Its
colour, which is at first pale yellow, becomes gradually yellow. As
the age of the mother increases, the daily elimination of water,
common salt, and phosphoric acid diminishes, its colour becomes
darker, its specific gravity higher.

8. Professor Quincke has ascertained that, whereas the urine
secreted during sleep is scanty and of high specific gravity, that
secreted during the first three hours after waking is more abundant
and of lower density than during any similar period of the twenty-
four hours. A number of observations were made to establish this
point, the subject remaining in bed and taking neither food nor
drink for the three hours in question. The fact admits of being
interpreted in various ways. We may suppose the absorption of
fluid from the intestinal canal to be arrested during sleep, and
resumed on waking. This hypothesis is a most unlikely one, for
the periodic variation takes place as usual when no liquid has been
taken within four hours of retiring for the night. It is probable
that the physiological activity of the kidneys may be checked
during sleep, owing partly to diminished energy of the secretory
nerves, partly to contraction of the renal blood-vessels, partly to a
lowering of tension throughout the arterial system, and this is the
most probable explanation.

9. Duval states that the milk of the cow contains a new acid,
which is obtained in solution by agitating ether extract with water
and filtering, by which means the fat is retained ; on evaporation,
a syrupy mass is obtained, which, according to Duval, is the pure
acid. In the milk it is normally in combination with ammonia.

224 Chronicle of Medical Science, [July^

Eespieation.

1. ZwEiFEL. Die Bespiration des Foetus. * Archiv f . Gynaecol.'

Band. Ix, p. 291. ' Cbl.,' 1876, p. 907.

2. ZuNTZ. TJeher die Respiration des Sangethier Foetus, In

'Pfliiger's Archiv,' Band, xiv, p. 605.

3. A. Stefani. Influenza delta Respirazione sulla pressione del

Sangue. ' Centrablatt.' Abstract, 1876, p. 950.

1. Zweifel showed, by means of the spectroscope, that the blood in
the vessels of the umbilical cord of the foetus presents the absorption
striae of oxyhaemoglobin, and therefore contains oxygen, which must
come from the blood of the mother. He opened the pregnant uterus
of an animal lying in a warm salt-water bath, and by inducing
artificial asphyxia, observed whether,and how soon, the blood assumed
a dark colour. He found that after exclusion of air the process of
asphyxia occurred almost as rapidly as in animals that had been
born.

2. Zuntz, whose paper is abstracted in the 'Academy' for May
12, 1877, maintains that foetal blood contains a smaller proportion
of haemoglobin than the blood of the adult ; that the embryo can
survive complete occlusion of its umbilical vessels for a much longer
time than closure of its trachea after birth, though the foetus is
asphyxiated quite as rapidly as the maternal organism, when the
placental circulation remaining intact the mother is deprived of air.
Hence the power of surviving temporary closure of the umbilical
vessels must be ascribed, not to any special independence of oxygen
on the part of the foetus, but to the slower rate at which its tissues
consume the relatively small store of oxygen contained in the blood.
This is in opposition to Zweifel, who thought the consumption of
oxygen by the foetus in utero to be relatively equal to that which
takes place after pulmonary respiration has set in.

3. Stefani placed dogs under the influence of curara, and then
made the usual arrangements for obtaining tracings of blood pres-
sure. He found that if the artificially-conducted respiration (neces-
sitated by the employment of curara) were suddenly interrupted
great augmentation of the blood pressure occurred, the rise amount-
ing to from 110 to 194 mm. of mercury. This, however, was not
always immediate, but after the lapse of a longer or shorter period,
the length of which is dependent on the store of oxygen that
happens to be present in the blood at the moment of arrest of the
respiration ; the larger the amount of oxygen the longer the duration
of the interval between the occlusion and the rise of the blood
pressure. An analysis of the blood-pressure curve shows that it is
not formed by a uniformly rising oblique line, but by a series of
undulations. As the pressure rises, the number of pulse-beats falls,
whilst the several pulsations are more protracted, a result that is due
to excitation of the vagus centre, for it no longer occurs when both
vagi are divided. If air be readmitted by recommencement of the
artificial respiration, the pressure of the blood falls, and the pulse

1877.] Report on Physiology and Histology. 22$

resumes its ordinary frequency and extent. Stefani explains these
phenomena on Schiff's theory in regard to the respiratory oscilla -
tious of the blood pressure, and repeated his experiments on dogs ,
in which the vaso-motor centre was paralysed by section of the
spinal cord. The result of this section was, as Y. Bezold showed in
all instances, a progressive diminution of the blood pressure ; and if,
after the section was made, artificial respiration was suddenly ar-
rested, the blood pressure rose, but never to the same extent as in
the uninjured animal. If the vagi were divided as well as the cord
in the neck, no increase of blood pressure or change in the heart's
action occurred. It hence appears that the increase of blood pres-
sure, consequent on arrest of the respiration, is independent of the
action of the vaso-motor centre, though it by no means rises to the
same amount as when that centre is intact; and we must admit
that the results of the chemical changes taking place in the blood
after arrest of respiration act, not only on the vaso-motor centre,
but also on the ganglia in the heart. By special control-experi-
ments, Stefani shows that the phenomena above described are not
due to the influence of the small vaso-motor centres demonstrated
by Goltz and Nussbaum in the spinal cord, nor to the innervation
centre of the heart, situated in the medulla oblongata, since they
occurred after section of the spinal cord and both vagi. Stefani
points out the practical importance of these researches by applying
the results to the treatment of apoplexy from effusion of blood,
for, in such cases, the maintenance of artificial respiration may
prolong life by relieving pressure on the respiratory centre, and
also, by diminishing the blood pressure, it may prevent the further
escape of blood.

Neeyous System.

1. W. KiJHNE. VorVduJige Mxttheilung uber Optographisclie

Versuche. In ' Centralblatt f. d. Med. Wiss.,' No. 3, 4, 11,
15, 1877.

2. Helereich. Netzhautpurpur. Idem, No. 7.

3. DiETL und Plenk. Netzhautpurpur. Idem, No 16.

4. H. Adleb. Sehpurpur am Kranhen und verletzten Menschen-

augen. Idem, JNo 14.

5. W. Keause. Die Nervenendigung in der Betina. * Archiv f *

Mikroskop. Anatomic,' Band xii, p. 742.

6. James De WAR. The Physiological Action of Light. 'Nature,*

March 15, 1877.

7. M. Lavdowskt. Untersuchungen iiber den ahustischen End

apparat der Sdugethiere. * Archiv f. Mic. Anat.,' B. xxxiii,
p. 497.

8. A. V. Mo JSisovics. TJeher die Nervenendigung in den Epidermis

der Sailger. In ' Wien. Akad. Sitz.,' B. Ixxi, p. 242.

9. Stetner. The Influence of Temperature on the Nerve and

Muscle Current, 'Eeichert's Archiv,' and 'Nature,' March 8,
1877.
119— LX. 15

226 Chronicle of Medical Science, [July,

10. Webee-Liel. Die Aquceductus des Labyrinths. In ' Central-
blatt f. d. Med. Wiss.,' 1876, p. 929.
U. Peitchaed. The Termination of the Nerves in the Yestibule •
and Semicircular Canals of Mammals. In the 'Quart. Journ.
of Microscop. Sci.,' vol. xxviii, p. 398.
H. MuNK. Ueher Parltialerregung des Nerven. 'B-eicliert's
Archiv,' 1875, page 41 ; ' Centralblatt,' 1876, p. 948.
11. Moeiz-Benedikt. Der Raubthiertypus am Menschlichen Gehirne.
In ' Oentrablatt. f. d. Med. Wiss.,' 1876, p. 930.

1. In November of 1876 Boll published a paper in the ' Keports
of the Berlin Academy of Sciences,' stating that the retina of all
animals that had been kept for some time in the dark presented a
purple tint, but that after exposure to a bright light it lost this
hue and became colourless. Kiihne, repeating Boll's experiments,
satisfied himself that the colour of the retina reacted to light and was
capable of self-renovation after removal from the body. He speedily
demonstrated that if the image of an external object be thrown
upon the retina as upon a screen, it is practicable to preserve it.
In mammals he found that the purpurogenic function o£ the retinal
epithelium is lost within a few minutes after death, and hence that
it is important, in attempts to preserve the image, to remove the eye
rapidly after a strong image has been thrown upon it during life.
The head and eye of a rabbit were firmly fixed in immediate proximity
to a window shutter having a square hole cut out of it. The head
was then covered for five minutes with a black cloth, after which the
cloth was withdrawn and the eye exposed to the light thus entering
for three minutes. This head was instantly decapitated, the eye
expeditiously extirpated under the monochromatic light of sodium,
opened, and plunged in a 5 per cent, solution of alum. The other
eye, without being removed from, the head, was two minutes after
treated in the same way. On the following morning the milk-white
retinae were cautiously detached in their whole extent and were then
foiind to exhibit on a beautiful rose-red ground a sharply defined
square image, which in the second eye was white and in the first
rose-red and somewhat less defined. By degrees on exposure to
diff"used daylight both images faded away. There can, then, be no
doubt that physical changes in the retina accompany the perception
of light.

2. Helfreich considers that the general colour of the fundus of
the eye as seen with the ophthalmoscope is due to the normal purple
of the retina, but this is opposed by (3) Dietl and Plank.

4. Adler, from pathological evidence and enquiry, has satisfied
himself that the presence and intensity of the retina-purple stands

n direct relation to the existence and degree of the visual power
of the retina.

5. Krause divides the retina of vertebrata into the following layers:
1. Pigment layer. 2. Epithelial layer, composed of rods (Eichtzellen.
li<2;ht cells), and cones (Farbenzellen, colour cells). Each rod cell is
coiiipotecd of rod, rod granule, rod fibre, and rod cone; and each

.1 877.] Report on Physiology and Histology. 227

cone cell of cone, cone granule, cone fibre, and proper cone. Krause's
rod and cone granule correspond to the external granules of the
older authors and of Max Schultze. 3. The nervous layer, which
is divisible into (a) membrata fenestrata, (5) granule layer, (c)
molecular layer, {d) ganglion cell layer, {e) optic cell layer, {f)
membrana limitans. Neither rods nor cones can be discovered in
Amphioxus lanceolatus nor in Myxine glutinosa. The Petromyzon,
however, although so little superior to them in organization,
possesses both, and both are present in bony fish. The Proteus
amongst Amphibia Krause believes has both ; but Boll thinks only
one form is present. The rods and cones of the axolotl have very long
delicate and conical external segments. The bacillar layer of frogs
presents four forms of elements, one of which possesses oil drops ;
the second no oil drops, but paraboloidal bodies ; the third are
ordinary cones ; and the fourth small rods. Lizards present two
kinds of elements — slender structures, one with yellow or yellowish-
red or pale blue fat drops and very fine pointed extremities ; and the
other more ventricose, which in place of the fat drops, present
molecular pale yellow ellipsoidal bodies. The blind worm has
yellow and greenish-yellow, pale blue and pale greenish-blue oil
drops in its cones. In regard to the retina of birds, Krause finds
the supposed colourless oil drops to be pale blue. In many rapa-
cious birds {Aster palumharius for one) a red oil drop has several
orange-coloured ones in its immediate neighbourhood. He thinks,
and in this is opposed to M. Schultze, that night birds have cones ;
but they only become fully developed and numerous in adult life.
Cones are also present in many other nocturnal animals, as in bats,
mice, hedgehogs, the hyaena iltis. Krause still holds strongly the
opinion he expressed ten years ago in his memoir on the fenestrated
membrane of the retina, that the true terminations of the optic
nerve fibres are to be looked for in the line between the epithelial
and nervous layer, that is to say in the vicinity of the membrana
fenestrata.

Krause, in a second communication, states that the retinal purple
can be dissolved out of the retina by bile, or the purified biliary
salts. The solution is of a bright carmine tint, and rapidly bleaches
on exposure to light. It allows yellow, orange and red light to pass
through it, but absorbs all rays from the yellow green to the violet
end of the spectrum. He further finds that the colouring matter
is not uniformly distributed through the retina, the posterior surface
o£ the fossa centralis being colourless.

6. Professor Dewar, in an interesting lecture delivered at the
Eoyal Institution, showed by a simple apparatus that the action of
light on the retina is attended with the development of an electrical
current, the amount of which can easily be estimated by the galva-
nometer.

7. Lavdowsky distinguishes four clifFerently constructed parts in
the terminal acoustic apparatus of mainuials — 1. The membrana,
basilaris with the arches of Corti (Corti's organ in the strict sense).
2. The supporting apparatus. 3. The terminal cell apparatus ; and

228 dhronicle of Medical Science. ["^wly^

4. The membrane of Corti or membrana tectoria. The supporting
apparatus he finds to consist of three parts, viz. of a pars reticu-
laris, a pars fibrosa, and a pars perpendicularis. The membrana
basilaris is composed of fibres possessing great elasticity stretched
like cords between the points of attachment of the membrane. They
are most distinct in the so-called zona pectinata, less marked in the
habenula tecta and perforata, where they are more slender and
arranged in two rows, between which is a structureless membrane.
The membrana basilaris breaks up into segments, each consisting of
about ten fibres and corresponding[to one of Corti's arches, but there
is no continuity of structure between the two. The arches are com-
posed of similar fibres, but the fibres are finer and less adherent to
one another. They exhibit clear indications of contractility when
stimulated by electricity. The supporting apparatus of the auditory
organ is composed of two morphologically diff'erent materials, epi-
thelioid tissue and connective tissue. The former constitutes the
whole upper part of the supporting apparatus, viz. the lamina
reticularis, fixing the terminal cells in position with their two
accessory plexuses. The latter is represented by certain connective-
tissue fibres found inside and outside of the tunnel of the arches.
Lavdowsky includes under the head of the terminal cell apparatus
in addition to external and internal hair cells (perceptive elements,
L.), the auditory granule layer situated at the foot of the internal
hair cells. He agrees with Waldeyer and Gottstein in regarding the
external terminal cells as twin cells, and accounts for the discre-
pancy in the description of them given by different authors by the
changes they undergo at different ages. The new-born animals the
two cells (Corti's and Deiter's cells) are already independent of one
another, though in structure and appearance they are almost iden-
tical ; subsequently the Corti's cell grows at the expense of the other.
The cells of Corti or rod-cells of Lavdowsky are very regularly
cylindrical and consist of a dark granular mass containing a
nucleus but destitute of a membrane. Deiter's cells (cone cells of
L.) are conical bodies of various form, possessing a membrane but
destitute of a nucleus. The auditory hairs are implanted in a horse-
shoe-like row on the extremities of the rod cells. They do not
themselves become stained with nitrate of silver, but the point of
their insertion becomes strongly stained. The cone cells are pro-
longed into delicate processes, which are inserted into the phalanges
of the membrana reticularis. The twin cone and rod cell possesses
a single strong basilar process which rises straight up from the
membrana basilaris, and these processes are arranged in three very
regular rows. Between and parallel with these are wavy fibres
belonging to the supporting system, which are in connection with
other similar fibres inside and outside of the tunnel. "Within
Corti's organ he finds two forms of nerve fibres, differing in their
anatomical course, mode of termination and function and these he
terms respectively radial and spiral nerves. The former pass by a
varicose fibre to the inner terminal cells and the cylindrical parts of

1877.] Report on Physiology and Histology. 229

the external rod cells, whilst the spiral nerves end exclusively in the
cone cells, around which they form a close plexus.

8. Mojsisovics, examining by the gold method the snout of the
pig, mole and mouse, finds that the nerves terminate between the
cells of the epidermis, in very fine and varicose extremities. He
regards the],tactile corpuscles as having the special function of
enabling the distance between two points to be distinguished, whilst
the fine extremities enable sensations of contact to be perceived.

9. M. Steiner has proved that the electro-motor force of the nerve
current from 2° upwards is greater the higher the temperature, that
reaches a maximum between 14° and 25°, and at a higher tempera-
tures, increases again. The force of the muscle current is likewise
from 5° upwards greater the higher the temperature. It has its
maximum between 35° and 40°, and at higher temperatures be-
comes less again, till when rigidity sets in it is almost nil. Thus,
for the nerve and muscle current, as well as for the other functions
of living organic forms, there is a temperature optimum which is as
distinctly marked, when by heating we rise to it from lower
temperatures as when we descend to it by cooling from higher
temperatures,

10. Weber-Liel states that his experiments have satisfied him on
the following points : 1. That the aquaductus cochleae in man forms
a connection between the perilymphatic space of the labyrinth and
the arachnoideal space, for if a small quantity of a solution of Prus-
sian blue be introduced into the wide external funnel-shaped aper-
ture of the aquseductus cochlea and suction be made with special
precaution through the superior semicircular canal, the fluid will
enter the perilymphatic space. 2. That the aquaeductus vestibuli
connects the endolymphatic space of the labyrinth with a sac lying
between the lamellsB of the dura mater.

11. Benedikt considers that the great apparent qualitative differ-
ence between the brain of man and carnivora constitutes a great
hiatus in the descendance theory. Neither embryology nor com-
parative anatomy has been able to supply a bridge connecting
these physiologically closely allied families. The main diff'erence
between the frontal portions of the brain of man and of carnivora
is that in the latter there are four, in the former only three primary
convolutions. This diff'erence is, however, only apparent. Every
comparative anatomist knows the small sulci which in man are
situated between the first frontal sulcus and the median border. In
some brains these sulci become greatly developed into a strongly-
marked furrow, which extends to the upper part of the anterior central
lobe. By this means the aspect of this part of the central lobe approxi-
mates to that of Apes. It hence appears that the first frontal con-
volution of man originates from the coalescence of the two first
primary convolutions of the carnivora and that the first undergoes
atrophy. The above-named small sulci should be designated as the
first; the frontal sulcus, now called the first, should be called
the second ; and the second the third. The atrophy of the
first frontal convolution in man probably depends upon the feeble

230 Chronicle of Medical Science. [July?

development of the sense of smell in man. In the parieto-tem-
poral region also of man the four-convolution type is easily demon-
strated. In the Primates the superior and external surface of
the temporo-parietal region is connected with the occipital region
by four more or less well-marked convolutions, but they are very
indistinct at first sight in man. Closer investigatiou, however,
shows that there are two parietal and two temporal lobes, but in man
they are peculiar in running backwards and inwards, instead of
downwards. There is still another point which he considers to be
important, namely, the coalescence of one or more of the three
central longitudinal sulci (E.oiland's, the pre-central and the inter-
parietal) with the fissure of the fossa of Sylvius. Lastly, Benedikt
maintains that the brains of carnivora and other mammals have
well-marked occipital lobes.

Muscles.

K. Katjfmann. — Veber Contraction der Muskelfasen. 'Beichert's
Archiv,' 1874, p. 273. ' Cbl.,' 1876, p. 941.

"W. E. GowERS. — The Automatic Action of the Sphincter Ani. In the
' Proceedings of the Eoyal Society,' No. 179, 1877.

J. Beenstein and J. Steinee. — Ueher die fortpflanzung der Con-
traction und der negativen Schwankung im Saugethiermushel.
Eeichert's Archiv, 1875, p. 526, and Centralblatt, 1876, p. 949.

Kaufmann refers to the three following views on the morphological
changes that take place in muscular fibres during contraction :

1. That of Hensen to the eff'ect that there is shortening in the
longitudinal diameter, with proportionate increase in breadth both of
the anisotropous and of the isotropous substance. (2) That of
Krause, that there is shortening of the longitudinal diameter with
diminution of the thickness of the isotropous substance, whilst the
thickness of the anisotropous substance remains unaltered, and
coincidently an increase in breadth and entrance of muscle com-
partment fluid between the muscle-rods. (3) That of Engelmann,
who admits the entrance of fluid into the longitudinal cylinder.
Kaufmann examined the muscles of the insects named Garahus
nemoralis, Amara apricaria, and Pygoera hucephala with a power of
800 diameters, and found that the muscular fibre of these animals
diminishes in length during contraction whilst it becomes broader ;
the isotropous substance, however, only loses in the direction of the
length of the muscular fibre, whilst the anisotropous substance does
not lose in this direction, or only to so slight an extent as to be im-
measurable. This is essentially in accordance with Krause's view.

Dr. G-ower's observations had for their object the determination
of the form of the reflex or automatic action of the sphincter ani of
man when voluntary power over it is lost. This reflex action is
believed to depend on an anospinal centre (Masius), situated in the
lumbar enlargement of the spinal cord, controlled in health by
higher encephalic centres. The larger number of observations were
made on a man who by a fall had apparently injured the posterior

1877.] Report on Physiology and Histology. 231

roots of all the sacral nerves, and both roots of the lowest sacral
nerves. There was loss of sensation in all the parts supplied by the
above-named branches, but no muscular paralysis or loss of nutrition,
except in the levator ani, the sphincter ani, and sphincter vesicae.
The spinal cord was not affected. In two other cases the patients
were suffering with paraplegia from disease of the spinal cord, and
had entirely lost voluntary control over the sphincter ani. It was
found that in all these cases the condition of the sphincter was
essentially the same, and that it was in a high state of reflex activity.
A small bag of india rubber was introduced into the bowel and con-
nected by a piece of tubing, with a drum and recording lever, as in
Marey's cardiograph. In all the cases, though the incontinence of
faeces was complete, the sphincter was habitually in a continuous,
slightly varying, contraction. Any slight irritation, such as a jet of
air, applied to the mucous membrane of the rectum inhibited this
contraction, but if the irritation was by a solid body there was, in
the first instance, a slight brief increase in the contraction. There
was, in both instances, a latent period, of a little more or less than a
second in duration, intervening between the application of irritation
and the commencement of a change in the contraction. When the
initial rise occurred, it lasted about r5 sec, and this was followed
by the fall lasting 4 sees. Then came a gradual rise, varying in
duration from 10 — 17 sees. This attained or went somewhat beyond
the original pressure, finally returning to the normal. As far as could
be ascertained the internal sphincter was alone concerned. The
action of the sphincter. Dr. Grower thinks, is only a specialised and
concentrated example of the ordinary peristaltic action of the
intestine, which is inhibited by the vagus and intensified by the
splanchnics. The effect, he goes on to observe, of the presence in
the intestine of a mass of faeces would be to cause, first, in the
moderately contracted intestinal wall in front of it an increased con-
traction, the effect of which would be to prevent the diffusion of the
contents along the intestine (which would materially interfere with
their movement) ; secondly, complete relaxation of the next portion
of the intestinal wall, into which the contents of the intestine could
pass ; and, thirdly, a strong contraction behind, sustained and
moving on the stimulating body as the initial contraction gave place
to contraction. The process would doubtless be modified by the con-
traction of the longitudinal fibres of the bowel, which would prevent
undue distension of the relaxed portion, and thus assist the trans-
mission onwards, both of the contents of the bowel and of the
resulting stimulation.

S32 Chronicle of Medical Science. [July,

■REPORT ON TOXICOLOGY, POEENSIC MEDICINE,

AND HYGIENE.

By Benjamin "W. Eichaedson, M.D., E.E.S.

I. — Toxicology.

Poisoning hy Cganide of Potassium. — Dr. Joseph Jones, Professor
of Chemistry and Clinical Medicine in the University of Louisiana,
to whose most able toxicological labours we have so often been in-
debted, records a remarkably characteristic case of poisoning by
potassium cyanide. The facts of the case, as reported to him by
Professor Le Monnier, run as follow : — " On Saturday, the 24th of
March, 1877," says Professor Le Monnier, " a messenger, out of
breath, entered my office, asking for a physician for the Spanish
Consul, who was very ill. In haste we hurried to the Consulship, two
squares distant, where I was told the Consul had taken poison. I sent
for some ipecac, immediately, and proceeded to examine the patient.
I found him in his bed, lying on his back ; respiration deep, difficult,
and slow, with fluttering of the lips, foam at the mouth during
respiration, the tongue once in a while protruding between the lips.
The face was pale; the pupils normal; the temperature below the
normal standard, with a cold clammy skin; pulse at the wrist slow.
The muscles were in a state of complete relaxation. Total absence
of consciousness. Whatever substance had been taken had pene-
trated the nervous system. We tried in vain to rouse him. On his
forehead were two bruises, caused by striking against his chair in
falling. I was then told that he had taken a dose of *' Simmons's
Liver Eegulator " — a tablespoonful or two — and a few minutes after-
wards had dropped. I smelt and tasted the contents of the bottle ;
the smell and taste, though familiar to me, I could not then recall.
In again examining the patient, I detected a strong smell ofprussic
acid in his breath. My diagnosis was now positive.

Cyanide of potassium in great quantity was in the bottle. In
the meantime Dr. Eormento had entered the room. I called his
attention to this fact, and he verified the diagnosis. The ipecac,
arrived (30 grains), which I put in a tumbler of lukewarm water,
and by teaspoonfuls administered it to the patient. By pouring the
draught into his mouth, and placing the hand over it, he would
swallow. The act of deglutition was not under control of the will,
as the patient was unconscious and life fast ebbing away. No effect
from the ipecac. Prognosis — fatal result. I expressed my opinion
to this effect to the surrounding friends, and to satisfy them (for
there was no hope of saving the patient), sent for my stomach-pump
and the antidote for cyanide of potassium. I expressed the opinion
that the man would be dead before their arrival. The pulse soon
disappeared at the wrist, and the man died, without a struggle or

1877.] Report on Toxicology ^ Forensic Medicine^ ^c, 233

moan, before the arrival of the stomach-pump. Besume. — Keached
the bedside of the patient at about 12.10. At 20 minutes to 1 p.m.
he was dead, from having taken, at about 12, a tablespoonful or two
of a bottle of " Simmons' Liver Eegulator," containing an unknown
but large quantity of cyanide of potassium. When I reached \iis
bedside, he was already unconscious."

Erom further observations on this case by Dr. Jones, it appears
that the deceased Consul, at half-past 11 o'clock, after his break-
fast at a restaurant, returned to his residence on Dauphine Street,
and retired to his bedroom with one of his friends, J. A. Bousquet.
After a few moments' conversation, he remarked to Mr. Bousquet
that he had taken poison. Hardly had he uttered the words when
he fell senseless. Mr. Bousquet, Signer Eafart, Vice-consul, and
Mr. Samuel Eusch, the Clerk at the Consulate, used every effort in
their power to revive him, but failed.

In the meantime, Drs. Le Monnier and Formento were sum-
moned. The verdict of the jury was death by suicide. The post-
mortem appearances are thus described by Dr. Jones :

" The brain was greatly congested, but was healthy through all its
textures. The brain exhaled prussic acid. The blood of the brain
upon analysis yielded prussic acid and cyanide of potassium.

" The liver was greatly congested with blood, exhaled prussic acid,
and upon analysis yielded prussic acid. Both the outer and inner
surfaces of the stomach were congested with blood. The mucous
membrane presented a deep scarlet, ecchymosed appearance, and was
softened and eroded, apparently by the action (post mortem) of the
gastric juice.

" The stomach contained about ten ounces of partially digested
matters, which exaled a powerful and sickening odour of prussic acid.
Chemical analysis revealed the presence of the cyanide and of
prussic acid in the contents of the stomach.

" The blood from all the organs examined gave out prussic acid
and yielded it upon analysis ; and although dark coloured when first
^..fia^psed, changed rapidly to the arterial hue. The coagulating
^" power of the blood was entirely destroyed.

" The bottle, labelled ' Simmons' Eegulator,' from which the
deceased is said to Have taken the fatal dose, contained eight and a
half fluid ounces of a dark-red liquid, which upon analysis contained
904-4 grains of cyanide of potassium. Each fluid drachm contained
13*3 grains of the cyanide of potassium.

" The entire capacity of the bottle was ten fluid ounces ; there-
fore one and a half fluid ounces were missing. It is not probable
that the deceased took the entire amount, as he is said to have been
in the habit of taking one or two tablespoonfuls of the ' Simmons'
Liver Eegulator ' a short time after each meal. It is probable that
he took about two tablespoonfuls of the poisonous mixture, which
would yield 1064 (one hundred and six grains and four tenths) of
the cyanide of potassium — a quantity sufficient to have destroyed at
least 21 (twenty. one) men. The entire amount of cyanide of
potassium originally introduced into the bottle was about 1110 (one

234 Chronicle of Medical Science. [July,

thousand one hundred and ten) grains, a quantity sufficient to have
destroyed 221 men, if the fatal dose be placed at 5 grains.

" I administered 20 minims of the liquid from the bottle, which
had caused the death of the Spanish Consul, to a dog, and symptoms
of poisoning commenced iu 20 seconds ; in 30 seconds, violent spasms
with a long piercing cry were emitted by the dog ; coma, preceded
by a prolonged spasm of muscles of the back, was established in 60
seconds after the administration of the poison, and death occurred
in 100 seconds. The body of the dog was perfectly relaxed and
flacid for 30 seconds before the extinction of the pulsations of the
heart and the cessation of the spasmodic respiration.

" The post-mortem examination revealed congestion of the brain
and internal organs, and distension of the cavities of the heart by
black blood.

" A strong odour of prussic acid was exhaled from the breath of the
dog during life, and from the blood and from all the organs and
tissues after death."

After narrating a long series of experiments, Dr. Jones draws
the following general conclusions as to the nature of the effects of
cyanide of potassium and hydrocyanic acid.

1. After the introduction of cyanide of potassium and prussic
acid into the subsutaneous tissue, or after their application to the
tongue and mucous membrane, a certain period of time elapses
before the manifestation of symptoms of poisoning ; and during tliis
period the poison is absorbed, mingles with the blood, and is dis-
tributed to the various organs and tissues, and is thus brought into
contact with the ganglionic cells of the cerebro-spinal system.

Various statements have been made as to the rapidity of the
effects of prussic acid and cyanide of potassium in producing poison-
ous symptoms and destroying life, which have not been sustained by
my experiments.

In the most suddenly fatal cases, the action has been referred by
some physiologists to nervous action, transmitted from the points at
which the poison touched the extremities of the nerves. The incor-
rectness of this view has been shown by experiments similar to the
following by Blake. The portal vessels of an animal being tied,
seven fluid drachms of Scheele's Acid were introduced into the
stomach on the sentient extremities of the nerves on which the poison
is said to act. Ten minutes elapsed without the slightest effect ; the
ligature was removed, and one minute afterwards the effects of the
poison manifested themselves.

It is evident that those who give this explanation of the sudden
effects of prussic acid, leave entirely out of view the fact that hydro-
cyanic is highly volatile, and that if a drop of the pure acid be
approached towards the tongue of a living animal, the acid evaporates
and reaches the lungs by inhalation, and is immediately diffused
over an immense absorbent surface, before the drop of acid actually
reaches the mucous membrane of the mouth. It is well known that
prussic acid is most rapidly fatal in the form of vapour. I have been,
upon more than one occasion, most seriously affected by the vapours

1877.] Report on Toxicology, Forensic Medicine, ^c. 235

of the acid during my experiments and post-mortem examinations.
The time of the action of this poison should be reckoned from the
moment that its vapour reaches the capillaries of the lungs ; and the
place of action should be considered the extensive absorbent surface
of the bronchial tubes and air-cells. Now it is well established that
the poison may reach the heart and cerebro-spinal and sympathetic
systems, in an almost inconceivable short space of time, from the^
lungs. That a sufficient interval elapses between the application of
the acid, and the moment when its first effects are produced, to
allow of its being brought into contact with the central ganglionic
masses, will be evident from the consideration of the following
facts :

Haller and Sauvages were the first to ascertain, by experiment,
with what velocity the blood is carried through the vascular system ;
their calculations, however, were erroneous, as they were founded on
the supposition that the movements of the blood depended exclu-
sively upon the action of the heart. Haller's conclusions respecting
the velocity of the circulation in frogs and small fish are more
correct, as they were confirmed by autopsies, but his observations
were confined to cold-blooded animals, and it is scarcely necessary
to mention how hazardous it would be to infer from them the
velocity of the blood in warm-blooded animals.

The same remark applies to the experiments of Spallanzani and
Dollinger.

In more recent works on the subject, the comparison of the
quantity of blood contained in the ventricles of the heart, with the
whole mass of the blood, and with the number of pulsations in a
certain time, was considered sufficient to determine the relative
velocity of the blood ; a method the uncertainty of which appears
from the circumstances, that the quantity of blood cannot be made
out with precision, and that the number of pulsations and the
capacity of the ventricles difier very considerably in diff'erent indi-
viduals. M. Herring, of Stuttgart, found the capacity of the left
ventricle in horses differing from 3 to 11 ounces, and that of the
right ventricle from 4 to 38 ounces.

M. Herring tried another method, which seems to lead to more
accurate results. He mixed a solution of the cyanide of potassium
with the, blood ; he then took, at certain intervals, small quantities
of blood from various parts of the body ; and from the chemical
examination of these different portions of blood, and from the com-
parison of the time which the substance required to arrive from one
vessel into, another, endeavoured to ascertain the relative velocity of
the blood.

The experiments were performed upon horses, and the following
conclusions were established : —

a. The time within which the cyanide of potassium, after having
been mixed with the blood, passes from one of the jugular veins
into the opposite, is from twenty to thirty seconds ; into the saphena
magna, twenty seconds ; into the arteria mesenterica, fifteen to
thirty seconds ; into the arteria maxilla externa of the opposite

236 Chronicle of Medical Science, [JulVj

side, from ten to twenty-five seconds ; and into the arteria metatarsi,
from twenty to forty seconds.

h. The cyanide of potassium, within a very short time after its
introduction into the blood, is excreted by the serous membranes, but
in small quantity. The time varies from two to eight minutes.

c. In the kidneys the excretion appears to take place with the
greatest rapidity ; in all experiments, within one minute after the
introduction into the blood, the cyanide of potassium was found in
the cortical, sometimes also in the tubular substance, and in a few
instances in the pelvis of the kidneys.

d. Only one minute is required to bring the substance from the
jugular vein into the thoracic duct.

2. Cyanide of potassium and prussic acid produce no absolutely
uniform alterations in the circulation of the cerebro-spinal system
reconisable after death ; and tlie cerebral and reflex symptoms are
not due to the engorgement of the vessels. In some cases, the
brain was not at all congested ; in others the veins were distended
with blood ; and the blood after 15 hours showed a great tendency
to transude through the coats of the vessels, from its disorganization,
and thus inducing a much greater appearance of congestion and
irritation than actually existed at the moment of death.

The symtoms of cerebral disturbance — delirium, coma, expansion
of the pupil — were as strongly marked in the cases in which the
brain was not specially congested as in the cases in which it was
most congested. Independent of these facts, it is evident that the
mere state of engorgement of the blood-vessels could not produce
death in so short a time. In some cases the spinal cord was not
specially congested ; in others the veins were distended with blood ;
and in others still, both the veins and arteries were filled with blood ;
Violent spasms, opisthotonos, and all the phenomena of aberrated
spinal action, were as well marked in one condition of the spinal
cord as in the other. We are compelled from these facts to con-
clude that cyanide of potassium and hydrocyanic acid produce no
absolute uniform alterations in the circulation of the spinal cord
recognisable after death ; and that the aberrated muscular actions
are not due to the engorgement of the blood-vessels of the spinal
cord and its membranes. Independently of the fact stated above, it
is evident the mere state of engorgement of the vessels of the spine
could not produce death in so short a time. Careful microscopical
examinations did not reveal any uniform alterations in the nervous
elements.

3. The peculiar phenomena manifested by the cerebro-spinal
nervous system, in poisoning by cyanide of potassium and hydro-
cyanic acid, are due to the action of the poison on the nervous
elements, conveyed to them by the blood ; to the action of the
altered blood on the nervous elements, and sudden arrest of the
capillary circulation of the cerebro-spinal nerves, in consequence of
the action of the poison on the sympathetic system and muscles and
ganglia of the heart ; to the reflex action of the sympathetic system,

i^77.] Report on Toxicology^ Forensic Medicine, ^c. &37

and to the complicated actions and reactions of the poison in the
individual structures.

4. In poisoning by cyanide of potassium and prussic acid, the dis-
turbances of the sympathetic nervous system are not less marked
than those of the cerebro-spinal nervous system. The slow, full
respiration, the slow action of the heart in some cases, and its feeble,
rapid action in others ; the feeble pulse, the diminution of tempera-
ture in the extremities, the rise of temperature in the trunk before
death during the first stages of the action of the poison ; the sub-
sequent fall in the temperature of the trunk before death in some
cases ; the accumulation of the blood iu the large veins of all the
organs and tissues, in most cases of poisoning by hydrocyanic acid ;
the engorgement of the veins of the stomach, small intestines,
spleen, liver, and kidneys ; the suppression of urine in some cases —
all point to aberrated nervous action of the sympathetic system.

The mere congestion of the blood-vessels of the sympathetic
nervous system could not account for any of these phenomena ; in
fact, if the sympathetic nervous system presides more especially over
the circulation, the stagnation of the blood in the vessels of the
sympathetic, and in fact, in the blood-vessels of the cerebro-spinal
nervous system, and of all the organs and tissues, is evidently the
effect, rather than the cause, of the aberrated sympathetic nervous
phenomena.

Erom these facts, it appears to be proper to conclude that the
aberrated nervous phenomena of the sympathetic system are due to
the direct action of the poison, conveyed in the blood, on the gang-
lionic cells of the sympathetic; to the action of the altered blood on
the same elements, to the congestion of the blood-vessels of the
sympathetic ; and to the reflex action of the cerebro-spinal system.

If the disturbances in the action of the sympathetic nervous
system do not precede, they are certainly coeval with those of the
cerebro-spinal system ; and are in both systems manifested precisely
at the moment when the blood containing the poison reaches the
nervous elements.

The arrest of the action of the heart, and of the peristaltic motions
of the intestines, must be referred to the direct action of the poison
on the sympathetic ganglia, and to the action of the poison on the
nnstriped muscular fibre.

5. Cyanide of potassium and prussic acid act on both the volun-
tary and involuntary muscles, and decrease or arrest entirely their
property of contractility ; and after death from these poisons, in
many cases, it is impossible to excite contraction of the muscular
fibres of the heart by mechanical or electrical stimuli.

6. The blood is altered ; its colour is changed, as if prussic acid
had entered into combination with the colouring matter ; in most
cases it coagulates imperfectly, and in some not at all.

7. Cyanide of potassium and hydrocyanic acid produce eff'ects on
all the organs and tissues with which they are brought into contact •
hence we cannot affirm that their action is confined exclusively to the
nervous system; and more especially would it be impossible to

238

Chronicle of Medical Science.

[July,

affirm that the action is confined either to the cerebro-spinal or
sympathetic nervous system, or that the primary action is on one or
the other. Cyanide of potassium and prussic acid induce alterations
in the constitution of the blood, and through this medium afi'ect all
the organs and tissues. We have established also that these and
other poisons act on vegetables, which are destitute of nerves, and
hence we may conclude that they are capable of acting on all the indi-
vidual cells of the living animal." — Beprint from the New Orleans
Medical and Surgical Journal^ May, 1877.

II. — Forensic Medicine.

On the Influence of the Seasons on Suicide. — Mr. Vincent E-ichards
reports that, in 1875, it was brought casually under his notice, by
native Doctor Q-opaul Chundra G-angooly, that suicides were of
much more frequent occurrence in the subdivision of Goalundo
during the hot months than at any other time of the year. On
making enquiries he found that such was the case in the subdivision
of Kooshteah also.

The following table gives the number of suicides, month by month,
for five and four years respectively :

Months.

Goalundo.

Kooshteah.

Total

January

February

March

April

May

June

July

August

September

October .

November

December

Total

. 87

112

Mr. Bichards was so impressed by the above fact that he noticed
it in his Annual Eeport in 1875. In an article on " Suicide in
France," in the * Saturday Eeview ' of a month or two since, he read
the following passage, which seems to confirm his view, that the hot
season has a marked influence on the suicidal impulse : " Inquiring
next into the influence of the seasons, we are prepared to find that it
is great, for every one is aware how profoundly the weather afiects his
own health, spirits, and general enjoyment of life. But we naturally
expected that it is in winter, when the days are short and the nights
long and cold, when rain and snow and frost intensify the suff'erings
of the poor ; when employment is scarcest, and necessities most
pressing, and when out-of-door life is not post«ible to many, that
suicide should be most prevalent. The very contrary is, neverthe-
less, the case. The proportion of the suicides in the first quarter of
the year is about 22*1 per cent,, in the second quarter 30*8 per
cent., in the third 27*1 per cent;, and in the last only 20 per cent.

1877.] Report on Toxicology, Forensic Medicine^ ^c, 239

Thus, in the six comparatively warm months, about 58 per cent, of
all the suicides occur ; May, June, and July, exceed any other three
months, June standing at the head of all. The mania increases, in
fact, up to midsummer, and then somewhat more rapidly decreases,
December having the fewest suicides as June has the most."
Through the courtesy of Dr. Mountain, Civil Medical Officer of
Bancoorah, Mr. Eichards obtained the following details regarding
deaths from suicide in that district :

Months.

Number of Suicides

Months.

Number of Suicides

January

July .

February

August

March .

September .

April

October

May .

November .

June

December .

Total

If we compare the above data we shall find that the months of
March, April, May, June, and July, are those in which the very
great majority of suicides occur. Thus, in Goalundo and Koosh-
teah during these months, 63'39 per cent, of the total number
occurred, and in Bancoorah 63"I5 per cent. Now, as to the reason,
the ' Saturday Eeview ' says : " What the reason of this should be
we cannot even conjecture. M. de Foville puts forward a fanciful
suggestion that, as the season of flowers is the most delightful to
the happy, it aggravates the wretchedness of the miserable." Apart
from the " fanciful " nature of the suggestion, M. de Eoville evi-
dently presupposes that the majority of suicides are the outcome
of deliberation consequent on mental despondency. If such were
the case, we should expect to find suicides more common in the cold
weather, when, as the ' Saturday Eeview ' says, " The days are
short and the nights long and cold ; when rains and snow and frost
intensify the sufi'erings of the poor ; when employment is scarcest,
and necessities are most pressing, &c." But the very great majority
of suicides are committed — no matter what the immediate cause
may be — during a state of mental excitement ; in fact, impulsively,
when the nerves are, so to speak, strung to the highest pitch of
irritability ; even those of the most phlegmatic temperament must
have experienced the comparatively irritating efiect of the hot
weather months. The reason, therefore, that impulsive suicide — as
distinct from premediated — is so greatly influenced by the hot
season in India, seems pretty obvious. Moreover, when we bear in
mind what impulsive, nervous creatures natives are, especially
women, who contribute so largely to the crime in this country, we
shall at once understand how it is that this influence is so much
more pronounced in their case than in the case of Europeans. Mr.
Richards has no doubt that an examination of the returns of suicide
in the United Kingdom would elicit the fact that this seasonal in-
fluence is less marked amongst Englishmen, and, perhaps, still less
so amongst Scotchmen. The subject is pregnant with interest, and

240 Chronicle of Medical Science, [July,

would repay investigation by any one who had the necessary mate-
rials at his command. He merely draws attention to it, in the hope
that some one with better opportunities will do it justice.

Drs. Sandiford and Davis furnished Mr. Eichards with the fol-
lowing information pertaining to the districts of Bogra and Pubna,
respectively. Of the 105 suicides which came to the notice of the
medical officer in six years, in the district of Bogra, 15 (1429 per
cent.) occurred in the first quarter of the year, 32 (3048 per cent.)
in the second quarter, 28 (26*66 per cent.) in the third, and 30
(28*57 per cent.) in the fourth. Of the 211 suicides, which came
to the notice of the medical officer in ten years, in the district of
Pubna, 48 (22-75 per cent.) occurred in the first quarter of the year,
64 (3033 per cent.) in the second quarter, 47 (22-28 per cent.) in
the third, and 52 (24*64 per cent.) in the last. In the former dis-
trict most suicides were reported to have occurred in the months of
June, July, and October, and in the latter, during May, June, and
December. It will be observed that, notwithstanding the variation
in respect to October and December, the statement that suicides
are more frequent in the hot months than in the cold, is again con-
firmed by the above data, though in a minor degree, apparently, in
the district of Pubna. Tables showing the daily range of tempera-
ture and reported suicides in each district, would be very interesting.
The temperature here has become suddenly higher during the past
two or three days, and two suicides have been reported in that time,
whereas there had been only two cases during the previous three
months and none for about a month and a half.

Dr. Davis has since sent Mr. Richards the following, which shows
the number of suicides for each month during the past four years, as
furnished hy the Police : —

January

July .

February

August

March .

September .

April .

October

May .

November .

June

December .

The influence of the seasons is here strikingly illustrated. — {Indian
Medical Gazette, April 2, 1877.)

Post-Mortem Appearances in Death hy Hanging. — Dr. Eobert
Harvey supplies an analysis of these signs, as there is still apparent a
tendency to rely unduly on particular signs which are not of neces-
sity conclusive, and are thus apt to mislead. Dr. Harvey's con-
clusions are derived from the medico-legal returns received from
the civil surgeons in the Bengal Presidency during the years 1870,
1871, and 1872. So many facts for analysis have never before been
collected, and they are of such extreme value that we give the
analysis at length.

(a) General appearance of the body. — This varies greatly with the
period that has elapsed since death, and there is no point on which

1877.] Report on Toxicology, Forensic Medicine, ^c. 241

medical jurists have been more divided in opinion. The true ^tata
of the case seems to be that, in the majority of instances, immedi-
diatelj after death, the features are placid, the face pale, the eyes
not unduly prominent, the mouth closed or half open, the tongue
pressed against the teeth, but not protruded, the superficial veins
full, but the head, neck, and trunk free from lividity. After a longer
or shorter time, however, and apparently after a few hours, in India,
all this is changed. Livid patches appear about the phest, back,
and shoulders ; the face and head become bloated and puffy ; the
tongue and eyes protrude ; and decomposition, setting in early, is
most marked in the upper part of the body, which is gorged with
stagnant blood. In most of the cases the body had not arrived at
the dead-house till these changes had taken place ; but the
above statement is based on a careful analysis of 63 cases where
the body is stated to have been fresh, and the particular points
which justify it are as follows : — The face is noted as placid 25 times,
livid 5; eyes natural 12, injected 7 ; mouth closed 23, open 5, half
open 4 ; tongue not protruded 23, protruded or partly protruded
11 ; veins gorged 12 ; livid patches absent 5, present 3.

In 297 cases the body was more or less decomposed ; in the
remainder its condition is not stated.

(b) Mark of the ligature. — This was distinct and well-marked in
1162, indistinct or absent in 99 cases, and in the others it is not
mentioned. It is noticed as ecchymosed in 165, and not echymosed
in 37 cases. Its appearance is described as depressed in 280,
parchment-like, tough, or leathery in 198, with or without ecchy-
mosed or livid edges. A blistered mark is noted 7 times, and a hard,
white, shining translucent band, from compression of the cellular
tissue, 30 times. This is the first stage of the vellum or parchment-
like appearance, and is chiefly noticed in fresh bodies. The mark
was abraded 109 times, and smooth 11 times, the suspending agent
being a soft cloth in 8 of these. In shape and dimensions it gene-
rally corresponded with the agent used, being narrow and well-
defined when a rope, broader and more irregular when a soft ligature,
was employed. Exceptions were, however, met with. Casper's
observations and experiments led him to the conclusion that " any
lig;ature by which any body may be suspended or strangled, not only
within a few hours, hut even dags after death, especially if the body
be forcibly pulled downwards, may produce a mark precisely
similar to that observed in most of those hanged while alive;" and
though few authorities go so far as this, the great weight of Casper's
testimony cannot be disregarded. His further conclusion, that
" the mark of the cord is a purely cadaveric phenomenon," seems
inconsistent with the fact that the characteristic mark is sometimes
found in non-fatal cases, though he himself had not observed it.
In eight instances in the present returns there was a " distinct"
mark ; in one at Q-auhati, where the patient was discharged from

119--LX. 16

242 Chronicle of Medical Science, [July,

hospital in a few days, Dr. Curran remarks that " the mark lasted
a long time."

(c) Protrusion of the tongue is noted in 243 cases, while in 69 it
is especially stated that the tongue did not protrude. It was
most commonly found swollen, pressed against the teeth and in-
dented by them^ or partially pushed between them and bitten, its
complete extrusion being rare, exept in putrid bodies.

{d) Marks of saliva running in straight lines down the chin and
chest are noticed a few times, but do not seem to be often looked
for. The sign (which Dr. Hutchison, of Patna, who first called
attention to it, invariably found, and which the writer has seen in
the only two hanged bodies he has examined in India) is a valuable
one, as indicating, in fresh bodies at all events, suspension during
life ; and if further experience proves that it is generally present,
as seems probable, it will be an important help in doubtful cases.

(e) Discharges (a) in the male. — Semen or mucus was observed
on the clothes in 46 inf*tances, and is noted as absent in 22 ; urine
was found twice, and blood from the urethra four times. The penis
is noted as erected in 5 cases, 3 of them from Nator, but any
priapism which may have existed at the moment of death had com-
monly passed away before examination. In a case at !Faridpur,
where this phenomenon is described in a highly decomposed body,
the erection must have been due to gaseous distension. (5) In the
female. — The genitals were found congested in 24 cases. A mucous
discharge from the vagina was observed in 22, and a flow of blood in
9 cases. Faeces were found on the clothes or about the anus 62
times, but it is probable that all these signs would be found more
frequently if looked for, although they are of no great value when
found. In a case by Mr. E, C. Bensley, in the Enjshahai return for
January, 1870, stains and clots of blood about the perineum and
anus proved to have come from some internal piles which had burst.

(y) Condition of the brain and its membranes. — One or both of
these are described as congested in 490 cases, and natural in only
21. In the remainder the skull was not opened, or the state of its
contents is not mentioned. Serum, plain or bloody, was effused into
the lateral ventricles eighty-five times, into the arachnoid twenty-
one times, and at the base three times ; while in 23 instances, op
nearly 4| per cent, of the cases where the state of the brain is
mentioned, blood was eff'used in or about it— a much larger propor-
tion than has ever been observed in Europe. It is curious, too,
that 12 of the cases occur among 151 reported from Dacca, and 9 of
these among 47 in the year 1870. The lungs were congested in all
but one. In 9 both sides of the heart contained blood, while in 2
only the right side alone was distended. It was empty in 6, but 3
of these bodies were putrid.

Blood had flowed from the ear in 6 instances ; but details are
wanting.

{g) Injuries of the cervical vertebrae and ligaments are rare.^

* So rare that Taylor — speaking: of fracture of the spine in hanging — remarks
(in his last Edition, p. 667) • — " So far as I am aware there is no case of suicide

1877.] Report on Toxicology ^ Forensic Medicine, S^c. 243

Hupture of the transverse ligament of the atlas was noted by-
Native Doctor Fatteh Ali^ of (ioalpara, in September, 1870. The
subject hung herself with a twisted cloth.

Dislocation ofvertehrcB. — No. 1, reported by Honorary Surgeon-
Major R. r. Thompson, Civil Surgeon of Hiighli.

Subject, a Mussulman, aged 39. "Distinct mark of a cord
around the neck ; no other marks of violence. Laceration of the
larynx and dislocation of odontoid process."

Reported by Mr. W. J. Ellis, Civil Surgeon of Harairpiir.

Subject, a male Hindu, aged 70. '* Mark of a cord round the
neck, superficial in frout, deep beliind. Second cervical vertebra
dislocated,"

Reported by Surgeon H. G. Hall in the Baital (CP.) return for
May, 1872.

Subject, a Hindu female, aged 22. *' The loop was placed between
left mastoid process and ear, and was so tightened as almost to cause
the head to rest directly on the shoulders j odontoid process dis-
located."

J:}y the same officer in the return for November, 1872.

Subject, a Gcudi, aged 20, " A deeply contused wound caused by
a rope which was tightly fastened round the neck ; knot in front of
angle of inferior maxilla on right side. Axis dislocated from atlas."

Fractures, — Two cases of fracture of the odontoid process in
bodies examined on the same day are given in a return for Septem-
ber, 1871. The post-mortems were made by a hospital assistant in
the absence of the Civil Surgeon, who has confidently informed the
writer that he considers the cases very doubtful and untrustworthy.

Reported by Surgeon E. B. Gardner in the Jhilum return for
April, 1872.

Subject, a Khatri, age and sex not given. " Found hanging on a
tree ; usual sigrs ; odontoid fracturtd. Rope, in double noose
without knot, a common dooree, such as is ut-ed for drawing water."

(/i) Appearances in the laryna; and trachea. — More or less of
congestion, varying from a slightly heightened pinkishness to a deep
j)lum-coloured injection, was noted in 303 of 401 cases in which the
condition of the windpipe is mentioned. As the windpipe is the
jirst organ affected by putrefaction, and is often found of a dull brick
or cinnabar-red colour when the rest of the body is almost quite
fcesh {Casper), it is probable that in some of the cases the appearance
was due to decomposition. In 47 the mucous membrane was natural
or pale. Frothy fluid, often tinged with blood, was noticed 93
times. Prominence of the follicles, with exudation of a gelatinous
mucus from them, is noted a few times. The trachea is described aa
compressed 23 times, and lacerated 11 times ; in two instances the
cartilages of the larynx were separated by the cord pressing on the
crico-thyroid membrane, and in cases at Dehra Ismail Khan and
Maldah the os hyoides was fractured. In five cases fractures were

on record in which such an injury to the neck has been found ;" and Chevers
(p. 611) says " fracture or lateral dislocation of the vertebral bones appears to
atford certain evidence of homicide."

244) Chronicle of Medical Science, \i\\\y,

found in the cartilages of the larynx, but there is nothing to show-
how this accident is conditioned. Extravasation of blood into the
cellular tissue of the neck and about the larynx is specified 43 times :
the blood was for the most part in soft clots, but in a few instances
it was fluid. In one of the Puri cases it had been poured into the
thyroid gland.

(i) Appearances in the lungs. — In 738 of 834 cases the lungs
were found congested, in 77 they w^ere natural, and in 19 collapsed.
Kupture of the superficial air-cells is noted in a few cases, and the
lungs were mottled with spots of sub-pleural ecchymosis in a few
more. Surgeon-Major C. T. Paske gives a curious case in the
Mirzapur return for August, 1872. The body of a woman, aged 27,
was so decomposed that a minute examination was impossible, but a
distinct rope mark, with extravasated blood beneath, was found on
the neck ; the tongue protruded and reddish froth issued from the nose.

'* Left lung ruptured posteriorly, with considerable extravasation
of blood in left pleura ; no external marks of violence could be dis-
covered ; stomach empty ; womb unimpregnated. Cause of death
hanging. The rupture of the lung must have arisen, I think, from
intense sudden congestion of the part."

The result of the case is not mentioned.

Condition of

Cases of

Hanging.

Cases of Strangling.

Pericardium.

No.

p. c.

No. p. c.

Empty

26-52

3 9.37

Plain Serum'

54-54

7 21-88

Reddish „ .

5.30

2 6-25

Bloody „ .
Blood

1 13-64

^l } 62-50

132

100-00

32 10000

(Jc) Appearances in the pericardium and heart. — In several of
the hanging cases w here bloody serum was present, there are indica-
tions, from the position of the ligature, that death was slow, the
supply of air being only partially cut off.

It must be admitted that bloody serum may be found in the
pericardium of a fresh body dead of suicidal hanging, although it is
no doubt rare.

In strangulation, on the other hand, it is very common. Mr.
Stewart found it in every one of "five suspected cases in which
evidence afterwards more or less showed that violence was the cause
of death."

The conditions of the heart is mentioned 626 times. In 320 the
right side was gorged, and the left almost or altogether empty. In
121 cases both sides were pretty equally distended, in 15 the leftside
alone contained blood, and in 179 both sides were empty. A
careful analysis of these cases has been made, but is of little value,
as the period between death and examination is very seldom men-
tioned. The main points seem to be — 1st, that in a large propor-
tion of the cases, especially if the body be fresh, the right side of
the heart, pulmonary artery, and venae cavse are distended with dark

^ Includes cases where the pericardial fluid is not described iu detail.

1877.] Report on Toxicology, Forensic Medicine j ^c. 245

fluid blood. In most of these cases the lungs are much congested,
and the signs of death by apnoea are well marked ; 2nd, that in a
considerable number both sides of the heart contained blood. In
some of these death has been slow, and the blood in the left heart is
found in addition to the ordinary. In others — and they are more
numerous than is commonly supposed — the appearances are purely
negative ; the brain, lungs, trachea, and larynx are perfectly natural,
as well as the heart, aud the conclusion that death has been caused
by hanging rests on the history of the case, the rope mark, and the
absence of any other cause of death. In such cases, Casper consi-
ders that death is due to neuro-paralysis or nervous apoplexy, such
as sometimes occurs after blows on the stomach affecting the solar
plexus ; 3rd, that when decomposition has advanced all the cavities
are very often empty ; and 4th, that in a small proportion of cases
(about 2i per cent, in the present returns) the left side only may
contain blood, the right being completely emptied by contrac-
tion after respiration has ceased (?). In 11 of the 15 cases
where blood was confined to the left side the lungs were much
congested ; this condition is not stated in 4. One was examined
thirty-three hours after death. Eighty-one of the 170 subjects in
which the heart was empty, are expressly stated to have been
decomposed, and Dr. Irving, of Allahabad, remarks, with reference
to such a body, that " if the post-mortem had been held sooner fluid
blood would most likely have been found in the right side of the
heart."

(Z) Appearances in the abdominal viscera. — The stomach was
found congested in 111, natural in 127 cases. The bowels were
congested 177, natural 142 times, but this includes a number of cases
where intestinal disease was the motive to suicide. The liver was
congested 155, natural 161 times. Kidneys congested 191, natural
55 times. The only point of much importance is the congestion of
the stomach, which might, and in one instance did, lead to suspicion
of poison.

The above analyses, imperfect as they are, amply prove, if proof
were needed, that there is no one sij^u which, taken by itself, can
justify an opinion that death was caused by hanging, and point to
the necessity of a careful examination in every case. Each sign,
though of comparatively little weight by itself, is strengthened by,
and strengthens every other sign. — Ibid, Feb. 1st, 1876.

III. — Hygie:n^e.
Belations of Fain to Weather.— Dr. Weir Mitchell, of Philadelphia,
with his usual original spirit of research, addresses his investigations
to this singularly interesting subject. He sets forth by stating the
long accepted fact that under certain states or changes of weather
there is return of pain in cases of old wounds, injuries and diseases
of bones, chronic rheumatisms, and the like, in the year 1872,
when writing his book on injuries of nerves and their consequences,
he had occasion to study the many curious symptoms of pain in the
the stumps of amputated limbs, and was struck with the number

246 Chronicle of Medical Science. [J»^y»

of person8 who stated that their comfort depended largely on the
state of the weather. The difficulties of getting reliable informa-
for precise scientific record were, Dr. Mitchell founds very great. At
last he was fortunate to find one who was a sufferer, and who, by his
intelligent observations, extending over three years, enabled Dr,
Mitchell to arrive at some correct and most interesting facts. The
gentleman to whom he was thus indebted is Captain Catlin, a
captain in the United States Army, aged 35, who in August, 1864,
at the Waldon Kailroad had his foot crushed by a twelve pound
round shot. The wound healed readily, but there was frequent
recurrence of pain in it, which has continued ever since. When
seen by our auihor in December, 1874, the pain was said to be in
the metacarpo-phalangeal articulation of the great toe, and some-
times tlirough all the toes, with more or less the sense of twitching.
The attacks are preceded by a tendency to sleep. After describing
the symptoms more minutely, Dr. Mitchell proceeds to explain
the accurate series of observations which his patient carried out
bearing on the variations of weather and the recurrence of pain.
The conclusions arrived at are ultimately stated as follows : —

" The relations of pain to the states of atmospheric pressure are
in this case apparently definite and nearly constant.

•'Thus we find that when the atmospheric pressure lessening, the
mercury falls, there is apt to occur during the fall, and before it is
complete, an attack of neuralgic pain or of burning in the lost foot,
and that this is most likely to take place when the lessening pressure
culminates in rain. In some months, as in September and October,
1875, this is most constant, indeed almost invariable, so that, at all
events in the present case, a falling barometer followed by rain as a
rule insures an onset of pain."

In summing up the author adds: — "The human economy is
arranged by nature to have, as it were, a climate of its own, with
very permanent states as to temperature, humidity, electric condi-
tions, and the like ; but all of these are subject to variations, some
of them natural, and, so to speak, rhythmic and chronal : others
more or less irregular. As they are part of the functional activities
of the body, so do they, of necessity, enter into every consideration
of the causation of pain.

" While, however, we may feel sure that they are thus active, their
precise relations to the existence or to the favouring of the birth of
pain are too uncertain for us to do more than surmise that they
sometimes obscure or interfere with or prevent the positive eflTects
of external climatic states in this direction.

"Any lowering cause, such as dyspepsia, overwork, anaemia, however
brought about, is apt to increase this sensitiveness to barometric
changes ; and so every enfeebling agency, as it were, tunes a man's
nerves up to the capacity of producing pain, when once there exists
a permanent cause in the way of neural disease. As an illustration,
I know of an officer who is the subject of stump-neuralgia, which is
very prone to show when a storm is imminent, but the liability is at
the maximum in the spring and fall, when he prone to feel the de-

1877.] Report on Toxicology, Forensic Medicine , ^c. 247

pressing influence of an old ague-poisoning, and when this is
mastered the weather loses its influence.

"A large number of neuralgic attacks seems to be definitely related
to those perturbations of atmospheres, which we know as storms.

"The separate factors of storms, such as lessened pressure, rising
temperature, greater humidity, winds, appear, as a rule, to be
incompetent, when acting singly, to give rise to attacks of pain.
Either, then, it is the combination which works the mischief, or
else there is, in times of storms, some as yet unknown agency pro-
ductive of evil. Such an agent may be either electricity or
magnetism.

" As concerns the former, we have failed to study its relations to
pain, because of difficulties as to instruments and methods of
research, difficulties which may, I trust, be overcome. Neither, as
1 said, have any observations been made as yet as to the influence
of magnetism for want of proper instruments; and this is the more
to be regretted because of the following facts. In 1867 and 1868,
the aurora borealis was frequent and remarkably brilliant, and
Captain Catlin then had it most forcibly called to his attention that
the neuralgia was apt to prevail when the northern lights were
intense. This may be due to magnetic or electric disturbance, but
it may also be owing to the fact that an intense aurora is apt to be
followed by a storm, indeed, is almost sure to be, if we may trust
the recent observations of Lieutenant Weyprecht of the Austrian
Polar Expedition ; also, it is a common belief among our Northern
Indian tribes. The pain, then, which followed the northern light
may be merely an ordinary storm pain ; but the question deserves
a more exact answer.

" There seems, then, to be every reason to believe that the popular
view which relates some pain fits to storms has a distinct foundation,
and, as we have seen, it has stood the test in this single case of a
long and patient scientific study. At the same time we have failed
to detect the single element of mischief, and are thus far driven to
believe that it is the combination of atmospheric conditions which
starts the pain into being.

** A still more valuable and novel conclusion has arisen out of our
study. Every storm, as it sweeps across the Continent, consists of
a vast rain area, at the centre of which is a moving space, of
greatest barometric depression, known as the storm centre, along
which the storm moves like a bead on a thread. The rain usually
precedes this by 550 to 600 miles, but before and around the rain
lies a belt, which may be called the neuralgic margin of the storm,
and which precedes the rain about 150 miles. This fact is very
deceptive, because the suff'erermay be on the far edge of the storm-
basin of barometric depression, and seeing nothing of the rain, yet
have pain due to the storm.

" It is somewhat interesting to figure to one's self thus — a moving
area of rain girdled by a neuralgic belt 150 miles wide, within which,
as it sweeps along in advance of the storm, prevail in the hurt and
maimed limbs of men, and in tender nerves and rheumatic joints,

248 Chronicle of Medical Science. [July»

renewed torments called into existence by the stir and perturbation
of the elements." — Separate Treatise extracted from the American
Journal of the Medical Sciences for April, 1877.

The Medical Organization of the Factory Acts. — Few measures
could tend more to the health of the factory operatives of this
kingdom than a perfect system of medical organization. To obtain
such perfection is one of the persistent and earnest efforts of Dr.
Arlidge, whose latest essay on the subject is now under notice.
The author very correctly contends that the primary purpose of the
Factory Acts was sanitary, in other words, factory legislation was
called into existence to rescue the workers in factories, and especially
the youthful workers and women, from' physical suffering, degeneres-
cence, diseas^e, and premature death, consequent upon overwork ;
unhealthy places of work, and the employment of the too young, the
infirm, the diseased, and the deformed. The danger now ahead in
respect to medical factory legislation is that the recommendation of
the late Royal Commission to dispense with the surgical examina-
tion of children after their primary entrance on work, may be
carried out. Against this danger Dr. Arlidge protests in the most
earnest manner. It is a recommendation, he says, destructive of
all good that can flow from medical inspection. It involves in
itself the absurd supposition that a child certified as of sufficient
strength and free from sickness at two years of age, will continue
to be so during the whole course of years it continues at work and
is subjected to the conditions of the factory laws. It seems to
ignore the possibility of casual disabling, sickness, and accident, the
outset of contagious maladies, and the morbid results that specially
follow upon factory labour. — Paper read at the Social Science
Congress at Liverpool, 1876.

[The argument employed by Dr. Arlidge throughout his admirable
essay is of the soundest character. It deserves the attention of the
sanitarian and legislator, and the gratitude of the industrial class,
in whose behalf it so eloquently pleads. — B. W. R.]

IV. Summary.

On the Dead as a possible Source of Infection. By Feancis Yacher.
Pamphlet, London, 1877. — A pamphlet by the Medical Officer of
Health for Liverpool. The author thinks it possible that the dead
body may be a source of contagion, and he suggests that better
provision should be made against the exposure of infected corpses.

Annual Beport for 1876 of the Committee of Management of the
Melbourne Retreat for the Cure of Inebriates, Northcote. Special
Report, 1877. By Charles McCarthy, M.D., Superintendent. —
Dr. McCarthy states that " a death from drink occurs in this colony
for every day in the year." He gives a gratifying report of the
success of the system at the Retreat over which he presides.

The Laio of Life Assurance. A lecture to the Institute of
Accountants and Actuaries in Glasgow. By Professor Robert
Berry, M.A. Separate Treatise, Glasgow, 1877. An admirably
clear and comprehensive lecture, dealing with the legal aspects
of insurance, but containing useful knowledge for medical men.

1877.]

Books J S^<;.j received for Review.

249

BOOKS, PAMPHLETS, &c., DECEIVED FOR REVIEW,

Clinical Lectures on Diseases of the
Liver, Jaundice, and Abdominal Dropsy.
% Charles Murchison, M D,, F.K.S,
Second Edition. London, 1877. Long-
mans, pp. 644.

The Physical Basis of Mind. With il-
lustrations. Being the Second Series of
Problems of Life and Mind. By G, H.
Lewes. London, 1877. pp. 493.

Lectures on Surgical Pathology and
Therapeutics, By Dr. Theodor Billroth.
Translated from the eighth edition. Vol.
i. London, 1877. New Sydenham So-
ciety, pp. 438.

Medicinal Plants. Being descriptions
with original figures of the principal
plants employed in medicine, and an ac-
count of their properties and uses. By
Eobert Bentley and H. Triraen, M.B.
London, 1877. Parts 20 and 21.

Cyclopaedia of the Practice of Medicine.
Edited by Dr. H. von Ziemssen. Vol. xii.
Diseases of the Brain and its Membranes.
London, 1877. Sampson Low & Co. pp.
902.

The Cottage Hospital ; its origin, pro-
gress, management, and work, &c. By
Henry C. Burdett. Lonaon, 1877-
Churchills. pp. 272.

A Guide to Therapeutics. By Robert
Tarquharson, M.D., &c. London, 1877.
Srnith, Elder, & Co. pp. 302.

Sanitas Sanitatum et omnia Sanitas.
By Richard Metcalf, F.S.S. Vol. i, 1877.
pp. 334.

Butter : its analysis and adulterations,
specially treating on the detection and
determination of foreign fats. By Otto
Hehner and Arthur Angell. Second Edi-
tion. London, 1877. Churchills, pp. 86.

Myelitis of the Anterior Horns or
Spinal Paralysis of the Adult and Child.
By E. C. Seguin, M.D. New York, 1877.
Putnam & Sons. Loudon, Sampson Low
& Co. pp. 120.

General Index to the New York Medi-
cal Journal. From April, 1865, to June,
1876. Bv James B. Hunter, M.D. New
York, 1877. D. Appleton & Co. pp.
144.

A Text-Book of Physiology. By M.
Foster, M.D., F.R S. London, 1877.
Macmillan & Co. pp. 559.

On Idiocy and Imbecility. By W. "W.
Ireland, M.D. Loudon, 1877. Churchills.
pp. 413.

Smellie's Midwifery. Vol. ii. Anno-
tated by A. H. McClintock, M.D., for the
Sydenham Society. 1877.

A Handy- Book of Forensic Medicine
and Toxicology. By W. B. Woodman,

M.D., and C. M. Tidy, M.B. London
1877' Churchills. pp. 1205.

The West Riding Lunatic Asylum
Medical Reports. Edited by J. Crichlon
Browne, M.D., and Herbert C. Major,
M.D. Vol. vi. London, 1S76. Smith,
Elder, & Co, pp. 309.

A Handbook of Medical and Surgical
Electricity. By Herbert Tibbits, M,D.
Second Edition, revised and enlarged.
London, 1877. Churchills. pp. 254.

Army Medical Department Report for
the year 1875. Voi. xvii. London, 1877.
pp. 290,

Sciatica, Lumbago, and Brachialgia :
their nature and treatment, &c. By
Henry Lawson, M.D. Second Edition.
London, 1877. Churchills. pp. 228.

Lectures on the Diseases of the Nervous
System. By Professor J. M. Charcot.
Translated by George Sigerson, M.D.
London, 1877. pp. 325.

Transactions of the New York Patho-
logical Society. Vol. i. John C. Peters,
M.D., Editor, New York, 1876. Wood
& Co. pp. 272.

The Endemic Diseases of Tropical
Climates, with their treatment. By John
Sullivan, M.D, London, 1877. Churchills.
pp. 211.

Explorations of the Aboriginal Remains
of Tennessee. Bv Joseph Jones, M.D.
Washington City,' 1876. Published by
the Smithsonian Institution, pp. 171.

Report of the First Congress of the
International Otological Society, New
York, September, 1876. New York, 1877.
D. Appleton & Co. pp. 159.

A Third Analysis of the Statistics of
Phthisis in Victoria, completing the series,
to which are prefixed remarks on one of
the modern m.odes of medical treat-
ment. Bv W. Thomson, F.R.C.S. Mel-
bourne, 1876. pp. 96.

A Handbook of the Theory and Prac-
tice of Medicine. By J'rederick T. Roberts,
M.D. Third Edition. In two volumes.
London, 1877. H. K. Lewis.

The Vivisection Question Popularly
Discussed. By Dr. L. Hermann. Trans-
lated and Edited by Dr. A. Dickson.
1877, Williams & Norgate. pp. 59.

The Treatment of Spina Bifida by a
New Method. By James Morton, M.D.
Glasgow, 1877. J. Maclehose. pp. 120.

The Histo-Chemistry and Pathogeny
of Tubercle. By W. Thomson, F.R.C S.
Edin. Melbourne, 1876. Stillwell &
Knight, pp. 54.

The Student's Mannal of Venereal Dis-
eases: being a concise description of

250

Books, ^c, received for Review.

[July.

those affections and of their treatment. By
Berkeley Hill and Arthur Cooper. London,
1877. Smith, Elder, & Co. pp. 97.

Sea-Air and Sea-Bathing : their in-
fluence on health, &c. By Charles Parsons,
M.D. ChurchiUs. 1877. pp. 119.

The Sanitary Duties of Private Indi-
viduals. Second Edition. Published by
the Ladies' Sanitary Association.

Transfusion of Human Blood by the
Method of J. Koussel, with a Preface by
Sir James Paget, Bart. Translated by C.
H C. Guinness, B.A. London, 1877.
ChurchiUs.

Dangers to Health in our own Houses.
A Lecture by T. Pridgin Teale, M.A.
London, 1877. ChurchiUs.

Saint Bartholomew's Hospital Reports.
Edited by James Andrew, M.D., and
Alfred Willett, F.R.C.S. Vol. xii. London,

1876. Smith, Elder, & Co. pp. 350.
With statistical tables of the patients
under treatment, pp. 74.

Fownes' Manual of Chemistrj', Theo-
retical and Practical. Vol. i. Physical
and Inorganic Chemistry. Twelfth
Edition, revised and corrected. By Henrv
Watts, B.A., F.RS. London, 1877.
ChurchiUs. pp. 551.

Headaches : their nature, causes, and
treatment. By W. H. Dav, M.D. London,

1877. ChurchiUs. pp. 312.

Sir W Fergusson, Bart. A biographical
sketch. By Henry Smith. London, 1877.
ChurchiUs.

What is Vital Force ? A short and
comprehensive sketch, including vital
physics, animal morphology, and epi-
demics ; to which is added an appendix
upon geology. By Richard F. Battye.
London, 1877. Triibner & Co. pp. 335.

The " Oriental Sore," as observed in
India. A Report by T. R. Lewis, M.B.,
and D. D. Cunningham, M.B. Calcutta,
1877. pp. 59.

Leprosy in India. A Report by T. R.
Lewis, IVi.B., and D. D. Cunningham,
M.B. Calcutta, 1877. pp. 73.

Transactions of the American Neuro-
logical Association for 1875 Edited by
F. P. Kinnicutt, M.D., and T. A. McBride,
M.D. Vol i. New York, 1875. pp. 257.

Gout : its cause, nature, and treatment;
with directions for the regulation of the
diet. By John Parkin, F.R.C.P. Second
Edition. London, 1877. Hardwicke &
Bogue. pp. 144.

The Hunterian Oration, delivered at
the Royal College of Surgeons, February,
1877. By Sir James Paget, Bart., F.R.S.,
&c. London, 1877. Longmans, pp. 65.

The Care and Cure of the Insane, being
t\ie Reports of the *Lan(et' Commission on
lunatic asylums, 1875-6-7. By J. Morti-
mer Granville, M.D. In two vols. London,
1877. Hardwicke & Bogue.

A Practical Tieatise on the Diseases of
Children. Bv J. F. Meigs, M.D., and
W. Pepper, M.D. Sixth Edition Re-
vised and enlarged. London, 1877. H.
K. Lewis, pp. 1012.

On some Undetermined Points in Ty-
phoid Fever. By David CuUen, M 1).
London, 1877. H. Kimpton. pp. 125.

The Lumleian Lectures on the Muscular
Arterioles. By George Johnson, M.D.,
F R.S. London, 1877. pp. 53.

Rajpootana Dispensary, Vaccination
Jail, and Sanitary Reports for 1875. Cal-
cutta, 1876. pp 85.

Reports of the Inspectors of Factories
for the half-3'ear ending 31st October,
1876.

Beitrage zur Medizinal Statistik. Her-
ausgegeben vom Deutschen Verein fur
Medizinal-Statistik. Heft ii. Stuttgart,
187,6. pp. 172.

Etude sur les Resulats Definitifs des
Amputations. Par le Dr. H. Viard. Paris,
1877. J. B. BaiUiere et tils. pp. 114.

LesEaux Mineralesdu Mont-Dore. Par
le Dr. Boudant. Paris, 1877. J. B.
BaiUiere et tils, pp.523.

Traite des Maladies de la Prostate. Par
le Dr. Henry Picard. Avec 83 figures
dans le texle. Paris, 1877. J. B. Bail-
liere et fils. pp. 400.

Considerations Pratiques sur le Traite-
ment des Nevralgies. Par le Dr. P. Fois-
sac. Paris, 1877. J. B. BaiUiere et fils.

Nouveau Dictionnaire de Medecine etde
Chiiurgies Pratique. lUustre de figures
idtercalees dans le texte. Directeur de la
redaction, le Dr. Jaccoud. Paris, 1877.
Tome xxiii. Mol-Nev. pp. 865.

Jissai d'Urologie Clinique. La Fievre
Typhoide. Par Albert Robin. Paris,
1877. J. B. BaiUiere et fils. pp. 264.

Essai sur une Forme d'Adeno-lymphite
Peri-uterine. Par Georges Mary, M.D.
Paris, 1877. J. B. BaiUiere et fils. pp. 66.

Clinique Chirurgicale des H6pitaux de
Paris. Par le Dr. P. Gillette, Chirurgien
des Hopitaux. Avec fieures ititercalees
dans le texte. Paris, 1877. J. B, Bail-
liere et fils. pp. 324.

Pamphlets.

Phthisis in Victoria. By John Single-
ton, M.D. (Reprint.) 1876.

Cancer, Tumours, and Minor Operations
Treated without the Use of the Knife.
By Thomas Gurney, M.D. London, 1877.

On some Conditions, Physical and Ra-
tional, in Effusions of the Pleura. By
Beverley Robinson, M.D. (Reprint.)
New York, 1877-

Smallpox : a new Treatment of this Dis-
ease. By a Layman. London, 1877.

Notes on the Surgical Treatnioit of
Aortic Anentism. By John Cockle, M.D.
London, 1877.

1877.]

Books J ^c.j received for Review,

251

Case of Exostosis of the External Audi-
tory Meatus drilled out by the "Dental
Engine." Bv Arthur Mathewson, M.D.
(Reprint.) New York, 1877.

On Sexual Debility and Impotence.
By S. W. Gross, M.D. (Keprint.) 1877.

The Progress of Oi)htbalinology in the
Last Quarter of a Century. An inaugural
address. By J. V. Solomon, F.K.C.S.
(Reprint.) Birraingham, 1877.

Hydrate of Chloral in Obstetric Prac-
tice. By W. L. Richardson. (Reprint.)
Boston, 1877.

Geography of Devonshire and Consump-
tion. By Dr. W. H. Pearse.

Note on the Anatomy and Pathology of
the Skin. By J. Collins Warren, M.D.
(Reprint.) Cambridge, U. S., 1877.

Discussion on the Influence of Medi-
cines on the Infant when administered to
the Mother. (Reprint.) New York, 1877.

Considerations in Relation to Diseases
of the Joints. By David Prince, M.D.
(Reprint.) 1877.

On the Dead Body as a Possible Source
of Infection. By Francis Vacher. London,
1877.

The Science of Living. By a Student.
London, 1877.

Surgical Diagnosis. An inaugurdl lec-
ture. By James G. Beaney, F.R.C.S.E.
Melbourne, 1877.

Religio Psycho- Medici. By W. A. F.
Browne, LL.D. (Reprint.) London, 1877.

Notes from a Dentist's Case-Book. By
Felix Weiss. (Reprint.) London, 1877.

The Use of Uterine Supporters. By
Clifton E. Wing, M.D.

The Diagnosis and Treatment of Audi-
tory-Nerve Vertigo. By W. R. Gowers,
M.D. (Reprint.) London, 1877.

Idiots, Imbeciles, and Harmless Luna-
tics. By Robert Boyd, M D. (Reprint.)
London, 1877.

On the Early Traces of Institutions
resembling in some particulars the mo-
dern hospital. Bv the Rev. E. Marshall,
M.A. Oxford, 1876.

Notes in Practical Medicine. A presi-
dential address. By Henry Barnes, M.D.
Carlisle, 1876.

The Actual Cautery and its Employ-
ment in Cutaneous Surgery. By Henry
G. Piffard, M.D. (Reprint.) Charleston,
1876.

Reports of the Sussex County Asylum
and of the Royal Edinburgh Asylum for
the Insane.

The Classification of Mental Diseases.
By W. H. 0. Sankey, M.D. (Reprint.)

The Digestion and Assimilation of Fat
in the Human Body. By H. C. Bartlett,
Ph.D. London.

International Exhibition of 1876.
Pamphlets issued in connection with.
Philadelphia, 1876. 1. List ol skeletons

and crania belonging to the United States'
Army Medical Museum, Washington. 2.
Description of the models of hospital cars,
by J. J. Woodward, Assistant-Surgeon
U. S. A. 3. Description of the models of
hospitals, by J. J, Woodward. 4. Descrip-
tion of the models of hospital steam-
vessels, by J. J. Woodward. 5. Descrip-
tion of Perot & Co.'s improved U. S. A.
medicine waggon and mess chest. 6. De-
scription of the U. S. army medical
transport cart, model of 1876, by D. L.
Huntington and G. A. Otis, Assistant-
Surgeons U. S A. 7. Description of se-
lected specimens from the surgical section
of the Army Medical Museum, by G. A.
Otis. 8. List of microscopical prepara-
tions from the Army Medical Museum.
9. Description of selected specimens from
the medical section of the Army Medical
Museum, by J. J. Woodward.

The Medical Staff of the United States'
Army and its Scientific Work. An ad-
dress. By Surgeon J. J. WoodAvard.

Typho-Malarial Fever : is it a special
type of fever .' being remarks introductory
to the Discussion in the section of medi-
cine, International Medical Congi-ess. By
Surgeon J. J. Woodward.

Journals.

Edinburgh Monthly Journal.

Dublin journal of Medical Science.
(Monthly.)

Journal of Anatomy and Physiology.
(Quarterly.)

Journal of Mental Science. (Quarterly.)

Lancet, Medical Times and Gazette,
British Medical Journal, and Medical
Press. (Weekly.)

New Preparations. A Quarterly Journal
of Medicine, devoted to the introduction
of new therapeutical agents. Vol. i, Nos.
1 and 1. Detroit, Michigan.

The Indian Medical Gazette. (Monthly.)

Canada Medical and Surgical Journal.
(Monthly.)

The Library Table. New York. (Weekly .)

The American Journal of the Medical
Sciences. (Quarterly.)

Philadelphia Medical Times. (Weekly.)

The American Practitioner. (Monthly.)

The American Journal of Insanity.
(Quarterly.)

The Araerifan Journal of Obstetrics and
Diseases of Women and Children. (Quar-
terly.)

The Boston Medical and Surgical
Journal. (Weekly.)

The New York Medical Journal.
(Monthly.)

New Remedies. A Monthly Trade
Journal of Materia Medica, &c. &c.

The Richmond and LouLsville Medical
Journal. (Monthly.)

252

Reclamation.

[July, 1877.

The American Bookseller. (Fort-
nightly.)

The Ohio Medical Recorder. Edited by
J. W. Hamilton, M.D., and L. F. Bald-
win, M.D. (Monthly.)

Archives of Dermatology. A Quar-
terly Journal of Skin and Venereal Dis-
eases.

Archives of Clinical Surgery. Edited
by E. J. Bermingham, M.D. (Monthly.)

The American Journal of Microscopy
and Popular Science. New Tork.

Archives Generales de Medecine.
(Monthly.)

Bulletin General de Therapeutique.
(Monthly.)

Eevue des Sciences Medicales en France
et a r fit ranger. (Quarterly.)

Le Progres Medical. (Weekly.)

Revue Mensuelle de Medecine et de
Chirurgie. 1877. (Monthly.)

Annales de Gynecologie. (Monthly.)
L'Annee Medicale. (Monthly.)
Union Medicale et Scientifique du

Nord-Est. (Monthly.) Nos. 1 and 2.

Reims. 1877.

Schmidt's Jahrbiicher der Gesammten

Medicin. (Monthly.)

Archiv fiir Gynaekologie. (Quarterly.)
Deutsches Archiv fiir Klinische Mediciu.

(Monthly.)
Archiv fur Pathologische Anatomie und

Physiologie. (Monthly.)

Lo Sperimentale. (Monthly.)
Archivio Clinico Italiano dei Medici

condotti. (Monthly.)

Rivista de Medicina y Cirurgia Practicas

nacional y extranjera. Madrid. 1877. (Tri-

monthly.)

Enciclopedia Medico- farmacentica. Ri-
vista scientifica y profesional. Barcelona.

(Weekly.)

Reclamation of Dr. J. W. Moore.

^ote to the JReview in our last number of Vols. 4 and 5 of Ziemssent
' Cyclopcedia of the Practice of Medicine.^

As bearing upon the discovery by Leyden of microscopic octohedral crystals
in the expectoration of some asthmatic patients, we have received a letter from
Dr. J. W. Moore, of Dublin, in which he calls attention to the fact that in the
• Irish Hospital Gazette ' for July 15, 1873, he has recorded his detection in
the sputa of a gouty subject of some uncommon varieties of uric acid crystals.
He describes them as presenting three forms : one resembling stearic acid,
another as having the appearance of diatoms, whilst some of the largest bore a
strong resemblance to spear-headed crystals of uric acid. A second scrutiny
proved that they were instantly soluble in liquor potassse, and slowly so in acetic
acid. Dr. Moore is of opinion that the crystals described by Leyden, and those
found by himself, are examples of the same pathological element. It is not
improbable that this may be the case; but Leyden's remarks being confessedly
imperl'ect, a more positive statement is not yet warranted. We have pleasure,
however, in giving further publicity to Dr. Moore's interesting observation. —
Rb VIE WEB.

THE

BRITISH AND FOREIGN

MEDICO-CHIRURGICAL REVIEW

OCTOBEE, 1877.
analytical ant» (Erttical l^ebietos.

I. — The Temperature in Phthisis and Tuberculosis.^

In the great development of medical thermometry which has
taken place during the last twenty-five years^ it was very
natural that the chief attention of clinical inquirers should be

1 1. JOCHMANN (P. A.) BeohacMungen uber die Korperwdrme in chronischen
^eberhaften Kranlcheiten, Berlin, 1853.

2. RiNGEE (Sydney). On the Temperature of the Body as a means of Dia-
gnosis in Phthisis and Tuberculosis. London, 1865. Also, Second Edition,
London, 1873.

3. WuNDEELiCH (C. A,). Das Verhalten der Mgenwdrme in Kranlcheiten.
Leipzig, 1868. Translated from the Second Edition by Dr. Woodman. On the
Temperature in Diseases. London, 1871.

4. BoiLEATJ (Assistant-Surgeon). The Correlations of Temperature, Fulse,
and Respiration in Phthisis. 'Army Medical Reports,' for 1868. London,
1870.

5. FiNLAYSON (J.). On the Temperature of Children in Phthisis and Tuber-
culosis. ' Glasgow Medical Journal,' November, 1869.

6. Fox (Ed. LoNa). Clinical Observations on Acute Tubercle. *Sfc.
George's Hospital Reports,' vol. iv, 1869. Also, Clinical Observations on the
Temperature of Disease. ' Medical Times and Gazette,' 1870.

7. EuDE. De la Marche de la Temperature dans la Fievre hectique. * Gaz.
Med. de Strasburg,' November, 8, 1871. (Canstatt's * Jahresbericht,' 1871,
p. 219.)

8. ROGEE (H.) jRecherches Cliniques sur les Maladies de VPlnfance. Tome i,
Paris, 1872. {De la Temperature chez les enfants. Pp. 203-466).

9. BiLHAiJT (M.). Etude sur la Temp&ature dans la Phthisic Pulmonaire.
Paris, 1872.

10. Bettelheim (K.). BemerJcungen uber einige JEigenthiimlichJceiten des
Fiebers im Beginne Phthisicher Zustdnde. ' Deutsches Archiv fiir klinische
Medicin.' Bd. x. Leipzig, 1872.

11. Alcock (N.). On the Nature and Variations of Destructive Lung DiS'
ease. ' Army Medical Reports ' for 1872. London, 1874.

120 -LX. 17

254 Reviews. [Oct.,

directed in the first instance to the phenomena of acute disease.
The study of the onset and the decline of pyrexia in its rela-
tion with all the striking symptoms of an acute illness, begun
and ended in a short period of days or weeks, was well calcu-
lated to arouse and sustain a lively interest in the observer.
The protracted course of a chronic disease, on the other hand,
w^hose beginning or end might be quite unknown, and whose
slow downward progress was apt to be complicated by morbid
processes which were often beyond recognition during life, and
were not unfrequently left in much obscurity even in the event
of a careful dissection, demanded more patience for its study,
and this department of thermometry could scarcely be developed
so early or so completely as the other. When, however, tem-
perature observations became part of the regular routine in all
well-ordered cliniques, the accumulation of such a multitude
of facts raised some hope of success in grappling with the
difficulties presented even by such chronic and such complicated
diseases as phthisis and tuberculosis. And just because of the
difficulties hinted at the subject has been pursued by a succes-
sion of inquirers with the utmost diligence. For if, as we know,
destructive processes can go on in the lungs without affording
proof of their presence by auscultation and percussion, or other
definite evidence, this seemed a strong reason for testing to the
utmost the resources of any newer appliance ; in the quiescent
forms of phthisis, on the other hand, such researches might
correct or supplement the evidence of physical signs in showing
that, although the organs were changed, the morbid processes
leading to such results had themselves come to an end. The
hope of thus aiding our means of diagnosis and prognosis be-
came a powerful stimulus in this inquiry ; questions of treat-
ment, and more especially the testing of the effect of various
remedies, were also directly involved in the same consideration.
But further, the forms of disease clinically grouped together
as phthisis have long been known to present certain very ob-
vious differences when they come to be examined after death,
differences so great, indeed, in the opinion of some, as to demand
the subdivision of phthisis into several varieties, or even to

13. Lebeet (Prof.). Verdnderungen der Korperiodrme im Laufe der Ikiher-
culose. 'Deutsches Archiv fiir klin. Medicin.' Bd. xi. Leipzig, 1873.

14. Fox (Wilson). On the Temperature, Pulse, and Respiration in Phthisis
and Acute Tuherculization of the Lungs. 'Medico-Chirurgical Transactions.'
Vol. Ivi. London, 1873.

15. Williams (C. Theodoee). On the Temperature of Phthisis Pulmonalis.
* Medico-Chirurgical Transactions.' Vol. Iviii. London, 1875.

16. ScHWAEZ (Albeet). Ueber den Fieherlauf hei Phthisis Pulmonalis.
' Verhandlungen der Physikal-Medicin. Gesellschaft in Wurzburg.' N. F.

Bd. ix, 1876.

1877.] Temperature in Phthisis and Tuberculosis, 25S

imply a revolution in pulmonary pathology. Here, again, it
was hoped that the thermometer might assist in the differentia-
tion of such cases, by the discrimination of the more serious or
the more rapid forms of the disease from the more chronic or
the more hopeful ; while by its means we might, perhaps, trace
the onset of complications, whether accidental or otherwise, and
so gain an insight into the less obvious pathology of this
dreadful disorder.

The most general result of the thermometry of phthisis
is to show that, as a rule, the patients present more or
less pyrexia during their illness. As this rule, however, is
subject to various qualifications and exceptions, we will first
consider the circumstances under which low temperatures —
ivhether normal or subnormal — are met with. All authorities
agree in stating that even in the midst of febrile disease there
is occasionally a dipping down of the temperature to the normal
or subnormal level, sometimes with and sometimes without other
signs of collapse. Such dips occur in phthisis also ; the evi-
dence of the reality of these depressions is to be found in the
record of such temperatures, even when the measurements are
made in the rectum or vagina, and so are more likely to in-
dicate the real heat of the body -} and these depressions are
specially apt to occur towards the fatal termination of phthisical
cases, as will appear when we discuss this subject in a separate
section. Again, the morning temperatures (those before 10 a.m.)
are in many phthisical cases either strictly normal or possibly
subnormal ; if to these we add the cases in which the elevation
of the morning temperature is so slight that we can scarcely
pronounce it distinctly unnatural, we have a very large pro-
portion of ordinEvry cases of phthisis, many of which, or, perhaps,
we should say most of which, would present unmistakable
evidence of pyrexia if the temperature were taken after mid-
day or in the evening. Dr. Boileau calls attention very
pointedly to this fact in the ^ Army Medical Reports for 1868,'
in connection wdth the use which invaliding boards might be
disposed to make of the thermometer, as these consultations
usually take place in the forenoon (p. 29^). The importance of
noting and considering thehour at which the temperatureis taken,
before judging of the absence or the degree of fever, is now so
universally recognised that we need not insist upon this point.
Of more serious import is this question : whether the tempe-
rature, when fairly taken at various periods of the day, and for

1 See Bilhaut (op. cit.), pi. i, fig. 3, where the temperature dipped down
to 37-8^ (100-04°) although usually between 39^° aud 40° (103-1° and 104°). Also
pi, ii, fig. 10, where it fell to 36° (96*8°) on two occasions, although usually
between 38° and 39° (100-4° aud 102-2°).

256 Reviews, [Oct.,

several days in succession, is always elevated in advancing cases
of phthisis and tuberculosis. This was the proposition which
■was generally supposed to be advocated in Dr. Sydney Ringer's
book when he published it in 1865, although from the preface
to his second edition it seems he has been misunderstood. It
appears that he meant that an abnormal elevation at some
period of the day was necessarily present only in those condi-
tions leading to fresh depositions of the morbid products,
formerly known as grey and yellow tubercle, and that he did
not refer to the destructive changes and fatal course which
alterations in such deposits might produce. Such a distinction
removes the discussion to the realm of theoretical pathology ;
for however important and interesting such a discussion may be,
we must agree with Dr. Pollock in considering that it " has not
much practical value.^l It may, in any case, be confidently
asserted that glaring cases of phthisis, characterised, perhaps,
by the expectoration of lung-tissue, frequently present a course
of temperature which may practically be called normal. Dr.
Hillier said that he had " certainly met with some cases of
tubercular disease in which the morbid process appeared to be
making decided progress, in which there was no distinct eleva-
tion of the temperature,"^ and Dr. Finlayson likewise arrived
at a similar conclusion in his inquiry concerning children.^
No less explicit are the statements regarding adults. Dr
Boileau* supplies details of a case observed for five months
before death, in which 100'^'' (37*88°) was the highest tempe-
rature noted, while the average of the first three weeks gave
98° {S6-66'') for the morning temperature, and 99° (37*22°) for
the evening, and during the last week of life the average was
98^° (36'94°). His cases appear to be carefully noted, and
they bear out his opening statement, " that a person may
progress to the stage of tubercular cavities in his lungs without
exhibiting general elevation of temperature."

Dr. Wilson Fox, in his tabulation of cases (Table V) gives
eight cases of phthisis as having an average evening tempera-
ture not exceeding 99° (37*22°), these eight cases constituting
a considerable percentage of the more chronic cases dealt with
in his summary. The majority indeed of his cases had an
average of the evening temperatures not exceeding 100° (37*77°).

Prof. Lebert found ten cases (-^V of the whole) with an
average temperature in the evening of between 37° and 38° C.
(98*6° and 100*4° F).

1 *• Clinical Varietiei of Consumption." By J. E. Pollock, M.D. * Med. Times
and Gazette/ 1874. Vol. ii, page 98.

3 ' Diseases of Children.' By Thomas Hillier, M.D. London, 1868, p. 115.
3 Op. cit., p. 24.
-« Op. cit, p. 295.

1877.] Temperature in Phthisis and Tuberculosis, 257

Dr. Schwarz found that 38^ per cent, of his cases could be
classified as having an evening temperature within the normal
range (38° C. = 100*4° F.).

Dr. Theodore WilHams considers the third stage of quiescent
phthisis, or that of chronic cavity, to be characterised by normal
or subnormal temperatures, so that the results of observations
on twenty patients show an average which does not exceed
98-6° (37°J at any period of the day (Table V), and the mean
temperature in his " first stage, quiescent," does not exceed
98-7° (37-05°) (Table II).

Dr. Ringer himself, in the second edition of his little book,
admits ^' that in some cases of tuberculization, or of catarrhal
pneumonia, there may be no elevation of temperature" (p. 9),
and " that a natural temperature must not lead us to conclude
that this disease is not slowly spreading" (p. 13).

But the most remarkable opinion as regards low temperatures
in phthisis is that of Surgeon Alcock, who seeks rather to
diagnose threatened tubercular disease by the detection of an

" Inability on the part of the person in whom the requirements for
tubercle exist and are about to be set in motion to maintain the
temperature of the body up to the natural standard, the deficiency
amounting to about one degree Fahrenheit ('55 C.) in the morning,
and to '5 of a degree F. ('27 C.) in the evening reading."

He goes on to say that —

" The value of this sign first forced itself into notice by its having
been accepted as a distinct proof of the non-existence of phthisis...
men, therefore, having many of the obscure premonitory symptoms,
but without any of the physical signs, were in consequence of the
low temperature confidently pronounced to owe their delicacy to
some other cause than incipient consumption, yet the result unex-
pectedly proved that the disease had been latent at the time" (loc.
cit. p. 404).

Diagrams are appended to illustrate the statement here made,
and from these it appears that in six cases in which signs of
tubercular disease became obviously developed in the course of
a period varying from a month or two up to a year or more, the
low temperatures represented in the diagrams had been pre-
viously noted. We do not venture to deny the occurrence of a
period of abnormally low temperature before the development
of recognisable tubercular disease, because opportunities of
observing such cases in such stages have seldom presented
themselves, but we cannot refrain from scrutinising the evidence
adduced with some scepticism. Researches leading to the
investigation of non-febrile states always convince the observer
of the variability of the human temperature, and of the fre-

258 Reviews, [Oct.,

quent occurrence of temperatures considerably below the gene-
rally recognised standard.

The diagrams given by Surgeon Alcock represent a range of
temperature between 97° and 98° (36' 11° and 36-66°), for the
most part, in this early stage, but occasionally it is recorded to
be nearly as low as 96° (35*55°). Unfortunately the author does
not mention what precautions he took to prevent errors from
imperfections in the application of the thermometer. It is quite
certain that, in special conditions of the surface temperature,
much time and patient care are required to obtain the maximum
temperature of the axilla. It is equally certain that the range
of the normal temperature is very considerable, as we will have
occasion to show further on, and so we must not too readily
pronounce a temperature to be abnormal although it is under
98° or even 97° (36-66° or 36-11°). We must look to army
surgeons for further information on such points, as they have
opportunities possessed by few others of determining the tem-
perature during slight ailments occurring before the distinct
manifestations of phthisis.

More serious still is the allegation that we may have actually
febrile attacks in the premonitory stages of phthisis, as mani-
fested by alterations in the pulse, by sweatings, and by other
general symptoms, without any appreciable elevation of tem-
perature. '^ Elevation of temperature," " pyrexia," and *' fever,''
have come to be used almost indifferently as meaning much the
same thing — a view attacked by Bettelheim, who alleges the
frequent occurrence of disturbances of various kinds in the his-
tory of phthisical patients before their disease is pronounced,
which he does not hesitate to call '' febrile," on the strength of
the indication of the pulse, sweatings, and such like ; the favor-
able influence of quinine seems also to him to strengthen this
view of the febrile nature of such attacks. This author alleges
that in such attacks, apart from intercurrent inflammations, the
temperature did not, as a rule, exceed 37-3° or 37*6° (99-14° or
99-68°), and scarcely once reached 38° C. (100-4°) Dr. Boileau,
in his paper on the " Correlations of Temperature, Pulse, and
Respiration in Phthisis," likewise referred to the coexistence
of a high pulse rate with a low temperature in phthisis, and
considered '^ the rapidity of the pulse to be more constant in
phthisis than the elevation of temperature" (p. 292). We are
prepared to admit the theoretical impropriety of using the word
*' fever," as simply synonymous with elevation of temperature;
perhaps '^ pyrexia'Ms a better word to express this important
element in such cases, and some observations by Dr. Burdon
Sanderson and others seem to imply that certain morbid pro-
cesses may prove fatal without any elevation of temperature in

1877.] Temperature in Phthisis and Tuberculosis, 259

certain subjects, although in most cases high fever is pro-
duced. But we are far from admitting that a diagnosis of fever
is clinically justifiable simply from the rapidity of the pulse,
or the occurrence of sweatings, even if periodical in their cha-
racter. The effects of exertion and excitement on the pulse-
rate are well known, but their potency can probably be only
realised by those who have made careful observations in a
regular and systematic manner ; in certain persons and in certain
conditions a turn of the body in bed, a word, or a cough, will
send it up to a height which is quite misleading. How much
we would be misled by an undue regard paid to the quickened
pulse-rate and the appearance of sweating may often be seen on
examining a rickety child while asleep in bed, although such a
position is extremely favorable for securing an undisturbed state
of the pulse. Indeed, we reckon temperature observations so
important, in cases of phthisis as well as in other diseases, for
the due estimation of the value of acceleration of the pulse, the
presence of sweatings, and the occurrence of shiverings, that
we feel but little inclined to attach much consideration to Bet-
telheim's remarks, or to any similar observations, unless the
investigations are stated in such a way as to carry conviction
that the utmost care had been used to avoid fallacies in the
taking of the temperature as well as of the pulse.

Before leaving this part of the subject we may add that cer-
tain complications of phthisis seem to have a tendency to
reduce the pre-existing febrile temperature ; meningitis, he-
moptysis, perforation of the bowel, and pneumothorax may be
named amongst these, but this effect is not constant, and is
usually quite temporary, for a febrile reaction not unfrequently
succeeds the depression, if the patient survives the shock of the
last-named accidents.

The character of the pyrexia in phthisis is the next point to
be considered. Of this it may be said, in general terms, that
it is usually slight or moderate, and only exceptionally very
high ; that it is usually of the remittent type, with the morning
temperatures nearly normal, or perhaps subnormal, and the
exacerbations falling on the afternoon or evening ; but this form
of fever is apt to be interrupted from time to time by the in-
version of this type, by the occurrence of a double daily
paroxysm, and by occasional oscillations of an irregular
character, as well as by periods of pretty high continuous
pyrexia.

The first effort to formulate the types of fever in phthisis and
other chronic febrile diseases was made by Jochmann. His
classification was remarkably elaborate, consisting of eight
divisions or subdivisions, the total number of cases dealt with

260 Reviews. [Oct.,

in his essay being only twelve. It must be regarded as a great
compliment to his observations that he seems to have recog-
nised most of the varieties subsequently more fully investigated,
and to have perceived the irregular way in which one febrile
type supplanted another in the same case. His results have
been considered so important that short accounts of his investi-
gation, and particularly of his classification, are given by Dr.
Finlayson and Dr. Wilson Fox at the beginning'of their papers.
Subsequent writers have recognised the undue complexity of
Jochmann's divisions, but they have not been very successful
in substituting anything better. Wunderlich speaks of the
pyrexia in acute miliary tuberculosis resembling that found
in the beginning of a catarrh, or that observed in the course of
enteric fever, or as resembling the course of an intermittent
fever ; and he says that in acute phthisis, while the type is
remittent, presenting considerable remissions, 3° C. (5'4° F.),
there are interruptions to this course, with periods of moderate or
even of normal temperatures ; in his remarks on chronic phthisis
he refers to the low temperatures apt to be induced in this com-
plaint through the influence of inanition. Various efforts have
been made to reduce these forms to three or four types. Thus,
Dr. Finlayson suggested three types, stated in a condensed form
by Dr. Woodman in his translation of Wunderlich's ' Medical
Thermometry' (p. 413), as follows :

"First type. The morning temperatures are normal or rather
less than normal, whilst the evening temperatures are more or less
high. Second type. The morning and evening temperatures are both
high, whilst there are evening exacerbations. Third type. The
morning and evening temperatures are both high, but there is a
tendency to exacerbations at odd times."

M. Eude, in his remarks on the temperature in hectic fever,
tried to reduce the types to four varieties : — First. The morning
temperature normal, the evening more or less high. Second.
The morning temperature as well as the evening abnormally
high. Third. The morning temperature abnormally low and
the evening abnormally high. Fourth. The morning tempera-
ture abnormally high and the evening normal, or at least less
elevated than the morning one.

Schwarz recognises five types ; we again make use of Dr.
Woodman's abstract ('Medical Record,' 1876, p. 394.)

" A. The type of normal temperatures ; both morning and evening
temperatures are within normal limits, the evening being a few
tenths above the morning (17 cases).

" B. Type with sHght evening fever, with normal but seldom sub-
normal morning temperatures (20 cases).

" 0. Type of more intense evening fever, in which we get —

1877.1 Temperature in Phthisis and Tuberculosis. 261

" (1) Morning temperature normal or subnormal, so that the
charts resemble those of an intermittent quotidian or tertian fever.

" (2) The morning temperatures are febrile also, but a few tenths
lower than the evening ones, thus resembling a continuous remittent
fever (50 cases).

" (b. and c. are, however, members of one family.)

" D. The inverted type. In this the morning temperatures are
febrile, often extremely so, and the evening normal or only mode-
rately febrile.

'• E. The typus inversus intercurrens, which occurs occasionally
in all varieties of the fever."

He adds that these types run one into the other, and are
seldom constant.

Even this classification, although somewhat complicated,
does not include the '^ duplicated quotidian'' type mentioned by
Wunderlich, to which we must refer subsequently. All preci-
sion and simplicity are marred by the introduction of a type
with exacerbations *' at odd times,'^ or by such a source of con-
fusion, as the '^ typus inversus intercurrens."

The reader will not, therefore, be surprised to learn that
Prof. Lebert declares for the absence of all specific peculiarities
in the tubercular temperature; he can only speak of it as re-
sembling that of protracted inflammatory diseases, with a
moderate or a highly febrile character. Certainly, on reading
Lebert's analysis of his cases, one despairs of finding any regu-
larity in the temperature viewed on the whole, or even of
finding special groups of cases, or special sets of symptoms,
associated with any very definite character of the pyrexia ; this
writer attributes the variations in the different forms of the
temperature course more to individual peculiarities than to any-
thing else. Dr. Wilson Fox gives full particulars as to the
maximum, minimum, and average temperature observed in
his different classes of cases, with statements of the amount of
the remissions and exacerbations, and the variability of the
periods, whether night or morning, at which these exacerbations
occur. But although he brings out many interesting points as
to the kind and degree of pyrexia commonly found, he cannot
venture on any definite classification of fever types ; moreover,
his division of cases for statistical purposes is based in part on
the high or low character of the temperature itself, and this
does not seem well calculated to give value to some of the per-
centages which he calculates for each class.

Dr. Theodore Williams approaches the question somewhat
differently. He classifies his cases according to the evidence
supplied by the history and the physical signs, his division
being, 1st stage active, 1st stage quiescent ; 2nd stage ;
3rd stage active and 3rd stage quiescent, the three stages corre-

262 Reviews. [Oct.,

spending to the formation of tubercle, to softening, and to
excavation. He has also attempted more completely than
had been hitherto accomplished (at least in this country), to
ascertain the course of the temperature of his patients, in these
various stages, at short intervals during the whole period of
the twenty-four hours. The necessity of frequent observations
during the day and night, for the proper estimation of the
febrile course in these affections, had indeed, been recognised
before. Jochmann's cases were noted only twice or thrice a
day, but he specially mentions his regret at their deficiency in
this respect. Wunderlich had evidently been accustomed to
record the temperatures frequently in phthisis, as in other
affections, and in this way, no doubt, detected the " duplicated
quotidian" paroxysms of which he speaks. We are not aware,
however, of any detailed observations being published by him
regarding the temperature in phthisis. In Dr. Sydney Ringer's
first edition some of the cases were noted frequently, and Dr.
Finlayson, in one or two of his cases gave the temperatures in
the night and early morning hours as well as during the day,
but their cases, were too few to be of much use in this respect.
M. Eude (whose paper, however, we have not seen in detail)
seems to have had observations made during the night, as he
fixes the hour of the minimum about 4 a.m., and otherwise
remarks on the elevations and depressions during the day.
Leber t insists strongly upon the different view which observa-
tions taken every hour, or every two hours, give us as to the
real course of the temperature, although his published tables
refer exclusively to the morning and evening records. Dr.
Wilson Fox, likewise, while only tabulating his morning and
evening temperatures, had seen, from even a limited number of
intermediate observations, the necessity of accepting the con-
clusions drawn from such a method with considerable reserve.

Some may be disposed to ask of what use is it to make
observations with such frequency, or at such hours, as to pre-
clude the adoption of the method as a regular means of
inquiry even in hospital work, to say nothing of private prac-
tice ? We need scarcely, however, point out that the value of
such inquiries may be considerable although but little adopted,
chiefly as rendering intelligible the records obtained by a less
irksome method, or as guiding the choice of the hours for our
observations when they can only be made once or twice a day.
The results of such laborious inquiries come to be available for
the benefit of all practical physicians in the same way as
similar tracings of the diurnal variations of the normal tempe-
rature are useful, although they are not verified in each par-
ticular patient.

1877.] Temperature in Phthisis and Tuberculosis, 263

Returning to Dr. Theodore Williams's investigation we find
that two main peculiarities of the temperature in phthisis
are thus stated by him :

" 1st. The post-meridian character of the pyrexia when pyrexia
exists at all.

" 2nd. The remarkable fall at night, and the subnormal tempe-
ratures of the early morning."

This last peculiarity, although present occasionally in all
forms, is specially marked, according to Dr. Williams, in those
cases of phthisis which he classifies as '^ third stage active."
He gives various tables and diagrams to illustrate the course of
the temperature, which he thinks may be regarded as pretty
typical m this particular phase of the disease.

" The general characteristics of ' third stage active' may be
summed up : — 1st, Afternoon and evening pyrexia. 2nd. Rapid
fall during night and early morning. 3rd. Recovery in the later
morning hours and consequent normal temperatures."

According to him the febrile rise may be said, as a rule, to
begin shortly after 10 a.m., continuing usually till the after-
noon, the maximum occurring, or being pretty well sustained for
some time, between 5 p.m. and 10 p.m., about which hour the
decline begins, so that the minimum is reached or maintained
somewhere between 3 and 6, or 7 a.m., when subnormal tem-
peratures are often recorded. The figures obtained from averages
range from 98° to 101 i° (36*66° to 38-61°), but in individual
cases go considerably above and below these numbers. The
author considers this a great departure from the normal course of
the temperature, and he appends a diagram constructed from
observations made by Dr. Parkes, supplemented by some made
by himself, with the view of showing that the normal tem-
perature in the adult does not go through any similar
variation, but maintains a pretty even course between
98° and 99° (36-66° and 37*22°) during the night as well as
during the day. This part of Dr. Williams's paper seems the
weakest point in it, the range of night temperature in healthy
subjects being given from one night's observations on one
person. We do not think it represents the real facts. Thus,
Dr. Parkes (in a paper subsequent to the one quoted by Dr.
Williams, ^ Proc. Royal Soc.,' Feb. 12, 1874) found, in a
soldier, 25 years of age, that the temperature taken in the
rectum varied from 97'8° to 100*8° (36-55° to 38*22°), in one day,
taken from 6 a.m., to 10 p.m., and the temperature in the
axilla underwent similar although slighter variations ; a
greater range might, no doubt, have been obtained if the few
hours before 6 a.m. had been included. The frequent occur-

264 "Reviews, [Oct.,

rence of figures but little above 97° (36*11°) in tbe measure-
ments of the temperature (both axillary and rectal) in this
healthy soldier show how careful we must be in admitting the
existence of subnormal temperatures as a characteristic of
phthisis. We do not understand why Dr. Williams did not
avail himself of the elaborate observations of Jiirgensen/ to
which he refers, in seeking to compare the phthisical with the
normal course of the temperature.

According to Jiirgensen, the temperature of the rectum varied
from a maximum of 37'7°, or even 37'9° (9986° or 100-2^°),
to a minimum of SQ'T, or even 36*3° (98-06° or 97-34°), while
the subjects were in bed : and in the case of one not so con-
fined the variation was from 38-1° to 36-2° (100-58° to 97-16°),
a range of 1*9° C. (3*42° F.). Moreover, it comes out in
Jiirgensen's inquiry that the temperature during the late even-
ing and the midnight hours is much lower than that of the
daytime.^ Now this kind of variation does not seem to differ
essentially from the variation regarded by Dr. Williams as so
characteristic of phthisis, except that the temperatures in the
latter are usually higher, and occasionally somewhat lower, so
that the daily increase and remission are more considerable than
in health. It seems, indeed, pretty clear that the daily exacer-
bations and remissions, so common in febrile states, are essentially
modifications or exaggerations of the normal variations.

In the first stage of phthisis, when '^active," and also in the
" second stage," Dr. Williams seems to have found a moderate
degree of pyrexia, culminating in the afternoon, associated
frequently with the occurrence of subnormal temperatures,
especially in the early morning, and traceable in the observa-
tions made at 8 a.m. It was but seldom, however, in any of
the classes that the temperature went below 97° or 96° (36-11°
or 35-55°).

We have referred in a previous section to the range of tem-
perature not exceeding the normal to any serious extent in
those cases of phthisis which Dr. Williams classifies as *^ first
stage quiescent" and "third stage quiescent.^'

It is remarkable that this writer does not seem to have met
with cases presenting the inversion of the periodicity of the
daily paroxysm, at least with such frequency, or in such a
striking form, as to call for his notice. Some slight explana-
tion is afforded of this peculiar type by finding in a certain

^ * Die Korperwamie des gesunden Menschen,' Leipzig, 1873.

^ Dr. Sydney Ringer's recently published paper *' On the Temperature of the
Human Body in Health," confirms the existence of a considerable range of tem-
perature, at least in persons under twenty-five years of age, 'Proc. Royal
Soc.,' vol. xxvi, p. 186 (1877).

1877.] Temperature in Phthisis and Tuberculosis. 265

number of such cases the occurrence of a maximum in the fore-
noon, or at midday, followed by a considerable diminution of
the fever (as if the height were too great to be maintained con-
tinuously), and then, perhaps, a second elevation in the after-
noon or evening, which sometimes falls short of the maximum
already attained. In such cases of a double paroxysm, referred
to by Wunderlich, Lebert, and Wilson Fox, our morning
observation may catch the temperature near its first maximum,
and our afternoon and evening observations may happen to
coincide with the periods of decline. It is, of course, in the
study of such variations that frequent observations are so im-
portant, as without them we can never know whether the most
extraordinary changes have not intervened between the exacer-
bations and remissions which appear from mere morning and
evening records. This part of the subject has not yet been
sufficiently worked out, so that we need not discuss the pecu-
liarities of the daily remissions and exacerbations in their
degree and sequence. It seems as if a more intelligent view of the
pyrexial course might sometimes be presented by comparing the
number, intensity, and duration of the paroxysms and remissions
which occur during say ^Q> or 48 hours^ than by calculating the
mean of morning and evening temperatures absolutely, as the
delay or the acceleration of the pyretic process for an hour or
two may give rise to averages for these two periods which are
quite misleading. Subsequent observers have confirmed Joch-
mann's remark as to unusually high temperatures being often
followed by unusually low ones, although the converse does
not hold. A certain tendency to tertian paroxysms also spoken
of by him has been mentioned by other writers as well.

The course of the temperature before death has already been
alluded to, but the subject is so interesting that we must refer
to it in more detail. Although this part of the course is not
always uniform, most of the cases present, for the last day or
two days, a certain diminution of the pyrexia, so that we have
sometimes normal and sometimes very low temperatures. The
reality of this diminution is shown by its occurrence, even when
the measurements are made in the rectum or vagina, figures
about 94° or 95° (34-45° or 35°) being not uncommon, and
even lower temperatures are sometimes noted. Occasionally a
general and moderate diminution of the temperature can be
noticed for a few days before death, leading up to a period just
before the end, when extremely low temperatures are attained ;
but even in cases characterised by this diminution before death
there may be a sudden start up of the temperature again to a
considerable height,' to be followed by further remarkable

> ' Bilbaut/ pi. in, fig. 13.

266 Reviews. [Oct.,

oscillations ; usually, however, the oscillation tends ultimately
to a lowered temperature. Jochmann and Wunderlich pointedly
called attention to the great daily variations in the phthisical
temperature as being determined, in part at least, by the pro-
cess of inanition, which M. Chossat found so potent in causing
a diminution in the midnight temperatures of birds and other
animals during starvation, although the midday temperature
was affected only slightly. In the greater depressions which
frequently occur during the last two days of life in phthisical
patients, we have a further point of resemblance to M. Chossat's
results, as he found that the depression of the temperature,
and the consequent oscillations, which had been advancing
pretty steadily all through the experiment, became so extreme
at the end, that he had to separate the records of the antepen-
ultimate and succeeding days from the other figures, to prevent
the indications being swamped by the changes developed in
a very extreme manner on the day of death.

But it must not be supposed that the end always occurs in
the midst of a lowered temperature. It may coincide with one
of those curious exacerbations to which we have referred
as arising sometimes in the midst of low^ temperatures.
Occasionally, indeed, as happens frequently in other febrile
diseases, the temperature never falls at all, but rather rises
towards the hour of death, and this seems to be commoner on
the whole in acute tuberculosis than in chronic phthisis ; the
more frequent course seems to be for the very extreme eleva-
tions and depressions of temperature to become moderated by a
series of minor oscillations, so that death actually coincides
either with a tempertiture which is nearly normal, or with one
which indicates only a slight amount of fever.

We have already hinted that this diminution of the tempera-
ture before death might be mistaken sometimes by the inex-
perienced for an indication of improvement ; we must equally
add that diminutions of the temperature, remarkably similar to
those which are the precursors of death, occur not unfrequently
at various stages of the complaint, and are often recovered from,
without apparently any very serious change having occurred,
so that we must not base an immediately fatal prognosis on
such a behaviour of the temperature.

The bearing 0/ thermometry/ on the diagnosis and prognosis oj
phthisis must be considered in further detail before we close.
As just mentioned, the diminution of the temperature, especially
towards the level of collapse, is so common at the fatal ter-
mination of this disease that we dare not regard it as of
itself a favorable prognostic ; we must anxiously consider the
general aspect of the patient, and the state of the pulse, before

1877.] Temperature in Phthisis and Tuberculosis, 267

drawing any favorable inference from the mere abatement of
the fever. Nor does the moderate severity of the pyrexia in a
case of phthisis afford much ground for even a relatively favor-
able prognosis ; many of the most hopeless cases are those with
an intermittent febrile course of but moderate severity. No
doubt the cases with intense fever with but slight remissions,
and those also characterised by occasional extremely high
exacerbations, occurring in an erratic manner, are on the whole
the most unfavorable. On the other hand, periods of high
pyrexia occasionally come to a crisis, as it were, being probably
dependent on special pneumonic processes or complications,
which terminate in this way, although the remaining disorder
in the chest is amply sufficient to prolong the fever course. In
the more chronic forms, the absence of fever may be taken as
an indication that the disease is more quiescent than if it were
associated with distinct pyrexia, although the mere fact of the
temperature remaining within the normal limits is no guarantee
that the disease is not advancing to the destruction of the lung
and even to death. While, therefore, to one who is familiar
with the disease, and the common forms of temperature asso-
ciated with it, considerable assistance can be obtained from the
thermometer as regards the prognosis, no very definite principles
can be laid down. Very high and very low temperatures may
in turn indicate approaching peril, or may equally be recovered
from for a time ; and a moderate fever, or even a normal course
of the temperature, are very common towards the end of this
fatal disorder.

As regards diagnosis, most of the writers have a deep con-
viction of the value of the temperature observations, although
when they have attempted to formulate any very definite
doctrine, it is apt to break down in their ownhands, or, at least,
in the hands of others. The resemblance of the course of the
temperature in acute tuberculosis to that of enteric fever is so
considerable that Wunderlich takes the latter as indicating one
of the types of turberculosis, but notwithstanding this, some
assistance is obtainable from the thermometer in the discrimi-
nation of these affections from each other. Sudden elevations,
with irregular remissions, are quoted by Dr. Long Fox as
points by Avhich we may recognise acute tubercular disease,
even when symptoms simulating enteric fever may happen to
be present ; he says the temperature " is as irregular in acute
tubercle as it is regular in enteric fever.'^i Professor Lebert, also,
who cannot be accused of undue confidence in thermometrical
indications, regards the two diseases as presenting considerable

i ' Medical Times and Gazette/ 1870. Vol. ii, p. 263.

268 Reviews. [Oct.,

contrasts in this respect. The quick ascent to a considerable
height is absent, he says, in acute tubercle; the morning and
evening temperatures are, on the whole, less ; the remissions
are less pronounced, and are besides very unequal ; and the
inverted type is not unfrequently present. But it frequently
happens that cases with symptoms pointing to enteric fever,
after preserving for a time the continuous type of temperature,
with slight daily remissions not uncommon in both disorders, enter
on a period with a lower range of temperature, especially as re-
gards the morning observations, the evening paroxysms being
still maintained ; such a range, while quite consistent with the
notion of the convalescent period of enteric fever, may be
prolonged to such an extent that this view ceases to be tenable,
and the presence of tubercular disease, or internal abscess,
becomes at length only too certain. Protracted suppurations,
indeed, present a course of temperature not unlike those found
in some cases of phthisis, and possibly the suppuration going
on in phthisical cavities is responsible for part of the pyrexia
in such cases. Chronic pneumonia, and catarrhal pneumonia,
present types of fever which are essentially similar to those
found in certain cases of phthisis, and even of acute tuberculosis,
and the statement as to the possibilityof discriminating 'phthisis
with tubercles ' from ' phthisis without tubercles,' has not met
with confirmation from the most experienced authorities,
although from the perturbations of temperature developed in a
chronic phthisical case we may sometimes suspect the super-
vention of miliary tuberculosis. The occurrence of periods of
considerable elevation of temperature cannot always, or perhaps
even usually, be satisfactorily explained by the detection of
fresh pneumonic processes, the appearance of softening, or such
like. Indeed, the inexplicable nature of many of the sudden
changes in the temperature has suggested the idea of a blood
poisoning, from the absorption of morbid products, and it is to
be confessed that a certain resemblance to the pysemic range
of temperature may be noticed occasionally in some cases
of phthisis and tuberculosis. If we suppose with Lebert, as
seems reasonable enough, that these products differ in their
toxic influence, we can readily understand the immense
diversity of temperature found in cases, which on dissection
. may seem very similar. Or, if we choose to carry our specu-
lations in a different direction, we may suppose, with Schwarz,
that the varying periods of pyrexia correspond to the varying
times at which absorption of the toxic products occurs, while
the intensity of the fever, or the absence of it, may be attributed
to the varying conditions which favour or oppose the absorption
of such products.

1877.]

*s Cyctopcedia of Practice of Medicine, !26^

But while thermometry seems as yet unable to assist materi-
ally in the discrimination of the various processes which go to
constitute the affections clinically recognised as phthisis, and
while it cannot define certain types of tubercular fever and
mark them off from other affections, or even discriminate the
temperature course in certain cses of phthisis from that found
in healthy subjects, there can be no doubt of its immense value
in diagnosis.

If by its warning indications we are led to the careful scrutiny
of all patients whose temperature continues elevated, without
obvious explanation, this of itself is no mean benefit. But we
must remember that various diseased states, giving, perhaps,
no unequivocal external sign of their presence, may likewise
give rise to a continued elevation of temperature. It seems
quite certain, for example, that pernicious anaemia is associated
at times with a persistent elevation of temperature without any
inflammatory complication to account for it, and without any
tubercular process being present ; and it is likewise very pro-
bable that in syphilis, in certain obscure nervous disturbances,
and in rare cases of rapid cancer, we may have a considerable
elevation of the temperature persisting for some time.

Notwithstanding all the difficulties and sources of confusion
and error to which we have alluded, the physician who is
familiar with the various phases of phthisis and tuberculosis,
as well as with those affections most liable to be mistaken foi*
them, will often be able to gain hints from the temperature, in
particular cases, which are simply invaluable, although he may
be quite unable to formulate laws which could lay the least
claim to a general character.

II.— Ziemssen's Cyclopsedia of the Practice of Medicine.*

Diseases of the Brain.

The readers of this volume must admit the fitness of its
authors to address them on the subject of diseases of the brain*
Their names are all known in this country, and some of them are
very favorably known. With one exception they are all pro-
fessors at German or Swiss universities ; they have all devoted
much of their time and ability to the investigation of nervous

^ Cyclopcedia of the Practice of Medicine. Edited by Dr. H. von Ziemssen,
vol. xii. Diseases of the Brain and itt Membranes. By Prof. H. Nothnagel,
of Jena ; Prof. E. HiTziG, of Zurich ; Prof. F. Obkeneiee, of Bonn ; Prof. O.
Heubker, of Leipsig ; and Prof. G. Huguenin, of Zurich. English translation.
London, 1877.

120— LX. 18

^fd ileview^. [Oct.,

pathology, and three out of the five have been, or are at the
head of establishments for the treatment of lunatics.

To Nothnagel is allotted the task of dealing with the brain
in relation to its blood-supply, and in an able article he dis-
cusses ansemia, hypersemia, haemorrhage, thrombosis, and em-
bolism. The vexed question of the cerebral circulation and the
possibility of any variation of pressure taking place in the cere-
bral arteries, has been set at rest by the discovery of the rela-
tions which exist between the cerebro-spinal fluid and the fluid
in the perivascular lymph-spaces to the amount of blood in the
blood-vessels. The error of Monro in supposing that the quan-
tity of blood within the cranium was always uniform was shown
in the first instance by Sir George Burrows, who demonstrated
by careful experiment that variations in the relative amount of
arterial and venous, and in the aggregate amount of blood,
actually do occur. Of more recent experiments, that of Gaetz-
heus seems the most important, by which it was shown that
forcible injection of defibrinated blood into the carotid of a
horse was capable of producing a rapid flow of lymph from the
lymph-vessels of the neck. As the question stands at present,
Nothnagel asserts that variations in the cerebral circulation
must be attended by the following results : —

" 1. Increase in the quantity of arterial blood by displacement of
the cerebro-spinal fluid and the contents of the perivascular lymph-
spaces ; or when the compensation thus made is insufficient, by
elevation of the intra-cranial pressure. 2. Venous stasis by a retar-
dation of the arterial afflux. 3. Diminution in the aggregate quantity
of blood by an afflux of cerebro-spinal fluid, dilatation and flooding
of the lymph-spaces, or where this is insufficient by diminution of
the intra-cranial pressure."

This volume cannot be said to open well, for a more barren
article than the one devoted to cerebral ansemia it has seldom
been our lot to read. Our Teutonic neighbours have a grand
faculty of saying ^' donH know " in a learned manner, but a
plentiful use of Greek words, and the employment of an elabo-
rate classification, will scarcely prevent the merest tyro in
medicine from seeing that the present article has been mainly
spun from the inner consciousness of the various authorities
appealed to. We are told that we must have regard to acute
universal cerebral anaemia, universal cerebral anaemia of gradual
development, and partial circumscribed cerebral anaemia. The
first class is composed of cases of syncope, and death from haemor-
rhage. The second comprises the various mental conditions
which result from exhausting fevers and chlorosis; and our
whole certain knowledge of the third class is derived from cases
of ligature of the carotid artery. Thus our acquaintance with

1877.] ZiEMssEN*s Cyclopedia. Diseases of Brain. 271

cerebral anaemia pure and simple is very slight indeed^ and the
author would have done well to have written as little as possible
concerning a subject of which we have necessarily very little
knowledge^ and to have borne in mind the fact that the great
aim of scientific authors is to impart knowledge lucidly, and not
to concatenate words and sentences. It is curious^ too_, that in
the clinical description of death from rapid anaemia the occa-
sional occurrence of exaltation both of sight and hearings and
the restlessness and jactitation of the patient should have been
omitted. It is difficult to understand the fascination which the
dead languages have for some authors. What useful purpose is
served by dividing fainting fits into three varieties, eclysis,
lipothymia^ syncope — a releasing, an escape of the soul, and a
falling together? If any glimpse is to be got through these
Greek derivatives of the etiology or pathology of the disease, by
all means let it stand, but if no such purpose is served, we strongly
deprecate this childish clinging to a vain show of mock learning.
If, again, Marshall Hall called one class of cerebral anaemias
by the name of Hydrencephaloidj we feel quite sure that the
author would have felt no disposition to retain so misleading a
word. Surely to speak of Autochthotious thrombi is a tautology.
A thrombus in its conventional medical sense can be nothing
but autochthonous — that is, an aboriginal plug of local origin ;
for if it be shot into its position from another source, we call
it by common consent an embolism. It need scarcely be said
that the thirty-five pages devoted to cerebral hyperaemia are
occupied chiefly by speculations on various cerebral pathological
possibilities, and that definite statements based on accurate
knowledge are few and far between.

Passing on to the next section — that which is devoted to
cerebral haemorrhage — we take leave of shadows, and are more
profitably occupied in dealing with substantial facts. The
etiology of cerebral haemorrhage is a matter which has been the
subject of much controversial discussion, but the facts which
have been elicited by modern pathologists with much pains-
taking and industry have been such as to cause a practical con-
currence of opinion on all the more important points. Such
notions as that propounded by Rochoux, that softening preceded
haemorrhage, or that (taught by Calmeil) haemorrhage was
due to an inflammatory process, have been absolutely discarded.
It has long been recognised that cerebral haemorrhage is due to
disease of the cerebral vessels, to which in some cases no doubt
is added an increase of the arterial tension. The fact which
was brought prominently forward by Bouchard and Charcot,
that cerebral haemorrhage was usually the result of the rupture
of miliary aneurisms situated on the cerebral arterioles, was of

272 Revietvs. [Oct.,

prime importance as serving to show the complete analogy ex-
isting between spontaneous haemorrhages occurring in the brain
with those occurring elsewhere. The correspondence which has
been shown to exist between the commonest seats of these aneu-
risms and the commonest situations of hsemorrhage, is also of
as much importance as interest. The order of frequency in a
progressive descending scale has been shown to be the optic
thalami and corpora striata^ the convolutions^ the pons, the
centrum ovale, the middle cerebellar peduncles^ the cerebral
peduncles, and the medulla oblongata. The correspondence also
between the frequency of occurrence of these aneurisms and ef
apoplectic attacks (rare before forty, and then progressively
more common till advanced age) seems almost to complete the
proof of the interdependence of the two conditions. The dis-
pute between Bouchard and Charcot, on the one hand, and
Zenker, on the other, as to the local pathological change which
produces these aneurisms, is of less clinical importance. Both
observers admit the occasional occurrence of thickenings
(arterio-sclerosis) in the internal coat, but Charcot and Bou-
chard differ from Zenker in asserting that the aneurisms are
not necessarily dependent on the sclerotic condition. As to the
atheromatous change in the large vessels, which has long been
recognised, and which was long held to be sure evidence of a
similar change in the smaller vessels of the brain, and an indi-
cation in fact of the actual cause of the haemorrhage, opinions
have changed. It is recognised that in many cases of cerebral
haemorrhages the large vessels have undergone no atheromatous
degeneration, and that such change has only a secondary in-
fluence on the occurrence of haemorrhage —

" By causing an impairment of the normal elasticity of the walls
of the large vessels, so that they cease to check the force of the
pulse-wave to the normal extent, in consequence of which the blood-
pressure in .the arterioles (the seat of the miliary aneurisms) of
necessity becomes abnormally great."

In the absence of any satisfactory evidence to the contrary
it may safely be assumed that alteration in the blood pressure
is unable, without change in the arterial coats, to produce
haemorrhage. Eulenburg states that a j)redisposition to cerebral
haemorrhage only exists with one form of cardiac hypertrophy,
viz. that which accompanies the contracted kidney and the
arterio- capillary fibrosis of Gull and Sutton, and not with that
which results from lesions of the cardiac valves. The other
certain facts which we have as to the etiology of cerebral
haemorrhage seem to be but two — that its frequency bears a
direct proportion to the age of the patient, and that it occurs
more frequently in winter than in summer. The pathological

1877.] ZiEMSSEN^s Cijclopcedia, Diseases of Brain, 273

anatomy of cerebral hsemorrhage presents many points of in-
terest. The explanation of Heubner and Duret of the great
frequency with which the corpus striatum and its neighbour-
hood suffers is probably correct. The branches first given off
by the anterior and middle cerebral arteries supply the anterior
and middle end of the corpus striatum, together with the len-
ticular nucleus and the internal and external capsule. The
anterior and middle cerebral^ being the direct prolongation of
the carotid, are exposed to the full force of any increased cardiac
action, and thus " direct and indirect causes unite to make the
districts which thus supply liable to be the seat of hsemor-
rhage.'^ The passage of the exuded blood and damaged brain
and vessels through gradual inspissation and organization to the
formation of a cyst or cicatrix was followed by Cruveilhier, but
it remained for Tiirck to point out the secondary changes which
occur in the white motor nerve-fibres. These degenerative
changes do not occur with superficial lesions of the cortex, but
only with deeper lesions involving white matter as well as grey.
Especially have they been observed after lesions involving the
corpus striatum and the internal capsule, while they are much
less common when the optic thalami are involved. These de-
generative changes have been observed to travel through the
crus, the pons, and the anterior pyramids to the posterior por-
tion of the opposite lateral column, and to the inner part of the
anterior column of their own side.

The symptomatology of cerebral haemorrhage has been and
still is steadily progressing towards greater accuracy. One of the
most difficult points is the appreciation of the difference between
the symptoms of profound apoplexy and coma from alcohol
or opium. Prevost insists that in those cases, in which the
general muscular relaxation marks the true nature of the
attack, the deviation of both eyes towards the non-paralysed
side, together with the occasional rotation of the head in the
same direction, will often give a clue towards a correct dia-
gnosis. The significance of convulsions at the outset is doubtful,
and the interpretations placed upon them by different observers
— that they are due to a large extravasation, to the implication
of the pons or medulla, or the rupture of the floor of the fourth
ventricle, or the destruction of the walls of the lateral ventricles
— may all be said to be in need of confirmation. The explana-
tions offered also of those rare apparent exceptions to the rule,,
in which paralysis occurs on the same side as the lesion, are
scarcely to be accepted without question. There is no doubt
that such cases do occur, and the theories invented for their ex-
planation, that the pyramids in such cases do not decussate
(Morgagnij Brown-Secjuard), or th^t they redecussate (Schiff)^

274 Reviews, [Oct.,

belong merely to the category of ingenious hypotheses. Am-
brosi's theory, that the paralysis in these cases is due not to the
primary but to a secondary lesion, is more probable, and one
case has been reported which seems to lend some colour to this
explanation.

The paralysis of individual nerves as the result of cerebral
haemorrhage is a rare phenomenon ; and it is a noteworthy fact,
and one to be borne in mind in reference to modern views of
cerebral physiology, that the individual nerves of the limbs
have never been known to be paralysed from a purely cerebral
lesion.

The movement of paralysed muscles in association with others,
in obedience to emotional or reflex stimulation, is a matter ol
very great interest.

" Thus the muscles of one half of the face, usually completely re-
laxed, may, in connection with those of the unaffected side, perform
motions necessary to changes of expression, sometimes contracting
even more strongly than do the healthy muscles, as in laughing and
the like ; in other cases, on the contrary, the difference between the
two sides of the face comes out all the more strongly under changes
of expression. Under the influence of emotional excitement, such
as anger, the paralysed extremities may be more forcibly moved than
the other ; when the patient coughs, gapes, or sneezes, during mic-
turition or defecation, the paralytic member may be jerked strongly
into the air, or may fall into a state of convulsive twitching ; if a
certain amount of contraction is already present, it becomes still
more decidedly marked ; and yet withal the utmost eff'ort of the will
may be unable to provoke the least motion."

Nothnagel also draws attention to the well-known fact that
when strychnia is administered the paralysed muscles are the
first to be the seat of " twitchings.'^

Those curious cases in which the motor impulse seems to
escape from the paths of exact volition, in which the paralysed
side imitates feebly the movements of the sound side, or in
which during recovery the reverse takes place, or in which,
during the voluntary exercise of a paretic limb, the antagonists,
as well as the muscles which it is wished to call into play, con-
tract, all aftbrd food for reflection, and remain to be explained.

The post hemiplegic contractions of muscles, which are best
seen in the flexors of the forearm, have also been the subject of
close scrutiny among clinicians. Hitzig has called attention to
the fact that they only become absolutely fixed and immovable
after a lapse of years.

"In the early period of their existence the contracted muscles
may relax so as to allow the paralysed limb to reassume its normal
position. This occurs when the patients have remained quiet and at

(

1877.] ZiEMSSEN^s Cyclopaedia. Diseases of Brain. 275

rest for some time, especially if they have been lying down without
moving. Since these conditions exist pre-eminently during sleep, it
sometimes happens that in the morning, on awaking, such patients
find the muscles, which were strongly contracted the evening before,
relaxed, and in part under the control of the will."

The theory put forward that these contractions are merely
due to the irradiation of motor impulses, to certain centres in
the lower sections of the encephalon, whence they reach the
muscles, seems to us to be so nebulous as scarcely to merit the
notice which is accorded to it by Nothnagel. When the con-
tracture of muscles is clonic, and not tonic, we are confronted
with those post hemiplegic clonic conditions which have been
long recognised, and which were scarcely in need of Hammond's
nonsensical name, athetocis.

The fact that paralysis, as a symptom of all nervous lesions,
whether central or peripheral, is always more marked than
anaesthesia, has long been recognised. Permanent ansesthesia
is one of the rarest phenomena of hemiplegia, and when present
is supposed to be due to the implication of the posterior part of
the internal capsule, the innermost division of the lenticular
nucleus, the external superficial layers of the optic thalamus,
and the adjacent parts of the corona radiata. Localised lesions
of the peduncles or pons have also been accompanied by anses-
thesia.

The trophic and vaso-motor disturbances which accompany
hemiplegia are chiefly remarkable by their absence. The limbs
retain their normal plumpness and colour, and the muscles
neither waste nor degenerate. Neither is there any undue
tendency to bed-sores, except in the case of the very feeble or
the neglected. A slight rise of temperature and a slight hyper-
semia, together with a spurious kind of slight oedema of the
paralysed limbs, causing a swollen appearance of the fingers, is
occasionally noticeable. The occurrence of acute bed-sore is
wholly exceptional, and the explanations given of it are, on the
whole, flimsy and untrustworthy. The reference of these
phenomena to the influence of '^trophic nerves'' is, so it seems
to us, the giving of names to '''airy nothings,'' whose local
habitations we are unable to define.

No more important advances have been made in cerebral
pathology than in the localisation of lesions, and Nothnagel is
to be commended for the temperate manner in which he has
discussed the entire question. Owing to a sudden illness just
as his article was going to press, our author was unable to
enter as fully as he had wished into the symptomatology of
lesions of the cortex cerebri. This omission may, we hope, be
repaired at some future period, for it is surely greatly to the

276 Reviews. [Oct.,

benefit of medical science that questions of this kind should be
discussed in the judicial spirit which is everywhere apparent in
this section, and not by violent partisans of this or that method
of experimenting, who, in the zeal for that reputation which
naturally accrues to discoverers of new things, are rather apt
to attempt to prove somewhat more than the facts warrant. The
facts which seem most favorable for the diagnosis of lesions in
the pons seem to be contraction of the pupils and paralysis of the
face on the opposite side to paralysis of the limbs. It must not
be forgotten that dilated pupils have been seen with haemor-
rhage in the pons, and that the distribution of the paralysis is
not constant, e. g.y paralysis of all four limbs, paralysis of hemi-
plegic type without implication of the face, extreme hemiplegia
without alternation and with implication of the facial, and
hypoglossal on the same side, hemiplegia with paralysis of both
facials, and paralysis affecting cranial nerves only, have all been
described. The occurrence of alternative paralysis is said to
occur with lesions of the lower part of the pons.

The occurrence of anaesthesia, impairment of speech (anar-
thria), and convulsions are also in favour of a lesion in the
pons. Here it becomes necessary to enter a protest against
this word anarthria, which is useless and misleading. The
word apOpov is used in medicine for articulation not of words,
but of joints, and although the word ap9p6u) has a meaning
which is applicable to the articulation of words, this is not its
conventional meaning. A child who speaks with its mouth full,
or one with a cleft palate, or with an ulcer on the tongue, are
all equally anarthritic, and there is nothing in the word itself
which would exclude ordinary aphasia. A Greek scholar would
interpret " anarthria '^ as a lack of joints, and could not, by the
word alone, be led to suppose that it indicated a paralysis of the
tongue, a localised tongue-palsy (not a bad word, and the same
length as anarthria), from implication of the hypoglossal.
Leyden has invented this foolish word, and we do not thank
him.

Lesions of the cerebral peduncles are often readily diagno-
sible. The paralyses are of true hemiplegic type, and if the
lesion is extensive, there may be considerable anaesthesia as
well as paralysis. The distinctive point is the implication of
the motor oculi on the side of the lesion. This occurs when
the inner half of the pons, which is mainly composed of centri-
fugal fibres, is implicated.

The symptoms due to lesion of the corpus striatum are well
known, and it does not seem possible to distinguish between
lesions of the lenticular and caudate nuclei.

Lesions affecting the optic thalamus exclusively are very rare.

1877.1 ZiEMs&EN^s Cyclopedia. Diseases of Brain. 277

and the general opinion seems to be that they do not cause
motor paralysis, although if the inner capsule as well as the
thalamus be involved, motor paralysis results.

The traditions of modern medicine are well maintained in the
present article by the smallness of the space devoted to the dis-
cussion of treatment :

" There is," says Dr. Steele, in a recent article on hospital mor-
tality, " no experience more painfully evident in hospital narrative
than the absence of guiding principles in therapeutics, and when we
come to examine the multifarious remedies which formerly were
vaunted as specifics, and which have been replaced by others that
in the course of another generation will be classed among the
fashionable follies of the day, it is impossible to avoid the conclusion
that physic per se is powerless as an agent in prolonging life, or
in grappling successfully with the ordinary fatal ailments of
humanity."

In the eyes of Nothnagel cerebral haemorrhage is a fatal
ailment, which forms no exception to the rule. In addition to
the dietetic and hygienic regimen to be observed, concerning
which most practitioners would agree with our author, Noth-
nagel speaks of the possibility of lessening (in some few cases)
the cerebral pressure by having recourse to venesection, and he
also lends his countenance to the practice, which is more com-
mon in Germany than in this country, of applying galvanic
currents to the head and to the affected limbs. He testifies to
the good results occasionally obtained by having recourse to this
practice. Anything which is recommended by so temperate a
writer certainly deserves a fair trial.

Nothnagel's articles on thrombosis of the arteries and sinuses
of the brain, and on the all-important subject of embolism, are
carefully written, and are admirable alike for their method and
their matter. It is only natural that frequent allusion should
be made to ^^ aphasia,^^ and it certainly would appear that a full
discussion of this important subject should have been made in
immediate connection with the causes which produce it. We
are constantly told, however, that aphasia is treated of " else-
where," but where that '^ elsewhere '' is is not very definitely
specified. It is nowhere in the present volume certainly.

We much regret that it is impossible within the ordinary
limits of a single article to do proper justice to a volume of this
kind, which contains so many exhaustive monographs, each one
of which is worthy of lengthy comment.

The section on tumours of the brain and its membranes, by
Oberneier, will be read with great interest, since the introduc-
tion of the ophthalmoscope has so greatly increased our power
of diagnosis in these cases^ and has so largely directed profea^

278 Revieivs. [Oct.,

sional attention to the whole subject. It cannot but be of in-
terest to our readers to set before them Oberneier's opinion on
this most important point. Speaking of the implication of the
functions of the optic nerves in cases of intra-cranial tumour,
he says :

" We have here amblyopia and amaurosis, as the cause of which
the ophthalmoscope shows the choked disc or congested papilla, and
neuro-retinitis, and attention must be specially directed towards
contractions in the field of vision.

" Decrease in the acuteness of vision, even complete blindness, is
not only very frequent in cases of cerebral tumours, but also often
one of the first symptoms. Upon the basis of a very diligently
collected complete complication o£ cases, Annuske arrives at the
conclusion 'that optic neuritis is almost without exception a con-
stant attendant upon cerebral tumours, and consequently occupies
the first rank among all the symptoms of intra-cranial neoplasms.'"

" So long as the absence of the choked disc in cerebral tumours is
regarded as a rare occurrence, as other ophthalmologists also con-
sider it to be, one cannot value the importance of the symptom in
question too highly, nor be insensible to the duty of subjecting
* suspicious disturbances of sight ' to a careful ophthalmoscopic in-
vestigation. It does not concern us here to enter into a description
of the ophthalmoscopic picture, to paint the swollen, opaque, and
imperfectly defined optic papilla, with its fine arteries and broad
and tortuous veins ; it is of more importance for the comprehension
of the appearances to remark that we have to deal with a degenera-
tive process in the nervous elements, in which the increase of the
intra-cranial pressure plays a chief part. If, namely, in consequence
of the development of an intra-cranial tumour the pressure within
the cavity of the skull is increased, the fluid between the sheaths of
the optic nerve which communicates with that in the subdural
space will become dammed up, and the optic nerve at its place of
entrance into the globe will become incarcerated, and will undergo
an oedematous swelling at this point, which, no doubt, hastens dis-
organisation in the prolongation of the nerve."

The diagnosis of the situation of tumours is also a subject
concerning which the experience of clinicians will be sought for
the confirmation or refutation of the teaching which physiolo-
gists are oiFering, as in the matter of functional localisation.
The amount of evidence of this kind is_, however, not great, and
it must be admitted that, for the present, Hitzig, Hiltsch, and
Terrier are ahead of clinical experience. Concerning hemiopia
as a sign of cerebral tumour our knowledge is more precise, and
the following is what Oberneier has to teach us as to the dia-
gnosis of —

" Tumours of the Base in the Neighbourhood of the Optic Chiasma.

" (a) Anterior to the chiasma. — Disturbances of the sense of
smell; injury of the fibres of the optic nerve, which pass to the

1877.1 Pathology of Granular Kidney. 279

inner half of the retina, and consequently hemiopia, in which the
defect lies to the outside in the field of vision of each eye.

" (5) Laterally from the cJiiasma. — When the tumour advances
towards the chiasma, disturbance of function of the optic fibrillae ;
those on the side of the tumour supplying the external half, those
on the opposite side supplying the inner half of the retina, hence
right- or left-sided hemiopia.

" ((?) Behind the chiasma. — Lesion of the optic fibrillae, which
pass to the outer half of the retina ; hence hemiopia with the defects
inwards on each side.'*

And here we regret that we are obliged to leave this very
important volume, a volume which adds immensely to our stock
of organised knowledge. We can have no doubt that, were it
possible to purchase this volume apart from its fourteen com-
panions, it would command a very large sale. One can purchase
a single volume of the ' Encyclopaedia Britannica/ and why not
a single volume of this ' Medical Encyclopsedia ^ ? We think it
would be more public- spirited on the part of the publishers to
issue the volumes according to the demand, and this would
surely be the most profitable course for them to pursue.
Among auctioneers it is a common plan to ^'lot '^ the worthless
with the attractive articles, but the trade of the auctioneer has
its necessities which medical publishers need hardly copy.

Heubner's articles on cerebral syphilis, Huguerin^s on in-
flammatory affections of the brain and its membranes, and
Hitzig's on atrophy and hypertrophy of the brain, are all full of
information and well written, and it is due to these authors to
state that it is only our want of space which compels us to leave
their very valuable work unnoticed.

III. — Pathology of Granular Kidney.^
Theue is, perhaps, no disease which better shows the methods
and success of modern medicine than the form of chronic Bright's
disease now generally known as the granular kidney. To those
sensitive and faithless persons who have not heart and vigour
to see that the time now our own is the greatest time the world
has yet ever seen, it might be a sufficient instance to take this
one disease, and point out how, within one generation, keen
patient observers, ardent in their great calling, have tracked out
the causation, the pathology, the clinics, and, let us add, the
therapeutics of it, to the great enlargement of our knowledge

1 1. Lumleian Lectures on the Muscular Arterioles. By Geoege Johnson
M.D., F.K.S. London, 1877.

2. Diseases of the Kidney and Urinary Derangements. By W. Howship
Dickinson, M.D. London, 1877.

3. Ziemssen's Cyclopcedia of Medicine, vol. xv. Diseases of the Kidney.
London, 1877.

280 Reviews. [Oct.,

and of our power, to the relief of pain and the lengthening of
life. Even among ourselves there are men — and these not the
least accomplished of physicians — who are heard to say that
the boasted advance of pathology has done but little for us, that
pathology is a pretty study, but one that leads, or has led, to
nothing. They say that the strokes of disease fall as heavily
as of old, that its weapons are as keen and its victims as nume-
rous. Such men are better than their words, for did they realise
what they profess, so curious a search into so painful a subject
as bodily decay would become revolting to them. Their lan-
guage arises from a misapprehension of the kind of help which is
to come. Even yet, dominated by the traditions of the merest
empiricism, such physicians, like their patients, have learnt to
believe in Jordan as little as in the rivers of Damascus, and
seek rather for some trenchant specific than for that power of
gradual counteraction and prevention which can come only of
minute knowledge of cause and consequence. In the malady of
which we have now^ to speak it is as certain as we have found it
to be in others, that organic disease is most frequently the record of
morbific impressions scored in more and more deeply, line upon
line, until the original characters of life are nearly obliterated.
Little can be done in the later states o^f such a palimpsest, and
the therapeutics of chronic disease must be rather in the early
detection and interception of such impressions. If we are to
succeed in therapeutics we must learn how, where, and when
we can work that our labour may bring its reward. It would
seem that the labour of many workers — chiefly English, we
gladly observe — has brought up the inquiry into the nature and
phenomena of granular kidney by many converging lines to
degrees which must shortly meet in some central and fruitful
generalisation. It is the difficult duty of a reviewer at such a
time, when other men would be silently working on, to speak,
however imperfectly, in the hope of so laying the matter before
his readers that the many may learn exactly the present direc-
tion of inquiry, and the few be led so to reconsider the present
phase of knowledge as the better to prepare themselves for
the pursuit of further researches.

The earlier differentiations of the diseases of the kidney
discovered by Bright are unknown to few persons, now that
the great divisions of them into tubular nephritis, granu-
lar kidney and lardaceous kidney, have been made familiar
enough by the work of such men as Johnson, Beale, Traube,
Dickinson, Grainger Stewart, Roberts and many others. And,
to go a step farther, it is now well known enough that, w^hat-
ever be the causes of each of these — and on this inquiry
observers differ— all are nevertheless agreed that they arise

1^77.1 Pathology of Granular Kidney. 2Sl

independently of each other, and that tubular nephritis never
gives rise to lardaceous disease nor lardaceous disease to tubular ;
and that, again, neither of these, as a rule, gives rise to the
granular kidney, however fully we admit that such a sequence
may be pathologically intelligible and occasionally seen; indeed,
we may take it as generally admitted that when an uneven
shrunken kidney does result either from the tubular or the larda-
ceous disease, this state is not wholly to be confounded with the
more definite granular kidney which, in the vast majority of cases,
has other antecedents, and runs a different course. It is to this
form, and its interesting relations with other changes almost
throughout the rest of the system, that we propose now more
especially to limit ourselves. How are we then to define the
disease under consideration ? Perhaps something after the fol-
lowing kind :

Granular kidney is a disease of a sub-inflammatory nature,
slow though always fatal at last, in which both kidneys at
similar but not identical rates (enlarge wholly or partially and
subsequently ?) diminish in volume, chiefly at the expense of
their cortical portion, their surfaces becoming granular in ap*
pearance and their capsules adherent and thickened. The
disease is associated with hypertrophy of the heart (especially
in its left ventricle), and of certain large groups of the muscular
arteries. Its more constant symptoms are high arterial ten-
sion, light urine, albuminuria, anaemia^ slight pigmentation,
emaciation and debility, and at a later stage nausea, vomiting,
coma and other common effects of ursemia. Its occasional and
intercurrent symptoms are diuresis, spasmodic dyspnoea, haemor-
rhages, epilepsy, partial blindness, serous effusions, bronchitis
and gout. It ends, for the most part, in apoplexy or ursemic
poisoning, or it may be by disease in the serous cavities. Its
better known causes — which, however, account only for some
of the cases — are (speaking provisionally) heredity, mental
anxiety, prolonged venous congestion, as, by way of pregnancy
or heart disease, obstruction in the urinary passages or ascent
of inflammation, lead-poisoning, alcoholism and gout.

Let us now take up our definition, and discuss each of its
points in turn, or such of them as may seem to demand discus-
sion. The disease is a slow one in its course and sub-inflam-
matory in its nature. The time of death, however, is too
uncertain to be surely or approximately predicted in the indi-
vidual case, the uncertainty chiefly arising from three things —
from th€ liability to acute intercurrent renal inflammation, and
to encephalic haemorrhage, and from thelessened margin of safety
in the organism as a whole. Ura^mic poisoning rarely occurs
till a late stage of the malady unless there arise an intercurrent

S83 Reviews. " [Oct.,

attack of acute renal inflammation; and whether it be that gra-
nular kidneys are especially susceptible of inflammation, or that
transient renal congestions which pass over sound kidneys without
harm gather to a dangerous height in the granular^ it is hard
to say. However this may be, intercurrent nephritis in these
cases is common, and may cut the thread of life by acute
uraemia or otherwise. It is now three years since 1 was called
suddenly to a man of middle life whom I found in epileptiform
convulsions and coma. He had been afl'ected with granular
kidney for some indefinite time previously, and after the cere-
bral symptoms and other evidences of acute nephritis were
subdued he drifted back into his former sallow state with big
heart, tense pulse, sallow skin and slight albuminous urine of
low gravity ; indeed, under continuous treatment, his condition
has been better during the last two years than for the twelve
months before the sudden anuria, hsematuria, and increased
albuminuria immediately preceding the acute ursemic out-
break which laid him by for three weeks. This is a well-
marked instance of a class of cases by no means uncommon.
Again, the patient who escapes intercurrent nephritis may be
stricken down by encephalic haemorrhage almost in any stage
of the disease. Jt is a fact insufliciently commented upon, not
only that patients with granular disease may, as post-mortem
experience proves, be smitten with such apoplexy in the early
stages of the disease, but that this is also true of men under
middle age. A man, therefore, of the age of forty or forty-five
years with granular disease is but little safer in this respect
than his seniors, whose arteries are otherwise more likely to
give way ; so that granular kidney, independently of senility,
causes or coexists with arterial incontinence. It has been said
of late, indeed, that haemorrhages both old and recent, too small
to be obvious in themselves or in their symptoms, are found more
or less abundantly in the brains of most of those who die with
granular kidneys. These details are of great importance, as
we shall see hereafter when we come to consider the relations
between this state of the kidneys and the arterial tree.^ Thirdly,
patients with granular kidneys are very liable to death before
the time of the direct issue of their malady, because their margin
of safety is lessened.

One of the first questions which the experienced physician
asks himself when called to the bedside of a patient in acute
disease is, what is the factor of safety ? If it be large all
may be well, if narrow the danger is the greater. In all engineer-
ing works, when the estimated strain has been calculated, the
bridge or crank is made equal to that strain, with the addition
^ Cf. pp. 293-4 of the present article.

1877.] Pathology of Granular Kidney. J^SS

of a large margin of strength to cover possible excess of
strain and certain internal molecular change. This addition,
known as the factor of safety, exists in the human frame, and
is in young persons very large, but it diminishes more or less
rapidly in later years, or in insidious disease. A recovery from
pneumonia may entirely depend not on the resistance of the
lung, but of the heart or of some other organ, and the condition
of no organ is a matter of more anxious questioning at such
times of stress than that of the kidneys. Like Archimedes, the
physician may say, " Give me good kidneys and I will move the
man.'' When I was first called' to the charge of medical wards
nothing startled me more than the frequent deaths of patients
from fevers and acute diseases, who, to a young observer, seemed
likely to recover. A close perusal of the dead body gradually con-
vinced me that such deaths are due not so much to the arrest of
the part attacked or to the intensity of the poison received as to
some pre-existing diminution of the factor of safety. Moreover,
it is in two organs mainly that we are liable to find the factor of
safety diminished, and these two are the heart and the renal ap-
paratus. Thus it is, then, that not only may the lives of subjects
of granular kidney be cut short before the normal term of that de-
generation by intercurrent nephritis, and by apoplexy, but also,
and perhaps more frequently and in still earlier stages, by a dimi-
nution of the factor of safety, which renders them liable to be car-
ried off by any chance poison or accidental malady. Subject to
these inessential changes, however, granular nephritis is a slow
disease; that is, it may occupy from five to ten years or more in
its course. In the next place it is subinflammatory in its nature,
though it must be said that here we are met by some divergence
of testimony. Dr. George Johnson, whose name as an early inves-
tigator of renal diseases comes second only to that of Bright him-
self, sees in granular kidney a change primarily intratubular,
and seated in the epithelium. Dr. Dickinson, on the contrary,
and with him many other original observers, both English and
continental, sees in granular kidney a process identical with that
which in the liver is called cirrhosis, namely, a morbid out-
growth of connective elements, which after their manner con-
tract as they mature, and thus strangle the kidney mechanically.
This process in some exceptional cases may be general and
acute, as seen in a plate upon page 865 of Dr. Dickenson's
treatise on albuminuria. This observer declares that the changes
in the epithelium are entirely of a secondary character, and
consist chiefly in those changes of form which mechanical com-
pression would necessarily produce. In the earliest stages of
acute general connective hyperplasia of the kidney, and of that
which results from pregnancy and heart disease, an enlargement

^84 Review^, [Oct.,

and condensation of the organ is seen ; in the chronic form a
stage of enlargement, if it exists, would rarely be seen, save in
cases of death from other causes ; and it is even probable that
the enlargement may not be universal, but so distributed in
districts that the bulk of the whole would suffer little or no
increase. The contraction, however, is probably as inexorable
as that of a burn in the neck, and how little we can arrest that
superficial and palpable movement many a poor creature knows
but too well. In the kidney it probably bears a definite and neces-
sary relation to the amount of foreign irritation and proliferation,
so that the latter being ended the grip of its consequence can
in no degree be eluded. If then the usual course of the affec-
tion be a gejieral hyperplasia, followed by a general couU?iQi\o\\,
interference after the first stage of the malady, — a stage pro-
bably of partial or complete latency, would be hopeless so
far as structure is concerned. Hence it is that it seems
incumbent upon us to learn exactly whether such be the
course of the disease, or whether, its early course be a
smouldering heat advancing from point to point, and thus
susceptible of some arrest or delay. Much of our therapeutical
hopes obviously depend upon the question of general or frac-
tional invasion. Once more ; it is by no means to be assumed
that all interstitial proliferation, even if identical in nature, must
in every case lead to contraction as a consequence. Abundant
nuclear matter is to be seen in the true skin in many an inflam-
mation which does not lead to scarring, and so, perhaps, few
cases of tubular nephritis are to be seen without some measure
of interstitial nucleation. Dr. Dickinson, Dr. Klein, Dr. Green-
field and others have shown that in the scarlatinal kidney for
instance, interstitial proliferation is almost as copious as intra-
tubular, and yet complete recovery from scarlatinal nephritis is
the rule, at any rate in young patients. On the other hand, it is
certain that same nuclear proliferation, if it does not vanish in
its youth, fibrillates in maturity and shrivels in age, for the end
of uncured scarlatinal nephritis is granular kidney. At the Man-
chester meeting Dr. Dreschfield showed a good section of kidney
in which intra- and intertubular proliferation were visible to-
gether, and on pp. 259 — 263 of Dr. Dickenson's work are
shown some beautiful woodcuts of the same coexistence. It is
probable that these diffuse inflammatory changes are more
common in the scarlatinal kidney than in the ordinary smooth
white kidney, but the difference is perhaps one of degree
rather than of kind. Dr. Grainger Stewart has insisted upon
this side of renal pathology for many years. It is of vital
interest for us as preservers of life to recognise the forerunners
and the initiation of granular kidney, seeing that to recognise

187^.]

Pathology of Granular Kidney. 2S5

it when fibrillation is widely extended or implied is a compara-
tively useless flash of diagnosis.

Before turning to causation, however, let us complete our re-
marks upon pathology. Our readers know well that the interest
excited by the changes discovered in the kidneys has almost paled
beside the emulous discussions upon the correlative changes in
the heart and arterial tree. These discussions, led by Dr. George
Johnson of the one part, and by Sir W. Gull and Dr. Sutton of
the other part, revolve about two main issues. Dr. George John-
son has it that the whole state of change is rooted in the kidneys
themselves — that the kidneys failing cease to purify the blood,
that the blood thus impure is offensive to the body and its tissues,
that the muscular arterioles therefore defend the capillaries and
the tissues against the entry of the impure blood, that they do
this by contraction of their muscular coat and diminution of
their lumen, that in this way the blood tension on the central side
is heightened, that the pressure upon the inner surface of the left
ventricle is thus heightened, that as a consequence of their ex-
cessive contraction the arterioles become hypertrophied, and
finally, that in consequence of their hypertrophy and increased
resistance the left ventricle of the heart in its turn grows
abnormally. Now, although Dr. Johnson attributes a selective
function to the arterioles, and attributes their overgrowth in
muscle to their excessive efforts in the defence of the tissues
before them, yet this assumption, if true, is needless to his
main argument ; and if other pathologists prefer, as certainly
many of us do prefer, to suppose that the impure blood directly
sets up contraction in the arterioles by irritation and reflexion,
the argument as a whole is but little altered, and not altered at
all in its main bearings. It still stands thus. The kidney
which should purify the blood fails to do so, and the blood so
far is stained with impurity ; the blood thus impure irritates
the arterioles which contract upon it, and in time become,
therefore, hypertrophied ; by their increased average pressure
the thrust upon the ventricle is increased, and finally this latter
is also hypertrophied. I suppose it is not improbable that the
heart, so susceptible to poisonous influences, may also owe
some of its hypertrophy to reflexion of the irritation of the
impure blood from its own lining to its own muscle : to this
point I shall return presently.

Sir William Gull joins issue with Dr. George Johnson both
in respect of fact and inference. Sir William, like many other
clinical observers, appears to be profoundly impressed by the
apparent constitutional character of that malady of which
granular kidney is, in his view, but one of the expressions.
By constitutional character we mean that the whole man seems
to suffer from some widespread or widespreading change, in-
120— Lx. 19

286 Heviem. [Oct.,

volving all his tissues, or whole and various districts of tissue in
a common degeneration. Without quoting Gull and Sutton
verbally, one may express their meaning in this way, — that the
change is one of retrogression or involution affecting several
tissues, especially in and by way of the blood-vessels, and this
a sa fibrosis, — that, in a word, the disease is a disease of senility,
using the word senility in the sense of organic rather than of
solar revolutions. To Dr. Johnson, then, the disease is a kidney
disease with its consequences, to his opponents it is a systemic
fibroid degeneration, mainly arterial and peri-arterial in distribu-
tion, of which the renal changes are but one expression. Upon the
facts their divergences are also curiously opposite. Dr. Johnson
stated, in 1856, that in granular kidney the muscular coat of
the arterioles is hypertrophied, in some degree perhaps every-
where, but especially in those districts which supply the kid-
neys, skin, and other glandular structures. Dr. Johnson admits,
of course, that degrees of degeneration are present, but believes
that they are secondary and nonessential. Sir William Gull and
Dr. Sutton deny, or almost deny, that any substratum of exces-
sive contractile power is present at all in the arterioles ; that
their obvious thickening is but a lower fibroid transformation
— a dead or dying surplusage. Here is a difficulty out of
which it may be hard to find a way — a direct issue upon
facts between eminent observers, which is not easily to be
reconciled by smaller men. Indeed, we cannot talk alto-
gether of reconciliation, for no quarter can be given to *'facts."
If the present writer may speak for himself he must say that
the view proposed by Sir W. Gull and Dr. Sutton has some-
thing very like truth about it at first sight, as it seems so
much in character with the causes, time of appearance, dura-
tion and issue of the malady. Moreover, that the kidneys
should primarily begin to cirrhose was so far unlikely as this,
that the liver, when it thus contracts, does so only in obedience
to the poison of alcohol. But granular kidney, if it may be
due to alcohol, is not usually so brought about. It is, on the
contrary, a disease from within, a disease often undoubtedly of
inherited or acquired tendency, and comparable with sclerosis
in nervous organs. It is found in persons whose family histories
are bad, or who have been subject to unusual wear and tear.
So much in limine. But for my own part I must confess that
other facts seem to me to be as reported by Dr. George Johnson.
By the kindness of Dr. Johnson I have been able to examine
his preparations with some deliberation and care ; I have had
also in my possession for three months Dr. Dickenson's prepa-
rations, which may be taken as impartial witnesses herein ; I
saw Dr. Sutton's preparations at Manchester ; and, finally, I
have examined not a few cases myself in the fresh state. The

1877.] Pathology of Granular Kidney, 287

result of my opportunities is, that I side undoubtedly with
Dr. Johnson, and am led to the conclusion that the arterioles
are the seat of genuine muscular hypertrophy, accompanied, as
one might well expect, especially in advanced cases, with
evidence of secondary degenerations in the adventitia and else-
where. If this be granted we must reason as follows. Hyper-
trophy of the muscular coat of the arterioles tells unmistakeably
of overwork, and by no means can be regarded as evidence of
primary decay. Now, what work have the arterioles to do ?
I do not agree with Dr. Dickenson that their contractile action
can ever be in propulsion of the blood. Their action is not
peristaltic, nor does it seem mechanically possible that the con-
traction of their muscle can have any result save the lessening
of their own lumen, and the creation of a hindrance to
the passage of their fluid contents. The tense and prolonged
blood-wave seen in the sphygmographic tracings of the patients
in question certainly proves that the blood-passage is not
favoured, but is hindered in the terminal arteries or in the
capillaries. Working backward, then, from what we believe to
be ascertained fact, we say first that the muscular coat of the
arterioles is hypertrophied, that it has therefore been con-
tinuously overworked, that its work is one work only, namely,
to lessen the calibre of these vessels, that such lessening, not
being peristaltic in character, and the contents being fluid,
must have resulted in a prolonged interception of the blood flow-
ing towards the tissues. This argument is supported by the fact
that in the agony of death from granular kidney the vascular
relaxation is often followed by free sudatory excretion, the
effused sweat, as it dries, leaving crystals of urea upon the skin
and hair. The diminution of blood, on the other hand, being
but imperfectly prevented by the hypertrophied heart, seems
manifest during life in the early wasting, superficial ansemia, and
general languor and nervo-muscular debility.^ The explanation
of this contraction seems to be that the acrid blood acts upon
the arterioles as a pin or a drop of acetic acid may be seen
to act upon them in the web of the frog. Now, in the absence
of intermediate valves the backward pressure due to this ter-
minal arrest must be felt partly in the elastic arteries and partly
in the inner surface of the left cardiac ventricle up to the mitral
valve. Indeed, as but little of it is converted in the elastic arteries
it must practically be nearly all returned to the ventricle. The
consequence of this must inevitably in the healthy heart be
hypertrophy of the left ventricle ; and here we touch facts again,

1 That the blood in renal disease is not merely under pressure, but is actually
impoverished, is unlikely to be forgotten. Uraemia seems not only to pollute, but
actually to destroy the blood.

288 Reviews. [Oct.,

: — the left ventricle as a matter of fact is genuinely hypertrophiedj
and no more than the arterioles is stuffed with decay.

It has been banteriugly said that Dr. Johnson^s hypothesis
implies a blind trial of strength between heart and arteries, and
that it is absurd to suppose that two organs will thus contend
at " pull devil, pull baker." 1 fail to see the unlikelihood or
absurdity of such a disturbed or perverted equilibrium, which
has many a parallel in disease. We know as a matter of fact
that the arteries do give way under these circumstances, and
we may surmise or even assume that were it not for the cardiac
hypertrophy the tissues would be so completely deprived of
their nutrient supply as to fail at an earlier stage of the malady.
The cardiac hypertrophy may be partly due to direct reflexion
between its own recipient and executive nerves, but no doubt it
is mainly compensatory, as will be urged presently. If the
patient's life be spared until the heart's hypertrophy recedes, an
early termination of the case by urasmia, as I have seen in many
cases, is almost certain. Perhaps the commoner event is the
occurrence of a rupture large enough to cause death during
the fulness of the cardio-arterial tension. That in granular
kidneys, however, some ^^ hyaline fibroid" change is seen in the
arterioles and about them does not admit of doubt ; and is, I
believe, admitted by Dr. Johnson. Indeed, it could not be
otherwise, for, as Sir William Jenner observed years ago, taking
congestion of the heart as his text, prolonged congestion of a
part, leading to continued high pressure and to interstitial
effusion, favours fibrotic or fibrinoid degeneration. Now, super-
excitation means supercongestion, and continued high pressure
in heart and arterioles means slow interstitial and periarterial
effusion which in its turn undergoes fibrinoid consolidation or
feeds a low fibrillating hyperplasia. In this way the heart
ultimately retrogrades not only in advanced granular kidney,
but also in cases of hypertrophy more obviously compensatory,
as in those of aortic regurgitation. But it may be urged that
Dr. Sutton's preparations cannot all be thus explained.
Probably not; but Dr. Sutton does not seem to me to meet his
opponents invariably on their own ground. Unfortunately, Dr.
Sutton was unable to be present at Manchester, and his pre-
parations were left to speak for themselves. I think, however,
the fault is not wholly in myself if I found them unsystematic.
Preparations were put side by side which seemed to me to belong
to wholly or very different conditions. They were of great and
varied interest, no doubt, but we wanted preparations of special
interest. Periarteriolar fibrosis is to be found in many dis-
eased states — states which have no more than a general connec-
tion with each other. For instance, cerebro-spinal sclerosis
may inosculate with nephritic sclerosis, but the two in most

1877.]

Pathology of Granular Kidney, ' 289

respects are alien to each other. To come a little nearer
again, there is a complaint not yet described, T believe, which
resembles granular kidney, with the part of Hamlet left out.
In it, too, we have high arterial tension and a thickened heart
and rigid arteries ; a heart which labours greatly but irregu-
larly, whereas in granular kidney the heart is usually regular
in its contractions. In these cases urine of good weight is
excreted, and the kidneys only show that amount of change
which is common to all the organs, or nearly so, and which,
moreover, would be expected in cardiac disease.^ I cannot say
what the earlier arteriolar changes are alike in these cases, as I
cannot get specimens to examine; but I suspect some of Dr.
Sutton's slides are taken from these. Now, although these
cases are related to gout, and so in a measure have a cousinship
with granular kidney, yet they are not granular kidney, and
are not to be confounded with it. Nor must it be here objected
that this cardio-arterial disease — this morbus innominatus — is
the same as granular kidney, with the saving thai the kidney
is included in the one and excluded in the other — that the
process is the same in both as to its essence, and different only
in its distribution. For the post-mortem table teaches us that
the closest relations of the malady with granular kidney are the
maladies with other kidney diseases. It has been shown, I repeat,
by many observers, and by Grainger Stewart in particular, that
in proportion to the degree in which inter tubular hyperplasia is
accompanied by extra-tubular or interstitial, is the tendency of
such cases to end in granulation or in something like it. Now,
in all cases of renal disease, and even in early stages of it, recent
observers tell us that arterial tension may and generally does
arise, and the heart and arterioles lend therewith to hypertrophy ;
and I believe Dr. J ohnson finds, in respect of these changes, little
difference between, say, the granular conclusion of a scarlatinal
nephritis in a young person and a nephritis in an older patient
granular from the beginning. The common factor, then, in
these cases at any rate is the nephritis, and the nephritis
cannot be regarded, as Sir W. Gull and Dr. Sutton may regard
it, as included or excluded in one and the same process of
cardio-arterial thickening. The conclusion seems forced upon
me that in granular kidney there is mostly or always a true

^ Take, for instance, the rough post-mortem made for me in one of these cases of
hypertrophy of the heart without renal disease. There was little or no arcus senilis.
Body stout and muscular, though the patient was in advancing years j the lungs
were dark and congested, otherwise healthy. Heart very large; weight 24 oz.
Left ventricle an immense fleshy mass. All the valves were efficient ; the aortic
a little thickened, and the mitral contained little gritty substances. The muscle
showed tendency to fatty degeneration. Liver soft, large, fatty. Kidneys large
and flabby, but healthy. Arteries. On the aorta small subserous deposits of athe-
roma. The smaller arteries rough and calcareous, inelastic, and lessened in calibre.

290 Reviews. [Oct.,

cardiac and a true arteriolar hypertrophy; such hypertrophy
carrying, of course, in its own superexcitation and superconges-
tion the conditions of decay, that such hypertrophy and the
decay of such hypertrophy are to be found in other renal
maladies of different causation and different in initiation, that
the renal disease is essential to their existence, that they show
not an essential but an accidental likeness to fibrotic endo-
and periarteritis of other kinds, and that this likeness arises
chiefly in their later stages of heterogeny.

I have hinted already that although thus far Dr. Johnson's
facts seem unassailable, his conclusions may not be equally so.
In speaking of the " stock-cock " theory, I am probably using
a term which this keen and able disputant has made so well
known as to need no explanation. At the outset one does not
see why the renal arterioles should close their doors against
blood which must be especially appropriate to the kidneys.
Such blood should open and not close the renal vessels. But
passing this, his position depends upon the probability that
muscular arterioles in their contraction hinder the blood current.
Now, is this simply so ? Were we to look at the arterioles
alone we should have to admit that such is necessarily the case.
But they are not alone ; they are bound up solidly with the
action and pressure in the heart itself. The nervous con-
nection between heart and arterioles was shown by Heidenhai'n
(in a paper I have mislaid, read, 1 believe, at the E-ostock meeting
of the German Medical Association), to end in this, that height-
ened cardio-arterial pressure in health means not a slackened
but an accelerated blood-stream in the vessels. This statement,
which seems now to be generallyaccepted, and which is borne out
by clinical experience, is explained by the increase of frequency
in the heart's action, which more than compensates the lessened
blood-stream and the increased friction in the arterioles. Lud-
wig showed long ago that irritation of the vaso-motor district
of the medulla both quickens the heart and contracts the
arterial system. If among the phenomena of the frog's foot are
seen arteriolar contractions with local anaemia, we must rejoin
that a local reflex action within a narrow circle which is
compensated by easy diversion of the blood into other channels
is not to be compared to a general influence tightening the
whole cardio-arterial tree. In this latter case the blood, which
cannot change its direction, probably increases its velocity abso-
lutely in spite of narrower canals and more friction. Let us,
for instance, take another case of universally heightened blood-
tension, namely that produced by digitalis. In asystolic states,
as, for instance, in impaired cardiac nutrition, digitalis, which
certainly heightens blood-tension in the arteries, does not the
more embarrass the heart and starve the tissues ; on the contrary,

1877.]

Pathology of Granular Kidney » 291

the patient finds much relief thereby, and indeed often finds his
only relief in continuing the use of digitalis for weeks and for
months. We must, therefore, explain the improved velocity of his
circulation by assuming that the heightened tone of the arteries
is more than compensated by the heightened tone of the heart.
Dr. Mahomed, who with the kindness and frank generosity of
the true lover of knowledge, has placed the whole of his most
recent views and facts on blood-tension entirely at my service,
shows me that digitalis, in large doses, produces the most
marked tracing of high blood pressure that can be had, far
surpassing that generated in any stage of granular kidney.
And I may add to this that positively in granular kidney the
one drug which of all others seems the least appropriate, but
which is, on the other hand, the most beneficent both tem-
porarily and permanently, is digitalis. Is it not almost a
necessary inference from these observations, if their truth be
granted, that the high-blood pressure in granular kidney is a
solid result of the cardio-arterial state, and that in it, on the
whole, blood velocity contends against narrower canals with
some temporary success, and that indeed cardiac hypertrophy
is not an evil to be combated but a compensation to be
encouraged — that it is not a disease but a remedy ? I do not
think, therefore, that the stop-cock theory will hold water.

To proceed, what is the cause of this cardio-arterial pressure?
Dr. Mahomed thinks that the cause lies in some delay in the
capillaries, and on the whole this seems to me to be the most
likely hypothesis. It is not an unwholesome feature in modern
reasoning that so-called ^^ vital" forces are not called in expla-
nation until the physico-chemical are proved to be inadequate ;
still it is not philosophical to forget that undoubtedly there are
modifications of force only manifest in organisation, and it is
not rash to speculate that disorder in the rhythm of nutrition
may well cause delay in the distribution of the nutritive fluid.
Perhaps as good a working hypothesis as any is as follows : ^ —
We may premise that such is the interlocking and correlation
of the parts of the body a function of one part becomes a
function of all — that all parts in fact conspire to the per-
formance of its special duty by each. From this truth we
may deduce that the presence of uric matters in the blood
while they excite the vasal centres of all other parts to resent
their presence, so cause a general increase of vascular tension
in all parts but one, namely, in the renal arterioles. Here
we may suppose that a relaxation takes place, the tension of
the renal artery being lowered; and this is not unsupported

1 This argument, and especially the postulation of some modification of urea,
which irritates without feeding the renal cells, I owe to my friend Mr. Charles
Smith, of Halifax.

292 Reviews. [Oct.,

by what we know of the phenomena of blushing, of the
effect of carbonic acid upon the respiratory centre, and so forth.
Thus, in the normal state is renal excretion favoured, and
thereby tension continuously equalised. But we may now
postulate that the blood, either by liver disorder or otherwise,
becomes charged with a substance so far allied to urea as to set
up vascular antagonism, but so far removed from it in molecular
constitution as not to pass off readily in the renal cells. Given
such a morbid variety of urea, we must have gradually increas-
ing arterial tension everywhere, and gradually involving even the
more open renal arterioles themselves. Thus the kidneys would
be flooded with blood; they could not cleanse. We should, in
such a state of things, expect to find what we do find, namely, a
large quantity of urinary water of low specific gravity, and the
gradual degeneration of a congested organ.

In the absence of any real knowledge I give this ingenious
hypothesis for what it is worth. The first argument against
it seems to be that the renal arterioles are as much hyper-
trophied as those elsewhere. It might, perhaps, be replied
that while the hypertrophy of the heart and other arterioles is
due to reflex irritation by offensive blood, that of the renal
arterioles is due to hyperdistension. But 1 think there is no
evidence that what I may call willing hyperdistension leads to
such hypertrophy. Perhaps it may be nearer the truth to
presume that the modified urea is too unlike urea to appease
even the renal arteries.

"We must now pass on to consider the more remarkable inci-
dental symptoms of granular kidney. The admirable lectures
on pulse tension by fir. Broadbent, which recently appeared in
the 'Lancet,' have been so widely read that we may pass lightly
over many of these symptoms interesting as they are. With
regard, however, to reduplication of the heart's sounds the pre-
sumption of Dr. Johnson that an auricular systole, becoming
audible by virtue of hypertrophy and fluid resistance, gives rise
to the first systolic sound, is to me at least highly probable, as
I had unwillingly accepted the current explanation of an
asynchronism in the ventricular discharge as most unsatisfactory.
The intimate connection of the two ventricles by their mus-
cular fibres seems almost to necessitate simultaneous action,
while, on the other hand, the phenomena of cases of mitral con-
traction lend countenance to Dr. Johnson's suggestion.

To the public, and even to the practitioner of medicine, no
event is more alarming than the sudden occurrence of an epi-
leptic attack in a person not previously known to be in disease.
Like the blindness of retinitis, however, this event is not infre-
quently the first manifestation of granular kidney. A man
may think himself dyspeptic, and his friends may think he is

1877.]

Pathology of Granular Kidney, 298

looking older when this terrible seizure bursts in upon him and
albumen is found in his urine. Albumen, however, is often
found in the urine after epileptic seizures when the kidneys are
healthy, so some caution is necessary in pronouncing upon the
nature of an attack, and the urine must be weighed and tested
for some days before a definite diagnosis is given. Dr.
Dickenson remarks that ursemic convulsions are often deter-
mined by mental emotion ; certainly I have noticed that mental
emotion often sets up the peculiar paroxysmal dyspnoea called
ursemic asthma, an affection probably of like generation. It is
important to remember that near the calamus scriptorius, where
a convulsion point is said to exist, there exists also a respiratory-
centre and a vaso-motor centre. We may bear in mind also
that rigors and convulsion often replace each other, especially
in children. Now rigors we know are connected with a crisp-
ing up of the superficial blood-vessels of the body, and we have
good grounds for also believing that convulsions depend upon a
like crisping up of blood-vessels within the cranium. In a
paper on ursemic asthma, read to the Yorkshire Branch of the
British Medical Association last October, I ventured to sug-
gest that this affection might also consist in a contractile
spasm of the pulmonary arterioles. In the Lumleian Lectures
of this year. Dr. George Johnson gives the same explana-
tion. Now, if we put together the well-known high tension
of renal disease (and by way of illustration I may add of
pregnancy also), the unquestionable hypertrophy of the
arterioles, and the almost necessary inference that the vaso-
motor centre is also in a high state of susceptibility, we have
conditions which almost compel us to infer that ursemic convul-
sions and ursemic asthma, like rigors, depend upon a spasmodic
closure of the arterioles in certain limited districts. And if
this be so it is easily intelligible that the onset of either seizure
may be favoured by cerebral irritation passing down to the base
of the encephalon. It may be said, however, that as hsemor-
rhages are often found after death from ursemic convulsions
(Mahomed), and as hsemoptysis commonly follows ursemic
asthma, we should rather infer that the vascular state is one of
dilatation. Now, I venture to think that neither haemorrhage into
brain or into lung is the rule in either case, yet of my knowledge
I admit it occurs in both in a considerable number of instances.
The explanation of this, I believe, is to be found in the arterial
degeneration which marks the later stages of granular kidney.
This degeneration progresses at various rates in various districts,
and as it progresses the vessels so degenerated are less able to
contract. Some of them, indeed, lose all power of contraction
and become brittle, while others have still an excessive contrac-
tile power. If, therefore; many arterioles contract firmly, and

294 Reviews. [Oct.,

the heart's impulse as suddenly increases, the access of pressure
thrown upon the enfeebled and open arterioles must be enormous
and their rupture must be a common accident. Dr. George
Johnson suggests that the haemoptysis in ursemic asthma is due
to engorgement of the bronchial circulation, which is a very pro-
bable supposition. Certainly evidences of sanguineous effusion
are more decided in ursemic asthma than fortunately is the case
in uraemic epilepsy. Ursemic asthma again is almost always fol-
lowed by coarse crepitation at the bases of the lungs, and the
brain is usually found wet in deaths from ursemic epilepsy.
Passing hastily over many points of less importance or needing
less discussion, we may now turn to consider the causation of
granular kidney, and herein lies all our hope of forestalling a
malady which is incurable when fully established. It was long
supposed that the chief cause of granular kidney was the abuse
of alcohol. The argument seemed to run thus — granular
kidney is very like hobnailed liver ; now hobnailed liver is due
to the abuse of alcohol, and we know that alcohol causes
diuresis ; therefore, granular kidney is due to alcohol. This
argument leaves much to be desired, and it fails to be justified
by facts. In my own experience I very rarely find a case in
which alcohol seems to have caused the disease. One apparent
instance of such causation I certainly have watched for years to
its recent conclusion. A young man of very healthy family his-
tory fell into tippling habits, and after some years had passed
he fell into an epileptic condition, and this was repeated some
months later. His aspect and symptoms now began to point
clearly to granulation of the kidney, and of this complaint he
ultimately died, at the age of 46, as verified by post-mortem
examination. Still, I repeat, cases like this in which alcohol
and alcohol alone seem to be to blame for the fibroid involution
of the kidney are rare. Perhaps from the time of Todd down
to the present day no cause has been more confidently credited
with this consequence than the gouty crasis. To attribute
granular kidney to gout has become a truism, and we are gravely
assured by more than one eminent author that the nexus be-
tween the antecedent and consequent is the teasing of the
kidney by fine crystals of uric acid or urate of soda. Nay, our
very eyes are witnesses in the case, for are not the crystals
actually shown upon the tubules of the kidney inciting the
baser elements into activity ? Yet, confidently as this belief
is held, it is assuredly false. If granular kidney were the
result of the irritation of gouty salts, who of the gouty should
escape it? Now, I appeal to any practitioner whose work
has extended over some years, and ask him whether he will
not support me in saying that the truth is rather the re-
verse of this ? So far from gouty subjects dying of granular

1877.] Pathology of Granular Kidney, 295

kidneys the fact is that, as a rule, they do not. Nothing sur-
prised me more in earlier professional life than this common
experience, that the men in whose systems gouty salts had been
settling for decades, who were bound to die of gouty kidney,
and whom I therefore regarded as the barbarians regarded
St. Paul, on the contrary, lived their three score years and ten,
or if they died in earlier years of chronic involution died with
irregular big hearts, chronic endoarteritis, and so forth, but
generally with heavy acid urine and no albumen. In such
persons, no doubt, we frequently find coarse kidneys, but kid-
neys which, for all their coarseness, many a poor man would
be glad of, as the children's books say. Then how is it that
the common error, if error it be, has arisen ? In the old way,
by the confusion of cause and consequence. Gout is the conse^
quence rather than the cause of granular kidney. Take the
safe instance of lead poisoning. We know lead poisoning often
produces gout, it often produces granular kidney, and it often
produces the two results together. It often produces, that is,
granular kidney with no gout at all, whereby we know that gout
is no necessary copula between the lead poisoning and the granu-
lations of the kidney ; on the other hand, it has never happened
to me to find a gouty painter, or other gouty victim of lead, whose
urine was heavy and whose kidneys were presumably adequate.
Again, if we leave lead poisoning and turn to ordinary consti-
tutional changes, what do we see ? We see a lady or gentleman
of middle or later life who comes to us for gout and we examine
the urine. We find it not lithatic ; we hear that it has never
been lithatic, of late at any rate, but, on the contrary, pale and
abundant : we find the specific gravity to be 1010 or under, and
we test the whole day's bulk daily for a week, and find it still
ranging always low ; perhaps we see a cloud of albumen on
pouring nitric acid below it in a beaker, or we find albumen in
more obvious quantity. We make further inquiries and we find
that our patient has become gouty rather quickly of late years
and has not earned gout by free living, and we decide surely
that the gout is the consequence of less and less perfect renal
work. The lithatic man, on the contrary, whose urine has been
the despair of the housemaids for twenty years, whose eyelids
and ears are full of concretions, and whose gnarled fingers and
roomy boots tell an old story, limps on his way through a
lengthening tale of years when his brother patient has been dead
of ursemia for years. Yet, surely, if gout worries the kidneys
into granulation, this man is the one who by all rights should
lie first in the churchyard. That there is no relation between
gout as an antecedent, and granular kidney as a consequence, I
am not prepared however, to say.

Dr. Broadbent reminded me, and the suggestion certainly

296 Reviews, [Oct.,

was in accordance with my own experience, that many persons
in whom granular kidney appears are of gouty stock. He
mentioned to me a family of five sons, of which two were very
gouty, and two others died of granular kidney. Gout was
strong in the preceding generation. This I believe is to be
accepted as a marked instance of a true proposition, that
although gout and granular kidney are not father and child,
they may be cousins. It is impossible as yet to find the nexus,
but its explanation is, depend upon it, something far more pro-
found than that which we may call the teazle hypothesis. So
far as gout and granular kidney coexist in the same person,
the latter is the cause of the former, and the common teaching
of the contrary must be reversed. How renal inadequacy, long
before anything like albuminuria is present, allows the standard
of blood purity to be lowered, and before it may cause obvious
gout, may turn the scale against the patient in either acute or
chronic disease is, however attractive, too long a story to take up
in this place. In the meanwhile the reader may be sure that
this point is one to which general attention must be turned. Still
more, prolonged high arterial tension from gouty blood will not
produce granular kidney, so it cannot be said that podagra is a
preservative from granular kidney. I have many times seen
patients who have suffered off and on for years from exhaustion,
melancholy, apprehensiveness, startings,dismal morning awaken-
ings and general pessimism — patients who have taken tonics
in vain for years, and who have found life and buoyancy in a brisk
saline purgative, whose pulse has been tense for years and have
not had granular kidney. So it is with gout and granular kidney.
In contemporary journals I have ventured for some years to
assert that the most distinct cause of granulation of the kidney
is mental anxiety and prolonged distress. What I have said
on this subject I have said at too great a length elsewhere
to permit of my repeating it in this place. I content myself
with adding that Dr. Brookhouse, of Nottingham, and Dr.
Dickenson, have both arrived independently at the same con-
clusion. How it is that under nervous stress the pulse tightens,
the blood pales, and the urine grows poorer, no one has yet
shown us ; but the fact is unquestionable. I have of late been
informed that very careful observations of the pulse curves of a
young and healthy man have shown increased tension during
twelve months of domestic anxiety; but, as aforesaid, the pulse
tension and granular kidney can only be regarded as common
consequences, and the former does not give rise to the latter.
Were it so we should find granular kidney arising in cases of
high arterial tension the result of cerebral disease, for some of
the very tensest aortas and pulses I have seen have followed
apopleptic seizures and other organic encephalic irritations.

i877.J 'Pathology of Granular Kidney. 297^

Cerebral irritations, then, organic or functional in origin, may
give rise to tense pulse, but this tense pulse cannot of itself force
the kidney into granulation. More probably the nutrition of the
kidney is in some subtle way deranged, as that of the liver is in
diabetes i from like causes, or some more general influence upon
the whole body favours involutions after the fasliion indicated by
Sir William Gull. Heredity is unquestionably a potent means of
propagating granular kidney, and, as before suggested, it may
occur with disproportionate frequency in individuals not
personally gouty but of gouty stock. Of those, however,
to whom this malady has descended as a damnosa hereditas,
none are more to be lamented than those young persons
who are carried off in the flower of their age as by a gal-
loping consumption. These awful cases, seen not infre-
quently in early adult life, are very terrible and inexplicable
in their course. These cases of premature seizure have in my
experience been found always in families of very bad health
history. Either they have sprung of actually phthisical fami-
lies, or of those sallow skinned, cold-fingered, genteel, listless
folk who are said to have " no constitution." A young scion
of such a house may have amaurosis or epilepsy before his
terrified relatives have realised that he is more than a little out
of sorts. ^ The still fountains of granular kidney run deep, and
we get but obscure hints of its causation and origin ; yet herein
lie our only hopes of therapeutics. It is the use of positive
methods and of arms of precision which has given us a
scientific knowledge of disease, and the sphygmograph and
the urinometer are to granular kidney what the thermometer is
to fever. By the sphygmograph we measure the tension of the
arterial tree, and we learn that tension may arise from many
causes, even from direct cerebral irritation. We learn, how-
ever, that while pulse tension will not cause granulation of the
kidney, yet this latter unquestionably produces the former, so
that the one may become a measure of the other. But probably
before granulation has actually invaded the kidney, the func-
tions of this organ become perverted, and therewith the arterial
tension is raised, and if the malady be recognised by urinary
chemistry and by the sphygmograph in this stage the false
tendency may be neutralised. By relief from mental anxiety,
by alteratives, by the forced inspiration of pure mountain air,

^ The mere passage of an excessive run of blood through expanded reual vessels
(as in diabetes insipidus ?) probably would not lead to granulation ; or cirrhosis
of the liver would be seen in the later stages of raelituria.

^ For example, a young man, set. 20, was brought to me complaining of little
beyond this : that one day when shooting at the butts at Cambridge, he found
himself blind of the right eye. He went to Mr. Critchett, who sent him to me,
and I found cardiac hypertrophy and albuminuria. His life was spared but a few
weeks.

1298 keviews. ' [Oct.,

by cherishing the functions of the skin (which seems to become
granular pari passu with the kidney)^ by diet and renovation
of the blood, that may be achieved which in a later stage has
become impossible. It is a growing habit with myself to take
sphygmographic tracings, or at any rate digitally to appreciate
the pulses of my patients as closely as possible when I am con-
sulted by persons showing some evidence of wear and tear or an
increasing sense of fatigue. With this let the urine be minutely
interrogated as to the adequacy of the kidney, and let any
deviation be closely noted 'svith a sense of the far greater pre-
ciousness of such warnings than of the brutal reply of albumen
to one's tests, which signifies almost a hopeless state of things
in respect of restoration of health. In cardiac hypertrophy we
find a compensating process which we may encourage by digi-
talis ; and with digitalis and iron on the one hand, and cutaneous
and alveolar stimulations on the other, more may be done than
by any other means. Still this very cardiac hypertrophy has
its own dangers in straining vessels which, if not primarily
diseased, tend to become so secondarily. Nor can any organ
change its course, even in a compensating process, without
disorder and injury to other parts. And if these dangers
be averted, yet the heart, hypertrophied for a while, in time
loses its muscular value, and its fibres become degenerate, and
even fatty. The pulse then loses its tension, and when this
fails, coma does not long delay to seize the victim whom apo-
plexy in the days of higher tension may have spared. Organic
disease cannot be cured, nor its consequences often averted. In
this we have no new grounds for despair, but, with the more
perfect sanitation of our own bodies, the time may come when
the presence of organic disease, like bad farming, will mean
that somebody is to blame ; let us hope that it may not be the
practitioner of medicine. — T. Clifford Allbutt.

IV. — Robin on Urine in Typhoid Fever, i

The book before us is a very valuable and interesting con-
tribution to urinology. It is the production of a distinguished
student of the Paris hospitals, who is also an excellent
chemist.

The study of the urine in disease has for several years been
sedulously pursued by some of the ablest physicians and clinical
teachers of Paris, amongst whom MM. Gubler, Jaccond, and

^ Essai jy Urologie Clinique ; la Fievre Typhoide. Par Albebt Robin, Aucien
Interne des hopitaux de Paris, chef des travaux chimiques au laboratoire de la
Charite, &c. Paris, 1877.

1877.] Robin on Urine in Typhoid Fever. 29^

Parrot take the lead, and with them M. Albert Robin has been
a fellow worker.

In ordinary practice it is generally deemed sufficient if the
specific gravity and acidity of the urine be ascertained, and if it
be tested for albumen and sugar, or occasionally for the chlo-
rides. Want of time and the complexity of the processes
required for an elaborate scrutiny have hitherto, even in hospital
work, prevented more complete examination. But as chemistry
has now furnished us with simpler modes of procedure for
minute investigation, and as most important information may
be gathered by putting them in practice, we trust that they
will soon be more generally adopted.

As a peculiar interest attaches to the colouring matters of
the urine, we shall give an abstract of M. Robin^s observations
upon them before noticing the special subject of his essay.
Unfortunately a needless difficulty has been introduced in their
study by the confused nomenclature which exists. Some of
them have three or four different denominations, and, still
worse, the same name has been given to different pigments.

M. Robin adopts a distinction, introduced by M. Gubler,
between colouring matter and chromatogenic matter; the
former manifests its presence at once ; the latter must undergo
further change before it is visible.

Of colouring matters he enumerates the following :
Urochrome. Hemapheine. Uroerythrine. Hemoglobuline.

And of chromatogenic matters :

Indican and Urohematine.

The latter are the producers of the indigo-blue and red
colours.

The origin of all these bodies is generally ascribed to the
globulin of the blood, and this appears to be correct, except,
probably, as regards indican.

Urochrome is the ordinary colouring matter of the urine, and
is derived from hsemoglobuline, directly or indirectly. Jaffe
believes that there is an intermediate stage ; he thinks that
the hsemoglobuiine first becomes bilirubine in the liver, and that
this is transformed into the matter under notice, which in con-
sequence he names urobiline. That this may easily and pro-
bably often does take place^ is undoubted ; but both M. Gubler
and M. Robin agree that ordinarily the intervention of the liver
does not come into play.

As to its clinical value, urochrome is the most complete
product of the combustion of hsemoglobuline. It is often in
direct relation with the activity of the liver, possibly also with
that of the spleen. It is increased in quantity whenever there
is rapid destruction of blood-globules. It is diminished in
ansemia, in chronic parenchymatous nephritis, and in diabetes.

300 Reviews. ' [Oct.^

Uroerythrine and HemaphSine. — The derivation from the blood
of these pigments appears all but certain.

The first is identified with the product well known as pur-
purine or purpurate of ammonia. The latter is so -closely allied
to urochrome that there is reason to believe that it is virtually
the same body.

M. Gubler considers both these pigments as indicative of
hepatic insufficiency. They appear either where there is a
destruction of red globules too considerable for the transform-
ing power of the liver, or where, from disease, the hepatic cells
are unequal to their normal work. Hemapheine he ascribes to
the first condition, uroerythrine to the second. The pathological
states in which they occur are very numerous.

Tndican and TJroliematine. — The former undoubtedly results
from albuminous decomposition. It is characteristic, says M.
Gubler, of severe fevers, where, notwithstanding the high tem-
perature of the body, the respiratory combustion seems to be
reduced in amount. Hence, as the albuminous waste of the
organism is increased, and as for want of oxygen it cannot pass
off as urea, it is voided as albumen, albuminose, and indican.
The latter thus seems to be albumen slightly changed. But
several German chemists maintain that it is analogous to vege-
table indigo, and that it takes its origin in indol, a product of
the digestion of albumen, which is always to be found in the
intestines. The indol thus formed is absorbed into the blood,
and is discharged by the kidneys as indican. Probably each
theory is true to a certain extent. It is met with in these morbid
states : — Disorders of the alimentary canal, with ganglionic
disturbance j where albuminous waste is too great for the
quantity of oxygen in circulation ; in many affections of the
liver, of which carcinoma is the type ; in affections of the spinal
cord ; and in Addison's disease.

Urohematine seems to be closely related to indican, but a
careful study of its composition and characters is still wanting.
It is found in the urine of patients suffering from profound
anaemia, acute miliary tuberculosis, intermittent fever, and
other diseases where there is a rapid destruction of blood-
globules. To these last-named bodies, rendered manifest by
ammoniacal fermentation in the urine in cases of cystitis or
purulent nephritis, the names of uroglaucine and urrhodine
have been erroneously given.

We now proceed to follow our author in his study of the
urine in typhoid fever, and for the benefit of those of our
readers who may not have an opportunity of seeing his book we
will give a summary of his most important conclusions.

He remarks that M. Gubler has taught for twenty-five years
that, from the characters of the urine alone, severe cases of fever

1877.] Robin on Urine in Typhoid Fever. 301

may J, from the first, be discriminated from acute inflammatory-
attacks. He describes the following as the most striking and
constant. During the stages of development and maturity in
typhoid fever the urine is of a dirty^ brownish-yellow colour,
like beef tea, and very acid. If to a goblet about three fourths
full, nitric acid be gently and slowly added until it occupies the
lower two fifths of the glass, there will be seen, in the course of
from three to five minutes, at the surface of contact between
the two fluids (1) an intense indigo-blue colour ; (2) a layer of
albumen, more or less thick, but constant ; (3) a faint diaphragm
of uric acid ; and (4) sometimes crystals of nitrate of urea.

During the stage of decline the urine becomes clear, the
albumen diminishes or disappears ; the uric acid increases, some-
times forming a deposit; the colour produced by nitric acid
changes gradually from blue to violet, then to red, and lastly to
a brilliant rose, which is an indication of full convalescence ; at
this period the uric acid is reduced in quantity, and the urine
becomes alkaline from an elimination of the fixed alkalies.

The details of this outline, as regards both the physical and
chemical characters of the urine, are described and discussed
with much minuteness and fulness.

In colour, aspect, and consistency the urine varies according to
the intensity, stage,and complications of the disease; the indica-
tions within certain limits being constant and reliable.

As regards quantity, density, and excretion of solid mattery
M. Robin concludes that, in a case of medium severity, during
the first and second stages, the amount voided is slightly less
than in health, the density and solid constituents somewhat
more. During the third week the quantity rises, the specific
gravity falls, and the discharge of solid matter is increased to a
small extent. When convalescence is taking place the quantity
again increases, and the specific gravity falls, whilst the daily
excretion of solid matter undergoes considerable augmentation.
These proportions, as might be expected, are modified where
there is much perspiration or diarrhoea, or where the case is
complicated within testinal hsemorrhage or internal inflamma-
tion. Peculiarities of odour have also been carefully studied.
The herbaceous and fetid smell sometimes noticed at the period
of decline is usually associated with an increase in the amount
of solid excreta, and is ascribed to fermentation in the extrac-
tive matters, always voided abundantly during that stage.

As regards the reaction, the most interesting fact is the
gradual transition from great acidity in the fir^t stage to alka-
linity in the third or during convalescence. M. Gubler has
pointed out that this character is generally to be noticed during
recovery from long-continued, debilitating disease, such as

120— LX. 20 •

30!^ Reviews, [Oct.,

typhoid fever or pneumonia. It is not usually present during
more than five or six days, sometimes only during one. It is
due to the fixed alkalies, and is recognisable immediately after
the urine is voided. It is noteworthy also that at this stage of
the disease fermentation very readily takes place in the urine,
and a few hours after being voided it becomes ammoniacal. In
direct opposition to the opinion of some writers it must be
deemed a favorable indication.

Deposits of one kind or another are common in the urine in
typhoid fever. The most frequent are the following : — The
ammoniaco-magnesian phosphate, which is generally seen in
the later stages and the less severe forms of the disease, and
associated with an ammoniacal state of the urine. Urate of
ammonia, often abundant in its earlier days, subsides in its
mature stage to reappear in its decline. Urate of soda is
rather more frequent than the preceding in fatal cases, and
rather less so in cases of medium severity ; it is common where
there is thoracic inflammation. Uric acid is rare in grave and
fatal cases. Indigose is frequently seen in severe forms of the
disease. White globules and mucus are not uncommon at all
stages of the complaint, but the occurrence of a distinctly puru-
lent sediment must be referred to associated catarrh of the
urinary passages. Blood, both globules and dissolved haemo-
globuline, may be present, and is often so in severe cases.
Urinary tube-casts and fat-globules are not rare, but are always
very grave indications.

There has been much discrepancy in the statements of writers
respecting the daily excretion of urea in typhoid fever.
Becquerel believed that it was reduced below the normal amount,
and this was also the conclusion which Anstie drew from his
observations. Sigmund and Vogel thought that the proportion
was increased during the early stages of the disease, and that
it gradually fell to its usual standard during convalescence.
Others have been of opinion that there was a relation between
its measure and that of the temperature of the body. M.
Robin states that nothing is more variable than the elimination
of urea in typhoid fever ; his notes of seventeen cases, which do
not, however, apply to the incipient stage, gave a slight reduc-
tion below the average, and this is more evident in severe than
in mild examples of the disease. In three fatal cases he found
a large diminution in its amount ; if any inference be warranted
upon such data it will be in contradiction to the judgment of
Anstie, who thought that he had noticed a direct relation
between the mildness of the complaint and the smallness of the
quantity of discharged urea. It seems probable that variations
in the amount of nutriment taken by patients under observation
may account for some of this diversity of result.

1877.] Robin on Urine in Typhoid Fever, 308

Uric acid is increased in quantity in severe forms^ and in
the earlier stages of the complaint,, but is much influenced by
the presence or absence of complications.

The extractive matters of the urine comprise all organic
principles not included under the preceding heads. Modern
chemistry has supplied us with a long list of these bodies, but
has not as yet given a simple and rapid mode of estimating
their quantity. It appears, however, to be clearly proved that
they are always augmented during the mature stage of typhoid
fever, and that they observe an inverse ratio with that of urea.
In the latter stages they decrease and even fall below the usual
standard. The not unfrequent appearance of albumen in the
urine during the height of the disease has been recognised for
a considerable time, but we are indebted to M. Gubler for the
establishment of the law of its constant presence. During
fifteen years, and in many hundred examinations, he has never
found it absent. It occurs in the second week if not before,
and its amount is proportional to the severity of the attack
and its complications. It should be stated that its quantity is
often so small as not to be revealed by the usual mode of test-
ing ; it may then be detected by M. Gubler's process already
described. This explains, no doubt, the opposing assertions of
writers on the subject. In grave cases it appears early, in
larger quantity, and continues present longer than in those of
average type.

The inorganic principles are largely reduced in quantity during
the first and second stages of typhoid fever ; they undergo a
sensible increase during its decline, and sometimes rise above
the usual rate, during convalescence. As regards the chlorides,
it has often been remarked that in all acute maladies where but
little food is taken their excretion is necessarily lessened ; but
of these diseases there are, as M. Robin observes, two classes ;
in one the chlorine, set free by disintegration of tissue, escapes
by the urine ; in the other it enters into the composition of
morbid products, and little or none passes oft' by the kidneys.
Typhoid fever belongs to the former class ; pneumonia to the
latter. Variations in the amount of chlorides have a certain
diagnostic and prognostic value; the reduction being much
less than in pneumonia, and generally also being proportionate
to the severity of the attack.

The phosphates undergo less diminution than the chlorides
during the first and second stages. The earthy phosphates are
reduced to a greater extent than the salts of potash and soda,
and undergo a corresponding increase during the third and
fourth weeks. An Italian chemist, Signor Primavera, has
founded certain indications upon this circumstance, but the
results are not sufficiently uniform to be of much value. The

304 tteviews. [Oct.,

quantity of these salts is much influenced by the presence or
absence of diarrhoea. M. Robin states that in cases compli-
cated with much nervous disturbance and delirium, an increase
in their amount is constant.

An estimate of the quantity of sulj^hates in the urine is of
importance, as throwing light on the degree in which albumi-
nous disintegration is going on in the body. In general, they
are but slightly augmented during the first stages of typhoid
fever, and decrease during convalescence. But little has yet
been made out respecting the carbonates. Respecting j^iymew/*,
and chromatogenic matters^ M. Robin observes that urohema-
tine is- found in increased amount in only a small number of
cases, and that these are fatal ones. In ordinary attacks it is
lessened during the early stages, and becomes normal as the
disease declines and during convalescence. He found it aug-
mented by the occurrence of pulmonary inflammation, or of
internal intestinal haemorrhage. Indican is more abundant in
fatal than in non-fatal cases, and in severe than in mild attacks.
It exists in largest quantity at the height of the disease, and
diminishes progressively as the fever subsides. It has been
copiously found where there has been profuse diarrhoea, or
where a high internal temperature coexisted with great sensi-
bility to cold, or where abdominal inflammation was present.
When it does not follow the course of the complaint and sub-
side with it, M. Robin believes that a formidable relapse may
be anticipated. He founds this opinion on four observations.

Hemapheine and uroerythrine are only exceptionally present
in the urine in typhoid fever. When they exist, it is at the
height of the disease and generally when it is associated with
pulmonary inflammation.

M. Albert Robin is the first to acknowledge that some of
these conclusions are, as yet, based upon an insufficient number
of facts, and may be consequently hereafter modified. He
regards his work as an outline to be filled up. We have not
space for a detailed comparison of his results with those of
other investigators ; nor indeed, at present, would the process
be a profitable one. Before it can be satisfactorily made we
must accumulate a considerable body of trustworthy records.
Both M. Gubler and M. Robin believe that more aid may be
obtained than has hitherto been done, from a careful study of
the urine in many doubtful and difficult cases. Several illus-
trations of this are given by our author, one of which we quote
as an example of his mode of dealing with such a problem.
One of the diseases most liable to be confounded with typhoid
fever is acute miliary tuberculosis. There may exist in common
diarrhoea, meteorism, splenic enlargement, headache and deli-

1877.] Robin on Urine in Typhoid Fever, 305

rium, redness and dryness of the tongue,, epistaxis^ and some-
timesj it is said, an eruption of rose-coloured papules. As
noticed by M. Jaccond, the thermometric changes are less
regular in the tuberculous than in the typhoid disease, and
the urinary characters are very different. The urine is usually
clear and of a dark red colour, scanty and of high specific gravity ;
it contains much urea and uric acid, and little, if any, albumen;
indican in small, and the other colouring matters in considerable
quantity. The recognition of these distinctions may decide the
diagnosis in favour of tuberculosis. And so with some other
diseases which under peculiar conditions may be mistaken for
typhoid fever. The urine in them presents a group of distinc-
tive characters which if not sufficient to establish a diagnosis
may be safely employed to confirm or correct an opinion.

Our prognosis may also be considerably aided by the careful
study advocated. As the alterations in the urine follow a
regular course with the evolution of the disease, and are even
sometimes the first evidence of bodily changes not yet manifest
elsewhere, so they serve to strengthen or control other indica-
tions. Thus, when the stage of decline is at hand, and the
temperature begins to fall, additional value is given to this sign,
if it be found that the quantity of urine and the elimination of
extractive matters are gradually increasing. The same conside-
rations also may govern our estimate of the importance to be
attached to the occurrence of perspiration at this period of the
complaint. If it be casual, both the amount of fluid and excre-
tion of solid matter are notably diminished ; but if it be critical,
they are scarcely, if at all influenced.

The observations and inquiries which we have been consider-
ing tend to elucidate the development, and may help to guide
us in the treatment of the disease. Although we may doubt
whether it ever be spontaneous, we are all agreed that, however
produced, a poisonous agent is at work in the body. The death
and disintegration of its tissues proceed at an increased rate.
The waste products, more or less prepared, are thrown out of
the system by various channels, or accumulate in the blood,
and add to the gravity of the attack. The proof of this pro-
position rests upon the repeated verification of such statements
as these : — the less the elimination of urea, and of solid matter
by the urine, and the more grave the seizure ; in severe cases,
the excretion of solid matter is greatest during the periods of
decline and convalescence ; where there is neither diarrhoea nor
perspiration, unless there be an enhanced discharge by the
kidneys, the danger rises ; critical perspiration coincides with
an increase in the solid elements in the urine ; and in cases of
relapse there has been in the early stages of the complaint a

306 Reviews. [Oct.,

deficient elimination of its organic constituents. M. Robin
also alleges^ in further support of these conclusions, that in
severe forms of the disease, whether owing to the influence of
the typhoid person, or to the imperfect action of the lungs, the
lowly oxygenised elements of the secretion from the kidneys are
most abundant.

It results from these researches that incomplete removal of
effete matter constitutes one of the chief diflSculties and dan-
gers in typhoid fever. This is mainly due, M. Robin thinks,
to its insolubility, a consequence of insufficient oxygenisation,
and to the serious implication of the different emunctories of
the body, and especially of the lymphatic system, by means of
which the chief drainage of the tissues is brought about.

The therapeutic indications follow logically from what has
gone before. They are : — (1) To destroy the typhoid poison.
(2) To fortify the body against its influence. (3) To aid the
expulsion of diseased products.

Our readers have only to compare the conclusions of which
we have given an abstract with the statements in our recent
treatises on typhoid fever, to appreciate the advance which has
been made. More and further observations, however, are wanted
for the extension, confirmation, or correction of our present
knowledge.

V. — Medico -Legal Aspects of Insanity. ^

The work of M. Tardieu claims consideration from the pro-
fession in this country, less from its being a systematic inquiry
into the legal relations of mental disease, than as an expression
of the experience and opinions of French alienists upon this
subject. It consists mainly of disquisitions, first, on the circum-
stances in which the medical man is called upon to determine
the mental condition of individuals whose acts demand inter-
ference in their own interests or the interests of society;
secondly, on the principles and rules by which the medical
expert should be guided in forming a judgment as to the
mental state, the conduct and the moral and legal responsibility
of the insane ; thirdly, on the appreciation of the nature,
extent, and influence of the different kinds of insanity ; while
a fourth section is devoted to a collection of typical examples

1 1. Mtude Medioo-Legale sur laFolie. Par Ambeoise Takdief, Professeur de
Medecine Legale a la Faculte de Medecine de Paris, Medeeine de I'Hotel Dieu,
Membre de I'Academie de Medecine. Paris, 1872.

2. Contributions to Mental Pathology. By I. Rat, M.D., Author of Medical
Jurisprudence of Insanity and Mental Hygiene. Boston, 1873.

1877.] MedicO'Legal Aspects of Insanity, S07

of medico-legal investigations affecting the life^ liberty, and
property of those supposed to labour under diseased minds.

In the first division of the subject the author affirms, and
rightly affirms, that the seclusion of a lunatic, or of a person
suspected to be a lunatic, under whatever circumstances, is
most improperly, though often popularly, regarded and repre-
sented as imprisonment — as an arbitrary deprivation of per-
sonal liberty ; whereas the person thus secluded is a patient, not
a prisoner, suffering under formidable, it may be fatal disease,
involving not merely himself but many members of the com-
munity; and in whose case observation and treatment are
absolutely required for his own sake as well as that of others.
He further affirms that such objects can be obtained exclusively
in an hospital where the structure of the house, the domestic
and social arrangements, and the services of specially qualified
physicians are all brought to bear upon the physical and
psychical state of the inmates, upon their accountability and
upon the re-establishment of their health and their restoration
to their original rights, positions, and privileges. This remark
is not a platitude, but refers in an especial manner to that pro-
vision under which persons accused of crime, or minor violations
of law, but who are supposed, or pretend to be, of unsound mind,
may be committed to an asylum previously to trial, in order
that their deportment and conversation may be tried and tested
and the amount of their responsibility determined by those
accustomed to such moral experiments, under favorable circum-
stances and free from the partisanship and special pleading
which sometimes disgrace courts of law, and from the difficulties
of diagnosis and the opportunities for deception which mar or
modify all examinations of the accused when in prison. When
commenting upon the suspicion and discourtesy with whichmedi-
cal witnesses are treated, and the efforts so frequently made to
confuse and perplex them rather than to elicit the truth, he illus-
trates his arguments by narrating an address by M. Troplong,
in which alienists are held up to scorn or ridicule as disposed,
and prepared to describe every man as a monomaniac, to con-
trovert and counteract the operations of recognised judicial
tribunals, to detect in every peculiarity a symptom of derange-
ment and to hold up the fancies of Pascal and the familiar
demon of Socrates as illustrations of mental perversion and
obscurity. He adds the anecdote of another judge, who, after
leading an expert into a dilemma, exclaims : " Ah, doctor, are
not all murderers in your eyes madmen ?" having previously
arrested the attention of the jury as if he were about to say a
good thing, by winking to them (un clignement d^yeux, p. xvii).
Although spared such vulgar ribaldry on this side of the

308 Reviews. [Oct.,

Channel, it would be well for the safety of those arraigned, in all
doubtful cases, as, for instance, of the imbecile, the drunkard,
the partially demented, and with the view of avoiding the risk
of such a miscarriage of justice as was nearly committed in the
case of Treadway the epileptic ; were such a probationary
course pursued as has been long recognised and is available in
France, and as has recently become statutory in some of the
American States. As an appropriate key-stone to the con-
struction of a treatise on the civil and criminal status of the
insane, M. Tardieu has introduced the law of 1838, and the
Royal Ordonnance of 1839. These legislative enactments have
been unrivalled in unpopularity, have provoked repeated resist-
ance and reclamations on the part of the public officials to whom
they chiefly apply, and have called forth protests so reasonable as
to have elicited promises of reconsideration and amendment from
the government. The i)recautions prescribed as to the interdic-
tion, incarceration, and management of lunatics may have
proved erroneous and unnecessary, but they so closely approach
in principle, however much they may differ in detail, those
existing in Britain, that it would be supererogatory to particu-
larise them or to advert further to their special characteristics
except where they appear fraught with evil.

In the first place it appears a most perilous adventure that
in terms of Article 3 and 14 the medical officers of public
asylums should be appointed or dismissed by the secretary of
state in conjunction with the local prefect; that transference
from one asylum to another, which cannot take place under a
service of three years, should be effected through the influence
of the same patrons, and this irrespectively altogether of the
experience or opinions of the commissioners intrusted with the
supervision and regulation of the fiscal and general affairs of
the establishments, and who assuredly are the only authorities
possessing opportunities of forming a judgment as to the con-
duct and capabilities of the officials directly in charge, or appa-
rently qualified or entitled to pronounce an opinion on the
suitableness of such officials for another and perhaps wider
sphere of duty.

The apprenticeship of three years here ordained is excellent; but
in a community where politicalopinion modifies if it does not over-
rule all other considerations, such a mode of promotion must be
regarded with dismay; but a yet more vicious provision is inau-
gurated in Article 6 of the Royal Ordonnance, where not merely
a co-ordinate, but what, confessedly, has proved an antagonistic
authority is conferred upon the physician and upon an officer
called the director, who is empowered to superintend the
internal order, and the police service, within certain limits,

1877.]

Medico-Legal Aspects of Insanity. 309

together with the administration of the domestic economy, and
of the arrangements for the admission and discharge of the
inmates.

In the medical attendance of a public infirmary for bodily
diseases it is possible, though difficult, to conceive that parallel
powers, the one affecting the existing ailment and the other
affecting the comfort and general sanitary and dietetic interests
of the patients, may be exercised distinctly yet harmoniously ;
but in an asylum for mental diseases, where the furniture, the
general movement, the moral influences, in short, every event,
however trivial, every accident, however insignificant in the
eyes of common observers, affects for good or for evil those
whom they reach, and become instruments of cure or alleviation
in the hands of a skilled medical man ; it is certain that such
independent, if not conflicting authorities as have been de-
scribed, must clash at every point and stage, to the detriment
of those principally concerned and to the neutralisation of many
of the most important objects in view.

This machinery has, however, worked advantageously in the
production of a large corps of distinguished superintendents and
administrators. In Britain some feeble essays have been
made in imitation of this plan, by intrusting factors, and
so-called lay directors with privileges as to the employment of
patients in occupation, &c., trenching upon the obvious and
acknowledged exercise of medical treatment, but these have
proved such signal failures or such sources of internecine
vexation that the issue of the experiment may be anti-
cipated.

The operation of this law in reference to sequestration may
prove cumbrous, but, in the eyes of certain alarmists, affords a
guarantee against arbitrary or irregular proceedings in the de-
privation of personal liberty.

It provides that no supposed lunatic shall be admitted into
any asylum unless certificated by one medical witness, and that,
in the case of private establishments, the patient shall within
three days be visited, and his condition and all evidence as to
the state of his mind examined and reported on by two experts
to the administrative authority under which they act. In Paris,
where the numbers of private patients are said to be very large,
two physicians are specially appointed for the performance of
this duty, while elsewhere it is confided to any qualified person.
Not satisfied with the security afforded by this machinery, a
demand has been made that the primary certificate should con-
tain the opinions of two medical witnesses. The effect of these
steps is to place the individual in circumstances favorable for
observation and treatment ; but where interdiction or inter-

310 Reviews. [Oct.,

ference with the validity of all civil acts and the appointment of
a guardian is regarded by relatives as expedient, it is prescribed,
in addition, that a personal inquisition or interrogatory, founded
upon the medical statements, should be made by a legal Official ;
a decision as to the existence of alienation being, of course,
practically revoked by the return of reason. This process, closely
assimilated to the inquests de lunatico inquirendo in Britain,
would, if the production of every patient in court or before a
judge and jury were imperative previous to confinement, realise
the theories of such Utopians as consider existing safeguards
insufficient.

Wherever the intervention of the law is necessitated it
becomes incumbent to affirm not merely the presence of mental
weakness or alienation generally, but to indicate the specific
character of the malady upon which any opinion is founded.
Three categories are supplied, under which exemption from
responsibility or the deprivation of civil rights may be craved.
These are habitual imbecility or congenital feebleness and limi-
tation of capacity; 2ndly, dementia, or the deprivation of
mental health and strength consequent upon other forms of
disease ; and, 3rdly, fury, comprehending the acute forms of
insanity marked by delirium, agitation, and violence. Where
the object is, as in a well-constituted community it ought to be,
the restoration or preservation of reason rather than any finical
solicitude as to the possible infringement of that abstraction
called freedom, these terms and the departures from health
which they represent would be found amply sufficient to carry
out, wisely and humanely, the objects in view. But although
broad and inartificial, they have been found practically inade-
quate, as all, even the most rude and rudimentary nosological
distinctions, will be found, to comprehend the proteiform aspects
of mental perversion; and dementia is, accordingly, made to
include all such modifications as cannot be classified under
feebleness or fury. The difficulties encountered, popularly, scien-
tifically, and judicially, in defimng the form and amount of such
cerebral afifections as appear to justify seclusion or the protec-
tion of an unhealthy individual against himself, has been felt to
be so great that recourse has been had to description, to a sub-
stitution of facts for opinions, to personal as well as collateral
experience ; in short the substitution of a picture for a deduction
from premisses.

It is obvious that the practice adopted in this country, how-
ever faithfully adhered to, has failed not so much in guarding
the rights of the citizen ; for the proceedings of a recent parlia-
mentary committee tend to show that these, far from having
been invaded, have scarcely been touched ; but in presenting

1877.]

Medico-Legal Aspects of Insanity. 311

tangible and universally appreciable grounds for the bold course
which they sanction. This failure is in part due to the igno-
rance, imperfect training, and defective discrimination of those
who testify, but, chiefly, to the intractableness of the subject,
to the impossibility of conveying in popular language what
should be the conclusion of protracted scientific investiga-
tion and its results; a dilemma which may ultimately ne-
cessitate a return to the time-honf)ured and expressive but
simple formula of a declaration of the existence of " mental
unsoundness/^

M. Demolombe is quoted in justification of the French
legislators, but when he says that *^they did not pretend to
define with rigorous scientific exactitude the diff'erent varieties
of mental maladies, and that in adopting the terms which they
have used — imbecility, dementia,fury — they sanctioned such as
were at once comprehensive and capable of general applica-
bility^^ (p. 34) ; he appears to concur nearly in the opinion which
we have ventured to advance.

But, in despite of all the precautions resorted to in order to
avoid injustice or rashness, French as well as British legal and
medical authorities are exposed to suspicions and accusations
which must disturb the interests and movements of society.
Of these an example may be adduced. One of these public
prosecutors or calumniators, as the case may be, asserts that
^' liberty is violated annually in the persons of upwards of 600
citizens^' only culpable of having undergone a more or less
marked alteration in the intellectual faculties, by the operation
of Clause 489 of the Civil Code,^' which orders '''that all those
of mature age who are in an habitual state of imbecility,
dementia, or frenzy, ought to be interdicted, even where this,
state presents lucid intervals." It might have been conceived
that protection was afibrded by the significant word " habitual,'^
but the addition of the pregnant qualification " lucid intervals^'
discloses a wide opening for the introduction of doubts, diflfi-
culties, and, it should be confessed, of suspicion. What is a
lucid interval? Is it a complete suspension or a mere mitiga-
tion of the aberration ? Is it to be determined or distinguished
from remission or intermission by its completeness or its dura-
tion ? These questions come home to psychologists as forcibly in
England as in France. Our law appears at present to rest in
an intermediate, perhaps a transition state, and to recognise
in the reasonableness of the act performed, whether that be a
contract of marriage or the execution of a will, the test of the
reality of the re-establishment of sanity ; independently alto-
gether of the time occupied in its performance or during which
symptoms of alienation could not be detected, and of the nature

312 Reviews, [Oct.

of the disease which pre-existed and followed the act^ and of the
physical antecedents of the actor.

But, besides the substratum of character and conduct, the
possibility of impairment or instability of will being compatible
and coincident with intellectual clearness, the precariousness
and inchoateness of all mental conditions in those suddenly or
recently awakened from mania or melancholia should enter as
an element in all such deliberations.

M. Tardieu relates an instance of the celebration of marriage
during a lucid interval of two days' duration. We have known,
in a hundred instances, judicious, benevolent, even noble deeds,
continuously and consistently performed by lunatics who were
notably, though not palpably, mad. We have known the dis-
appearance of all moral exaggeration and error for long periods
while the physical signs proclaimed the persistence of general
paralysis. We can recall the history of a lady who appeared to
be quite recovered for eleven months, in whom paroxysms of
excitement depended upon herself; and of many hysterical
maniacs who could simulate sanity and serenity with nearly the
same success as excitement, folly, or fatuity.

The elasticity of the provisions for the discharge of persons who
have laboured under mental disease is strongly contrasted with
the rigidity of the regulations affecting their sequestration. The
liberation of a patient supposed to be cured depends, in a
majority of cases, upon the opinion of the superintendent of the
hospital; and that the standard upon which such conclusions
are formed must differ widely and vary with the mental constitu-
tion of each physician is demonstrable, not merely by the fre-
quency of relapse, but by the fact that suicide and violence have
followed almost immediately the emancipation thus granted ;
sufficient time, however, having generally elapsed to permit of
many actions and contracts necessarily falling under the cogni-
sance of the law. It may be fairly inquired whether the space of
time between the fiat of the physician and the murder or the mar-
riage which may have followed should be regarded as a genuine
lucid interval. But still greater perplexity is introduced into
such an inquiry, by an innovation now in operation in Britain,
where, by the Act, patients may leave the shelter of an asylum
on what is called probation or trial, and are entrusted to the
care of relatives or guardians, while their restoration is partial,
doubtful, or precarious for the purpose of ensuring a complete
reestablishment of reason or responsibility. The clause by
which this arrangement is sanctioned was dictated, we feel
assured, by sound and benevolent, and, it may be, by economic
motives; but it is obvious that the competency of the indi-
vidual to discharge the duties of a citizen is left undecided, and

1877.] Medico-Legal Aspects of Insanity. 31^

that where the currency of the probation is extended over a
long or indefinite period there may be created ample opportuni-
ties for questioning the validity of the whole conduct of the
person in whose favour such a concession has been granted.
In shorty is a patient under probation — in other words^ recover-
ing from madness — responsible? There prevails, we under-
stand, in Scotland, a course, likewise sanctioned by statute,
which is calculated to produce still greater confusion. When
an inebriate feels that his orgies have been carried beyond the
bounds of prudence and safety, when his mind is darkened,
decaying, tottering on the brink of disease, and even when he
has rushed into the gulf beyond, he may, upon petitioning the
Board of Lunacy, obtain admission into an asylum without any
medical certificate or other legal formula, under the designation
of a voluntary inmate ; and retaining the power — we must call
it perilous privilege— -of discharging himself after three days'
notice, whenever his fears have declined, his belief in his own
self-control has resumed its sway, or whenever the regulations
and restrictions of his self-imposed retirement have become
irksome or intolerable. To certain classes who have not sown
the whirlwind in dissolute or dissipated habits, but who may be
sad or forlorn or fickle, who may shrink from the trials and
turmoil and conflict of social life, or who may feel themselves
incompatible with their own surroundings, such a temporary
refuge may prove most salutary, and may save them from
greater evils, and avert that ruin which they dread; but the
question must arise, and will be found somewhat difficult of
solution, — are such recluses, whether inebriates or abstainers,
irresponsible during their temporary stay in a lunatic asylum ?
Would a testament executed under such circumstances be ad-
mitted ? Would a homicide be exonerated from punishment ; or
would a marriage entered into by a so-called dipsomaniac, even a
few hours after the removal of his self-elected restraint, be
recognisable in law ?

M. Tardieu holds with other psychologists that epilepsy may
coexist with perfect reason ; but his proposition that the periods
between convulsive attacks, even where alienation has super-
vened, should not be identified with lucid intervals, will not,
except as a verbal distinction, be accepted as containing a sound
principle by many of his fellow-labourers. In conjunction with
this view he invariably advocates the sound doctrine that phy-
sical conditions and morbid bodily complications should be in-
cluded with the mental phenomena in the consideration of moral
accountability. Indeed, his invariable illustration of the causes
which interfere with the operation of the moral sense is that of
an external force or agent which dominates an impaired or

^14 tieviews, [Oct.,

perverted will. He advances a step further_, and expresses a
desire that influences altogether external to or apart from the
actor, suchas provocation, intimidation, and, we would add, temp-
tation, should be placed in the same rank as those irresistible
impulses and constraining passions or intellectual errors which
originate in the mind itself. It is argued that this disturbing
influence, whether esoteric or exoteric, must be present and
detectible at the moment of the commission of the crime and of
every insane act where no criminality is involved, but that, in
judging of the nature or degree of the mental freedom and
lucidity during the transaction, the alienist must embrace the
whole course of the disease, whatever may have been its dura-
tion, and, we would add, the whole previous character,
conduct, and the social and family relations of the person
implicated.

In discussing the morbid conditions which he designates
" external forces," our author recognises the existence of irre-
sistibility in monomania, partial delirium, and brief paroxysms
of insanity, but inconsistently protests against the reality of
mania transitoria. It is not very clear why the element of time
should be mixed up with an analysis of morbid impulses, seeing
that pain, a frequent and important factor in the perpetration of
crime as well as in the achievement of noble ends, may be as
fugitive as ideas or emotions, and that incessant and successive
change is the characteristic of states of consciousness, and, lastly,
that continuous irresistibility is scarcely conceivable unless a
wider range of mental disease or deterioration be admitted.

In connection with the subject of temporary and of impaired
but not abolished volition there naturally falls to be considered
the theory of graduated responsibility. The prevalent custom in
France in the administration of justice, where there is no plea
of alienation, has led to the proposal that exemption from the
penal consequences of ofi'ences attributable to the minor or less
demonstrable forms of derangement might be obtained under
the plea of extenuating circumstances. This is nothing more
than the substitution of a legal term in general use for what is
as yet a physiological assumption, that the capacity for per-
ceiving the calls or obligations of duty and the promptings of con •
science difi'er in difi'erent individuals at diffierent times, in dif-
ferent circumstances, and are affected, not only by the amount
of cultivation, but by the bodily condition, and even by the most
trivial incidents which daily occur. It might be difficult to con-
struct a scale in accordance with this view, but from the accom-
plishment of such a project must ultimately be evolved any pos-
sible reconciliation between legal and medical opinion, between
the enactments of law and the conclusions of science. One of the

1877.] Medico-Legal Aspects of Insanity ,^ 31 S

obstacles which will always interfere with success in effecting
this object will be that the insane are often as keenly alive to
the respective nature of virtue and vice, to the import of their
intentions and conduct, to their liabilities ; that they premedi-
tate, take precautions against detection, and in the act alone
which places them under the judgment of the court and of the
world is to be found a proof, or at all events an indication, of
mental disease.

Except in the use of the vague term " non compos mentis,"
our lawyers have interfered but little with the definition of
insanity or with the morbid states which may be comprehended
under this term. That the employment of a more ample
nomenclature, or rather the recourse to a simple nosological
arrangement, has not materially assisted our fellow-labourers
in France in the elucidation of the subject, or in dealing with
the difficulties which are obtruded at every step in estimating
moral freedom, may be gathered from the inclusion of numerous
morbid conditions, the existence of many of which is still con-
troverted, under the head of imbecility, fatuity, and fury. Of
these conditions that which has provoked most discussion in
Britain, which would be repudiated as exculpatory by legists, and
which, as vet, finds little favour with either metaphysicians or
alienists, is '^Instinctive Impulses,'"' which are sudden, irresistible,
inexplicable, and transient, which are neither preceded by reflexion
nor originate in any intellectual operation ordinarily admitted
as sane or insane. The passion, propensity, perversion, thus
constitute, while they continue, the whole mind or conscious-
ness and the disease. It is perfectly true that, however un-
popular and illogical such a ground of exemption may appear to
us, even this form of insanity, and perhaps all others of a similar
kind, may be covered by the expressions contained in the opinions
of the judges : '' If from disease of mind he (the criminal)
laboured under such a defect of reason as not to know the
nature and quality of the act he was doing, or if he did know
it, that he did not know he was doing what was wrong,'-* as in
a mind agitated and occupied by intense, exaggerated instincts,
the ordinary laws of mind are abrogated and suspended, and
there is neither reason to determine, conscience to guide, nor
any exercise of will except that merged in the impelling feeling.
But as the prefix of '^ disease of mind" to the words " did not
know the nature and quality of the act" seems to imply that
the inability to perceive the nature of the act was a consequence
of an undefined, antecedent mental state, it is to be apprehended
that any pleading or reasoning upon the assumed existence of
irresistible impulse would be rejected. And even this, when such
a symptom is developed in conjunction with others, and when

316 Reviews. [Oct.,

there is either intellectual obscuration or perverted sentiuients
or delusions ; but it might be admitted as strengthening an argu-
ment in support of the existence of irresponsibility^ yet it is very
doubtful whether its appearance in epilepsy, in dipsomania, in
imbecility, in the degraded, the eccentric, the hypochondriac,
the hysteric, during pregnancy, lactation, &c., would be accepted
as demonstrating the insanity, and, therefore, the irresponsi-
bility of the individual ; as appears to be the case in France.
However desirable a certain expansion of our own code might
be, and however readily the group of conditions now enumerated
may be admitted as morbid, such admission must proceed on
the supposition that they impair but do not extinguish freedom
of action ; that they are extenuations of culpability, but not
grounds of exemption from all punishment.

TJnder mental weakness, as affecting accountability, there
fall to be included idiocy in its various grades, dementia in its
various stages, deaf-mutism and the confusion, the forgetfulness,
and feebleness of the moribund, and of those suffering under
fatal or severe bodily ailments. Pathology has sometimes been
called in to aid in the determination of the nature and extent of
alienation. Where suicide has occurred it can be understood
that the absence of all structural disease may be received as
evidence of the mental health and of the validity of recent
doings of the deceased ; but the untrust worthiness of the
results as yet accumulated in this department of science must
greatly limit the applicability of such a means of diagnosis, and is
well exemplified in the work before us. The following case illus-
trates this observation : — An aged man having died during the
preliminary steps necessary for interdiction, his brain presented,
according to three medical reporters, engorgement of the veins
of the pia mater, false membrane connected with the arachnoid,
serous effusions compressing to a considerable extent the surface
of the brain, and, lastly, softening of its substance. Upon these
appearances was founded the opinion that there had existed in the
deceased grave and long-established mental disease. The
validity of his will was consequently disputed and a legal
inquiry instituted, in the promotion of which the following in-
terrogatories were addressed to the experts, MM. Parchappe,
Baillarger^ and Leger, retained by the pursuers.

1st. To what cerebral disease are the structural alterations
enumerated to be attributed ?

2nd. What condition must have resulted from such structural
changes during the latter years of the deceased?

The conclusions arrived at were : the appearances noted
were, without doubt, pathological ; and although not individually
connected with any morbid state, in their nature, and especially

1877.] Medico-Legal Aspects of Insanity. 317

in their totality, they must be regarded as connected with
dementia. Many of these, particularly thickening of the mem-
branes and eflFusion, should be regarded as positively incom-
patible with the normal functions of the brain, and with the
integrity of the intellectual faculties ; impairing inevitably
mental energy and strength, and even motility. Provided the
encephalic disorganisation did produce dementia, its morbid
characteristics would consist mainly in interference with the
exercise of the intellect and the will, but the precise date of
its origination or duration cannot be affirmed, although it is
highly probable that it had continued for years, and had become
more pronounced towards the close of life.

These inferences were combated with great earnestness by
MM. Trousseau, Grisolle, Falret, FoUin, and Lasegue, who
contended that the attempt to determine the mental condition
from changes in the brain detected after death, and the con-
clusion, from the state of the meninges, that the deceased was
capable or incapable of choosing his heirs was unqualified non-
sense ("non-sens inqualifiable''), and they further speculated
that the premises were neither clearly ascertained nor fairly in-
terpreted, inasmuch as the degeneration depended upon may
have been the effects of senile decay, of antecedent inflamma-
tion, or even of cadaveric changes. But, while admitting that
what was observed may have been either the cause of senile de-
mentia or general paralysis, or the consequences of intellectual
confusion or weakness, this difference of opinion involving doubt,
they hold that the proof of the existence of any of these morbid
conditions is too insignificant and insufficient to invalidate the
act under consideration ; and they emphatically protest against
the innovation thus initiated, and against any judgment formed
from other evidence as to the existence of sanity or insanity, ex-
cept that derived from the words and deportment of the individual
during life. M. Tardieu pursues a middle course, and would, in
the adoption of an opinion, be guided by anatomical as well as
physiological evidence. Yet, when estimating the value of the
former, he confesses that such a source of knowledge is rarely
appealed to, that it is necessarily fallacious, because in certain
cases no lesions whatever are discoverable, because such lesions
may be encountered in those who have possessed perfect health
until the period of dissolution, and, he might have added, that
the same lesions may be associated with widely different and irre-
concilable mental phenomena. He suggests the expediency of
directing microscopic examinations to all parts and organs of
the body, as well as to the nervous system; pays a merited
tribute to the researches of M. Voisin, although these have
been almost exclusively confined to chronic cases where phy-

120— LX. 21

318 Meviews. [Oct.^

sical alterations may legitimately be represented as the con-
sequences of morbid action, and concludes with the truthful
though now trite remark, that modern appliances may throw
incalculable light upon regions which are now dark and un-
explored. It should be here observed that these subjects have
received but limited consideration from both moralists and
psychologists.

In a very extensive category characterised by delirious con-
ceptions may be classed individuals affected with mania, mono-
mania, lypemania, the mania of suspicion and persecution, the
mental consequences of paralysis and states of somnambulism ;
in all of which the civil and criminal relations of the patient
are comparatively palpable. In reference to sleep-walking, and
the extraordinary, almost incredible achievements performed
under its influence, among others sexual intercourse and impreg-
nation, some difficulty may arise ; but if it be identical with or
allied to epileptoid trance or petit mal, this difficulty will
be transferred to the investigation of the bearings of epilepsy
upon sanity, which, although involved in obscurity, is less im-
penetrable than that directed to sleep, sopor, coma. But what-
ever the psychical relation of this state may eventually be deter-
mined to be, it must be recognised as morbid, as a delirium, as
an acted dream under the guidance of certain of the external
senses, as beyond the range of consciousness and partially inde-
pendent of the empire of the will. Popularly the analogy between
dreams and delirium is well known, but these states have a more
intimate alliance, or more strictly speaking they approach each
other at a number of points, although they may not come posi-
tively into contact. Homicidal attacks have been made at the
moment of awakening, in that ill-defined, perhaps indefinable
confusion which succeeds sleep abruptly broken and that twilight
of the mind conceived to connect sleeping and waking when, as
has been intelligibly argued by French observers, the moral nature
is but imperfectly enlightened by reason, religion, and prudence.
In tragedies of this kind a dream may have become a motive, a
premeditation ; or, what is more probable, a determination pre-
viously formed may be carried into effect during a waking
dream or the imperfect consciousness which succeeds. We have
known, an instance where insanity arose in and from a dream
and lasted for years ; and it is worthy of inquiry whether the
vague and clouded impressions which arise during the preva-
lence of petit mal may not precipitate similar catastrophes.
This suggestion becomes still more important when such sub-
jective impressions assume the character of permanent false
judgments and fixed ideas and become the powerful, it may be the
omnipotent regulators and rulers of conscience and conduct.

1877.] MedicO'Legal Aspects of Insanity. 319

Mono-ideaism even in the sane is destructive of that equipoise
between the reflective and emotive parts of our nature which
constitutes the activity and comprehensiveness of healthy mind.
Men of one idea, like those of one talent or of one book, gene-
rally display great inordinate energy within their limited
sphere, but this restriction, as when the eye is fixed upon a
single luminous spot, excludes the influence of other faculties
and lessens the general force by exalting the special exercise of
an individual state of consciousness. It is not, however, in the
fixity or isolation of the intellectual condition, but in its nature,
that alienation consists. It is, accordingly, an error or a
misnomer to place general paralysis in the same class with
monomania, for, in the first place, the current of delusions is
continuous as well as turbid, and, although the kind or character
of these erratic or ambitious thoughts, desires, pictures, be inva-
riably the same, they are innumerable and multiform ; and
secondly, because while as an entirety this afi'ection is distin-
guishable from all others, it presents not merely a phantasma-
gora of imaginations and impulses, but frequent deviations from
a fixed or constant course, complexion or complications. In
the first stage, where there may be little more than elevation
and joyousness of spirits, some trivial interruption to regularity
of habits, some hesitation in speech, serious misdemeanours
may be committed which it has been found vain or hazardous
to explain or excuse on the pretext of incipient alienation ; in
the second stage, where rank, riches, Herculean or invulnerable
power or immortality are arrogated by a feeble tremulous
pauper, the mania of pride may be diagnosed from the extra-
vagant delusions and collateral symptoms, but not from the
fixity of what is in reality fluctuating in colouring, phrase and
extent ; while, in the third stage, the physician has before him
an example of profound and stationary dementia still tinged
with the brilliant hues of hope. This is, perhaps, the only
aspect of confirmed derangement which cannot be successfully
imitated; whereas many of the less expansive forms, and
those complicated with physical diseases, have been imper-
sonated so faithfully as to deceive observers. It may be due
to the histrionic aptitudes and tendencies of our neighbours
that such impersonations occur so frequently in France.

An entire chapter has been devoted by M. Tardieu to the
history of the mode and detection of such dissimulations. He
divides the subject into, first, a description of pretended insanity
where measures, sometimes cunningly, sometimes clumsily
devised, are resorted to in order to transfer suspicion and blame
from the really guilty ; secondly, where the off'ender assumes or
endeavours to assume the manifestations of a certain species of

320 Reviews, [Oct.,

alienation. In the search after truths, or rather in the effort
to trace and expose deceit, it is recommended that the previous
state of health, the occurrence of former attacks of mental
disturbance and the seclusion or other kinds of management
adopted under such circumstances should be inquired into ; and
that next the present deportment and the act which has called
for investigation be compared with the known disposition, con-
duct, and general antecedents of the accused. All modifications
of aberration have been simulated, from mania to mutism, but, in
general, violence, fury, agitation, are the means of concealment
attempted. The attitudes, gesticulations, costumes, songs,
cries, vociferations, dances, contortions, laughter, weeping,
vehemence, destructive and degraded habits resorted to, under
the impression that these represent real disease, are generally
over-acted, exaggerated, and so grotesquely combined as to pro-
voke astonishment and mirth rather than conviction. The
sudden transitions likewise from grave to gay, from drivelling
insanity and endurance to impassioned oratory and witty sar-
casm, often raise the curtain and reveal the plot and object of
the drama performed. Such transformations are so rapid and
incongruous as to be readily distinguished from the marked
stages ; of excitement which merge into depression in folic cir-
culaire. But, however clever or astute these theatrical extra-
vagances may prove, for they are often reproductions from the
stage ; and however much they may perplex and even impose
upon the physician, they cannot stand the test of minute and
prolonged vigilance and experiment. It is impossible to dis-
semble as to insomnia, constipation, affections of sensibility
and motility and other physical diseases. In the prosecution of
such an inquiry the most trustworthy means available are pro-
tracted and repeated observation by experts at all times and
under various circumstances, especially within the walls of an
asylum where the restrictions, the supervision and associations
render the doings and designing of the inmates transparent.
In reaching a judgment upon such cases, three guiding rules
may be kept in view in conducting such moral experiments ;
1st. The origin and especially the time of the origin of the
symptoms in the supposed lunatic should be accurately ascer-
tained ; but as mental perversion may lurk long unobserved, or
may be precisely coincident with crime, such a rule, if rigidly
applied might prove fallacious and lead to fatal error. 2nd. A
comparison between verbal and occasional incoherence and
shrewd or sensible and dexterous behaviour in ordinary situa-
tions and when alone, must be carefully instituted. 3rd. The
wise and humane caution to the effect that pretended diseases
may become real and permanent, that, under long-continued

1877.] Medico-Legal Aspects of Insanity, 321

deceit and affectation, especially when practised under the insti-
gation of fear, or avarice, or pietism, convulsions may pass
beyond the control of the will and of the original motive and
become morbid and involuntary, the mind and even the muscles
wasting and weakening under incessant strain and stimulation.
We have known these, confessedly simulated for a purpose,
pass into genuine epileptiform seizures, when consciousness was
undoubtedly suspended and where these eventuated in fatuity and
death. Upon no very intelligible grounds, chloroform, cautery,
and all tests which are stigmatised as injurious because they
inflict pain, are protested against in these attempts to detect
imposture and, as a consequence, to promote justice, to vindi-
cate social and individual rights, and it may be to save the life
and fair fame of the innocent.

In such examinations we should be impressed with the fact
that we are not engaged in watching the developments of a
dramatic harlequin, that, although it be dogmatically enun-
ciated that there is no type, no gradation, no connection
between passion and frenzy, that in nature there is ; and, again,
that, although it is contended that there is no line of demarca-
tion between disease and dissimulation, there actually is ; and
that this line is drawn and traced by signs of morbidity, that
such tracing may be the border-land, the boundary, joining
imperfect health with irresponsible unhealth, and that in this
region are met the difficulties and darkness which obstruct the
decision of the jurist consul.

Lemoine is appealed to as trusting to the psychical lesion to
the dethronement of will and moral freedom, to the disorder of
intellect, to errors of judgment, to the anarchy or tyranny of
the feelings, appetites, and instincts, as constituting the founda-
tion and features of alienation, although these cannot be re-
garded as exhausting the constituents of mental disease ; while
Falret presses the proposition that the true diagnostic element
must be sought for in pathology, not in psychology ; must be
elaborated from the entire breadth of clinical symptoms, and
not from one, and from the physical as well as the moral deve-
lopment of the patient. It need not be argued here that the
latter views are most consonant with the principles and expe-
rience by which experts are influenced in this country ; but it is
apprehended that greater attention and importance are still
attached to intellectual perturbations and metaphysical distinc-
tions than to symptoms attributable mainly or entirely to the
bodily condition. Formal precepts would prove rude or prag-
matical, but it is certainly desirable that in the examination of
transactions in which culpability may be involved, all mor-
bid features which can possibly affect freedom of will should

322 Reviews. [Oct.,

be scrutinised in detail. It is perhaps natural that mental
manifestations should primarily attract notice, that multiplicity,
incoherence^ fixidity or rapidity of ideas, even when the deduc-
tions from these are reasonably logical; that the excitation,
perversion, or extinction of sentiments, passions, instincts, and
hence impairment of will — that natural as well as artificial lan-
guage as embodied in the facial expression, gait, and peculiarities
of manner — that hallucinations, delusions, abnormal visceral
sensations, and delusions ; should be tried and tested. But,
although in these affections, which, according to Calmeil, form
the " basis and food" of partial insanity ; it is imperative in any
generalisation, that there should be considered the form of the
head, the presence of asymmetry, of injuries, wounds, in the
same region, the integrity and functions of the skin, the con-
dition of the heart and arteries, anaemia, and vitiated digestion,
nutrition ; abolished, exalted, perverted, general, and special
sensibility ; sleep, paralysis, convulsions, symptoms which,
although deserving observation, must be regarded as the causes
rather than the proofs of the existence of alienation. Again,
any inquiry of this kind would be imperfect were there omitted
the family as well as the personal history of the individual, the
hereditary tendencies, the training, the surroundings, tempera-
ment, habits of thought, tastes, moral tendencies, and style of
writing.

This long catalogue — which has been, however, greatly epi-
tomised from the original — will serve to show how extensive,
almost exhaustive, the French procedure is when the mental
condition is investigated, especially in reference to responsi-
bility. But a more valuable and convincing illustration of this
course is furnished in the fourth part of the volume before us,
where copious narratives are given of typical cases where the
interference of experts was called for in process of law. These
reports derive an additional importance as representing the
opinions of a very large majority of French alienists. To those
familiar with the pages of the ' Annales Medico-Psychologiques '
this department of medical literature will be well known, but
to a large proportion of our profession, especially those whose
practice lies outside the narrow limits of psychology, it will
appear both novel and instructive. As the defects of the work
under criticism are verbosity and copiousness, if not logomachy,
our selection must be very limited. On a demand for interdic-
tion on the ground of alleged dementia or imbecility, it was
affirmed that the patient, a lady of rank and affluence, was
unfilial and insubordinate towards her mother, whom she ap-
peared to hate, revolted against the discipline of the conventual
school where she was placed, and was removed ; was passionate

1877.]

Medico-Legal Aspects of Insanity, 323

and peculiar in her home^ which she left in order to secure
access to a domestic to whom she was attached, and whose dis-
charge led to a mortal quarrel with her parent ; gave way to
violent paroxysms of rage, during which she destroyed vases,
her watch, refused to appear at table, continued correspondence
with the servant, struck her mother, menaced vengeance and ex-
posure, consummating her threats by escaping to Paris, where,
after eight days^ concealment, she was discovered in a lodging
provided by the servant formerly mentioned. She was visited
there by M. Lasegue by the authority of her mother. He cer-
tified that she was of feeble intellect and totally deficient in the
moral sense. As a consequence of this opinion she was sent to
a private asylum ; subsequently, on an application from the
family council, interdiction was called for, when, during the
interrogatory which followed, the replies of the patient indicated
perfect coherence, a consciousness of her position, and no men-
tal weakness or waywardness, although some of the questions
were crucial and extremely embarrassing. Permitted to leave
the asylum in order to meet her friends, she eloped with a person
who had sought her in marriage, and with whom she lived
several weeks in Belgium. This incident was followed by the
resumption of the medical inquiry, which was conducted by
MM. Parchappe, Grisolle, and Tardieu, and which consisted, as
in all similar cases, of an instruction, in this instance from the
first tribunal of the Department of the Seine, to ascertain,
under oath, whether the patient is in an habitual state of
dementia or imbecility; secondly, of the perusal of all the
documents connected with the case, these being the judgments
of the Civil Tribunal on a former occasion, the deliberations of
the family council, the previous interrogatory, a number of her
letters ; and, thirdly, of a further examination of the patient,
and medical report founded thereon. Their verdict, very much
abbreviated, founded to a great extent upon the explanations of
the patient, such as that her dislike and desertion of her mother
was the result of harshness and tyranny, of blows inflicted by
the servants ; that there was no improper intimacy or inter-
course with the coachman, &c., was substantially that the
patient's intellect reached, but did not exceed, the ordinary
standard of capacity ; that she understood their questions, and
displayed correct notions of moral obligations, of modesty and
reserve ; that her conduct was far from being irreprehensible or
justifiable towards her parent ; that her accusations and recri-
minations had not been free from injustice and exaggeration ;
that her errors of conduct and character had been deeper and
darker than what she had avowed ; but that she was justified in
defending herself against the imputations of mental disease;

324 Reviews. [Oct.,

and that there could not be discovered in the various steps of
the inquiry proofs of the original or acquired imbecility attri-
buted to her. It must be obvious that this woman''s deviations
from a reasonable and virtuous course were due either to moral
insanity or immoral sanity.

As an example of the intervention of experts in elucidating
the mental condition of the moribund there may be selected the
following : — 1st. After an undescribed illness of twelve hours
there were found impeded articulation, want of symmetry
between the sides of the face, symptoms so grave as to
necessitate a consultation. The patient as examined by
three medical men was found to be prostrated, with resolution
of the muscles, squinting, deviation of the mouth, tympanitis,
distension of bladder, slow irregular respiration although the
lungs were healthy ; there were no symptoms of intestinal irri-
tation, no dilation or inequality of the pupils, no anaesthesia or
paralysis properly so called, but great feebleness both in motility
and sensibility ; and he appeared to be in a state of exhaus-
tion of the intellectual powers. Passive while his case and
condition were discussed in his presence, he was roused to utter
a few incoherent words and to protrude his tongue, but, except
by the rude test of raising his arm, the existence of paralysis
was not determined. He replied correctly to questions subse-
quently put and then relapsed into sopor or unconsciousness.
One of the witnesses described his articulation as difficult and
interrupted, and that it was aided by signs and gestures. No
diagnosis was arrived at, but, in the evening, one of the con-
sultants on questioning him as to whether he suffered, obtained
the response "there" while the abdomen was touched; which
was supposed to result from the state of the bladder. After a
period of twelve hours catheterism was ineffectually resorted to
without disturbing the patient, and puncture of the bladder
was discussed. It does not appear that on this occasion any
attempt was made by questioning to probe the mental condi-
tion. At this stage the religious ceremony of marriage was
performed. The medical attendant then proposes the application
of a sinapism, but the newly made husband seems to have died an
hour or two after. In supplementing the very defective, we think
discreditable medical testimony, a notary deposes that to a single
inquiry as to his health, on the day previous to death, the patient
declared that he was perfectly well. To the clergyman who
urged marriage in order to atone for the sin of concubinage, he
argued against such a course, in consideration of the claims of
his own relatives; then repeated prayers so volubly that he
required to be stopped ; but with the exception of the words
*' yes" and '^ no/' as answers to interrogations by lawyers and

1877.]

Medico-Legal Aspects of Insanity.

325

inclinations of the head while the marriage was proceeding —
signs which the priest declined to interpret — he did not further
manifest consciousness and was either unable or unwilling to
acknowledge the caresses of his daughter. The facts above
condensed were derived from inquests before the courts of
Tonnerre and Paris, and from the personal examination of the
different individuals_, medical, clerical, and lay, who had been
brought into contact with the deceased during the latter hours
of his life. The reporters, Lasegue and Tardieu, were of
opinion that the cause of death was to be found in the brain,
that the symptoms detailed were those of paralysis, depending,
probably, upon congestive, apoplectic,or inflammatory conditions,
involving the whole encephalon and in different degrees all its
functions ; and that, although no information had been supplied
as to the state of the circulation or of the renal secretion, such
a termination might be naturally expected in one of a gouty
constitution. During the somnolency or coma which accom-
pany such affections the will and intelligence are almost or
altogether annihilated, although they may be momentarily
excited by external stimulants ; and that such revival is con-
fined to mere movement in acquiescence or in compliance by
a gesture; that such was the physiological condition of the
deceased, incapacitating him for the performance of voluntary
acts, and, therefore, that the act of marriage was null and void.
By a more circuitous and laborious process and depending upon
evidence of a different sort, the medical concurred essentially
with the legal arbitrators. Apart from the scientific deductions,
the case may be said to have rested upon the spontaneity of a
mere syllable.

V. B. executed a will by dictation of his lawyer during his
last illness, the validity of which was disputed. The experts,
MM. Tardieu, Blanche, and Baillarger, were instructed to con-
sider whether the deceased was or was not able to see on an
evening specified, and whether he was at the same time able to
read the writing of the testament drawn up by his lawyer.
There were submitted in the inquiry the evidence deposed in dif-
ferent inquests, written statements by medical attendants, the de-
liverance of the Court of Tarbes in nullifying the will, letters by
the testator, his will, and a memorandum as to the events of his
last days. It was established that, at different periods previous
to his decease, V. B. had been subject to articular rheumatism,
stupor, attended with feebleness in the right arm, a tendency to
somnolency after taking food ; and, prominently, to congestive
attacks requiring the application of leeches, but it was not affirmed
that his vision was implicated or that its state prevented him from
reading without the aid of a glass a few days before his demise,

326 Reviews, [Oct.,

Another physician described V. B. as subject to gout^ as present-
ing many of the concomitants of that malady, as being diabetic,
as having been seized while playing at cards with some cerebral
disturbance attended with temporary embarrassment of speech,
but did not allude to loss or failure of sight. It was distinctly
proved that he could read medical prescriptions, that he could
write legibly and clearly, that he rarely used an eye-glass, and
only in consequence of the degree of presbyopia to be expected
at his age ; up to 15th September, 1863. After this date
V. B.'s caligraphy continued precise and correct up to the
month of October, and if any alteration was detectible, then
or subsequently, it should have been attributed to increased
feebleness, and ultimately to prostration, tremor, and muscular
subsultus. It is noteworthy that the glass in his possession was
of low multiplying power which he never sought to increase and
was used, according to himself, merely to correct the dazzling
effect of minute characters, and in no way corroborated the hypo-
theses of long-continued or signal impairment of vision. A sup-
posed error in counting a sum of money was traceable to mental
obscurity, to that sudden stupor under which he had repeatedly
laboured, and not to imperfect vision which was not required in
the operation. Notwithstanding the adynamic state preceding
his dissolution, he replied with accuracy when addressed, could
take hold of objects presented to him, conversed a long time with
his notary ; and there was afforded no proof in his voluntary
actions of confused perceptions or a blunting of his usual capa-
city ; and that the probability was he could see with the same dis-
tinctness as previously, especially when the writing was familiar
and the transcript of what he himself had dictated ; that he
would be roused to exert his powers to the utmost and that he
might have sought the assistance of the glass he was accustomed
to use. The incidents that he called the attention of the writer
of the will to his signature, and devolved upon him the reading
of the document, were held to indicate, not an inability to read,
but the disinclination of the dying man to exert himself. In
opposition to one of the medical witnesses and to the decision
of the Court of Tarbes, it was concluded that on the day libelled
y. B. could have read the disputed document.

M. Tardieu entertains strong convictions on the efficacy of
handwriting as a guide in such difficulties. The appendix con-
tains specimens of letters produced during different forms of
alienation, and he is disposed to connect particular forms and
styles of character with particular mental states. We confess
that, independently of the thoughts and feelings expressed, and
of such pathognomonic signs as are afforded by the omissions and
misspelling of general paralytics, and of the tremulousness and

1877.] Medico-Legal Aspects of Insanity, 327

uncouth characters of dements and paralytic dements ; we have
not been successful in confirming this speculation. It is under-
stood that the " echo-sign '^ or the repetition or reiteration of
certain words in epileptics, which has been so much insisted
upon in America, reappears in the writings of that class.

Pretended insanity is illustrated by the history of an indivi-
dual who used the body of his murdered wife as a mattress upon
which he lay, that, when the dried and attenuated corpse was
discovered, four months after death, the perpetrator inflicted a
slight wound on the throat, twice enacted partial hanging in his
cell, articulated in a low and altered voice, but neither spoke nor
acted irrationally. On examination in the hospital of St. Louis,
where he was placed for surgical treatment, he endeavoured to
conceal his complicity in the death of his wife by constructing
the romance that they had agreed upon committing suicide
simultaneously, that she swallowed laudanum and died, that he
failed to accomplish his purpose, and that, in order to avert
suspicion falling on himself, he secreted the body where it was
found. He had been formerly an inmate of Bicetre, in con-
sequence of having struck a fellow-workman with a pair of
scissors, but was almost immediately discharged. But during
his sojourn in the hospital, and at the time of the accusation,
he appeared in all respects acute and responsible. The partly
decomposed and mummified remains of his victim imparted a
different aspect to the transaction which he had attempted to
explain ; the temporal bone having been found fractured, appa-
rently by violent blows with a hammer, which could not have
been self-inflicted, while the other organs of the body were free
from disease. The culprit was declared by the expert to be of
perfectly sound mind, both at the time of the murder and
subsequently.

Our space will not permit of dealing further with this sub-
ject, except by reproducing the titles or marked features of a
few of the remaining reports, twenty-six in number.

{a) Incendiarism in an ineducable youth of limited intelli-
gence, referred to impulsive instincts.

[h) Falsification, forgery, referred to a combination of de-
rangement, duplicity, and imposture.

(c) Menaces against royalty, vagabondism, absurd claims
and pretensions ; referred to moral perversity and intellectual
derangement.

[d) Eccentricity, perversion, moral and intellectual, hoarding
in a ruinous house, nudity, is sent to Charenton, where, on his
own petition, he is twice examined by six experts, who find him
insane, and recommend, on the score of his personal safety and

328 Reviews, [Oct.,

of public morals, his being confined in an asylum or confided to
the care of a tutor.

(e) Murder under hallucination, saturnine, solitary, vindictive,
displayed in assaults followed by imprisonment ; heard insults
never uttered — shot offender — choosing place for aim — described
deed calmly — defence that he was a reasoning homicidal,
monomaniac, impelled by hallucinations ; but was condemned,
according to our author unjustly, to twenty years' penal servi-
tude.

(/) Nullification of will on demand of relatives, whom it
disinherited, on the ground that the testator formerly believed
himself to be surrounded by enemies, that he secluded himself
for two years, during which he constructed a guillotine with
which he affected self-destruction.

' The Contributions to Mental Pathology,' by Dr. Ray, Phila-
delphia, known to our readers as the author of perhaps the best
work on Medical Jurisprudence, published in 1836, has been
classed with M. Tardieu's 'Medico-Legal Studies on Insanity,' as
it is assimilated in scope to the concluding portion of that work.
Many of the trials recorded are reprints from various American
periodicals, and are but little known in this country ; but they are
of paramount interest, and in their collected form must take a
high place among the standard authorities in the department with
which they are connected. They are the production of a veteran
student of psychology, in the best and scientific sense of that
term ; of one practically and for long years acquainted with the
relations between medicine and law as affecting the insane ; of
a calm, deliberative, j udicial mind ; of a pure, honorable, upright
character ; of a philosopher as well as a philanthropist, whose
beneficent and successful labours in the cause of truth and
humanity have gained for him, by the unanimous acclamation
of his fellow-workers, the well-earned and noble title of '' the
Master.''

VI. — Sanitary Work in India.i

Our July number for 1875 contained a brief sketch of the
progress of sanitary work in India in 1872-73, and of the
manifestations of the more important forms of disease met with

1 1. Eleventh Annual Report of the Sanitary Commisioner with the Oovernment
of India, 1874. Calcutta, 1875.

2. Twelfth Annual Report of the Sanitary Commissioner with the Government
of India, 1875. Calcutta, 1877.

3. Eleventh Annual Report of the Sanitary Commissioner for the Government
of Bombay, 1874. Bombay, 1875.

4. Meport of the Sanitary Commissioner for Madras, 1874. Madras, 1875,

1877.] Sanitary Work in India. 329

during that period. We now propose to place before our
readers an outline of the prominent facts of the two following
years.

The first point which naturally presents itself, and that on
which the weight of all our statistical investigations of disease
depends, is the degree of trustworthiness of the registration of
deaths which has now been in force, to a varying extent in
different localities, for several years. The results at the com-
mencement were, as was to be expected, very unequal and
imperfect ; but strenuous efforts have been made to improve the
mode of collecting the facts, and the Sanitary Commissioners
and their provincial subordinates give, in the reports under
consideration, several illustrations of how far these now repre-
sent the actual death rate among the population at large.
Thus, in Bengal proper, where the registration was commenced
several years after the other provinces, with a population of
60 millions, the deaths enumerated in 1875 amounted to 10*01
per 1000 only, while in certain selected areas in that province,
with a population of ^l millions, in which more care is given
to the subject, the mean ratio was 24:"8, but with rates varying
from a minimum of 14 to a maximum of 45 at different points.
In the North-west Provinces, with 30^ millions of population,
the mean ratio was 21*82 per 1000, varying from 18 to 87 in
different districts ; in the Punjab, with 17^ millions, the mean
was 25"57, varying between 9 and 42, though, had certain
frontier districts which are less in hand been excluded, the
minimum would have been 18 instead of 9. The Madras
Presidency, with 80^ millions of inhabitants under registration,
had a mean mortality of 21*1, varying from 12 to 48 in different
districts ; and that of Bombay, with 16^ millions, had a mean
of 28*15, the extremes being 6 and 82. Great difference of
mortality must be looked for in different parts of a country so
extensive as that from which these details are obtained, not
only from year to year, but even in the same year, under the
varying incidence of the severe epidemics to which they are
liable ; but it is obvious, from what we know of death rates
elsewhere, that the lower ratios in the respective provinces just
given must be very much under the truth, and that the regis-
tration in these at least is still far from perfect. In the larger
towns of the Central Provinces, and in the municipalities of the
Punjab, where special attention has now for some time been paid
to the subject, the death rate is very high, being 81*6 per 1000 in
the former, and 48*7 in the latter. With regard to the Punjab,
Dr. De Renzy states, " The returns of this (1875), as well as
of those of previous years, show that a death rate varying from
about 40 to 60 per mille is the normal standard of mortality

830 Reviews. [Oct.,

in Punjab towns, and in appreciating the importance of these
results it is to be remembered that the returns still err on the
side of defect, for there can be little doubt that many deaths
occur that do not appear on the register/' Though a great and
valuable commencement has thus been made, it is apparent
that it will still require unremitting attention, and possibly
much time, before the registration can be rendered tolerably
complete ; in the meanwhile, as regards certain forms of disease
at least, it supplies us from month to month, and from year to
year, with approximations to the mortality they cause, which,
imperfect as they are, are of far greater value than the loose
estimates we had to fall back on before they became available.
As cholera occupied the chief place in the remarks of the
various Commissioners in previous reports, so in those forming
the basis of this notice it continues to receive the greatest share
of their attention, and the varying incidence of the disease
during the last two years presents features of the highest in-
terest. By referring to our last notice it will be seen that, in
1872, there was a severe epidemic of cholera throughout Hin-
dustan, but in 1873, while in Bengal proper there was an
increase over the previous year, and in British Burma a consider-
able epidemic, the Punjab, the North-western Provinces, and
Oudh, had a large decrease of mortality from cholera from the
previous year, and the remainder of Hindustan was unusually
free from the disease. Its fluctuations in 1874-75 may be best
appreciated from the following table of the deaths caused by
it in these years, in which the different provinces are arranged
from north to south, as nearly as can be, except British Burma,
vv^hich, being to the east of the Bay of Bengal, cannot be placed
among the others. The numbers for 1873 have been added for
comparison.

(

1873.

1874.

1875.

Bengal ....

148

6,246

North-western Provinces

15,268

6,396

41,106

Oudh ....

3,961

23,321

Bengal Proper

60,498

56,876

112,276

Central Provinces .

344

14,643

Berar ....

22,465

Bombay Presidency .

"283

47,573

Madras Presidency .

840

313

94,547

Ceylon ....

...

1,817

British Burmah

8,109

960

761

Here it is seen at once that, while the mortality in Bengal
proper underwent a sensible reduction in 1874, in every other
part of Hindustan the disease diminished very much, and in
British Burma was scarcely one eighth of what it was in 1873.
In 1875, again, there was a very severe and extensively diffused

1877.1 Sanitary Work in India, 3Sl

epidemic, reaching from Ceylon to the Punjab, while in Burma
the mortality was smaller even than in 1874. To complete the
view of the relations of these epidemics it is necessary to add
the following remark by Mr. Cornish in the Madras Report for
1873 :

'* While the Peninsula of India has on this occasion escaped in-
vasion, it must not be forgotten that cholera has been noticed in
great force in the territories to the east of the Bay pf Bengal. In
Burma, Tennasserim, Cochin China, the Straits Settlements, and
the islands of the Indian Archipelago, the destroyer has reaped a
goodly harvest of victims" (par. 384, p. 91).

Thus it appears that in 1873, while the epidemic, which was
experienced extensively over Hindostan in 1872, was under-
going rapid diminution in most places, a fresh one became
developed over the countries to the east of the Bay of Bengal,
extending from the Indian Archipelago and Singapore in the
south, to Bengal in the north ; in 1874 this epidemic, so far
as our information goes, became much reduced in force over
these countries, while in Hindostan, except in Bengal proper,
and the adjacent portion of the north-west provinces, cholera
as an epidemic may be said to have disappeared. In 1875,
again, while to the east of the Bay of Bengal the disease does not
seem to have been frequent, it commenced in Ceylon in January,
and soon after became active at various points on the mainland,
culminating in a very severe epidemic embracing the whole
peninsula, with certain exceptions, as far as Lahore. These
facts have a most important bearing on our speculations as to
the causes of this disease ; they show that, in 1873, factors suffi-
cient to determine its epidemic prevalence were in operation
from Singapore to Bengal, while in most of Hindostan and
Ceylon they were in abeyance, and, in 1875, these became
equally active in the latter countries, while in the former (with
the exception of Bengal) their influence had almost ceased.
What hope can be entertained of our being able to extend our
knowledge of the causes which determine the appearance and
diffusion of epidemics if we continue to neglect, as we have
done hitherto, the unavoidable inferences from such facts.

The steps by which cholera extended over India in 1875,
too, are full of instruction. Hitherto, there have been two
prominent theories on this subject, one advocated by Dr.
Bryden and the other by Mr. Cornish. The former, following
up the idea announced many years ago by Jameson, believes a
material miasm is produced in what he has designated the
" endemic area," embracing Lower Bengal and some neighbour-
ing districts, which not only produces cholera among those
exposed to it there, but portions being carried by the winds

332 Reviews. [Oct.,

from the endemic area not only cause cholera in other localities,
but, if circumstances be favorable at the time, may then also
serve as the seed for a fresh growth, part of the new crop
exciting the disease in the locality, and part by a similar transfer
originating it to other places in advance. In this way mainly.
Dr. Bryden believes, the active cause of cholera is transmitted
from the endemic area to the north-west by the south-east
winds from the Bay of Bengal during the south-west monsoon,
and from the valley of the Ganges, across the peninsula to the
west coast and to the southward, by the northerly and easterly
winds, which prevail during the north-east monsoon. Mr.
Cornish, on the other hand, while of opinion that the cholera
epidemics of Southern India originate in the endemic area,
believes the disease to be communicated from person to person,
and attributes their extension to the movements of persons
from one part of the country to another, in the usual course of
their avocations ; and further, he describes the epidemics of
Ceylon as being derived from those in the neighbouring districts
in the Madras Presidency. The remarkable immunity of Ceylon,
and of all Hindustan beyond the endemic area, from cholera in
1874, permitted of the steps which led up to the severe epi-
demic of 1875 being traced with a clearness unattainable on
previous occasions, in consequence of the lingering remnants
of preceding outbreaks masking the first indications of those
which followed, and the evidence they afford militates against
both these theories in several important points, which it is well
to particularise.

As already mentioned, cholera was frequent in Bengal proper
in 1874; the mortality was greatest in the districts to the east
of the Hooghly in the early months of the year -, in these it
declined in July, and remained low from August to October, but
in November and December it became very active again, and
remained so to May, 1875. To the west of the Hooghly, and
south of the main stream of the Ganges, with little of the
disease in the first four months of 1874, the deaths from it were
pretty numerous from May to September, but fell in November,
and, with the exception of Balasore and Cuttack, did not show
any disposition to increase until March, 1875. In the Balasore
and Cuttack districts, on the coast, though the deaths were few
from November to January, in the former there was a marked
increase in February, and in March in the latter, which led up
to an epidemic lasting into July. In the Ganjam district of
the Madras Presidency, adjoining Pooree and Cuttack, there
were, in 1874, 243 deaths from cholera up to September, after
which no other was registered until February, 1875, when, and
in March, there was one each month. Practically, during 1874

1877.] Sanitary Work in India, - 333

and up to February, 1875, cholera as an epidemic was not met
with anywhere on the continent of India to the south or west
of a line extending from Ganjam on the coast to Benares, and
from thence north to the foot of the Himalayas.

But, although in 1874, cholera as an epidemic was confined
to the limits just specified, it appeared sporadically at several
places beyond them. Sixty-eight deaths from it are recorded in
Oudh, in a population of eleven millions ; and in the portion of
the North-west Provinces, extending from Oudh northwards, in
a population of fourteen-and-a-half millions, there were 46^
deaths, nearly equally distributed over the different months, and
spread over fourteen of the eighteen districts embraced in it.
In the Punjab, with seventeen-and-a-half millions of people,
there were but 78 deaths ascribed to cholera. To the south and
east of these provinces the traces of cholera were even much
fewer ; in Rajpootana, the Central Provinces, and Berar, occu-
pying the whole country between them and the Bombay Presi-
dency, there were but eight deaths registered as from this
disease in 1874. In the Bombay Presidency there were thirty-
seven deaths from cholera, of which nineteen were in the city
of Bombay from January to October, and fourteen of the re-
mainder were in the districts of Surat and Ahmedabad, to the
northward on the Gulf of Cambay. In the Madras Presidency
there were 313 deaths registered from cholera in 1874, of which
243 were in Ganjam, as already stated ; of the remainder thirty-
three were in the district of Tanjore, nineteen in that of south
Arcot in its vicinity ; these were distributed over almost the
whole year, February in the former, and January and June in
the latter, being the only months in which no death was regis-
tered, and twelve deaths occurred in Malabar, on the west
coast, from May to August, and another in November. As to
the nature of these cases in Southern India, Mr. Cornish re-
marked in his Report for 1873 —

" There is, in South India, an endemic form of cholera which seems
to differ from the epidemic variety only in not spreading, and it
must be further remembered that the deaths now and then regis-
tered as cholera in non-epidemic seasons may really be due to other
causes," p. 95.

'• In what particular respects the endemic cholera of Tanjore and
other localities of the south, differs from the epidemic variety of the
disease, is a subject for investigation and report when a sufficient
number of facts have been accumulated," p. 95.

And in the Report for 1874 is the following statement :

" Correspondence with the Zillah surgeon Tanjore, on the subject
of the cases of cholera which occurred in that district, showed
that the disease was sporadic, with no tendency to become epidemic ;

120— xy. 22

334 Reviews. [Oct.,

although the symptoms were, in several cases, undistinguishable from
those of true epidemic cholera, the majority of them were directly
traceable to improper or excessive food ; and in no case was the
disease communicated," p. 69.

The above details will enable our readers to realise the amount
and distribution of cholera in the Indian Peninsula in 1874, and
its manifestations in the endemic area in the early months of
1875 ; with a clear perception of these they will be able to
appreciate the full significance of the various stages pursued by
the disease in spreading over the country in 1875.

The Madras Report usually contains a detail of the deaths
from cholera in Ceylon, but as there is no notice of the disease
there in that for 1874, we conclude there could have been very
little, if any, in the island that year. In the Report of the
Sanitary Commissioner with the Government of India for 1875,
there is a return of the deaths from cholera each month in
Ceylon that year, from which it appears there were 12 at Co-
lombo in January, increasing to 57 in February, and 194 in
March. The disease seems to have been confined to Colombo
in January, but in February there were deaths at Negombo to
the north and Galle to the south, and at the latter during the
next three months these amounted to 111. It was only in June
that the Manar district near the northern part of the west coast,
which is in common communication with the opposite shore,
became affected, and in the same month the disease extended
along the central districts of the island as far as Kandy. In
July and August there seems to have been but little extension,
but in September the disease appeared in a considerable number
of fresh localities, and this month only became prevalent in
Kandy, though to a moderate degree ; indeed, at no time during
the year did the epidemic acquire much force at any point.

In the Madras Presidency it has been shown that sporadic
cases of cholera were met with in the Tanjore and South Arcot
districts up to December, 1874; in the former there were 18
deaths from cholera during January, February, and March,
1875, and in the latter 9 in January and February ; 2 deaths
in Ganjam, 5 in Malabar, and one in Trichinopoly adjoining
Tanjore, were the only others recorded during these months in
the whole Presidency. In April the deaths from cholera in the
Tanjore district rose to 65, in May they were 1589, in June
4972, and in July 7184. In the South Arcot and Trichonopoly
districts the disease became epidemic in June, in that of Tinni-
velly in the extreme south of the peninsula, where there had
been an increasing number of sporadic cases since April, the
disease became epidemic in July, and the same month Madura,
lying between Tanjore and Tinnivelly, where previously there

I8?7.j

Sanitary Work in India. ^35

had been a single death from cholera in May, came under
it. In July also the districts of Salem and Coimbatore west of
Tanjore, Cuddapah and Nellore considerably to the north, were
under the epidemic, while the districts of North Arcot, Chingle-
put, and Madras town, lying between these and South Arcot,
had a few sporadic cases, and only showed epidemic prevalence
the following month. In August, too, the Bellary and Kurnool
districts north of Cuddapah, the table-land of the Mysore, and
the Malabar district on the west coast, were invaded.

From these facts it is clear that cholera became epidemic in
Ceylon in 1875, at a time when there were but a few sporadic
cases at distant points in Southern India, and consequently the
outbreak in the former could not be referred to extension of an
epidemic from the latter, as Mr. Cornish supposes, but must
have arisen independently. In the Tanjore district, where
cholera first became epidemic in the southern part of the penin-
sula in 1875, there had been, as we have seen, a series of
sporadic cases through 1874, the symptoms in several of which
were " undistinguishable from those of true epidemic cholera;"
these continued in the early months of 1875, and in April
became more frequent, assuming epidemic proportions in May,
at which time all the rest of the Madras Presidency had no
trace of an epidemic. Subsequently the disease spread over
the surrounding country, embracing the Bellary and Kurnool
districts in August, where it met the epidemic, which by this
time had reached the river Kistna from the north. It is ob-
vious, then, that this epidemic arose in the Tanjore district
without connection with one coming from the north through
the intermediate country, and, after so originating, the disease
actually extended to the north. It is possible, therefore, for
an epidemic to spring up in the south without continuous con-
nection with the endemic, are in the north ; and hereafter, the
mere fact of such connection cannot be received as satisfactorily
explaining the extension of the disease as a series of factors
similar to those which led to the development of the epidemic
in the Tanjore district, may have come into operation at each
intermediate point successively, and so have caused its appear-
ance there ; and, unless this possibility can be excluded, the
fact of continuity of manifestation can establish nothing further
than that these factors were active over the area under the epi-
demic. We have long thought that the opinion so common in
India, that all the cholera epidemics of Bombay and Madras
proceeded from the endemic area, was not satisfactorily esta-
blished, and it is but due to Mr. Cornish to state that he noticed
this some years ago; in Appendix I of his Report for 1871,
referring to the epidemic of that year, he says :

336 keviews. [6ct.^

'* Simultaneously with the disappearance of cholera in the south,
there was a distinct movement of the epidemic to the north and
west. In this new movement we find the districts of Cuddapah,
Nellore, Kistna, and the Nizam's country reinvaded, not by a new
emanation travelling from north to south, but apparently by a
retrogression of the cholera wave of the south," p. 7.

The progress of cholera in the endemic area at the end of
1874 and in the early part of 1875, has already been men-
tioned. In the North-west Provinces and Oudh, as far as
Allahabad and Banda, cholera became active in March and
April ; further north, though present, it did not present much
activity before June, and in the Punjab a month later. To the
south and west of the endemic area the first indication of its
extending westward was met with in the Bilaspur district,
where in February there Avere 7 deaths, and in March 77 ; Rai-
pur, still further west, had 16 deaths this month, and at both
it became epidemic in May. In March, 10 deaths occurred from
cholera in the Nasick district of the Bombay Presidency, which
lies just east of the western Ghauts, in lat. 20'^ N., and on the
line of railway from Bombay, to Allahabad at the junction of
the Jumna and the Ganges. In April, the deaths at Nasick
rose to 481, and the disease appeared in the Poona and Ahmed-
nagar districts and City of Bombay, to the south of Nasick, and
in those of Khandesh to the north, and of Kaira and Panch
Mahals, at the head of the Gulf of Cambay. The districts of
Sholapur and Satara, south of Poona, became aflfected in June ;
those of Kaladgi and Belgaum, still farther south, in July; and
Dharwar, which adjoins Bellary in the Madras Presidency, in
September. Up to March, when the disease appeared in the
Nasick district, there had been only 2 deaths from cholera
recorded in the Bombay Presidency in 1875 — at Bombay itself,
and through the country to the east none was known to exist
nearer than Raipur, and the Rewah territory south of Allaha-
bad ; none was met with along the line of railway, and, even up
to the end of the epidemic, a considerable portion of this on either
side of the Jubbulpore ran through country that was scarcely
touched by cholera, if it did not wholly escape. In Nasick
then, as in Tanjore, cholera sprang up, and soon became epi-
demic over a large extent of country, a long way from, and
without continuous connection with, places where it was already
prevailing, thus presenting another instance of the possibility
of the disease becoming active and extending widely, without
being preceded by its approach more or less measured through
the districts intervening between its supposed starting-point and
ultimate destination.

The points where the epidemic first appeared, both on the

1877.] Sanitary Work in India. 337

east and west of Central India, have been mentioned already ;
from both it extended towards the centre of the peninsula, and
from July to September was active from Najpur to Hyderabad,
south of which, as stated above, it was met in the Kurnool and
Bellary districts by the extension of the epidemic from the
south. To the north of the Nerbudda the epidemic which had
appeared in the Kaira and Panch Mahal districts extended
into the neighbouring native states for some distance, but, as
in 1872, there was a devious tract of country with little or no
cholera, extending from Rajpootana south-east to beyond Jub-
bulpore, and from that place continued some distance between
the rivers Nerbudda and Taptee, interposed between the cholera
fields along the Jumna and Ganges to the north-east, and the
central provinces, native states, and Bombay Presidency to the
south-west. Two other tracts which escaped the epidemic were
the Kistna, Godavery, and Vizagapatam districts, extending along
the east coast from the Kistna river to Ganjam, and the south
and north Kanara districts on the west coast from \%^ to 15° N.
Though there were 42 deaths from cholera at Karachi in No-
vember and December, Sindh generally escaped the epidemic.

There are several subordinate points of interest in connection
with cholera on which the experience of 1874-75 is detailed in
the reports, but to which our space does not permit us to do
more than allude. We have given the most interesting occur-
rences during the two years at considerable length, and the facts
leave no doubt that epidemics of cholera may arise at various
points in Hindustan besides the endemic area, and the distri-
bution of the disease from 1873 renders it important that the
causes of the epidemic in India, in years past, should be re-ex-
amined in connection with those in neighbouring countries to
the greatest extent that trustworthy evidence concerning its
progress in these will permit. Inasmuch, too, as the factors
which are necessary to develop a cholera epidemic elsewhere
cannot present any material difference from those which lead
to the same result in India itself, the obvious conclusions from
the facts observed there in 1875 require the most careful con-
sideration of epidemiologists.

In 1873 smallpox had caused a high rate of mortality in the
Punjab, North-west Provinces, Oudh, Berar, and the Madras
Presidency. In 1874 the ratio in the North-west Provinces
remained high, 3*03 per 1000, while that in Madras was some-
what, and those in the Punjab, Oudh, and Berar, much more
reduced, but in the central provinces the ratio rose from 1'37
in 1873 to 2-38 in 1874. In 1875, with the exception of the
Central Provinces, in which the ratio rose to 2'73, and of the
Punjab, in which it increased from '^9 in 1874 to '78, the puor-

338 Reviews, [Oct.,

tality from the disease underwent a diminution everywhere,
reaching very moderate proportions in a country as yet so little
protected by vaccination. I)r. Cunningham states that small-
pox was generally more fatal in the towns and districts where
innoculation is still practised, and he especially notices the
marked exemption of Kumaun and Garhwal in 1875, where
vaccination has been carried on with so much success; in
Kumaun the deaths from the disease were only 1 in 100,000
persons, and in Garhwal 5 in the same number, whereas in
Lalitpur, a district to the south-west of Allahabad, where small-
pox was prevailing, the deaths among the same number of the
general population were 1612, and in Narsinghpur, in the same
vicinity, 1696; taking the children in the latter district by
themselves, the deaths from smallpox were in the ratio of 4179
in 100,000. These results, it is true, are for a single year only,
and in Kumaun and Garhwal may be modified materially in a
subsequent one by the advent of an epidemic, but so far they
are in accordance with experience elsewhere, and indicate what
may be done by well directed efforts, even with the apathetic
and prejudiced population of India.

The vaccination of the general population is under the super-
intendence of different authorities in the different provinces ;
thus in the Madras and Bombay Presidences, in the Central
Provinces, Berar, Oudh, and British Burma, it is included
among the duties of tl.o Sanitary Department, while in Bengal
and Assam it is under the Surgeon-General of the Indian Medical
Department, and in the North-west Provinces, and Punjab, there
are separate Superintendents- General of Vaccination, who are
directly responsible to the local governments. There are returns
of vaccination for one year (though not all for the same one),
in the above-named provinces of the Bengal Presidency, and
also in the Madras Report for 1874 for that presidency ; from
these we find that in the former the succcessful vaccinations
were on the mean 14-5 per 1000 of population, varying from 2*0
per 1000 in Oudh to 22*3 in Berar, and 277 in the Central
Provinces ; in the latter, as a whole, the successful cases were
11*2 per 1000. Much has yet to be done before the population
can be regarded as fairly protected, but these results show that
a decided impression has been made, and as the natives come
to see the advantages of the operation, their prejudices against
it will gradually give way.

Fever, to which, with its complications and sequelae, about six
tenths of the mortality among the civil population in India is at-
tributed in the returns, evidently embraces many other forms of
disease which elsewhere, or with persons sufficiently acquainted
with their characters, would be separated and classed under other

1877,] Sanitary Work in India. 339

designations. The numbers given the returns, therefore cannot
be viewed as more than approximative j yet a fair estimate of
the fluctuations of fever in particular districts may be formed
from these when they arelDorne out by the more precise evidence
afforded by the troops or dispensaries, or the observations of
the local officials. From these various sources it appears that
while in 1873 fever had reached a minimum in most of the
provinces of Bengal, and in the other two Presidencies (each
taken as a whole), in 1874 there was a sensible reduction in the
Punjab, the ratios in the North-west Provinces and Oudh, and
in the Bombay and Madras Presidencies, remained much the
same ; but in the Central Provinces and Berar there was a
marked increase ; in 1875 the increased rates were maintained
in the last two, and the Bombay Presidency, Oudh, and the
Punjab, all had very considerable additions to their mortality
from this cause. Thus fever, which in the great majority of
instances in that country is malarial, undergoes fluctuations
which embrace an extensive area at the same time, and which
must be due to the influence of some factor or factors of equally-
extended operation acting in combination with those local
factors to which alone the disease is now more commonly attri-
buted.

Enteric fever among the European troops continues to receive
attention. In 1874 there were 166 cases returned in the three
presidencies, with 84 deaths, and in 1875 the numbers were
243 cases and 101 deaths ; in the former year there were cases
at 53 out of 100 stations occupied during the period, and in the
latter at 43 out of 94. In both years the majority of the attacks
were in men under two years in the country. The difficulty of
distinguishing this form of fever from remittent, in its early
stages, will always leave a doubt as to its nature, unless in
fatal cases, in which the diagnosis can be confirmed by finding
the characteristic intestinal lesion. The general impression
seems to be that the disease is of local origin, and has not been
introduced from this country, as was suggested some years ago,
but the local conditions under which it arises have not been
well defined.

A good deal has been done, if not as yet to ameliorate, at all
events to initiate amelioration in the sanitary condition of the
towns and villages throughout the various provinces, among
which may be classed legislative sanction for improvements in
drainage, for better conservancy in towns and villages, and for
supplying these with water ; also for the prohibition of innocu-
lation of smallpox ; while rules for the conservancy of villages,
in the vernacular, have been circulated in Bengal, and consider-
able benefit is reported to have resulted from bringing home tg

340 Reviews. [Oct.,

the people in this way a knowledge of the conditions which
promote health and obviate disease. There is no doubt that
the present rate of mortality among the native population may
be very much reduced by good sanitary arrangements, and the
course most likely to affect this desirable result is to bring home
to those concerned the necessity for improvement, while suitable
enactments enable them to take united action when that may
be required.

In the appendix to the Report of the Sanitary Commissioners
with the government of India for 1874, there are two reports
by Drs. Lewis and Cunningham, one on the so-called " Myce-
toma,'' or fungus disease of India, the other, " On the Soil in
its relation to Disease;" and in the Report for 1875 there
are other two by the same gentlemen, " On the Oriental Sore,"
as observed in India, and " On Leprosy." These are all papers
of considerable length, bearing the impress of the care and dis-
crimination which characterises the observations of these
authors. It is impossible for us to do more here than mention
the results they announce.

As to the Mycetoma, Drs. Lewis and Cunningham were
unable to detect, or by cultivation to obtain, the fungus to
which it is said this disease is owing, and they attribute the
peculiar products found in it to a local degeneration inde-
pendent of the growth of fungi. The points to which
attention was directed in connection with the soil were
the moisture, temperature, and varying quantity of carbonic
acid in the soil air, at different depths. There are records of
the distance of the water from the surface, from February,
1872, to August, 1874, and of the temperature and quantity of
carbonic acid from July, 1873, to October, 1874, and for some
time similar observations as to the carbonic acid were made at
a point about fifty yards from the other, which was found to
give results differing very materially as to quantity from those
observed at the same time at the first. As to the connection of
these conditions with disease, it is admitted the period was too
short to allow of any decided opinion being formed, and the
necessity for observations of a similar nature being prosecuted
elsewhere, to afford a basis for satisfactory conclusions pointed
out.

Drs. Lewis and Cunningham^s observations on the " Oriental
Sore," as met with by them at Delhi, where it is common, has
led them to the conclusion that it is due to a growth of granular
lymphoid cells, from t-oVo to 3-0V0 of an inch in diameter, in a
matrix, from which they may be brushed as in ordinary adenoid
tissue. This growth is found in intimate relation with the
f^ljyentitia of the vascular tissues, notably those of the lym-

1877.] PiCARD on Diseases of the Prostate, 341

phatics, of the corium, and the more superficial portions being
pushed forward by the continued generation of fresh cells be-
neath that find their way to the surface through rents in the
papillae, and ultimately form the prominent ulcers characterising
the disease. They consider this affection as analogous to lupus,
and to be unconnected with scrofula, or syphilis, or the action
of parasites; they attribute it to the employment of water largely
impregnated with mineral salts, and containing much unoxi-
dised organic matter.

The report on "Leprosy" gives the general distribution of that
disease in India, as ascertained during the census operations in
1872, from which it appears there are 99,000 lepers in the
British territory, the distribution varying from 1 (or fewer) in
100,000 of the population, in some districts to 21 in the same
number in Kumaun. The minutes and records of the Leper
Asylum at Almora were carefully examined, and as the out-
come of the whole evidence the authors conclude that it contains
nothing in favour of contagion being the cause of the disease,
while it indicates that hereditary influence is a most important
factor in determining its occurrence.

VII.— Picard on Diseases of the Prostate.^

This is the first of three volumes on diseases of the urinary
organs, in preparation by the author, and treats of the affection of
the prostate gland ; the second volume will be concerning diseases
of the urethra ; and the third upon those of the bladder.

The work exhibits a good knowledge of the literature of the sub-
ject, and though in some parts rather diffuse is carefully and
clearly written.

It commences with a clear description of the surgical anatomy
of the gland, and of its relations to surrounding parts. The
arrangement of the fasciae, and of the venous plexuses of the part
is given with especial care, and is shown to have much surgical
importance. Several measurements of the size of the prostate are
given, and its structure defined according to the researches of
Professor Eobin. The second chapter is devoted to physiological
and pathological considerations, in the course of which the influence
of prostatic diseases upon the bladder, kidneys, and even upon the
heart is pointed out, as well as its importance both to the genera-
tive and urinary systems. The characters of the prostatic secretion
are also given.

1 Traite des Maladies de la Prostate. Par le Dr. Henei Picaed, Professeiir
Jibre de Pathologie des yoies urinaires ^ I'ecole pratique, Paris, 1877,

342 Reviews. [Oct.,

Absence of the prostate occurs in three conditions : 1st. With
complete absence of the genital organs; 2nd, in many cases of
extroversion of the bladder; 3rd, in a few rare cases the prostate
only is wanting.

There may also be a want of union between the two lobes of the
gland, in which case the wall of the urethra is only separated from
the rectum by a little thin tissue.

Injuries of the prostate form the subject of the fourth chapter,
and are divided into contusions, wounds, and false passages. Con-
tusions are not common, and give rise to the ordinary symptom
of inflammation. Wounds are chiefly those made by the surgeon,
and if extensive or bruised, are sometimes followed by phlebitis,
cellulitis, or obliteration of the ejaculatory ducts; but if simple,
clean and small, usually heal rapidly.

The next chapter deals with the subject of inflammation and
abscess of the prostate, and has a subdivision upon prostatorrhcea.

Inflammation of the prostate, whether acute or chronic, is hardly
ever primary, but most often secondary to urethral mischief, and
may have its origin in gonorrhoea, the use of irritating injections or
of the catheter, the presence of a calculus, the operation of lithotrity,
or any other source of urethral irritation.

Exposure to cold, excessive drinking, and chronic constipation
are alluded to as aggravating influences. The gland may also be
the seat of secondary abscesses, the result of purulent infection.
The author points out that inflammation of the prostate is a disease
of adults ; it does not occur in children, and when seen in old age
is never attended with suppuration.

In acute inflammation the most striking pathological change is
the swelling of the gland, which may rapidly go on to abscess. In
the chronic form there is less swelling, but the excretory canals are filled
and enlarged with altered secretion, or even with pus. When abscess
occurs it bursts most often into the urethra, sometimes by several
openings, or it may open (and this is the next in order of frequency)
into the rectum. More rarely the pus makes its way into the peri-
neum, the ischio-rectal fossa, or even into the bladder. In abscess
connected with tubercular disease the prostate becomes excavated
into numerous cavities, and the matter is apt slowly to burrow into
surrounding tissues.

The symptoms of acute prostatitis are described as frequent and
painful micturition, pain in defaecation, tenesmus, a sense of fulness
in the perineum, swelHng in the rectum, and, perhaps, retention of
urine. There is also constitutional disturbance, and if suppuration
occur there are rigors. The pain attending the disease increases
till the bursting or opening of the abscess.

In the chronic form of the malady the pain is less acute, and
occurs most at the end of micturition ; it is said by the author that

1877.] PicARD on Diseases of the Prostate. 343

the pain is worse in the morning, on account of the congestion of
the pelvic veins, produced by lying in bed. This, however, is by
no means always the case, for the suffering is often greatest at night,
after the movements and exercise of the day, so that in this as in other
respects the symptoms frequently much resemble those of calculus,
as Thompson has pointed out. Picard alludes to the sensation,
which is often present, of th^re being something in the rectum
which requires to be expelled, so that the patient is tempted
to force the action of the bowels. There is a discharge of pus or
of ropy fluid from the urethra, and seminal emission also may some-
times be provoked by the irritation of the prostate.

The diagnosis of chronic inflammation of the prostate is very
carefully considered j and the author points out that in doubtful
cases much aid may be obtained by the method, practised by M.
Richet, of pressing out the secretion of the prostate by the finger
in the rectum, and by an examination of the fluid thus obtained.

A section is devoted to the so-called '^ prostatorrhcea," wherein
the author shows that there is no such thing as a true prostatorrhoea ;
that is to say, the discharge in inflammation of the prostate is
never composed solely of the secretion of that gland, but is a
mixture of the secretion of the various glands of the part along with
urethral mucus. A description of these secretions is given, and the
diagnosis between this condition and true spermatorrhoea is clearly
described ; this latter is believed by the author, as by M. Eobin, to
be nearly always consecutive to disease of the spinal cord, the
brain, or the bladder.

The treatment of inflammation of the prostate is elaborately
described, and we think that this is the best part of the work.
Antiphlogistic measures are advocated for the acute stage, and these
may be aided by suppositories and enemata. The author advises
that the administration of opium should be avoided, and we have
ourselves seen an opium suppository greatly aggravate the symptoms.
Belladonna, in the form of suppositories, or as an ointment, applied
to the perineum is especially useful. The occurrence of suppura-
tion may terminate in the opening of an abscess into the rectum, the
urethra, the ischio-rectal fossa, or the perineum. It is the chronic

I form of the disease, however, which receives the greatest attention
from the author, and the troublesome nature of the afi'ection quite
justifies the space he has devoted to its treatment. He insists upon
the necessity for keeping the rectum empty, and particularly recom-
mends cold enemata and various local applications. The methods
of using these remedial agents are described, as well as the internal
remedies that have been found most useful.
Periprostatic abscess is next treated of, and an early opening is
advised, to prevent as much as possible the extension of the suppu-

344 Reviews. [Oct.,

The seventh chapter is upon ulcers of the prostate ; these are
divided into inflammatory and diathetic; several varieties of each
are described which must often be very difficult to distinguish
during life. We think that the author is inclined to take too
limited a view of these afi'ections, some of which, the scrofulous for
instance, we believe, are rarely if ever confined to the prostatic
urethra. He gives, however, a proper value to constitutional treat-
ment, which is often of more avail than any local measures.

Cancer of the prostate is next treated of. The disease is rare, but
when it does occur is most often of the encephaloid variety. The
curious fact is mentioned that not only are the pelvic glands invaded,
but in some cases even lumbar, mesenteric, and inguinal lymphatics.
This glandular infection is the most valuable diagnostic sign.

Tubercle in all stages may be found in the prostate ; grey granu-
lations, caseous nodules, or similar masses softening and breaking
down, with resulting excavations and fistulse. There is an interest-
ing chapter on prostatic calculi, in which the varieties of these
concretions are well described.

The prostate of nearly every adult contains a varying number of
small brown concretions, having a nitrogenous nucleus; and so
constant is their presence that it is a question whether they are not
a natural product. Of more importance are the prostatic calculi,
often found in considerable numbers and occupying cysts in the
gland.

Senile hypertrophy of the prostate is very fully described by the
author, who quotes M. Sappey's researches, showing that an increase
in the number and volume of the normal concretions plays an im-
portant part in carrsing this affection. Moreover, the increase in
the stroma and the dilatation of the glandular canals of the gland,
together with the presence of concretions, gives to many of the
cases of enlargement of the prostate more of the character of a
senile degeneration than of a true hypertrophy. The author agrees
with the opinion originally stated by Sir E. Home, and more re-
cently by M. Mercier and others, that these changes depend chiefly
upon a retardation of the circulation through the part — an opinion
confirmed by the observations of the last-named writer, which show
that prostatic enlargement is most common among those who suffer
from varices, haemorrhoids, and feeble venous circulation.

The section devoted to the treatment of enlarged prostate is less
satisfactory than the rest of the work, and no mention is made of
supra-pubic puncture of the bladder. We think also that the im-
portance of thoroughly emptying the bladder in cases of enlarged
prostate might have been more prominently alluded to. The work
closes with a short chapter on atrophy of the prostate.

It has a table of contents, but no general index ; the latter would
b^ve been ?^ ponvenient additiop to 9, wprjc of nearly 400 pages,

11^77.] Ireland on Idiocy. 34S

VIII — Ireland on Idiocy .1

This is a large book on a subject which is forcing itself gradually
and pertinaciously, not only upon the notice of the profession, but
also upon that of the legislature. The sympathies of mankind are
strongly manifested towards the helpless-ever-childlike, for asylum
after asylum is raised and fostered as this great social skeleton of
idiocy unshrouds itself; and thus practical benevolence, leading to
scientific treatment, is yearly developing in their behalf. And this
truly earnest desire to aid the idiot has brought its reward, not only
in the increased comforts, better education, and happiness of the
class, but also in stimulating research into the causes and treatment
of this great incubus on humanity. Most people who may take up
one of the few books on idiocy, or who see the word at the head of
a magazine or review article, pass on to something more congenial ; or
if they dip into the matter, soon become uncomfortable at the recital
of the defects, and incredulous of the numbers of the most un-
fortunate of the human family. But a few true philanthropists,
and still fewer medical men, have laboured year after year, most
unselfishly, in the cause of the idiot, and now the public can know,
if it likes, the inevitable results of certain social crimes and
follies, and that the number of the idiotic may be diminished
by a scientific and philosophic morality and wisdom of life. It is
horrible to think of the thousands of idiots amongst us, especially
when, as Dr. Ireland remarks, the indisposition of the public to
admit the idiocy of children has diminished the census return at
least 25 per cent., and still the numbers in 1871 in England and
"Wales were 29,452. Where are they ? If there is one imbecile in
every 771 persons, what is being done for them? The answer is
most unsatisfactory, for there are not 2000 of these unfortunates
under reasonable care and education in the United Kingdom. The
rest are in lunatic asylums, workhouses, unions, cottages, and at
home, hidden up out of sight, out of mind, a scandal to our legis-
lature, with its imperfect conception of the distinction between the
insane and the idiotic, and to our sound sense as a nation. The
origin of the idiot asylum was a matter of purely Christian charity ;
the objects for it were the subjects of a most disinterested philan-
thropy, and, therefore, a good wholesome sentimentality carried
along with it a few of the medical profession. Science was in this
instance stimulated by something else than stern logic, and the
scientists who have taken up the unsavoury subject have not been
without singular and characteristic mental qualifications. One can

1 On Idiocy and Imbecility. By WiLLiAM W. Ibbland, M.D. Edin. Pp. 413*
London, 1877.

346 Reviews, [Oct.,

fancy that a man without a good deal of discursive talent and
without literary accomplishments would soon sink down to the level
of a drudge or simple money-maker, were he to devote his energies
to the treatment of the idiotic; and we may believe that the
peculiar mental endowments of the author of the book before us
have been of no small assistance to him. Sympathy and a love for a
varied literature are, however, not good foundations for exact
science, and hence idiocy is still without its great book, its pathology
is still obscure, and its treatment a matter of question. Dr. Ire-
land''s work consists of original essays, which have already appeared
elsewhere, of compilations, and of some new matter. In his
preface he does not lay claim to have made much progress in the
study of the treatment, causation, and prophylaxis of idiocy, but
considers that the principal merit of the work is, that it brings
together the widely-scattered studies of able observers on the
subject. He hopes that the book, although mainly intended for
medical men, will be more or less useful to those who are interested
in idiots and imbeciles. This is a very fair and modest self-criticism,
and it is evident that the profession will benefit by the perusal of
the book, and that outsiders will find it full of interesting anecdotes,
curious information, and not a little useful wisdom. Dr. Ireland
considers that *' idiocy is mental deficiency, or extreme stupidity,
depending upon mal-nutrition or disease of the nervous centres,
occurring either before birth or before the evolution of the mental
faculties in childhood.'^ " Idiocy bears much resemblance to the
ordinary condition of infancy. In idiots the mental state may be
said to be fixed in the infantile state, or very slowly to move towards
the efficiency and -maturity of the motor and reasoning powers
which characterise the normal adult.^' Seguin, in his very wonderful
'Traitement Moral, &c., des Idiots,' 1846 — the first and still un-
surpassed book — has an amusing chapter on the definitions of idiocy,
in which he laughs at the futile endeavours of his predecessors to
define this very wide condition, and he wisely declines to commence
his work with a hard-and-fast and positive definition, and proceeds
to state what idiocy is not. Probably he would have found fault
with that just given. The first part of it says nothing about the
extraordinary bodily defects which are invariable in some form or
other in idiocy, and would reduce the condition to a psychological
infirmity. In the second part, the statement of the analogy of
idiocy, with a kind of persistent normal early childhood, is certainly
not* correct, and requires both modification and explanation. Is
there a correct resemblance mentally and physically between a small-
headed profound idiot of five years' growth and an ordinary baby of
one year ? Certainly not. Compare the same idiot at one year with a
baby of one month's growth, and the intelligence and slight powers
of movement and expression of the last are superior to those of the

1877.] Ireland on Idiocy, 347

first. It is some physical defect, some loss of motor or sensual
power, some deficiency or increase of sensibility, that, with a lack
of the ordinary baby intelligence, first make the mother tremble for
the future of her offspring. The value of this kind of comparison
has been thus stated by Duncan and Millard : '^ It is a very striking
method of showing the mental deficiency of a member of any one
of these classes (congenital idiots) to compare its mental gifts with
those of children of perfect mind at younger ages." Thus a boy
of the fourth (highest) class, aged eighteen years, may not have
greater mental power than a perfect child of four years ; he is to
all intents and purposes four years old and dull for his age. An
idiot of the second class, of eight years of age, may not be more
than eighteen months old when compared with perfect children,
whilst the gaiety and spontaneousness are wanting.''-' With regard to
the first (profound idiots) class these authors state : " Grant to the
highest of them all the gifts ever seen in any of its class, and
compare them with the powers of a child of the same age, and how
striking is the difference (Duncan and Millard^s ' Manual of Idiocy,'
1866). It would appear that this comparative guide is all the more
fallacious as the idiocy is deeper, so that at last the profound idiot
and the normal babe are not comparable.

A good distinction between the demented and the idiotic, almost
unnecessary, however, follows on this definition of idiocy; but here
again exception may be taken with some assertions. ^' The expres-
sion of the idiot is generally soft, good-natured, and confiding; that
of the dement is heavy and sullen : past grief and pain have left
their deep cross furrows on his brow, and traced broad wrinkles
below the eyes ; while the forehead of the idiot remains smooth till
a late age." This is not our experience ; and there are cross-looking
wrinkle-browed idiots as well as good-natured, soft, simple-looking,
glad demented ones.

After separating the idiotic from the demented, and omitting to
distinguish between the highest idiots and the lowest of the normal-
minded, and really not having satisfied the general reader what an
idiot really looks like. Dr. Ireland plunges into the statistics of
idiocy. In this important part of his work he has been greatly
assisted by the labours of the Charity Organisation Society, and an
examination of the figures is well worthy of the consideration of the
statesman. There is a curious point with regard to the ratio of
idiots or imbeciles to the population in the several divisions of
England. Thus, whilst in the northern districts there is 1 idiot in
1028 of normal population, in Yorkshire 1 in 901, North- Western
1 in 833, there is an increase in the Midlands, Eastern Counties,
and to the south. Dr. Ireland notices that the Earlswood Asylum
and other institutions containing people of this class, being in the
south-east divison, raises the ratio there, but he does not explain

B4§ keviews, [Oct.,

what appears at first to be very remarkable. In London the ratio is
only 1 in 1708^ but really there are four or five thousand imbeciles
at Caterham and elsewhere which belong to the metropolis^ so that
the ratio is of no value. The want of reliable statistics in Scotland
is noticed ; and Dr. Ireland believes that there are twice as many
idiots and imbeciles amongst that reticent and cautious nationality
than appear on the statistics. After considering the interesting
Erench, German, and Swiss statistics, our author analyses those
of Norway, and makes the important inquiry, why there should
have been an increase in the number of the insane and a decrease
in the number of idiots in Norway in the ten years from 1855 to
1865. There is not a chapter upon the influence of locahty on idiocy,
and it is therefore to be presumed that a very curious Danish
work in which the geological nature of the districts and the ratio of
the idiot to the rest of the population are treated of, escaped notice.

After noticing the want of value of the American statistics.
Dr. Ireland passes to the causes of idiocy, and he considers them
under the heads of heredity, consanguine marriages, scrofula, drunken-
ness, gynagogues, fright to the mother, and he puts in some remarks
on idiots born into healthy families, and on the causes of deafness.

There is nothing very new in this part, except the testimony of
Alfred Huth and George Darwin upon the unreliable nature of the
evidence that is believed by the public, to show the marriage of
first cousins to be pernicious. One point relating to this popular
belief in the inadvisability of the marriage of first cousins has
escaped notice. In the East, consanguineous marriages are and
have been matters of course, for hundreds of generations, yet idiocy
has not deteriorated those pure races. Moreover, there are cousins
and cousins, and the fool of a family is very likely to fall in love
with the first girl who is not distant with him, and who does not
require the usual polite approaches due to a stranger. The cousin,
especially if there be property to keep in the family, is apt to consent
too readily, and the marriage certainly is often not productive, or
else the children are often characterised by deficient innervation.
On the other hand, the results of the marriage of cousins and of
that of the offspring of cousins are notoriously not invariably to add
to the idiot stock. On the influence of drunkenness Dr. Ireland
very properly writes: "Drunkenness generally brings other debasing
influences along with it, such as poverty, disgrace, and disappoint-
ment, and thus a drunken father may lower the whole tone of health
of his family. That alcohoUc intoxication has a lowering effect
upon the constitution, which may lay the foundation of idiocy, or
neurotic diseases bringing idiocy in their train, is probably what
none will deny.'''' The increase of idiocy in the State of New York
has been referred to certain immoral habits which are classed under
the abominable Greek derivative gynagogue. Dr. Ireland leaves

1877.] Ireland on Idiocy. !34^

much to the imagination as to what Seguin and gynagogues mean ;
but it may be supposed that ' Fruits of Philosophy/ philtres^ Mor-
monism and Tree Love are in the back-ground. One can readily
admit them as proximate and ultimate causes of idiocy. Fright to
the mother during pregnancy is undoubtedly a cause, although it
has been denied over and over again, but it is certainly very extra-
ordinary that, long after the development of the cranial bones and
general form of the skull and the body, a fright should produce
deformity. Nevertheless, there is no doubt about the correctness,
and Dr. Ireland''s statement that he sees no reason for denying that
such influences (fright and extreme distress) may in some cases
produce idiocy in the child of healthy parents who would otherwise
have been born free from it.

A presumed cause of idiocy is not noticed in this chapter which
is certainly its proper place, and it will have be sought in the part
of the work which treats of traumatic idiocy. There the question
of artificial and natural pressure to the skull in early life is ably and
interestingly treated, and Dr. Downs' statistics and views on the
obstetrical aspects of idiocy are fairly considered, and appear to
coincide in the main with Dr. Ireland's experience. Suspended
animation, prolonged pressure in the maternal passages, especially
in primiparse, and the inevitable pressure of the forceps, are to a
certain extent factors, and the second especially. But as hosts of
perfect children and able men have developed out of babes whose
heads have been compressed in the passages and subsequently not a
little squeezed out of shape by the forceps, and whose lungs have
had to be assisted by artificial respiration, one must, even admitting
the natural and unnatural violence to be causes of idiocy, look with
great reason on their having been only adjuvants or assistants;
or, as Dr. Ireland states, the injuries become the proximate causes
of idiocy.

With regard to the efi'ects of artificial production of the flat head
by pressure during early life, it may be very safely stated that it has
but a doubtful effect in developing idiots ; and the experience of
the profession is not in favour of the opinion that direct injury to the
skull by accidents often produces idiocy. The exceptions are more
numerous than the rule, and the bearing of this is ably put by the
author, who writes : " In our study of the physiology of the brain,
the desire to formulate our knowledge is continually checked by
exceptions which occasionally seem to clear the way even of the
vaguest generalization.^'

Dr. Ireland remarks that " in some families, indeed, there is much
disease, especially of a scrofulous or tubercular kind, and all or most
of the members are feeble of mind and body, and the frequent con-
nection of idiocy and hereditary neurosis is indisputable." " On the
other hand, it often happens that idiots are born into a family where

120— xz. 23

350 Reviews. [Oct.,

the father and mother and the sisters and brothers are apparently
quite healthy^ and live in obedience to the laws of health." He
notices that an idiot more frequently appears in a large healthy
family than when the number of children is small ; but here, again,
there are thousands of large healthy families whose members have
no taint of mental decadence or deficiency. It is a matter of expe-
rience that the last child of a large family is more frequently the
idiot than any of the others, and in one remarkable instance, its
appearance was contemporaneous with the evident mental aberration
of the father, whose private insanity had been a source of anxiety
to the wife for a year before. This question of the occur-
rence of idiots in really healthy and sober and sedate families,
although a most unsatisfactory one and beyond our comprehension,
may turn out to be that which will be at the bottom of the solu-
tion of all that relates to the modus operandi of the causation in
idiocy. An unsatisfactory question for the moralist and religionist
is this production of sour grapes and thistles from a good vine and
well-cultured field, and one can excuse a gentle lady writing in the
weariness of her spirit to ask the physician, " Will my idiot child
rise from the dead in all its horrible ugliness of body and want of
spirit, to live for ever thus ? " Well may the pessimist urge that
suffering humanity is a mistake, and difficult is the task to the
optimist to reconcile the terrible fact with his philosophy.

The classification of idiots has already been attempted by Dr.
Ireland, and his method has not met with much favour. But the
subject is comparatively new, and very few careful observers have
dealt with it at all ; so, if this classification is useful and practical, its
truly scientific merit may be, in the present aspect of cerebral patho-
logy and its relations to psychology, considered of secondary im-
portance. It is true, as remarked by the author, that no classification
of diseases was ever attempted which was not liable to numerous
objections, and that it is the duty of opponents to find a better one,
and not to find fault only. This is true and to the point, and
therefore it is necessary to look back at what has been done, espe-
cially as Dr. Ireland knows of no " tolerable^^ classification of idiots
existing before his own. But before examining one or two of the
systems of classification which have appeared, let us consider what
a classification of idiocy should relate to. Pathology is the philo-
sophical basis of nosology, but when the pathology is imperfect the
classification by symptoms is alone possible, and it becomes scientific
because it deals within the limit of exact knowledge. Now, the patho-
logy of the nervous centres implicated in the idiot is in its very
infancy, and there are not a score of men in the United Kingdom
who are competent to dissect brains and slice, and prepare by recon-
dite methods for long- continued and exhaustive microscopic com-
parison. The skill of a Lockhart Clarke is required, and such an

1B77.] Ireland on Idiocy, 351

amount of time and means that one brain would take months for
its critical examination. It will not do to use the unprepared brain,
for the enormous amount of cell matter^ fatty granules, and con-
nective tissue prevents the true structure of the superficies of the
convolutions and roots of the commissures being properly seen.

The same kind of symptoms indicating idiocy may be shown by
children who have never been free from them, by others who were
healthy and who have suffered from cerebral disease^ or who have met
with accidents in which disease of the great nervous centre has super-
vened. Therefore presumably there is the same pathology in all these
cases. But is the microscopic structure of certain parts of the brain
identical in them all ? Do not comparative hardening and too pulpy
a condition of brain produce the same symptoms of absence of mental
power, spontaneity, conduction, and special limb ailments ? The
answers to these questions are definite enough to any medical observer
who has studied idiocy, and their effect is to antagonise the practica-
bility and value of the philosophic method. Seguin, in 1846,
showed that all sorts of diseases more or less mimetic of idiocy were
classified by Esquirol as belonging really to the state, and was led
to disentangle a true idiocy from others. His true idiot was so from
before birth ; the affection was congenital and the condition was
simulated by non-congenital cases — the product of causes acting
after birth. He distinguished backward children, the demented,
&c., from those cases where there was a mental and physical defect
ingrained in the constitution before birth. Idiocy as a disease
occurring during uterine development was clearly separated by him
from consecutive or induced diseases, with many of the same phy-
siological symptoms. His classification included profound and
superficial idiocy, the one state merging into the other, and both
characterised by an original vice of construction or nutrition of the
brain. In 1866 Duncan and Millard classified idiots in two great
groups ; one the congenital, which included Seguin\s two groups,
and the other, the non-congenital or imbeciles, which contained
supervening or induced idiocy, the result of post-partum disease of
the brain, epilepsy, hydrocephalus, and injury ; and they added
a class resulting in adults from a certain vice. They clearly
saw that Seguin was right in separating congenital idiocy from con-
ditions where the physiological symptoms were more or less identical,
but where the same pathological condition could hardly be. Deny-
ing, however, the existence of hard-and-fast lines between their
classes composing their groups, they made the following classifica-
tion : Group congenital idiots — Class 1. True or profound idiots ;
%. With slight intelligence, able to stand and walk a little, and
capable of some instruction ; 3. Able to walk, run, use their fingers,
to be made to attend sHghtly to dreary mechanical work, to feed
themselves, memory and perception very weak and variable in power ;

354 Reviews, [Oct.,

4. T'eeble-minded. Group non-congenital, or imbeciles — Class 1.
Subsequent to birth — diseases of the brain (traumatic included)
which have been arrested have left their results ; 2. With perma-
nent diseases of the brain — epilepsy and paralysis j 3. Cases born with
hydrocephalus which has stopped ; 4. Cases degenerate from vice.
The diagnosis of these classes is given in full with illustrative cases,
and it is evident that the first class of the congenital idiots is
synonymous with Seguin's, and that the second, third, and fourth
classes are identical with his superficial idiocy. These classifica-
tions are not " tolerable " according to Dr. Ireland, or rather he
does not mention them, and states he has not found a tolerable
classification. He quotes Seguin, so must have studied his work,
and in one place he pooh poohs the other authors, so it may be
assumed that he glanced at their work. Under any circumstances,
according to the recognised rules of scientific ethics, prior views
have a right to be brought forth, and it must be confessed that if
they had in this instance. Dr. Ireland's classification would have
been shown to be open to the application of the old saying — What
is new is not true, and what is true is not new. Dr. Ireland states
that, " coming to the state of idiocy, after having gained some
experience in medicine, I have from the beginning viewed it from
the standpoint of pathology ; and my idea of idiocy is compounded
of the following classes, which are generalised from individual exist-
ing idiots who resemble one another by having the same or similar
diseases, as they resemble the type of idiocy by having mental defi-
ciency along with a corporeal disease.^' This is rather difficult of
comprehension, but the classification explains itself. The divisions
are as follows : Genetous, microcephalic, eclampsic, epileptic, hydro-
cephalic, paralytic idiocy, cretinism, traumatic idiocy, inflammatory
idiocy, idiocy by deprivation — making in all ten forms. It is im-
possible to separate the first two divisions, and the word genetous is
a recondite barbarism. The next two and the fourth may well be
combined, and both inflammatory and the accessory group of hyper-
trophic idiocy may well find a place in some clearly- defined superin-
duced class of idiocy. The descriptions of the cases, the carefully
collected pathological details, some of which are very worthless, the
selection of quotations, and the ideas of treatment, are of course
excellent, and render a disagreeable subject most readable ; but the
impression remains that the classification is very intolerable, and
not as good as those already mentioned. Dr. Ireland has a splendid
field before him, and the profession will hail a work on the patho-
logy of idiocy from him, and when it is written his candour will
probably cause him to alter his old classifications.

Before concluding this part of the review of this interesting book
the remark must be made that in many of the idiot asylums of this
and other countries the classification has been so lax that the non-

1877.] Ireland on Idiocy, 353

idiotic have been admitted. Some of these intruders have been
made the^^' show pupils/' and such an one was the shipmaker at
Earlswood ; but the desire for science being greater than the phil-
anthropic impulse, it is not probable that this state of things can
persist. It may also be remarked beneficially that the general
racial characters, both as regards temperament, ability, and consti-
tution, should have some influence on classification, and should
influence our estimate of some foreign observations. Thus Dr.
Kindts observations about the growth of the Langenhagen idiots is
true for them, but not for those in England, unless the exception
nearly equals the rule. And when Dr. Ireland states that he never
saw an imbecile who appeared naturally mahcious, save one, a boy
who was also born deaf, and who when at home used to beat his
little brothers and sisters unmercifully, and to put skewers into
the flre with the intention of running them into his very respectable
mother ; those of us who have seen a good many, must acknow-
ledge that racial characters are not without their influence on the
characters of idiots.

The chapter on insanity in children and insane idiots and imbeciles
is interesting, and especially Dr. Ireland's own contributions to the
subject. He gives some cases which show how difficult it is to
draw hard-and-fast lines between some forms of quasi idiocy and
insanity. " We had a boy who was always trying to tear the other's
stocking, turning on the gas to let it escape, or attempting to set
things on fire ; when punished he would howl, but never shed a
tear, and the effect soon passed away. I never saw him angry, nor
showing any ill will to those who had punished him. He was
detected putting stones on the railway line, and had to be removed
at the age of fourteen. Though of short stature he was physically
strong and unusually energetic for an idiot. He might have been
taught to work for his bread, could his tendency to mischief been
kept within bounds." This case is one of a not uncommon type,
and the grade of idiocy into which it could be admitted is a high
one. Such cases are the great troubles of many families, especially
when unusual wealth has civilised the unfortunate to a certain
extent. The so-called eccentricities and immoral scandals of many
who are hedged round by social position and wealth, are frequently
the result of this unsatisfactory union of simpletonism, slight idiocy,
and an amount of want of self-control, which is insane.

Mania, melancholia, and delusions have been observed by Dr.
Ireland in imbeciles, and his illustrative cases are a proof of this
assertion. One case of melancholia to which a portrait is attached
is true to the life, and pitiful indeed both to the beholders and to
the compassionate.

In treating of the sensuous and mental deficiencies of idiots, Dr.
Ireland asserts that '' the essential deficiency of idiocy consists in

354 Reviews. [Oct.,

want or hebetude of the intellect, not in imperfection of the senses ; "
and he adds, at the close of his opening sentence, " In idiots the
senses are often more or less defective/' To the first statement
there will probably be much objection, and the second is doubtless
correct, unless it be insisted that the word ''often"" should be omitted,
a suggestion contradictory to the above rather dogmatic assertion,
but certainly consistent with experience. There are idiots that
hear but will not listen, see and do not perceive, touch and do not
feel, and use their organs of taste and smell with results contrary to
those accompanying ordinary and normal enjoyment of those par-
ticular senses. Again, there are idiots mute, incapable of distin-
guishing certain sounds, unable to fix their eyes so as to distinguish,
and either having excessively tender or senseless spots on the surface.
Finally, in the highest of the imbeciles there is a sensuous want
somewhere or other, or some abnormality of sensation. So constant
is the sensuous abnormality that the definition of idiocy is incomplete
without it, and as the intellect owes much to the senses, it is all the
more clouded as they are deficient or perverted in idiots. The
physical defect is not only in the nervous centre, but in the peri-
pheral nerve structure, not only in the dynamic grey substance,
but also in the commissures. Just as perfect elegance and elaborate
combination of normal muscular effort is impossible to the idiot, so
the correct employment of the senses is never seen. Both defects
depend on primary nervous abnormalities, and are as intrinsic in
idiocy as is hebetude and bad memory.

After noticing the authorities relating to the deficiency of the
sense of touch and of general cutaneous insensibihty, Dr. Ireland
proceeds to consider visual defects, but he does not enlarge on
that very characteristic local excess of sensibility which did not
escape the acute Seguin and Duncan and Millard. The visual
apparatus of idiots is generally good, in Dr. Ireland's opinion, and
we may presume from his remarks that the function is usually so
also. It is a well-known fact that there is a very remarkable
staring vision in profound idiots, accompanied by insensibility to
strong Hght, and by incapacity to direct the eyeball on any stimulus
or apparently by volition. In such cases the conjunctiva is remark-
ably insensitive, and, indeed, it is hard to believe that the function-
less eye has a normal structure. Equally unsatisfactory are the
observations on hearing, but he is correct and in accordance with
experience in the description of the nature of taste and smell.

The mental symptoms of idiocy are considered in this book in a
very wide sense, and certainly the thirty pages which relate to them
are most readable, interesting, and amusing. Vast is the learning
displayed, and the following authors are quoted therein : — Aber-
crombie> Esquirol, Aristotle, Averroes, Homer, Wilde, Adam Smith,
Darwin, Itard, Parrish, Tyler, Laplace, Carpenter, Du Chaillu,

1877.] Ireland on Idiocy. 355

Duncan, Millard and Cheadle, -^schylus, Wilbur, Madame de Gas-
parin, Trelat, Dickens, Cardan, Niepce, Gottfried Mind, Forbes
Winslow, Griesinger, H. G. Atkinson, Dr. Home, Guggenbuhl,
and Todere. The author, as may be imagined, does not contribute
much except by way of criticism to this subject, and hence it is
treated, more as a literary or review article. It is a pity that Dr.
Ireland should not have been aware of Seguin's terse pages, or the
resume of the mental defects given by Duncan and Millard. The
first paragraph or two of Dr. Ireland^s notice of the mental
symptoms may be taken as typical of the confused manner in
which he treats the subject : —

** The study of the mental symptoms in idiocy is of the first im-
portance. No amount of skill in the diagnosis of pathological
conditions can dispense with the careful analysis of the existing
mental powers. On the other hand, by ascertaining the amount of
intelligence, we can form some notion as to the amount of the
nervous or cerebral lesion. An experienced observer can generally
on a single examination, assisted by parents and friends, gain a pretty
correct estimate of the amount of intelligence possessed by an idiot.
It is more difficult to find out whether he is educable {sic) or not."

Great exception will be taken to these statements, for they intro-
duce the preposterous idea that in the present condition of the
knowledge of the state of the brain and spinal cord in idiocy, their
abnormalities can be predicted from the mental symptoms.

Commencing his subject. Dr. Ireland rushes off at once to the
distinction between idiocy and dementia, and he states : *' The best
psychical classification of idiocy is that of Esquirol, in which he
takes speech as the criterion." Then Dr. Ireland's classification of
idiots from these mental manifestations is given. The value of the
standard of comparison between idiots and ordinary children at a
given age, and this which has been carefully considered by one or
two authors whom Dr. Ireland persistently neglects to quote, leads
to the first generalisation which relates to the subject on hand.
'* Idiocy in its mental manifestations at least may be viewed as a
fixed infantile condition. Idiots remain all their lives children in
intellect ; often so in their feelings and desires.'' This statement
is wisely qualified as follows : —

" Of course there is always this difi'erence between an idiot and
another child, that though at a given time the potential intellect
of the one is no greater than that of the other, the idiot has the
benefit of a larger experience. Nevertheless, we must have some
scale of comparison, and if we neglect this one we are not likely
to have any other."

The value of this standard has already been noticed, and the
more experience one has with idiots and normal young children the
greater objections arise to its employment. The early development

356 Reviews. [Oct.,

of movement, hearing, and of taste, with a decided muscular action
in normal children, is then considered, and we are told that "there
is no sense so variable in its development as speech." Then the
deficiencies of the idiot are further considered : —

** In idiots this evolution of the senses is sometimes much slower ;
some can scarcely he brought to suck at all, though others do so
without difficulty. The child does not notice things, smile, or stretch
out its hands to grasp them like other infants. Idiots of the lowest
class seem to have nothing more than the passive intellect (have
they even this ?) ; the optical apparatus of the eye are perfect ;
but if the creature apprehends the sensation of light, it does not
use it as a perception, or perhaps it only notices a sudden flash
of sunshine, or the difference between day and night, or perhaps
objects swim before his eyes like the waves of the sea, so confused
and unnoticed that he can scarcely be said to see at all." "As
regards the perception of sensation, the idiot may be somewhat
in the condition of a man half asleep, or heavy with extreme
fatigue, or on the verge of fainting, or deeply intoxicated. ■ The
sluggishness of idiocy may be occasionally owing to all efforts of
attention beeing painful, so that impressions are allowed to wander
through the mind without any attempt being made to fix or exercise
them."

This notion can hardly be accepted, for it assumes a normal amount
of receptive power of the brain. Dr. Parrish is then quoted to show
the want of volition, although this defect has been noticed by the earlier
writers, and Dr. Ireland gives an instance of astonishing strength of
the will. The author then considers the slow and tentative manner
in which the use of the " muscular apparatus '^ is gained, and very
properly, although one does not see what it has to do with the
mental defects, states that, " in general, idiots or imbecile children
are awkward in their motions, and slow in learning to walk.''
'^ Idiots in general have a bad balance.'^ " In the lower grades of
idiocy the grasp is often very deficient."'' Why ? Nothing can be
more satisfactory than the answer given by Segain, and enlarged upon
by Duncan and Millard. It is not a mental defect, but it has to do
with that want of co-ordinating muscular power which is as
peculiar to idiocy as is mental deficiency, and which has doubtless
a physical origin in an abnormality of the commissural tracts.

Dr. Ireland does not appear to grasp this lack of co-ordination
as a symptom of idiocy, and does not explain or enlarge on the
automatic or mechanical movements so evident in idiots.

The difficulty of receiving the idea of numbers, by idiots is very
properly considered in relation to abstract matters of form and
colour; and Dr. Ireland remarks, with regard to memory, that
sometimes the teacher in an idiot school finds that what he has
taught his pupil is totally forgotten, fading gradually or suddenly
away out of its mind, "This i§ most common in epileptic idiocy

1877.] Ireland on Idiocy, 357

after renewed fits ; but occasionally it is noticed in other forms of
idiocy^ without an accompanying symptom." It may thus happen
that the same lesson has to be taught three or four times over/'
The credulity, unsettled purposes, weak judgment, and feeble power
of comparison of the idiots are very striking, and when some educa-
tion has been given the result is not always, or indeed ever satisfac-
tory. Dr. Ireland states : " Often after having accumulated a
considerable store of acquired knowledge the original childishness
remains, sometimes brought into ludicrous relief by the increased
power of display given by education." The opponents of the
" payment by results" system, and of the existing mania for exa-
minations, will be dehghted by the following statement of our author :
^' I have seen individuals who had sufficient mental power to pass
college examinations, take degrees, and even gain prizes, who were
so manifestly unfit to conduct themselves in the ordinary afi'airs of
life that they were a laughing- stock to the most ignorant people
around them." Clothe one of these feeble-minded in black, get
him to hold his tongue, invest him with wealth and a family name, and
there is no telling where he may not go to in the social scale ; but
place such an one in a class where he has to compete with his
fellows, to hold his own in life, and to suffer from the results of
incompetency, and he will soon find his level, and say. Blessed are
the rich, for they inherit the earth. The odd wit of idiots is
amusingly illustrated by Dr. Ireland : " B — D — spoke in a very
stolid manner, never trying to be humorous, but almost everything
he said had something droll in it. Once when he was in hospital
the doctor said to the nurse, ^^ Give him a pill and a half.^' He said,
"Oh, just mak it twae and a half, doctor." Another time he called
to the nurse, " Oh ! Mary, give me more water to wash my mouth,
and I will give you it back when I am done with it."*' He used to
say, "Alexander is my right name, Sandy is my left." An imbecile
boy from the north had still something of the shrewdness and
caution of canny Aberdeen. I once said to him, "Jamie, why do
you not offer me a bit of your cake ?" " Because you would tak
(take) it,'' was the laconic answer. The temper, disposition, and
the influence of puberty are slightly noticed, and there are some
interesting notices of idiots possessing wonderful gifts. The chapter
on the best methods of educating idiots and imbeciles commences
with the history of the subject. St. Vincent de Paul heads the list
of truly benevolent men who have sacrificed much wealth and
comfort for the idiots. Dr. Ireland notices that the first training-
school in England was founded at Bath, in 1846, by Miss White.
She had four idiot children under her. The institution at Highgate
was founded in 1847, and this was destined to lead to the present
development of idiot asylums. Dr. Ireland should know that
Mr. W. Millard, whose description of the first attempt at Highgate

358 Reviews. [Oct.,

is so well worth knowing, did the hard and practical work on which
resulted Essex Hall and Earls wood. He carefully says nothing
about Essex Hall, and indeed little about Earlswood, yet we are
under the impression that some scientific besides philanthropic work
has been done in both places. Essex Hall was founded in 1850,
and Earlswood arose out of it. There is not much new valuable
information on the methods of education, and indeed the author
writes: "In writing on the training of idiots we cannot be expected
to enter into the whole subject of education, which the instructor
must learn from another source." He does not mention the source.
He criticises and suggests considerably, and therefore fails to give
that definite instruction which is required at the hands of one who
has such abundant opportunities for original work.

The results of the treatment and training of idiots and imbeciles
are principally treated by quotation from what Dr. Ireland calls un-
impeachable sources. No statistics are given, nor are any of his
own conclusions, but there is a sentimental speech from a late
commissioner in lunacy, forming not a bad but well-deserved
advertisement for the institution at Larbert, and there is also an
extract from a paper by Dr. Bucknill, E.R.S., which deals in the
vaguest generalities, and ends with the assertion, which we contradict
most emphatically, that '^ the helpless imbecile may sometimes be
educated up to the point which renders it possible to introduce him
into the social life of our age as an independent and efiicient man.''
There is also an extract from Dr. Home, and also from one of the
reports for the New York Asylum for Idiots, but neither gives any
statistics ; and finally, Dr. Ireland mentions the resolutions of the
Special Committee on Idiots, London, 1867, which is, of course, to
the point, but still is only a general statement. Statistics are of
the greatest importance in this and on all other subjects connected
with the insane, for there is a shrewd suspicion afloat that the
satisfactory results are not invariably confined to the patients. The
latter part of this book, indeed, no less than sixty pages of the
whole, is devoted to the laws for idiots, and a treatise on wolf-boys.
The absurdity of making the same law for the lunatic and idiot is
now admitted, and Dr. Ireland notices the grievous hardships many
idiots had to undergo by imprisonment in lunatic asylums. He is
not quite correct in his statement about the diflFerent attempts
which were made to get a change in the law by the friends of the
imbecile. He thinks that two bills were actually prepared, one by
the late Mr. Lutwich, and another by the Earl of Devon. But
no bill has ever come to light from Mr. Lutwich's pigeon-holes,
and it was a mere draft, and is not in existence ; and Mr. William
Millard drew up certain suggestions for Earl Devon, and these never
came into any bill. It is not necessary to consider the wolf-boy
stories, and they probably will be omitted in the next edition. In

1877.]

Tait on Diseases of Women,

359

reading this really very interesting and instructive work everybody
will pay a tribute to Dr. Ireland's literary powers ; but the student
of the low types of humanity will long for that light which the
author can give if he likes. We believe, with Seguin, that there is a
speciality of idiocy, a condition imitated by the results of brain
disease, but in the abstract a real affection of the nervous centres and
peripheric prolongations. What is required are careful dissections
and microscopic analyses after preparation by Lockhart Clarke's
plan, in relation to well-recorded cases of true idiocy. The amount of
time and trouble required in doing this is great, but the position held
by the medical superintendents of large asylums should enable them
to devote some hours a day to science. The skill in preparation
is not difficult of attainment, but reading nature requires much expe-
rience, a quality very necessary to avoid mistaking normal structures
for abnormal. Until such researches come from the great asylums
of the country, idiocy will still remain a blot on medical science.

IX. — Tait on Diseases of Women.^

The chief object of the author, he tells us, has been to offer the
results of his own experience in as condensed a form as possible.
More than one third of the book is occupied by the author''s Hastings
prize essay on diseases of the ovary, which was published some
four years ago, and now appears in a somewhat amplified form.
This has been already fully noticed in our columns, and we do not
propose to offer any further observations upon it now. It was an
essay which unquestionably added much to the author's reputa-
tion, and embodied much conscientious microscopical and practical
experience.

The arrangement of the work is hardly that which will commend
itself to the reader; it is too artificial. The female generative
organs are so intimately associated with their function — the one
with the other — that it is difficult to treat separately of diseases of
the mons veneris, vulva, vagina, uterus, broad ligaments, fallopian
tubes, ovaries, and pelvic bones. In fact, the classification is not
altogether satisfactory, according to the author's own admission.
Thus, on page 171, under the heading " Broad Ligaments," he
states, '' Most of the diseases of these structures either have been
discussed in connection with the uterus and ovaries, or will be when
I speak of diseases of the fallopian tubes." Again, on p. 114,
perimetritis is described under the head of ovaritis, and little more
need here be said about it, &c.

1 Diseases of Women. By Lawson Tait, F.R.C.S., Surgeon to the Birmingham
Hospital for Women. London, 1877.

360 Reviews. [Oct.,

On the other hand, there are some advantages in thus dealing
seriatim with the various disorders. We scarcely recognise the
necessity of separating the mons veneris from the vulva, the
diseases of the one often extending to the other, the division
appearing somewhat arbitrary. The various eruptions and parasites,
inflammations and ulcerations, abscesses, tumours, and malforma-
tions, are severally discussed, and many important pathological
distinctions given. The directions for treatment are not as complete
as could have been desired. Thus, in speaking of warts, the author
merely states, " there is no treatment of them so rapid, safe, and
satisfactory, as removal by scissors.''' Nothing is said of the advan-
tages of keeping the opposed surfaces separate and dry by means of
desiccating powders, tannic acid, alum, oxide of zinc, calomel, &c.
In speaking of mucous tubercles, the author believes they are not
primary sores, but is quite certain they may be the source of primary
infection in the other sex; in fact, he is satisfied that the great
majority of men who suffer from syphilis are infected by these
soft sores; whilst men, on the contrary, convey the disease from
hard sores.

(Edema of the vulva he regards as pathognomonic of vaginitis
from infection, the condition not being present in simple catarrh.

Congenital cheilosyncleisis is the most appropriate distinctive
title the author can manufacture for cellular union between the
nymphse.

Some valuable original remarks are given of a peculiar degenera-
tive and atrophic change occurring in the nymphse at or after the
climacteric period ; very often, but by no means always, associated
with vascular caruncle of the urethra, causing much miserj and a
great deal of the climacteric drunkenness too common among
women. Spots, varying in colour from a palish brick-red to a
bright purple, transitory and spreading, extend serpiginously on
the inner surface of the labise. During its progress the vestibule
of the vagina slowly contracts until frequently it is almost obli-
terated.

Great relief is obtained, though only temporary, by the applica-
tion of strong carbolic acid to the red spots.

In speaking of vascular growth of the urethra the author tells us
'^the only remedy is removal by scissors." This statement few will
accede to who have had much to do with these troublesome growths.
The galvano-caustic is a most valuable and effective method of
destroying these growths without incurring the risk of haemorrhage.
The application of chromic, nitric, or carbolic acid is often sufficient
to arrest their growth and prevent the necessity of resorting to any
more serious operations.

We commend to the notice of practitioners generally the advice
given that *' the rectum should be emptied by a small enema every

1877.] Tait on Diseases of Women, 86l

morning for at least three weeks after the operation for ruptured
perinseum,'' and that ^' the stitches should not be removed until
after the twelfth or fourteenth day."

How frequently is the success of the operation marred by re-
moving the stitches too soon, and confining the bowels for the first
week or ten days by means of opium, and then trusting to some
ignorant nurse to administer an enema to relieve the bowels.

Any one who has tried the two methods will soon find the
immense gain to the patient's comfort in having the bowels regu-
larly relieved; and if only proper care be taken the practitioner
will not have to regret any non-closing of the rent, or irritation
of the passage of the fseces. On the contrary, the part will be far
healthier and much more likely to unite firmly than if irritated
and unduly distended by the unnatural accumulation that is
still frequently allowed to take place.

We doubt whether the author is justified in making the remark
that in chronic granular inflammation of the inner mucous surface
of the OS — the so-called ulceration of the womb — ^' a simple astrin-
gent lotion of sulphate of zinc or of alum will, in the majority of
cases, speedily cure it." Patients very frequently present them-
selves with manifest symptoms of this chronic cervico-endome-
tritis, and state that they have been under treatment for it for
months past, it may be even years, employing astringent lotions
and taking internal remedies. On inquiry they tell you they have
never been examined ; it was not considered requisite. If
now an examination be made, the actual condition of the cervix
detected, and some escharotic such as the nitric acid, nitrate
of silver, chromic or carbolic acid be properly applied at ap-
propriate intervals, more progress will be made in a few weeks
than has taken place in months before, and a complete cure will
ordinarily be effected within three months at the most, lotions
being meanwhile persevered with. Under ordinary circumstances
the OS uteri is more or less closed, and lotions as usually in-
jected do not gain access to the cervical canal, which in these
cases is the seat of the disease, the granular condition of the
OS itself being but an external indication of the state of the cervical
canal as well.

The clinical part of the book is not as satisfactorily dealt with
as the pathological. The treatment given is as a rule vague and
sketchy. Thus in uterine cancer we are told how to arrest the
haemorrhage, but there is no word telling how best to assuage the
pain which is generally the symptom most urgently demanding relief.

In speaking of subinvolution, the influence of bromide of potas-
sium and ergot in expediting the process of involution are justly
insisted on, and the evil influence of iron referred to.

The remarks on endometritis membranacea, which term the

S62 Reviews, [Oct.,

author employs in place of membranous dysmenorrhoea, do not
altogether agree with the views generally entertained at the present
time. He believes that it is an adventitious structure^ the result
of an inflammatory action, and not, as usually considered, an
exfoliation of the entire mucous membrane of the body of the
uterus — a true menstrual decidua thrown off at each catamenial
period. Microscopic research seems to confirm this latter view,
the cast being found to consist of the living membrane of the
uterus, hypertrophied in all its elements, almost exactly as it is Ih
pregnancy.

Mr. Tait tells us he has never seen the membrane passed by a
virgin, though he does not assert that every case of membranous
endometritis, where the mucous surface of the uterus is shed, must
necessarily involve unchastity in an unmarried patient. He regards
it as a menstrual miscarriage, to which he has given the came of
^^ fruitless pregnancy,^' believing it to be caused by an absence of
complete fertility in one or other parent, most probably on the part
of the male ; and that the so-called hydatidiform mole is merely a
variety of it.

Perimetritis and parametritis he regards as useful terms in
expressing the difference between inflammatory action in the peri-
toneal investment of the uterus and inflammatory action in the
cellular tissue in the neighbourhood of the uterus, and therefore
retains them, though the latter term is not strictly classical.

Pelvic hsematocele afi'ords the author an opportunity for some
practical remarks. The relative frequency of intra- and extra-
peritoneal heematocele is yet a matter of discussion ; and, if we
take only post-mortem records into account, we can understand
those who hold with Bernutz that the intra-peritoneal is the more
common, and that extra-peritoneal haematocele is very rare. Never-
theless, from his own clinical experience he believes that the extra-
peritoneal is probably ten or twelve times more common than the
other, and also that it is very seldom fatal.

He thinks that all cases of intra-peritoneal haematocele should
be left alone, save under the most exceptional circumstances, and
should be treated on general principles only ; for suppose that the
peritoneum be tapped, or opened from the vagina, is it likely
either that the clots can be removed or the haemorrhage arrested ?
And there is the immense risk of setting up peritonitis where it
did not exist, or of aggravating it if already threatened.

Thus far we quite agree with the author ; but " if the case be
one of tubal pregnancy the doubt of a favorable issue to the opera-
tion for the arrest of haemorrhage is, in my opinion, so great as to
place it out of the question," is an axiom we are unwiUing to admit.
If the history of the case be clear, and the symptoms so marked
that an error of diagnosis is hardly possible, we should consider

1877.]

Tait on Diseases of Women,

363

ourselves perfectly justified in opening the abdomen and attempting
to secure the bleeding vessels and to obviate the otherwise inevitable
tendency to death from continuous internal haemorrhage.

As to uterine flexions and versions, Mr. Tait cannot find that any
more complete and satisfactory account of them has been given
since the appearance of Simpson's clinical lectures. The reader will
seek in vain for any " satisfactory account" of these conditions
here. "Simpson's original ring pessary will be found far more
generally apphcable than any other/' is about all Mr. Tait has to
tell us. We quite agree that, "in all cases where it is possible,
intra-uterine stems should be avoided, for they are always sources
of anxiety, and sometimes of danger.^' Still it would have been well
to have entered somewhat more in detail into the various forms
of instruments least objectionable and most useful in cases of flexion
attended with dysmenorrhoea, sterility, &c., that often prove of
great value in the hands of experienced gynaecologists.

The terms fibroid, fibrous, and fibroma, as applied to uterine
tumours, are, the author believes, so completely erroneous that they
should be banished from pathological nomenclature. He has exa-
mined a large number of solid uterine tumours, and has never met
with one in which simple fibrous tissue played any but a very
subservient part, unless in extremely exceptional cases. The chief
constituent of the tumour is fusiform muscular fibre. The most
common natural ending to the growth of uterine myomata is the
arrest at the menopause, a process Mr. Tait has attempted to
imitate by the removal of the ovaries, but hitherto without success.
He considers it, however, an operation which, in suitable cases, will
prove a more successful plan than removal of the uterus. The
suitable cases are those of women still distant from the menopause,
and in whom the haemorrhage is menorrhagic.

The other natural terminations of myomata are cited, and indi-
cations for treatment deduced therefrom. Here the author can
speak with authority, for he has directed much attention to the
subject, and his remarks are suggestive and very valuable to any
intending operator, though the young practitioner would doubtless
like to have seen the circumstantial details more fully given.

The question of extra-uterine pregnancy is very briefly considered.
He maintains that every case is tubal in its origin, and that it may
become intra-peritoneal or extra-peritoneal, just as the tube happens
to burst, and that none of the cases of ovarian pregnancy will stand
the test of criticism. In not a single instance which he has seen^
nor in any of which he has found on record, has the pregnancy been
anywhere but in the tube. Yet the late Dr. Parry, in his recent
valuable contribution to the literature of this subject, after much
careful research, states : "The weight of authority is in favour of
the possibility of ovarian pregnancy/'

864 Reviews. [Oct.,

We are at a loss to comprehend what place to assign to Mr. Tait's
volume. It is certainly not a student's book ; it contains but one
illustration; it makes no attempt to enter upon the symptomatology
of the subject ; the indications for treatment are the vaguest pos-
sible in many instances, and altogether insufficient. The young
practitioner, if he attempt to take it for his guide, will be sadly
disappointed with the meagre details of many important subjects.
And yet there is something in it for every one to learn — many useful
pathological researches, records of individual experience, hints for
further investigation, and suggestions as to treatment. Though we
can hardly call it a complete or exhaustive treatise, it is more a
contribution of personal experience upon subjects connected with
gynsecology, for which the author deserves our thanks.

X.— -Magnan on Alcoholism.^

The profession and the public must be well-nigh weary of the
discussion as to the use of alcohol as a food and a medicine,
and the searcher after truth may be ready to despair of ever
attaining to it in the presence of conflicting statements and of
opposite but equally positive inferences drawn from observation.
The work before us happily does not take up the debateable
ground, but is occupied solely with the one aspect of alcohol as
a morbific agent, and seeks to make clear what are the changes
in structure and function caused by its introduction into the
system, and how to relieve or cure them.

This being its object, we concur with the translator. Dr.
Greenfield, that the treatise fills up a gap in medical literature.
It is, moreover, the production of a physician having ample
experience of the subject he writes about; for its author. Dr.
Magnan, is one of the two physicians attached to the Bureau
d' Admission of the department of the Seine, in Paris, to which
are brought all cases of delirium and mental disturbance caused
by drink or otherwise which fall into the hands of the police.
It is, indeed, a place only for temporary lodgment, but, in fact,
the whole treatment called for by a large number of cases of
delirium tremens and simple alcoholic delirium from the lower
and middle classes is there carried out and completed. This
institution has, besides, an out-door department, where those
who are suffering from the chronic results of alcoholism, in the

^ On Alcoholism : the various forms of Alcoholic Deliriiim and their Treat-
ment. By Dr. V. Magnan, translated by W. S. Geeenfield, M.D. London,
1876.

1877.]

Magnan on Alcoholism. 365

■

shape of nervous disorders^ and especially of epilepsy, come
under treatment.

The volume opens up with a physiological disquisition on
the effects of alcohol exhibited experimentally in animals^ and
of the comparative effects of simple alcoholic drinks and of
absinthe in man and some of the lower animals ; and it well
brings into view the distinctive and specially destructive pro-
perties of absinthe, which has unhappily become so popular as a
liqueur in France.

It will be enough to point out that the action of absinthe is
especially upon the medullary and cervical regions of the cord,
whilst that of alcohol is on the lower portions of the cord.
Hence we find the former productive of giddiness with confu-
sion of thought, disturbances of intellect, and convulsions ;
whilst the latter, although productive of mental disorder in the
form of illusions or hallucinations, becomes so at a later period
and after longer abuse than in the case of absinthe, and, instead
of convulsions and epileptic symptoms, is rather productive of
tremor and of paraplegia. M. Magnan rightly objects to the
loose manner in which the term delirium tremens is applied,
and attributes to this circumstance the cause of the discrepancy
of statistics of the curability and of the mortality of the dis-
order. On his part he deals with the delirium produced by
alcohol under two heads, viz. alcoholic delirium, and febrile
delirium tremens.

The delirium of alcohol is marked by hallucinations, seldom
otherwise than painful or annoying, but at the same time very
changeable, and apt to be associated in their character with the
previous employments and incidents in life of the sufferers.
Magnan distinguishes maniacal, melancholic, and " stupid "
varieties of alcoholic madness, of which the first is the most
frequent in occurrence. Further, according to the type is the
character of the actions aroused by the mental excitement.
At the same time, cases of a mixed kind are common, and tran-
sitions occur altering the psychological manifestations.

The intellectual aberration usually commences at night, and
presently extends to the day, and when recovery supervenes
recedes in the reverse order. The eyes and ears are much
oftener the seat of illusions and hallucinations than are the
other senses.

The author classes the victims of alcoholic delirium in three
groups, according to the clinical data afforded by the antece-
dents of the patient and the course and termination of the
disease. These groups are as follows : — a. Patients with easy,
complete and rapid convalescence, b. Patients with slow con-
valescence and tendency to relapse, c. Predisposed patients

120— LX. 24

366 Reviews. [Oct.,

affected with alcoholic delirium with frequent relapses. In
other words, patients may have slight attacks and promptly
throw them off entirely ; or may have more lingering seizures,
in which the intellect does not so readily clear up ; or lastly,
may inherit, or may produce by dissipation, a weak brain, in-
capable of furnishing them with moral power or control, easily
acted upon by alcohol and slow to recover from its disordering
influence, even when possibly the dose taken is comparatively
small and its physical manifestations of slight intensity.

This classification is of little value practically ; it is but an
after-construction, when the cases have run their course and
betrayed their historical antecedents; and though it may at
times, as in the instance of patients belonging to the third group,
influence prognosis, it affords no guide to treatment.

Magnan admits the truth of the general impression that
drunkenness is one of the principal causes of suicide, but the
statistics collected by himself respecting this point do not bear
out those put forward by some other writers with regard to the
frequency of this cause. He says —

" Our figures are less than those given by other authorities for two
reasons : we have cut off the list of homicides and suicides all acci-
dents (and they are numerous) arising in a casual manner. Eor
instance, a person affected in this way by alcohol imagines he is
pursued and jumps through a window, thinking it is the door ; this
is an accident, and not an attempt at suicide. Another sees in front of
him a phantom, an armed man ; he seizes a chair, strikes and injures
his child which is lying near him ; this, again, is an accident, and not
an attempt at homicide. Furthermore, we have only mentioned
cases in which we possess positive information. This statistical
result should, therefore, be considered a minimum" (p. 62).

The next section is occupied with a clinical history of the
action of absinthe on man. One of the first noticeable pecu-
liarities of this liqueur is the rapidity with which it developes
hallucinations, accompanied by attacks of fright and anger, of
outcries and agitation. They appear before the combined
alcohol has had time to excite motor disturbances, and with
them are also associated, in the earlier and slighter stages,
muscular shocks and vertigo, and in the later and more com-
plete stages of intoxication epileptic seizures.

Respecting epileptic attacks in alcoholic delirium the author
remarks : —

" The attack of epilepsy is not, as many physicians think, the
highest expression of the disturbance of motor functions in alco-
holics, it is not the most extreme degree of that general tremulous-
ness which is seen in delirium tremens, but it is a symptom of a
different order, which is superadded to the other motor phenomena.

1877.]

Magnan on Alcoholism,

367

To be convinced of this it is only necessary to note the circum-
stances under which the attacks are produced. Sometimes they
surprise the patients at the onset, sometimes at the decline, of the
alcoholic delirium, when the trembling is but slightly marked ; at
other times, on the contrary, they show themselves at the middle of
the attack, when the trembling is at its maximum ; but whatever be
the time of appearance of the attack, the tremt)ling remains the
same after as it was before. It subsequently diminishes if the
attack of alcoholic delirium is on the decline, whilst, on the contrary,
it increases if the fit has come on at its commencement..,. It is not
then a question of trembling, but rather of attacks preceding the
trembling, and which, moreover, themselves disappear. There is
then no correlation between the attack and the degree of trembling'*
(p. 75).

Magnan farther on observes —

" When fits of epilepsy come on in the course of violent attacks
of delirium tremens, one finds in the antecedents of the case the
abuse of absinthe, so that we may say in a general way, ' no fits, no
absinthe,' with the exception, however, of some rare cases in which
the patients have abused white wine, bitters, or vermouth."

In fact, this poison possesses the peculiar property of stimu-
lating, in a fixed, definite manner, the excito-motor functions of
the cord and medulla, without the intervention of determination
of blood to the brain, supposed by some to play the principal
part in the production of convulsive seizures. Moreover^the cere-
bral hemispheres take no part in the production of the convul-
sive attacks, which, under the influence of absinthe, occur with
the same characters in animals previously deprived of the lobes
of the cerebrum.

In his introductory remarks on febrile delirium tremens the
author guards his readers against supposing that the differen-
tial diagnosis between it and simple alcoholic delirium is to be
found in the intensity of the delirium ; for if this be commonly
more pronounced in febrile delirium it is not necessarily so^
and may be equalled in simple delirium. The first and most
important distinctive sign is the presence of fever, not accounted
for by the existence of concurrent disease :

" If the temperature taken in the rectum, after having oscillated
two or three days about 102°, rises to 104° or 105°, the prognosis
will be grave, and its gravity will augment with the increase or even
the persistence of this elevation of temperature. When, on the
other hand, after a somewhat rapid elevation to 102° or 103°, one
sees the temperature go down at the end of twenty-four or forty-
eight hours, the prognosis ceases to be unfavorable, and soon all
the symptoms taken together enable us to foresee a favorable
result. In the case of acute alcoholism of mild form the mercury

S68 Reviews. [Oct.,

may rise to 101° or 101*5,° in consequence of the agitation, extreme
at times, of the alcoholic, but this limit is rarely exceeded, and in
all cases, as soon as the patient has a moment's respite, the column
rapidly descends, and oscillates about 100*4°" (p. 105).

The pulse does not follow the course of. the temperature^ and
furnishes no precise information. But, besides the fever,
another important sign are the disorders of movement, with
respect to which we have to distinguish intensity from activity,
and to note their duration, persistence, and degree of generalisa-
tion, for on these particulars must greatly depend our
prognosis.

Wide-extended but transient trembling need not alarm, but if
the tremors, or rather quiverings and shocks, affect all the
muscles of the body, even though not intense, and if they per-
sist during sleep, nervous exhaustion may be looked for about
the second or third day. We must not trust to what we
observe in the face, or to simple inspection of the surface, which,
indeed, is often moist, and does not to the hand betray the
febrile heat, but must carefully feel the muscles to appreciate
the irregular contractions, and to estimate the extent of the
irritative progress going on in the spinal cord. A third, though
less constant prognostic sign, is to be found in the enfeebling
or actual paralysis of the extremities, mostly of greater extent
in the lower limbs.

From what has been already noted of the pathology of simple
alcoholic delirium and febrile delirium tremens a differential
diagnosis may be formed. Magnan goes a step further, and
describes the differential diagnosis of febrile delirium tremens
and delirium tremens associated with intercurrent diseases and
with injuries, but the description is too long for quotation. It
remains for us to notice the third principal division of his
subject, viz. chronic alcoholism. The account he gives of this
diseased condition is very complete and clear.

In the chronic alcoholic we have a greater or less transforma-
tion of the individual in respect of his mental powers and of
his bodily organs. Permanent changes, by long-continued in-
dulgence, have been wrought in the nutrition of his organs,
involving fatty degeneration and local active morbid changes
and irritations, witnessed by sclerotic alterations. ^'And
according to the predominance of steatosis or of sclerosis in the
nervous centres do we see the chronic alcoholic progressing
towards dementia (steatosis and atheroma) or towards general
paralysis (diffuse interstitial sclerosis).'^ Likewise in the liver
and glands generally, the change towards cirrhosis or fatty
degeneration is set up.

From the tendency or mode of termination of chronic alco-

1877.] Magnan on Alcoholism,

holism Magnan distinguishes three varieties, viz. cases tending
to dementia, cases terminating in general paralysis, and cases
accompanied by hemiplegia and hemi-ansesthesia of common
sensation and of the senses.

The psychical phenomena of progressive dementia need no
description ; but besides the cerebral we have likewise distinct
spinal symptoms; nevertheless the two sets of phenomena in
relation to each other follow no regular order of development
nor of intensity. The spinal disturbances may dominate over
and precede the intellectual, or, on the contrary, be less pro-
nounced. The two will not Sidyamce pari passu, and their rela-
tive preponderance may from time to time vary in the same
individual. The alterations noticed in the cord at one time in-
dicate diffuse myelitis, at another fasciculated sclerosis and
usually more or less diffuse sclerosis, at another degenerative
changes due to fatty deposit or to atheroma. In like manner
in the encephalon similar morbid processes pursue their course
and affect more or less of its substance and membranes, giving
rise to characteristic symptoms. Thus it happens that when
alcoholism passes, as is the rule, gradually into general paralysis,
there is superadded to the fatty and atheromatous degeneration
a diffuse interstitial sclerosis of the brain matter. Withal, the
sclerotic change is not confined to the nervous tissue, but in-
vades that of other organs, particularly of the liver and kidneys.

"The most frequent mode (writes Magnan) of termination of
chronic alcoholism is dementia, which is often associated with partial
paralysis ; this condition answers to fatty degeneration accompanied
by atrophy of the cortical layer, together with more or less numerous
foci of haemorrhage or softening, generally scattered in the form of
lacunar spaces in the optico-striate centres and in the white matter,
or at the periphery of the encephalon, all of these being lesions
analogous to those of senile dementia, and having their starting-
point in the changes in the vascular system, that is to say, the
atheromatous patches and sometimes miliary aneurisms of the arte-
ries. These anatomical lesions, varying in degree and distributed
in an irregular manner throughout the vessels of the encephalon,
may lead to the most diverse localised affections, some of them of
sudden occurrence and rapid course, others, on the contrary, taking
place in a slow and progressive manner, or by successive steps.
Hence arise numerous symptomatic manifestations, variously com-
bined, and often confused with each other, both as regards the
intellectual phenomena and those of a physical nature, whether
motor or sensory."

Of such complex results the hemi-angesthetic termination of
chronic alcoholism affords an example — marked at the same
time bjr paralysis gf one side of the body and diminution ox

370 Reviews, ' [Oct.,

total loss of the general sensibility and of the special senses.
The anaesthesia is not confined to the surface, but extends to
the deeper parts of the paralysed region, and is likewise accom-
panied by loss of the muscular sense. Even the sensibility of
the mucous surfaces, such as the conjunctiva, the nostrils, and
mouth, does not escape, and the special senses fall a prey to
morbid change, becoming weakened in every degree up to
entire destruction of function.

It would be instructive and interesting to follow the author
in his analysis of the symptoms of the hemi-ansesthetic state in
question, to note the attendant psychical phenomena, referable
to dementia, and to examine the relation of the features gene-
rally of the malady with the pathological changes discoverable
after death. The examination he has instituted, although illus-
trating the great advance of late years in nerve-pathology, and
the value of pathological research in unfolding physiological
truth, yet shows how wide still is the field of research open to
observers. But we must here content ourselves, in conclusion,
by briefly referring to the final chapter of this valuable work,
on '^^the combination of alcoholism with various mental con-
ditions, and its association with intercurrent diseases.^'

Under this heading Magnan adverts to the action of alcohol
in cases where some disease is pre-existent, pointing out the
modifications it produces in the symptomatology and course of
the primary aff'ection. He first devotes two or three pages to
dipsomania, regarding it as a distinct condition from alcoholism,
as being '^ a peculiar form of instinctive monomania, having its
source most frequently in heredity. Alcoholism, on the contrary,
is a simple poisoning which appears in the same naanner in all
persons, and, we may add, in animals as in man.^^ The article,
however, on this subject adds nothing to our knowledge, and is
only of value on account of the two cases quoted in illustration.
The same may be said of the short essay on alcoholism and
general paralysis, and, in fine, the whole chapter under consi-
deration must be held to be superficial and incomplete. It is
but fair, indeed, to say that it is introduced with an apology, as
only an outline of a wide subject which did not precisely fall
within the compass of the work the author had taken in hand.
Yet it is to be regretted that so competent a writer was unable
to deal with the matter in the way it deserved. At the same
time, we may well be grateful to him for the amount of infor-
mation he has conveyed in his valuable work, of which we have
endeavoured to give a brief outline — one, at least, of its patho-
logical teachings. For the therapeutics of alcoholism in its
different forms, and for the illustrations appended to the descrip-
tion of each form in the shape of cases narrated, we must refer

1877.] Granville on Care and Cure of the Insane. 371

our readers to the work itself^ which will well repay their
attentive study.

In conclusion, we must thank Dr. Greenfield for introducing
this able treatise by translation to English readers. He has
well executed his part as translator, with which and the writing
a preface he has been content.

XI. — Granville on Care and Cure of the Insane.

This work is the most voluminous of all books on the subject
it handles published in this country. It possesses peculiar
merits and peculiar defects. The latter originate in the cir-
cumstances under which it was called into existence. As the
title-page informs us, it is a reprint of the '' Reports of the
' Lancet' Commission " on the lunatic asylums for Middlesex,
the City of London, and Surrey. As a report it presents a
sketch of the general structure, the administration, the arrange-
ments, and the treatment pursued in each asylum, visited in
turn. The several notices consequently are detached and frag-
mentary, and require collation to enable the reader, who would
get general views regarding the care and treatment of the
insane in English asylums, to arrive at the desired result.

As a matter of course, a reporter on the asylums inspected
had not only to recognise excellencies, but also to spy out
defects ; in other words, he was perforce critical. And it must
be admitted that he was a most competent and intelligent
critic. Moreover, from all that appears he viewed matters as
an outsider, as one officially unconnected with asylums and not
committed to the stereotyped notions and usages which cling so
tenaciously to asylum officers. At the same time he proves
himself to be sufficiently instructed in matters touching the
care and cure of the insane to apprehend the end and aim of
the asylum system ; to grasp and sufficiently to appreciate the
means employed, whether administrative, moral, or medical ; to
recognise their weakness and deficiencies, and generally to
point out a more excellent way. But this critical department,
again, has the same inherent weakness as the descriptive, and
from the same cause. The criticisms, the suggestive notes,
and recommendations recur from time to time, and useless
repetitions of sentiments and opinions as a consequence en-
cumber the pages of the treatise.

^ The Care and Cure of the Insane ; being the Reports of the * Lancet ' Com-
mission on Lunatic Asylums, Sfc. By J. Moetimeb Geanyille, M.D. In two
volumes. London, 1877.

372 Reviews, [Oct.,

These defects in the arrangement and construction, therefore,
being, as before intimated, due to the mode in which the tale
he has to unfold had to be placed before the public, small
blame attaches to the author for their existence. But in his
desire to make his original notices more complete he has very
copiously added to them severally historical and critical matter,
with the necessary result of heaping up fragmentary observa-
tions and multiplying repetitions, when, otherwise, he might
have left those notices in the shape they appeared in the ^Lancet,'
and have grouped together, under appropriate headings and in
systematic order, the conclusions he had arrived at and the
opinions and principles he had to enunciate, expanding them
as he deemed needful in a subsequent portion of his work. In
fact, he has done the one thing and not left the other undone ;
an action somewhat of the supererogatory sort. For, after the
copious additions to his original notes and reflexions, he has
produced in the second volume a retrospect and a large chapter
of " notes," bearing on all the topics which pertain to asylum
administration and the care of the insane, and which, in the
detached notices of the several asylums visited, he has more or
less already amply dealt with. What we urge as preferable
would have been a volume of notes on asylums, with current
remarks, and a second volume, setting forth the writer's general
impressions and conclusions regarding the existing aspect of
the care and cure of the insane, together with a systematic dis-
cussion of the principles he advocates for the better provision
and treatment of lunatics, embracing all the points now debated
in different disconnected portions of the present treatise.

With respect to the merely descriptive notes which appeared
in the pages of the * Lancet,' their immediate value is but
ephemeral. They exhibit the institutions as the reporter found
them, and they will doubtless be interesting to students of a
future time diligent in learning the state of asylums in the
latter portion of the nineteenth century. On the other hand,
the writer's own impressions and opinions of what he saw
should be read with interest by the present generation of asylum
officers and rulers, particularly as they come, as already inti-
mated, from an outside and presumably unprejudiced observer.

We have enlarged sufficiently on the defects of these volumes;
it is a much more agreeable task to refer to their excellencies,
and it is one we can, in this case, perform with much confi-
dence. The good sense and intelligence of Dr. Granville make
him a good reviewer of the conditions and circumstances sub-
mitted to his scrutiny. He is decided in his views, and not
sparing of his criticism; at the same time he is no reckless
fouU-finder, but seeH^ t^Q TUftHe §\\xe of the bftsjs for bis remarks,

1877.] Granville on Care and Cure of the Insane, 373

The appendix of communications from superintendents of asy-
lums indicates how seldom he has misrepresented^, or rather
misinterpreted, what he saw or heard.

His convictions and his principles concerning the care and
cure of the insane are most fully set forth in the supplementary
observations appended to the notices originally published in
the ' Lancet/ in the " General Remarks on Public Asylums
Visited/' at the close of the first volume, and in the concluding
retrospect and chapter of " Notes " in the second volume.

At the very outset of his work, on the seventh page, in
introducing the account of the new Surrey County Asylum at
Brookwood, the great problem of the day touching the public
provision for the insane forces itself upon him. The story of
Brookwood points the moral of the mistake, repeated with sad
uniformity throughout the country, of trying to overtake the
demands for accommodation for the insane by erecting addi-
tional huge new asylums, and filling them forthwith by a
population of incurables, drafted from all the workhouses
around and from private houses receiving insane paupers ; a
proceeding whereby recent and curable cases become excluded
altogether from the possible benefits of the asylums, or else
more or less lost sight of as far as curative treatment is con-
cerned, amidst the crowd of hopeless incurables among whom
their lot is forthwith cast.

Dr. Granville thus very truly and plainly puts the matter :

" How best to secure four objects essential to the result and
interdependent :

" 1. The existence of a highly curative establishment, replete with
every convenience, furnished with all necessary or desirable appli-
ances, and so organized as to aflford the greatest facility for the
prompt, rapid, and effectual treatment of insanity in its various
forms and under divers conflicting conditions.

" 2. That every case of mental disease falling under the control of
the public authority, and chargeable to the rates, shall be placed at
the earliest moment, without being delayed or intercepted by any
other machinery, in the institution already described.

" 3. That no case proving incurable, or passing into a condition
which renders active treatment hopeless or unnecessary, shall be
allowed to occupy space or waste power in the curative establish-
ment.

** 4. That the asylum or hospital in which ' cures ' are to be
effected shall be able to accommodate the whole of the recent, or
curable, cases in the district it is designed to protect."

These principles or objects to be kept in view and acted
upon are repeated in the author's comments, with more or less
expansion, in connection with the history of several . asylums
visited, ^ud further recur in the ht,\QX sectigns of the secoucl

374 Reviews, [Oct.,

volume^ where he discusses the '' asylum question." They are
principles, we must add, which recommend themselves to
common sense, and have been laid down by not a few writers
on asylums and the insane. In one or more papers in this
Review they have been earnestly advocated ; and we may
indulge in the hope that ere long they will take hold of the
public mind, and lead to a reversal of the present mischievous
policy, upheld, as it mainly is, by the inertia of routine.

The author's conception of the needs of the insane and the
purposes of treatment is most fully unfolded in the additional
remarks attached to the account of the Brook wood Asylum.
He lays it down as an axiom, that the insane are not only
irresponsible but also incapable of self-control. This defini-
tion is open to the objection that it is too wide. The whole of
the so-called moral treatment proceeds on the assumption that
the insane are, in varying degrees, capable of self-control, under
the stimulation of external influences and conditions, or of cir-
cumstances overmastering or displacing the dominant and
enslaving powers or motives which have possessed them. We
will not dispute the statement that "every true lunatic is a
slave to some infatuation ; " but we cannot endorse the author's
conclusion that it is " vain to hope to achieve his freedom by
moral violence ;" for otherwise, " moral " treatment could find no
place for recognition, no scope for usefulness. It is an act of
" moral violence " to shut up a lunatic in an asylum, to cut him
off from his relatives and surroundings, and to subject him to
the control of strangers and a host of conditions foreign to
those he has been accustomed to ; and we know that such an
act, almost it may be per se, will often be attended by the happy
rescue of the slave from his infatuations.

At the same time we quite coincide with Dr. Granville's
views generally as to the principle of placing lunatics on the
footing of children, with a view to their re-education; placing
them under " conditions and surroundings as nearly as may be
like those of the life they are afterwards to live," " with the
circumstances of sane life, and then with carefulness and
watchfulness, by personal example, counsel, and such measures
of enforcement as are adopted in the training of a judiciously
managed family of children, instructing them in the avoidance
of danger, the self-restraint of wrong propensities, and the in-
telligent choice of good and evil ways and courses of conduct
in preference to those which are bad and must end in moral
and physical disaster."

This teaching is right enough as a protest against making a
" madhouse like a prison in its internal arrangements, and
against proceeding on the assumption that lunatics are to be

1877.] Granville on Care and Cure of the Insane, 375

jealously kept out of reach of any possible instrument and ap-
paratus which may prove a source of danger, instead of being
taught and in a gentle way compelled to apply these imple-
ments of domestic life to their proper and ordinary purposes."
Yet we contend, notwithstanding, that relegation to an
asylum is something more than a change of residence, and it is
that something which makes the act one of '* moral violence,"
and a successful factor in loosening the insane individual from
the fetters \oi delusions which have fastened themselves upon
him. Indeed, the histories of recoveries from insanity abound
in examples of " moral violence," of strong mental impressions,
and even of the accessions of bodily sickness, operating as
curative agents.

It appears to us that, in propounding the principles of treat-
ment quoted as of universal application, the author has erred
by reason of keeping too prominently in his mind the more
chronic examples of lunacy, and losing sight of the recent
forms. Just as with acute bodily maladies at large, so with
uncomplicated acute insanity, it has a natural tendency to re-
covery; and ^'physiological rest" is as important an element
of treatment in mental as in corporeal lesion. An acute
attack of madness, although very materially influenced by the
surroundings, offers limited scope for the re-education por-
trayed by Dr. Granville ; it is too much of an explosive con-
dition to be dealt with by counsel and the sort of training
requisite to the judicious management of a family; it calls for
control, for discipline, for conditions of constraint, if not of
restraint, and for calmatives — for " physiological rest.'' It
demands something more than the surroundings of every-
day life, and in every well-constructed and well-administered
asylum it finds that something.

We are happy to endorse Dr. Granville's view as to the in-
expediency and folly of endeavouring to keep every instrument
or implement, or constructive detail, capable of mischievous or
hurtful employment, out of the way of patients. Fully to
achieve the result is an impossibility ; to aim at it as far as
possible, a mistake. Our forefathers failed signally in the
management of the insane by opposing morbid activity by
mechanical appliances, and by making their patients close
prisoners, with the view to keep them from harming them-
selves or others. If our modern superintendents have advanced
on the road towards freeing madmen from mechanical restraint
and sore bondage, they have halted on their onward march, as
it were, to make sure their position, and have expended their
energies in small devices contrived to outdo the morbid inge-
nuity and the proclivity of their patients to disorder and

376 Reviews, [Oct.,

mischief; and further, to secure quiet and order, they have
devised a system of rigid routine, pervading the entire ad-
ministration of asylums, and sooner or later bringing all
unruly members within its paralysing grasp. Indeed, it happens
unfortunately that both administrators and those ministered
to alike become victims to its injurious influence. It usurps
the place of treatment, and leaves the duly *^ classified'^ patient
a mere member of a group subordinated to the same general
scheme of management.

With Dr. Granville we can distinctly aver that ^' uniformity
is the too dominant idea ; " the individuality of patients is
sacrificed to it, and therewith also the individual treatment
essential — pre-eminently so in curable cases. And we concur
with this physician's opinion that it is probable the mental treat-
ment of insanity will make no "real progress, or even assert
its intrinsic claims to confidence, until psychologists begin to
recognise the full scope of its intention. The aim should be
to deal directly and specifically with the individual mind
organism, its idiosyncrasies and sources of weakness, those
defects which left the citadel of the intellect an easy prey to
the enemy. . . . Moral treatment must be individual. It
is no more possible to propagate principles of self-control in a
multitude of minds dealt with e?i bloc than to make sincere
believers by prohibitory or compulsory religious ordinances."

Real progress in the curative treatment of the insane, history
and experience tell us has not been effected, notwithstanding
the immense advancement made in some directions, the enor-
mous expenditure incurred on behalf of the insane during the
last fifty years, and the vigorous eff'orts made to improve their
condition. Our best attempts to do good have been paralysed
by some imperfection in the mode in which our reforms have
been carried on. That this is so Dr. Granville's statistical in-
quiries respecting the rate of cure in former and latter years
clearly demonstrate. This demonstration, moreover, is only con-
firmatory of a general conviction among medical men, gathered
by observation and by research in the past history of insanity.

The author remarks — "The circumstance I should like to
see discussed by writers on insanity, and, if possible, explained
by medical practitioners among the insane, is, that there has
not only been no substantial improvement in the results obtained
since the abolition of restraints, but what amounts to a positive
diminution of the proportion of cures .^*

Tovvards an explanation of these discouraging results Dr.
Granville arrives, as the general result of his inquiry, at two
inferences — " First, that the existing method of dealing with
lunatics is chiefly notable for its negative advantages. It is

1877.] Granville on Care and Cure of the insane. 377

free from the objections which public opinion urges^ on grounds
of humanity, against the restraint system, but it has few posi-
tive excellences of its own, and of those few scarcely one is
remedial. The second inference is, that the method of provid-
ing for the insane in asylums at present pursued is faulty. It
can never overtake the need for accommodation . . . and it
deprives recent cases of the full advantages of treatment. It
is, therefore, opposed to the dictates of true economy, and
injurious to the welfare of the insane."

By collating the opinions and remarks of the author, scattered
up and down in the two volumes of his work, we arrive at a
pretty clear notion of his apprehension of the defects of the
prevalent plans obtaining in asylums, of the impediments to
curative treatment, and of the reforms demanded to place the
care and cure of the insane on a proper footing.

In the first place, he holds the colossal asylums of the present
day to be a mistake. The error is increased a hundredfold by
bringing together all varieties of insanity, acute and chronic,
within the same building and under the same medical and
general management. For such a mixed community, for the
purposes of management, an attempted classification of its
members must be made; but the sort of classification commonly
seen is not a classification for cure, but for convenience. It is,
as the author calls it, " a system of shelving, by which work
that cannot be done in detail, because the task is too vast, is, in
a fashion, done in the mass. It would be more candid to confess
that it is not done at all. . . . Classification such as this,
suggested by convenience, is the bane of asylum practice, and
one of the greatest obstacles to progress."

In accord with this kind of classification is the whole system
of routine and uniformity so elaborately organized as an essen-
tial element in the government of large masses of people, though
at the same time undoubtedly inimical to curative treatment.
We have this routine in the uniform dress of patients, and
often also of attendants ; in the prescribed and rigid dietary ;
in the fixing of hours for all the requirements of life, — for
knocking patients up in the morning and sending them to bed
at night; for turning them out for exercise, &c.; in limiting their
exercise to confined courts and leaving them therein to disport
themselves as they please, satisfied only that the courts are
safe against escapes, and that their accessories do not bristle
with dangers. The patients by all this lose their individuality,
and are dealt with as units of a group possessing some features
in common which render their grouping a convenience.

To quote again Dr. Granville's very pertinent remarks,
'' There is a radical fault at the base of the asylum system,

^78 Reviews, [Oct.,

and everything is made to conform to it. Uniformity is the
too dominant idea. It is impossible to deal with minds in the
mass. A body of men may be trained to act together like
machinery^ but the training and results will be simply physical.
In an institution designed for the cure of mental disease,
where minds are to be recovered from derangement, and from
which it is hoped they may be sent back to the world, the
individuality of patients should, on no account, be sacrificed
to uniformity. Individual treatment, personal obligations to
self-control, variety in surrounding objects, diversity of cloth-
ing, of occupation, as far as possible even of food, are essential,
and ought to form component parts of the governing idea."

As an accessary to routine in dealing with masses of persons,
not a few of whom are liable to injure themselves or others, we
meet with the principle of minimizing danger, as carried out
in a multitude of constructional and mechanical details, and
upon which far too much pains have been expended by asylum
officers. It would be, indeed, folly to lose sight of the prin-
ciple, but harm arises from its exaggeration, and whenever and
wherever intelligent oversight and control, watching and tend-
ing, can effect the purpose it more rudely seeks to serve.

To quote Dr. Granville's own words, " Frankly, I do not
believe in minimizing the pains and trouble required of those
in personal charge of the insane. By multiplying the me-
chanical appliances and regulations devised to lessen the de-
pendence on personal care, the sense of personal responsibility

is diminished Further, it is not cheap to piece out

meagre personal service." Continuing with the author's cata-
logue of defects, we come next to a most important one, viz.
the filling of asylums with chronic and incurable cases, among
which the recent and curable ones are so mingled that they
lose the benefit of appropriate care and treatment, and very
largely drift into a chronic state of insanity, adding to the
already existing accumulation.

Routine having usurped the place of rational and intelligent
treatment, it is no wonder that the medical superintendent of
a large asylum is made small account of, that his services are
looked upon principally as incidental, and only required against
special medical emergencies ; and that the lay members of the
committee, assisted by the host of lay assistants they themselves
appoint, and under their direct control, deem themselves com-
petent to carry on the very simple rules dictated by a rigid uni-
formity. This lay government obtains at the Surrey Asylum,
Wandsworth, and at the Middlesex Asylum, Hanwell, but
presents its maximum development at Colney Hatch. Were
not the consequences too sad, it would be amusing to recount

1877.] Granville on Care and Cure of the insane. 379

the instances of over-weening self-importance and self-suffi-
ciency on the part of the Committee of Visiting Justices. They
record in their own reports the labours they perform in the
general management, in the suggestion of treatment, in the
supervision of the measures pursued by their medical officers in
treating the patients, in the hiring and discharging of attend-
ants and servants. " They exercise supreme authority; and the
medical officers, with more or less docility, carry out their in-
structions," humbly submitting themselves to adopt or to lay
aside any particular practice they may have pursued in the
treatment of the mental lesion, and to have the daily surround-
ings, the discipline, and the moral regime of the patients, ordered
and administered by the committee and their officers. The
medical superintendent is but a humble servant of his com-
mittee ; and the asylum, in lieu of being a place of treatment, is
simply one of detention.

We have not exhausted the list of defects, of errors in con-
struction and management, of our large mixed asylums. Nor
have we unfolded to our readers any actually novel views and
statements, for the like have long been insisted upon by various
writers, and notably by Dr. Arlidge, in his essay ' On the State
of Lunacy ' (1861) ; but we are persuaded that demonstration
enough has been afforded of grave defects, clearly detrimental
to the welfare of the insane and the progress of enlightened
and successful treatment.

Let us now turn to our author's views as to the nature and
scope of the reforms demanded for the care and cure of the
insane. In respect to these, we again find that Dr. Granville
has been largely anticipated by the author just referred to ;
and, indeed, follows equally in the wake of several writers, par-
ticularly among those of recent years.

Admitting that insanity is a curable disease in a large pro-
portion of its varieties, and that it calls for early individual
treatment, the first suggestion is, that there should be special
asylums, or rather hospitals, for the insane when first attacked,
to be furnished with all necessary appliances for the physical
and moral treatment of insanity. Attached to this kind of
hospital Dr. Granville would have, " so far as the control of
its general arrangements is concerned,'* one, or if necessary
more than one, institution to which patients, not either requir-
ing or likely to be benefited by active personal treatment, but
still needing medical care, might be removed, when, in the
course of each individual case, it becomes apparent that this
transfer will not prejudice the final chances of recovery. In
connection with the workhouse, or in some appropriate institu-
tion— for example, a '^ workhouse asylum '^ — provide suitable

S80 Review^, [Oct.,

wards for the senile and infirm, whose recovery is impossible,
and who tarry only for death. This threefold system being
efficiently organized, the necessary circulation of cases may be
readily maintained, without either indefinitely multiplying
costly buildings or allowing the curative establishment to be-
come blocked against recent and curably, by the stagnation of
chronic, cases."

The curative establishment must be kept of small magnitude,
and the number of its inmates not exceed that which it is
possible the physician in charge can individually treat. To-
gether with proper structural arrangements must be associated
an organiaation fitted to make the establishment an instrument
of treatment, all its details leading up to one purpose. " The
medical superintendent of a curative establishment for the
insane should be its chief and immediate director. Every sub-
ordinate officer, from the matron to the meanest official, ought
to look to him as master. An appeal to the committee is fatal.
Justices should hold their physician responsible for everything
that concerns the institution under his control," and not weaken
his influence by personal interposition, but allow to him an
undivided authority.

Besides the threefold mode of distributing lunatics. Dr.
Granville recognises as advantageous to a class of pauper
lunatics the plan of boarding-out '^ with friends ; " but he
would restrict the expedient within very narrow limits, and
rather advocate the construction of detached buildings, in con-
nection with asylums, for the accommodation of trustworthy and
convalescent patients, who should have almost perfect liberty and
contribute by their work towards the cost of their maintenance.

We have now passed under review the principle opinions,
conclusions, and recommendations of Dr. Granville in the two
interesting and instructive volumes before us. There are others
referring to minor points touching the care and cure of the
insane well worth quoting, but which our waning space
warns us to leave unnoticed. To thoroughly appreciate the
value of his opinions it is necessary to read them as more fully
recorded in his own language, together with the arguments he
has employed to enforce his recommendations.

It is a melancholy tale that the reports of the Lunacy Com-
missioners, and of the many asylums — ever growing in number
and size — have to tell us year by year, namely, that the demands
for accommodation of the insane exceed the supply, although
this is actively kept up, and that every asylum is crowded by
chronic lunatics and imbeciles, and contains few inmates whose
recovery can be anticipated. With such a history before it, it
might reasonably be presumed that the public would show a

1877.]

Forensic Medicine and Hygiene, 681

lively interest in any work undertaking to discuss and solve
the pregnant question — what are we to do with our lunatics ?
But any such interest has hitherto been wanting, and a glar-
ingly faulty system of dealing with our insane has been allowed
to continue and to expand^ as though the British public had
handed itself over to the doctrines of fatalism, accepting the
present state of things as inevitable. Nevertheless, we must
yet hope that the public mind will be aroused to contemplate
the serious question we advert to; and are consequently pleased
by the appearance of this work, as a means of supplying the
information needed to arrive at a satisfactory conclusion.

XII. — Forensic Medicine and HygieneA

There is nothing in the history of our country more remark-
able than the present development of thought and action on
the subjects of health and life. For much longer than the
quarter of a century we have, in the pages of this Review, been
active in season and out of season in teaching the truths of
sanitary science. Sometimes we have stood alone, then we
were for a brief period joined by other journals specially de-
voted to subjects of public health. Again we have stood alone,

1 1. A Handy Book of Forensic Medicine and Toxicology. By W. BathuesT
Woodman, M.D., F.R.C.P., and Chaeles Mbymott Tidy, M.B., F.C.S. Lon-
don, 1877.

2. Sanitas Sanitatum et Omnia Sanitas, By Richaed Metcalfe, P.S.S.
Vol. i. London, 1877.

3. Rouse Drainage. By Rogees Field, C.E. London, 1877.

4. Societe Frangaise d' Hygiene, sa raison d'Stre, son but, son avenir. Par
M. le Docteur de Pietea Santa. Paris, 1877.

5. Functions of a General Police Force for the extinction of fires and adminis-
trative improvements especially needed in the metropolis. By Edwin Chadwicz,
Esq., C.B. London, 1877.

6. Report on the Air of Glasgow. By E. M. DixON, B.Sc. Sanitary Depart-
ment. Glasgow, 1877.

7. Our Medical Charities. An Address delivered by Sampson Gamgeb,
F.R.S.E. London, 1877.

8. Contagious Diseases and the Insufficiency of the measures adopted for their
prevention. Pamphlet. London, 1877.

9. Statistical Sanitary Report of Margate. By W. Knight TeevbeS,
F.R.C.S., Medical Officer of Health. Margate, 1877.

10. " Dust to Dust." Sanitary Modes of Burial. By Samuel Phillips Day,
London, 1877.

11. The Quarterly Journal of Inebriety. Published under the auspices of the
American Association for the Cure of Inebriates. Vol. i. Nos. 1, 2, 3. Hart-
ford, Connecticut, 1876-7.

12. Restriction and Prevention of Scarlet Fever. Document issued by the
State Board of Health of Michigan. 1877.

120— LX. 25

383 tleviews. [Oct.,

and now we may say that, instead of standing alone, we are
practically swamped in the sea of literature on health topics
which has gathered around us. We are not jealous on this
account. On the contrary, we are proud that it has been our
mission^ quarter by quarter, to hold steadily the light of science
when often there were no other hands to hold it. We look,
indeed, on the present results as a proof of the usefulness of our
work, and, as we give a last gaze back on it, are content to leave
it to the judgment of those who in the future will be sure to
judge it justly.

As we now write our table is loaded with books inviting our
attention. They deal with a multitude of subjects, all appa-
rently different, all mostly bearing relation to the one subject —
the health of the people and the mode in which it is best
maintained and promoted.

Our hand rests on the first volume named on our list, the
work called ' A Handy Book,' by Drs. Woodman and Tidy.
We touch it with a feeling of great respect, because one of the
authors of it has not lived to see the result of his labours. A
mind too anxious, a heart too anxious, cannot always live the
natural span, and Bathurst Woodman, long our friend and
worthy colleague, though he fell under his work, unhappily, is
one not soon to be forgotten by those who knew how earnestly,
how honestly, how lovingly, he laboured for his race in the short
space alloted to him for labour.

As to the book called " a handy book," a handy book it is
not. It is a very large book and very laboured. It has all the
faults, the invariable faults of a book written by two heads,
which, whatever they may be in other affairs, are never in
book writing wiser than one. For though we detect easily
enough in this work that one head was the more active, we
do not fail also to detect the absence of unity of design and
method which follows the dual effort. We dare not say the
book is a great book in the way of literary effort. It may be
the nucleus of such a work, but as it stands it does not appear
to us as a work specially called for, and therewith naturally
supplied. It is deficient in all the charm and originality of
Beck, and is equally deficient in the experience and personal
knowledge of Taylor. At the same time it is not guilty of the
great defects of Taylor's really great work. It is conceived in a
better spirit, is free of all attempts to submerge opposition by
an avalanche of attack, and in so far it may be considered a safer
if not a sharper forensic guide.

In detail the book is accurate, and the strain that has been
made to finish detail without the introduction of new science

1877. J Forensic Medicine and Hygiene, 383

is probably at one and the same time its chiefest virtue and its
gravest failure.

The book ' Sanitas Sanitatum ' is of a very inferior order.
Its writer is an advocate of the Turkish bath, and is, we believe,
the well-known proprietor of the baths in Paddington. His
book is naturally in favour of the bath, the whole bath, and
nothing but the bath, and, in short, it is only written for the
bath, although it deals with an infinitude of other subjects,
relevant and otherwise. The most interesting, as it is also the
most amusing, part of the work is included in a series of testi-
monials on the bath, extending from the S25th to the 328rd
page of the comely volume. They are called " letters from
statesmen, noblemen, medical men, literary men of eminence,
and others," and surely in another day will be read with much
humour and insight into character. How they were got is
itself worthy of note.

The commissioners of baths for the parish of Paddington
were, it seems, seized with an irresistible and laudable impulse to
improve the health of the people of that ilk. They therefore
undertook to find baths and washhouses for the working classes
— a very wise procedure. But before setting to work the authori-
ties must needs ask a few questions. Some proposed that
Turkish baths should be added, " Mr. Metcalfe and other
commissioners supporting this proposal." The commissioners,
therefore, asked the opinions of the statesmen, noblemen, medical
men, and others whose names are hereinafter mentioned as
having furnished replies. The said replies follow, and a curious
congregation they are. Mr. Spencer Wells tells the commissioners
that he has published his opinions long ago. He objects to giv-
ing anything like a testimonialon any subject. "Oh,wise and far-
seeing man, with eyes so wide open, what shall be thy reward ?"

George Cruikshank washes in cold water all the year
round; he has actually never used a Turkish bath; — he
has actually never seen one. Unable, therefore, to give any
opinion on the subject, he refers the ardent inquirers after
truth *' to the Medical Inspector of Paddington." Prudent
George Cruikshank !

Mr. Spurgeon believes no one has ever been clean who has
not taken a Turkish bath, but he fears the time required for its
use will prevent the working classes using it extensively. Com-
mon sense Mr. Spurgeon !

Sir William Gull succeeds in giving an opinion without
signing it. Somebody, the letter says, is directed to write for
him, to present his compliments, and to say,'^ that the advantages
to the working classes of properly arranged baths and wash-
houses cannot be over-estimated, but that Turkish baths are

384 Reviews, [Oct.,

more adapted to the indolent and luxurious than to those who
toil for their livelihood." How luxurious this opinion is in
itself our readers will see. The mystery, and there is a mystery
about it, is, who it was that was directed to write it. Was it
the great Mogul ? We regret our deponent sayeth not in this
edition of his work ; in the next he will, perhaps, enlighten
us, for surely he holds the secret.

To these specimens " we could and we would" add some
dozens more. We forbear. Our author is not, indeed, altoge-
ther satisfied himself about some of them, and so we will not
pain him by repeating disaster. He says that with regard to
the letters from medical men generally, they may be considered
highly favorable; '' but Drs. Watson, Parkes, Sir W. W. Gull,
T. King Chambers, Andrew Clarke, Burrows, Sieveking, C. B.
Williams, Ballard, Bristowe, and Nicholas, all agree upon the
medical efficiency of the Turkish baths, but add some remarks
which are scarcely worth noticmg." Morsels of similar delicacy
are to be found in other parts of the work ; but we must stop.
We stop with the expression of the deep regret that any such
opportunities should even have been supplied for exhibition of
character and caricature.

The book we rest on next is once more of an entirely
different kind. The work on administrative organization, by
Edwin Chadwick, is a book pretending to little more than
pamphlet form, but full of the most useful, the most thoughtful
advice and instruction. It may seem at first sight that an essay
on the functions of a general police force for the extinction of
fires has a purpose removed far away from the subject of
sanitary reform. In fact, however, it is the heart of such
reform. In many pages the author insists that the police
service and the fire service should be one and the same, and
that, as matters now stand, the police are deprived of half their
beneficent duties as a great organization. He comes at last to
the consideration of " sanitary evils and waste from disjointed
sanitary works and want of administrative organization and
skill." In this part Mr. Chadwick adverts to the connection
which the administrative arrangements in question for the pre-
vention and spread of fires have with the larger subject of the
prevention of epidemic diseases and excessive mortality. In
his report of 184^ on the sanitary condition of the labouring
population of Great Britain, he had reason to observe upon the
inefficiency and waste from the disjointed action of local admi-
nistration, from the all-pervading want of principle in the
arrangements for the public service. He then said — and many
of the old sanitary reformers will remember well the statement —
that division of labour in the arts derives its efficiency from

1877.] Forensic Medicine and Hygiene. 385

combination,, adaptation, and subordination of action to one
end ; but that which appears to be a division of labour
in local administration is, in fact, an insubordinate sepa-
ration, weakening the means of procuring adequate skill
and power, occasioning obstruction and defective execution
and enhancing expense. "Were pins and machines made as
local works are constructed, shafts of pins would be made
without fitting heads ; in machines screws would be made with-
out sockets, and it might be confidently stated that there would
not be a safe or well-working machine in the whole country."
He illustrates the truth of this observation by reference to the
water supplies of different towns. In his reports as a sanitary
commissioner, he and his fellow-commissioners provided,
amongst other combinations, those of hydrants to be applied by
the police. These arrangements were allowed to fall through
in the metropolis, but were partially adopted in the provincial
cities with the great results of increased security and reduced
expense. But even, says the author, in those cities the arrange-
ments proposed for carrying away the waste or fouled water
were not comprehended, and have been neglected, with the
effect of the aggravation of the evil of undrained sites and the
frustration of the results due to the improvement of the public
health by the introduction of improved supplies of water.

In Liverpool this error has at last been detected, and Mr.
Chadwick very naturally is triumphant on the results which
have been recently published by the chairman of the water
committee. The facts are sufficiently important to deserve a
short notice in this place. The chairman of the water supply
of Liverpool gives the results obtained in fourteen test districts
where the distribution of water had been at about the main rate
of distribution in the metropolis, viz. 33 gallons per head of
the population. In one district, where the consumption had
been 54 gallons per head per diem, it has been reduced to 17
gallons ; in another, where it had been 41, it has been reduced
to 10 ; in yet another district, and that one in which water-
closets are used, it had been reduced to 6 gallons per head per
diem. The mean of the reduction has been at the rate of 13*32
gallons per head. This has been done by a system of outside
observation, by meterage; and it has been shown that the
saving of water effected has been equal to 1,180,789,428 gallons
per annum. The financial result is not less important. It
stands as follows : —

Increase of revenue ..... dG27,526 0 0

Annual value at cost price of the 8,501,167 gallons per
week of absolute decrease in the quantity delivered,
which water is now stored at Rivington , . 13,954 0 0

^41,480 0 Q

386 Reviews. [Oct.,

This amount capitalised represents a sum of £1,037,000.
Turning next to the sanitary results, it is shown that the death
rate in Liverpool has been reduced from 35 in the 1000 in 1871
to 27 in the 1000 in 1876. It is, of course, very difficult to
distinguish all the causes which have led to so great a decrease
in the death of a great centre like Liverpool in so short a time,
and it may be fair to say that the more systematic supply of water
is only one of the causes of such reduction. Of this the chair-
man of the water committee is himself candidly aware, and he
does not claim more than the just share of credit for the labours of
his committee. When it is remembered what his committee
has done we can, indeed, reasonably and willingly admire the
quiet modesty with which every claim is made. They have
blocked up the drains of 1896 cottages^ and so prevented the
distribution of sewer air through them ; they have avoided the
necessity, in most instances, of emptying the mains for plum-
bers' repairs ; they have removed defective lead service pipes in
the drains and alleys ; they have prevented storage of water in
tubs and other receptacles in the poorest parts of the town ; and
they have given a constant supply of pure water by night and
by day, which even in summer is cool and refreshing. The
chairman adds, that when it is remembered that a reduction of
the death rate by 1 per 1000 represents 559 lives saved
annually in the borough alone, and that those 550 lives after
all bear a small proportion to those suffering from sickness, the
question at once strikes us as one of the most important that
can occupy attention.

To these observations of the chairman of the water committee
at Liverpool Mr. Chadwick alludes with justifiable satisfaction.
He quotes the following from the same official authority: —

" In addition to the pecuniary results, we have converted a nine-
hours' seiTice into a constant service ; we have saved water suffi-
cient to meet the increasing wants of the town and neighbourhood
for eight years longer than would otherwise have been the case j
we have given additional facilities for the extinguishing of fires ;
we have relieved the cottage-owners of the maintenance of 9700
taps in the courts and alleys ; and we have, with the assistance of
the Health Committee, undoubtedly contributed to the lowering of
the death rate."

And then he proceeds to add, in comment —

" As to the sanitary results obtained from the amendment of the
ill-regulated distribution of water and bad house service, I can
corroborate them from earlier experience obtained in a number of
of towns, where the principles of sanitation for the reduction of the
damp of habitations were then set forth in the instructions of our
Board, were fairly attended to.

1877.]

Forensic Medicine and Hygiene, 387

" In 1865 an inquiry was made, at the instance of the medical
department of the Privy Council, into the results of works con-
structed more or less in accordance with the principles we promul-
gated. I might take exception to the completeness of that inquiry
as it was conducted; but the general ascertained result was a
considerable reduction of the total death rates, and especially of
the death rates from the foul air diseases. It was, however, parti-
cularly noted by Mr. John Simon that the inquiry involved facts for
which he was ' not in any degree prepared,' that the drying of the
soil in the improved towns had let to the diminution, more or less
considerable, of phthisis. ' The facts which are yet in evidence
seem most strongly to support this conclusion. Should it be sub-
stantiated, it will constitute a very valuable discovery, evolved by
Dr. Buchanan, from the inquiries here reported on.' * It will be
seen that the reduction of phthisis where certain works have been
executed, is far too large and too general to be regarded as an acci-
dental coincidence.' ' The reduction in the first fifteen towns in
Dr. Buchanan's table are as follows : — ^Salisbury, 49 per cent, of its
previous rate ; Ely, 47 per cent. ; Rugby, 43 ; New Banbury, 41 ;
Worthing, 36 ; Macclesfield, 31 ; Leicester, 32 ; Newport, 32 ; Chel-
tenham, 26 ; Bristol, 22 ; Dover, 20 ; Warwick, 19 ; Croydon, 17 ;
Cardiff, 17 ; Merthyr, 11.' On this, which I must treat as a revival
of sanitary doctrine in 1865, 1 have to state that, in my Eeport of
1842 on the sanitary condition of the labouring population, will be
found a chapter setting forth the investigations then held on the
results of land drainage, or of the reduction of damp, in the health
of men as well as of animals ; the facts on which I was led to
specify as preventible next after — epidemic, endemic, and conta-
gious diseases, fevers, typhus, smallpox, measles— the great cate-
gory of the ' diseases of the respiratory organs, consumption, pneu-
monia, and others ;' and later on, in 1848 and 1850, the causes, the
dampness of sites, induced by a discharge of pipe water in urban
districts, equivalent to the saturation of the subsoil with a double
rainfall. Mr. Simon, speaking of the recorded results then obtained
by inquirers, which he promised should be continued, observed that
' they may serve to fulfil very important provisional uses, not only
to confute persons who have despaired, or affected to despair, of
any great preventibility of disease, but still more to justify in the
public eye, and to encourage in some of the noblest of human
labours those who for long weary years have been spending their
powers in this endeavour, and to whom surely it will be the best of
rewards to see the demonstration of the good they have wrought.'
But the ofiicial examinations which we had contemplated as a fixed
and responsible duty of the first health department were not sys-
tematically proceeded with, and if they had been it must have been
to record such continued and fatal dereliction of principle as have
been hereinbefore set forth. A further illustration of the lack of
competent inspection and warning may be presented in respect to
the common conditions of the water supplies.

" In a number of towns, Liverpool itself included, fresh supplies of

388 Reviews. [Oct.,

water have been introduced, and, lo ! the death rates have not been
reduced as expected and promised, but have even been increased.
Engineers, whose only practice has been for trading companies to
carry water to the doors of houses, and who have nothing to do with
it afterwards, or any concern as to how it is to be carried into
houses, or in what condition it is left there or gets away, and even
some medical men, have pointed to the fact that pure soft water
supplies have had no effect in reducing the prevalent heavy death
rates. It has been observed, moreover, that the introduction of the
new and pure supplies of water has not had the effects promised —
of reducing the drinking habits of the population ! How should it,
when the cold of the wretched absorbent brick habitations is made
worse by increased damp, and those miserable depressing conditions
are aggravated which impel even persons of higher position to have
recourse to alcoholic stimulants to withstand them ? Again, the
water, by the conditions of internal distribution in which it is kept
stagnant, absorbing the mephitic gases, is rendered mawkish, impure,
repulsive to the taste, and itself a provocative of intemperate habits.
The use of such excessive quantities of water is excused on the score
of the necessity of cleansing the drains and sewers, which it does
not do, inasmuch as it merely runs over indurated deposit, the result
of forewarned and unamended bad constructions. But it is to be
observed that the sanitary conditions and increasing waste have
been commonly treated as constant by engineers, and as a pressing
case of necessity for some great engineering works for augmented
supplies — leading to augmented waste. In Liverpool itself, very
recently, the introduction of a lake supply has been urged as of an
immediate necessity to meet the demands of the increasing popula-
tion, which the waste -prevention achieved in the important Report
cited, will serve, as it states, to postpone for ' eight years' to come.
For the metropolis two projects have been urged for nearly doubling
the quantity of the existing supplies as insufficient, and that they
cannot be too ample in the face of demonstration that they are as
distributed in pernicious excess. Amongst the evils of this excess,
and one requiring distinct notice, is the injury done to the manurial
value of manure by the excessive quantity of water with which it is
diluted, as well as by storm water, by which, at times, it is impro-
perly encumbered.

" It admits of renewed demonstrations.

" That the like sanitary evils arising from errors in the internal
distribution of water into houses, described as having been preva-
lent at Liverpool, prevail to grievous extent throughout the metro-
polis, especially in the houses of the poorer classes in the lower
districts.

" That the like reduction of waste, with attendant sanitary im-
provement, may be effected to as great an extent in the metropolis,
that has been achieved in Liverpool.

" That such reduction of waste may be effected in the metropolis
with even greater proportionate economy than has hitherto been
in Liverpool.

1877.]

Forensic Medicine and Hygiene, 389

" But that, for the attainment of these results for the benefit of the
population, the entire works, internal as well as external, must be
placed under unity of management, by competent public authority,
responsible for the execution of the work as a special trust.

" When it is proposed to vest the works for the supply of water
under a public trust, it is to be considered that they now are, virtu-
ally, under a public trust constituted by statute. The companies
are traders, contracting for the sale of supply of water at prices, and
of qualities and under conditions, set forth and regulated under
Government officers or water a examiner as to quality, and of an
auditor as to prices, by a Government department. What is needed
is, then, really an enlargement of the powers and of the conditions
of that public trust, including the abrogation of the contract with
those traders, on compensation to them, as may be given on settled
principles. Viewing the Government as trustees for the public
under the exceptional conditions of the metropolis, what should be
required of them under those conditions may be considered as if
they were trustees for a private estate or property ? What would
be their responsibilities for allowing it to continue in its present
condition of disorder and waste of life and of property ? Would
they be sanctioned in allowing their trust to devolve upon such a
body as the Metropolitan Board of Works, as an incident to other
and desperate duties, and to a divided and distracted and irrespon-
sible attention — .upon a body who had proposed a double and even
a fourfold expenditure, and who had ignored proved practical large
economies ? Would it be sanctioned in intrusting the work of fire
prevention in charge of a numerically inferior force, and dispensing
with the service of the numerically superior force ? of continuing
the work of water supply in hands apart from those charged with
its effective application ? The example of the success of the pro-
vincial municipal authority may be superficially regarded as coun-
tenancing the notion of administering the trust in question by a
metropolitan municipality. But the success of each of the provincial
municipalities was only attained after years of favour to recognise
and act upon the principles propounded ; and even now, when exa-
mined, there are yet serious shortcomings and defective action,
especially in respect to our outer ring, which it were unnecessary to
discuss. In magnitude, the metropolis is equal to eight Liverpools.
In action and in conception to meet its requirements the course of
the so-called metropolitan representative body will be found, on an
impartial examination of the evidence, to be flagrant and reprehen-
sible and conclusive as to its dangerous untrustworthiness. The
population of the seat of government of the empire may surely ask
for a befitting special executive authority responsible directly to
their representatives in Parliament, at least provisionally, for the
purpose of organisation, by an extended trust. This I can declare
as an expression of the concurrent opinion of provincial officers, as
well as of engineers of great practical experience and observation."

We have extracted at length the statements of Mr. Chadwick

390 Reviews. [Oct.^

for the simple reason that it is impossible in any way to con-
dense them. They are, moreover, so instructive, they deserve
all the attention that can be paid them. We rejoice as we read
them to feel that the hand which so ably raised the standard of
sanitation in 1838 is now, in its fiftieth year of sanitary work,
still so efficient and still so wisely and powerfully pursuing its
craft for the good of the State and the vital interests of the
people.

The remaining books that lie before us are all of interest, and
some of true value. The essay of Mr. Rogers Field is a good
exposition of sanitary details in reference to house drainage.
Dr. Pietra Santa's doctrine explains the origin of the French
Society of Hygiene, a society recently founded in France after
the plan of the Sanitary Institute of Great Britain. Dr. Dixon's
report on the air of Glasgow is drawn up with much scientific
care, and is a work which gives promise that we have in its
author a new hand who will be heard more of in due time. Mr.
Gamgee's address on ' Our Medical Charities ' is the work of a
master who never takes up the pen without having some original
thought for its work, who is never happier or more useful than
when he is laying bare some great evil, and who never laid
bare more skilfully a greater evil than that which he now brings
to the fore.

' Dust to Dust,' by Mr. Samuel Phillips Day, is the work of
a scholar who is well conversant with the sanitary modes of
burial. Mr. Day inclines clearly to cremation as the best mode
of disposing of the dead ; but, pending the advanced time when
this method will be consonant with the sentiment of the nation,
he advocates the earth-to-earth system, which Mr. Wyman
Herden has so earnestly and ably supported. The 'Report on
the Statistical Sanitary Report of Margate,' by Mr. Trovers, in-
dicates how excellent a medical officer of health he is, and how
much the oldest and still the most popular of watering-places
near to London is improving in sanitary condition.

The new journal, to which we call attention at the commence-
ment of this review, and which is named ' The Quarterly Journal
of Inebriety,' is a singular indication of the progress of thought
on what is popularly known as the drink question. The journal
is published in Hartford, Connecticut, and is the official journal
of the American Association for the Cure of Inebriates. The
papers in the first three numbers are of unequal merit, but sound
and practical. They show how greatly in advance the American
nation is in its management of the drunken insane.

The last book to which we refer is the document issued by
the State Board of Health of Michigan, on the restriction and
prevention of scarlet fever. It is drawn up by Dr. Baker, with

1877.1 Contagion; What do we know regarding it ? 391

whose sanitary labours English readers are so familiar, and we
need not say it is most ably done. We do not see that it con-
tains any original suggestions, but it is a simple working model
of a report which all who will may read, and we name it spe-
cially as a model which we in England may take pattern from,
as we progress in the sanitary education of the masses of the
people.

This education is the grand medical work in the future of
medical science.

XIII. — On Contagion : What do we know regarding it.^

The two problems at present absorbing the attention of
scientists (medical and lay) are, the Evolution of Life, and the
Germ-nature of Contagium. In the following pages we desire
to side neither with the panspermists nor with the heterogenists.
We shall trace the origin of contagium no further than pub-
lished researches enable us, shall avoid all hypotheses respecting
its relations to the evolution of life, and shall keep ourselves
uninfluenced by any theory of fermentation and putrefaction.
There exist a sufficient number and variety of observations to
allow us to state certain potent reasons for applying the term
germ to the ultimate entity of contagium, in so far, at least, as
found in some contagious diseases. With the primary origin of
such an entity or entities we do not concern ourselves, as this is
as yet an unfathomed ocean ; on the other hand, recent obser-
vations throw light, to a certain extent, on the behaviour of
contagium under certain conditions ; but of the further develop-
ment of any one contagium, or its transmutation in form or
substance, we know nothing positive. So, also, the relationship
of contagia to one another is as yet a strange inquiry.

Dr. Maclagan's excellent resume of the whole subject, the
*Germ Theory of Disease,' as also Dr. Rosses very thoughtful and
suggestive monograph, the * Graft Theory of Disease^ (which has
been already reviewed in this Journal), and Drs. Braidwood
and Vacher's Reports to the Science Grants Committee of the
British Medical Association, on the 'Life History of Contagium,'
are good examples of work done by industrious and thoughtful

1 1. T. Maclagan. The Germ Theory applied to the Explanation of the
Phenomena of Disease. London, 1876.

2. Reports of the Medical Officer of the Privy Council. New Series.
No. vi.

3. Beaidwood and Vacheb. First and Second Contributions to the Life-
History of Contagium. ' Brit. Med. Journal,' 1875, 1876, and 1877.

4. W. Roberts. On Spontaneous Generation and the Doctrine of Contagium
vivum. * Brit. Med. Journal,' Aug. 11th, 1877.

392 Reviews. [Oct.,

practitioners ^^ during odd hours snatched from the busy routine
of practice.^' On the other hand, we dare not overlook the
researches of Drs. Burdon Sanderson, Klein, and others em-
bodied in the Privy Council Reports, and others published in
'Ziemssen's Cyclopaedia of Medicine,' even though we regard the
results of these observers as " not proven."

What reasons are there for believing that " many diseases
are due to the presence and propagation in the system of minute
organisms, haviug no part or share in its normal economy ? "
On what observations is the Germ Theory of disease based?
What proof have we of the " coinpetence of germs to produce
the phenomena of disease ? '' In the next place, are all germs
capable of inducing disease of similar natures — are they of like
form, of uniform habits, or in what respects do they differ ?
Since the middle of the seventeeth century, w^hen Hauptmann
first suggested that epidemic diseases might be caused by the
presence in the air of invisible germs, there have been pub-
lished, from time to time, many similar guesses at truth, many
more or less plausible efforts to interpret the phenomena of
contagion by theories leaning on probabilities or analogies,
sometimes only on possibilities. There is no evidence that all
contagious diseases are communicable by infecting liquids, nor
are all varieties of contagia, liquid or dissolved, or suspended in
liquid. It must, however, be admitted that the contagium, or
the several contagia of diseases known to be i7ioculable, must be
contained in the liquids with which we can perform inoculation ;
of this class the contagium most readily obtainable and most
easily handled is that which forms the infective principle of the
various group of diseases, and which is found in the vesicles
of variola and vaccinia. Accordingly, most investigations into
the nature of contagium have been made with vaccine virus.
To discover this contagium the microscope was first used, and
Dr. Lionel Beale, in December, 1863, announced the discovery
of transparent particles of extreme minuteness in vaccine lymph,
and expressed his conviction that the contagious or active pro-
perties of the lymph lay in these particles. This observation
is now admitted beyond doubt, but the relation of these particles
to infection, and their physical properties, were debateable points,
till a few years later M. Chauveau submitted vaccine lymph to
physical tests. Having proven, through separation by subsi-
dence and through filtration, that the leucocytes and other
constituents of vaccine lymph did not retain its infective power,
but on the contrary, that its serum (which by microscopic
examination revealed these minute sparkling particles) was
still virulent; M. Chauveau proceeded to separate these ^'^ elemen-
tary granules ^' of the serum^ now often termed micrococci, by

1877. J Contagion; What do lue know regarding it *^ 393

means of diffusion. From such experiments he concluded "that
the vaccinal serosity is not virulent, and that the activity of
vaccine resides in the solid granules, either in all or only in
one part of these little elementary organisms." Mr. Chauveau's
researches^ contained in tvs^o papers in the ^ Comptes Rendus
des Seances de FAcademie des Sciences ' for 1868, led Dr.
Burdon Sanderson to test these observations, improving the
method of procedure in various particulars. Still later. Dr.
Braidwood and Mr. Vacher employed diffusion for the purpose
of separating the contagium of vaccine, and by attention to
certain details overlooked by their predecessors, they may be
said to have avoided all possible sources of error. All these
observers have arrived at the same conclusion, viz. that " we
possess the strongest proof (we can have no direct proof till we
have learned how to wash off all trace of plasma from the
bodies it suspends) that the contagium of the virus with which
we are most familiar consists of transparent particles, not ex-
ceeding (according to Sanderson) the 20,000th of an inch in
diameter, neither soluble in water nor in watery liquid, and
not capable, without losing its properties, of assuming the form
of vapour. Further, inasmuch as these particles do tend to sub-
side, though (according to Chaureau) they never dispose them-
selves completely in the lower layers,we are assured that they are
of a specific gravity only slightly greater than that of the plasma
surrounding them, while, from their not sensibly diminishing
the transparency of the liquid containing them, they refract
light in the same degree as this, and by examining fresh
vaccine microscopically any one can observe these minute,
highly refractive, colourless bodies to be moving, and to form
groups of threes and fours. Now, these minute, distinctive
particles (Sanderson's micrococci) are to be seen, not only in
vaccine lymph, but also in the lymph of human and ovine
variola. Hence it may be concluded that such are the physical
characters of the contagium of the virus of all the diseases
composing the variolous groups.

We come next to consider whether such an end has been
reached in the study of any of the other contagious diseases
which attack human beings and animals. At this point we are
met by the great, almost insuperable, obstacle that no other class
of contagious affections supply us with a secretion suitable for
inoculation and for microscopical and physical examination.

No contagion, except that of the variolous group, has hitherto
been at all capable of isolation. It is true, that some conti-
nental investigators, consider that they have satisfactorily proven
by experiment, the contagion of erysipelas and diphtheria to
consist of, or to be intimately connected with, the microphytes

594 Reviews. I Oct.,

or bacteria, associated with the septic transformation of nitro-
genous matter {vide Dr. Sanderson^s Reports for 1874) ; while
others regard such contagious diseases, as typhoid and relapsing
fever, and the splenic fever of veterinary pathology, to be due
to *'a vegetation of recognisable peculiarities of form and de-
velopment, differing from those met with either after death in
the normal tissues or liquids of the body^ or during life in the
products of primary or secondary inflammation ; " of the former
class of investigations it may be stated that they require con-
firmation, while respecting the vegetable origin of typhoid fever
in as far as such has been delineated in the ' Reports of the
Medical Officer of the Privy Council,^ new series. No. VI.
Dr. Creighton's investigations, published in the ^ Proceedings of
the Royal Society,' vol. xxv.. No. 17^, show that bodies closely
resembling this vegetable organism are to be met with ^^ when
fresh tissues are put in solutions of chromic acid and alcohol,
causing coagulation of mucus and other albuminoid fluids."
The peculiar rod or staff-shaped bodies first described by
Pollender as the characteristic contagium to be found in the
blood and tissues of animals which have succumbed to or suffer
from milzbrand or splenic fever have been observed in this
affection by Brunell, Bollinger, and others. The pathology of
splenic fever has more recently acquired a wider interest from
this disease being identified by Buhl wiih that affecting the
human subject which he termed mycosis intestinalis. The
rarity of the disease, at least in this country, may be regarded
as the cause of its not having been studied here. But the
elaborate experimental investigation of this affection by Koch,
leaves no reason to doubt that the rod-shaped bodies, about as
long as the breadth of a blood corpuscle, found in the blood,
spleen, lymphatic glands, and in some other tissues of animals
suffering from spleen fever, are intimately connected with the
contagious nature of this disease. Koch found that mice were
peculiarly susceptible to the virus of splenic fever. The
minutest particle of the fresh blood or spleen of an infected
animal invariably produced the disease when brought into con-
tact with the living tissue of a mouse. He found further that
he could cultivate the organisms artificially outside the body.
After being placed in the incubator the rods were observed in
a couple of hours to begin to lengthen, growing to twenty or
a hundred times the length of the original rods, and they
began by-and-bye to assume a dotted appearance. ** The dots
gradually increased in size and distinctness until, after the lapse
of fifteen or twenty hours from the beginning of the experi-
ment, they acquired the appearance of strongly refractive oval
bodies, which were placed at regular intervals along the threads.

1877.] Contagion ; What do we know regarding it ? 395

Finally, the threads broke down, and the oval bodies, which
could be nothing else than spores, were set free and sank to
the more depending parts of the drop. If the supply of nutri-
ment were then exhausted, the process ended here, and the
spores remained permanently unchanged ; but, if additional
nourishment were provided, the new spores were seen presently
to elongate into rods, exactly resembling those originally exist-
ing in the blood or spleen. If the conditions were favorable,
the new rods, after a period of rapid multiplication, in their
turn entered on the formation of a new generation of threads
and a new generation of spores.'* (Dr. W. Roberts' address,
'Brit. Med. Journ.,' August 11th, 1877.)

With the view of testing the pathogenic activity of the rods
and spores cultivated in this manner, Koch introduced minute
quantities of the rods, or of the spores alone, subcutaneously
by incision into a mouse, causing speedy death from splenic
fever in every instance.

"Koch found, without exception, that if the tested materials pro-
duced threads and spores in the incubator, it also produced splenic
fever when inoculated into the mouse ; and, on the contrary, if no
such growth and development took place in the incubator, the tested
material produced no effect when inoculated into the mouse."

The variable duration of the activity of the contagium of
splenic fever was now explained.

'* Koch found that the rods had only a comparatively fugitive
vitality ; they lost their infective power generally in a few days— at
the most in about five weeks. But the spores retained their infec-
tive activity for an indefinite period, in spite of all kinds of maltreat-
ment. They could be reduced to dust, wetted and dried repeatedly,
kept in putrifying liquids for weeks, and yet at the end of four years
they still displayed an undiminished virulence."
Cohn further found that the organism above described as cha-
racteristic of splenic fever was identical in form and develop-
ment with the Bacillus suhtilis — a form of bacteria.

Dr. Obermeier's (of Berlin) discovery in 1872 of minute spiral
organisms (spirilla) in the blood of patients suffering from
relapsing fever, has been fully confirmed by subsequent obser-
vations. These organisms are found during the paroxysms;
they disappear at the crisis, and are absent during the apyrexial
periods. They consist of spiral fibrils of the most extreme
tenuity, varying in length from two to six times the breadth
of a blood" corpuscle, and in the fresh state they move about
actively in the blood. They have not been detected in any of
the fluids or secretions of the body except the blood, nor in
any other disease except relapsing fever. '^ In form and botanical
characters they are almost identical with the Spiroch(Bte jpU»

fe^ Reviews. [Oct.,

catilis of Ehrenberg, a species of bacteria," and have been
termed by Cohn Spirochcete Ohermeiri. The most recently
published monogram on this subject is by Dr. Heydenreich, of
St. Petersburg, whose conclusions are based on a most careful
study of forty-six cases of relapsing fever.

" He found that every rise of temperature, whether that of the
paroxysm, or that following a pseudo- crisis, or those occuring during
the intermissioDS, was invariably preceded by the appearance of
spirilla in the blood. They disappeared entirely shortly before the
crisis, and remained absent during defervescence and the subsequent
apyrexial periods. During the whole of the main paroxysms spirilla
were usually to be found in the blood, but their number varied in
the most puzzling manner from day to day. One day they were
abundant, the next day they were scanty, and the day after again
abundant ; they even varied at different hours of the same day ;
sometimes they vanished altogether for a time, and then reappeared
in vast numbers a few hours later. Throughout these variations the
temperature remained steadily high, or with only slight or moderate
oscillations " (vide Eoberts' Address).

Previous investigators had observed these discrepancies, but
with Heydenreich rests the credit of explaining them.

" He found that, when a little blood containing spirilla was ab-
stracted from the patient and kept at the ordinary temperature of
the room, the organisms lived in it for several days ; but if the blood
was placed in an incubator, and maintained at the normal tempera-
ture of the body, they died in from twelve to twenty hours, and if
the temperature was kept up to fever heat (101° F.) their life was
still shorter — they only survived from four to twelve hours. This
led him to the conjecture that, during the main paroxysm, not one,
but several successive generations of spirilla were born and died
before their final disappearance at the crisis. He surmised that in
the usual course the broods would overlap each other more or less,
the new brood making its appearance before the last survivors of the
old brood had passed away. This explained the variable number of
spirilla found on different days and different hours of the same day.
Sometimes the old brood would have altogether perished before the
new brood reached maturity ; this explained the occasional absence
of spirilla from the blood ; it also explained the remissions or pseudo-
crises sometimes observed in the course of the paroxysms " (Dr. W.
E/oberts' Address).

From Heydenreich's careful observations only one inference
is eligible, that the spirilla are, or form the actual virus of
relapsing fever. This seems to be confirmed also by experi-
mental investigation, for experiments made in Russia on indi-
viduals who voluntarily submitted themselves to inoculation
with the blood of patients suffering from relapsing fever, show
that such blood is infective only during the paroxysms, but not

1877.] Contagion : What do we know regarding it ? 395^

at the crisis, nor during the apyrexial periods. Moreover, none
of the fluids or secretions of the body, except the blood, were
found infected when tested thus.

From these observations it may be concluded beyond dispute
that certain infectious diseases (those we have specified) are
induced in the system by a " morbific agent, which is propa-
gated in and given oiF from the bodies of the sick, and is
capable, when received into a susceptible healthy body, of pro-
ducing in that body a disease similar to the one during whose
course it was formed ^^ (Maclagan, p. 5). Further, the particu-
late nature of the contagium, or morbific agent of infectious
diseases, is not only sufiiciently defined by the observations
above described, but it offers a ready explanation of a well-
known, and on any other view, an inexplicable fact in the history
of infectious diseases, viz. that of two persons situated in exactly
the same circumstances, and exposed in exactly the same degree,
to a given infectious disease, the one may be seized after a
single exposure, while the other may be equally exposed for
months without being attacked, and may even escape alto-
gether. The contagium particles in a patient's breath resemble
an enemy's bullets. The breath would be harmless without the
particles, just as an enemy's powder would be without his
bullets.

But what evidence is there in favour of regarding the conta-
gium particles as organic germs or products of animal or vege-
table development. As Dr. Baxter states with emphasis in his
'^ Report on an Experimental Study of certain Disinfectants "
(' Reports of the Medical Ofiicer of the Privy Council,' new
series, No. vi), the ''characteristic quality of a contagium or
virus of a communicable disease is its capability of undergoing
almost unlimited multiplication when introduced into an appro-
priate medium ; " hence also its effects are to a great extent
independent of the quantity introduced into the system. " This
power of development, and this faculty of breeding true, were the
first, and have ever been regarded as the chief arguments in
favour of the germ theory of disease," observes Dr. Maclagan,
" and it is difficult to see how these properties of contagium
can be accounted for on any other view of its nature." It
would be superfluous here to follow Dr. Maclagan's description
of the chemical analogy of contagium to the process of crystalli-
sation advocated by some. Another argument in favour of
the germ nature of contagium is that, like all organised matter,
it is prone to undergo change when separated from the condi-
tions essential to its vitality ; and this very proneness becomes
an argument, not against, but in favour of the view which re-
gards it as consisting of minute organisms. " If all the ova of
120— Lx. 26

398 Ueviews. , [Oct.,

every parasite came to maturity, few animals would be free
from these pests. If every smallpox germ which came into
existence developed and reproduced its kind in the same way as
the parent from which it sprung, the civilised world would have
been all but depopulated before the days of Jenner." While
chemistry and physic, moreover, throw no light on the mode of
growth or reproduction of contagium particles, the microscope
has assisted though it has not unravelled this mystery. Dr.
Beale, for example, has figured the reproduction of these par-
ticles from the contagium particles found in the secretion in
various diseases. He summarises the results of his observations
thus in his brochure ' On Disease Germs,' p. 244.

" Without, therefore, pretending to identify the actual particles of
the living bioplasm of every contagious disease, or to be able to
distinguish it positively from other forms of bioplasm, healthy and
morbid, present in the fluids, on the different free surfaces, and in
the tissues in such vast numbers, I think the facts and arguments
I have advanced prove— first, that the contagious virus is living
and growing matter ; secondly, that the particles are not directly
descended from any form of germinal matter or bioplasm of the
organism of the infected animal, but that they have resulted from
the multiplication of particles introduced from without ; thirdly,
that it is capable of growing and multiplying in the blood ; fourthly,
that the particles are so minute that they readily pass through the
walls of the capillaries, and multiply freely in the interstices between
the tissue elements or epithelial cells ; and lastly, that these par-
ticles are capable of living under many different conditions — that
they live and grow at the expense of various tissue- elements, and
retain their vitaHty, although the germinal matter of the normal
textures, after growing and multiplying to a great extent, has ceased
to exist."

Still, more distinct evidence is furnished by Drs. Braidwood
and Vacher's observations. They state in their ' First Contribu-
tion to the Life History of Contagium,' that the corpuscles,
whose multiplication forms one of the characteristic appear-
ances produced by the vaccine virus, " are to be seen in the
crypts or hair-follicles budding or throwing off minute,
round, highly refractive bodies." Similar corpuscles, seen in
sections of skin affected by variola, are stated by these ob-
servers to be noticed germinating or throwing off spores on the
fourth day of the eruption. At this point we exhaust our
positive knowledge of the origin and reproduction of contagium.
As stated by Dr. Sanderson many years ago, '^ all microzymes
are not contagia, but all contagia may be microzymes." All
forms and varieties of bacterifi seen in contagious fluids and
in diseased tissues are not contagium particles; and this is the
point which specially concerns us.

1877.] Contagion : What do we know regarding it ? 399

" From the presence of bacteria in a given fluid we can postulate
nothing as to its disease-producing properties " (remarks Dr. Mac-
lagan. " The fluid may be full of bacteria, and yet be incapable of
causing disturbance ; it may contain few, or none of them, and yet
a single drop introduced into the circulation may give rise to a
most virulent disease."

The next stage in this inquiry refers to the circumstances
favorable to the propagation of contagiumparticlesj and to those
inimical to their reproduction. For the development of or-
ganisms certain external conditions are necessary; they will
not grow in very low temperatures, and are destroyed in very
high ; they cannot thrive without water, and largely appropriate
nitrogen in their growth. But contagium particles require
something (as yet unascertainable) additional to these.

"We know," observes Dr. Maclagan, "that the contagium of
typhus, besides requiring for its development the conditions requisite
to the propagation of organisms, has need of something more, which
it finds in the human body ; that the contagium of measles also
requires its own peculiar element, which is also found in the human
body, and is quite different from the element appropriated by the
typhus contagium; and so on, with all the other contagia."

The subject is only imperfectly understood until chemistry or
some of the other sciences discloses this something or potency,
which is a necessary constituent of the contagious state. We
cannot know and cannot understand the natural history of con-
tagia till we can tell the exact circumstances under which each
prospers, and can indicate the special elements which each
appropriates to itself. Here we would point out a false step
which has been frequently taken by those studying contagium,
an error pregnant of much mischief. The action of contagium
on the animal economy has often been compared to that of medi-
cinal agents or poisons. This has led to further error. As
inorganic poisons and certain organisms can be made to exhibit
their special properties external to the natural conditions in
which they are found, it has been attempted to -submit contagia
to such an ordeal, and to unravel the mysteries of contagium
by propagating it outside of the body.

" We do not think," observes Dr. Maclagan, " that any fair or
legitimate analogy can be drawn between the eff'ects of either an
inorganic or organic poison acting on this or that organ, and those
of an organised substance, which is reproduced to an enormous
extent within the system, which requires for its reproduction the
elements which are requisite to the well-being of its victim, and
whose morbific action is intimately connected with its organic
reproduction."

This point is ably discussed in Dr. Maclagan's monograph

400 iteviews. - [Oct.,

(p. 35), and he puts familiar truths in plain, striking language,
with logical terseness, and with a complete knowledge of the
suhject handled. After the introduction into the animal
economy of a poison or of a contagium a definite sequence of
phenomena is noticed. Each has a definite and specific action ;
a certain time elapses after the reception of the substance into
the system before morbid symptoms are developed ,* the severity
of the symptoms varies with the dose of the substance intro-
duced; the effects are modified by temperament or constitu-
tional peculiarity on the part of the recipient ; and after a time
the substance is eliminated from the system. But, the existence
of so many definite and distinct contagious diseases proves that
the poisons which give rise to them are specifically distinct.
*^ For the explanation of the phenomena which are common to
the eruptive fevers," remarks Dr. Maclagan, " we look only to
the organism; for the interpretation of those which constitute
their specific differences we look beyond the organism to the
disease germ."

Now, what are some of the conditions affecting the life of a
contagium ? The first to suggest itself on reflection is the in-
fluence of dilution, gaseous or liquid, on the vitality or infec-
tive power of contagium. The amount of air or water with
which a contagium should be diluted to render it inert is a point
not yet decided. M. Chauveau found that vaccine mixed with
fifty parts of water ceased to act with any degree of certainty ;
sheep-pox virus, after being diluted to one part in a hundred of
water was successful, and even when diluted with ten thousand
times its weight of water it was not inert. In the next place,
with regard to the influence of drying on contagium, the de-
priving it of one of the essentials for its growth. Dr. Burdon-
Sanderson found that mycrozymes and the germinal particles
which they produced were rendered inactive by thorough
drying, without the application of heat (Appendix No. 5 to the
' Thirteenth Rep. of the Med. Off", of the Privy Council,' p. 61).
This observation is confirmed by Dr. Bastian (' The Beginnings
of Life,' vol. ii, p. 5). These very meagre results show that
here is offered wide scope for experimental research. Not only
as an interesting and important point in exact science, but of
great value in preventing the spread of contagious diseases, it
would be well worth labour and time spent to determine the
amount of dilution with air and with pure water sufficient to
render a contagious atmosphere or a contagious liquid innocuous.
Further, the analytical method of depriving a contagium of one
source of nutriment after another, would no doubt assist in
solving some of the problems suggested by a study of the life-
history of contagium.

1877.] Contagion: What do we knoiv regarding it? 401

The influence of certain physical and chemical conditions on
the vitality and activity of some contagia has been pretty fully
demonstrated by the experimental researches of various ob-
servers. The earliest recorded study of the effect of increased
temperatures on the vitality of contagium is Dr. Henry's (Man-
chester) original article in vol. x (new series) of the ' Philoso-
phical Magazine/ pp. 363-9, dated October 14th, 1831, and his
further observations recorded in vol. xi, 1832, of the same
journal. He considered it established by his experiments
" that vaccine matter is not destroyed by a temperature of 120°
Fahr; and it is even probable that it would sustain, without
losing its efficiency, a heat several degrees higher/^ but it is
" rendered totally inert by exposure to a temperature of
140° Fahr.^' He stated further that the virus of scarlet fever
was rendered inactive by a temperature of 204° Fahr. These
observations were conducted by Dr. Henry with the object of
ascertaining whether or not the heating of raw cotton prevented
its acting as a medium for the introduction of the plague into
this country. Hence, they did not proceed further than was
necessary to determine the amount of heat which such material
could stand without receiving injury, and an amount sufficient
also to act as a disinfectant. Many imperfections and errors
are noticeable in the conduct of Dr. Henry's observations.
This line of enquiry has been pursued much more carefully by
Drs. Braidwood and Vacher in regard to the influence of
increased temperatures on vaccine lymph.

Their observations were conducted with strict attention to every
detail, and the heat was conveyed through water to the conta-
gium particles in their natural moist state. The results obtained
were these : Lymph could not be safely exposed without impair-
ment to a temperature above 139° ; did not lose all its specific
properties at 146°, but its activity was totally destroyed at 149*5°
Fahr. Further, exposure for a few minutes was as effective as
exposure for two hours.

Our knowledge of the influence of low temperatures on con-
tagium is not even so far advanced as our knowledge of the
action of increased temperatures. Fluids containing fungi and
bacteroid bodies have been exposed to low temperatures by means
of frigorific mixtures ; and because certain organisms maintain
their vitality for a time surrounded by solid ice, it is inferred
that contagia may survive being frozen ; but the amount of cold
necessary to destroy any of the specific known contagia remains
to be discovered. We are equally ignorant as to the effect of
sudden falls of temperature on contagia, though such changes
are doubtless not less inimical to them than to higher organisms.
The only carefully conducted observations on the influence of

402 Reviews. [Oct.,

very low temperatures on contagium are those of Drs. Braid-
wood and Vacher, published in their second contribution. They
found that the exposure of vaccine in the fluid state for an hour
and a quarter to a temperature of 166° Fahr. below the freezing
point of water did not in the slightest impair the activity of the
lymph. It would not be logical, probably also not correct, to
conclude from these observations that other contagia possess a
like immunity from the influence of cold. The marked
diflerences in the severity and duration of epidemics which have
been noted during almost the entire history of medicine indicate
that atmospheric conditions, as alterations of temperature and
amount of moisture, to affect the vitality and activity of conta-
gium. It is to be desired and to be hoped that ere long this
problem will also be solved.

The behaviour of various contagia in the presence of chemical
substances, termed disinfectants or germicides, has been studied
by many observers, and results of considerable importance have
been reached. The knowledge which has been obtained by noting
the effects produced by various chemicals employed in attempts to
arrest the spread of contagious diseases, though of much prac-
tical value, is necessarily unscientific. Information of this kind
is very plentiful, and is well furnished by such works as
Chevalier's ' Traite des Disinfectants.' Whatever little direct
evidence we have upon this subject is mainly derived from
experiments with vaccine lymph ; and of the numerous obser-
vations conducted both on the continent and in this country
with the object of elucidating thus some portion of the mystery
surrounding contagium only the most recent need be noticed.
Dr. John Dougall (^ Glasgow Medical Journal'), conducted an
extensive series of experiments to ascertain the relative power
of various substances in preventing the germination of animal-
culse, and the action of certain vapours on vaccine. He exposed
separate portions of vaccine lymph to various volatile media
under bell-jars for twenty-four hours, after which each portion
was liquefied with glycerine, and its reaction ascertained.
" Vaccinations with lymph exposed to the vapour of carbolic
acid, chloroform, camphor, sulphuric ether, or iodine (the re-
action of the mixture being in each case neutral or alkaline),
were successful, while vaccinations with lymph exposed to the
vapour of sulphurous, of nitrous, of hydrochloric, or glacial
acetic acid, or to chlorine (the reaction of the mixture being in
each case acid), were unsuccessful. Dr. Dougall's further expe-
riments tended to show that carbolic acid, though it suspends for
a time, leaves unimpaired the infective property of vaccine." i

The next series of observations to be noted are those of Dr.
1 Vide Braidwood and Vacher*s * First Contribution,' &c.

1877.] Contagion: What do we know regarding it? 403

Baxter ("Report on an Experimental Study of certain Disin-
fectants/' in the ' Reports of the Medical Officer of the Privy
Council/ new series, No. vi). The method employed by Dr.
Baxter for the purpose of testing the disinfectant efficacy of
any substance consisted in allovving the reputed disinfectant
to act on matter which is known to have the power of communi-
cating specific disease, and inoculating subsequently therewith.
" The positive or negative result of inoculation/' he says, " must
needs furnish a reliable test of the ability of the disinfectant to
fulfil the duty laid upon it." The only legitimate test of the
effectual disinfection of any virulent substance is its inability,
when introduced into a suitable host or medium, to bring about
the specific train of phenomena v^^hich coincide with its multi-
plication. ** The disinfectants," that is, " agents capable of so
modifying the contagium of a communicable disease, during its
transit from a sick to a healthy individual, as to deprive it of
its specific power of infecting the latter" — tested by Dr. Baxter,
were potassic permanganate, sulphur dioxide, chlorine, and car-
bolic acid. The contagia selected for disinfection were vaccine,
the virus of infective inflammation in guinea pigs, and the virus
of glanders. The results Dr. Baxter obtained with the first
of these three contagia we shall alone notice ; for the discre-
pancies connected with the others, and the dubitable ground
entered upon complicate rather than simplify the question.
Dr. Baxter examined the action of disinfectants on vaccine
using this contagium both in its normal fluid and in the dried
state, and found that the proportion of potassic permanganate
required to destroy the infective energy of fluid vaccine is
relatively large, '^^but that, in such excess, it is capable of
doing the work ; " that unless chlorine be added in sufficient
quantity to render fluid vaccine acid, it '^ has no appreciable
influence in restraining or abolishing its infective power ;" that
one per cent, or less of carbolic acid exerts no influence on the
activity of fluid vaccine, while a proportion of one to two per
cent, renders its action irregular, and two per cent. *^ seems
enough to destroy its infective power with certainty." Of his
observations on the action of disinfectants on dried vaccine
Dr. Baxter remarks, " One striking result is manifest, the very
marked superiority of sulphur dioxide to carbolic vapour and
chlorine gas, and this under conditions which seem, above all
others, to render the virulent particles less susceptible to
destructive influences. '' " It is sufficiently obvious, '^ he adds,
'^ that the quantity of chlorine given ofi* into a room from a
basin filled with chloride of lime, or the vapour of carbolic
acid generated in a vaporiser, would be utterly inadequate to
destroy vaccine virus, and by inference, the contagium of small-
pox, when imbedded in a matrix of dried albuminous matter ;

404 Reviews. [Oct.,

and it is not unlikely that the virulent matters for whose
destruction aerial disinfection is employed are commonly pro-
tected in some such way.'*

Very extensive series of experiments to test the influenc
of disinfectants or germicides on our typical contagium,
vaccine, are to be found in Drs. Braidwood and Vacher's
reports already referred to. These observers added the germi-
cide solution to fluid vaccine, and inoculated with this mixture
human subjects and heifers. The disinfectants employed were
carbolic acid, sulphurous acid (in solution or in fumes), quinine,
ozone, permanganate of potash solution (B. P.), chloralum,
chlorine (in solution and in fumes), salicylic acid, boracic acid,
cupralum, terebene, and feralum. The results obtained were as
follows : a solution of carbolic acid required to be some time
in contact with fluid vaccine to render it inert; sulphurous acid,
in^the fluid or in the gaseous state destroyed the energy of
vaccine at once; ozone required some time to produce this
effect ; chloralum was inefficacious ; chlorine seemed to be
active, like sulphurous acid, whether applied in the liquid or
in the gaseous form, and destroyed the activity of vaccine at
once ; an aqueous solution of quinine muriate acted efficiently
after having been some time in contact with the vaccine ; sali-
cylic and boracic acids seem to be innocuous ; but cupralum,
terebene, and feralum, rendered fluid vaccine sterile ; and lastly,
Liq. Potas. Permangan. (B.P.) appeared to destroy the activity
of the lymph in freshly prepared mixtures, but, when the mix-
ture was kept, the vaccine regained its power.

Thus far in our inquiry we have learned somewhat regarding
the physical nature and the behaviour of the contagious particles
or entities of certain infectious diseases. We shall next en-
deavour to interpret certain of the phenomena common to all
infectious eruptive fevers, by studying another line of researcli,
which has been pursued more especially by continental investi-
gators. '^Though each of the eruptive fevers," remarks Dr.
Maclagan, "has its own definite history and phenomena, the
whole group have certain features in common. Each has a
tolerably definite period of incubation. Each has for its most
prominent symptoms the existence of that aggregate of pheno-
mena to which we apply the term fever. Each possesses a
characteristic local lesion. Each has a pretty definite period
of duration. Each, occurs, as a rule, but once in a lifetime.''
It would occupy too much space to examine these several
phenomena separately, as Dr. Maclagan does in his excellent
monograph. Suffice it for us to look into and endeavour to
explain that aggregation of phenomena included by the term
*' the febrile state." Have we any definite knowledge, then,
pf the causation of the high temperature, the quick pulse, the

1877.1 Contagion : What do we know regarding it ? 405

thirst, the wasting of the tissues, and the increased formation
of urea, which characterise that state of the system termed
fever.

The view most generally accepted at the present time to
explain febrile increase of temperature is that of Professor
Virchow, which attributes this phenomenon to increased tissue
change. According to this theory, " fever consists essentially
in elevation of temperature, which must arise from an increased
consumption of tissue, and appears to have its immediate cause
in alterations of the nervous system ; " but, as Dr. Maclagan
remarks, this theory *' serves to indicate rather than to explain^'
this febrile condition. ^' Why is there increased consumption
of tissue ? and why should the nervous system exercise other
than its usual and normal action?" The reply to these queries
would carry us a step further back than the point from which
Virchow starts, but even then a constant and essential feature
of the febrile state, viz. increased consumption of water would
remain unexplained. The late Dr. Parkes, who confirmed and
ably elaborated Virchow's theory, endeavoured to account for
this last febrile phenomenon by supposing the existence in the
blood of some substance which has an unusual attraction for
water. He conjectured that this substance " may be some
gelatinous compound which is formed in the rapid metamor-
phosis of the albuminous tissues, and which is ultimately
converted into urea and uric acidj" but, as argued in the
monograph under review, *^ why is this gelatinous compound
formed in such enormous quantity as it must be to cause so
great a consumption of water ? and what becomes of the urea
and uric acid into which it is ultimately resolved ? "

To give a satisfactory reply to such queries as these, which
crop up the more closely we study the subject, it is necessary to
abandon Virchow's view and seek for an explanation elsewhere.
The late Professor Traube,in 1863, ascribed febrile heat, not to
increased production, but to increased retention of heat, conse-
quent on contraction of the minute arteries, an hypothesis the
inaccuracy of which has been demonstrated since then by Lieber-
meister and Leyden. Later (1873), Senator has stated '* that
there are periodic diminutions of loss of heat, together with a
constant though not great increase of heat production." The
former he attributes to occasional contraction of the minute
vessels resulting from the action of the fever-cause, the latter
he attributes to increased oxidation. Thus we find one
further problem to embarrass the inquiry. As Dr. B. Sander-
son remarks (A, Appendix, in the ' Reports of the Medical
Officer of the Privy Council,' No. vi, 1875), to explain the
nature of fever and its relation lo the febrile process two possi-

406 Reviews. [Oct.,

bilities are open to us, *' One is, that fever originates in disorder
of the nervous centres, that by means of the influence of the
systemic functions the liberation of heat at the surface of the
body is controlled or restrained, so that by retention the tem-
perature rises, and finally, that the increased temperature so
produced acts on the living substance of the body so as to
disorder its nutrition. The other alternative is, that fever
originates in the living tissues, that it is from first to last a dis-
order of protoplasm, and that all the systemic disturbances are
secondary. By both hypotheses it is tacitly assumed that fever
is the product of a material fever-producing cause contained in
the blood or tissue-juice, the morbific action of which on the
organism is antecedent to all functional disturbances whatever."
This leads us to the same conclusion as that arrived at by Dr.
Maclagan, that fever "is a collection of different and various
phenomena, all of which are abnormal, and all of which are
developed subsequently to the reception of the contagium, and
the co-existence of which in the body is conveniently charac-
terized by the term fever.'*

The contagium being, then, the cause of the fever, becomes the
cause of the individual phenomena which constitute the febrile
state. To understand our position, it must be borne in mind
that each of the minute organisms — contagium particles — re-
produces myriads of similar organisms, and in so doing appro-
priates for their growth elements requisite for the nutrition of
the body in which they grow. Here we have a starting-point,
from which, by careful logical reasoning, the various phenomena
of the febrile condition are gradually evolved by Dr. Maclagan.
He shows clearly that the nitrogen essential for the vitality of
the contagium particles is derived from the constructive store, the
albumen of the tissues, that " this consumption of nitrogen by
the contagium particles is the primary cause of the rapid wast-
ing of the nitrogenous tissues which takes place during fever,^'
that the agency which thus eats up the tissues acts also in
diminishing their nutritive supply. " Blood continues,'^ he
remarks, " to be supplied to and to circulate through the tissues,
but it is blood charged with an organism which utilises for its
own ends the materials which ought to go to nourish and buikl
up the body." Moreover, not only do the contagium particles
use up an excessive amount of nitrogen in their growth and
deteriorate the blood, but they also consume water in large quan-
tity, thus deranging nutrition and diminishing the bulk of the
tissues.

Further and very valuable evidence in favour of this explana-
tion of the most important phenomenon characterising fever Dr.
Maclagan derives from Salkowski's observations on the elimina-

1877.] Contagion : What do we know regarding it ? 407

tioii of potass and soda during fever. Salkowski found " that
the quantity of potass eliminated on a febrile day was three or
four times, sometimes as much as seven times, greater than on a
non-febrile day;'^ and that ^'the soda discharge was reduced to
a minimum during the febrile state, and rose again when the
fever had ceased." Now, potass exists in largest quantity in
the muscles and blood-corpuscles, while the chief seat of soda
is the liquor sanguinis. The contagium particles, then, accord-
ing to the experimental evidence quoted, consume the nitrogen,
water, and potassium salts of the constructive store albumen
found in muscle and blood; and this affords a full explanation of
the wasting and irregular elimination of urea which characterise
the febrile state. According to Dr. Burdon-Sanderson (ibid,
cit.) clinical observations show —

" That in the early stage of fever a patient excretes about three
times as much urea as he would do on the same diet if he were in
health ; the difference between the fevered and the healthy body con-
sisting chiefly in this, that whereas the former discharges a quantity
of nitrogen equal to that taken in, the latter wastes the store of
nitrogen contained in its own tissues."

It is not necessary to apologise for having so fully discussed
the preceding very important known facts regarding contagium,
but it would be unprofitable to pursue the subject further.^
The extracts quoted show the exhaustive and trustworthy
method pursued by Dr. Maclagan in his monograph ; the
observations we have cited enable the reader to estimate the
very important advances which have been made during recent
years in our knowledge of contagium, its nature, and its beha-
viour. We have now only to desire that ardent, truth seeking
investigators will not hereafter be wanting to work patiently,
industriously, perseveringly ; their noblest reward will be the
diminution, through their efforts, of that greatest scourge of
human life — the class of diseases induced by contagium.

^ The hypothesis we have found to account for the wasting of the tissues applies
also to the other phenomena of fever. .The propagation of contagium particles in
the tissues induces an excitement of the normal process of nutrition in these tis-
sues ; this implies a greatly increased demand for blood, which in its turn is met
by a general hastening of the blood- stream in the minute vessels, and necessarily
increased frequency of the heart's action. Now, such a disturbance of equilibrium
of necessity affects the power of tension in the machinery implicated, and clinical
observation has long ago demonstrated that one of the principal causes of death
in febrile attacks is weakness of the cardiac muscle. Further, the heart has not
only a great strain thrown on it, but it participates with other viscera (especially,
as we have seen, the muscular viscera) in the deprivation of material necessary
for its nutrition. " We accordingly find that, with a large propagation of the
contagium, or, in other words, in a severe attack of fever, the heart's action is not
only rapid, but, after a time, feeble," and that malnutrition often gives rise to
alteration in the cardiac structure.

408 [Oct.,

asifiliograyeual 3Rerorir*

United States Medical Library. i— These works deserve notice in
this Review owing to their size and importance ; they give at the
same time an opportunity of recording what progress has been
made in the attempt to form a complete collection of medical litera-
ture in the United States. Dr. J. S. Billings, to whom the medical
profession will ever owe a deep debt of gratitude for his wonderful
labours, justly says —

" Comparatively few persons have any idea of the amount of
medical literature in existence, or of its proper use and true value,
and the result is that the same ground is traversed over and over

again The record of the researches, experiences, and

speculations relating to medical science during the last four hundred
years is contained in between two and three hundred thousand
volumes and pamphlets ; and while the immense majority of these
have little or nothing of what we call ' practical value,' yet there is
no one of them which would not be called for by some inquirer if
he knew of its existence. Hence it is desirable, in this branch of
literature, as in others, that in each country there shall be at least
one collection embracing everything that is too costly, too ephe-
meral, or of too little interest to be obtained and preserved in
private libraries." 2

The National Medical Library, which was formerly called the
Library of the Surgeon-GeneraFs Office, though formed within the
last twelve years, now numbers about 40,000 volumes and 40,000
pamphlets. It is comparatively full in American, English, French,
and German medical literature of the present century, and in works
relating to surgery, pathological anatomy, and hygiene. It possesses
a few valuable manuscripts, the oldest of which is a fine copy of the
* Lilium Medicinse' of Bernard de Gordon, dated 1349.

A very considerable approach has thus been made towards the

^ 1. Photographs illustrating rare hooks in the National Medical Library {In-
ternational JExhihition of 1876, Medical Department U. S. Army). Two vols.,
fol. Philadelphia, 1876.

2. Catalogue of the Jjihrary of the Surg eon- General's Office, United States
Army. Three vols., 4to, Washington, 1873-74.

' Public Libraries in the United States, chap, vi, p. 171, Tbe rei^der wUl

1877.]

United States Medical Library. 40^

ideal in this short period, and a medical library has been formed
which may justly be compared with any in Europe in extent. It is,
perhaps, superior in one respect — I mean, in its collection of periodi-
cals, for of the 10,736 volumes extant, 8214 have been already
procured.^ It is, also, very rich in inaugural dissertations, a class
of literature important to the librarian, and the value of which is
usually underestimated. To obtain complete series of these is even
more difficult than to get journals, for the reason that they are more
ephemeral, and because it is scarcely possible to ascertain what have
been published or when the series may be considered complete.
Por a few schools, hsts have been published of the theses presented
by their graduates, such as Paris and Edinburgh, but even for Edin-
burgh, the only catalogue of the theses which the writer has been
able to obtain does not show when the regular printing of all theses
ceased. Callisen has been led into error in this way in his other-
wise very complete Bibliographical Lexicon, in which he gives the
titles of many theses which were never printed, notably of the
universities of Pennsylvania and Transylvania. The value of these
theses is fourfold. As material for the history of medicine they may
be taken to represent the theories and teaching of the school; they
often contain reports of cases, or accounts of investigations made by
the student under the direction of a professor, which are of much
value, and they are necessary to medical biography, the more so as
in most of the German universities a sketch of the life of the candi-
date is appended to the thesis. In addition to this, prior to the era
of medical journalism, it was the custom for the president or one of
the professors to add an introduction of ten or twelve pages to the
dissertation, treating on some subject usually having no direct rela-
tion to the thesis, and forming the sort of paper which would now
be sent to a medical journal.^

In so large a collection there must be many books that are un-
common and some that are decidedly rare. Specimen pages of
some of these have been reproduced by photography, and such

find in this chapter a very interesting account of medical libraries. Further
reference may be made to the chapter contributed by Dr. Billings to " A Cen-
tury of American Medicine," Phil., 1876, in which there is much statistical and
other information, not only as to medical libraries, but as to books printed in the
United States, medical journals, societies, and schools. His remarks on medical
museums might be applied to many collections in this country with good effect.
" The practical value of large special museums in connection with good libraries
devoted to the same specialities is great, but they are useful rather to the edu-
cated physician than to the student; and the numerous small collections which
are scattered over the country in hospitals and private cabinets, are simply so
much wasted and unused material, in a scientific point of view, and, though
gratifying to the owner as trophies or mementoes, are of little more real use
than the strings of teeth which the barbers of old hung out as signs of their
skill."

1 Loc. cit., p. 177.

' Loc. cit., p. 178.

410 Bibliographical Record. [Oct.,

copies form the two volumes quoted at the head of this article.
The photographs in all number 104^ and may be considered as
consisting of three series. The first is taken from early printed
books and from other works which are rare at least in the United
States. The second relates to surgery and especially military
surgery ; and the third series is from rare books and pamphlets
connected with American medical history. We may mention the
subjects of a few of these as examples. No. 1 is a specimen page
from the manuscript of the ' Lilium Medicinae ' already mentioned.
No. 8 is the title-page of the 'Uegiment der jungen Kinder/ printed
at Augsburg in 1473. No. 15 is the first page of the ^ Artzneibuch '
of Ortolff von Beyrland, printed at Augsburg in 1479. No. 16 is
the first page of the first edition of the surgery of Petrus de la
Cerlata, printed at Yenice in 1480 ; the page in the original is
adorned by illuminated letters. No. 28 is the title-page to the
celebrated tractate on syphilis by Grunpeck de Burckhausen.
No. 29 is the first page of the treatise on the same disease by John
Widman_, 1497. Nos. 49 and 50 contain a copy of an auto-
graph poem by Philip Melancthon, ' De consideratione humani cor-
poris/ written on the fly-leaf of a copy of the first edition of
Yesalius, 'De humani corporis fabrica.' No. 71 is the title-page
of the first edition of Harvey's ' Exercitatio anatomica de motu
cordis et sanguinis in animalibus/ published at Prankfort in 1628.

The catalogue of the library is in three volumes quarto, and was
published at Washington in 1873-74. The first two volumes con-
tain the works of known authors arranged alphabetically according
to the author's name. The titles are very fully copied ; the number
of pages and often of the plates is mentioned. The paper and
printing are excellent, and though I have found here and there an
error in a title, I can testify to the very great care taken in correct-
ing the press. I hope that supplementary volumes of this cata-
logue will be published from time to time, and would suggest that
from any such continuation non-medical works should be omitted,
such works for example as H. L. Abbot on siege artillery ; simple
reprints of papers from medical journals should likewise be rigidly
excluded. Works published in a collection should be entered
under the title of the collection, with only a cross-reference under
the author's name {e.g. the three works in the catalogue under
"Actuarius^' should be under '^Medicse artis principes,'' with merely a
reference at '^Actuarius^'). Lastly, journals or collections should
never be entered under the editor's name.

The third volume contains in four divisions the anonymous
works, transactions, reports, and periodicals. The anonymous
works are arranged under the name of the subject to which they
refer ; the transactions are distributed according to the countries
and towns; the reports are classified according to the subjects; the

1877.]

United States Medical Library. 411

periodicals according to countries alone. In my opinion this
volume should be cancelled and replaced by one containing all
these works in a single series, the titles being arranged alpha-
betically according to the rules in use for anonymous books (or,
better still, be included in the supplementary volumes just sug-
gested). On the other hand, I consider the mention made of
journals not in the library by titles printed in small type most useful.

About a year ago a specimen fasciculus of a fresh catalogue of
this library was issued, "in order to show the character and scope
of the collection, to obtain criticisms and suggestions as to the form
of catalogue which will be most acceptable and useful, and to
furnish data for the decision as to whether it is desirable that such
a work should be printed and distributed/'

The specimen submitted is of a combined catalogue of subjects
and authors, arranged alphabetically in a single series. It contains
also references to articles in journals, transactions, and collections,
arranged according to the subjects, and printed in small type. I
must preface the following remarks by saying that a careful exami-
nation of the specimen soon after its publication^ caused me equal
pleasure and surprise. The execution of the work was admirable.
I was charmed with the accuracy and surprised by the industry
shown in every page. Many doubts, however, arose in my mind
as soon as the first feeling of dehght had passed, and the result of
some further consideration and research was a conviction that the
plan proposed would not be the best in every respect.

The first and most important question is the size of the proposed
work. It is stated in the preface that " the complete catalogue on the
present plan would make five volumes of about one thousand pages
each.'' Is this correct ? The seventy- two pages of the specimen corre-
spond to about ten pages of the former alphabetical catalogue, and
there are in the two volumes of authors' names 2147 pages, so that,
assuming the same proportion to hold good, about 15,000 pages
would be needed, or three times the estimate. This would pro-
bably be under, rather than over, the amount of space required,
owing to the many additions still to be made to the references in
the specimen. The same conclusion appears certain from an exami-
nation of the number of entries. There are of them about 55,500
in the three volumes of the former catalogue, and 300 fresh entries
correspond to 200 old ones in the specimen (more exactly 327 to
218), so that with cross-references (say 5000) there would be at
least 142,500 entries under authors' names in the complete work.

1 The substance of these remarks was given in a MS. review which I sent to
Dr. Billings at that time. I insert them here because the profession throughout
the world is interested in the success of his undertaking, and because in the
many notices of this specimen in the journals no attempt has been made to
ezaouzi* it critically and no Buggestion has been offered for its improvement.

412 Bibliographical Record. [Oct.,

Each entry must be repeated once or more under the respective
subject. We should have thus far a total of 285,000 entries. A
page in the specimen contains about forty entries, so that 7125
pages would be occupied. There are in addition thirty-two out of
the seventy-two pages in the specimen filled with references to
journals, and for these 5700 additional pages would be required
(= 32 of references to 40 of authors). This would make a total of
12,825 pages. We have still to add many pages for additions and
especially additional references; indeed, if the latter are to be
moderately complete, they must be very much extended. I, for
my part, after comparing the references given with others, think it
would not be safe to estimate the additional pages so required at
less than 6000. The conclusion is that the complete catalogue,
printed as the specimen, would occupy more than 15,000 pages, or
say fifteen to twenty very thick volumes. It is scarcely necessary
to point to the cost and other objections in order to prove the
desirability of diminishing the size if possible.

Now, the utility of the three portions, which form by their union
this specimen, is very different. A catalogue of books arranged
according to authors' names is absolutely necessary for the officials
of a large library for the ready finding of the books demanded by
readers, and, indeed, in all cases to determine at once whether a
given book is in the library. For this purpose it must be complete,
and such completeness is usually and most readily effected by suc-
cessive manuscript additions; in a rapidly increasing library a
printed catalogue a year old is already out of date. Such a cata-
logue is also, indeed, of occasional assistance to the few who are
interested in medical bibliography. All this has, however, been
provided for to a large extent in the two volumes described ; to
reprint the titles contained in them would add to the expense and
size, but in no considerable degree increase the utility of the new
catalogue. I must repeat that I shall be glad to see what has been
so well done in respect to an alphabetical catalogue supplemented
from time to time by similar volumes.

The list of books arranged according to their subjects would be
of service to a much larger number, indeed in some degree to
all who can refer to a large medical library, but chiefly to
those who have ready access to Washington. Finally, the re-
ferences to periodical literature would probably, if not in too
cumbrous a form, be used by almost all readers, in fact by all
who can refer in a private or public library to one or more sets
of journals. I will not attempt to decide whether it would be
better to combine the two latter parts, but will suggest as worth
consideration whether the index to periodical literature would
not be more serviceable if divided into parts according to the lan-
guage. The great majority of medical men read but one language;

i877.] the Works of Paracelsus, 41 S

even those, who can read more, rarely have access to the books
themselves. Be that as it may, I should urge that if such an index
is to be reliable and permanently of use, it must be exhaustive for
the period chosen ; the references should include all original papers
and cases, and a list of the journals, transactions, or collections,
indexed, should be appended. Any attempt at a selection of papers
would be fatal .1

In conclusion I warmly congratulate the profession of the United
States on their good fortune in possessing so able a bibliographer
as Dr. Billings, who has the intellect to appreciate the importance of
a great public medical library and the enthusiasm and diligence
sufficient to overcome the endless difficulties met with in the forma-
tion and management of such a collection. Surely his efforts and
his great success will have a reQex action on European, especially on
English, librarians. Nowhere are there such numerous opportu-
nities for buying rare and curious books and manuscripts, as in the
London auction-rooms, yet no use seems to be made of them by
any of the London medical libraries at the present time.

Thomas Windsoe.

Works of Paracelsus.2 — Every one knows that the know-
ledge of history in general has been steadily advancing in the
present century by the publication and careful investigation of the
statements found in original documents, state-papers, accounts of
eye-witnesses, and the like. A similar study of the history of
medicine would inevitably clear up many disputed questions and
correct many erroneous assertions. In many cases, however, a pre-
liminary examination of the writings themselves is required to show
how far they can be admitted to be genuine. This is what Dr.
Mook, who intends to publish hereafter a biography of Paracelsus,
attempts in the 136 quarto pages of his volumes. He commences
with an introduction, in which he quotes many authors to show
how various and contradictory have been the characters given of
Paracelsus at different times and by different authors ; he was a
pious man and a blasphemous heretic, a cabalist and a charlatan,
a reformer of medicine, a homoeopath and magnetiser, the intro-
ducer of the German language into scientific medicine, a giant who
destroyed authorities and doctrines universally received, and, again,
a half-witted fanatic. Little is known with certainty about his
name, his life, or his works. It would almost seem as if, in regard
to this man, who inaugurated the transition from the medicine of
the middle ages, we had no history ; histories indeed ! —history not.

1 I may mention that, many years ago, I offered the New Sydenham Society
to prepare a complete index to all British medical journals up to the year 1860
(see also this Review for Jan., 1863, p. 88).

^ Theophrastus Faracelsuf, Eine kritische Studie von Fe. Mook. Wiirzburff,
1876.

120--LX. 27

414 bibliographical Record. [Oct.,

The reason of this is to be found in the present condition of his
works, in the wilderness of writings published under his name, and
which yet require critical examination. Dr. Mook counts six edi-
tions of the collected works^ three German and three Latin, and
247 separate works in all, most of which appeared between 1561
and 1578, many years after the death of the supposed author.

Marx was the first who endeavoured to point out certain marks
by which the genuine books could be recognised, but unfortunately
the criteria proposed by him are, according to Dr. Mook, quite
valueless. Dr. Mook lays down the following propositions :

Genuine are —

1. The original manuscripts.

2. The works published by Paracelsus himself during his life.

3. These, being compared with Huser's edition, must decide

whether Huser's statements are worthy of belief.

4. If this point is settled in favour of Huser, we must recog-

nise as genuine all writings stated by him to have been
printed from a copy in the handwriting of Paracelsus.

5. The writings which, compared with those so far recognised

to be genuine, bear clear signs of his authorship both in
form and contents.

Dr. Mook has been unable to find any of the original MSS., though
he expects that some of them at least will be recovered. He has,
however, found eleven works published during the life of Paracelsus,
of which three appeared in a second edition during the same time ;
six of the eleven contain predictions, the remainder are medical.
Now, after comparing these with Huser's text and his statements
about the sources he drew from, the author concludes that there is
no reason whatever to question Huser's truthfulness in any respect,
so that all must be attributed to Paracelsus, of which Huser states,
that he takes it ecc manuscripto Theophrasti. The fifth and last
point is left to the decision of future critics.

A large portion of this essay is occupied by a detailed account of
all the works and editions with which the author has met. In
addition to his account we may mention that some seven of the
works in question are also in the library of the Manchester Medical
Society, and among them a manuscript copy of the ' Tractatus de
peste cum commentariis Jobi Kornthaueri,' which is dated 12 Maii,
1613, and is probably an original. There is alsoin the Chetham Library,
at the same place, a manuscript translation from the German of
Huser into Dutch, which has, we believe, never been printed. An
edition of another work is in our hands, which differs somewhat
from those mentioned by Dr. Mook; its title is ' Prognosticatio ad
vigesimum quartum usq3 annum duratura, per eximium dnm ac
Doctorem Paracelsum, ad illustrissimum ac potentissimu principem
Perdinandum, Roman Eegem semper Augustum, &c., Archi-

1877.] Catalogue of the Radford Library, 415

ducem Austriae, &c., conscripta. Anno xxxvi/ Then follows the
'' Marcus Tatius ad lectorem/' as in the edition No. 10 (p. 27), and
the '' Cum gratia/' &c., except that '^ ne quis imprimat " takes the
place of '' ut quis imprimat.''' Twenty-four quarto leaves without
pagination. No date, place, or name of printer.

We have read this work with much pleasure, and hope that the
author will soon favour us with his promised biography. — T. W.

Catalogue of the Radford Library.^ — The library contains about
3400 volumes, among which there are many consisting of tracts
bound together. Pormed by Dr. Eadford, it was given by him in
1853 to the St. Mary's Hospital, and he has since continued to
enrich it by many additions. He has placed an endowment fund in
the hands of trustees, which will become available after his death.
"Works on obstetrics and the diseases of women and children predo-
minate, and we think it would be wise to confine further purchases
to these subjects. Glancing over the catalogue we miss many books
which ought to be found in such a collection ; such are Siebold's
History of Midwifery, the old but still useful bibliographical work
by Osiander, the very curious collection by Schurigius, the sperma-
tologia, the gynsecologia, the syllepsilogia, the parthenologia, and
the muliebria. We should like to see, too, tolerably complete
series of the editions of some of the early books, such as Eaynalde's
woman's book, of which there appear to have been ten or eleven
editions, extending for more than a hundred years after 1540, the
date of the first edition. The woman's book was itself a translation
from the Latin edition of (Ehodion) Rosslin's 'Der swangern
frawen und hebammen rosegarten ;' of the latter a copy of an early
edition, perhaps the first, is in the library of the Manchester Medical
Society. Raynalde's book is usually supposed to have been the
first treatise on this subject published in English ; we have, how-
ever, the impression that some twenty years earlier another work
had appeared in London. Though writing from memory, and
without any opportunity at the present moment of confirming our
impression, we mention this all the more because Dr. Aveling, in
his very careful and interesting book on English midwives, quotes
no " book in the vulgar tongue" before this translation.

We may notice that many reprints of papers from such publica-
tions as the ' Obstetrical Journal ' are entered in the catalogue ; in
our opinion they should be almost invariably excluded, as serving no
useful purpose.

A few rare books are here to be found ; the works of Louise
Bourgeois ; the translation of H. van Eoonhuyse, ' Some observa-

1 Catalogue of the Radford Library, St. Mary's Hospital, Manchester. Bj
C. J. CuLLiNawoBTH. Manch., 1877, pp. vi aud 2S8.

416 Bibliographical Record. [Oct.,

tions and practices relating to some extraordinary cases of women
in travel ;' Chaupin's theses, which are said to have been suppressed,
' De partium externarum generationi inservientium in muliebribus
naturali, vitiosa, et morbosa dispositione / a Latin edition of
Rousset, * De partu csesareo', his ' Dialogus apologeticus pro
csesareo partu/ and a manuscript copy of his ' Eesponsio ad Jacobi
Marchant declamationem ;' there is of Marchant's work the De-
clamatio la et 3a (did the second ever appear?); a Trench
translation of Ehodion, published at Paris in 1536 ; S. Eoulliard,
' Capitulaire auquel est traicte qu^un homme nay sans testicules
apparens, et qui ha neantmoins toutes les autres marques de
virilite, est capable des ceuvres de mariage ;' Tagereau, * Discours sur
rimpuissance / and Wolveridge's ' Speculum matricis.'

The books have been arranged, and the catalogue has been pre-
pared, according to the methods in use at the library of the Man-
chester Medical Society, by Mr. CuUingworth, who deserves much
praise for the accuracy and care everywhere displayed. The printer,
Mr. Alcock, has also done his part well. — T. W.

Spender on Bath Waters.^ — A book of this kind deserves the
especial patronage of the profession, because it differs from most
medical works in dealing largely with the experience of the past,
which in modern days we are apt to forget. It offers many in-
teresting ghmpses of the medicine of former days, and furnishes
amusing accounts of the habits and the ways in successive genera-
tions of society at the Bath, as it was called par excellence.

The cures wrought in old days were as real as any that are
wrought now. Of the rationale of the cures we do, perhaps, know
a little more than formerly ; but after all it is only a little more —
much still remains to be explained.

There are various oversights and omissions in the work to which
we could easily point ; for instance. Dr. Spender tells us that Tissot
spoke of a bath in the Yalois where people spent most of their
time in the bath. Immediately after, Dr. Spender says that this is
the case even now at Leuk, not seeming to know that it was the
place alluded to by Tissot.

But we shall not enter into the ungracious task of minute cri-
ticism, and can say with every justice that a great deal will be
found in this work which will be useful to practitioners who think
of sending patients to use the waters of Bath, or even to reside in
that city, as also a great deal that is interesting to all persons of
an antiquarian turn of mind.

We cannot but hope that this book will help to draw attention
to waters which, notwithstanding admirable bath arrangements and

^ The Bath Thermal Waters, Historical, Social, and Medical. By John Kent
Spendeb, M.D. 8vo, pp. 300. London, 1877.

1877.] Philadelphia Exhibition — Medical Objects. 417

the comforts of the city in which they are situated, are by no means
appreciated as they once were or as they deserve to be.

The appendix to the work gives an ample account of the charac-
teristics of the climate of Bath, which was undoubtedly a desi-
deratum.

Myrtle on Harrogate Waters.^ — It is satisfactory to learn that
many of our mineral waters still keep up the number of their
visitors in spite of foreign competition. Harrogate and Buxton
are crowded every season, and the physicians at these places occa-
sionally favour us with the results of their practice. This is not
the first time that Dr. Mrytle has given us some account of his
large experience. His present work contains a good deal of shrewd,
practical observation, and, as he hopes, may serve as a sort of guide
to medical men in selecting patients for Harrogate. But if the
book be intended for medical men chiefly, we do not see why it
should have been written in so familiar, we might almost say so
slang a style. Indigestion, aff'ections of the liver and jaundice,
gout and rheumatism, and some nervous derangements, but above
all skin diseases, are the affections most usually considered fit sub-
jects for Harrogate, and are the ones which are chiefly and very
lucidly treated of by Dr. Myrtle. Perhaps something might have
been added on habitual constipation and haemorrhoids, a class of
patients that ought to profit by Harrogate. It is a little surprising
to find that Dr. Myrtle, though essentially a practical man, is full
of theories. He tells us that sulphur waters ^' burn up useless
fat," and finding that there is no complete explanation of the
operation of Harrogate vi^aters (as of many of the ordinary articles
of the Materia Medica for that matter), he tries to explain an
ignotum per ignotius, and calls in certain possible electric action of
rubidium and csesium which have not as yet been discovered in
them, and which possibly never may be found. We also do not
see the object of his classing together waters of such different
qualities as Carlsbad, Strathpfeffer, and Harrogate, Piillna, and
IMedrichshall, even if he did not convey the idea that he supposed
Piillna and Friedrichshall to be places to which patients resort or
even have resorted. Notwithstanding such drawbacks, the book
may be consulted by practitioners with advantage.

Philadelphia Exhibition.— Medical Objects. 2— Since the date of
the Crimean war great care has been bestowed in all the armies of

1 Chronic Diseases best fitted for Treatment ly the Harrogate Mineral Springs.
By A. S. Mtetle, M.D. London, 1876. 8vo, pp. 92.

2 1. International Exhibition of 1876. Philadelphia, 1876. 2. Description
of the Models of Hospital Cars. 3. Description of the Models of Hospitals.
4. Description of the Models of Hospital Steam Vessels. 5. Description of
Ferrot Sf Co.'s Improved U. S. Army Medicine Wagon. 6. Description of the
U. S. Army Medical Transport Cart Mode of 1876, By D. L. Hxtntinqton au^
0, A, Otis, Asiistant-Surgeons, U. S. Army.

418 Bibliographical Record. [Oct.,

Europe on hospital arrangements in the field, and on the systematic
supply of medical stores and comforts. A further impulse was
given by the German and still more by the Franco-German war,
and by the various charitable societies whose efforts were called
forth by them, and were devoted to providing medical men and
nurses and hospitals to supplement the regular services of armies.

In England the subject has not been neglected. A committee
was appointed, which sent in a valuable report in 1868, and, ever
since, the medical authorities have had under their careful con-
sideration how to supply the best ambulances and modes of transit
for sick and for medical stores. Medical officers, who formerly
could learn such duties only by experience in the field, are now
systematically instructed in them at Netley, and we believe at
Aldershott, and thus can enter on a campaign with some distinct
ideas as to their duties in the field.

The great question has always been how to provide ambulances
and waggons that are at once substantial and not too heavy.

In endeavouring to solve this question our American brethren
appear to us to have applied their native ingenuity to good purpose,
but our notice of what they have done must, unfortunately, be very
brief, and therefore imperfect.

One of the reports treats of the best methods of adapting the
ordinary rolling stock of American railways to form conveyances for
the sick. We observe that the cars are made to rest on semi- ellip-
tical plate springs ; while in the ambulances, after an examination of
the different kinds of springs in use, india-rubber springs were
adopted as having great advantages over steel.

In the American war the medicine waggon, though strong and
most convenient, was too heavy, and required four horses or six
mules to drag it. A lighter one has now been invented, though it
has not been used in the field. It weighs, including fixtures and
all supplies, 2630 lbs. It seems to be a very complete article.
Besides the medical stores inside, which are so arranged that com-
pounding can be done under shelter, and that almost all the whole
back half of the waggon is left empty for the use of the surgeon,
the waggon has strapped on the inside two camp stools. On hooks
attached to one of the waggon bows are three lanterns. On the
outside are four hand-litters, and under the waggon the amputating
table is attached.

The lighter or medical transport cart has not yet been tried in
the field, but appears to us to be singularly convenient. It con-
tains three boxes, a medical, a surgical, and a mess or medical-
comfort chest. The weight of the cart is only 420 lbs., and when fully
equipped, counting the driver, the weight does not exceed 1220 lbs.

But perhaps the portion of these reports that is most interesting
to us as a maritime people is the account illustrating the plans

1877.] Wythe^s Microscopist, 419

actually employed during the war of 1861-5 for adapting the ordi-
nary steamboats of the rivers and the merchant steamers of the
coast to the transport of sick and wounded soldiers. The following
extract conveys some valuable hints for adding to the comforts of
our steam-vessels in the tropics :

'^A large quantity of ice was carried in the hold of the river
steam-vessel; this was taken advantage of by an arrangement of
pipes to convey ice water to the different parts of the hospital. A
tank was placed on the upper deck forward^ connected with the
steam-pump, and kept constantly filled with water ; pipes from this
ran down into the hold of the vessel to a coil embedded in the ice,
whence the cold water made its way through pipes to the several
parts of the boat where it was required. This worked admirably,
giving all the hands plenty of ice water, and with great economy in
the use of the ice.

A fan ran through the whole length of the main ward, worked by
the machinery below. It made about twenty-nine revolutions a
minute, and as the transom-windows opened just above it at the
sides it created a pleasant current of air, and had besides another
effect, that was not anticipated at the time when the fan was ordered,
viz. that it drove out all flies and mosquitoes."

There are many hints to be gathered by us from the models
exhibited at the Philadelphia Exhibition.

Wythe's Microscopist.^— This work, the third edition of which
we have for review, claims in its second title to be ' A Compendium
of Micro-mineralogy, Biology, Histology, Micro - chemistry, and
Pathological Histology.' This somewhat extensive range of subjects
is discussed in about 250 not at all closely printed pages, space
being still left for explanations of the bearing of microscopical
science on the progress of the arts, commerce, and theology. As
a manual of histology, which might serve to teach a student either
structural facts or methods of manipulation, this book is by the
mere fact of its size foredoomed to failure, and we prefer, therefore,
to look on it as an essay on the scope and importance of the micro-
scope in all departments of science and art. After an introductory
chapter, in which the praises of the i;picroscope are sung in no
measured terms, the optical principles on which the simple and
compound instruments are constructed are fully explained. Those
troublesome luxuries, the several microscopic accessories, are next
shortly enumerated, and the preliminary part of the book ends with
a chapter on the use of the microscope and the avoidance of some of
the common errors of observation. The ground having been thus
far cleared, the next chapters are devoted to the methods of exa-

1 The Microscopist J a Manual of Microscopy and Compendium qf the Micro-
scopic Sciences. By T. H. Wythe, A.M., M.D. Third edition.

420 Bibliographical Record. [Oct.,

mination and preservation of objects. Here we have found nothing
that may not be read far more carefully described in books pub-
lished several years ago, and notably in Beale's ' How to Work with
the Microscope/ to which Dr. Wythe seems largely indebted.

Nothing can be more bald than the manner in which these
" modern methods of examination'^ are explained, and a single
example will be sufficient to show the uselessuess of such loose
descriptions.

''Nitrate of Silver Pluid. — Fresh membranous tissues exposed
to 0*5 to 0*2 p.c. solution of nitrate of silver, washed and exposed
to the light, often show a mosaic of epithelium, &c.

"Chloride of gold. — The solution should be similar to that of
nitrate of silver. Exposure to light stains the nerves, &c., a violet
or red colour.^'

The "et cetera,'^ here so lightly used, seems to us to cover a
multitude of sins.

The microscope in geology and in chemistry forms the text
for a couple of short sections containing a very fair account of the
application of the microscope to these sciences. In " The Microscope
in Biology" Beale is again closely followed, even to his illustrations ;
while the chapter on vegetable histology is a very pale reflection of
Carpenter, with the addition of a classified list of Diatoms taken from
the ' Micrographic Dictionary.'

It is hardly worth while to consider in detail the remainder of this
book, which is occupied with zoology and animal histology, for the
complete absence of detailed information makes it valueless to any
one wishing to gain the veriest smattering of the subjects. We
cannot, however, conclude without noticing the illustrations, or, as
they are here called, " plates.^' In these we have not been able to
find a single original drawing ; most have been taken from the first
edition of ' Carpenter's Microscope,' published a quarter of a century
ago, and it excites in us almost a feeling of indignation to find these
time-honoured old woodcuts coming out again in all the glory of
hot-pressed paper and coloured inks.

Tibbits on Medical Electricity .^ — This second edition of Dr.
Tibbits' well-known work has been amplified somewhat and improved
by the incorporation of experience gained by the author since the
appearance of the first edition. Dr. Tibbits has attached his name
to certain batteries, and we trust this is not a symptom that prac-
titioners who employ electricity are about to imitate the tactics of
obstetricians who employ pessaries. "Tibbits' " batteries are only
modifications of others which are well-known. Thus the " Tibbits' "
voltaic battery is composed of Leclanche elements with collector and
commutator not materially differing from those which have been

^ A Handbook of Medicine and Surgical Electrieity. By Hebbeet Tibbits,
M.D. Second edition, revised -«rnd enlarged. London, 1877.

1877.1 International Otological Society. 421

long in use. In fact^ the commutator might be altered with advan-
tage, as it is inferior to the barrel commutator in not having a
neutral point. The only real innovation in the " Tibbits' '' consists
in a piece of wood which prevents the lid of the battery from being
fastened while the poles are in " contact." This is, though useful,
a small matter and hardly of sufficient importance to warrant the
impression of the inventor's name inside the hd of each box.

International Otological Society.^ — A list of members of the
society and the minutes of the first meeting are followed by a report
on the progress of otology in 1875-1876, divided into two parts,
one by Dr. C. H. Burnett on anatomy and physiology, the other by
Dr. C. J. Blake on pathology and therapeutics. There are also the
following papers and cases : — Aspergillus glaucus in the tympanum,
primary acute periostitis of both mastoid processes, a case of exos-
tosis of the external auditory meatus drilled out by the dental
engine, test-sentences for determining the hearing power, two cases
of acute inflammation of SchrapnelFs membrane, a comparative
sketch of the early development of the ear and eye in the pig,
together with a new account of the development of the meatus
externus, drum, and Eustachian tube, a case of perforation of the
membrana tympani with scarcely a symptom of disease, one of remark-
able vertigo following an injury of the middle ear, on gaseous inter-
change in the tympanic cavity, paper dressings in the treatment of
perforations of the membrana tympani, a case of abscess over the
mastoid region extending to the squamous portion of the temporal
bone and involving the brain without harm to the auditory appa-
ratus, syphilis of the cochlea, hyperostosis of the mastoid. Many
of the cases are very instructive, but none has interested us so
much as that in which an exostosis nearly occluding the meatus
was drilled out by Dr. A. Mathewson so successfully that at the last
report the meatus was almost restored except at one point, where a
thin remnant of the exostosis projected from the anterior upper
wall : the posterior lower part of the membrana tympani could be
seen. There was no irritation or unpleasant symptom of any kind,
and the hearing had risen to nearly the normal standard. The
author remarks that —

" In comparison with any of the methods employed in the cases
collated, that with the dental engine seems to me the best, as being
less tedious, less dangerous, and more effective. That it is less
tedious, a few tests of this and any hand-drills in perforating dense
bone will demonstrate. It is less dangerous for the reason that,
with the rapidly revolving drills, perforations can be quickly made
with so slight a pressure that there is little risk of injuring the

1 Report of the First Congress of the International Otological Society, New
YorJc, September, 1876. Published by a Committee composed of C. J. KiPP, A,
Mathewson, J. S. Pbout, and J. D. Rushmobb. Jfew York, 1877.

422 Bibliographical Record, [Oct.,

deeper parts of tlie ear, or the walls of the meatus, by the slipping
so likely to occur in operations with hand-drills or with hammer
and chisel. The instrument is also held between the thumb and
fingers in such a way as to interfere to a less degree with the illu-
mination and inspection of the meatus during the operation. The
drills and burrs can also be used, not only to perforate with their
points, but also to enlarge openings already made, to any desired
extent or direction, by lateral pressure with their sides. Other uses
for the dental engine in surgery readily suggest themselves. There
is a great variety of burrs, drills, and saws — more than three hun-
dred in all — figured in the manufacturer's catalogue, which can be
attached to the engine, and would be of great assistance in operations
on bony growths occurring elsewhere, like those of the orbit, in
some cases of resection, and in any case where there is small space
to employ the ordinary instruments efiectually without endangering
the neighbouring parts."

The form of engine known as Elliott's suspension engine was
used in this case.

We may safely recommend, though any commendation can
scarcely be required after the list of papers which we have quoted,
this publication to all aural surgeons. The society will hold its next
meeting at the same place as the international ophthalmological
congress (Heidelberg, in 1880), and the provisional committee con-
sists of Prof. E. Voltolini, chairman, Prof. A. Politzer, Prof. S.
Moos, secretary, and Dr. N. Lowenberg.

System of Ophthalmic Medicine.^— This great work, in seven
closely printed volumes, is near its conclusion, a part of one volume
alone being yet wanting. The contents of the volumes are as follows :

I. Macroscopical anatomy, by F. Merkel; microscopical anatomy,
by W. Waldeyer, A. Iwanoff, J. Arnold, and G. Schwalbe.

II. Development and malformations, by Manz ; comparative
anatomy, by R. Leuckart ; circulation and nutrition of the eye,
by T. Leber ; physiological optics, by Aubert.

III. Functional examination of the eye, by Snellen and Landolt;
operations, by Arlt.

IV. Diseases of the conjunctiva, cornea, and sclera, by T.
Saemisch ; diseases of the eyelid, by Michel.

Y. Glaucoma, by H. Schmidt; afiFections of the lens, by 0.
Becker ; diseases of the retina and optic nerve, by Leber.

YI. Abnormal states of mobility, by A. Graefe; abnormal
states of accommodation and refraction, by Nagel; diseases of
orbit, by Berlin.

YII. Diseases of lacrymal organs, by Schirmer ; relations of
ophthalmic to general diseases, by Forster ; history, by Hirsch.

Like all works written by a number of authors, the articles are

Mandhuch der Qesammten Augenheilkunde. Redigirt von Prof. A. GbjLBFB
und Prof. T, Saemisch. Leipzig.

1877.] Neurological Essays. 423

unequal ; all are good, but some better than others. The portion
on comparative anatomy might well have been omitted, and that on
the examination of the eye considerably extended. It would be
more convenient to have the bibliographical lists together in the
same volume. A chapter on the dissection of the eye, on its micro-
scopical examination, and on the preservation of specimens, would
be of value. The reader may remember that the portion by Prof.
Arlt on operations has been already noticed in this Eeview. Por the
rest we need only say that, owing to its fulness and the large
amount of original matter, the work will for many years be most
useful to every ophthalmic surgeon for study or occasional reference.

Magnus on Cataract.^ — The author, who is already well known as
an ophthalmic surgeon, and who has for years paid much attention
to the history of ophthalmic medicine, gives in this work a most
careful account of the successive opinions and discoveries in respect
to the pathology and treatment of cataract. He justly remarks
that, whilst ophthalmology has been rendered in recent years one
of the most exact branches of medicine by the labours of men like
Graefe, Donders, and Helmholtz, the critical study of its history
has been much neglected. This is to be regretted, because a
thorough insight into its present state is scarcely possible without
a knowledge of its former fortunes. In fourteen chapters the
gradual evolution of our knowledge is traced from the Egyptians
to the present time, the apprehension of the earher opinions being
rendered easier by a picture of a section of the eye, copied from
Ryff^s ^Kleine Chirurgie,' printed at Strasburg in 1542, and drawn
according to the ideas of the ancients. We heartily thank the
author for his work, in which, by a constant reference to the
original sources, he has thrown much light on many difficult ques-
tions.—T. W.

Recent Neurological Essays.^ — The American Neurological Asso-
ciation, as judged of by its professed object, "the cultivation of neuro-
logical science in its normal and pathological relations,"taken together
with the contents of the first volume of its transactions, places itself
on the level of the British Medico-Psychological Association. If it
be less fully occupied with the consideration of mental diseases, it is
that it has not originated, as in our own case, with those engaged,

I OeschicMe des grauen Staares. Von Dr. Hugo Magnus. Leipzig, 1876.
8vo, pp. xii and 315.

Sistory of Cataract. By Dr. H. Magnus.

' 1. Myelitis of the Anterior Horns. By E. C. Sequin, M.D. New York,
1877.

2. Transactions of the American Neurological Association. Vol. i. New
York, 1875.

3. Considerations pratiques sur le traitement des Nevralgies. Par le Dr.
FBOI88AO. Paris, 1877.

424 Bibliographical Record. [Oct.,

more or less exclusively, with asylum duties or the treatment of the
insane. This volume of transactions, however, is not wanting in
papers that will be of special interest to the alienist.

We notice among the names of those who have initiated
this association those of many distinguished cultivators of neu-
rological pathology — names famihar to all students of this
department of scientific medicine. It may suffice to enumerate
those by whom the association was called together, viz. Drs.
Hammond, Bartholomew, Clymer, Jewell, Seguin, Putnam, and
Cross.

We could have desired to place before our readers an analysis of
this first volume of transactions, but the limitations of space prevent.
We must rest content with brief references. Dr. Putnam relates a
case of *' analgesia,'' and appends thereto a lengthy dissertation
upon the physiology of sensibility. With reference to the patho-
logy of the case related he arrives at this rather indefinite con-
clusion :

" Whether this impairment of function concerns the entire
nerve (or all of the terminal filaments) or only certain portions
which have become endowed with special properties, and exactly
what molecular changes are involved, can only be settled by
further physiological study ; but it is highly probable that both of
the conditions referred to at times prevail."

Dr. Schmidt, of New Orleans, has contributed a valuable essay
on the structure of nervous tissues. Dr. Hammond has a short
paper on pigmentary deposits in the brain as a result of malarial
poisoning.

The editor. Dr. Kinnicut, publishes two cases of " Insanity in
Children induced by Masturbation.^' The ages of these two patients
at the time of the development of the melancholia were severally
twelve and thirteen, masturbation having been previously practised
in both instances. In one of these complete recovery took place
under careful treatment and discontinuance of the vice, while in the
other, under the influence of an hereditary instability of brain, the
morbid state became fixed. These examples are of interest, inasmuch
as it has been held by men of eminence that masturbation is rather
a consequence than an antecedent of insanity. The extent to which
this disgusting practice prevails in lunatic asylums would lend coun-
tenance to the latter opinion.

The volume also contains articles on the relation of cases of in-
jury to nerves, and cases of neuralgia. Dr. Emerson, of New York,
remarks upon the treatment of neuralgia by phosphorus. After
reciting the observations of many writers, both American and British,
he speaks in terms of satisfaction as to its effects, and expresses
the belief that a higher degree of success would have been attained

1877.] CuLLEN on Typhoid Fever. 42o

had the drug been pushed farther, either by giving larger doses or
by repeating the dose at shorter intervals.

Dr. Froissac addresses himself to the task of disentangling the
constitutional causes of neuralgia from its local excitants. " Neu-
ralgia/' observes Dr. Froissac, "is, of all maladies, the most
obscure and irregular." Kegarded from the author's point of
view it must inevitably be so ; as, to our apprehension, he singles
out only the one symptom — pain — from various constitutional
disorders. It is, doubtless, an important point to determine
the seat of the affection; to determine, if possible, whether it
be central or peripheral, and that, with reference to treatment,
since, as Dr. Froissac points out, many a severe case of neuralgia
of constitutional origin has been regarded as peripheral, and
handed over to the tender mercies of the dentist, instead
of having been consigned to the scientific therapeutics of the
physician. The sovereign remedy of Dr. Froissac is opium or its
alkaloid morphia. Subsidiary to this medicine the author makes
mention of the use of datura, belladonna, bromide of potassium,
spirits of turpentine, acupuncture, and electro -puncture, but does
not make mention of phosphorus, the effects of which, as we have
seen, are lauded by Dr. Emerson, of New York. Dr. Froissac's
essay gives a good resume of various theories on the subject of
neuralgia, and if it does not advance our knowledge by notably new
views, it, at all events, strengthens confidence in our treatment.

Dr. Webber contributes an article on myelitis, as supplementary
or additional to the independent monograph of Dr. Seguin, the object
of which is to demonstrate that spinal paralysis and muscular
atrophy, acute, subacute, and chronic, in the adult, are essentially
the same as infantile paralysis, viz. myelitis of the anterior horns
of the spinal cord. This may be either localised or diffused, pri-
mary, or secondary to other disease of the cord or brain. A long
series of forty -five cases of this form of disease is given by Dr. Seguin,
from which he deduces an analysis of the symptoms under the several
heads of disorders of movements, disorders of sensibility, disorders
of nutrition, general and special symptoms, electro-muscular con-
tractility, concluding with the pathological anatomy, tabulated from
twenty -nine autopsies, the most obvious lesion being degeneration
of the cells of the anterior horns, together with such lesions of other
tissues as are consequent upon inflammatory action.

CuUen on Typhoid Fever^. — This tract is the production of the
Eegistrar of the Netley Hospital, an army surgeon of large ex-
perience. It bears token of having been hastily put together, but
contains some interesting notices of forms and outbreaks of fever in
different parts of the world.

1 On some Undetermined Foints in Typhoid Fever. By Dayid Cullen, M.D.
Surgeon-Major A.M.D.

426 Bibliographical Uecord. [Oct.,

Bearing upon the etiology of the disease, the author narrates
several histories in some of which its development was supposed to
have been spontaneous. But in more than one of them there is
ground for question whether the disease was really typhoid. Of
the production of the disease by the use of polluted water, or the
absorption of sewage emanations further evidence is given.

Dr. Cullen also adduces a considerable amount of testimony in
favour of the belief that much of the severe fever prevalent in tro-
pical and eastern countries, as well as in America, is typhoid,
masked or modified by concurrent miasmatic conditions. This
seems highly probable.

With the clearer ideas now possessed by our younger brethren in
the public services, we trust that ere long much of the obscurity
still resting on the subject of tropical fever will be cleared away.

McCall Anderson on Tubercular Affections.^ — This little work
consists of two lectures published with the view of raising the ques-
tion whether true tubercle is so rebellious to treatment as it is
usually considered to be.

In the first, the subject is regarded as bearing upon tubercular
peritonitis. The author briefly narrates four cases which he believes
to have been examples of the disease, and which were successfully
treated by him. The details published, however, are so few and in-
sufficient that we are unable to accept either his premisses or his
conclusions. In the history first given, the patient, a girl, aged ten
years, had ascites of three months' duration, with some condensation
of the summit of the left lung. It is stated that there was dulness
on percussion, wavy respiration, with an occasional snoring rale.
On the strength of these signs Br. Anderson infers that she had
tubercular disease of the lung, and tubercular peritonitis with
effusion. She recovered in about two months under the use of
pancreatic emulsion, iodide of iron, and cod-liver oil.

That there may have been some low inflammation in both lung
and peritoneum is highly probable, but to call this tuberculous,
without more proof than is given, is an instance of laxity in the
use of language which we regret to see.

The reports of the other cases are even shorter and more unsatis-
factory ; in two of them the only warrant for calling the attacks
tubercular was that they occurred in the children of unhealthy
parents.

In the second lecture the curability of acute phthisis is discussed,
and three cases are narrated in support of the affirmative proposi-
tion. In the first the disease appears to us to have been capillary

1 Clinical Lectures on the Curability of Attacks of Tubercular Ptritonitis and
Acute Phthisis. By Dr. McCall Andbbson, Professor of Clinical Medicine in
the University of Glasgow.

1877.]

Sullivan on Tropical Diseases. 427

bronchitis, with some pneumonic consolidation of the left apex and
right base. Improvement commenced in a fortnight, and complete
recovery was effected in a few weeks. The second also seems to
have been a case of broncho-pneumonia, there being universal
musical rales, with dulness over the right apex and rusty expecto-
ration. Here the acute symptoms subsided in a fortnight, and
complete restoration to health took place in about two months.

In the third patient the attack was sudden, its development rapid,
and productive of extreme prostration. Here there was from the
first some dulness on percussion over the left apex, which quickly
extended and was associated with musical rales over the whole chest.
There was high fever, which abated in eight days and ceased in
twelve. A perfect and seemingly quick recovery was made. Dr.
Anderson beheves that these cases were examples of acute phthisis,
whether tuberbular or non-tubercular he does not pretend to say.
The histories fail to produce any such conviction on our mind, but
they illustrate well the power and value, in pulmonary attacks, of
careful, judicious, and supporting treatment.

Sullivan on Tropical Diseases.^ — In the preface to this work
the author informs us he passed many years in practice in tropical
climates; and, from incidental notices elsewhere, we learn that
these embraced Peru and Cuba, a field sufficiently wide to aff'ord
ample scope for the study of many forms of tropical diseases as
they present themselves among the different races to be met with
in these countries. These the author describes in the volume before
us from his own experience, as well as that of others, with the object
of affording a useful compendium of the facts for such as have not
themselves the opportunity of studying disease within the tropics.

The work contains sections on anaemia in hot climates, marsh
malarial fever, latent or marked malaria, pernicious fever, tropical
bilious fever, marsh diathesis and marsh bacteria, dysentery, acute
and chronic, diseases of liver, hepatitis, jaundice of different kinds,
yellow fever, and Asiatic cholera. The relative frequency of these
forms of disease varies very much in different localities, but unless
the practitioner in the tropics be familiar with them, more especially
with those connected directly or indirectly with the action of
malaria, he will often experience the greatest difficulty in detecting
the true nature of the cases which come under his care, and may
utterly fail in devising measures for their relief. He may have a
case, for instance, with distinctly marked symptoms of meningitis or
cerebritis, with more or less fever, which appeared to give way to
his remedies in the course of twelve to eighteen or thirty- six hours,
but, while congratulating himself on his success in checking the

' The Endemic Diseases of Tropical Climates, with their Treatment. By JoHlT
SULLITA¥, M.D. London, 1877. Pp. 211.

428 Bibliographical Record. [Oct.,

cerebral affection, at his next visit he may find it had returned in
greater intensity, to give way again,, perhaps, but leaving his patient
much weaker and in a more critical state, and, should another exacer-
bation take place, it would in all probability destroy life. The
practitioner may be anxious to avoid giving quinine lest he aggravate
the cerebral mischief, but if he do not prevent, or at all events very
much reduce the force of the ensuing paroxysm, it will almost certainly
prove fatal. If he administer quinine with proper caution, using at
the same time other measures suitable to the case, he will most hkely
find the expected exacerbation much less severe, if not altogether
prevented, and a continuance of the treatment will soon remove all
danger. As with meningitis or cerebritis, so it is with every other
form of local disease met with in these countries ; they may arise and
run their course uncomplicated by malarial poisoning, but when
they are, and this is very frequently the case, it is hopeless to expect
to cure the local affection unless the malarial element be first over-
come, and often the only indication of that being in operation is the
aggravation of the local mischief at regular intervals. Latent or
marked malarial affections are of this nature, and, in different cases,
may simulate any variety of disease. Pernicious fevers are merely a
modification of the same combination, in which the local complica-
tion, involving some important organ or function, appears inter-
currently, or at least assumes a threatening aspect during the course
of an attack commencing as an ordinary intermittent or remittent.

Dr. Sullivan arranges pernicious fever in two groups, the algid,
comprising the fainting dysenteric and choleraic varieties, and the
comatose, including the tetanic, lethargic, and convulsive, and he
gives some interesting illustrations of these. In the comatose form
he tells us *' post-mortem examination reveals no inflammation of
the brain or of its membranes, nor any lesion to which might be
traced the severity of the symptoms ; " to the naked eye, no doubt,
this appears to be so, but if submitted to microscopic examination,
we believe distinct indications of active exudation into the cerebral
substance will be found in most of such cases, especially when they
have undergone more than a single paroxysm.

The author limits the designation of bihous fever to a form met
with among acclimatised Europeans, Creoles, or negroes, who have
already suffered from intermittent, and " in whom the bihous ele-
ment begins to show itself." Jaundice occurs early and is accom-
panied by bilious vomiting, and the urine ^' is of the colour of ink
or coffee-grounds," owing to the presence of bile with a large
proportion of blood ; the latter may recur with each exacerbation of
the fever, and diminish or disappear with the remission or apyrexia,
and is connected with enlarged and congested kidneys. Those who
have practised in other parts of the tropics will recognise the variety
of fevers here described, but most of them, we believe, will regard

1877*.J Sullivan on tropical Diseases. 429

it as merely the ordinary endemic fever with hepatic derangement^ in
an old resident, had not a distinct species of fever, for we must add,
the affection of the kidneys and hsematuria are much more rarely
met with in several of the other West Indian islands, and on the
African coast, than from the author's account they seem to be in
Cuba. Indeed, we are inclined to think his theoretical view as to
yellow fever being always a continued fever, has induced him to
include under bilious remittent many cases which really were yellow
fever in the remittent form. It is difficult otherwise to appreciate
his position that in yellow fever blood, or more commonly matter
resembling black vomit, may exude from all the mucous membranes,
including '' the surface of the vagina and uterus, but blood never
oozes from the kidneys. In the latter character yellow fever differs
from bilious remittent, in which blood in the urine is an essential
element" (p. 166).

The author approaches, but hesitates to grapple with the disputed
question as to the origin of yellow fever, which, he says, "like
cholera, must have for its origin a special miasma, unknown to us in
its essence and conditions of birth''' (p. 157); but he informs us
this fever '^ is a specific infectious disease, capable of reproducing
itself, with the same character and intensity as in the endemic focus
itself" (p. 156), and when introduced into the West Indian islands,
under conditions favorable to its development, it rages with severity,
while, under unfavorable conditions, people who have come from the
endemic focus die from yellow fever without its extending, unless in
very rare instances. '^ It is imported or conveyed by man by the
clothes he wears, merchandise, or trading vessels. It creates for
itself a new focus of infection far from the original one'' (p. 156).
An infected vessel, loaded or in ballast, contain in its timbers all
the elements of the disease capable of reproducing it wherever the
vessel may cast anchor, supposing the population predisposed by
those general and special conditions by which the disease is evolved''
(p. 160). When conditions favorable to development are considered
so essential to the communication of this disease, it appears to us
it would have been advisable to have examined how far these were
connected with the independent productions in the locality of the
special miasma referred to above, and if this could not be excluded
satisfactorily, what proof have we that " yellow fever is a specific
infectious disease capable of reproducing itself?" How can we be
certain that this miasma may not have been produced in every
instance where a fresh case has arisen ? That persons who have
been in a locality where the miasma was existing might carry away
a portion in their clothes is very likely, just as they might carry
away a portion of dust or any other material matter that might be
suspended in the air at the place, but this has never yet been shown
to be the means of actively spreading the disease. Ships, no doubt,

120— LX. 28

430 Mbliographical tlecord. [Oct.,

do occasionally carry its cause, but those that do are merely moveable
localities, which happen to contain within them that assemblage of
conditions necessary for its development; but though there are
many instances in which persons in Europe, or elsewhere, visiting
them have contracted the disease, there is no well-authenticated case
of any individual being affected who had not been on board, or
within the range of those emanations from their holds with which
this fever is associated.

Dr. Sullivan considers yellow fever is always a continued fever,
and that those presenting periodicity are altogether diff'erent and
distinct from it. His description of yellow fever is neither so full
nor precise as is desirable for the sake of those who would consult
his work for information regarding it, and a practitioner anxious to
decide whether a case was yellow fever or one of those forms of
bihous or other fever which sometimes resemble the yellow, will
receive but little' assistance from his remarks on their differential
diagnosis in solving his difficulty. In fact, fevers presenting every
characteristic feature of yellow fever are met with in different
localities, not only in the continued but in the remittent and even
the intermittent forms, as many of the older writers on the disease
pointed out, and the experience of recent years, supported as it has
been by the test tube and microscope, has borne out these conclu-
sions. Had our author not adopted the theory which defines yellow
fever to be a specific infectious fever of a continued form, he might
have presented the relations of the different tropical fevers in a
clearer and more correct manner.

In the treatment of yellow fever our author has little to recom-
mend from his own experience, in which respect he is in the same
position as many who have preceded him. As he informs us that
'^ in mild cases the mortality is as one to three ; in the complete
form is as seventy to one hundred,-'^ we can scarcely avoid the
conclusion that the sick from whom those ratios were obtained must
have been under very unfavorable circumstances, such indeed as
would have told seriously against the success of any treatment.
Though sufficiently formidable under the most favorable circum-
stances, we believe the mortality from yellow fever in the present
day will be found considerably under that just mentioned.

It is unnecessary for us to notice the sections on dysentery, hepatitis,
and cholera, diseases which, though met with in the West Indies, are
much less common than those in other parts of the tropics, as the
above remarks on fever which are frequent in the former; and we
beheve the genuine product of the country will enable our readers
to form a fair idea of how far the author has succeeded in effecting
his object.

1877.] Fleming on Genito-tlrinary Organs, 431

Fleming on the Genito-Urinary Organs.^— There are many and
various reasons for writing a book — some good and some bad, and
some indifferent. A young man may write one as an advertisement,
another may, out of the fulness and newness of original work, give
the profession something of extreme value. Many a busy teacher
puts his lectures into shape for his pupils, or gives the profession
some monograph on the subject which has taken up most of his
time and thought ; and again, in old age and well- won leisure the
veteran fights his battles over again, and selects from the ripe expe-
rience of the past years of work cases and observations which he
trusts may help his fellows.

The work before us is, we believe, one of the last variety and a
most favorable specimen. Such works are nearly always clinical
and historical, generally ill-arranged or not arranged at all, some-
times showing a little the garrulity and diffuseness of age ; often
showing here and there that Horace was right, and that the old
man is ' laudator temporis acti se puero,' fortunate if he is not
' censor castigator que minorum.'

This work contains, or rather is made up of, a long series of most
interesting cases, concisely told and well commented on. Along
hospital experience well used has given Dr. ^Fleming most extensive
and varied material, and he and his editor have done their work
well, making the book not only instructive but entertaining.

The first chapter on the Pathology of the Urine in its relation to
surgery is well arranged for the student, and his memory is aided
by two most truthfully executed chromo-lithographic plates, con-
taining twelve different specimens of urine glasses, with sediments,
colour, &c., contrasted with each other, and also some excellent
sections of calculi.

The second chapter on obstructions of the urethra from injury
contains accounts of a large number of most curious cases, illus-
trated by good chromolithographs, though in some of them the
colours are too strongly contrasted.

The salient points of Dr. Fleming's teaching that strike us are,
first, his patience — he knows in what cases to wait, to hold his hand,
not to pass the catheter, not to incise ; and secondly, his belief in
the internal use of tartar emetic and opium, and the external use of
stupes of tobacco juice. Patience may be, and even by Dr. Fleming
is, carried too far, but it is a valuable protest against the early
and forcible catheterism so often counselled and practised in inflamed
urethras. The tobacco stupes may be often useful, but the tartar
emetic and opium may be pushed too far. The reason we find for

' Clinical Records of Injuries and Diseases of the Genito- Urinary Organs.
By Cheistophee Fleming, M.D., &c. Edited by William Thomson, M.B.,
M.D. Dublin, 1877.

482 Bibliographical Record, ' [Oct.,

Dr. Fleming's love of these potent drugs is that he is afraid of
chloroform. He does not seem to use it so often or so thoroughly
(see Case 36) as we do.

There is much truth in the following sentences, and such teaching
is sometimes required : —

" When the penis is in a state of congestion (in some cases
almost bordering on priapism), the operation of catheterism is most
objectionable. It should never be had recourse to except under the
most urgent and pressing circumstances, every expedient having
been previously adopted by the surgeon to dispense with its use.
In some cases, especially in those of acute gonorrhoea in young
subjects, where retention of urine occurs, venesection may be ad-
visable ; in others, local bleeding, followed by copious fomentations,
medicated or otherwise, will be found most effective, and in all, the
exhibition of tartar emetic and opium, combined with saline cath-
artic or diuretic medicines, in doses proportioned to the urgency of
the symptoms, and repeated at intervals, will prove most useful
adjuncts. I attach very much value to the stuping with tobacco
fomentations. I have found them most effectual even in cases of
paroxysmal retention of urine identified with stricture." Pp. Ill,
112.

There must be something in the cheerful ingenuity and self-con-
fidence of the Irish character that impels them to use such extra-
ordinary means of relieving themselves of symptoms or results of
stricture, or we should not find such a number and variety of foreign
bodies introduced into the urethra. A thorn-twig figured after its
removal by Dr. Fleming is a good example of the national trait. He
also records and figures various pieces of bougie and one whole one,
which must have demanded in their possessors a faith in their own
property analogous to that shown in the rotten reins and string-
mended harness of the national vehicle. Surely the same easy-going
faith is not found in Irish surgeons to the extent implied in the
following caution : —

" I may here make the general observation upon the importance
in all cases of catheterism of examining the condition of the stilet
before introducing the instrument ; the wire is very often allowed
to become rusty and encrusted and the canal of the catheter to be
partially blocked. The wire should not be passed in until it is quite
clean and smooth, and this is best done {sic) by means of a little
sandpaper and chamois {sic). This is a rule which also applies to
all canulae, for I have seen some awkward surgery result from in-
attention to these details in tapping hydroceles and the bladder, the
trochar being almost immovably fixed in its sheath." P. 188.

In the account of chronic prostatic diseases we fail to discover
Dr. Fleming's views as to form, mode, and frequency of introduc-

1877.] Fleming on Genito -Urinary Organs, 433

tion of catheter, and general surgical management. Such cases are
often very perplexing, and involve long and tedious treatment.

Hsematuria is discussed as an important symptom, the result of
very varying conditions. The cases given illustrate well some of the
more frequent causes of it — injury, disease of the liver, cancer of
various kinds, and polypus. Mr. Fleming does not seem to have
met with that rare and interesting form of bladder disease called
sometimes villous cancer.

Stricture is briefly described. As regards the position in which
the patient should be when the catheter is being passed, Mr. Fle-
ming has found that a very satisfactory plan is to introduce the
instrument while the patient is sitting either on the edge of the bed
or in an arm-chair. The patient's feet should be on the ground, and
the body be thrown well back, allowing the perinseum to be freely
exposed (p. 234).

Suprapubic puncture seems to be a favourite resort of Mr. Fleming
when the usual methods of relief have failed ; we agree with him in
preferring this method in many cases to the rectal puncture, espe-
cially now that in the aspirator we have a means of tapping above
pubis both safe and successful.

Under the head of affections of the scrotum a somewhat rare
malady is described —

" An affection of the scrotum and penis which I have observed in
a particular class of men, viz., wine-bottlers. It is their habit, in
pursuance of their occupation, to place the bottle between the
thighs, and then to drive the cork home. I have seen several cases
in which this practice has set up irritation at a point where the
scrotum joins the penis in front, just as we know that soot causes
epithelioma of the scrotum in sweeps. In the cases which have
come before me the irritation was followed by abscesses, which in
time burst, leaving an unhealthy, ragged, lupoid-looking ulcer."
Pp. 265-6.

The account of the cases of stone in bladder, treated by litho-
tomy and lithotrity, is valuable, in that it is not a mere record of
successes, but that the failures and errors in diagnosis are told as
well with a frankness and honesty not by any means invariably seen.
And amongst them is a record, illustrated by excellent chromolitho-
graphs, of a case which is probably unique — a fibro-calcareous tumour
of the uterus, opening into the bladder by pressure and protruding
into it. The symptoms were those of stone, and an attempt was
made to relieve the patient of it, first by the urethra, and afterwards
by the suprapubic operation — both, of course, unsuccessful.

The book is capitally got up, and the chromo-lithographs are most
telling, though some are rather brilliant in tteir colouring. The
editor has kept himself entirely out of sight, but has done his part
of seeing the book through the press most carefully.

434 Bibliographical Record, [Oct.^

Black on Bright's Disease.^— This book cannot be commended
either as an original work or as a good compilation. To the former
character, indeed, it lays but little claim, although here and there
vague statements are made as to orignial investigation. As a com-
pilation it is not deficient in presenting an array of names sometimes
with and sometimes without references to the works and passages
quoted. Occasionally a curious compromise between these two
methods of reference is effected, as when the author quotes (p. 121)
'^Dr. Noel Gueneau de Mussy (Union Medicale),^^ or when he
refers (p. 101) to what he calls in a footnote " Deut. Arch. Klin,
fiir. Med.,^' without any mention of volume or year. These are
perhaps trifling defects in themselves, but a certain looseness of state-
ment, with obscure and inelegant expressions, abounds in the
volume.

The most startling section is the one on treatment. According
to Dr. Black, diluents are dangerous, cream of tartar is deadly,
possessed of what he calls " killing properties," and saline purga-
tives are on no account to be advised. Instead of what he terms
'Uhe fashionable waiting-upon-death of modern physicians," he
recommends general bleeding to be resorted to at once, " if there be
a history of exposure to cold or damp, with albuminous urines, with
or without the other indications of nephritis," this to be replaced or
followed up by cupping or leeching ; in the later stages mercury is
recommended. Then we are advised to use counter-irritation by
cantharides, or by tartar emetic ointment and croton oil, supple-
mented, when the skin is tender, with mercurial or iodine inunctions;
or, " instead of the ordinary counter irritation, the actual cautery
may be applied, or setons may be established," &c. (p. 143).

Dr. Black does well to say, immediately after sketching this plan
of treatment, to his students, '^Notwithstanding your utmost endea-
vours, nephritis will prove of the greatest gravity ; " this sentence
may perhaps direct the more intelligent of them to search for safer
guides and better forms of treatment, by which the gravity of
nephritis may be lessened instead of increased.

Transactions of the American GynaBcological Society.^ — This
Society, numbering among its Eellows most of the leading obste-
tricians of America, was founded last year for the promotion of
knowledge in all that relates to the diseases of women and to
obstetrics.

The President, in his opening address, expresses the hope that
'^ the Society will exert a marked influence in stimulating inquiry,

1 Lectures on JBrighfs Disease. By D. Campbell Black, M.D. London,
1875.

2 Transactions of the American Gynecological Society for the year 1876.
Vol. i. Boston and London.

1877.] Transactions of American Gynaecological Society. 435

investigation, and recorded observation, and thus be an important
agent in contributing to the progress of science and our national
reputation in this branch of our profession."

The council intend to publish in each volume of the ' Transac-
tions ' a complete bibliography of everything that appears pertain-
ing to obstetrics and gynsecology during the current year, not only
in English but in foreign literature. The number of Fellows being
limited to sixty, and '^ no one being eligible for active Fellowship
until he shall have submitted to the council a paper on some sub-
ject connected with gynaecological science," the approval or rejection
of such paper determining the nomination for election or otherwise
of each candidate, we may fairly expect that the class of papers will
be such as to ensure the success of the ' Transactions,^ and help to
give the Society a high scientific position.

The opening annual address of the President, Dr. Pordyce Barker,
is one of much interest, and contains many valuable suggestions that
might with propriety be adopted in this country. He very properly
divides into two classes the papers contributed : (1) those which would
be useful and interesting to be read and discussed at the meetings,
and (2) a second class of papers of such a character that no one could
listen to the reading of them with interest or advantage. All sub-
jects^ relative to questions in pathology and practice which have not
yet been settled by the general sentiment of the profession, he con-
siders, will appropriately belong to the former class ; all practical
questions which involve great statistical research, analysis, and
deduction, and all papers based on original, physiological, anatomical,
and pathological studies, will come under the second category.

He suggests that the discussion should be the expression of care-
ful study, deliberate judgment, and mature experience ; the time of
the Society being too valuable to be taken up by listening to the
crude, impulsive, badly arranged outbursts of the moment.

Considering that the Society was somewhat hastily constituted, it
was to be expected that the first contribution would have little of
an original character ; in fact, many of them are simply old friends
with new faces, others bear evidence of having been very hurriedly
put together, and some few would perhaps have been better omitted
altogether as conducing neither to the renown of their authors nor
to the value of the ' Transactions/ The volume itself is, however,
one of great interest, and contains many valuable contributions from
well-known physicians.

Dr. T. A. Emmett contributes the result of many years' experience
on ' The Etiology of Uterine Flexures, with the proper mode of
Treatment indicated.^ He enters minutely into the statistics of the
frequency of flexion among some 3447 cases, the subject of various
diseases and injuries peculiar to women. He considers that '^ flexures
of the cervix have their origin at about the age of puberty, by the

436 Bibliographical Record. [Oct.,

balance being lost between the relative growth of the body and
cervix." Anteflexion, he thinks, has its origin after puberty, and obser-
vation indicates it to be the result of obstructed circulation from
impaired nutrition. E/ctroflexion he regards as a deviation from a
previously existing retroversion.

He never divides the neck of the uterus laterally, except for the
treatment of fibroid or for partial closure of the os. He thinks the
operation as practised by Simpson, or any modification of it, un-
called for and detrimental.

Dr. R. Battey relates the history of ten cases of ' Extirpation of
the Functionally Active Ovaries for the Remedy of Otherwise In-
curable Diseases.' Two of the cases proved fatal, the remainder
were benefited by the treatment in various degrees. In his opinion
the removal of the functionally active ovaries, is indicated in the
case of any grave disease which is either dangerous to life or de-
structive of health and happiness, which is incurable by other and
less radical means, and which we may reasonably expect to remove
by the arrest of ovulation or change of life.

Dr. J. Mattliews Duncan has a short paper on ' Central Eupture
of the Perineum.' Dr. E. W. Zenk directs attention to the value of
Yiburnum Pruni folium in all uterine disorders characterised by
loss of blood. Dr. Robert Barnes, of London, contributes an in-
teresting article on the * Relations of Pregnancy to General Patho-
logy,' well worthy of perusal, though difficult to summarise. Dr.
W. H. Byford directs attention to the ' Spontaneous and Artificial
Destruction and Expulsion of Eibrous Tumours of the Uterus,' in
which he refers to the action of ergot in these cases. Dr. T. Gail-
lard Thomas gives the ' Report of a Case of Abdominal Pregnancy
treated by Laparotomy,' with success as regards the mother. The
foetus had been dead some little time. The placenta was left alone,
a large glass drainage tube being placed in the lower extremity of
the incision. The decomposed placenta was found protruding from
the wound five weeks after the operation, and was removed. The
patient made a rapid recovery.

Dr. H. F. Campbell writes an exhaustive article on ' Pneumatic
Self- replacement in Dislocations of the Gravid and Non- Gravid
Uterus,' — a subject to which he has directed attention for years.
His method is far less frequently practised in this country than it
should be. Its simplicity apparently is not sufiiciently important
to ensure attention, and yet it is one of the most efficacious methods
of treatment we know of in many cases of retroversion and flexion
of the uterus.

Three important conditions — I might say powerful influences —
all applicable to, and bearing upon, the displaced uterus, are found
to be coexistent when the woman is placed in the genu-pectoral

1877.] 'transactions of American Gynaecological Bociety, 4B7

position : first, reversal of gravity ; secondly, draft of the viscera ;
and, thirdly, external atmospheric pressure."

Most of us are familiar with the postural method of treatment
in cases of prolapse of the umbilical cord during parturition — the
genu-pectoral position — where gravity alone is sufficient to retain
the replaced funis. Surgeons more frequently resort to the expe-
dient of elevating the hip in cases of perineal protrusions, with a
view to reduction, " the draft of the viscera " being really the force
assisting. In addition to these forces we have a third, viz. ex-
ternal atmospheric pressure, by means of air allowed to enter the
vagina.

The whole subject deserves more attention among the profession
than has hitherto been accorded to it.

Dr. W. L. Eichardson, in a short paper, treats of the 'Advan-
tages of Hydrate of Chloral in Obstetric Practice.' * Labour com-
plicated with Uterine Eibroid and Placenta Previa ' forms a brief
but interesting communication from the energetic hon. sec, Dr.
J. E. Chadwick. Dr. Emil Noeggerath, again, brings prominently
forward the subject of ' Latent Gonorrhoea, especially with regard
to its Influence in Pertility in Women.' Since the author first pub-
lished his work upon this subject, some five years ago, professional
opinion has altered considerably. The statement that about ninety
per cent, of sterik women are married to husbands who have suf-
fered from gonorrhoea, either previous to or during married life, was
scarcely credited by many, and indeed will probably be doubted by
most practitioners now ; still, that gonorrhoea forms an important
item in the list of producing causes of cervico-endometritis and
various forms of perimetritis cannot be denied.

Dr. W. Goodall contributes a short ' Clinical Memoir on some of
the Genital Lesions of Childbirth,' in which he briefly discusses the
question of immediate operation in rupture of the perineum during
parturition. The cases are too few to admit of any reliable deduc-
tion, but we quite agree with the author that, while the immediate
operation does not prove so successful in complete ruptures as in
incomplete ones, yet a far better chance of union is afforded in
both forms of laceration by the suture than by the " let-alone "
treatment.

In a brief note on ' Hermaphroditism,' by Mr. Lawson Tait, of
Birmingham, attention is called to the common mistake of the inex-
perienced, confounding arrested development for cases of bisexuality,
where the actual presence of the organs of both sexes in the same
individual has been revealed by a post-mortem examination. In some
cases there is distinct evidence of over-development or hypererchesis.
On the strength of these observations the author concludes that
we must accept Darwin's theory of the descent of man, the occurrence
of such malformation being regarded a reversion of type. ^' This

438 Bibliographical Record. * [Oct.,

acceptance at once becomes the explanation of the occasional occur-
rence of bisexual vertebrates, and consequently of true hermaphro-
ditism in human individuals."''

Dr. J. R. Chadwick also contributes an article on ' Rare Forms
of Umbilical Hernia in the Foetus/ illustrated by five woodcuts.

The volume concludes with a brief memoir of the late Dr. Sneider,
by Dr. Paul F. Munde, a well-executed and most expressive steel
engraving accompanying the text.

Gout: its Cause, Nature, and Treatment.^ — It is very difficult to
determine how this book should be received by the profession, for
while it exhibits a large amount of scientific and literary research
and some good reasoning, it is so dogmatic in its tone in many parts
as almost to exclude it from serious notice. It is quite true that
the treatment of gout has long been a matter of controversy, and is
still very often unsuccessful, but yet it is supposed by a great
number of the profession that its causes and nature are pretty well
known, that its therapeutics and dietetic management are, on the
whole, tolerably well understood, and that, making allowance for a
certain latitude of practice, the rules by which the practitioners
should be guided in this disease are pretty well defined. But Mr.
Parkin informs us that all our knowledge on the subject is founded
on error, that the cause and nature of gout have been hitherto mis-
taken, and that the treatment generally pursued is altogether erro-
neous. According to Mr. Parkin the disease is not due to any
specific materies morbi, but is caused, in common with various
epidemics, by malaria ; that the blood in gout is not acid, but
alkaline ; that uric acid is not free in the system, but in a state of
combination ; that colchicum is worse than useless in the treatment
for it — is positively injurious and poisonous ; and that the true
specific for gout is carbonic acid gas ! This gas is to be adminis-
tered in the form of soda water or seltzer water, or still better, in a
state of eff'ervescence in the ordinary draught made by combining
carbonate of soda with citric or tartaric acid. The efficacy of this
mode of treatment is vouched for by a number of cures which Mr.
Parkin has performed.

Clinical Studies in the Non-Emetic Use of Ipecacuanha.- — Al-
though it would be inconsistent with sound medical practice to
treat nearly all diseases with one remedy, inasmuch as experience

^ Gout ; its Cause, Nature, and Treatment, with Directions for the Regulation
of the Diet. By John Paezin, F.R.C.P.E., &c. Second Edition, pp. 144.
London, 1877.

^ Studies, chiefly Clinical, in the Non-Emetic Use of Ipecacuanha, with a Con'*
trihution to the Therapeusis of Cholera. By Alfeed A. Woodhull, M.D.,
Assistant-Surgeon U. S. Army. Pp. 155. Philadelphia, 1876,

1877.] * Hospital Mortality. 439

teaches us that a variety (9i drugs are applicable to different morbid
conditions, yet it is perhaps true that ipecacuan is available in a far
greater number of cases than is generally admitted, and that its
value as a medicine is still somewhat underrated. Hence, although
Dr. Woodhull is rather enthusiastic in his eulogies of this drug,
and other practitioners might be less successful than himself in its
employment, we think he has done good service in offering the
present little book to the medical public. It consists essentially of
a series of special reports to the Surgeon-General of the United
States Army, which were afterwards published, with additions, in
an American journal; but Dr. Woodhull has now collected and
arranged the materials afresh, and the whole constitutes a really
valuable monograph on a very interesting practical subject. Admit-
ting, of course, the great value of ipecacuan as an emetic, the
author claims for it also the quality of being a direct nervous stimu-
lant, acting chiefly, if not entirely, upon the sympathetic system.
In the treatment of dysentery in its various forms Dr. Woodhull
considers it to be extremely valuable, and he gives a series of cases
in corroboration of his opinion; but he also recommends it as
being more or less efficacious in a variety of very different diseases
and morbid conditions, such as cholera, uterine and other haemor-
rhages ; some forms of dyspepsia, vomiting of pregnancy, nervous
and other coughs, drunkenness and delirium tremens, neuralgia, inter-
mittent fever, acute hepatitis, &c. We have already expressed our
doubts whether an extended experience would justify all the commen-
dations bestowed on ipecacuan by Dr. Woodhull, but at the same
time we believe that much of the author's reasoning is correct, and
we may express our own opinion that the medicine is a most valuable
one, and that it is not injurious even when it is unsuccessful.

Hospital Mortality.^— The discussion upon hospital mortality
raised by Sir James Y. Simpson shortly before his death ceased
soon after that time, and the term hospitahsm became almost for-
gotten. We believe the discussion at that time did much good,
and drew attention to much that was bad in our hospital arrange-
ments, and has doubtless, by making hospital authorities more alive
to the necessity of attending to hygienic details, done much to limit
the number of preventible deaths. The cessation of the discussion
we believe to have been due in great measure to the fact that, instead
of talking, hospital surgeons and committeeshave been acting, and
in every way labouring to improve the hygienic conditions of the
buildings under their care. As a proof of this we may mention

• ; ' — — ' ~~~~~~"

1 An JEssay on Hospital Mortality ; based upon the Statistics of the Hos^
pitals of Great Britain for Fifteen Years. By Lawson Tait, F.B C.S.
London, 1877.

440 Bibliographical Record. [Oct.,

that thousands of pounds have been expended in rebuilding or
reconstructing old hospitals. As examples we may mention Edin-
burgh and Manchester, where new hospitals are in process of con-
struction; Norwich, where the building is completed; and in London,
Westminster, Charing Cross, St. George's, St. Mary^s, the Children's,
and others, in which either partial or complete reconstruction has
been, or is in process of being carried out. Moreover, the remedies
proposed by Sir James Y. Simpson were so absolutely impracticable
in large cities that practical men felt little inclination to discuss
them, and, instead of talking about abolishing all hospitals, were
content to do their best to diminish to the greatest possible extent
the unavoidable evils of such institutions. At Sir James Simpson's
death his papers fell into the hands of Mr. Lawson Tait, and he
has apparently felt himself bound to continue the same line of
investigation, and to pile up a heap of figures exceeding in amount
those of his " great master.' ' Sir James Simpson followed a plan
of investigation at any rate calculated to lead to some definite
results. By limiting himself to one set of cases only he was able to
draw comparisons between hospital and private practice which were
certainly of some value, though they only confirmed the universally
received opinion that amputations do better in private houses and in
the country than they do in the crowded hospitals of great cities.
Mr. Tait found that this part of the subject had been so thoroughly
done by Sir James Simpson that he ^' felt that any further investi-
gation of the subject must be prefaced by research in another
direction." The more he thought on the diificult subject of discover-
ing something which should be more than a repetition of Sir James
Simpson's work, " the more he became satisfied that the first step
was to establish the facts of a total hospital mortality for a definite
and somewhat extended period," and he has therefore, with infinite
labour, collected the mass of figures contained in this book. In
order to arrive at any accurate general conclusion it is, of course,
necessary to collect the largest possible mass of particulars, and it
is to be hoped that if the mass be sufficient the various causes of
error will neutralise each other. If, however, after having arrived
at the general conclusion, we attempt to apply it to individual cases,
the errors will, of course, reappear. All Sir James Simpson
attempted to do was to prove the general proposition that the
mortality after major amputations is greater in hospital than in
private practice, and that it is greater in large hospitals than in
small. He did not attempt to point out individual hospitals, and
lay, as it were, manslaughter to their charge because their death-rate
might be peculiarly high, without pretending to investigate the
causes of such an exceptional mortality. Mr. Lawson Tait has not
in this point followed in the steps of his " great master." He is
constantly, all through his remarks, holding up two or three hospitals

1877.J Hospital Mortality. 441

as models of low mortality, and some others as places in which it
is incumbent on the managing body to show that they are not
killing their patients by bad management and negligence. Thus, he
tells us that as the district mortality of St. Bartholomew's is higher
than that of St. Thomas's, there seems a priori no reason why there
should be such a great difference in the death-rate of the two
hospitals. " If the death-rate of St. Thomas's was as low as that
of St. Bartholomew's, 220 valuable lives would be saved every
year." If this sentence has any meaning at all it is that there are
220 preventible deaths annually in St. Thomas's Hospital. Mr. Tait
assumes that it is the duty of the authorities of St. Thomas's Hos-
pital to prove that this statement is not true. We think it was
the duty of Mr. Tait to prove its truth before making so rash and
grave an accusation. Mr. Tait's object being to estabhsh a general
hospital mortality, that is to say, the percentage of all patients
admitted to a hospital that die, he has for this purpose obtained
reports from nearly 300 hospitals and infirmaries. The number
of beds in the institutions from which his statistics are derived
varies from 700 to 5. The statistical tables are divided into
nine columns. In the first is given the full number of beds con-
tained in the institution; in the second the average number of
these occupied; in the third the average yearly number of in-
patients ; in the fourth the average number of patients annually to
each bed ; in the fifth the mean residence ; the sixth and seventh
contain the average mortality per hundred beds and patients ; and
the two last columns contain the death-rate of the district in which
the hospital is situated, and the ratio of the hospital to the district
mortality. The average number of patients to each bed is calcu-
lated by dividing the average number of full beds into the yearly
number of patients. Thus, let us say a hospital of a hundred beds
has on an average only ten full, and receives one hundred patients
per annum. Mr. Tait would put the patients per bed as ten. Another
hospital of one hundred beds might have every bed full all the year
round, and receive a thousand patients, and Mr. Tait would still
call the average per bed ten, and would say that one hospital was as
" active " as the other. Thus, while making comparisons between
the high death-rate of University College Hospital and the singu-
larly low death-rate which he attributes to St. Bartholomew's, he
states that ^Hhe work of one is quite as active " as that of the
other. On turning to his tables we find that he gives the average
number of patients per bed at Bartholomew's as ll'll, and at
University College as 12*75. If, however, we divide the number
of in-patients by the full number of beds in the hospital we find
that at Bartholomew's each bed receives 4*7 patients, while at
University College each bed receives 11-8. How the work of one
can be called as "active" as the work of the other we do not

442 Bibliographical Record, [Oct.,

understand^ and what conclusion of any value can be drawn from
such a calculation it is difficult to conceive. On the other hand, if
calculated from the full number of beds, the patients per bed is an
important indication of the character of work done in the hospital.
If, for instance, the margin of empty beds is small, and the number
of patients per bed large, it is clear that there must almost con-
stantly be a considerable strain on the accommodation of the hospital,
and only the most urgent and severe cases will be admitted, and a
high death-rate under such circumstances is not to be wondered at.
The mortality per bed is also calculated from the average number
of beds full, and not from the full number of beds in the hospital.
"The mortality per cent, of patients is, however, the chief object
aimed at in this work, and we find that 6* 24 of every hundred
patients admitted into the hospitals of the United Kingdom die ;
but having found this, are we much the wiser or better for the
knowledge ?. The tables show us that some hospitals rise high
above this figure, and the others, chiefly country cottage hospitals,
fall far below ; but there is not one word in the book or one figure
of this vast mass of calculations which can really help us to guess
the cause of this variation. We venture to think that if the medical
cases were separated from the surgical, if those cases which die
within three days of admission were excluded, and if deaths from
diseases usually supposed to be attributable to faulty hygienic condi-
tions were separately tabulated, and the chief causes of all the deaths
were also stated, some conclusions of value might be drawn. It
may be replied that the labour of this would be too great for any
man to undertake. Then let the author limit his number of
hospitals, and do what he does attempt thoroughly. We do not see
that anything but fallacy can arise from comparing the statistics of
a small cottage hospital with those of one of the great hospitals of
our large cities. These small hospitals might we, believe, have
been excluded altogether with advantage, and Mr. Tait would then
perhaps have found time to tabulate more fully the results of our
large hospitals. If, then, he was able to show that in any one the
death-rate was unduly high, and that this was due to preventible
disease, he would have rendered real service to his profession and
his country. The variations in the nature of the cases admitted in
various hospitals is too great for mere statistics such as we have
before us to be of any value. Some hospitals take in large numbers
of simple cases which in smaller hospitals are treated as out-patients,
and amongst whom it is scarcely possible for a death to occur.
Some keep incurable patients till death terminates their sufferings,
others send almost all hopelessly chronic cases to the parish in-
firmary. In hospitals to which medical schools are attached a case
likely to terminate fatally at an early date is by no means unwel-
come, while in many others, especially in small towns, such cases

1877.] Diseases of the Skin. 44^

are not at all desired, for fear of raising the death-rate. Some
hospitals fill half their beds with venereal diseases, whilst others
rigidly exclude such cases, by a rule of the committee. No doubt all
this does not in any way invalidate the truth of the main statement
of this book, that 6-24 of every hundred hospital patients die, but it
renders it utterly impossible to apply the statement in any useful
way to any individual hospital. With regard to the accuracy of the
figures we can only say but little. We have, of course, no means
of verifying the great majority, but the first of all (St. Bartholo-
mew's Hospital) we hope is not a fair specimen of the rest. We
find the number of beds put down at 710, "excluding ophthalmic
beds/' The prospectus of St. Bartholomew's Hospital for the
session 1877-8 contains the following statement: — ''The clinical
practice of the hospital now comprises a service of 710 beds: of
these, '^'H are allotted to the medical cases, 322 to the surgical,
26 to diseases of the eye, 20 to diseases of women, and 81 to the
syphilitic, while 34 are at the Convalescent Hospital at Highgate."
Thus, we see, in estimating the death-rate, Mr. Tait has included
81 syphihtic beds in which death is hardly hkely to occur, 26 eye
beds which he says he has excluded, and 34 beds in a convalescent
home four miles away. We must say such gross blunders about a
hospital, of which the prospectus and the printed report can be
obtained by any one, has rather shaken our faith in the accuracy of
the rest of the table. At the end of the book are some remarks
on the statistics of ovariotomy and on the mortality of lying-in
hospitals, but on both these subjects it would be difficult to say
anything new.

In an appendix are some statistics of major amputations, and
here we may remark that these tables show very clearly the fallacy
of man'y of the conclusions drawn from those at the beginning of
the work. The hospital held up as the type of all that is bad is
University College Hospital — that of all that is good is St.
Bartholomew's. However, we find that in the former the mortality
after amputation is 1 in 4*3, in the latter 1 in 3*7, whereas the
general death-rate is given as 11'91 in the former and 5*12 in the
latter. Mr. Tait's '*^ great master," Sir James Simpson, would
therefore have considered University College to be more healthy
than St. Bartholomew's, and used this as a proof of his statement
that the death-rate varies directly as the size of the hospital. If,
therefore, the pupil and master are at such utter variance, it is
evident further investigation is necessary before either of their con-
clusions can be considered reliable.

Diseases of the Skin.^ — The recent increase in number and size of

1 A Practical Treatise on Diseases of the Skin. By LoriS A. DuHEIifG,
M.D. Philadelphia, 1877.

444 Bibliographical Record. [Oct.,

the treatises on skin diseases has become a positive source of alarm
to the medical reviewer. No sooner has one ponderous volume
been digested than another issues from the press, and again have we
wearily to examine the tedious pages devoted to the oft-told story
of the anatomy of the skin and the varying classifications of its
diseases. Surely the time has arrived when professed anatomists
and histologists may be trusted to embody an accurate account of
the structure of the skin in their proper text-books, and the derma-
tologist may assume, as do the writers upon most other departments
of medicine, that his reader is sufficiently acquainted with the ele-
ments of anatomy, physiology, and general pathology. If he is not
already well grounded in the principles of medicine he is not pre-
pared to undertake the study of a special department, and detached
chapters are not likely to help him. Dr. Duhring is evidently of a
different opinion. He begins, in the orthodox manner, with the
anatomy of the skin. He even goes further, and assumes that we
do not know what the skin is, as he actually takes the trouble to
inform us that jt is " a covering which invests the body completely,
giving it form {sic) and also protecting it.''"' He tells us that
'^ hairs, either fine or coarse, are found upon almost all regions of
the body ; they are more highly developed in certain parts than
others .^^ For whom can such a sentence be written ? Why is not
the intelligent reader further informed of the more general preva-
lence of the whisker among the male sex ? If by the time he begins
to study diseases of the skin he is unacquainted with the somewhat
obvious fact that a man usually has more hair on his head than on
his feet, statements not beyond the requirements of an infant school
can scarcely be too minute for him ; he must, in truth, be an abso-
lute ignoramus. To speak more seriously, it is sheer waste of time,
paper, and printing ink, for a writer on a special subject to occupy
any portion of his book with general information. This either is,
or ought to be, previously well known by the reader. What we
require of a specialist in the present day is not a ponderous volume,
but well-digested individual observation of clinical, histological, or
pathological facts, with as little padding as possible. Dr. Duhring's
book consists of no fewer than 600 pages octavo, without counting
indices, &c. Of these pages the paper is good, the type excellent,
and the margins are cut. These are common and praiseworthy
features in most American books. Other, but less admirable, marks
of nationality are to be found in the peculiarities of diction in
which our author not unfrequently indulges. For instance, the word
'^ trouble," in its transatlantic sense, is largely employed. We read
of " troubles of the nerve-centres," ^'kidney- troubles," "troubles of
the alimentary canal," and so forth. To the reader unacquainted
with Yankee colloquialisms it may be necessary to explain that
^' trouble " is a word constantly in the mouths of American patients.

1877.] Diseases of the Skin. 445

A lady, for instance, will speak of having *^ head-trouble," meaning
thereby migraine, and not mental distress. Such slight degree of the
latter as may fall to the lot of a young lady on account of freckles
is expressed by our author in the uncouth word '^ worriment.^^

The matter of the book, though not original, is sound. The
author is a follower of Hebra, whose classification he adopts. He
is evidently a firm believer in his teacher's system of local treatment.
Great reliance is placed upon soft soap, tar, and the litharge oint-
ment ; but he approximates more nearly to the English school in
regarding the ordinary diseases of the skin as due to more or less
remote causes. He insists strongly on the necessity for diligent
investigation into the conditions of internal organs, and evidently
holds firmly to the doctrine that the majority of chronic skin affec-
tions are in intimate relation with diseases or ^' troubles " of the
stomach, nervous system, blood, or uterus. This, we need scarcely
remind our readers, is a very important deviation from Hebra, who
in his teaching has discouraged all speculation of this kind. He
holds that as the skin is a very large and exposed organ it is there-
fore of necessity liable to be the seat of primary disease. The most
direct treatment is, therefore, the best, and the most direct treat-
ment is the local. He passes in review a great number of internal
remedies, only to condemn them as worthless. He speaks disre-
spectfully of the most revered medicinal idols. Dr. Duhring seems
to accept without hesitation Hebra''s testimony as to the value of
local treatment, but seems unwilling in his own practice to trust to
it alone. Thus he says —

" Eczema is a perfectly curable disease. For its relief two dis-
tinct methods of therapeusis are employed — one directing all its
force against the skin itself as the ofiTending organ, trusting by this
means alone to restore health to the part ; the other endeavouring
to remedy the disorder by the employment of internal or constitu-
tional remedies, intended to act against the real or supposed source
of the disease. The plan which appears to me to be the correct one,
and which in my experience has proved most satisfactory, is that
which recognises both local and constitutional remedies as being of
equal value. I am confident that, viewing the matter in a broad
light, this doctrine aff'ords us the best results in practice."

"We must admire the frankness which admits that an internal remedy
may be employed against the supposed source of the disease, but we
are scarcely capable of viewing it in a sufficiently broad light to
consider it of any value at all. Now, as this is a very good descrip-
tion of the way in which drugs, in the present state of our know-
^icdge, must be applied, it follows that internal treatment cannot be
iqual in value to local. With topical applications we know exactly
what we are doing; we can see for ourselves whether a tract of skin
requires soothing or stimulating, and we are able to judge by mere
120— IX. 29

446 ISibliographicat Record. f Oct.|

inspection how far our remedies fulfil the indications. On the whole,
however, Dr. Duhring's directions for treatment accord with our
views. We are told to correct dyspepsia, remove constipation ; that
diuretics are of service when there is deficient renal action, and so
forth. He does not seem to place undue reliance upon specifics, and
shares the prevalent belief that arsenic has been overrated. He gives
good rules for its employment in eczema, and mentions Hutchin-
son's recommendations of it as a specific in some cases of pemphigus.
He mentions phosphorus in general terms only, but does not seem
to have made any trial of it in psoriasis. We have found no reference
to the new therapeutic toy, chrysophanic acid, nor even to the virtues
of the more primitive goa-powder. The directions for the employ-
ment of topical remedies are generally precise and ample. The stu-
dent who is unacquainted with the Sydenham Society's translation of
Hebra's great work can obtain a good idea of the Vienna treatment
from Dr. Duhring's pages. Altogether the book may be fairly
recommended as embodying a trustworthy account of the dermato-
logical knowledge of the day. It lacks originality and personal
testimony, and greatly needs compression ; but though not remark-
able for any striking merits, it is commendably free from error, and
may be taken as a safe guide to the study of skin diseases.

Transport of Sick and Wounded by Pack Animals.^ — This work
forms Circular No. 9, issued from the Surgeon- GeueraFs Office in
Washington on 1st March, 1877, and is intended to embody- the
experience of the medical officers of the United States Army in
transporting sick and wounded in localities unsuitable for wheeled
carriages ; other modes of transport on animals, employed elsewhere,
however, are noticed. The operations of the American forces
against hostile Indian tribes, of late years, have taken place in
mountainous districts without roads, and presenting such obstacles
to the employment of wheeled transport that, to admit of free and
rapid movement, it has been thought better to trust entirely to
pack animals for conveying the necessary supplies. The troops
employed have on several occasions amounted to from 1200 to
1500 men, and the Indians they encountered being bold and well
armed, numerous casualties have resulted, and such of the wounded
as could not proceed on horseback have had to be transported to
the base of operations by such means of conveyance as could be
improvised on the spot. These, in nearly all cases, seem to have
taken the form either of a litter for one person recumbent, carried
by two horses or mules, or of the " travail " or '^ travels," a very
old Indian arrangement, resembling the litter in form, but drawn
by a single horse or mule, while the hind ends of the side poles are

1 On the Transport of Sick and Wounded by PacJc Animals. By Gboege A.
OxiS, Assistant Surgeon U.S. Army, 4to, pp. 32.

1877.]

tVhat is Vital Force ? 447

allowed to trail on the ground instead of being carried by a second
animal. Opinions are divided as to the relative merits of these
two modes of conveyance; the former is admitted to be more
comfortable for cases that have to be carried altogether recumbent ;
but as two animals are required, with a man to guide each, and two
others at the sides of the litter to check undue oscillation, or four men
and two pack animals for the transport of a single patient, there may
be many occasions when the services of so many could not be spared.
With the '^ travail," on the other hand, a single pack animal and
a driver are sufficient for the removal of a single case, unless where
there is very rough ground or streams to cross, when additional
assistance may become necessary. Wounded have been transported
long distances in such conveyances with comparative ease, and,
when the materials to construct them can be procured, they are well
worthy of a trial. Mr. Otis speaks approvingly of the French
mule litters, but points out that, however desirable it would be to
adopt them in the American service, it would be hopeless to attempt
it unless mules of sufficient size properly trained, and with attendants
accustomed to manage them, were at the same time available.

What is Vital Force ^^ — An octavo volume of 328 pages bearing
the above title is likely to induce a reviewer to search for merit,
and a casual encounter with such a work would naturally induce the
reader to look for original observations, novel theories, or recently
established facts. In the case of the book under review he will
find a remarkable conglomeration of a few well-known data gleaned
from authors ancient and modern (even from Holy Writ), stated in
such an incoherent style, in long, ungrammatical, non-understandable
sentences, denied moreover or doubted, till he lays down the work
in disgust. No purpose is discernible, no definite conclusions
reached, but the work is full of false premisses leading to mystified
or incorrect inferences. In the very first page we are startled by
Mr. Battye rejecting the law of gravitation. A few pages further
on (p. 6) we meet with the following paragraph, the purport of
which is hard to guess :

" In whatever tissue active vital functions, either of a chemico-
vital or cell-destructive power, are going on, there mucous memhrane
is recognised, purely and solely from its active vital functions,
altogether irrespective of the form of difi'erentiation it may assume ;
i.e. if in its vitality it includes active vital processes that are not
contractile processes, there the functions of mucous membrane
exhibit a certain special active property, which declares what is its
proper place in the grouping of the membranes in any special
tripartite membrane.'*^

^ What is Vital Force 1 or a short and comprehensive slcetch, including Vital
Physics, Animal Mor'phology, and Epidemics ; to tohich is added an Appendix
upon Geology: is the Detrital Theory of Geology tenable 1 By RiCHAED
Fawcett Battye. London, 1677.

448 Bibliographical Record. [Oct.,

The largest portion of Mr. Battye's monograph (pages 148 to
298) is occupied by a discussion of the subject of epidemics. We
look here in vain for any important facts to elucidate the mysteries
still surrounding this subject ; certain peculiar, perhaps original,
ideas are stated without genuine evidence to support them, and
they deserve notice merely as examples of the shallowness of the
author's argument :

*' But " (he says, p. 232) " in addition to fungi, is it not possible
to suppose an animal sarcode as perfect and yet as simple in structure
as the fungi (bearing in mind in all animal growth the tripartite
element), and capable of transportation, as a light and almost im-
palpable dust, from person to person, as much as we imagine that
fungi are, as evidenced in certain skin diseases which are propagated
by close contact or actual touch, and much easier of conveyance
than the ponderous acari, on the animal side, propagating their
brood of ova, to be kindly housed in the next neighbour's hand,
who by gentle contact is sufficiently felicitous to be honoured with
their presence ?"

It is scarcely conceivable that in 1877 there are published sen-
tences, nay pagefuls, like the above, showing total ignorance of
recent microscopical and experimental investigations on contagium.
Again, Mr. Battye states the following novel idea in his introduc-
tion (p. 28) : — " The secular variation of the compass from east to
west is about 320 years, and back again another 320, so that a
complete revolution is about 640, or the period here fixed, by ob-
servation from history, as being the period or epoch of an epidemic
era.'' But, when we refer to page 209, we find an astonishing
numerical discrepancy, or, at all events, a very loose use of
numbers. To continue examining Mr. Battye's monograph criti-
cally might be amusing, but would certainly not be profitable.
Any one desiring to obtain strange information from such works as
the Book of Maccabees, Mrs. Mariet's * History of Astronomy,'
Lardner''s ' Cabinet Cyclopaedia,' 1831, &c., can have their satiety
of such in Mr. Battye's reply to the query ^^ What is vital force ;"
but any earnest student of the subject will avoid it as undeserving
his attention.

The Rational Treatment of Wounds.^— This is an exceedingly in-
teresting little brochure by a commission of distinguished Russian
surgeons on the rational method of treatment of wounds. Fortu-
nately for us, and for European medicine in general, it is written in
excellent French, and with great plainness of speech the commission
give the result of their experiments and inquiries.

The sum and substance of the whole matter is that they believe,

1 Traitement Mationnel des Plates. Methode d'aeration. Moscow, 1877.
Pp. 44.

1877.] Clinical Surgery in Paris. 449

as many excellent surgeons have done before them, that all
bandages and dressings to a wound are evils, perhaps in some cases
necessary evils; that free egress to serum, pus, and blood, with
freest possible ingress of air to aid in drying up secretions and
assisting granulations, are the chief objects of a judicious surgeon.
Still, the wound must be protected from other injurious effects, such
as dirt, pressure, and the like. Theoretically we fancy the aim of
our Russian confreres would be best attained by placing the patient,
or at least his injured limb, in a sort of wire-ganze cover, such as
is to be met with in well-ordered larders, so that flies, dirt, and
pressure, could be kept off", while air is let in.

Several ingenious plans are adopted for aerating the wounds,
and other modes of dressing are discussed. The Lister plan of
swathing the part in multitudinous folds of gauze is regarded as not
so objectionable as it would otherwise be, because the gauze admits
air and lets out discharges.

It is fortunate that nature has great powers of healing, even
without extensive dressings, exorcisms, or poultices of figs, for we
fear that in the Shipka Pass many a poor fellow has more chance
of having to try the method of aeration than more elaborate or
expensive dressings.

Clinical Surgery in the Paris Hospitals.^ — This book is
rather a curious one, in that it is a collection of surgical cases and
observations from all the Parisian hospitals, and the practice of many
or most of the distinguished surgeons of that city. The cases are
selected and arranged at the will of the collector, and their de-
scription seems sometimes to be in the words and from the point of
view of the observer — sometimes to be in the ipsissima verba of
the master who gave clinical commentaries on his own cases. They
are arranged in different ways. Now, we have an account of the
cases illustrating certain forms of disease from the wards of a single
surgeon ; again, we have in the same chapter cases treated by
different surgeons at different hospitals ; and, perhaps, related to
each other by some resemblance, real or imaginary. Thus, the
account of an aphasic at the H6tel Dieu is followed by that of an
operation for blepharoplasty at the Pitie, and then of blepharo-
phimosis at the Hotel Dieu, and one of paralytic strabismus at the
Saint Louis. Many of the cases are interesting, while again, others,
trivial and commonplace, seem to act as padding. On the whole,
however, the work gives a fair idea of what may be found to in-
terest and instruct the surgical student in the hospitals of Paris.
Some subjects have been better worked out than others ; among
those which have received most development are traumatic tetanus,

^ Clinique Chirurgicale des Mdpitaux de Paris. Par le Pocteur P» Gjllettb,
Chirurgieu des H6pitjiux, &c.

450 Bibliographical Record. [Oct.,

and the different modes of treatment; tumours of the eye and orbit,
especially those melanotic ones which so often recur ; fibrous polypus
of the uterus ; spontaneous fracture ; dislocation of the thumb, and
of the astragalus ; erectile tumours.

An excellent alphabetical index to the cases enables the reader at a
glance to select any subject in which he is interested, and very
considerable care has been taken to collect and arrange biblio-
graphical references to rare cases or modes of treatment.

Dr. Gillette is evidently able to read and enjoy our language, as
his references to British and American surgery are frequent. This
volume refers to clinical work extending over four years. We can
fancy that such a work, if published yearly, with the same care
and common sense, would make a most valuable record of Parisian
surgery. We confess that we do not envy our confrere the labour,
which is unselfish, and we fear that the business of selection and
revision of other men^s cases may prove a somewhat delicate task.
Are the successful cases only to be reported ? or should the results
be let alone ?

Excision of Elbow-joint.i — This is an interesting brochure, con-
taining the results of excision of elbow-joint by Dr. E. M. Hodges
during a period of ten years.

First. — As to method of operating : a straight incision behind,
and attention to preserving {a) the connection of the triceps extensor
tendon with the investing aponeurosis of the arm and forearm, {b)
the attachment of the brachialis anticus muscle to the shaft of ulna
and base of coronoid process, and {c) the insertion of biceps into
radius. A claim of originality in the teaching and practice of this
method seems to be well substantiated, so far back as 1855 in the
dead subject, and 1866 in the living.

Second. — As to the cases : we are at once struck by the very great
proportion which the excisions for injury bear to those for disease —
fourteen having been performed for injury, three for anchylosis,
and four only for disease.

Third. — As to fatality : five out of the twenty-one died ; all of
these were excisions for injury, and of these two were complicated
by other injuries ; two died of blood-poisoning and one of tetanus.

Fourth. — The results as to usefulness were all good ; some ex-
ceptionally brilliant, especially two or three of the traumatic cases.
One is depicted in two positions of the arm wielding a heavy
hammer.

^ Excision of Elhow-Joint, showing results. From a series of twenty-one cases
operate^ on at the Massachusetts General Hospital. By H. H. A. Beech, M.D.

1877.] Eustace Smith on Diseases of Children. 451

Eustace Smith on Diseases of Children.l — In the present work Dr.
Smith treats only on diseases of the lungs and acute tuberculosis.
Like previous work by the author, the present is characterised by
carefulness and thoroughness. The book opens with some admirable
remarks on diagnosis and treatment, which are of especial impor-
tance and value.

Collapse of the lung is next fully and clearly considered. The
mechanism of its production is lucidly explained, and its most fre-
quent causes are set forth. The remarks on treatment are very
judicious. Croupous pneumonia is also well described, and the
cases given in illustration are good. We cordially commend the
chapter on pleurisy, and entirely endorse the sentence with which it
opens — " that of all chest diseases in children, pleurisy is perhaps the
one in which mistakes in diagnosis are most often made," the error
consisting, in our experience, in the circumstance that the disease
is frequently overlooked, and even unsuspected.

The author states clearly the causes, symptoms, and treatment of
the different forms of pleurisy, and "his teaching is sound and reliable.
There is one cause of pleurisy and empyema, however, which he
does not mention, perhaps only because he may not have met with
it, to which we are disposed to attribute some importance, viz. frac-
ture of the ribs. It might be thought that such fractures would
be readily detected, but our own experience leads us to think that
they not unfrequently escape observation. A fracture of an infant's
rib would be of the "green-stick" variety, and might not give rise
to symptoms indicative of the injury, as in an adult or older child.
The projection inwards of the injured rib would irritate the parietal
pleura, and " fret " the visceral pleura and the lung at every inspi-
ration and expiration. We have seen more than one illustration of
this — one case proving fatal from empyema, which opened spon-
taneously at the seat of fracture ; there was no necrosis of bone.

In discussing the next subject (catarrhal pneumonia) Dr. Smith
clearly sets forth the differences, pathological and clinical, between
that form of inflammation of the lung and croupous pneumonia.

Chronic catarrhal pneumonia and pneumonic phthisis, its frequent
termination, are well described.

Dr. Smith writes very ably on all lung affections, and we would
especially commend this section of his work.

Another valuable chapter is that devoted to fibroid induration
of the lung. This form of lung mischief, though not so common in
children as in adults, probably occurs in youth with greater fre-
quency than is generally believed. Dr. Smith has very ably pointed

* Clinical Studies of Disease in Children. By Eustace Smith, M.D. London,
1876.

452 Bibliographical Record. I Oct.,

out its characteristics, and the chapter will well repay careful
perusal.

The author's intimate practical acquaintance with children's dis-
eases is well shown in the section devoted to acute general tuber-
culosis. The recognition of tubercular mischief is probably as
important to the practitioner as that of any other disease which
affects children. Not that it is very amenable to treatment — for,
unfortunately, little is to be hoped for in that respect — but because
of the importance, for prognostic and therapeutical purposes, of
making the differential diagnosis between it and other maladies
which are curable.

Dr. Smith gives a very good account of tubercular meningitis,
and the truthfulness of the clinical picture drawn by him will be
recognised by all who are at all familiar with the disease. There is
but one point on which we should be disposed to joiji issue with
Dr. Smith, and that is respecting the duration of the illness. He
says, " It seldom ends sooner than seven days, or lasts longer than
twenty-one." Our own observation would lead us to the conclu-
sion that the duration considerably exceeds three weeks in not a
few cases ; these are the unfortunate cases in which delusive hopes
are from time to time excited, leading only in the end to bitter
disappointment.

We congratulate Dr. Smith on the present work, and trust that
in due time he will favour the profession with a complete and ex-
haustive treatise on children's diseases. Even were it not already fully
acknowledged. Dr. Smith's experience with children's diseases would
furnish ample justification for the consideration of infantile maladies
in a further treatise.

Atthill on Diseases of Women.^ — Dr. Atthill does not put forth
this work as a complete treatise on gynaecology, but offers it as a
contribution to the subject from a clinical standpoint. It embraces
a number of important affections, and in the main affords reliable
guidance to the diagnosis and treatment of most of them.

In the first lecture directions are given for the examination of
patients. They are clear and sufficient. Leucorrhoea and vaginitis
are next discussed, but not at all as clearly or accurately as might
have been expected. In the midst of this lecture remarks on
vascular growths of the urethra are interpolated, which are neither
sufficient nor consistent ; for if they are called " trifling though very
troublesome," " their removal is a matter of difficulty."

The subject of amenorrhcea is pretty fully and judiciously treated,
and dysmenorrhoea is also well handled. We are somewhat afraid,
however, that Dr. Atthill too lightly estimates the dangers attending

1 Clinical Lectures on Diseases peculiar to Women, By Lombe Attbill, M.D,
Fourth edition. Dublin, X876.

1877.1 Atthill on Diseases of Women. 453

division of the cervix uteri. They are confessedly so serious that
the operation should only extremely rarely be performed.

Menorrhagia is fully, though we think not very satisfactorily,
handled. The wisdom of placing nitrate of silver in the uterine
cavity appears to us doubtful. Probably Dr. AtthilFs plan of using
fuming nitric acid is preferable, though that is not an easily applied
remedy.

The author frequently makes use of the term ^' granular ulcera-
tion," which he applies to the granular erosion so often met with
in gynaecological practice.

The condition in question is not one of true ulceration, but of
erosion, and such erroneous pathological teaching is, therefore, mis-
leading.

We cordially approve of the author's emphatic recommendation
to dilate and explore the uterine cavity in cases of menorrhagia,
which are not due to some readily discoverable constitutional or local
condition. Many of these cases are due to intra-uterine lesions,
and are curable only by local treatment.

The remarks on uterine polypi are practical, and we would
especially commend the teaching of Dr. Atthill in respect of treat-
ment. Dr. Atthill recommends the removal of polypi by the wire
ecraseur, because he has seen such profuse hsemorrhage from the
use of the knife and scissors. He also dwells upon the fact that
" intra-uterine polypi, in the majority of instances, occur in women
who have never been pregnant,'' a statement that our own experience
enables us to confirm.

We commend the lecture on fibrous tumours as sound and
practical ; but we are surprised that no reference is made in it to
the treatment of large growths by ablation of the uterus when relief
is demanded and other methods of treatment are impracticable.
Such operations are undoubtedly grave, but so also is the disease,
and the experience of Pean, Keith, Koeberle, Wells, and others, has
been so encouraging that this mode of dealing with large uterine
fibroids merits discussion in any work professing to deal with the
surgery of the subject. Inflammation of the cervix uteri is next
usefully discussed ; but pelvic cellulitis and pelvic hsematocele are
most meagrely and imperfectly dealt with. These are important
and serious affections, and we cannot but regard the work as gravely
defective in respect of these affections, for other matters might
usefully have been omitted to make room for the consideration of
them. It would appear that the author has selected for his lectures
those subjects with which he is most familiar, or in which he takes
the greatest interest. Flexions and versions of the uterus are ably
treated. The statements made are accurate and sensible, and the
teaching is thoroughly reliable.

Lecture XII, on '^ enlargements of the womb/' is not satisfactory.

454 Biblio graphical Record, [Oct.,

This very important subject is dealt with in a disconnected and
fragmentary manner, quite insufficient for practical purposes. It
might reasonably have been expected that in a lecture devoted to
uterine enlargements, a comprehensive and complete survey of the
whole matter would have been given, together with indications for
the differential diagnosis of the various forms ; but such is not
the case.

On the other hand, we gladly commend the lecture on uterine
cancer as on the whole excellent, though we can hardly agree with
the author that in cases of cancer of the body of the uterus we are
" utterly powerless." Ovarian disease is but poorly handled ; and
a practitioner would derive but little help in the diagnosis or treat-
ment of any forms of ovarian disease from the perusal of Dr.
AtthilPs lectures.

But Dr. Atthill is decidedly strong in his excellent remarks on
''uterine therapeutics."" The only thing to be wished is, that he
had given fuller indications respecting the kind of cases in which
the remedies he recommends should be employed.

On the whole, it may be said that in spite of deficiencies, which
their able author would have but little difficulty in amending, these
lectures form a very useful contribution to an important department
of medicine. They excite in us the wish that Dr. Atthill would
undertake a more complete and exhaustive work.

1877.] 455

I.— On the Transmission of Syphilis from Parent to Offspring,
with an Appendix of Cases. By Jonathan Hutchinson,
F.R.C.S., Senior Surgeon to the London Hospital.

That acquired syphilis developes itself with exceedingly
different degrees of severity in different persons all will admit.
For the most part we are obliged to accept this fact without
explanation, and to say simply that in itself it proves that
individuals differ much in their degree, or kind, of susceptibility
to the syphilitic virus ; or perhaps we ought to express our
meaning in somewhat different words, and say that the tissues
of different persons show differing tendencies under the influ-
ence of syphilis. For there are a class of facts which show that
it is not so much differing susceptibility as different kinds of
reaction. Of twenty persons who may show the disease in
exceedingly different phases of severity it may be true that no
one differed from the others as regards susceptibility. All con-
tracted the malady with equal ease, all went through the same
stages, and all were equally protected by it as regards future
attacks ; but how different may have been the kind of ma'ni-
festation. One may have had a sore which lasted, it is true, a
month or two, but which gave him no trouble, and which was
not followed by anything which could be recognised as a con-
stitutional phenomenon, whilst another may be covered from
head to foot with eruption, have lost his hair, had sores in the
throat, iritis, and a state of general ill health which laid him
up for months. That the one as truly went through the stages
of the syphilitic fever as the other is proved by the almost equal
liability to tertiary symptoms, and the equal risk in each of
transmission to offspring. Some physicians — Dr. Wilks, I
think, for one — to whom we are much indebted for investiga-
tions as to severe visceral forms of tertiary syphilis, holds that
it is exceptional in these cases to be able to obtain any good
history of secondary symptoms. Without adopting this opinion,
and whilst believing that the secondary and tertiary sym-
ptoms are usually as regards severity in direct rather than in
inverse ratio, it is yet of importance for my present purpose

456 Original Communications, fOct.

to allude to it, and to admit that it is one for which much
might be said.

It is not true that this varying severity in the secondary stage
is to be explained by reference to the patient's state of health,
temperament, age, sex, or diathesis. The most robust are often
those to sufiPer most severely ; and though we may admit that
syphilis does acquire certain minor diflPerences in connection
with the age, sex, and temperament of its victims, yet these
certainly go but very little way in explanation of the startling
variations in severity to which I have adverted. That the
secondary symptoms are usually in ratio with the primary seems
probable, at any rate it is very rare for a patient who has had
a chancre of unusual development in respect to size and hard-
ness to escape, excepting as a consequence of treatment, a
severe outbreak of eruption, &c. In saying this^ however, we
say little more than that the manner and degree in which a
chancre indurates may be taken as a specimen of the manner
in which the cell-structures of the individual are likely to
behave when brought under the influence of the syphilitic virus.
Apart from this we possess no knowledge which will enable us
to predict during the first stage of syphilis or before it as to
any given person whether he is likely to suflPer severely from
syphilis or not. It would be as easy for a physician to pick out
those who will have smallpox badly. Both in the case of the
medical exanthems and of syphilis it would appear that the
difference in constitution which determines severity or mildness
may be a very slight one, for it is common enough to witness
that, of brothers or other near relatives apparently of similar
temperaments and in like conditions of health, one may suffer
very severely and another escape with a very slight illness.

I feel sure that it is almost impossible to estimate too highly
the importance of this fact, that acquired syphilis is, for rea-
sons which we cannot explain, very unequal in its incidence in
different persons. From want of giving it due weight we are
exposed to endless fallacies in our inferences, both as to the
natural history of this disease and the results of treatment.

A precisely similar line of argument is applicable to inherited
syphilis. We do not yet know within what limits of severity or
of mildness the disease may vary. Our investigations here are
even more beset with difficulty and uncertainty than in the case
of the acquired disease. We do not, in the first place, know
whether inherited taint is always the same kind. It has been
customary to assume, as regards inheritance, that the child
born nearest to the parent's taint is the one most likely to
suffer severely, and the younger, if they do not escape entirely,
ma^ perhaps suffer only slightly. But a possible fallacy under'

1877.] Transmission of Syphilis. 457

lies our creed in this matter which it is very desirable to expose.
It may be that, after all, there are no degrees of severity in inhe-
ritance, no varieties in the potency of the virus received by the
child, and that if a child inherits any taint whatever it inherits, as
a necessity, the whole disease. It is possible that the extremely
unequal severity with which different children suffer is to be
explained rather by differences in idiosyncrasy than by supposing
that one received a large dose of the poison and another a small
one. That this is really so may be made probable if we can
show that of children born within equally short periods of the
parental contamination the range of variation in severity is as
great as in those more remote. It is with the hope of supply-
ing some evidence on this and on many other points in respect
to the facts as to inheritance of taint that I have collected the
following cases from my note-books. They are purposely put
as concisely as is possible consistently with clearness of state-
ment. Isolated cases prove but little, and, being firmly con-
vinced that it is only by the most liberal citation of evidence
that we can hope to arrive at truth, I make no apology for
trespassing on the reader's patience with so many case nar-
ratives.

I cannot better illustrate the apparent irregularity with which
the taint of syphilis is transmitted to children than by mention-
ing two cases which were brought recently under my notice on
the same day. On the morning in question a surgeon from the
country consulted me respecting his own case. He had mar-
ried three or four years after syphilis, having been under treat-
ment in the first instance for about six months, and having
believed himself quite well for two years or more. His wife
never suffered, but her first two conceptions ended in dead
births, and the next two children, although born alive, died
with the usual symptoms of inherited disease. Seven children
now living have all in turn shown symptoms of infantile
syphilis. Thus, it would appear that eleven conceptions have
in succession been tainted, the inheritance being from the father
only, he being in fair health, and a period which has now reached
fifteen years having elapsed since he contracted the disease.
Let me mention my next case in contrast. On the same morn-
ing my friend Dr. Fletcher, of Camden Town, brought to me
a married lady from the country whose antecedents he was well
acquainted with. This lady^s husband had contracted syphilis
during her first pregnancy, and been treated for it by Dr.
Fletcher. His wife about six months later showed the usual
symptoms — had rash, lost her hair, and had sores on the tongue.
Her primary symptoms had been neglected, her husband not
choosing to run the risk of exciting her suspicions. After this

458 Original Communications. [Oct.,

Mrs. has remained under Dr. Fletcher's observation at

times until the present date_, and she still shows numerous sores
on the sides of the tongue and at the angles of the mouthy and
has a few patches remaining on the skin. It was for these per-
sistent symptoms that she was brought to me. Now, the
remarkable fact as to inheritance is this, that this lady has,
during the last two years, borne two children, and that neither
of them has shown any symptoms. It will be seen that they
are the oflPspring of parents both of whom have suffered within
three years, and one of whom (the mother) still shows symptoms
indicating considerable activity in the virus. I have been care-
ful to say merely that they have shown no symptoms, not that
they have escaped, for I do not believe that they have escaped.
I should almost regard it as impossible that children could be
born under such circumstances and escape a taint. Without,
however, believing that they have really escaped, the two series
of facts may serve well enough to illustrate my point as to very
unequal severity in the incidence of the disease, and to suggest
a source of fallacy in our observations which we ought con-
stantly to keep in mind, and for which it is almost impossible
to make too much allowance.

I. Inheritance from Father and Mother. — Case of Esther R — , 46,
and daughter; (Bag ^'Syph. Paralysis"). — Mother had an eruption
six weeks after marriage, which her husband told her was caused by
venereal disease from him. This was sixteen years ago ; two years
ago she had sudden left hemiplegia, and paralysis of right fifth
nerve ; was unconscious for three weeks. Gradually recovered, but
had a relapse on same (left) side, and again has nearly recovered
power of left arm and leg, and partially sensation of right face j
right eye lost. No details as to husband.

1. r., set. 14, no history of infantile symptoms, but a doubtful
account of keratitis.

2. F., died at birth.

3. F., set. 9, now under my care. Periostitis of left tibia;
double keratitis ; typically notched teeth.

4. F., died at birth.

5. F., died at birth.

There were also two miscarriages at about three months, the dates
of which in reference to the other pregnancies is not noted.

II. Inheritance from hoth parents. — Anne H — , 4, M. F. " 0,*'
p. 128, and Honora H— , M. F. "0," p. 140.— Mother had
primary and secondary syphilis eleven years after the birth of her
first child. No note of father.

1. Reported to be quite healthy. Now mother's syphilis.
Since then seven other children. Of these five have died : one

1877.] Transmission of Syphilis, 469

at three weeks; one at one week; two born dead; one at two
weeks ; two are living, viz. Honora (see reference above), set. seven
years. Typical aspect and nose. Sores in mouth from sharp
teeth. Anne, set. four years. Scars about anus and on legs
(" ? small-pox ^^) and strumous ophthalmia.

III. Inheritance from ioth pare^its. — Sarah G — , 26, and son,
M. E. N., Nos. 2896, p. 133, and 30, 58.— Mother married eight
years. Good health till then, but failed afterwards. No history of
primary or definite secondary disease. Had sore tongue and mouth ;
then four years after marriage serpiginous eruption on knees ;
then nodes on tibia, and now enlargement of right femur, rapidly
diminishing under iodide. No note of father.

1. Mi. eleven, reported to be healthy and never to have ailed
anything.

2. Died, set. five weeks, with snuffles and rash.

3. M., James G — , set. 6. Had severe snuffles and rash, and a
condyloma on tongue, which was burnt, and scar remains. Now
kerato-iritis.

The evidence as to the father is negative ; the wife may have
acquired it elsewhere after marriage, but her history is more that of
disease from conception.

IV. Inheritance from Father ? — Case of Mora C — , B. 33, and
my book, p. 168. — No history of syphilis in either parent to be
obtained from mother. She thinks her husband may have had it
before marriage.

1. r., died at one month.

2. M., died at birth.

3. E., died at birth.

4. F., died at nineteen months.

5. E., died at four months.

6. Died at ten months, ^'atrophy."
Several of these had blotches, &c.

7. Elora C — , 10. No history of infantile symptoms. Now
most typical teeth and physiognomy. Lately, extensive choroido-
neuro-retinitis in each eye, and partial idiotcy.

8. E., died at ten months.

9. E., seven years old, '^ healthy."

Remarks. — Persistency for seven years, at least, very probable.

V. Inheritance from Father and Mother. — (H — family. M. E.^
vol. 1, case 207 ; vol. 3, pp. 63 and 139 ; vol. O, p. 106 ; vol. M,
pp. 165 and 292 and 107 ; vol. K, p. 29.)— Eather had primary
syphilis and suppurated buboes at set. 20, two years before marriage.
Now (set. 27), has psoriasis palmaris. Wife had no symptoms till
after birth of first child, when she suffered from sores and condy-
lomata.

4^60 Original Communications. [Oct.,

1. M., Edward H., set. 5, Sept. 29, 1857. Had snuffles for
three or four months, and was puny till set. two years. Then '4arge
patches of psoriasis'' on face and chin, which afterwards became
*' slightly tubercular/' and was cured by iodide. Then at set. 5
condylomata at anus.

2. M., John W. H., at set. 5 weeks ; '^beginning to waste/' and
commencing ^^ syphilitic psoriasis'" January, 1856.

3. M., Thomas H., set. 6 months, (Oct. 1859). Snuffles, severe
cachexia, psoriasis, &c. Syphilitic onychia {nails sketched) .

Bemarls. — It is possible from the above statements that the
mother contracted primary syphilis after she had borne a syphilitic
child. If so we should have an exception to Colles' law. But
against such a supposition is the fact that if it were true we should
have to suppose that the husband had fresh syphilis within a short
period of his first attack. I have thought it best to let the notes
stand as I made them twenty years ago, but my present belief is
that the wife must have been mistaken in her history, and that
probably what she described as her first symptoms were only a
relapse.

We have proof of persistence of transmission for seven years,
and I beheve that it extended much longer. Mrs. H., who sufi'ered
most severely, was under my observation for ten years or more, and
brought me child after child all suffering with equally definite and
severe symptoms. The last that I saw suffered just as severely as
the first. All were born alive, and I believe that under treatment
all survived. I regret that my notes do not supply details of more
than the above three.

VI. Inheritance from Mother only, — Bag "Hered. Syph.," drawer
34. Joseph A — , 3. — Mother caught syphilis from a nurse child
seven years ago and between her third and fourth pregnancies. She
had a sore on nipple and copious secondary symptoms ; good health
since. No note as to father.

1. M., died at ten years of '^phthisis.'' No history of syphi-
litic symptoms.

2. Living, 8^ years old; reported good health.

3. Died of " fever.''
Now mother's syphilis.

4. Died at three months, "gastric fever." History of syphilitic
symptoms.

5. Joseph Andrews, 3. Had bad snuffles and rash and swellings
on head, which did not break. At three months, inflamed eyes
resulting in occluded pupil in the right (iritis). Scars at angles of
mouth, head large, nose flat, upper incisors decaying.

6. Died at seven months.

UemarJcs. — Death-rate two in three before the syphilis, and the
same subsequently.

1877. J On the Transmission of Syphilis. 461

This case and the following are alike, in that the mother con-
tracted syphilis accidentally and at a known date. There is every
reason to believe that in each the inheritance was from her only.
In Mrs. D.'s case I myself saw and treated her chancre. Both
women had borne children before the accident. It is a warning
lesson against hasty inferences to note that in each the infantile
death-rate had been very heavy before the disease was introduced.

YII. Inheritance from Mother only. — Mrs. D — , 36, and infant
M. F. L., pp. 13 and 384, and K., p. 32.— Mother contracted
syphilis by nursing a neighbour's child, which shortly afterwards
died of the disease.

She had a characteristic hard chancre on the nipple, followed by
rash and condyloma. She had weaned her own baby just about the
time when she began to suckle the neighbour's child. Her own
baby remained healthy. The neighbour's child had a badly ulcerated
mouth.

Born before mother's syphilis :

1, 2, 3, 4, 5, 6, 7, four dead (no details) ; three living, and
reported healthy.

8. Living and healthy, weaned just before mother caught syphilis.
Now mother's syphilis; chancre, December, 1857 ; rash, &c., to

June, 1858.

9. Born dead in October, 1858.

10. M., George D., set. 1 month, born September, 1859, at
eighth month. Was very ill at birth, and soon wasted ; under care
for severe syphilis at aet. one month, and died soon after.

VIII. i^^^^(?r.— George P—, 47, and son, G. 313.— Father denies
ever having had any venereal disease, but admits risk before marriage.
He is under care for cycloplegia of one eye (incomplete) and had
old choroiditis in the other.

1, 2, 3, 4, 5, and 6. All F., all alive, and reported to be and to
have been healthy. None are deaf, and none have had bad eyes.

7. M., died at set. three years, of " smallpox'' ; all the others also
had the disease, but the parents did not take it.

8 and 9. Miscarriages.

10. M., set. 9 ; now under care for severe double keratitis, with
a small hypopyon in one eye. Teeth suspicious.

Remarks. — It may be plausibly suspected that the disease was
introduced between the seventh and tenth birth.

IX. Father and Mother.— M.ZXI B— , 14, M. F. J., p. 1631.—

There is here no history of syphilis in father, and only an account
of some sores about genitals and anus in mother '' after one of her
early confinements." The husband, a few years after marriage,
was found to be living with another woman, and from the facts
120— IX. 30

462 Original Communications. [Oct.,

as to the children, it becomes nearly certain that syphilis was
introduced by him between his wife's first and second pregnancies.

1. F.j set. 18, well grown, florid, and shows no signs whatever of
syphilis.

2. Born dead.

3. Died at nine months, '' water on the brain.''

4. P., Mary B., set. 14, extremely marked syphilitic physiognomy,
typical teeth, nearly blind from most severe keratitis and iritis, for
which she attended hospitals between set. 6 and 10. Not deaf.
History of nodes on head. Very severe rash and illness in infancy.

5. Died at two weeks.

6. Died at ten months.

7. Living, set. 11 years. Forehead large, but nothing charac-
teristic of syphilis in physiognomy. Is dehcate.

8. P., died at eight months.

9. r., died at ten months, with "the head."

10. M., Living, set. 6 years. Eeported healthy.

11. r., died at ten months.

The facts as to the cause of death of several of the infants are
wanting, but there is no proof that the disease persisted long in the
family. It is not certain that more than one suffered, although the
two following deaths may be suspected.

X. Inheritance from Father (G. 211). — Father had syphilis at 17,
and has since had much psoriasis, benefited by mercury; now has
nerve symptoms. (The above is from the surgeon who has attended
him throughout.) Mother is the subject of well-marked hereditary
syphilis, with keratitis ; is eighth of thirteen, nine of which were
stillborn. One of the four living ones has fits and is partly out of
his mind. She has had no disease from her husband (direct
questions) .

1. M., set. 12, now has interstitial keratitis of one eye and
choroiditis in other. History of severe infantile symptoms.

2, 3. Born dead.

4. Living; said to have had no symptoms.

5. Born dead.

6. 7, 8, 9. Living, and reported to have had no symptoms.
10. Born dead.

Of the six living five are males, one female.

Of the four still-born two were males, two females.

Remarhs. — In this and the following case it of some interest to
note that the mother was herself the subject of inherited taint.
Had it happened that the history of disease in the father had not
been forthcoming it might have been assumed that the child in-
herited from her mother, and that we had proof of transmission
0 third generation. All facts seeming to support such a supposi-

1877.] On the Transmission of Si/philis» 463

tion must be received with much doubt, unless the history of the
other parent is very clearly negative.

XI. Inheritance from Father. — Case of Sarah E — , F. 374. —
Date of father's syphilis not ascertained; has been ''very gay," and
is now (set. 53) hemiplegic. Mother married to him thirty-one years,
and now 53 ; has several times had gonorrhoea from husband, but
no history of syphilitic symptoms. She is herself the subject of
hereditary syphilis.

1. Miscarriage at third month, twelve months after marriage.
Now the interval of twelve years without a pregnancy ; during this
time and three years after marriage husband gave her gonorrhoea
for first time.

2. M., born dead at full time.

3. 4, 5, 6, 7. All miscarriages.

RemarJcs. — Not a single viable child, but no proof that any were
syphilitic.

XII. Father J probably. — Case of Mary Anne B — , 9, G. 319. —
Father reported by mother to have had good health till after birth of
first child. Between first and second child he became ill of " rheu-
matism.'' Was very ill for a year and a half, and never well after-
wards, but no history of syphilitic symptoms. He died at 43 of
" bronchitis " and " consumption.'' Mother robust and healthy,
appears to have had no symptoms.

1 . M., living, 23, always had good health. Now father's ill-
ness, probably syphilis, with severe rheumatic symptoms.

2. M., died at fourteen months; a "healthy fat baby," died
after six days' illness ; " teeth and inflammation."

3. Born dead.

4. M., died at first month. " Delicate."

5. P., died at fourteen months. Weakly; "abscess on shoul-
der."

6. P., died at five years. " Diseased bone behind ear," probably
result of '* measles and scarlet fever."

7. M., died at eight months.

8. F., died at eight months.

9. F., Mary Anne B — , set. 9. Interstitial keratitis of right.
Extremely typical teeth. Slight deafness. Moderately characteristic
physiognomy. Scar of an abscess under right lower jaw (probably
strumous).

It is very probable, but not certain, that the father had syphilis.
The great mortality is remarkable.

XIII. Inheritance from Father (F. 398). — Father had venereal
disease, with bad throat, twelve years ago. Has had multiple round
ulcerson right leg since primary disease, and now has paresis of left
sixth nerve and noise in left ear of three weeks' duration.

464 Original Communications, [Oct.,

Wife has had seven children, six M._, some of which were born
dead, and all the rest died within a few days of birth.

1. P., living, set. 8. She shows no signs of syphilis, but has not
yet cut permanent incisors. She is about the middle one of the
seven.

Remarks. — But one child living out of seven. All died within
a few hours of birth, but there is no absolute proof of syphilis in
any.

XIY. Inheritance from Father. ^Odi^o, of Mr. P — , 44. Priv. H.
197. — Father had severe ''gonorrhoea" twenty years ago, lasting
many weeks (twelve years before marriage). No history of lecond-
ary symptoms or of a chancre. He has, however, characteristic
white marks on tongue and inside cheeks. Married eight years.
Wife appears not to have suffered.

1 and 2. P., both living and healthy; had no symptoms.

3. M., died at a few months. The surgeon said it was syphilitic.

4. M., born prematurely; died at two weeks.

5. M., living and well.

6. M., died at six weeks. Was covered with '' syphilitic rash."
Remarks. — This case is difficult of interpretation. It is difficult

to avoid the suspicion that the taint was introduced by one of the
parents between the birth of the second and third, probably by the
father. If this be so we have three deaths out of four.

XV. Inheritance from both Father and Mother. — Case of
Edward H— , 9. G. 146. — Father "gay;" wife knows he "had
venereal disease several times, both before and since marriage.'^
Details wanting. Wife has had vaginal discharge repeatedly, and
some history of recent secondary symptoms.

1. M., a*^seven months' child; died at birth.

2. M., Edward H — , 9; a seven months' child. Had bad
snuffles; no rash. Interstitial keratitis; typical teeth. Charac-
teristic physiognomy. Badly grown. History of purulent ophthal-
mia in infancy.

3 and 4. M., Twins, born dead at six and a half months.

5. M., died at eighteen months, ''teething." Thrush and
snuffles. A seven months' child.

6. M., died at birth. Seven months' child.

7. P., living, set. 14 months. Had snuffles. Now pale and
badly grown.

Remarks. — The taint has lasted through the whole family, unless
in one or other parent it has been reintroduced.

XYI. Inheritance from both Father and Mother. — Mrs. J — ,
H. S. D. Daughter at Moorfields, for keratitis, Nov., 1873.— Hus-
band had syphilis between the second and third child ; treated and

1877.] On Transmission of Syphilis. 465

got quite well, and has remained so ever since. Mother had it from
him during her fourth pregnancy ; she had it mildly, but five years
later began to suffer from severe ulceration of nose, leading to loss
of bone and destruction of the alse. Cured by iodide at Skin
Hospital, and has remained well for the last six and a half years.
Was my patient at Skin Hospital.

1. I"., 16. ^ Good health.

2. Miscarriage.

3. M., 14. Good health.

During next pregnancy the syphilis occurred. It is not stated at
what period of pregnancy the mother became infected.

4. F., 12. Had snuffles, and gave her mother much trouble in
infancy. At aet. 12 had typical interstitial keratitis ; under my
care at Moorfields. Typical syphilitic teeth.

5. M., 11.

6. F., died at ten weeks.

7. M., 8. In good health.

8. F., 6. In good health.

9. F., 5. In good health.

10. M., 4. In good health.

11. F., 9 months. In good health.

Several of these had snuffles in infancy, but none ailed much.

Remarks. — It may be doubted whether the younger children
have really inherited any taint. The single symptom of snuffles
estimated only by the mother cannot count for much, still it is
possible that it was of syphilitic origin. It is an instance of a child
in utero contracting syphilis from its mother, but unfortunately
the stage of pregnancy at which the disease was acquired is not
known.

XVII. Inheritance from both Father and Mother. — Case of
Lillian W — , 5. F. 388. — Mother had venereal disease, with spots
on thighs, a month or two after marriage. No positive history of
symptoms in father.

1. F., born dead.

2. F., LiUian W — , 5. Had snuffles in infancy ; now has inter-
stitial keratitis and suspicious physiognomy.

Remarks. — We have here the first born, after recent disease in
both parents, killed probably by it, and the second suffering severely,
but surviving.

XVIII. Inheritance from both Father and Mother (?). — Case of
Eliza T — , 2. G. 16. — Mother had sores on genitals and spots on
thighs three weeks after marriage ; no history of general rash, but
her hair came out. No particulars as to date of syphilis in father,

1. F., born dead at seventh month.

2. F., born dead at eighth month.

466 Original Communications, [Oct.,

3. F.j Eliza Taylor, %. Had snuffles, thrush, and eruption on
head and buttocks. Now has choroido-retinitis in each eye.

4. M., set. 6 weeks. Eeported healthy.
P.S. — Two and a half years after above notes.

5 and 6. Born since above notes, and reported healthy.

Remarks. — As in the preceding case, we have first dead births,
then a child suffering severely but surviving, and then healthy
children.

XIX. Inheritance from Father and Mother (F. 347). — Case of
Mrs. M — , set. 36. — There is no statement as to syphilis in the
father, but there can be very little doubt. The mother, who has been
married to him fifteen years, and seems never to have had symptoms
of syphilis till nine months after the twelfth confinement, when she
came under care for paralysis of one third nerve, which passed off
in two months under iodide.

1, 2. M., born dead.

3. Y.J born dead.

4, 5, 6, 7, 8, 9, 10, 11. M., all born dead.

12. M., set. 10 months. Had bad thrush, eruption and snuffles,
and now has a somewhat prominent forehead, depressed nasal
bridge, and sore at angle of mouth. No condyloma.

Remarks. — A good instance of what is supposed to be very
common — a long series of dead births due to taint. If we may
assume that syphilis was the cause, and that no second introduction
of the disease occurred, we have proof that transmission may occur
twelve or fifteen years after the primary malady.

XX. Inheritance from hath Father and Mother. — Amelia L — ,
set. 9 (M. P. N., p. 174). — Eather has now badly cracked syphiKtic
tongue. Mother no symptoms, except pains in bones.

Eour pregnancies ; one miscarriage (date not given), three born
alive, as under :

1. F., Amelia L — , set. 9. Treated by Mr. Startin in infancy
for rash on buttocks, &c. ; had no snuffles ; now kerato-iritis
(began with unusually well-marked iritis, the corneal haze super-
vening shortly after) .

2. Living, and reported healthy.

3. Died at two months. Was a six months' child.

XXI. Inheritance from both Father and Mother (S. H. Letters,
1868-70, 246).— Harriet T— , set. 44.— During the last four years
mother has had several large gummous tumours on left arm and
elsewhere. In other respects has had good health since marriage.
Husband reported healthy, but no details as to whether the syphilis
was derived from him.

J. M., died at four months.

1877. J On Transmission of Syphilis. 467

2. P., set. 14; lias notched and screw-driver teeth, but nothing
else.

3. P;, set. 13. No signs of syphilis in teeth or physiognomy.

4. M., died at four months.

5. M.J died at two months.

6. 7, 8, 9. All P. Living, and reported healthy ; one who comes
shows no signs.

Remarks, — The children were brought up by hand, away from
home, and mother knows nothing of the symptoms in the third
(M.), who died in infancy. In this instance the taint appears to
have ceased, and the younger children have shown no symptoms.

XXII. Inheritance from Father only, — S. H. Letters, 1875,
375. James L — , 43. — Father had a chancre, for which he took
pills till his mouth was sore, eight years ago. Had no secondary
symptoms. Comes for pityriasis palmaris of one hand, which has
rapidly healed under bichloride of mercury.

The primary disease occurred after death of his first wife and
one year before he married a second time. The conceptions ter-
minated as follows :

1, 2. Miscarriages at third month.

3. P., died at birth.

4. P., died at two weeks.

5. P., living, set. 9 months ; reported to have snuffles.
Memarhi. — Here we have two miscarriages, a dead birth, and

an infant which died early, and then a living infant which showed
symptoms. An instance of too early marriage after syphilis.

XXIII. Both Farents,—'L. H. Letters, 1868-70, 468. Emma
P — , 32. — Mother suffering from serpiginous tubercular eruption on
forehead, of nearly two years' duration. It began about five months
after first confinement, probably by conception. No note as to
husband ; married three years.

1. P., born nine months after marriage ; died at two days.

2. P., living, set. 1\ year. Had snuffles, but no thrush. Bridge
of nose depressed, frontal eminences prominent, upper incisors have
already dropped out.

XXiy. Father. ^Y.,^.\h^. Case of Maria D—. Pathernowin
late tertiary stage ; has lost bone from hard palate and had extensive
ulceration of soft palate and uvula ; dates of syphilis and marriage
not given. No note as to mother.

1. born dead.

2. M., living and reported healthy.

3. Born dead.

4. M., living and reported healthy.

5. P., comes to hospital at request. No signs of syphilis; no
history of past symptoms.

468 Original Communications. [Oct.,

6. M., living and reported healthy.

7. F., Maria Daff, 13. Typical teeth and symmetrical inter-
stitial keratitis and iritis ; deafness.

8. 9. P.

10, 11, 12. Miscarriages.

13. M.

14. F.

15. M., aet. 6 weeks. Reported to have thrush.

Bemarks. — In all probability the disease was acquired by one or
both parents between the sixth and seventh births. The subse-
quent notes are imperfect.

XXY. Inheritance from Father prohahlT/. — Case of Matilda J — ,
19, 1\ 304. — No conclusive evidence as to source of the syphilis.
Mother married twice, and several of the children by the second
husband furnish more or less conclusive evidence of the introduction
of the disease by one or other parent at that date.

By first husband :

1. P., set. 27. Shows no signs of syphilis.

By second husband (probable date of introduction of syphilis) :

2. M., died in infancy.

3. P., died in infancy.

4. E., Matilda J — , 19. Interstitial keratitis; screw-driver
teeth ; scarred angles of mouth ; chronic synovial thickening of left
knee-joint.

5. r., living, set. 17.

6. r., living, set. 15.

Said to be, and always to have been, in good health.
Remarks. — The taint would appear to have ceased with the fourth
child.

XXVI. Inheritance from Father, ^Q^, 301.— Father had well-
marked syphilis about eighteen years ago (date in relation to mar-
riage not stated). Was salivated for the secondary symptoms.
Now paresis of right third nerve.

1, 2, 3, 4, 5, 6, 7. Miscarriages.

8. F., set. 13. Is very stunted ; looks only eight. Physiognomy
suspicious, but not more. Teeth normal. A single ahruptly defined

patch of choroidal atrophy at periphery of one eye.

9. M., set. 8. Healthy looking and well-grown.

10. Living, reported healthy.

The choroidal patch is important and interesting evidence.

Remarks. — It is probable that the child was born within five
years of her father's syphihs. No facts as regards the escape of the
mother are recorded. Four years after the birth of the tainted but
viable child we find healthy infants.

1877.] On Transmission of Syphilis, 469

XXVII. Father {}), — Case of Mary A. S — , syphilitic keratitis.
—Father a sailor. Mother knows of no suspicious symptoms either
in him or herself. He is troubled with "abscesses." Probably
the father had the disease before the birth of the fourth child.

1. M., 28.

2. r., 26.

3. E., 24.

Conjectural date of syphilis.

4. Born dead at eight months.

5. Born dead at seven months.

6. F., 20^ Mary Anne. Has still the remains of keratitis, which
occurred at set. 9. Teeth typical.

7. P., died at six weeks " from a small bleeding sore.""

8. M., 16. Good health.

9. M., died at 3 of measles.

10. P., died at nine months of measles.

11. M., 9. Good health.

12. P., died at a year and three quarters, of measles.

13. 14, 15, 16, 17, 18. Miscarriages at about four months.
None of the children, according to the mother's memory, had

suspicious symptoms in infancy, but the sixth was the most delicate
baby.

Remarks, — We have here a large family only one member of
which shows undoubted signs of inherited syphilis, she being born
after two miscarriages, which had been preceded by three healthy
children. After five others had been born, all of which remained
free from symptoms, we have a series of six miscarriages.

XXYIII. Inheritance from Father. — Case of Pairlie D — , 8.
P. 280. — Husband probably had syphilis before marriage. No evi-
dence that the mother ever suffered at all. Married eleven years.

1. M., a premature birth, died at five days.

2. M., Pairlie D — , 8, kerato-iritis and characteristic physio-
gnomy. Teetii malformed, but not characteristic of syphilis.

3. P., died at one week.

4. Miscarriage.

5* M., living, set. 5.

6. P., died of '^ wasting^' at four months.

7. Miscarriage.

8. M., born dead at seventh month.

Remarks. — The taint has probably persisted through eleven
years.

XXIX. Inheritance from Father , prohahly. — C. 313. Case of
Alice B — , 8. — Date of syphilis doubtful. Father had a deep ulcer on
one arm ai30ut three years ago. Mother had eruption of red blotches
on her legs after birth of the eleventh child (the patient) ; these

470 Original Communications. [Oct.,

have left stains eight years after. Thus, probably the mother's
disease was due to her foetus.

1. M., died at six years.

2. E., living, 22. No symptoms in infancy or since.

3. r., living.

4. 5, 6 and 7. Miscarriage at about third month.

8. M., 16 ; no symptoms at any time; healthy.

9. I^., 15 ;

10. M., 11 ;

Probable date of syphilis in father.

11. F., Alice B — . Scaly rash on forehead at three months;
subsequently severe symmetrical keratitis, partial deafness, elonga-
tion of tibise. Teeth good.

12. M., 6. Healthy (not seen).

Bemarks. — A single member of a large family suffering from
syphilis; predecessors and successor reported healthy. Several
miscarriages at a distance from the syphilitic child, and with healthy
children intervening. Probably the disease was contracted by one
or both parents not long before Alice B — was conceived.

XXX. Inheritance from Mother and Father , prohahly. — L. H.
Letters, 1871, 343. Louisa S — , 29. — Mother had sores on genitals
before first confinement, but does not remember any rash. Now has
ulcers and scarring on one forearm and on front of neck. No
history of husband.

1 and %, Both born dead.

3. Died with snuffles and rash at three months.

4. Living, set. 5 years. Attended at L. H. for a rash on the
face, but no details obtainable.

5. Living and reported healthy and not to have had any
symptoms.

6. Died at nine weks with eruption and other suspicious
symptoms.

Remarks. — Here the taint ^eems to have persisted through the
family, but to have fallen on different children with very varying
severity.

XXXI. Inheritance from Father. — Case of Mary Anne S — . F.
356. — Father had some venereal disease when set. 18, two years
before marriage. Was salivated for it, and " afterwards " had ulcers
on the left leg for several years, which have left scars. No definite
history of secondary symptoms.

Mother died of " decline" at 54.

Family consisted of sixteen children, born alive. Of these only
five are now living ; eleven are dead ; some died at a few days,
some at about fifteen months, and one at 26, of "decline.''

The five living children :

1877.] On Transmission of Syphilis. 471

1. (the first born), set. 27; married. No history of symptoms.
(Order of the next three doubtful.)

2. F., set. 21. Married; no history of symptoms.

3. M., set. 18. No history of symptoms.

4. Mary Anne S — , set. 15. Well-marked interstitial keratitis
of long duration. Other evidence wanting.

5. P. (the ].6th and last child), set. 12. No history of sym-
ptoms.

RemarJcs. — It is possible that in this family the tendency to
transmit syphilis extended over many years. This depends upon
the assumption that the one who died set. 26, and who had been
under my care for her eyes, was tainted. If she were, then it is certain
that a sister, ten years younger, suffered also. On the other hand,
the disease may have begun either for the first or second time
just prior to the begetting of our patient, Mary Anne.

XXXII. Inheritance from Father and Mother. — Case of Wm.
M — , 18, G. 318. — Father, formerly a soldier, told the mother
that he had had venereal disease several times before marriage,
but never admitted having it after marriage. It is probable, how-
ever, that he had syphilis during or just before his wife's fourth
pregnancy (miscarriage). After this event he was in military hos-
pital for four months for an inflamed eye, while immediately after
the miscarriage his wife had well-marked secondary syphilis, for
which she was salivated. The history of the children makes it
highly probable that the father had had syphilis also before marriage.

1. -F., living, 23. Had bad snuffles and thrush.

2. Miscarriage.

3. F., living, 20. Weak health. No infantile symptoms.
Now father's syphilis (? second attack).

4. Miscarriage.

Now mother's secondary symptoms.

5. M., Wm. Matthews, 18; history of condyloma (probably) at
one year, and about same time severe rash of '^ round places like
burns," " as large as shillings all over him " (? late secondary).
Now has interstitial keratitis, typical teeth, and characteristic
physiognomy.

6. M., died at three months. "Convulsions."

7. F., died at nine months. " Whooping-cough" and ''debility."

8. F., died at one month.

9. M., died at five months. " Measles."

10. F., born dead.

Since the last child there have been two or three miscarriages,
also about six or seven between the various children ; eighteen or
twenty pregnancies in all, and only three children surviving infancy.

Remarks. — The mortality in this family was very heavy indeed.

472 Original Communication. [Oct.,

It is unfortunate that I had no opportunity of seeing Nos. 1 and 3,
and making certain whether or not they were tainted. If they
were then it is probable that both parents had syphilis twice, the
father after chancre-syphilis and the mother after syphilis by con-
ception.

XXXIII. Inheritance from Father. — Case of Albert B—, 13,
G. 91. — Father had "clap^' for three weeks two years before
marriage; '" cured by three boxes of pills." Had no secondary
symptoms. No note as to mother.

1. M., living, set. 15. '' In infancy covered with sores all over.''

2. F., living, set. 14. '' Well till vaccinated, then all her teeth
decayed."

3. Miscarriage.

4. M., Albert B — , 13. Severe double keratitis ; deafness ;
typical teeth and characteristic physiognomy. Eemarkably soft
skin. Death at set. 15^, of " disease of the brain."

5. M., died at four years. ''Consumption;'' was very delicate
from birth.

6. F., living, set. 9.

7. Miscarriage.

8. M., born dead.

9. F., living, aet. 4.

10. Miscarriage.

11. M., living, set. 11 months. Is delicate.

It is very probable that the fourth child suffered from a taint
contracted before marriage. The facts are imperfect, because none
of the other children were inspected.

XXXIY. Inheritance from Father and Mother. — Wm. W — ,
7 months. M. F. J., p. 421. — Mother had syphilis from husband
a month after marriage. No other details.

1. Born dead.

2. Wm. Wooley, set. 7 months. Born twelve months after first
child. Is under care for well-marked snuffles, syphilitic rash, and
sores at angles of mouth.

XXXV. Inheritance from both Father and Mother. — Mrs. M — ,
26, and child, M. F. K., p. 173. — Mother married twice. During
first pregnancy by second husband she had syphilis fully. She was
not fully salivated.

The mother's children by first husband are —

1 and 2. Living and reported quite healthy.

Now father's (second husband) and mother's syphilis during
pregnancy with —

3. Born dead at seven and a half months.

4. Hannah Elizabeth M — 1, set. ten weeks. Healthy at birth, but

1877.] On Transmission of Syphilis. i7S

soon began to snuffle, and now has in addition well-marked syphilitic
rash.

Eemarks. — In this case it would appear that syphilis contracted
during pregnancy (exact date uncertain) caused the death of the
foetus.

XXXVI. Inheritance from loth Mother and Father. — Case of
Mrs. W — , 33, Priv. H. 344. — Father has had syphilis, but its date
is not stated. The mother had chancre and secondary symptoms six
years ago, soon after her first confinement. Probably took mercury,
but not to salivation. Now has fissures in nostril.

1. Born dead at full time, nine months after marriage.
Now mother^s syphilis.

2, 3, 4, 5, 6. All born prematurely at six to seven months, and
died a few hours or days after birth. The sixth had spots on skin,
and died in half an hour.

Remarks. — It is not improbable that the mother really had her
chancre just before her first confinement, and that the foetus died in
consequence. The eff'ect of the taint as regards the subsequent
conceptions was unusually fatal.

The foregoing series of facts have been taken, with but little
selection, from my note books, and they comprise but a small
portion of those which I possess. They are sufficient, however,
not alone to illustrate some of the difficulties which attend the
inquiry, but to furnish valuable evidence on several of the
questions under debate. Amongst the difficulties is to be men-
tioned, first, the circumstance that in most cases the history
has often to be collected backwards from the memory of un-
trained and uninformed observers. It is but very seldom that
the whole history of a syphilitic family can be got from a
medical witness who has himself been conversant with all the
facts. This risk as regards errors in statement, which applies
to almost every individual case-narrative, renders it needful to
place a large number in juxtaposition, that thus the fallacies of
some may be corrected by others.

I shall not attempt any statistical analysis of my facts, since
such could not be otherwise than tedious and unsatisfactory. I
must leave the reader to form his own impression as to their
teaching, and shall base the few remarks which I append in part
upon them and part upon my recollections of others.

One of the most important of the fallacies which we en-
counter is that of —

The possible influence on offspring of second attacks in one or
other parent.

Although second attacks of true syphilis are rare, yet they do

474 OHginat CommunicaUon. [Oct.,

undoubtedly occur. That the course of the disease differs much
from what is usual in first attacks seems highly probable. In
not a few a second infection ends^ or appears to end, with the
local sore, and in those in which constitutional phenomena are
witnessed they are usually mild. Now and then, however, a
person who has at a distant period been through a well charac-
terised attack of syphilis passes through a second one, which is
complete in all its stages. It is, of course, very common for
patients to tell us that they have had the disease several times,
and although in the majority of cases we put aside this state-
ment as a mistake, yet it is not safe to do so always. This
possibility of a second infection makes it unsafe to measure in
all cases the period of liability to transmit from the date of a
known attack.

I have endeavoured, whenever possible, to trace the taint to
the parent from whom it originated, with the object of trying
to answer the question —

Is inherited syphilis more severe when derived from the
mother than from the father ?

I take for granted (although I know that there are still
some who doubt) that it is possible for a father to transmit the
taint, the mother being at the time of conception wholly free.
I believe, indeed, that in practice this is by far the most com-
mon way in which syphilis is transmitted. Whether in these
cases it is correct to speak of the inheritance being paternal
only is, as we have just seen, another matter, since it is pos-
sible that in every instance the mother derives an infection
from the foetus, and may thus in return influence it. It is,
however, scarcely probable that an embryo in which the disease
existed in such power as to be competent to contaminate the
maternal organism, should be susceptible of further hurt in the
manner suggested.

It is, fortunately, not common to encounter cases in which
married women have had syphilis, either before marriage or
subsequently, independently of their husbands.

We have, therefore, comparatively few observations of fami-
lies born to a tainted mother, the father being free. The
foregoing list contains two such, in both of which the mother
after marriage was infected through a chancre on the nipple
(See Cases VI and VII). In each instance the subsequent
children suffered severely, but not more so than in many in-
stances in which the inheritance was paternal only. From time
to time other cases of this kind have come under my notice,
and although I have formed a general impression that it is rare
for the children to escape when the mother has suffered from
chancre-syphilis, yet I know of no facts which would uphold

1§77.]

On Transmission of Syyhitis, 475

the belief that they do so more severely than under other
circumstances.

The question, Is inherited syphilis more severe when inherited
from both than from one parent? must be answered in the same
manner as the preceding one, there is no proof that it makes
any difference whether the inheritance is from one or both.

That the noteworthy differences bet\Teen chancre-syphilis and
the inherited disease are to be interpreted by consideration of
the differences in the tissues of the growing child and the adult
is made very probable by what is observed when a mother near
the end of pregnancy becomes infected with primary disease.
In such a case the foetus, nearly full grown, acquires the disease,
without a chancre, directly from the maternal blood. It is
acquisition, not inheritance, for at the date of conception both
the paternal and maternal elements were free from taint, and
during the first six, seven, or even eight months of intra-uterine
life the foetus remained healthy. Yet, as I have proved else-
where by citation of cases, syphilis obtained in this peculiar
method resembles exactly that which comes by true inheritance,
and not that which follows a chancre. This important fact goes,
with many others, in support of the belief that the poison of
syphilis remains identical, however obtained, and that the dif-
ferences which are so patent in its manifestations are due to
differences in the state of its recipient.

For the present, I am certainly inclined to believe that we
must abandon the old doctrine as to the possible transmission
of less or more of taint, and must hold that whenever a child
derives the disease by inheritance, it derives it as a whole, and
with liability to its full development. In proportion to the
distance from the parental acquisition is the probability that
the offspring will escape, and hence the frequency with which
we see the eldest in the family suffer, and the others escape.
If, however, the others escape, they do so altogether, and not
with the liability to the development of the disease in slight or
imperfect forms. In close connection with this statement
comes the question as to whether it is possible for a parent
in whom the disease exists to fail to transmit it ; whether,
for instance, of twins, one may suffer and the other escape,
or whether of three successive births one and three may suffer
and two escape. Probably it is not possible when syphilis
exists in an active form in a mother for her offspring to escape
it, but in the case of the father we can by no means feel so
certain. That the virus may be present in the semen on one
occasion and absent on another is quite conceivable. Here
again, however, Colles' law comes in to our confusion, and here
again we have to admit and remember the wide range of varia-

476 Or^tyinal Communication. [Oct.,

bility in the severity of the disease. It is not possible to feel
sure that any given child has escaped^ for we know very well
that all infantile symptoms may have been absent, and the
growth and development may have been perfect, and yet at
puberty, or even much later, for the first time symptoms un-
questionably due to inherited taint may show themselves.

Note. — The cases are given very briefly, and are mere
abstracts of longer narratives. In most instances I have re-
tained references to their manuscript, partly for my own guid-
ance and partly that I may be able, should it be necessary at
any future time, to supply more facts.

1877.] 477

€i)vomtU of ileirical ^titntt.

EEPOET ON MATERIA MEDICA AND THERAPEUTICS.
By EoBEET HuNTEK Semple, M.B.,

Fellow of the Uoyal College of Pliysicians of London, Physician to the Bloomsbury Dispensary, London.

0)1 the Therapeutical Employment of the Double Cyanide of JPotas-
sium and Zinc. By Doctor E. Leltj and Gr. Lugan, of Paris. — In
January, 1875, Dr. Luton published a long account of the employment
of the cyanides in the treatment of articular rheumatism, and the
success of this mode of treatment was so striking as to draw general
attention to the results. But the inevitable alteration, and conse-
quently the variable composition, of the cyanides employed induced
the authors of the present paper to endeavour to find a product of easy
preparation and, at the same time, of stable composition — that is to
say, always containing the same amount of cyanogen, and consequently
being identically alike in all pharmaceutical establishments. Dr. Lelu
and M. Lugan, in the first place, pass in review the cyanic compounds
hitherto employed, and the objections to the use of each. Hydro-
cyanic acid is very easily decomposed, and, moreover, in its concen-
trated state it is very dangerous to prepare. The cyanide of potassium
is also very easily decomposed, and is hence very variable in composi-
tion. The cyanide of zinc is stable, but insoluble, and it is not decom-
posed but dissolved by acids, and thus no doubt it acts in the human
system ; but the acidity of the gastric juice differs in diff'erent indi-
viduals, and hence the efficacy of the cyanide in some cases and its
failure in others. From these considerations the authors conceived
the idea of having recourse to the double cyanides, and they selected
the double cyanide of potassium and zinc already proposed by Ger-
hardt. This salt is obtained by dissolving cyanide of zinc in a solution
of cyanide of potassium. The cyanide of zinc is first prepared by pre-
cipitating cyanide of ammonium by sulphate of zinc quite free from
iron. The precipitate is thrown on a filter and washed with boiling
water, and then separated and dissolved in a solution of cyanide of
potassium. After evaporation the double salt crystallises in beautiful
octohedra, which are transparent and anhydrous. The cyanide thus
obtained has a sugary taste, but without any smell of hydrocyanic
acid ; it is very soluble in cold water, has a very constant composition,
and is easily attacked by acids with the disengagement of prussic acid.
The authors prepared 50 to 60 grammes of this salt about two years

120— LX. 31

478 Chronicle of Medical Science. [Oct.,

ago, and since that time it has undergone no alteration, and although
the vessel in which it was kept was frequently uncorked, it never
allowed the least smell of prussic acid to be perceptible. One gramme
(about 15 grains) of this salt contains "42 of cyanogen, corresponding
to "44 of anhydrous prussic acid. They have emploj^ed this cyanide
only in three cases, of which they give the particulars, all being cases
of articular rheumatism. The results obtained were cessation of pain,
reduction of the temperature, lowering of the pulse, and diminution of
the duration of the disease, and were similar to those recorded by Dr.
Luton with the cyanic compounds he employed, but which, however,
were of three different kinds. Dr. Lelu and M. Lugan consider that
the double cyanide now described possesses all the beneficial qualities
of the different cyanides formerly recommended, without their incon-
veniences, for it is unalterable in the air, it is soluble, its chemical
constitution is constant, and it is easily decomposed by acids, even the
weakest ones. They recommend il to be given with distilled water
containing some simple S3'^rup and some essence of peppermint. —
Bulletin General de Therctpeutique, May 30th, 1877.

On the Use of Oxide of Zinc in Obstinate Diarrhoea. By Dr.
BoNAMY, of the Hospital of Nantes. — Dr. Bonamy had occasion, in
the year 1876, to observe at the Hotel Dieu at Nantes a number of
patients affected with obstinate diarrhoea, which in most cases liad
lasted for several months, and was characterised by the abundance and
the great frequency of the stools. In general the evacuations had a
sero-bilious appearance, and held in suspension some epithelial frag-
ments, but they did not resemble the stools of dysentery, and if they
contained any blood it was only in the form of streaks or little clots.
The pain felt by the patients was a kind of vague colic along the large
intestine, and of moderate acuteness. Some of the cases, in which the
diarrhoea had lasted a long time, exhibited extreme emaciation ; the
tongue had often the heef-steaJc appearance, and the buccal cavity was
red and sometimes ulcerated. Dr. Bonamy resolved to try the effect
of oxide of zinc in these cases, as was first suggested by Professor
Gubler, and the mode of administration was to take 3^ grammes of
oxide of zinc with 50 centigrammes of bicarbonate of soda, divided into
three or four doses, one to be taken every three hours. Seven cases
are recorded in which this treatment was adopted with success. In
all of them the symptoms seemed to point to a chronic catarrhal con-
dition of the whole mucous membrane of the intestine. All the
patients were persons who had been coarsely fed, and were unable to
guard themselves against sudden cooling of the temperature, and one
of them had an organic disease of the heart. The advantages of the
oxide of zinc in obstinate diarrhoea' appear to Dr. Bonamy to be the
following, viz. — (1) Superiority of action ; for all the cases treated
had resisted other kinds of medication, and the diarrhoea reappeared
as soon as the oxide was replaced by some other agent; and (2)
rapidity of action ; for the cases which had lasted for several months
were relieved as soon as the first doses of the drug were administered.
— Bulletin General de Th^rapeutique, March 30th, 1877.

1877.] Report on Materia Medica and Therapeutics. 479

On the Employment respective!;^ of Chlorate of Potash, Cubebs, and
Salicylate of Soda in the Treatment of Diphtheria. By Dr. Seelig-
MULLEK, of Halle, Prussia, and Dr. Cadet de GtAssicotjrt, of the
Hopital Sainte-Eugenie, Paris. — A great number of substances, as is
well known, have been recommended, from time to time, in various
countries, as remedies for diphtheria. Among these substances, chlo-
rate of potash, cubebs, and salicylate of soda have lately been employed,
and have been extolled by some writers. Dr. SeeligmuUer (whose
paper is accompanied by tlie expression of some reservations on the
part of the Editors of the Journal in which it appears) regards chlo-
rate of potash as a specific in diphtheria, and uses it locally as well as
generally. He contrasts the great fatality of diphtheria among the
patients under his care when former remedies were employed, with the
remarkable success obtained when the chlorate of potash was used in
large doses and in saturated solution. The proportions he adopted
were 10 grammes of the chlorate in 200 grammes of distilled water,
and of this solution half a tablespoonful was ordered for children under
three years old, and a whole one for the elder children, every two
hours, and every hour if the case was serious. He considers that this
saturated solution of the chlorate exerts a local and general action on
the progress of diphtheria — local, like caustics, in displacing the false
membranes, and general, by supplying the oxygen which is carried
away from the blood by the bacterise and by destroying the latter.
This author adopts the parasitic theory of diphtheria.

But Dr. Cadet de Gassicourt, in a comparative survey of the use of
chlorate of potash, cubebs, and salicylate of soda in the treatment of
diphtheria, takes a wide view of the therapeutic question, deriving his
materials from facts observed by himself during the years 1874-75-76,
and the first three months of 1877. In the first place, he divides the
cases of diphtheria into two groiips, namely, diphtheritic angina and
croup, or, in other words, into the cases in which the back of the
mouth is the seat of disease, and those in which the larynx and trachea
are involved. He explains that the number of the former cases was
limited in his hospital, because the slighter cases of diphtheria are
usually treated at home, and it is only when the symptoms are very
urgent and suffocation is threatened that the parents of the children
bring them to the hospital for the performance of tracheotomy. On a
rough calculation of the respective efficacy of chlorate of potash,
cubebs, and salicylate of soda in the treatment of diphtheria, Dr.
Cadet de Gassicourt found that 15 cases were treated by the first, and
15 were cured; that 7 were treated by the second (cubebs), and 6
were cured and 1 died ; that 5 were treated with salicylate of soda, and
3 were cured and 2 died. At the first view, therefore, it appears that
chlorate of potash is far superior to the other remedies in efficacy, but
a careful examination of all the facts by no means bears out this view,
for, as the author explains, out of the 15 cases treated by the chlorate,
12 were very slight, and of the 3 others only one was very severe.
While, therefore, he regards the chlorate as one of the best remedies
in diphtheria, he does not rank it as a specific, nor does he think it
advisable to give it in ^uch large doses as those recommended by Dr.

480 Chronicle of Medical Science. [Oct.,

Seeligmuller. As for cubebs and copaiba, Dr. Cadet de Gassicourt
finds that out of 7 cases there were 6 cures and 1 death, but of the 6
cures 1 case was very slight, 3 were of moderate severity, and 2 were
serious. He employed the salicylate of soda in 5 cases, 2 of which
were ver}'^ slight and were cured, 1 was serious but was also cured, and
the other two died. In drawing some general conclusions and tabu-
lating the results of treatment, the author observes that the fortunate
or unfortunate issue of each case appears to depend on the severity of
the attack rather than on the medicine employed, and he doubts
whether any specific for diphtheria has yet been discovered.

In discussing the value of the remedies under consideration in the
treatment of croup, by which name the author denotes laryngo-tracheal
diphtheria, he divides the cases into those in which tracheotomy is
performed and those in which it is not performed, and here, he
observes, the result of the cases is subject to totally different conditions
than those of faucial diphtheria, and the value of any mode of treat-
ment is very difficult to determine. The best medicine is undoubtedly
that which would cure croup without having recourse to tracheotomy ;
the next best is that which would cure the disease after the operatioii
is performed ; and all medicines must be rejected which do not cure
either before or after the operation. By tabulating the results of cases,
it is found that chlorate of potash, cubebs, and salicylate of soda have
pretty nearly an equal value when tested in the manner just indicated,
and this value. Dr. Cadet de Gassicourt remarks, is not great, and he
believes that they are all of doubtful efficacy in the treatment of diph-
theria. He does not deny that his results are discouraging, but never-
theless he does not wish to convey the impression that the expectant
treatment is regarded by him as the best in this disease ; and although
he does not believe that diphtheria is a catarrhal disease to be cured
by balsamic remedies, or that it can be cured by chlorate of potash, by
supplying oxygen and destroying hacterice, yet he employs various
remedies with a hope of arriving eventually at favorable results, and
rejects only those medicines and those forms of treatment which are
proved to be dangerous. He condemns all medicines and all modes of
treatment which tend to weaken the patient or to interfere with ali-
mentation and sleep. It is above all necessary, he observes in con-
clusion, by alimentation, by cordials, and by tonics, to endeavour to
give to the patient the strength in which he is deficient, and thus to
supply him with the vigour necessary to resist the attacks of the
disease, or to wait for the relief afforded by tracheotomy. — Bulletin
General de Therapeutique, May 15th and June 15th, 1877.

On the Employment of Cold Baths in the Treatment of Typhoid
Fever. By Professor Peter, of the Hospital of La Pitie, Paris. —
Dr. Peter, in a series of very able papers, denies altogether the efficacy
of cold baths in the treatment of typhoid fever, and believes, on the
contrary, that this kind of medication is attended with the most
dangerous and even fatal results, and he argues the question both on
general principles and from the results of actual experiment in the
practice of various hospitals.

He observes that the advocates of the cold-bath treatment restrict

1877.] Report on Materia Medica and Therapeutics, 481

their field of inquiry to the contemplation of a single symptom,
namely, hyperthermia, instead of regarding the numerous circum-
stances which combine to constitute typhoid fever ; and he maintains
that the principle of this treatment is not to attack the primary cause
of the disease, but one of its effects, namely, the exaggerated heat, or,
in other words, not to aim at removing the combustible material, but
to subtract the caloric produced by the combustion. Thus the struggle
is between hypothermia and hyperthermia, and, the patient himself
being disregarded, the manifold and imperious demands of his organi-
sation are made secondary to a question of a greater or less amount of
heat. Dr. Peter regards hyperthermia as only one of the elements of
a general and serious morbid condition, the others being delirium, dry-
ness of tongue, haemorrhage, congestions, &c, ; and he thinks it quite
as absurd to treat typhoid fever by temporarily reducing the tempera-
ture as it would be by moistening the tongue of the patient to expect
to remedy the febrile condition indicated by that organ. He distrusts
all therapeutical fornmlse of a so-called rigorous character, that is to
say, when they are exclusively employed, and the more simple they
are the more are they deceptive ; the operations of the healthy organ-
ism are infinitely complex, and those of the unhealthy are still more
so, and therefore therapeutical applications cannot be simple, for it is
impossible to simplify what is not simplifiable (il est impossible de
simplifier ce qui n'est pas simplifiable).

Dr. Peter thinks it is easy to prove by facts that the hypothermic
plan does not succeed, by means of cold baths, in diminishing the heat
for a sufficient length of time, and hence the necessity of repeating the
measure at frequent and short intervals, or as it is termed, " coup sur
coup i' and, on the other hand, that sometimes the desired result is
too successfully achieved, and hypothermia is realised too far. He
gives an instance in proof of this latter proposition, where a patient
was so successfully cooled by means of the cold bath, that the tempera-
ture in the axilla and the rectum fell to 35*3 and 35'6 C, and it was
very difficult to restore the temperature, the patient eventually dying
with an enormous mortification on the sacrum and oedema of the lower
limbs. When the refrigerant treatment succeeds, Dr. Peter argues
that the result is not owing to the mere abstraction of heat, but to
the effect on the nervous system, and this is the base of the hydro-
therapeutic system which operates by action and re-action, and does not
depend only on its power of subtracting caloric, but by its sudden,
active, and energetic excitement of the sensitive nerves of the skin. In
typhoid fever he denounces this violent mode of treatment as being
full of dangers, the chief being syncope, inflammation, and haemor-
rhages. Syncope is a kind of death, and is unsuitable as a therapeutic
agent in a depressed condition of the system such as exists in typhoid
fever, in which the nervous shock cannot be borne without the greatest
inconvenience. Haemorrhages are admitted to be common in typhoid
fever under any treatment, but Dr. Peter believes that the cold -bath
system aggravates the risk of such discharges, and even causes them
from organs which are usually unaffected ; while various inflammations
ftre traceabk to th§ §ame cause, such as capillary brpnchitis, bropcho*

482 Chronicle of Medical Science. I Oct.,

pneumonia and lobar pneumonia, and renal congestion advancing to
albuminuria and Bright's disease. Dr. Peter gives a number of facts
in confirmation of his opinion, and he shows from statistical results
that the number of deaths in the cases of typhoid fever treated by cold
baths is rather in excess of that which is noted in other forms of treat-
ment. The excess of deaths is not great, amounting indeed to only
about 1 per cent., but Dr. Peter argues that even if the number of
deaths in the new treatment was exactly the same as in the old, there
is no reason for changing what he calls the old and rational medication
for one which is difiicult to impracticability and painful to cruelty.

His general conclusions on the whole subject are the following: — 1.
Typhoid fever is not the only factor to be regarded by the physician,
but the numerous conditions presented by the patient must be taken
into account. 2. Still less ought the physician to fix his attention on
a single morbid element of the disease, namely, hyjpertliermia. 3. All
systematic treatment directed to a single symptom is absolutely
illogical and insufficient. 4. The advantages of the refrigerant system,
if it has any, are not due to the lowering of the temperature, but to a
thorough disturbance of the nervous system. 5. Therefore this modi-
fication can be effected by hydro-therapeutic methods different from
cold baths, and not dangerous, as they are. 6. There are cases where
cold lotions used imprudentl}- or repeated too often are dangerous, for
a nervous shock, although slight, may become injurious in an organism
rendered susceptible by the typhoid poison. 7. When a serious result
is produced by cold baths in typhoid fever, the danger is excessive and
out of all proportion to the possible benefit. 8. In conditions which
are analogous in all points, tliC cold-bath treatment has given in Paris
returns of mortality higher than those recorded under the rational
modes of medication. 9. The best system in therapeutics, above all
in the treatment of typhoid cases, is that which admits no special
system. And 10, and lastly. When a rational mode of medication
(namely, one founded on the indications), supported by the logic of
facts and advocated by the highest medical authorities^ has been justi-
fied by long years of experience, it is necessary to reflect carefully
before trying to change it, for every dangerous therapeutical experi-
ment has the double disadvantage of plunging some minds into a
painful condition of irresolution, and of committing others to a scepti-
cism still more fatal. — Bulletin General de Therapeutique, March
15th and 30th, and April 15th, 1877.

On Chinese Materia Medica, and especially Opium. — It appears
that early in the present year a collection of medicinal substances was
transmitted from Shanghai to the Earl of Derby, the Secretary ,pf
State for Foreign Affairs, and by him forwarded for investigation to
the London Society of Apothecaries. The specimens were obtained in
1875-76, in the course of a mission to the part of China called Yiinnan,
and they are found to consist chiefly of such of the vegetable products
of this district as are applied by the inhabitants to medicinal purposes.
There are no mineral substances in the collection, and the articles con-
sist almost entirely of roots, stems, leaves, barks, and woods ; there
are but few fruits or seeds, and there are no gums or resins. The

1877.]

Report on Materia and Therapeutics. 483

specimens are all carefully wrapped up in paper parcels, inscribed with
the name of the contents in Chinese and English characters, and it is
from the information thus conveyed, together with the careful exami-
nation of the botanical peculiarities of each, that the genera of the
plants have been determined. The investigation has been conducted
by the present Master of the Society, Mr. Bradford, assisted by Mr.
Moore, the Curator of the Society's Botanic Garden at Chelsea, and,
as to the chemical analyses, by Mr. A. Stewart, the principal Chemical
Operator to the Society. It will, perhaps, be anticipated that the
results obtained are rather curious than practically useful, and such
indeed appears to be the fact, but nevertheless it is interesting to learn
the sources from which so many millions of the human race as are in-
cluded in the Chinese Empire derive their supply of medicinal sub-
stances. It is found that the plants regarded as useful in medicine
by the Chinese are little esteemed in this country, although many of
them are ornamental or fragrant. Among the last-named are some
belonging to the natural order of Lahiatce, as the sage, the mint, and
the balm ; but the smilax, yielding sarsaparilla, the uncaria, from
which a kind of catechu is prepared, and elaterium, are among the
few which are known to possess active properties. It is found that
among the parcels there is one of a coleopterous insect, the mylabris,
used by the Chinese as a blistering fly, and there are some nut-
galls, apparently the product of some hymenopterous insect. In
arranging the specimens in their natural orders, it was observed that
those orders which grow in temperate climates, and are known to
contain active principles, were almost absent in the collection. Thus,
for instance, there were no Cruciferce or SolanacecB, and scarcely any
CompositcB or TfmhelUfercB, no ScrofulariacecB or Euphorhiacece, and
only one imperfect specimen of rhubarb.

The most important part of the collection, both in a scientific and
commercial point of view, appears to have been the opium. This drug
might be obtained to an unlimited amount if a demand for it existed,
for the poppy is cultivated to an enormous extent in China, and is said
to be probably indigenous in Yunnan. The opium in the collection
now alluded to was of two kinds, namely, hard and soft, and Mr.
Stewart, the chemical operator who examined and analysed the
samples, supposes that the soft specimens are probably watery extracts
prepared from the hard ones, with a special view to increase the per-
centage of morphia in the drug. The soft specimens in fact yield
nearly three times as much morphia as the dry ones. The results of
the analyses made by Mr. Stewart show that the hard specimens
are inferior to Turkey opium in the yield of morphia, which is the
standard of the commercial value of opium, the highest result obtained
by him being 805 per cent., whereas from 10 to 12 per cent, is
obtained from fine Turkey opium. The soft specimens contain much
more morphia, but the quality in this respect is not uniform, and
hence, for general pharmaceutical purposes in England, none of the
samples would be of much use, because the British Pharmacopoeia
requires uniformity of strength. But, with regard to the commercial
aspect of the question, Mr. Stewart observes that, looking at the high

484 Chronicle of^ Medical Science. [Oct.,

percentage of morphia in the soft samples, and their low price (for
we may notice that the Chinese affix the price to each of the speci-
mens), it is probable that these might enter successfully into competi-
tion, even in England, with Turkey or any other opium for the manu-
facture of morphia. — Medical Times and Gazette, July 21st, 1877.

On tlie Use of Iodized Chloral-Phenol as a Uterine Escharotic,
Altei ative, and Local Ancesthetic, with some Remarks on its Use in
Other Diseases. By Dr. J. P. Thomas, of Kentucky. — After using
carbolic acid and hydrate of chloral separately as adjuvants to iodine
for several years, Dr. Thomas conceived the idea of combining them,
and he devised a formula for the purpose, consisting of f ss of resub-
limed iodine and 3J of hydrate of chloral and 5J of crystalUsed carbolic
acid. The iodine and chloral are to be rubbed together to a fine
powder, and after liquefying the carbolic acid by the aid of heat, the
ingredients are all to be rubbed together until a homogeneous liquid is
formed of the consistence of thin syrup, and of a dark mahogany
colour. Dr. Thomas states that this formula has great anaesthetic
power, and is anodyne and escharotic ; and after an experience of its
use for nearly four years, he is enabled to claim for it a very great
value in the treatment of uterine disease. In chronic hypertrophy and
induration of the os and cervix uteri he has found it to excel all other
preparations in remedial power. In several other diseases Dr. Thomas
considers it also very valuable, as, for instance, in the treatment of
carbuncle, in scrofulous ulceration of the parotid and cervical glands,
as a dressing to old and indolent ulcers, and in a few cases of stubborn
skin disease. He mentions a case of disease of the scalp, attended
with the exudation of fetid pus, and in which, after removing the scurf
and scabs by a few applications of acetic acid, the application of the
iodized chloral-phenol eflfected a rapid cure. He finds it also the best
remedy in ringworm of the scalp. — The American Practitioner, May,
1877.

On the Use of the Seton in Paralysis and Epilepsy. By Dr. T. J.
G-EIFFITHS, Surgeon of the United States Marine Hospital Service. —
Since 1870 Dr. Griffiths has treated eighteen cases of paralysis and
five of epilepsy in the United States Marine Hospital at Louisville,
Kentucky, by the seton introduced at the back of the neck. In only
one case was this treatment altogether unsuccessful, and in the other
seventeen, ten recovered, and the others were much benefited. Dr.
Griffiths is at present cognisant of eight of the ten who recovered, and
they have had no return of their former disease. In the seven men
who were discharged improved, the paralysis was noticeable in their
walk, but they were able to go about and perform a considerable
amount of light work. In the cases of paralysis no treatment except
the seton and tonics was employed, but bromide of potassium was
given in one of the cases of epilepsy, and all had tonics. Since 1870
Dr. Griffiths has also treated eight cases of hemiplegia in private prac-
tice by the seton with beneficial results, for six recovered and two
improved. Before the date mentioned his practice was to follow the
usual routine of treatment by electricity, strychnia, iodide of potas^
gium, &c., but RQ such results were realised ^s were obtained by thQ

1877.1 Report on Materia Medica and Therapeutics. 485

use of the seton, and lie does not remember a single case of complete
recovery treated under the earlier plan. He has long since abandoned
the use of electricity and strychnia as remedial agents in paralysis.
His plan is to introduce a large seton, fifteen to twenty strands of silk
or flax thread, and allow it to remain for months, if necessary, remov-
ing it only when the patient seems to be permanently improved or has
recovered. He has also used the seton with good results in the treat-
ment of obstinate cases of iritis, whether syphilitic, rheumatic, or from
other causes. Chronic cases, which seemed to improve slowly or not
at all under ordinary treatment, often showed a marked improvement
a few days after the introduction of the seton. — The American Prac-
titioner, March, 1877.

On the Influence of Medicines, particularly Narcotics, on the
Infant, when administered to the Mother during Pregnancy and
Labour. By Drs. Munde, Baekee, Peaslee, Gtillett, and
Thomas, of New York. — In a series of discussions on the above
subject, held lately at the New York Obstetrical Society, the members
were divided in opinion, some believing that the administration of
narcotic and other powerful drugs to the mother during pregnancy
and labour exerted an injurious effect on the infant, while others
entertained a contrary view. One member related a case where
morphia was administered hypodermically to the mother, who was
suffering from puerperal convulsions, and the infant on its birth was
asphyxiated, and afterwards convulsed, but eventually recovered. But
Dr. Munde, who appears to have had a large experience, after alluding
to the literature of the subject, stated that for more than twenty-five
years he had been in the habit of administering chloroform in labour
cases without having ever observed any injurious effects to be pro-
duced on the child, and as to opium, he states that his experience is
of the same nature. He mentions two cases in which the mothers had
been habitual opium-eaters, and yet their children were in no way
injuriously affected. He concludes from the whole of his investigations,
that there is no evidence which can be accepted in science that
narcotic drugs administered to the mother ever produce their specific
eftects on the foetus in utero, and therefore such drugs may be
used without fear of their effect on the foetus whenever they are
necessary for the health or the life of the mother. The most promi-
nent advocate of the opposite view was Dr. Gillett, who declared his
firm belief that certain narcotics administered to the mother during
parturition may affect the foetus in utero or the new-born child, and
that, in particular, morphia, when administered to the degree of pro-
ducing its physiological phenomena in the mother, will invariably
produce a relative condition of narcotism in the new-born infant. He
adduced a number of cases in which morphia was administered to the
mother, and the new-born child was more or less affected, though all the
children eventually recovered, and he relates two cases in which
atropia was administered hypodermically to the mother, but one only
of the two children exhibited dilatation of the pupil. Dr. Thomas,
who acted as President of the Society, and who wound up the discus-
gion with some remarlis of his own, admitted the digculty of arriving

486 Chronicle of Medical Science. [Oct.,

at a positive conclusion on the question proposed. He related two
cases in his own practice where parturient women had taken large
doses of laudanum, but no effect was produced on the child. He him-
self inclines to the belief that the use of narcotics and anaestljctics by
the mother has no injurious effect on the child, but he admits that
there is evidence on the other side. In Dr. Grillett's cases, where
morphia had been used, the child in each case showed the symptoms
of opium poisoning, and in one of the cases where atropia had been
used, the child's pupils were widely dilated. He was unable to regard
these results as mere coincidences, and thought that they tended to
prove that large doses of narcotics, especially when used hypodermically
for the pregnant woman, might injuriously affect her child. Still, he
observes that, although morphia may be administered to the mother
during labour and the child may die, it does not prove that morphia
killed the child.

It does not appear that any definite conclusion was arrived at as a
consequence of the discussion, Dr. Grillett still maintaining that the
use of opium produced symptoms of narcotic poisoning in the child,
while Dr. Peaslee doubted whether Dr. Grillett's cases really supported
his conclusions. He (Dr. Peaslee) could not admit the affirmative of
the question till the narcotic was actually detected in the blood or the
urine of the new-born child, and the symptoms in the latter were
proved to be clearly due to the morphia detected. — Transactions of
the New York Obstetrical Society, 1877.

Deductions from Three Hundred and Nineteen Observations of the
Action of Ghrysarobin, a New Einetic Purge. By J. Ashbueton
Thompson, M.D. — Chrysarobin is another word for Groa-powder, and
it has received the new name for the following reasons. The powder
is known in Bahia by the name of aroba-powder, but as it is the
active part of a whole tree, it is convenient to use the single word
arobin instead of the compound one, and as the colour of the newly
prepared powder is yellow, the prefix chrys- is used, and hence the
word chrysarobin, or yellow aroba-powder. Professor Attfield's analysis
of chrysarobin shows that this substance contains nearly 90 per cent.
of chrysophanic acid, and hence there Is reason for believing that the
latter may be the active principle. The crude powder and the ex-
tracted acid have the same locally irritant effects, and either, kept in
contact with the skin, produces inflammation and irritation, and when
introduced in minute quantity into the eye causes conjunctivitis.
Some other plants contain chrysarobin, such as common dock (rumex),
rhubarb and senna, and the properties of these plants seem to have
some connection with their chemical composition. Dr. A. Thompson
thinks he has ascertained that chrysophanic acid is a purgative of
decided cholagogue powers, and as it might be supposed that it would
be useful in medicine he undertook its clinical investigation in 1875,
with specimens prepared by Messrs. Young and Postans, of Baker >
Street. Chrysophanic acid is a granular powder of a fine bright oiange
colour, has neither smell nor taste, and may be crystallised. The resin
which exists in chrysarobin is of two kinds, and Dr. Thompson used a
combination of the two in his experiments. He made the first experi-

1877.] Report on Materia Medica and Therapeutics, 487

ments on himself and his brother, and he ascertained that chrysarobin
in a small dose had no very active properties, for a dose of sixty grains
produced only vomiting and purging of a mild kind. In using it in
ninety cases, thirty children and sixty adults, he found that its
action was emetic and purgative, vomiting being the first sign of
action, but being unattended by any such depression as that caused by
tartar emetic or ipecacuan, and the purging being marked by watery
stools without griping pain. With regard to the dose of chrysarobin,
it was found that twenty grains was a moderate one for an adult, and
that, generally speaking, twenty-five grains might be regarded in
adults, and six or more grains in children, as a good emetic purge un-
attended by any inconvenient symptoms. The effect of chrysophanic
acid is similar to that of chrysarobin, with this difference — that, while
in a suitable dose each will cause vomiting and purging, if the dose is
too small chrysarobin is likely to purge only, while chrysophanic acid
is likely to cause vomiting only. As to the dose of chrysophanic acid,
Dr. Thompson finds that the action is certain for an adult in a dose of
fifteen grains, and that a scruple is in general too much ; and that in
children the effect is rather uncertain, which is not the case with
chrysarobin. Dr. Thompson has made ten observations upon adults
with the resin of chrysarobin, and the results were that the action was
identical with that of the crude powder and of chrysophanic acid, but
was very much more powerful. From the whole series of his investi-
gations Dr. Thompson draws certain definite conclusions as to the
action of chrysarobin and its constituents. He regards chrysophanic
acid as an emetic purge, having an action as certain, when given in
appropriate doses, as that of any other drug acting in either of these
ways. He thinks that its action is favoured by the mode of adminis-
tration, and it is best given in diffusion in water, in the form of pill,
and above all, in combination with a strongly alkaline fluid. He sees
reason to regard it as a useful addition to our list of remedies, because
it affords a means of clearing out the primce vies with a thoroughness
and promptitude not equalled by any other medicine with which he
is acquainted, a combination of tartar emetic and ipecacuan alone ex-
cepted, while it is at once more certain to produce hoth purging and
vomiting than the last-named combination, and is unattended by the
serious depression which is often an inseparable objection to its employ-
ment, and he thinks that the power of evacuating large quantities of
bile, which he claims for it, especially fits it for the purpose named. —
British Medical Journal, May 19th, 1877.

On Gurjum Balsam and some of its Therapeutical Applications,
By Dr. Luc Deval, of Paris. — In this essay, which constitutes the
inaugural thesis of Dr. Deval for the doctorate in medicine, the
properties of gurjum balsam are considered, both in their applica-
tion to the treatment of gonorrhoeal affections and to that of lepra
and some other diseases of the skin. The substance to which the
essay relates is furnished by several trees belonging to the genus
Bipterocarpus, which grows to a great height in some of the islands
of the Indian Archipelago and on the eastern coast of Bengal. The
balsam is obtained by making large incisions in the trees, and col'

488 Chronicle of Medical Science. [Oct.,

lecting the fluid, which exudes when the part is heated. The
gurjam balsam was first employed by Sir William O'Shaughnessy in
1838, as a substitute for copaiba in the treatment of gonorrhoea, and
it has since been pretty extensively recommended, principally by-
British practitioners, for the same purpose. In 1873, however,
Dr. Dougall, of the Madras army, found it efficacious also in the
treatment of lepra, and this success was confirmed by Mr. Erasmus
Wilson, who also employed it in various diseases of the skin. In
the treatment of lepra it was used by Dr. Dougall, both internally
and externally, the dose given by the mouth being about fifteen
grammes, administered with lime water. More lately Dr. Yidal has
introduced this substance into France as a remedy for gonorrhoea,
and in his wards Dr. Deval was first made acquainted with its the-
rapeutical properties. The author, while admitting that this balsam
has been serviceable in the treatment of lepra and some other skin
affections, thinks that further experience is required before it can be
exclusively employed in such cases. But the success which has
attended its use in gonorrhoea entitles it to a well-marked place by
the side of copaiba and other balsamic remedies, and its external
and internal action in the treatment of vaginitis appears more
energetic and rapid than that of copaiba. It must be added that
the abundant supply obtained from the trees which produce it, and
consequently its lower price in comparison w:ith copaiba, will probably
attract the attention of medical practitioners. — Thesis of the Faculty
of Medicine of Paris, 1877.

On the Therapeutical Importance of tlie Common Phosphate of
Soda. By Dr. Luton, of Eheims. — After glancing at the general
therapeutical properties of the phosphate of soda Dr. Luton con-
fines himself, in the present paper, to the consideration of this salt
as a respiratory agent employed in the treatment of asthma and
pulmonary phthisis. He relates three cases, one of asthma in an
old man, and two of pulmonary phthisis, one in a young man and
one in a young woman, in all of whom the phosphate was given
with great success. Dr. Luton believes that the common crystallised
phosphate of soda acts on the human subject as a phosphorised prin-
ciple, and that it presents itself to notice as an agent having the
properties of phosphorus without any of its dangers, and that as a
phosphorous compound it is suitably employed in those diseases
where phosphorised substances are required, such as organic debility,
marked adynamic conditions, impotence, amenorrhoea, and perhaps
progressive locomotor ataxy ; as an alkaline body, also, it is
applicable in gout, rheumatism, diabetes, biliary calculi, &c. In
pulmonary phthisis there are two morbid elements, namely, the
functional respiratory disturbance and the organic debility, the one
influencing the other ; and it is natural to suppose that the phos-
phate of soda would be efficacious in this disease, either in combating
its essential principle or in counteracting some of its acquired
results, and in these characters Dr. Luton regards it, and recom^
mends the trial of its properties by others. — Union MMicale SoieU'.
tif^ue du Nord-Mst^ February, 1877.

1877.] Report on Materia Medica and Therapeutics. 489

On an Extract of Ergot of Bye for Hypodermic Injection. By M.
Yyon, of Paris. — Ergot of rye is a complicated substance, consisting
of fatty oil, ergotine, osmazome, raannite ; gummy, extractive, and
colouring matter, albumen, fwigin, phosphate of lime, and a few-
other matters. In 1876 M. Tauret, of Troyes, announced the dis-
covery, in ergot of rye, of a new solid and fixed alkali, which he
called ergotinine, and in the same year Messrs. Dragendorff and
Padwissotzky published some very complete researches on the com-
position of ergot. According to these chemists the active principle
of ergot is viscous and of a colloidal nature, and is called by them
scleromucine, and the ergot contains, besides, an acid which they call
scleromucic acid, and some other matters to which they have also
given names. M. Tvon thinks that there is still much to be learned
in reference to the chemistry of ergot of rye, and he does not him-
self profess to throw any new light upon this part of the subject
but he wishes to introduce to therapeutical use a better preparation
than any at present employed. The only certain fact with regard
to the active principle is that it is soluble in water, and beyond this
fact all is doubtful as to its chemical properties. M. Yvon describes
his method of obtaining a preparation for hypodermic use, the
process being rather a complicated one. The fixed oil is first
removed by sulphuret of carbon, and the residue, dried and pow-
dered, is mixed with tartaric acid ; carbonate of lime is subsequently
added to neutralise this acid ; the active principle is filtered, rendered
colourless by animal charcoal ; salicylate of soda is dissolved in it,
and finally a liquid is obtained equal in weight to that of the ergot
employed. The liquid thus obtained is of an amber colour, of a
very pleasant smell, and is easily preserved. It is well adapted for
hypodermic injections, and M. Yvon has made with it several ex-
periments on the lower animals. M. Dujardin-Beaumetz has also
made a series of injections with this fluid on patients in the wards
of the Hopital St. Antoine, in Paris, and he found that they caused
no local irritation, and that they produced all the therapeutical
effects of ergot of rye. — Bulletin General de Therapeutiq^ue, July 30th,
1877.

On the Use of the Qlycerole of ^uhacetate of Lead in the Treatment
of Chronic Eczema. By Balmanno Squiee, M.B. Lond. — Mr.
Squire disagrees with those who believe that chronic eczema, because
it is a " blood disorder," must necessarily be combated by some in-
ternal medication, although he admits that in its acute form the
disease may require constitutional treatment. He believes that,
after a certain brief duration of the disease, the original cause ceases
to operate, and that the malady is perpetuated by an acquired con-
dition or habit of the integument, and on this the chronicity of the
affection depends. Hence the object of the dermatologist should be
to alter this morbid condition of the surface by appropriate local
medication. Mr. Squire, after referring to various applications at
present in use against chronic eczema, such as the benzoated oxide
of zinc ointment and the unguentum diachyli, gives his reasons for
preferring a preparation of lead with glycerine. He first tried the

490 Chronicle of Medical Science, [Oct.,

acetate of lead ointment of the Pharmacopoeia, then he thought a
mixture of the liquor plumbi diacetatis with lard a more efficient
application, and finally he substituted glycerine for lard. The gly-
cerine of subacetate of lead is prepared in precisely the same way
as the liqour plumbi diacetatis, only that glycerine is used instead of
water. Mr. Squire takes care to explain that he restricts the term
" chronic eczema" to its real meaning, and that he does not include
in it such affections as lichen and trephulus, prurigo or pityriasis,
but only the cases characterised by a colourless viscid sweating
from the skin, whether this sweating be abundant or scanty, or
whether there be small, raw, scattered, but more or less clustered,
weeping excoriations. — Medical Times and Gazette, 1876.

Drugs in the Treatment of Disease. By Bobert Hamilton,
F.E.C.S., Surgeon to the Eoyal Southern Hospital, Liverpool. —
The author of this paper points out the erroneous nature of the
popular belief that drugs are the most potent weapons in the phy-
sician's armoury, and constitute the true remedies for healing the
sick. Drugs, in fact, take a subordinate place in the presence of
the curative means now more generally employed, such as diet, rest,
heat, cold, light, air, water, and electricity. It is not certain, too,
as the author observes, that drugs do not sometimes effect more harm
than good by setting up morbid action where none previously ex-
isted. Still, Mr. Hammond does not by any means adv^ocate the
disuse of drugs altogether, as he is thoroughly convinced of the
efficacy of some of them, but he hesitates more in using them than
he formerly did. He alludes to the history of homoeopathy as
showing that this so-called system was merely the result of the
dissatisfaction felt with the uncertainty of drugs ; and he states
that, although the gross absurdities of the views of Hahnemann can
excite only ridicule and contempt, yet that the practice o£ what is
called homoeopathy — that is to say, letting nature take her own
course — is sometimes, and, indeed, often, attended with success.
As this conviction is gaining ground in the minds of reasonable
people homoeopathy is receding, and is gradually passing into the
limbo of forgotten things ; and it could not be otherwise, for the
intelligence of man could never have rested satisfied with the dogma
which asserted that the billionth of a grain of any drug could have
a greater influence on the system than a grain of the same drug. —
Pamphlet, 1877.

1877.] Ueport on Pathology and Medicine. 491

HEPOET ON PATHOLOGY AND THE PPtACTICE OF
MEDICINE.

Br John T. Aelidge, M.D., A.B. Lond., E.E.C.P. Lond.,

Physician to the North Staffordsliire Infirmary, &c.

Progressive Facial hemiatrophy. — Dr. H. M. Bannister, of
Chicago, details two cases of this rare affection in the pages of the
' Journal of Nervous and Mental diseases,' a quarterly journal
published at Chicago, of much merit, and to which we are pleased
to direct attention. The first case was that of a young German
printer. lu working a hand-press in hot weather he perspired
only on the right side of the face, whilst elsewhere on his body no
difference in the cutaneous transudation was discoverable. With
this functional disturbance was associated a marked difference be-
tween the two sides of the face ; the left side was less full than the
other ; the skin appeared tenser and more shining, the subcutaneous
adipose tissue was lacking, causing hollowness between the muscles,
which on their part retained their volume ; a cut or scratch on the
affected side was slow to heal ; the hairs of the moustache fell out,
largely, but no paralysis, twitching, or any disorder of mobility
was present ; the left eye was a little less prominent than the
other, and the temperature of the affected side was lower than that
of the right one ; the secretions of the eye and mouth were normal,
and tactile sensibility unaltered ; special senses normal, excepting
that of taste, which was diminished or lost on the left posterior third
of the tongue ; the first upper molar of the left side ached at times,
the gum was wasted, so that the root of the tooth was largely exposed ;
brown freckle-like blisters occurred equally on each side of the face.

There was no history of accident or of injury of other than slight
character, but he had at a previous period of his life acted as a
waggoner, and been exposed to cold and bad weather. Pressure on
the cervical ganglion was without effect. The pupils were symme-
trical.

The second case was that of a merchant, set. 42, who, some ten
years previously, had severe scalp wound over the coronal suture,
followed, after the lapse of a day, by delirium, lasting for a month.
After recovery from this state a dull pain remained at top of head,
with confusion of mind aggravated by exertion, mental or physical,
compelling retirement from active business for two years more.
Ever since, moreover, unusual mental worry or excitement, or loss
of sleep, has caused return of these unpleasant head symptoms.
When examined, the left side of face was distinctly smaller — nar-
rower— than the right, the atrophy affecting not only the soft
tissues, but also the bones \ the facial muscles were all. diminished in
volume, but functionally as active as ever ; the adipose tissue was
wasted ; skin the same on both sides, but the beard on the left side

402 Chronicle of Medical Science. [Oct.,

tLiuly developed, and its growth arrested, so that shaving was not
required on that side; the cutaneous secretions appeared un-
changed, and the temperature on the two sides was the same ;
nothing abmormal in the mouth. Tactile sensibility reduced on left
side, and so likewise were the hearing and taste ; but the eyesight
appeared equal on the two sides. This facial inequality had ap-
peared within ten or twelve years.

Dr. Bannister remarks that the first of these two cases was in
an earlier or an undeveloped stage compared with the second, in
which, not, only adipose tissue, but also muscles and bones, were
atrophied. No apparent cause was cognisable in the first case ;
whereas, in the second, there was history of an injury to head and
brain, and with it sensory disturbance, not seen in the other in-
stance. A traumatic origin is noticed in the cases recorded by other
authors, but in neither of these two examples was a local discolora-
tion, noted by other observers as a phenomenon j^receding wasting,
and consequent on absorption of subcutaneous fat, present. No
pain seems to have attended the progress of the atrophy in either
patient ; but with regard to temperature there was a decrease in the
former case, but not in the latter ; and this want of uniformity
in this matter would appear general in similar cases. Again, there
was no perspiration in the first instance recorded on the aff'ected
side, whereas, in the second, there was a general absence from the
face on both sides. .

It would seem that the secretory nerves connected with the
several nerve centres, sympathetic and others, are involved in this
morbid state ; but an alteration of function, as far as regards
sensory nerves, appears to be uncommon. It is, however, worth
while to mention that in the two cases reported the defect of taste
had not been recognised by the patients themselves, but was first
brought to life by experimental testing; consequently, it may have
happened that in some other instances recorded the loss of taste
may have been overlooked.

Excepting Laude, who (in 1870) attributed this malady to a
primary affection of the connective tissue, all writers upon it have
described it as a neurosis, some regarding it as an affectica of the
vaso-motor system, others as due to an alteration of the trophic
influence conveyed mainly through fibres contained in the trunks of
other, chiefly sensory, nerves, especially those belonging to the fifth
nerve.

Dr. Bannister accepts the latter view, and thus summarises his
opinions :

" Progressive facial hemiatrophy is a neurosis. This is indicated
by its limitations to one side of the face, and to the regions supplied
by special nerves ; by the implication, in some cases, of the sensi-
bility, and even special senses ; by the merely dystrophic character
of the changes it produces in the tissues without any indications of
disease, or alterations of the essential structure ; by the close
analogy in some respects with neuralgias, attended w^ith local
atrophies, &c.

1877.] Report on Pathology and Medicine. 493

"2. As regards the nature of the nervous trouble, it appears,
from an analysis of the symptoms in a majority of the cases reported,
that the essential lesion is not in the vaso-motor system, but rather
in the trophic functions of other nerves. Yaso-motor symptoms,
properly speaking, are lacking in a majority of cases.

"3. From the evidence afforded by a large proportion of the
reported cases, it seems justifiable to suppose that the trophic func-
tions of the fifth nerve are especially implicated. The facts that
render this probable are the frequent limitation of the atrophy to
the regions supplied by this nerve, or its separate divisions, the
analogy with the neuralgic atrophies, and the occasional sensory
symptoms. I may add, also, that the lack of symptoms that would
lead to the inference of implication of the facial nerve, is in favour
of this view, at least, as assisting in a kind of diagnosis by exclusion.
The hypothesis that the atrophy depends upon alterations in the
ganglia on the fifth nerve, cannot be said to be very well supported
by the facts in our possession, as to the results of disease ojp these
ganglia, but it may be the correct one.

" 4. In some cases there are evidences of positive lesions of other
cranial nerves than the fifth ; paralysis, or irritation of the sympa-
thetic (Seeligmueller, Brunner) paralysis of the abducens (v. Graefe),
of the auditory and glosso-pharyngeal (cases reported in this paper).
In some of these observations, where the disorder was apparently
due to traumatic causes, syphilis, &c., the facial atrophy is perhaps
to be considered as only one of the manifestations of the more
general intracranial disease, of which these other phenomena were
also symptoms. Still, there are some facts that indicate an altera-
tion of nerve nuclei in the medulla, in many of the cases, the direct
cause of which is not obvious.

" 5. The symptoms of the disorder indicate a chronic trophic
asthenia or paralysis, rather than any irritative action. This is
proven by the slow progress of the disease, its usual unirritative
character, and by such symptoms as that testified to by one of the
patients in the cases here presented, viz. that slight injuries, wounds
scratches, &c., were longer in healing on the affected side than on
the other.

" 6. That the disorder, however, is not merely one of arrest of deve-
lopment is shown by the actual wasting of the tissues, the more
solid ones, such as the bones, among them in many cases. In this,
it has a resemblance to the atrophy of old age, with which it seems
to have other atialogies, suggestive in regard to its pathology. The
cases of congenital facial atrophy that are not infrequently met with
have not generally the progressive character of this affection, and
are more properly to be reckoned as due to arrest of development.
Still their relations with this disorder may be closer than we think.

" 7. There are various peculiarities of this disease which, in the
present state of our knowledge, cannot be accounted for in any way.
Still they serve to support the neurotic and local theory of the
affection. Such is its unilateral character, the greater frequency of
its occurrence in females than in males, &c.

494 Chronicle of Medical Science. [Oct.,

"8. Therapeutic measures have, so far, failed to produce lasting
benefit, for the most part. Two or three cases seem to have been
benefited by faradisation (two of Baerensprung) and the prognosis,
as regards recovery or arrest of the disease, is not altogether hope-
less. If, as has been suggested as possible, in one of the cases here
related, it ever depends upon a reflex cause, or when it seems due
to specific disease, like syphilis, the cutting off of the original irri-
tation or proper specific treatment would seem to be the most
promising remedial measures.

" 9. The disorder does not seem to involve life. It is possible,
however, that in some cases it might extend to organs that are
essential to life, especially if the nuclei of various cranial nerves are
involved in the morbid process."

Dr. T. Whiteside Hine, in the 'British Medical Journal' for 26th
August, 1876, has furnished a communication on this singular lesion.
He partakes the more general belief that it is a neurosis, the terminal
nerves regulating the nutrition of the tissues being the agents con-
cerned. He cannot agree with Brunner's views that it is due to
alterations in the great sympathetic nerve ; for in one case observed
by him the signs of such changes were absent. Moreover, in a
patient seen by him, in whom perspiration was absent from one half
the face, accompanied by hsemorrhagic effusion, and due to an injury,
there was no difference between the two halves of the face, although
there were clear indications of vaso-motor disturbance.

Coutet likewise narrates a case of unilateral atrophy of the face,
diff'ering in many material features from the general history of like
cases. It was that of a vigorous young man who had never met
with an injury. "When about 11, he had many short but violent
attacks of dental neuralgia. When 15, a blueish spot appeared over
the dental foramen of lower jaw, which in the course of three years
attained the size of a five-franc piece, but lost its colour. In this
interval, likewise, atrophy had taken place in the subjacent tissues,
and he suff'ered violent pain, closure of the jaws, and muscular
tremor in the superficial muscles. In the buccinator, at all times,
there was continuous heavy pain, if violent suffering was absent ;
the muscles in face, and also the tongue, suffered with rigidity. The
lips of the right side, though wasted, did not prevent his playing a
wind instrument. Paroxysms of pain were induced by exposure to
cold. The movements of the face were not attended by deformity.
The atrophy was limited between the third cartilage and the upper
lip at the median line. The infra-orbital region and the wing of
the nose were involved. On the external aspect there was no defi-
nite boundary. Probably the pharynx was included in the wasting,
but the velum, the tongue, and the lower jaw were unmistakably
atrophied. The facial muscles and masseter were wasted, and
suffered with tremor. The skin at large retained its normal colour,
but the lower lip and chin were of a dull yellowish hue, having the
appearance of a cicatrix, but with no adhesion to the subjacent
bone. Neither the sensibility of the surface, nor the muscular
movements, nor the organs of sense, were affected.

1877.] Report on Pathology and Medicine, 495

Tor several months the patient was submitted to the local action
of the continuous current without benefit. — Revue des Sciences
MSdicales, tome ix, p. 147.

Flexiform Nemoma. — Dr. Cartaz narrates a case of this unusual
form of neuroma, and takes the opportunity to record its history
and pathology. The whole number of cases on record amount only
to thirteen. It is especially a disease of childhood and early
youth ; it may be congenital ; and its most frequent site is upon
some part of the head. It is indolent in its course, and does not
attract attention by pain or other circumstance, until it has attained
the characters of a definite tumour, covered by a thickened, dense,
rugose, or furrowed skin, of a brownish-red colour, and not unfre-
quently adherent with it by continuity of disease. The sebaceous
glands of the skin also become greatly enlarged.

"When the neuroma occupies a mucous surface, like hypertrophic
changes take place in the submucous tissue, which grows hard and
produces a prominent mass.

The growth of these tumours is unaccompanied by inflammatory
action, and as pain is absent they may be freely ^handled. The
only exception to this rule occurred in the case recorded by M.
Verneuil, where the neuroma appeared later in life on the prepuce,
and was the cause of great pain, especially when touched. The rule,
indeed is, that the surface of the tumour is of blunted sensibility, so
that a needle may be thrust into it without signs of pain. This
circumstance is explicable by the pathological character of the
growth, which presents either degenerated nerve-fibres, or otherwise
a great production of connective tissue around the nerve-fibres,
where these still remain normal.

Further, adenitis is a common concurrent condition, though not a
consequence, and associated with indications of scrofula. The neu-
roma is not marked by increased vascularity, excepting that the small
subcutaneous, and the deep veins are dilated. However, in a case
recorded by Winiwarter, the cellular proliferation had seized upon
the capillary vessels generally, causing obstruction and minute
thromboses.

When examined minutly the tumour is seen to be made up of a
network of contorted nerve-fibres, considerably hypertrophied, and
bound together by an excessive growth of connective tissue. It has
been noticed in some instances that the nerves fibres, though them-
selves greatly thickened by hyperplasia of connective tissue, are
not bound down by the surrounding mass, but may be drawn out,
as if from sheaths, for a greater or less distance. Further, in some
cases the overlying integument is involved and adds much to the
dimensions of the tumour. Owing to this skin complication some
have proposed to distinguish two forms, one cutaneous, the other
subcutaneous ; but there are not sufficient grounds for the distinction.

The nerve fibres are curiously twisted on themselves, after the
fashion of varicose veins, and by means of the excessive growth of
connective tissue around and between them, they are pressed upon
and become at places obliterated, the myeline undergoing granular

496 Chronicle of Medical Science, [Oct.,

degeneration. A microscopic section sliows a transparent fibrous
mass, permeated here and there by dark lines, indicating the rem-
nants of nervous substance. It is the persistence of these lines of
myeline that distinguishes this form of neuroma microscopically
from the ordinary one ; for in this latter there is a hypergenesis of
all the constituent parts of the nerves with ulterior atrophy of all
nerve elements.

In making a diagnosis, these tumours have to be distinguished
from cirsoid aneurisms. This is easy, by reason of the absence of
vascularity, of bruit, of expansive movements, and of pulsation.
Their difference from old varices, grown thick, and with thromboses
on parts, is less pronounced ; but these lesions are commonly found
in the lower limbs, are of wide extent, and occur among those ad-
vanced in age. Moreover, the history of a past stage, when the
vessels were pervious and soft, will determine the diagnosis. Again,
lipoma and circumscribed elephantiasis exhibit in some points a
resemblance. But though a lipoma may be of slow growth, and its
lobulation simulate vaguely the varicose cord feeling of neuroma,
the latter does not form so definite a tumour, is less isolated, and
has the skin often adherent, and hypertrophied and discoloured.
Lastly, plexiform neuroma differs from a localised elephantiasis,
by the contorted cord-like feeling of its tissue, and by the early age
at which it is found, probably dating from the period of birth.

As to treatment, it has to be remembered that though the evolu-
tion of these tumours is slow, it is progressive, and that they like-
wise may undergo sarcomatous degeneration ; consequently the early
removal of the diseased mass suggests itself as the proper course.
— Archives Ohierales de Medecine, August, 1876.

Classification of Mental Diseases. — Dr. Sankey, formerly of
Hanwell, has essayed a classification of mental diseases, a subject
often enough attempted but never satisfactorily realized. He
objects that previous systems have not been founded upon the
essential characters of the disease itself, meaning by the word
disease the sum of all the phenomena, comprising the first indications
of deviation from health, the evolution of the symptoms, their pro-
gress, order of succession, and mode of termination.

Taking a general survey of cases of insanity, he makes two divi-
sions : — " A. in which the mental symptoms are primary, or essen-
tial, or idiopathic ; and b, in which they are secondary, or
symptomatic. This grand division (a.) or the purely mental cases,
may be further divided into two subdivisions, viz. (a) in which the
cases depend upon a purely pathological change, or on what is
really disease ; and {h) in which the mental symptoms are due
rather to developmental causes. In the former category («), he
can recognise as yet but two species, viz. : — i, insanity proper ;
and II, general paresis. In the subdivision (b), there are also two
kinds of cases : (1), in which the developmental anomaly is an original
formation, or idiocy, and (2), in which [it is due to decay, or senile
imbecility."

" The division b, in which the mental phenomena are only symp-

1877.] Report on Pathology and Medicine. 497

tomatic, or accidents in the cases, forms, perhaps, a smaller moiety
of the inmates of asylums ; and the most frequently occurring kind
of cases are the four following; epileptic insanity, alcoholismus,
spinal disease, extending to the cerebral regions, organic disease of
the brain, as the result of apoplexy, &c.

*' The old division of mental disorders into mania, melancholia, &c.,
rests simply on a symptomatic basis, and the characteristic
symptoms are themselves fluctuating, replacing each oth^r oft-
times in the history of the same case. But, * a disease does not
change its essential characters during its progress ; it may have well-
marked stages, but we cannot imagine that each stage is a distinct
species of disease.* "

According to Dr. Sankey, *a case of ordinary insanity, at its
first outset, commences by a stage of melancholy, which is at first
considered as acute melancholy. The case has in this stage four
modes of termination — (1) in recovery ; (2) in death ; (3) in
passing into mania ; (4), in becoming chronic (chronic melancholia.)
When, in its evolution, it becomes mania, it has been falsely called
a new disease. This stage, too, or acute mania, has various modes
of termination — (1) in cure; (2) in death; and (3) in chronicity."
Termination by the last mode presents many psychological variations
to which as many names have been assigned.

The forms of insanity, named with regard to their supposed cause,
or pathological connection, or leading psychological feature, such as
puerperal mania, phthisical mania, dipsomania, suicidal, homicidal,
and syphilitic mania, moral insanity, religious melancholy, suicidal
melancholy, melancholy with stupor, melancholia agitans, nympho-
mania, and kleptomania, are not to be regarded as distinct diseases.
Thus, with respect to puerperal insanity, examples of it have nothing
in common except the outbreak of mental disturbance in parturition
and its immediately preceding and following stages ; — nothing in
the character of its symptoms, progress or termination distinctive
from other cases of insanity. So with dipsomania, or oino-mania,
the uncontrollable desire is sometimes a vice and the prelude to
mental disorder ; at others it is allied with imbecility or idiocy, or it
may be a symptom recurrent of insanity, or an accompaniment of the
first stage of general paresis. This is not the place to criticise, but
it seems to us that Dr. Sankey whilst seeing the weakness of other
attempts at classification, is scarcely cognisant of that of his own,
although, it must be admitted he modestly puts it forward only as
an imperfect scheme. The right basis for classification has, to our
mind, yet to be discovered. — Beprint from the Journal of PycJio-
logical Medicine, vol. iii, Part i, 1877.

Hay-fever, its causes. — Dr. Blackley, who investigated the causes
of hay-fever and published his results in 1873, has since extended
his experimental researches and published them in the form of a
pamphlet. His later observations are confirmatory of previous ones.
The causes of old assigned, such as heat, light, strong perfumes, and
dust, are entirely insufficient to account for the disease. Benzoic
acid has also been put forward as a cause, but considering that it

498 Chronicle of Medical Science. [Oct.,

volatilizes only at temperatures much higher than any we ever have
in the atmosphere, it is difficult to conceive what led to the suppo-
sition. More comprehensible causes were imagined in the shape of
coumarin, the odoriferous principle of the anthoxanthum odoratum
(one of the meadow grasses), and of ozone. The former, although
a volatile body of a very penetrating odour, had no effect in pro-
ducing hayfever, at least not in the experimenter, who has long
been a sufferer with the disease. Schonbein suggested that ozone
might be a cause, and Dr. Blackley has, therefore, very fully inves-
tigated it.

To test the presence and quantity of ozone in the atmosphere, he
tried the test paper, made after Schonbein's plan, but could get no
satisfactory results with it. Accordingly, he contrived a new kind
of test paper (the method of preparing which is given in the essay
before us) and finds it to answer for the two objects he had in view,
namely, " 1st. To determine in what ratio the quantity of ozone
increased in ascending a given scale ; and 2nd. To ascertain what
relative quantity of this body would have to be inhaled to bring on
catarrh, if it was found to have the power to do so."

To carry on his experiments the writer invented several ingenious
instruments calculated to give him correct data. These are figured
and described in the pamphlet. At the seaside, ozone, when in the
largest quantity, as measured by the accurate meter adopted, " did
not (writes the author) at any time bring on hay- fever, and two of
our most experienced meteorologists tell me they have never known
it to bring on catarrh. Moreover, when we consider that the spot
where ozone is most abundant is the place where hay-fever patients
are most free from their ailment, we cannot but wonder that this
substance should ever have been thought to bring on the malady."

G-lass -slides, covered with a thin layer of glycerine and spirit,
afford a simple and convenient means of collecting, and determining
the quantity of pollen in the air. Besides working at ordinary
levels. Dr. Blackley, by means of a kite and a specially constructed
instrument attached to it, explored the higher regions of the atmos-
phere for pollen, reaching the altitude of two thousand feet, and
the remarkable fact came out, " that we have more than nineteen
times the quantity of pollen in the upper atmosphere than we have
in the lower." " Pollen wherever applied, produces disturbance. A
decoction of pollen applied to the conjunctiva brought on congestion
of the vessels, and this after a time was followed by severe chemosis.
When fresh pollen was applied to an abraded portion of the skin
oedema of the subcutaneous cellular tissue was produced, but there
was an inflammation of the true skin. An important and interesting
question is how pollen produces all this disturbance. When placed
under the microscope and breathed upon, as it is when in the nares,
the pollen grain first begins to swell, then the granular matter
alters its position, and eventually escapes by bursting through the
intine or inner membrane, and 'whilst this is going on it will fre-
quently move half way across the field of the microscope. My
conclusion is, that the influence which pollen exercises upon the

1877.]

Report on Pathology and Medicine. 499

mucous membranes and other tissues is of a mixed kind. The
sneezing is, I think, due partly to mechanical and partly to physio-
logical action. The inflammation of the conjunctiva is probably
due to mechanical action entirely. The chemosis of the conjunc-
tiva as well as the oedema of the submucous and subcutaneous
cellular tissues are, I believe, entirely owing to the physiological
action of the granular matter."

Not content with his apparent success in showing pollen to be a
cause of hay-fever. Dr. Blackley set himself to work to determine
the actual weight of it necessary to bring on an attack of the
malady ; and by the aid of a delicately contrived machine and of the
microscope, has satisfied himself that rather less than -jJ^yth of a
grain inhaled, in each twenty-four hours will keep up hay-fever in its
severest form.

The way in which pollen is distributed on the mucous membrane,
when inhaled, may partly account for the effect which so small a
quantity produces. Of the two recognised forms of pollen, the
coherent and the non-coherent, the former is seldom or never found
floating in the atmosphere, and therefore cannot be a cause of hay-
fever. The grains of non-coherent pollen are always found floating
singly, and may, therefore, be assumed to be distributed singly on
the mucous surface, thus enabling each grain to exert its full effect.
Whether the pollen acts upon the capillary blood-vessels or on the
lymphatics of the mucous tissue, the author is not prepared to say.

On this same subject of pollen as a cause of hay-fever, we have
a further pamphlet by Dr. Elias Marsh, read originally as an essay
before the New Jersey State Medical Society. It is generally con-
firmatory of Dr. Blackley's views. Like the gentleman just named,
Dr. Marsh has, during his lifetime, been a victim to the disease.
The form of the malady best known in the United States is called
autumnal catarrh, and according to Dr. Marsh, coincides in the
time of its occurrence with the flowering of the ambrosia arteme-
sifolia, known popularly as B-oman wormwood or hogweed, and
growing nearly everywhere in waste places. Dr. Wyman, who
wrote on autumnal catarrh (in 1872), first recognised the property
of this plant in inducing hay asthma by its pollen.

Dr. Marsh represents the malady as prevailing in proportion to
the frequency and luxuriancy of the plant, and that the catarrhal
symptoms never come on previously to the time of its flowering.
By means of slides both he and his friends have determined the
presence of pollen grains in the atmosphere, and his opinion is that
the pollen of ambrosia is a special or specific cause of hay-fever.

He compares the action of pollen upon the mucous membrane
with that of the Bhus toxicodendron on the skin. From each sub-
stance result heat, swelling, exudation, pain, itching, with little
febrile movement, but more or less nervous disturbance. In both
cases only a small number of individuals are so affected ; in other
words, there must be a peculiar susceptiblity of constitution before
the respective poisons can act. The sensitiveness, in both cases, is
of varying grade, and an equal exposure does not equally affect all.

500 Chronicle of Medical Science, [Oct.,

From Thus poisoning some have a mild attack of erythema, and
others a degree of inflammation approaching erysipelas ; some re-
quire the immediate contact of the juices, while others are affected
by the minute amount of volatile acid wafted by the wind. Erom
hay-fever some have a troublesome coryza only, and others suffo-
cative dyspnoea. In both affections removal from the cause proves
curative, for the disease is known in districts only where certain
plants grow. The only or chief differences in the character of the
two diseases arise from the difference in the persistent or transient
duration and application of the poison. In rhus poisoning the
irritant is of more or less force during the entire year, and conse-
quently the disease has no defined period of attack. In hay-fever
the poison is active for a few weeks only of each year, during the
blossoming time of the plant, and consequently the disease is
periodical, recurring annually at the same date. In rhus poisoning
there is usually only a single application of the poison, and the
irritant being then removed the disease seems to yield to treatment.
In hay-fever the application of the poison is continuous, hence the
disease is persistent, and treatment has no effect in limiting it. If,
however, the patient be removed from the cause, then it yields as
quickly as in the former case.

Dr. Marsh cannot admit hay-fever to be a constitutional disease,
or one of the nervous system, but argues that it is only a local one,
dependent solely on a local and special cause, although requiring a
peculiar susceptibility for its development. Lastly, it would seem
that it is not pollen in all states and stages, but that only which is
mature and derived from a plant in full vital activity under favor-
able atmospheric conditions of light and heat.

No specific remedy is known. Hypodermic injections of morphia
usually relieve, as does also chloroform, at times, when inhaled for
the asthma. Removal from the locality where the attack occurs,
and particularly to the seaside, is the most potent source of relief.

We are not disposed to consider the etiology of hay fever fully
explained by this hypothesis of pollen poisoning. The very same
symptoms occur where the action of pollen may be ignored, nor can
we admit that pollen of all sorts, as seems implied by Dr. Blackley,
is a cause of hay fever. Experience shows that a very large number
of flowers have no effect ; in seed we can imagine some would be
curative.— (Eep.)

1877.] Report on Midwifery, ^c, 501

REPOET ON MIDWIFEEY AND DISEASES OF WOMEN
AND CHILDEEN.

By Alfeed Wiltshiee, M.D., M.E.C.P. Lond.,

Joint-Lecturer on Midwifery and the Diseases of "Women and Children at St. Mary's Hospital;

Vice-President of the Obstetrical Society of London ; formerly Medical Inspector to

Her Majesty's Privy Council, &c.

Midwifery.

1. Albuminuria during Pregnancy. — Cure by Jaborandi. Bj M.

Langlet ('Union Med. du Nord Est/ No. 6, 1877).

2. Spontaneous Rupture of the Uterus in the Sixth Month of Preg-

nancy. By Dr. Ltjstgarten (' Wiener Med. Presse/ No.
13, 1876).

3. On Temporary Glycosuria inthe Puerperal State. By M. Gubler

(' Gaz. Med. de Paris, and Soc. de Biol.,' 1877).

4. Acute Hyperplasia of the Anterior Lip of the Uterus during

Pregnancy. By L. Kessler (' Dorpat Med. Zeitsch.,' vol.
vi,p. 103).
6. Intra-uterine Injection of Hot Water in Post-partum Haemor-
rhage. By Dr. Etjnge (' Berliner Klin. Wochenscli.,' March,
1877.

6. Smallpox in a Six Months* Foetus. By Dr. Botjteillier

('Union Med. de la Seine Inf.,' April, 1877).

7. Novel Treatment of Retroversion of the Gravid Uterus. By M.

Massart (' L'Union Medicale,' September, 1877).

8. On New Forceps. By Professor Tarnier (' Memoire,' Paris,

1877).

1. M. Langlet relates a case of albuminuria, accompanied by
oedema, which occurred in a muciparous woman when about six
weeks pregnant and which he treated by jaborandi.

The patient was threatened by abortion, and had premonitory
symptoms of eclampsia. The urine was very scanty and was highly
charged with albumen. There was fluid in each pleural cavity.

None of the remedies employed benefited the patient until she
took jaborandi. The most notable effects of the drug were a con-
siderable augmentation of the urine and great salivation, sweating,
though free, being less marked.

The drug was given for fifteen days, at the end of which time the
urine became markedly bloody. There had been a few globules
before, but now there was distinct haematuria, which Dr. Langlet
attributes to the powerful diuretic action of the drug. The patient
went to the full term of pregnancy and was delivered of a fine
child. The only thing remarkable about the labour was the large
amount of liquor amnii which escaped.

2. Dr. Lustgarten gives details of a case of spontaneous rupture

502 Chronicle of Medical Science. [Oct.j

of the uterus at the sixth month in a young woman, set. 28, preg-
nant for the second time. The first confinement took place five
years previously, and, though laborious, was normal. Without ap-
parent cause she was suddenly seized with violent pain in the
abdomen and vomiting.

At the autopsy a rupture of the size of the thumb was found in
the upper and left part of the body of the uterus ; and on opening
the organ it was found that the placenta was solidly fixed on the
lower segment of the uterus, entirely occluding the*internal orifice
of the cervix ; it was, in fact, a case of placenta praevia lateralis
dextra.

3. The conclusions of Dr. G-ubler's memoir on temporary gly-
cosuria in the puerperal state are as follows :

(1.) Glycosuria is not a normal phenomenon of lactation.

(2.) It appears on the suspension or premature suppression of
suckling when the mother is well, or at least when the great func-
tions have not sustained any serious disorder.

(3.) In other words, glycosuria appears only as the consequence
of a rupture of the equilibrium between production and consump-
tion, giving rise at first to lactossBmia, comparable to sanguineous
super-albuminosis whence dyscrasic albuminuria is derived.

But it may be asked why the suspension of the secretion of milk
gives rise to the elimination of one only of its immediate prin-
ciples by the renal glands. For M. Gubler has never seen tran-
sitory albuminuria accompany glycosuria in these pathological
conditions. It is because the passage of sugar, a crystalloid and
dialysable body, is much more easy than that of albumen, which is
a colloid body, and will not pass through the dialysers. Albumi-
nuria always supposes at least a renal hypereemia, which confines
itself to the first degree of an inflammation, whilst glycosuria may
take place without any anatomical modification of the kidney.
Lastly, resorption of milk carries into the blood but a small pro-
portion of the albuminoid materials, whilst it reintroduces into the
circulation a large quantity of sugar of milk.

4. Dr. Kessler relates the case of a woman who, a month after a
fall, in the thirty-fourth week of her fourth pregnancy, found a mass
in the vagina during micturition. It was as large as a hen's egg^
and was found on examination to spring from the anterior lip of the
cervix uteri. She was in due time delivered by the forceps, and some
weeks afterwards the growth was removed, as it did not decrease with
the rest of the uterus.

The author remarks that cases of tumefaction of the anterior lip
of the uterus are rare. On analysing them he thinks they can be
reduced to three kinds.

(a.) In the first, the anterior lip is pressed and rubbed by the
foetal head, during labour, against the pelvic walls, whereby more
or less intense swelling is caused. This is only a passing tumefac-
tion, which disappears after delivery.

(5.) In the second, hypertrophy has existed before pregnancy,
but augments with it in proportion to the increase in the volume of

1877.] Report on Midwifery^ ^c. 503

the uterus. Ordinarily this also disappears during the puerperal
period, but sometimes it increases, as in the cases observed by
Schroder and Scholler.

(c.) In the third, the normal anterior lip swells during pregnancy.
This tumefaction is transformed into hyperplasia, which may persist
or disappear after delivery.

As regards pathology and etiology, the knowledge of the formation
of these tumours, and also the histological researches, are defective
or insufficient. The author has designated his case as one of hyper-
plasia, and this hyperplasia may resemble that which Virchow named
simple and uniform hyperplasia of the lips ; and if one compares this
alteration with that which Klebs called " myoma of the uterus," one
might denominate it by the term diffuse myoma ; for in Klebs' case
the hyperplasia was limited and separated from the healthy substance.

This tumefaction, according to Virchow, appears to be due to a
species of oedema or inflammation resulting from pressure of the lips
between the head and the pelvis.

As regards treatment, the pressure should, if possible, be relieved.
If practicable, the lip should be pushed up ; if not, the forceps should
be applied when the neck is sufficiently dilated.

5. Dr. Eunge states his experience of hot water injections in post-
partum hsemorrhage. He injected water as hot as from 117° to
124° Fahrenheit. The remedy was successful when ergot, ice, and
external manipulation of the uterus had failed.

The injection of water at the higher temperature caused so much
pain in some cases that it had to be reduced. Though Dr. Eunge
cites Windelband, Jakoch, and Landau, he does not state that the
injection of hot water for controlling uterine haemorrhage is practised
in America with much success by Dr. Fordyce Baker, Dr. Emmet,
and others. The remedy seems to be a powerful one, but probably
some caution should be exercised in applying it.

6. Dr. Bouteillier exhibited, at the Medical Society of Eouen, a
foetus showing variola. The mother, set. 31, had been vaccinated in
childhood. She was attacked with smallpox in October, 1876, in her
third pregnancy, and aborted about two months later. The
foetus presented a general eruption of umbilicated pustules. It is
remarked that " this observation is remarkable for the length of
time which appeared to have elapsed between the epoch of invasion
of variola in the mother and its probable invasion in fhe foetus ;"
and this is certainly very singular.

Dr. Pennetier related the case of a lady who had smallpox during
her pregnancy, but gave birth to a healthy child, who was " refrac-
tory to several attempts at vaccination."

Dr. Thierry made the following excellent remarks :

(1.) Variola is rare in the foetus of six months. It ordinarily
declares itself in the eighth or ninth month.

(2.) The pustules in foetal variola are few on the face, while
they may be confluent on other parts of the body.

(3.) Eelative to the influence of maternal variola on the aptitude
which the child will afterwards have to contract the disease, observa-

504 Chronicle of Medical Science, [Oct.,

tions have in a general manner taught that variola must be contracted
by the mother before the seventh month of her pregnancy for the
infant to become refractory to the disease. After the eighth month
the same immunity is not acquired by the foetus or child.

(4.) The evolution of variola seems to occur more slowly during
intra-uterine life than after birth, and this greater length seems to
pertain to the incubation, which may be of a month's duration.
Cases are on record of variolous foetuses being aborted two months
after variola in the mother.

The Thesis of Laurens (Paris, 1871) narrates the case of a woman
who gave birth to a variolous infant forty-one days after she had
been in contact with a woman who had smallpox, and without herself
having bad the disease. The pustules on the child indicated the
seventh to tenth day at most, from which we may conclude that, in
this case, the period of incubation was at least thirty-one days.
Lastly, he cited cases of twin-birth, in which one only of the children
was born variolous, the mother escaping. And Dr. Chantreuil
has related a similar fact.

7. M. Massart, of Honfleur, communicated to the Havre Con-
gress of the French Association for the Advancement of Science a
remarkable case of retroversion of the gravid uterus, which was
cured by a means borrowed from the old Norman bone-setters,
which consisted in applying a " pot de chambre" as a cupping glass
on the belly of the patient in such a way as to diminish the pressure
which the intestinal loops exercised on the displaced uterus.

8. Professor Tarnier, of Paris, has recently introduced some new
forceps for which he claims superiority in certain important respects
over those in common use. Briefly stated, the chief advantage
gained is that of being able to make traction on the foetal head in
exactly the proper axis o'f the pelvis without any guidance or control
on the part of the operator. The mechanism whereby this is
secured consists, in addition to forceps similar to those of ordinary
construction, of a pair of movable traction stems, which are inserted
one into the lower edge of each blade close to the fenestrum, and
which must be kept parallel to the handles of the forceps, the latter
acting as indicators of the direction in which the head is descending.
The forceps have not handles of the usual form, because traction is
not to be made through them but through the traction stems, by
means of a transverse bar attached to their extremities. The operator,
after properly applying the forceps to the foetal head, has only to
make traction, maintaining always complete parallelism between the
traction stems and the handles of the forceps. Competent observers
have stated that Professor Tarnier's new instruments appear to be
very efficient, but more extended experience is required to com-
pletely establish the claims of the learned professor.

1877. J Report on Midwifery, ^c, 505

Diseases of Women.

1. The Significance of Pus in Ovarian Fluids. By Dr. Chadwick

C Reports of Boston City Hospital/ 1877).

2. On a New Cause of Vaginismus. By O. Johannsen (' Peters-

burg Med. Wochensch./ No. 9, 1876.

3. On Erythema Exudativum. By G. Lewin ('Berliner Klin.

Wochensch,' No. 23, p. 321).

4. On Urethral Affections in Women. By A. Blum (' Arch. Gren.

de Med.,' August and September, 1877).

5. Double Uterus and Vagina with Fibroid Tumours and Absence of

one Kidney. By Mr. John Clay (' Lancet,' July 21, 1877).

6. On the Treatment of Vegetations of the Mucous Membrane of the

Interior of the Uterus. By M. Gtallaed Q L'Union Med.,'
Sept., 1877).

7. Sanguineous Infiltration of the Lower Limbs ; Cutaneous Ecchy-

moses and Purpura coinciding with Menstrual Suppression.
By M. Ledouble (' Annales de Gynecologic,' April, 1877).

8. On hysterotomy for Uterine Tumours. (' Annales de Gyneco-

logie,' April, 1877.)

1. Dr. Chadwick gives an interesting note on the significance of
pus in ovarian fluids, based on the observations of a case in which
tapping was repeatedly performed.

At the first tapping the fluid was clear and mucilaginous, but at
subsequent tappings it was found to contain pus. There were,
however, no symptoms pointing to inflammation of the cysts, " no
general malaise, no loss of strength or flesh, no fever, no chills, the
pulse and temperature were normal on the only occasion on which
they were recorded. The case, therefore, suggests that pus in the
fluid taken from an ovarian cyst is, in the absence of symptoms
pointing to acute inflammation, pathognomonic of ulcerative action
in the cyst. The perforation of the cyst wall, in the course of this
process, indicates the imminent danger to which patients are subject
under these circumstances, and calls for quite as prompt operative
interference on the part of the surgeon as do the symptoms of acute
inflammation."

2. Dr. Johannsen relates the case of a young married woman who
had had no children, who for a long time sufiered severe pain during
coitus which was not relieved by treatment. Micturition was painful,
and as pressure of the urethra against the pubis was extremely
painful, Dr. Johannsen examined the canal with a speculum, and
found on the floor of it two yellow points about the size of pins'
beads. These points were the orifices of two fistulse. The larger
of the two fistulae was split up, and the other touched with caustic,
after which the vaginismus disappeared.

(3) , In an important work on the influence of the vaso-motor
nerves in the production and development of cutaneous afl^ections.
Dr. Lewin states the results of the observation of thirty-nine cases

t06 Chronicle of Medical Science. [Oct.,

of erythema nodosum. Though generally occurring without pro-
dromata, the eruption may be preceded by fever; it is mostly
symmetrical on the two halves of the body, and the seat of predi-
lection is where bones are covered by inconsiderable layers of
muscle, ap the backs of the hands and feet, the extensor sides, and
front of the legs, &c. Ultimately, various other parts of the body
may be invaded. The infiltrations occupy the subcutaneous tissues
and may assume various forms, as tubercular, papular, and nodular.
The disease attacks by preference young persons, and especially of
the female sex. In severe cases, inflammatory affections of the
joints may supervene, which may be attended by serous or purulent
effusions ; and occasionally, in the latter case, anchylosis may ensue.
There may also be valvular endocarditis, leading to disorganization
of the valves. Lewin thinks that some of the cases of valvular
endocarditis of doubtful origin may be explained by an old attack
of exudative erythema.

As regards the etiology of exudative erythema, exposure to cold,
which is so generally admitted, is only one of the factors. In a
large proportion of cases, especially in females, an inflammation or
ulceration of the urethra presents a direct causal relation with the
erythema. The cutaneous affection must be considered as the mani-
festation of a reflex irritation proceeding from the urethral mucous
membrane, and acting on the vaso-motor nerves of the skin ; it is,
in fact, comparable to blenorrhagic rheumatism.

This view is based on clinical and experimental observations.
Thus a great number of the women treated by Lewin for erythema
had at the same time a blenorrhagic inflammation, ulcerous or not,
of the urethra. One patient, cured by Dr. Lewin of the urethritis
and erythema at the same time, had a recurrence o£ erythema on a
relapse of the urethral affection.

An experimental proof was furnished by another patient, in
whom, after the cure of the urethritis and erythema, irritation of
the urethra by the sound, or by the introduction of savine ointment,
was sufficient to establish a severe attack of erythema.

Lewin states that sometimes exudative erythema appears epidemi-
cally, and it appears then to be produced by a volatile contagium
similar to those of other acute infectious exanthems.

4. Dr. Blum contributes a copious essay on urethral affections
in women, chiefly condensed from various periodicals, as he finds but
little relating to the subject in classical works. The essay will
repay perusal, though it shows how much is still wanting to com-
plete our knowledge of this exceedingly troublesome class of
affections.

5. An extremely interesting case of double uterus with two vaginaB,
complicated with fibroid tumours and absence of one kidney, occurred
in the practice of Mr. John Clay, of Birmingham. The nature of
the tumours was doubtful, and as aspiration failed to make any im-
pression, an unsuccessful attempt was made at enucleation per
vaginam. The patient died of peritonitis, and at the post-mortem
examination it was found that there were two uteri and two vaginae.

1877.] Report on Midwifery ^ ^c. 6O7

Both uteri contained fibroid growths. No kidney was found on the
left side, but there was a ureter on that side which was obliterated
some distance up. There were only two ovaries, one to each uterus,
so that the case must be regarded as one of bipartite uterus and
vagina.

6. M. Gallard made a communication to the French Association
for the Advancement of Science, at its late meeting at Havre, on the
nature and treatment of vegetations of the intra-uterine mucous
membrane. The subject had been well handled by Eecamier, but
the practice he recommended had suffered reverses. Dr. Gallard,
however, thought the method of treatment by the curette capable of
rendering real service, and he related a remarkable case in proof of
this assertion.

[We have certainly ourselves seen some very remarkable instances
confirmatory of Dr. Gallard's views. — Eep.]

7. Dr. Ledouble records a most interesting case in which blood
was effused into the lower limbs as the immediate consequence of
acute suppression of the menses. The limbs swelled and were
painful; large ecchymoses and petechiae rapidly formed. The legs
were nearly twice their natural size, and the swelling was hard and
did not pit. Eegarding these symptoms as due to suppression of
the menses. Dr. Ledouble ordered sinapisms to the breasts, and gave
fl 5SS drachm doses of ether every two hours. On the following day
the menses re-appeared, and from that moment a sensible ameliora-
tion was apparent. A month afterwards acute suppression of the
menses took place from fright ; the same symptoms appeared and
yielded to the same treatment. After that the menstruation became,
as before, perfectly normal.

[Dr. Ledouble' s case has an important bearing on the question of
the occurrence of general vascular disturbance during menstruation.
He is evidently of opinion that something of this kind occurs, for he
concludes his reflections on the case as follows : — " It is in a part
already weakened by an anterior organic lesion, or by excess of
functional work, that pathological manifestations are by preference
produced. Under the influence of vasculo-nervous erethism the
fluxionary movement due to the suppression of the menses deter-
mines haemorrhage in the part of the body which, owing to an anterior
lesion or an excess of work, even physiological, has lost the greater
part of its resistance." — Eep.]

8. At a late meeting of the Academy of Medicine of Paris, M.
Pean exhibited specimens from a case of hysterotomy, the nature of
which not being clear, the parts were referred to a committee con-
sisting of MM. Depaul, Eobin, and Laboulbene.

Dr. Pean had previously presented to the Academy a group of
observations of twenty-seven hysterotomies practised with the view
of relieving the patients from voluminous uterine tumours. These
observations were thus distributed : — 18 operations for uterine
fibromata : 12 successful, 6 unsuccessful ; 6 operations for fibro-
cystic tumours : 4 successful, 2 unsuccessful ; 2 for ablation of utero-
cystic (?) tumours: both successful. (Since that time he had

508 Chronicle of Medical Science, [Oct.,

practised 7 new hysterotomies : 3 for ablation of fibrous tumours,
2 for utero-cystic tumours, one for a carcinomatous tumour of cystic
form, and lastly the case in question.

[The success which has attended the operations of Pean, Koeberle,
Wells, and others, for the removal of fibroid and fibro-cystic tumours
of the uterus, is so great, seeing the extreme gravity of the disease
in the cases which demand this form of operation, that it is to be
hoped that other competent operators will not neglect the operation
in suitable cases.

A success equal to that which has happily attended ovariotomy is
hardly to be anticipated; but many suflTerers who now succumb without
an attempt being made to relieve them by operation may thus be
rescued from a lingering and painful death. — Rep.]

Diseases of Children.

1. Renal Sarcoma in a Child aged Seven Months. By Dr. Ba-

GiNSKY ('Berlin Klin. Woch.,' No. 18, p. 249).

2. On Dyspeptic Asthma. By Dr. Henoch ('Berliner Klin.

Wochensch.,' No. 18, p. 242).

3. A Case of Spina-Bifida cured hy the Elastic Ligature. By Dr.

CoLGONESE (' Bull, dellc Scienze Medici,' April, 1877).

4. Erysipelas in Infants caused hy Bancid Fat. By M. Siredey

(' L'Union Medicale,' September, 1877).

1. In Dr. Baginsky's case there had been haematuria for several
weeks. On examination a tumour was found in the left side extend-
ing from the costal margin to the median line and down to the iliac
crest. As dyspnoea arose from increase in the size of the tumour a
puncture was made, which gave exit to 470 cubic centimetres of dark
beer-coloured fluid which contained much blood, and some urea and
uric acid. The child died on the following day without having had
convulsions. At the post-mortem examination the left kidney was
found to be transformed into a cystic tumour composed of two
parts, an enormous cyst and a solid mass, nearly as large as a foetal
head. The growth was adherent to the abdominal walls and to the
diaphragm ; and the ascending colon was found on its surface. The
tumour was examined by Yirchow, who found it to be a fusiform-
celled sarcoma, with but few remains of kidney structure. The
right kidney showed a marked specimen of parenchymatous nephritis.

2. Henoch, describes cases of dyspeptic asthma, two of which
occurred in children aged respectively nine months and nine years.
Both were very severe. The dyspnoea was urgent and a fatal issue was
in each case feared. Henoch first observed theaflfection in company
with Traube, and whilst he could not renounce the idea of an affec-
tion of the circulatory apparatus, in spite of the negative results of
examinations, Traube, relying on the experiments of Mayer and
Pibram (' Sitzungsberichte der Wiener Akadamie der Wissen-
schaften,' 1872), considered them to depend on irritation of the

I87f.]

Books y ^d.y received for Review. 609

stomach. He explained the chain of phenomena in the following
manner; reflex irritation starting from the stomach, vaso-motor
cramp in the small arteries, whence coldness of the extremities,
insensibility of the pulse, stasis in the venous system and right
heart, cyanosis, accumulation of carbonic acid in the blood, and, as
a consequence, frequent and dyspnoeic.
Emetics and dry cupping gave most relief.

3. Dr. Colognese's case of spina-bifida was one which sprang
from the level of the ninth dorsal vertebra. It was of the size of a
large orange, had a pedunculated base, and contained transparent
fluid. The skin covering it presented a normal appearance. The
tumour moved with respiration and when the infant cried : — a
hydro-rachidian tumour was accordingly diagnosed ; serous fluid was
evacuated by puncture. An elastic ligature was placed around the
pedicle, care being taken to avoid tightening it too much at first,
and also to avoid dragging on the spinal canal or skin. The child
was comfortable and slept well at first, afterwards it cried a great
deal and refused the breast, but ultimately, on the ninth day, the
mass dropped off", leaving a healthy wound, perfectly closed, and from
which no fluid escaped.

4. In an unaccountable endemic of erysipelas among the infanta
in the Lariboisiere Hospital, at Paris, M. Siredey discovered that
the disease was due to the application of rancid lard, which was em-
ployed to anoint the buttocks of children who were suffering from,
or threatened by, diarrhoea. As many as fifteen cases occurred in
the half year, and only two of these recovered. Healthy as well as
cachectic children were attacked, and the erysipelas did not start
from the umbilicus, but from the buttocks, genital organs, and parts
covered by napkins. The disease ceased to be endemic when fresh
lard was used.

BOOKS, PAMPHLETS, &c., PvEGEIVED.

Cyclopsedia of the Practice of Medicine. On Curvatures of the Spine ; theii?
Edited by Dr. H. von Ziemssen. Vol. xv. causes and treatment. By Richard Bar-
Diseases of the Kidney. By Prof. Carl well, F.R.C.S. Third Edition. London,
Bentels and Prof. W. Ebstein. London, 1877. Macmillan & Co, pp. 238.
1877. Sampson, Low & Co. pp. 796. Nineteenth Annual Report of the

St. George's Hospital Reports. Edited General Board of Commissioners in Lu-

by W. H. Dickinson, M.D , and Timothy nacy for Scotland. Edinburgh, 1877.

Holmes, F.R.C.S. 1874-76. Vol. viii. St. Thomas's Hospital Reports. New

London, 1877. Churchills. pp. 580. Series. Vol. vii. London, 1876. Churchilla.

A Report to the Surgeon-General on pp. 392.
the Transport of the Sick and Wounded Eighth Annual Report of the State
by Pack Animals. By George A. Otis, Board of Health of Massachusetts. Jan-
Assistant-Surgeon U.S. Army. Wash- uary, 1877. Boston, pp. 498,
ington, 1877. Epitome of Skin Diseases, with For-

lUustrations of Clinical Surgery, with mulae for Students and Practitioners. By

descriptive letterpress. By Jonathan Tilbury Fox, M.D., and T. C. Fox, M.B.

Hutchinson, F.R.C.S. Fasciculus viii. Second Edition. London. Renshaw. pp.

Churchills. 1877. 144.

JL20--BX. 33

510

Books, ^c.y received for Review,

[Oct.,

Hints on Ophthalmic Out-Patient Prac-
tice. By Charles Higgens, F.R.C.S. Lon-
don, 1877. Churchills. pp. 87.

The Ketrospect of Medicine ; a Half-
yearly Journal. Edited by W. Braith-
waite, M.D., and James Braithwaite,
M.D., January to June, 1877. London,
1877. Simpkin, Marshall & Co. pp.
376.

Medicinal Plants. Being descriptions
with original figures of the principal
plants employed in medicine. By Robert
Bentley and H. Trimen, M.B. Parts 21
and 22.

British Medical Association Scientific
Keports. Second Contribution to the Life-
History of Contagium. By Peter M.
Braid wood, M.D., and Francis Vacher.
London, 1877. (Reprint.)

The Morphology of the Skull. By W.
K. Parker, F.R.S.,and G. T.Bettany, M.A.
London, 1877. Macmillan & Co. pp.
368.

The Examiner in Anatomy ; a course
of instruction in the method of answering
anatomical questions. By Arthur T.
Norton, F.R.C.S. London, 1877. Smith,
Elder & Co. pp. 174.

Transactions of the American Gynaeeo-
logical Society. Vol. i. For the year
1876. Boston, 1877. Houghton & Co.
London, Triibner & Co. pp. 396.

Diseases of Women. By Lawson, Tait,
F.R.C.S., &c. London, 1877. Williams
& Norgate. pp. 310.

Internal Urethrotomy, with its Modern
Improvements. By Edwd. Lund, F.R.C.S.
London, 1877. Churchills.

Examination Papers for the use of Me-
dical Students. Compiled by W. J. H.
Lush, M.R.C.S., &c. Churchills. 1877.
pp. 112.

The Question of Rest for Women during
Menstruation. By Mary P. Jacobi, M.D.
Illustrated. London, 1878. Smith, Elder
& Co. pp. 232.

Etude sur le Baume Gurjum, et quel-
ques-unes de ses applications therapeu-
tiques. These par Luc Deval, M.D.
Paris, 1877.

De I'Atrophie Musculaire consecutive
aux Maladies des Articulations. Etude
clinique et cxperimentale. Par Emile
Valtat, M.D. Paris, 1877. J. B. Bailliere
et fils. pp. 155.

Clinique Medicale de la Pitie. Par T.
Gallard Medecin de I'Hdpital de la Pitie.
Avec 25 Figures intercalees dans le Texte.
Paris, 1877. J. B. Bailliere et fils. pp.
617.

Traite d'Hygiene Navale. Par J. B.
Foussagrives, Medecin en Chef de la
Marine, en retraite. Deuxieme Edition,
avec 145 Figures intercalees dans le
Texte. Paris, 1877. J. B. Bailliere et
fils. pp. 919.

Traitement Ratiouel des Plaies Me-

thode d' Aeration. Rapport de la Com-
mission Speciale du Traitement des Plaies
a la Societe de Chirurgie de Moscow.
Moscow, 1877.

Etude sur le Spina Ventosa accom-
pagnee d' observations recueillies a rH6-
pital Ste. Eugenie, &c. Par Edouard
Goetz, M.D. Paris, 1877. J. B. BailUere
etfils. pp.118.

Famphlets.

Poisonous Effects of Cyanide of Potas-
sium. By Joseph Jones, M.D. New
Orleans, 1877. (Reprint.)

A Synopsis of Private Obstetrical Prac-
tice for Forty-two Tears previous to
January 12, 1876. By William Ingalls,
M.D. Cambridge, U.S. (Reprint). 1877.

Labour complicated with Uterine Fi-
broids and Placenta Praevia. By James
R. Chadwick, M.D. Boston, 1877. (Re-
print.)

Rare Forms of Umbilical Hernia. By
James R. Chadwick, M.D. Boston, 1877.
(Reprint.)

Pus in Ovarian Fluids. By James R.
Chadwick, M.D. Boston, 1877. (Re-
print.)

The Discovery of Anaesthesia. By J.
Marion Sims, M.D. (Reprint.) 1877.
Richmond (U.S.)

Hannover, Funiculus Scleroticae, un
reste de la feute foetale dans Toeil humain.

A Preliminary Analysis of Ten Hun-
dred and Sixty Cases of Asthenopia. By
C. R. Agnew, M.D. New York. (Re-
print.) 1877.

New South Wales Inspector of the
Insane. Report. 1876-77.

Hospital for the Insane, Gladesville,
New South Wales. Report. 1876.

Report of the Sanitary Condition of the
Hackney District for 1876. By J. W.
Tripe, M.D.

Morphia in Childbirth. By W. T. Lusk,
M.D. New York, 1877.

The Toner Lectures. Lecture V. On
the Surgical Complications and Sequels
of the continued Fevers. By W. W.
Keen, M.D. Washington Smithsonian
Institution. 1877.

On some common Misapprehensions as
to the Curability of the Admissions of
County Asylums. By T. Algernon Chap-
man, M.D. 1877. (Reprint.)

Note on the Comparative Mortality of
Different Classes of Patients in Asylums.
By T. A. Chapman, M.D. 1877. (Re-
print.)

Analysis of Seven Hundred and Seventy-
five Cases of Skin Disease. By L. Duncan
Bulkley, M.D. (Reprint.) New York,
1877.

No Sectarianism in Medicine. By
Samuel Cockburn, M.D. ; being a reply ^to
the London School of Homoeopathy.

1877.]

Books, ^c.j received for Review,

511

Drugs in the Treatment of Disease.
By Robert Hamilton, F.R.C.S. Liver-
pool, 1877.

The Operative Treatment of Genu
Valgum. By Alexander Ogston, M.D.
(Reprint.) 1877.

Hay Fever, or Pollen Poisoning ; an
Essay, read before the New Jersey State
Medical Society. By Elias J. Marsh,
M.D. 1877. (Reprint.)

The Woman's Hospital in 1874. By J.
Marion Sims, M.D. New York, 1877.

Fourth Annual Report of the London
Temperance Hospital. 1877.

History of a Case of recurring Sarcoma-
tous Tumour of the Orbit in a Child. Il-
lustrated. By Thomas Hay, M.D. (Re-
print.) Philadelphia, 1877.

Report of the Sanitary Condition of
Birkenhead. By Francis Vacher. For
1876.

On the Use of Large Probes in the
Treatment of Strictures of the Nasal
Duct. By Samuel Theobald, M.D. (Re-
print.) Baltimore, 1877.

The Strumous Element in the Etiology
of Joint Disease, from an analysis of 860
cases. By V. T. Gibney, M.D. (Reprint.)
New York, 1877.

Some Relations of Mental Disease to
Inheritance. By G. H. Savage, M.D.
(Reprint.) 1877.

Our Medical Charities. An Address
delivered by Sampson Gamgee, F.R.S.
Edin. London, 1877.

"Weekly and Quarterly Returns of
Births and Deaths from the Registrar-
General.

Journals.

Edinburgh Monthly Journal.

Dublin Journal of Medical Science.
(Monthly.)

Journal of Anatomy and Physiology.
(Quarterly.)

Journal of Mental Science. (Quarterly.)

Lancet, Medical Times and Gazette,
British Medical Journal, and Medical
Press. (Weekly.)

Canada Medical and Surgical Journal.
(Monthly.)

The Indian Medical Gazette. (Monthly.)

New York Medical Journal.
(Monthly.)

The American Journal of the Medical
Sciences. (Quarterly.)

The American Journal of Obstetrics and

Diseases of Women and Children. (Quar-
terly.)

The Library Table. New York. (Weekly.)

The Chicago Medical Journal and Ex-
aminer. Edited by W. H. Byford, M.D.
(Monthly.)

The American Practitioner. (Monthly.)

Philadelphia Medical Times. (Bi-
weekly.)

The American Journal of Insanity.
(Quarterly.)

The Boston Medical and Surgical
Journal.

New Remedies. A Monthly Trade
Journal of Materia Medica.

The Quarterly Journal of Inebriety;
published under the auspices of the
American Association for the Cure of
Inebriates. Vol. i. Nos. 1, 2, and 3.
1877.

Archives of Dermatology. A Quar-
terly Journal of Skin and Venereal Dis-
eases. Edited by L. DuncAn Bulkley,
M.D. (Quarterly.)

New Preparations. A Quarterly Journal
of Medicine, devoted to the introduction
of new therapeutical agents. Edited by
G. S. Davis and C. H. Leonard, M.D.
Detroit, Michigan.

Archives Generales de Medecine.
(Monthly.)

Union Medicale et Scientifique du
Nord-Est. (Monthly.)

Bulletin General de Therapeutique
(Fortnigthly.)

Revue des Sciences Medicales en France
et a 1' Stranger. (Quarterly.)

Le Progres Medical. (Weekly.)

Annales de Gynecologic. (Monthly.)

L'Annee Medicale Journal de la Societe
de Medecine de Caen et du Calvados.
(Monthly.)

Revue Mensuelle de Medecine et de
Chirurgie. Paris. (Monthly.)

Schmidt's Jahrbiicher der Gesammten
Medicin. (Monthly.)

Archiv fur Gynaekologie. (Quarterly.)

Deutsches|Archiv fiir Klinische Medicin.
(Monthly.)

Archiv fur Pathologische Anatomie und
Physiologic. (Monthly.)

Gaceta cientifica de Venezuela. Revista
Quincenal Redactores MM. Ponte y J. T.
Torralbas. Primer Ano, 1877. Caracas.

Lo Sperimentale.

Giornale' Critico di Medicina e Chi-
rurgia. (Monthly .)

PUBLISHEKS' NOTICE,

It is with much regret that we have to announce to our
readers that this is the last number which it is intended to
publish of the ' British and Foreign Medico-Chirurgical Review/
For a period of thirty-eight years the Review has been looked
upon by the profession as holding a position above that of the
weekly and other medical periodicals, the contents of which,
from their more frequent publication and the haste in which
they must often be compiled and printed, are necessarily more
ephemeral in character, while the standard position of the
Review has been again and again attested by the importance
which anxious authors have been wont to attach to its critical
remarks upon their literary productions. But in the present
day he who would succeed in life must mark the signs of the
times. For several years we have witnessed the gradual decline
in sale of that which once was a good property, and, in spite of
all our efforts to infuse new life into our old friend, we have
been obliged to stand by and see it languish, so that the period
has at last arrived when to continue to publish it would be to
incur an annual loss which would rather increase than diminish
as time went on. The reason of all this is that the day for
quarterlies is gone by, and, in the face of the daily and weekly
periodicals, a quarterly, with its thoughtful articles and well-
digested reviews, is no longer appreciated as formerly. This
remark applies, we may state, not less to general than to medical
literature.

The remarks we make are few, as in writing our farewell
words we feel as though taking a last leave of one we have
known for many a year. We cannot, however, conclude with-
out reminding our readers of the list of names of those we have
had the happiness to secure as editors of this time-honoured
publication. §uch men as the late Sir John Forbes and Dr.
Parkes, as Dr. Carpenter, Dr. Sieveking, Dr. J. W. Ogle,
and our present esteemed friend Dr. Arlidge, are a proof that
the literary excellence of the Review has been of the highest
order, and to them and to the able collaborateurs who so well
seconded their efforts we shall always look back with feelings
of the greatest gratitude.

INDEX TO YOL. LX

OF THE

BRITISH AND FOREIGN MEDICO-CHIRURGICAL REVIEW.

PAGE
Address by publishers . . .512
Adler on the retinal purple . . 226
Albuminuria of pregnancy cured

by jaborandi .... 501
Alcock, on temperature in lung

diseases 253

Alcoholism, Magnan on . . 364
Alt on sympathetic ophthalmia . 211
American asylums, Bucknill on . 173
Gynaecological Society's

* Transactions' .... 434
American Neurological Association

* Reports' 423

Amphibia, article by Huxley . 114

Amputation, results of . .158

Anatomy, introduction to, by

Turner 138

Anderson, McCall, on tubercular

affections 426

Antiseptic operations with surgical

fever 201

Arlidge on medical organization

of Factory Acts . . .248
■ — report on pathology and

medicine 491

Asiatic cholera, history of . . 165
Asthma, dyspeptic, Henoch on . 508
Asylums, American, Bucknill on . 173
Atthill, on diseases of women . 452
Auditory canal, brain wounded

from 204

Auscultation, Flint on . . . 171
Automatism, doctrine of . . 114
Balsam, gurjum, uses of . . 487
Bannister on progressive facial

hemiatrophy .... 491
Bathing, sea, Parsons on . . 162
Bath waters, Spender on . . 416
Battye on vital force . . . 447
Baumler on syphilis . . 40

Benedikt on brain of man and

carnivora ..... 229
Bennet on nutrition . . . 171
Bennett's translation of * Thome's

Botany' 114

Bettelheim on the fever of phthisis 253
Baginsky on renal sarcoma in a

child 508

Biedermann on stomach epithe-
lium . ... . . 220

Bilhaut on temperature in phthisis 253
Black on diseases of urinary organs 96

on Bright's disease . . 434

Blackley on causes of hay fever . 497
Bladder disease, Gant on . . 149
Blood of animals recently deli-
vered 219

PAGE
Blood, pressure, Basch on . . 219

' as influenced by

respiration . . . " . 224
Blum on urethral affections of

women 506

Boileau on temperature of phthisis 253
Bombay Medical Society's * Trans-
actions 177

Bonamy on use of zinc oxide in

diarrhoea 478

Bones, lymphatics of . . . 218
Books received .... 249
Botany, Thome's text-book of .114
Boudant on waters of Mont-Dore . 157
Bouteillier on smallpox in the

foetus 503

Braidwood and Vacher on conta-

gium 391

Brain, chemistry of . . .1

on differentiation of brains

of man and carnivora . . 229

diseases of . . . 269

on functions of . .99

wounds from auditory canal 204

Breast, male, cancer in . . 212

Brietzcke on urea in relation to

muscular force .... 190
Brigham on value of sponges in

surgical dressing . . . 202
Bright's disease. Black on . . 434

pathology of . 279

Bristowe's treatise on medicine . 161
Brunton's tables of materia medica 169
Bucknill on American asylums . 173
Budge on lymphatics of bones . 218
Bull's ' Hints to Mothers' . . 174
Busch on blood pressure . . 219
Cadet on remedies for diphtheria . 479
Cancer in male breast . . . 212
Cartaz on plexiform neuroma . 495
Carter's reports on leprosy . . 139
Cataract, Magnus on . . . 423
Cellulitis, acute, of orbit . . 214
Chadwick on significance of pus in
ovarian fluid .... 505

— on a police force . . 381

Charcot on changes in liver on

tying the duct . . . .59
' ' — lectures on diseases of

nervous system . . . 180

Cliarities, medical, on, by Gamgee 381
Chemical constitution of brain . 1
Childbirth, the blood in . . 219

, urine in . . . 222

Children, diseases of, report on . 508

by Eustace

Smith 451

514

PAGE
Childron, management of, by Bull 174
Chinese materia medica . . 482

Cholera, Asiatic, history of . . 165
Chrysarobin, uses of . . . 486
Cirrhosis of liver . . . .59
Classification of mental diseases . 496
Clay on case of double uterus with

a tumour 506

Cleland on dissection . . . 153
Clinical Society's ' Transactions' . 181
Clinical surgery of Paris hospitals. 449
Cold baths in typhoid fever . . 480
Colognese, case of spina bifida

cured by elastic ligature . .509
Contagion, what do we know about

it? 391

Contagious diseases, prevention of. 381
Contagium, life-history of, by

Braidwood and Vacher . . 391
Coutet on facial atrophy . . 494
Crede on antiseptics and surgical

fever 202

Criminals, diseases of . . . 182
Cubebs in diphtheria . . . 479
Cullen on typhoid fever . . 425
Cullingworth's ' Catalogue of the

Bedford Library' . . .415
'Nurse's Compan-
ion' 164

Cunningham on Indian leprosy . 139

on Oriental sore . 144

on mycetoma . . 340

Curability of acute phthisis, by

McCall Anderson . . . 426
Curling on diseases of rectum . 17
' Cyclopaedia of Medicine,' by

Ziemssen . . . .23, 40, 74
Dallinger on spontaneous genera-
tion 218

Day, S. P., on modes of burial . 381
Dead, the, as a source of infection 248
Death by hanging, signs of . . 240
Deval on uses of gurjum balsam 487
Dewar on action of light on retina 227
Diagnosis of heart diseases . . 159
Diarrhoea treated by zinc oxide . 478
Dickenson on granular disease of

kidney 279

Dickson on vivisection . . . 146
* Dictionary of Medicine and Sur-

gery,'by Jaccoud . . . 175
Diphtheria, treatment of . . 179

treated by chlorate of

potash 479

Digestion, physiology of . . 220
Diseases of brain, * Ziemssen's Cy-
clopaedia' 269

of invalid criminals . 182

■ of skin, Duhring on . 443

Dissection, Cleland on . . . 153
Dixon on the air of Glasgow . 381
Double uterus, with a tumour, case
of 506

INDEX TO VOL. LX.

PAGE
Drainage of houses . . . 381
Drugs in the treatment of disease 493
Duhring on diseases of skin . . 443
Dunham on theory of medical

science 168

Duval on equinic acid in milk . 223
Ear, internal histology of . . 229
Ear-structures, histology of . . 227
Eczema treated by glycerole of

subacetate of lead . ... 489
Elam on doctrine of evolution . 114
Elbow-joint, excision of . . 450
Electric bath, Schweig on . . 160
Electricity, medical, by Tibbits . 420
Emergencies, Swain's manual for . 176
Epilepsy treated by setons . . 484
Epithelium of stomach . . . 220
Ergot extract for hypodermic use . 419
Erysipelas in infants caused by

rancid fat. . . . '. 509
Erythema exudativum, on . . 505
Essays on neurology . . . 423
Eude on temperature in hectic . 253
Evolution, doctrine of . . . 114
Excision of elbow -joint . . 450
Exudative erythema . . . 505
Facial hemiatrophy . . . 491
Factory Acts, medical organization

of 248

Faralli on treatment of diphtheria 179
Feeding, infant, on . . . 170
Ferrier on functions of brain . 99
Field on house drainage . . 381
Finlayson on temperature of

children in phthisis . . . 253
Fleming on genito-urinary organs 431
Flint on percussion and ausculta-
tion 171

Foetus affected by smallpox . . 503
Forceps, new, by Tarnier . . 504
Forensic medicine, report on . 232

— — handy book of,

by Woodman and Tidy . . 381

and hygiene . 381

Foster's ' Practical Physiology ' . 32
Fox, E. L., on temperature and

tubercle 253

Wilson, on temperature in

phthisis 253

French Hygienic Society . . 381
Frerichs on glycogenic function of

liver 222

Fritz on rupture of oesophagus . 207
Froissac on neuralgia . . . 423
Gallard on treatment of uterine

vegetations .... 507
Gamgee, S., on medical charities . 381
Gant on diseases of bladder . . 149
Gastrotomy, Lanelongue on . . 208
Generation, spontaneous, Roberts

on 391

Genito-urinary organs, diseases of 431
Germ theory, Maclagan on the . 391

INDEX TO VOL. LX.

PAGE
Gerster on lymphatics of testes . 219
Gillette on French clinical surgery 449
Glasgow, Dixon on air of . . 381
Glycogenic function of liver . 222

Glycosuria in puerperal state . 502
Gout, Parkin on . . . .438
Graefe and Sarmisch, system of

ophthalmic medicine . . 422

Granular kidney, pathology of . 279
Granville on care and cure of the

insane ..... 371
GriflSiths on use of seton in paraly-
sis 484

Gubler on temporary puerperal

glycosuria .... 502

Gurjum balsam, uses of . . 487
Gynaecological Society's * Transac-
tions ' . . . . . 434
Hamilton on drugs in the treat-
ment of disease . . . 490
Hanging, death by, signs of . . 240
Hanot on hypertrophic cirrhosis of

liver 59

Hanley's demonstrations of micro-
scopic anatomy . . .32
Harrogate waters, Myrtle on . 417
Harvey on signs of death by hang-
ing 240

Hay-fever, causes of . . . 497
Head injuries, on trephining in . 202
Health, Parkes on . . . 129
Heart, action and sounds of . . 179

diseases of . . .74

diseases, Samson on . 159

Heath's illustrations of operative

surgery 155

Helfreich on colour of fundus

oculi 226

Hemiatrophy of face . . . 491
Henoch on dyspeptic asthma . 508
Hermann on the vivisection ques-
tion 146

Heubner on diseases of brain . 269
Hilton on rest and pain . . 151
Hine on facial atrophy . . .494
Hints to mothers, by Bull . . 174
Histology, report on . . . 217

practical, text-books . 32

Hitzig on diseases of brain . . 269
Hospital mortality, Tait on . . 439
House drainage, by Rogers Field . 381
Huguenin on diseases of brain . 269
Hutchinson on transmission of

syphiUs from parent to offspring 455
Huxley on amphibia . . . 114
Hygiene, report on . . . 232

and forensic medicine . 381

Hygienic Society of France . . 381
Hyperplasia of anterior lip of

uterus 502

Hypertrophic cirrhosis of liver . 59
Hypotheses regarding contagion . 391
Hysterotomy for uterine tumours . 507

515

PAGE
Idiocy and imbecility, Ireland on . 345
Image?, retention of, by retina . 226
Imbecility, Ireland on . . . 345
India, sanitary work in . . 328
Indian leprosy, report on . . 139
' Inebriety, Quarterly Journal of '. 381
Infant feeding, on . . .170
Injuries, subcutaneous, of lower

extremities .... 209
Insane, on care and cure of . . 371
Insanity, medico-legal aspects of . 306
Insane, asylums for, Granville on . 371
International Exhibition, Phila-
delphia, medical exhibits . . 417

Otological Society's

report 421

Hygroma, infra-patellar . . 213
Invalid criminals and their dis-
eases 182

Ipecacuanha, on non-emetic use of 438
Ireland on idiocy and imbecility . 345
Jaborandi, a cure for albumiuaria
of pregnancy .... 501

Jacobson's edition of Hilton on
rest and pain . . . .151

Jaccoud's * Dictionary of Medicine
and Surgery' .... 175

Jochmann on temperature in dis-
ease ...... 253

Johanssen on a new cause of vagi-
nismus 505

Johnson, G., on renal diseases . 279
Jones on poisoning by potassium

cyanide 232

Kelsch on adenoma of liver . . 59
Kelper on hyperplasia of lip of

uterus 502

Kidney diseases, 'Ziemssen's Cyclo-
paedia' 279

granular, pathology of . 279

Klein's ' Handbook to the Physi-

logical Laboratory ' . . .32
Kleinwachter on urine of childbed 222
Krause on the layers of retina . 226
Kretschy on physiology of diges-
tion 220

Kiihne on histology of pancreas . 221
Kiihne's ' Optographical Re-
searches ' 226

Kiilz on glycogen of liver . . 222
Lanelorgue on gastrotomy . . 208
Langlet on jaborandi in albumi-
nuria of pregnancy . . . 501
Lavdowsky on histology of inter-
nal ear 227

Lea on histology of pancreas . 221
Lead, glycerole of subacetate, uses

of 489

Lebert on thermal changes in

tuberculosis .... 253
Ledouble, case of infiltration of
legs with menstrual suppres-
sion 607

516

PAGE
Lelu on uses of double cyanide of

potassium and zinc . . . 477
Leprosy iu India .... 139

reports on . . . 139

Lewin on erythema exudatiorum 505
Lewis on Indian leprosy . . 139
— — on mycetoma . . . 340

on Oriental sore . .144

Light productive of electric ac-
tion in retina .... 227
Liver glycogen, Kiilz on . . 222
Liver, hypertrophic cirrhosis of . 59
Lugan on double cyanide of

potassium and zinc . . . 477
Lustgarten, case of spontaneous

rupture of uterus . . . 501
Luton on uses of phosphate of

soda 487

Lymphatics of bones . . . 218

of testes . . .219

Macilwain on vivisection . . 133
Maclagan on the germ theory . 391
Macnamara's history of cholera . 165
Magnan on alcoholism . . . 364
Magnus on cataract . . . 423
Margate, sanitary report of . . 381
Marsh on cause of hay -fever . 499
Massart on treatment of retro-

versio uteri .... 504
Materia medica of Chinese . . 482
■ medica tables. . . . 169

Medical charities, an address on,by

S. Gamgee . . . .381

Library of United States . 408

organisation of Factory

INDEX TO VOL. LX.

Acts.

science, theory of

248
168
Medicine, theory and practice of,

by Bristowe . . . .161

— — report on . . . 491

Medicines, influence of, on foetus . 485
Medico-legal aspects of insanity . 306
Mehu on non-existence of mucus

in urine 222

Menstrual suppression with infil-
tration of legs .... 507
Mental diseases, classification of . 496
Metcalfe's 'Sanitas Sanitatum' . 381
Michel on ranula .... 206
Microscopic anatomy, by Harley

and Brown . . . .32
Microscropy,manual of, by Wythes 419
Microphytes, growth of . . 217
Midwifery, report on . . . 501
Milk, a new acid (equinic) found in 223
Materia medica report on .
Mitchell, Weir, on relation of pain

to weather . . . . 245
Mojsisovics on terminal nerves of

snout of pigs, &c. . . . 229
Mont-Dore, mineral waters of . 157
Mook's critical study of Para-

celgus . . . . . 413

PAGE
Moore, J. W., reclamation of . 252
Morton on spina bifida . . . 148
Mothers, hints to, by Bull . . 174
Mucus, absence of, in urine . . 222
Muscular currents affected by tem-
perature 229

Muscular force in relation ta urea 190
Mycetoma, Cunningham and Lewis

on 340

Myrtle on Harrogate waters . . 417
Narcotics, influence of, on the

foetus 485

Nasse on the blood of parturients . 219
Nerve-currents influenced by tem-
perature 229

Nerves, peripheral, disease of . 23

termination of, in snout of

pigs, &c 229

Nervous system, Charcot's lectures

on 180

Neuralgia, Froissac on . . . 423
Neurological essays . . . 423
Neuroma, plexiform . . . 495
Nicolson on diseases of criminals . 182
Nothnagel on brain diseases . . 269

* Nurse's Companion,' by Culling-

worth 164

Nutrition, Benuet on . . . 171
Oberneier on diseases of brain . 269
(Esophagus, rupture of . . . 207

* Operative Surgery,' by Heath . 155
Ophthalmia, sympathetic . . 211
Ophthalmic medicine, system of,

by Graefe . . . ... 422

Orbit, acute cellulitis of . . 214
Oriental sore, pathology of . . 144
Lewis and Cunning-
ham on 340

Otis on transport of wounded . 416
Otological Society, report of . 421

Ovarian fluid, pus in . . . 505
Pain in relation to weather . . 245
Fallen on perineal lacerations . 215
Pancreas, histology of . . . 221
Paracelsus, works of . . . 413
Paralysis treated by setons . . 484
Paris hospitals, clinical surgery of 449
Parkes on personal care of health 129

on public health . . 129

Parkin on gout .... 438
Parsons on sea-air and sea-bathing 162
Pathology, report on . . . 491
Pathological Society of Phila-
delphia, 'Transactions' . . 178
Paton on action and sounds of

heart 179

Percussion, Flint on . . . 171
Perineal lacerations. Fallen on . 215
Peripheral nerves, diseases of . 23
Peter on use of cold baths in
typhoid 480

* Philadelphia Pathological J'raus-

actions' 178

INDEX TO VOL. LX.

PAGE
Philadelphia Exhibition, medical

objects in 417

Phthisis, acute, on curability of • . 426

—— temperature in . . 253

Physiology, practical, by Foster

and Langley . . . .32

report on . . .217

Picard on diseases of prostate . 341
Planck's report on leprosy . . 139
Plexiform neuroma . . . 495
Poisoning by potassium cyanide . 232
Police force, Chadwick on a . . 381
Potash chlorate in diphtheria . 479
Potassium cyanide, poisoning by . 232
and zinc, cyanide of,

uses of 477

Power, report on physiology . . 217
Pozzi on trephining in head in-.

juries ..... 202
Pregnancy, blood in . . . 219
Prostate, diseases of . . . 341
Public health, Parkes on . . 129
Publishers' valedictory address . 512
Puerperal glycosuria . . . 502
Pus, significance of, in ovarian fluid 505
Quincke on influence of sleep on

renal activity .... 223
Radford Library, catalogue ofj . 415
Ranula, Michel on . . . 206
Ray on mental pathology . . 306
Reclamation of Dr. J. W. Moore . 252
Rectum, diseases of . . .17
Renal sarcoma in young child . 508
Reports on leprdsy by Carter . 139
Report on medicine . . . 491

midwifery . . . 501

materia medica . . 477

physiology . . .217

^^ surgery . . . 201

• on toxicology . . 231

Reports of Medical Officer of the

Privy Council ....
Reproductive organs, diseases
Respiration, its influence on blood

pressure .....
of foetus .

391
96

224
224
157
226
226
226

Rest and pain, by Hilton

Retinal colour, nature of .

images preserved

— — — layers, histology of .

Retroversion of uterus, novel treat-
ment of 504

Richards on influence of seasons
on suicide 238

Richardson's report on forensic
medicine 232

Ringer on temperature in phthisis 253

Robin on urine in typhoid fever . 298

Roberts on growth of microphytes 217

Roberts on spontaneous generation
and contagion . . . . 391

Roser on brain wounds from audi-
tory canal , , , , 204

51*

PA.GE
. 170

Routh on infant feeding

Runge on hot- water injections in

uterine haemorrhage . . . 503
Rupture of oesophagus, case of . 207

spontaneous, of uterus . 501

Rutherford's ' Practical Histology' 32
Sanitary Commissioners' (Indian)
reports . . . . . 328

mode of burial . . 381

work in India . .328

Sankey on classification of mental

diseases . . ■ . . . 496
Sansom's lectures on heart diseases 159
Sarcoma, renal, in young child . 508
Scarlet fever, prevention of . . 381
Schafer's ' Practical Histology ' . 32
Schwalbe on lymphatics of bone . 218
Schwartz on the fever accompany-
ing phthisis .... 253
Schweig on electric bath . .160
Sea-air and sea-bathing . . 162
Seasons, their influence on suicides 238
Seguin on myelitis . . . 423
Semple's report on materia medica 477
Seton, use of, in paralysis and epi-
lepsy 484

Sireday on endemic of erysipelas

caused by rancid lard . . 509
Sanitary sanitation, by Metcalfe . 381
Skin diseases, Duhring on . . 443
Sleep, its effects on urinary secre-
tion 223

Smallpox in the foetus . . . 503
Smith, Eustace, on diseases .of

children 451

Smith's, Johnson, report on sur-
gery 201

Smith on surgery of rectum . 17

Soda-phosphate, uses of . . 487
Soda salicylate in diphtheria . 479
Sonnenburg on acute cellulitis of

orbit 214

Spender on the Bath waters . . 416
Spina bifida cured by the elastic
ligature . . . . . 509

— — treatment of . . 148

Sponges, value of, for dressing . 202
Spontaneous geueration, Dallinger

on . . . , . .218
Squire on glycerole of subacetate of

lead in eczema .... 489
Stefani on effects of respiration in

blood-pressure .... 224
Steiner on temperature in relation

to nerve- currents . . . 229
Stomach epithelium, Biedermann

on 220

— — fistula, researches on di-
gestion in 220

Suicide as affected by seasons . 238
Sullivan on tropical diseases . 427
Surgical dressing, use of sponges
in 202

51B

INDEX TO VOL. LX

Surgical fever after antiseptic ope-
rations ....

Surgery, report on

operative, by Heath

Swain's manual for emergencies . 176

.211
. 40

PAGE

201
201
155

Sympathetic ophthalmia
Syphilis, Baumler on .
— — — on transmission of, by

Hutchinson .... 455
Tables of materia medica . . 169
Tait on diseases of women . . 359

on hospital mortality . . 439

Tardieu on medical jurisprudence

of insanity .... 306
Tarnier on a new forceps . . 504
Temperature, influence of, on nerve

and muscle currents . . . 229
in phthisis and tuber-
culosis 253

Theory of medical science, by Dun-
ham 168

Thompson on uses of chrysarobin 486
Thudichum on chemistry of brain 1
Tibbits on medical electricity . 420
Toxicology, handbook of, by Wood-
man and Tidy . . . .381

— — report on . . . 232

* Transactions of Bombay Medical

Society' 177

of Clinical Society . 181

of Philadelphia Pa-
thological Society* . . . 178
Transmission of syphilis . . 455
Treatment, rational, of wounds . 448
Trendelenberg on infra -patellar

hygroma 213

Trephining in injuries of head . 202
Trevers, sanitary report of Mar-
gate' 381

Tropical diseases, Sullivan on . 427
Tuberculosis, temperature in . 253
Turner's * Introduction to Anatomy' 138
Tyndall on growth of microphytes 217
Typhoid fever, Cullen on . . 425

treated by cold baths 480

urine in " . . 298

408

190
506
96
222
223

United States Medical Library .
Urea, its relation to muscular

force

Urethral affections of women
Urinary organs, diseases of .

secretion in childbirth

Urine as affected by sleep .

in typhoid fever .

— — non-existence of mucus in .

PAGE
Uterine haemorrhage treated by
hot-water injections . . . 503

hot-water injections in

haemorrhage .... 503

retroversion, treatment of 504

tumours treated by hystero-

tomy

vegetations, treatment of .
Uterus, anterior lip of, hyperplasia
of

case of spontaneous rup-
ture of

— — — double, with a tumour
Vacher on the dead as a source of

507
507

502

501
506

248
505

507

209
158
447
133
146

133

212
245

infection

Vaginismus, new cause of .
Vegetations of uterine cavity,

treatment of .
Verneuilon deep-seated injuries of

lower extremities
Viard on results of amputation
Vital force, Battye on .
Vivisection, on, by Macilwain

■ question discussed

— — report of commission

Wagstaffe on cancer in male

breast

Weather, relations of, to pain
Weber- Liel on histology of in-
ternal ear 229

Williams, C. T., on temperature in

phthisis . . ► . . 253
Wiltshire, report on midwifery . 501
Women, diseases of, report on . 505

by Atthill . 452

by Tait. . 359

urethral affections of . 506

Woodhull on uses of ipecacuanha 438
Woodman and Tidy's handybook •

of forensic medicine . . .381
Woimded, on transport of . . 446
Wounds ef brain from auditory

canal 204

rational treatment of . 448

Wunderlich on temperature in

disease 253

Wythe's microscopical manual . 419
Yvon on hypodermic use of ergot . 489
* Ziemssen's Cyclopaedia '

23, 40, 74, 269, 279
Zinc oxide, use of, in diarrhoea . 478
Zuntz on respiration of foetus . 224
Zweifel on foetal respiration . . 224

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